1. To Treat or not to treat? A health care reform debate J. Alberto Martinez, M.D.
2. Case presentation. History RS is an 85 Y.O. male referred emergently by an ophthalmologist for a severe corneal ulcer, left eye. CC: Seven day history of decreased vision and discharge, left eye. Denies pain. Patient is on his last few radiation treatments for throat cancer. Mr. RS lives with a septuagenarian couple who are his friends and help take care of him. Patient still smokes ½ pack of cigarrettes per day
3. EXAM Fragile, cachectic male able to ambulate slowly. Able to cooperate, slowly, grumpily. VA: OD: sc 20/25 OS: sc: HM Poor blink OU Normal anterior segment OD, well centered IOL OS: Massive corneal infiltrate with bulging cornea. No seidel’s, deep anterior chamber, pseudophakic.
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6. Diagnosis and Treatment Corneal ulcer, severe, probably associated with exposure keratopathy TREATMENT?
7. Initial Treatment Corneal scraping for culture and sensitivity Start VigamoX every 1 hour around the clock until fortified antibiotics ( Ancef and Gent) obtained. Shield Assesed home condition, spoke with social worker, home friends to improve compliance, given patient’s general condition. Daily follow-up.
8. Clinical Evolution Infiltrate appeared to get smaller over the next three days. Compliance appeared to be good. Difficulties with transportation. Cultures were negative. On the fourth day, the chamber collapsed
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11. Now What? To transplant or not? No transplant: Ulcer may be sterilized, perforation would be vascularized, eye would eventually may become pthisical. Transplant: 90% plus chances of saving the eye and eventually good vision. Patient given the option: “he wants his eye”
12. ETHICS Should we invest about $10,000 on this eye? Patient’s quality of life would be essentially unchanged with a successful transplant. Cost to SOCIETY.