In the October Blink, it is likely that the iris may be sequestered inferonasally through a scleral rupture under the conjunctiva, or in the angle (which would explain the increased IOP), and is hidden by the residual conjunctival hemorrhage. Ultrasound biomicroscopy should help to find it. This would also explain the slight temporal shift of the IOL, as some zonules may have been damaged, resulting in asymmetric zonular forces.
If reconstruction of the iris is not possible, the remaining tissue should be excised, and an iris prosthetic implant (under FDA clinical trial or compassionate use exemption) should be considered once the inflammation subsides, as the fully exposed multifocal optics will not work well with the pupil fully dilated.
I have had good success with both the Ophtec and HumanOptics iris prosthesis in traumatic aniridia spanning my past 15 years of experience.
Kenneth Rosenthal, MD
New York, N.Y.
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Ethics and Informed Consent
The May Academy Notebook asked the Ethicist to help us in properly informing other medical doctors when we deal with them as patients. The Ethicist covered the essentials well, and no contradictory remarks need to be presented. However, the Ethicist would have made the important subject of informed consent clearer if several other comments had been made.
The essential point is that we must take nothing for granted when presenting the clinical details and management plan.
As experts in jurisprudence on the subject of informed consent will advise, there is no such thing as informed consent. Specifically, after an alleged medical misadventure, the court may perceive that the medical risks were not adequately communicated; thus, the patient was not able to properly assess the situation or, ultimately, make a qualified medical treatment decision. Both the provider and the patient are usually held responsible for this type of miscommunication. But the ensuing lawsuit will relate to aspects of the treatment that the patient believes were not properly discussed.
This leaves us to assume that our job is to provide basic information about the disease, management options, and recommended treatment as well as the expected outcome and any potential complications. In the end, the following issues must be resolved:
- The patient (including the physician-patient) must feel that the explanation of the disease and the management options have been carefully and completely presented, so that the patient understands and is comfortable with the management process.
- The patient must have time to ask questions that relate to the entire process.
- Generally, the patient must indicate that the diagnosis and management are fully understood.
Many of us have adopted the following mnemonic formula: RBEU & A + NQ. This formula is used to determine whether the patient understands the Risks and Benefits as Explained and that they are Understood and Accepted, with No further Questions. Please note that medically trained personnel usually require a fuller and more detailed explanation of the treatment process than the average person does.
It behooves the treating doctor to personally provide the informed consent details to the physician-patient.
With that in mind, the treating doctor should provide sufficient time in as relaxed an environment as possible for the discussion and recognize when the physician-patient has demonstrated complete satisfaction with the proposed treatment plan and its risks and benefits.
Rod Morgan, MD, FRCSC, Dipl. ABO
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