CLINICAL JUDGMENT AND COMMON SENSE BY Charles E. Iliff, M.D. MY

TALK TODAY BRINGS NO WONDERFUL NEW DISCOVERIES, NO CONTRIBUTIONS

to the Science of Medicine, and nothing that would qualify as continuing medical education for license renewal. Instead, I am speaking to you as teachers rather than learners. You, as respected members of our specialty, are helping to teach and guide the students and residents who follow. Sometimes, in teaching the facts and procedures required for the practice of ophthalmology, we take for granted many of the elements which are included in the term "The Art of Medicine." This embodies common senise, which some inherit and some learn, and clinical judgment which comies with experience. Patient care should be based on these. In reading the current literature, our journals, and throw away sheets, a numiiber of questions come to mind. UNDER WHOSE AUSPICES AND TO WHAT LENGTH SHOULD STUDIES OF QUESTIONABLE VALUE BE PURSUED?

The operation oIn unilateral congenital cataracts, even when performed in the first few weeks of life and followed immediately with a contact lens fitting has produced the most discouraging visual results. This eye, no matter what is done to it cannot equal the normal eye. Yet I am sure that evenl nlow, in this wild race to present a first, intraocular lenses are beinig inserted in the eyes of infants with a unilateral congenital cataract. Unider present laws, the mnedicolegal responsibility for the care of children is niot limnited bv the three-year statute of limitations. It extends through the child's 18th year so that new and untried procedures should be used oni childreni onlx' unlder the most rigid controls. It is unfortuniate that the fine work being done in Miami for the control of lenis imnplanitationi could niot also have been the basis for the spread of informnationi rather than the mushroominig courses that have occurred sintultanieously throughout the country. Lens implanitationi advertising is now miiore commllnoni than that of phacoenutlsification. Meetings are spiiigiig tup everywhere cruise the Mississippi on the Delta Queen, fly to Hawaii, go to Russia - anid while doing this you can learn how to Tlo. A\I. OPi,rrii. Soc., vol. LXXV, 1977

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put in an intraocular lens. In no way can such courses make competent surgeons. Ophthalmic reporting has reached the tabloid stage. The March issue of Ophthalmology Times contains a report made at the American College of Surgeons meeting in Chicago, in which the anatomy of the optic canal was beautifully described. As the article continued, it was stated that surgical decompression of the optic canal following cranio-orbital trauma should result in a partial return of vision in 60 to 70% of these cases. The amazing point about this statement was that the doctor had studied the course of the optic canal on cadavers, but had done no operations on live patients. This is heroic reporting, rather than heroic surgery. Perhaps it is the fault of our institutions, when pressure to publish in order to obtain recognition and advancement in academic standing causes the hopefuls to rush into print with material which is often inadequately researched and even misleading. ARE HEROIC PROCEDURES INDICATED IN OPHTHALMOLOGY?

We, as ophthalmologists are seldom faced with a situation such as two friends of mine have recently been subjected. Their father, age 88, dying of cancer was depending on morphine for relief from pain. The drug was discontinued by a misguided physician because of concern about addiction, thereby subjecting the patient to withdrawal symptoms as well as his pain. Nor are we likely to be expected, as ophthalmologists, to resuscitate an arrested heart of a cancer patient only to keep some sort of life in that unconscious body for another three days. Yet, extensive procedures for the removal of orbital tumors in some instances with ablation of half the head are being recommended. Is complete tumor removal, or the treatment of the patient the goal? When an operation produces massive mutilation, far beyond the probable damage form the tumor itself, it's value is indeed questionable. We must consider what the patient's life will be like after one of these mutilating procedures and suggest that perhaps relief of symptoms rather than complete tumor removal is the better treatment for the patient. Not uncommonly, radiation therapy and chemotherapy will control the lesion until the patient dies from some other cause. IN CONSIDERING HEROIC THERAPY, WHAT WEIGHT SHOULD BE GIVEN TO STATISTICS FROM THE ARMED FORCES INSTITUTE OF PATHOLOGY WHICH PRESENTS A BROAD VIEW OF TUMOR PROGNOSIS?

For instance, reports from this Institute give discouraging statistics for life in patients with adenoidcystic carcinoma of the lacrimal gland. These

63 Judgment and Common Sense statistics should not be the only guide for the care of the patient. It is obvious that the course of metastases already present at the time of the initial operation will not be influenced by that surgery. The ophthalmic surgeon, the plastic surgeon, or the neurosurgeon are unable to tell at the time of operation the extent of tumor invasion in bone, nor can they utilize the skill of the ophthalmic pathologist with frozen sections, since bone must be decalcified before it can be examined. Considering the above points, is the extensive procedure recommended at the last American Academy of Ophthalmology meeting justified or should the socalled conservative en bloc procedure, advocated by Dr John Henderson be advised? In an attempt to remove all the involved bone the operation becomes such an extensive procedure that the patient's remaining life must be greatly curtailed by the deformity. Dr Henderson's recommended operation does not destroy the eye and the result is cosmetically acceptable. It will take many years to evaluate the two procedures. However, since metastases present at the time of surgery are beyond the surgeon's control and because the exact extent of bone invasion cannot be deteriained without doing such an extensive operation that the patient is severely mutilated, I caninot help but feel that Dr. Henderson's conservative approach is the one of choice. On the brighter side, Zimmerman reported that orbital angiomas in children may have the histologic appearance of angiosarcomas but in fact are benign. Several years ago, I had a child of four referred for exenteration of the orbit because the biopsy had been read as an angiosarcoma. Because of Zimmilermani's study, a simple removal of this benign tumor was done and the child is well. Yet, there is a false impressioni obtained fromn the literature that because skin angiomas tend to disappear with age or corticosteroid therapy, orbital angiomas should respond in the same wax. I wish to state categorically that the diagnosis of an orbital tumor must be absolutely determined and that the possibility that the mass is a benigni angiomiia is not sufficient to delay an operation in hopes that it will disappear. Three patients demonistrate this point. The first, is a 6-monith-old infant with an unlexplainied exophthalmos. At operationi, it was founld to have anl encapsuilated cavernious hemanigiomna, which was removed and the child is well. The seconid, a child of 2 years, had a rapidly increasinlg exophthalmos which imparted a bluish tint to the lower lid. An angiolma was suispecte(d but the tumnor was a lymphanigiomna in which a hemlorrhage ha(l occutrre(l. It is difficult to remove these tumnors comnpletely, but they cal l)e conitrolled by repeated excisionis. The third, anl inifanit with a

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gradually increasing exophthalmos also had a bluish discoloration in the lower lid. Clinically, an angioma was suspected and at operation the tumor cut like an angioma. On frozen and permanent section, it was a rhabdomyosarcoma. The orbit was exenterated and the child is well five years later. FIT THE CLINICAL PICTURE, WHAT SHOULD BE DONE?

WHEN A DIAGNOSTIC TEST DOES NOT

New tests are constantly being devised. Computerized medicine seems the goal of the future yet we as clinicians have to decide what to do when tests such as the 32p scan and computerized tomography do not fit into the clinical picture. Nevi and angiomas have both been known to give positive 32p tests and we must base our decision for therapy on the evidence of the observed change of the tumor in question. In the last three months, I have seen two patients with unilateral exophthalmos in which the computerized tomography gave the picture of a round discrete apical orbital mass, when the clinical picture was that of an euthyroid patient. In the first patient, a second scan revealed that the apparent tumor mass was merely produced by an unresolved view of the enlarged muscles. Lateral and orbital floor decompressions were done and an excellent result obtained. Obviously no tumor was found. The second patient presented a bit more of a problem in that he had a seminoma removed seven years before the present exophthalmos occured and in addition to this had a chronic ethmoiditis. The computerized scan demonstrated a similar apical orbital mass but in addition showed a slight enlargement of the extraocular muscles in both eyes. The amount of exophthalmos was not great, yet his vision had rapidly decreased so that lateral and orbital floor decompressions were done. No tumor was found and within 48 hours after the decompression his vision had returned to normal. Even as sophisticated a diagnostic tool as computerized tomography can be misleading unless it matches the other clinical findings. IN TEACHING INSTITUTIONS, SO MUCH INTEREST MAY BE

GENERATED

IN AN

INTERESTING PATHOLOGIC CONDITION THAT THE CHIEF COMPLAINT OF THE PATIENT IS FORGOTrEN

Recently, I saw a patient referred by a local ophthalmnologist for a ptosis of the right upper lid. She had entered the hospital on the nose anid throat service for a deviated septum. A submucous resection was propose(l and(l the otolarvnlgologist suggested that at the samiie time the ophthalmiiologist repair her baggy lids. So, in additioni to the niasal opera-

Judgment and Common Sense

65

tion, a blepharoplasty was done which resulted in a right ptosis. Her complaints were rather bitter and she was referred to another hospital. She saw an associate professor of ophthalmology, who found her to have a corneal abnormality. He referred her to another associate professor, who was head of the corneal service and was interested in such problems. She was subsequently studied by the resident on the service and then turned over to the intern for final disposition. Following this, a very good paper was written on the corneal dystrophy of the patient and her two brothers. However, the patient's complaint of a right ptosis was not taken care of. She then saw her own ophthalmologist who referred her to me for ptosis surgery. By this time, the patient was irate and rightly so. Our medical profession is under great governmental and social pressures and we should increase our efforts to control the one-upmanship that is outstripping good clinical investigation and making headlines in the press. A plan of treatment should not be based solely on a statistically poor prognosis but on the consideration of the patient as a person, taking into account his age, his general health, and his probable future way of life. When one piece of a puzzle, a diagnostic test, does not fit the clinical picture, the test may be suspect. Listening to the patient's chief complaint is really just common sense. Clinical judgment should be reestablished as a part of our curriculum. DISCUSSION DR TULLos 0. CoSTON. In his forthright and thoughtful mannler Dr. Iliff has presenited maniy of the problems which call for coImm111on0 sense judgments in the practice of ophthalmnology. I enjoyed readinig this paper and I find nothing in it with which I disagree. I would like to broaden the discussion by speaking of unnecessary operations. I see increasinig numbers of patienits who come to me in consultationl, having been advised bv anl ophthalmologist to have cataracts removed. I am shocked to find some of these in(lividuals performiing adequately with 20/25 and 20/30 vision. Sad to sax somne ophthalmic surgeonis (lo not trouble themnselves by performing an ade(juate refractioni before advisinig an operationi. Sadder than that is the ophthalmologist who feels that all cataracts must be removed anid so informiis the patient. If (questionedl by the patienit the answer is so oftenl, "Well the cataract always adlvances anid eventually has to be remnoved. " Of course this is not true. Concealmiienit through canidor ofteni guaranitees duplicity with honor. A good rule of thuLmb) to presenit to the patienit with cataracts is "You max consider having the cataracts removed if you canniiot do what you need to do and wish to do because of vour lowered visual acuity." One should make it (quite clear to the patient that the presenice of a cataract is not harmful to the eye except in most unusual cir-

cumiistanices.

Ann

Iliff

So many cataracts are removed unnecessarily. I am reminded of a recent ruling by Blue Shield Insurance which states that removal of organs just for the simple reason the patient wishes this done fearing that a cancer might develop in such an oragan in the future will not be covered by Blue Shield. If this were carried to its ultimate conclusion a woman might have both breasts, both ovaries, and the uterus removed. A male, fearing cancer of the prostate or testes might have these organs removed. Of course, the best prevention for development of cataract would be to remove the clear lenses. I knew a man who owned a small garage in an east Texas town. I worked for him during the summer months. A model-A Ford would drive up with some rattle, he would look under the hood and underneath the car and often say "Mister I don't find anything wrong, you just have a rattle." The customer would often insist there must be something wrong and his pat answer was always, "If it ain't broke don't fix it." Indeed the hucksters have invaded the field of ophthalmic surgery. We have lunch hour cataract operations. We have direct advertising. This reminds me of the medicine man who came to the village square some 50 years ago. He always had his bottles of tonic and he had a monkey or he had a dancing girl or someone who played a fiddle for entertainment. He would yell out, "Come one, come one and all, my show is free you pay me only $1.00 for my wonderful tonic." The modern huckster outside of his operating room now says, "My show is $500.00, my book is free." DR CHARLES ILIFF. I wish to thank Dr Coston for his usual delightful discussion.

Clinical judgment and common sense,.

CLINICAL JUDGMENT AND COMMON SENSE BY Charles E. Iliff, M.D. MY TALK TODAY BRINGS NO WONDERFUL NEW DISCOVERIES, NO CONTRIBUTIONS to the Science of M...
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