September 28, 2018 - HYNES - Physicians Conference
AM - Cataract - Successful Surgical Strategies for Comples and High-risk Cataract Surgery
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified current strategies in preventing surgical complications in high risk cataract surgery as a practice gap.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
- Reviewing best practice for patient selection, consent process and surgical decision-making for potentially complex cataract surgeries, in order to maximize alignment between patients’ expectations and outcomes in high risk cases
- Addressing ways to anticipate and prepare for a range of specific surgical challenges ahead of high-risk cataract surgeries.
- Discussing specific strategies, techniques, medications and equipment that can be useful to prevent and manage complications in order to maximize outcomes
Cataracts and glaucoma are age-related ophthalmic conditions that commonly co-exist. One in five patients undergoing cataract surgery have a diagnosis of glaucoma, and glaucoma patients are known to have hastened cataract development. In general, routine cataract surgery results in IOP-lowering especially in those with high-tension open-angle glaucoma, pseudoexfoliation glaucoma, and primary angle closure glaucoma. However, complications can occur at a higher rate after routine cataract surgery in eyes with glaucoma compared to those without. Patient and procedure selection is therefore critical in the pre-operative evaluation of cataracts in the glaucoma patient. More recently, patient selection for combined cataract and glaucoma surgery has been influenced by the increasing options for lower-risk glaucoma procedures.
Intraocular lens selection for cataract surgery in patients who have previously undergone LASIK or PRK can be challenging for many reasons. These patients are typically prepared to pay extra money to obtain optimal results. Oftentimes they are spectacle free and want to remain this way after cataract surgery. They are often interested in premium cataract surgery options like laser assisted cataract surgery, intraoperative aberrometry and they have high expectations. This combined with the typical absence of information about their eyes prior to their refractive surgery can make it more challenging to obtain emmetropia after cataract surgery. In the past, we were dependent on historical information to get great results for these patients. Fortunately, with advancements in technology, in addition to newer formulas that do not require historical data, intraocular lens selection does not have to be so daunting. In this talk we will discuss how to: 1) Manage patient expectations; 2) Estimate their previous refraction; 3) Adjust lens selection based on previous treatment; 4) Choose a lens formula; and 5) Use intraoperative technology to obtain excellent outcomes; 6) Managing unexpected post-operative outcomes.
The loose phakic or pseudophakic lens can be challenging for any anterior segment surgeon to manage. The evaluation and management options are continuously evolving. This video-based presentation will address the clinical thought process with the assessment of these patients, followed by surgical pearls to stabilize an intraocular lens (IOL) in these eyes. Surgical planning and strategy with careful pre-operative planning are imperative. Intraoperative stabilization of the phakic lens may be required to safely perform extraction of the cataract, and capsule tension segments or hooks can be utilized. The loose or dislocated pseudophakic lens also has special considerations, including scleral-fixation of the existing lens or potential IOL exchange. Various options exist to stabilize an IOL, and include one or a combination of the following: capsular tension devices (standard rings, Cionni variant, Ahmed segment), scleral fixation techniques (suture, glue, flanged instrascleral Yamane), and iris-suture fixation of the IOL.
Deborah K. VanderVeen
Visual impairment from cataract is a disability that can co-exist with other disabilities, whether physical, intellectual or emotional. Cataract patients may have physical disabilities that preclude proper positioning during surgery, but other types of disability that merit special consideration for cataract surgery include intellectual impairment, autism, and behavioral or emotional disturbances. These patients are typically unable to cooperate for an optimal office examination, pre-operative biometry, require general anesthesia, and may be unable to comply with typical post-operative care plans. Preparation strategies for the patient can include pre-operative training at home, and environmental control in the pre-operative area. Modifications in surgical technique can also improve safety, and post-operative care can be improved when considering individual behavioral needs. Utilization of such techniques can improve the experience for the patient and family, and contribute to a satisfactory surgical outcome.
Cataracts are a common complication in patients with uveitis, secondarily either to the natural disease process in entities such as Fuchs heterochromic iridocyclitis, or due to treatment with topical, periocular, or systemic corticosteroids which are often an integral part of uveitis therapy. Patients with uveitis pose unique challenges to the cataract surgeon, both technically in approaching a case which may be complicated by posterior synechiae or zonular instability, and intellectually as perioperative decision-making with regard to ongoing and prophylactic uveitis treatment which can have a significant impact on complication rates and surgical outcomes. Special consideration must be given to these patients with regard to when and how to proceed with surgery. Thorough preoperative evaluation with thoughtful presurgical planning can help prevent intraoperative complications, and prudent perioperative medical management can minimize the risk of recurrence of inflammation, thereby improving surgical outcomes. Recommendations for preoperative, intraoperative, and post-operative considerations in these complicated patients will be presented.
PM - Ethics - Dysfunctional Physicians
Program Gaps: The Program Committee believes that reviewing problems of the 'Dysfunctional PHysician' is an imporant gap in the education that members have not identified in surveys
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically
designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
1. Information provided to help physicians recognize dysfuntional physicians
2. Action steps to intervene when a dysfuntional physician is recognized
3. Information on protecting patients from dysfunctional physicians
The practice of medicine is inherently stressful and some situations can lead to maladaptive behaviors in some individuals. Employees under stress can become disruptive or abusive when pushed beyond their abilities to cope resulting in behavior such as being disrespectful, having emotional outbursts, yelling and occasional violence. Every organization should have a comprehensive and carefully reviewed process for dealing with those prone to acting out in these ways. A team of invested leaders should be versed in the steps required to quickly respond to the instigator in order to mitigate the situation and prevent further incidents. A rigorous reporting system is essential for record keeping and for creating a culture of community responsibility wherein everyone feels safe to raise issues of concern.
Consequences for disruptive employees include first warnings, training/coaching, withdrawal of privileges or termination. The principal goal in instituting these actions is to help the individual become aware of and grow beyond these poor coping mechanisms in order to make them a more effective medical provider.
According to the American Medical Association, disruptive behavior by a physician is defined as verbal or physical conduct that negatively affects patient care. This is often manifest as personal conduct that impedes the ability of the healthcare team to work together effectively. A survey by the American College of Physician Executives found that over 70% of physicians interviewed see disruptive behavior monthly and 10% see it daily. Tolerating inappropriate behavior can increase the likelihood your practice will be sued or that a charge will be filed with the Equal Employment Opportunity Commission (EEOC). This talk will describe disruptive behavior in physicians from the OMOC and AAO Ethics Committee archives and describe lessons learned.
The relationship between physicians and lawyers has historically been characterized as that between prey and preditor--but it need not be this way. An understanding of the law by physicians (and medicine by lawyers) can go a long way toward developing a constructive relationship that can help physicians better take actions to improve patient safety and to more effectively respond to patient danger or injury by an impaired or dysfunctional colleague. Using case examples, the varying roles of colleagues, ethical norms, the medicine board, and the courts will be summarized and a way forward suggested.
Medical malpractice claims and ethics challenges often arise because a health care provider failed to obtain informed consent prior to performing a medical procedure that caused harm. If a patient is injured as the result of a procedure that they did not formally consent to, the surgeon may be challenged both legally and ethically. It is important to remember that informed consent is more than simply getting a patient to sign a written consent form. It is a process of communicationbetween a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention. Ignore at your own risk.
Ethical dilemmas arise everyday in healthcare and leaders must address complex conflicts that arise that may impact patient outcomes, compliance with federal/state statutes, and deep moral and ethical values. This presentation illustrates through four case studies how ethical conflicts should be addressed in a deliberative and proactive manner to prevent adverse outcomes, legal actions, and publicity which can undermine the mission of your healthcare organization and system.