upfront
Choices on the Ophthalmic Decision Tree

Beginning in medical school, we were taught that a key aspect of good medicine is choosing the right treatment option for our patients. This decision-making process begins with the first patient encounter, evaluating their signs and symptoms, and then performing appropriate diagnostic tests to arrive at a conclusion regarding the etiology of their complaints and a reasonable management approach. Our colleagues in internal medicine, as well as in many subspecialties, have frequently been faced with a myriad of choices for management of their patients� conditions. Until very recently, however, the choices we faced in ophthalmology were often limited. When a patient presented with a retinal detachment, the decision was simple: could it be fixed and how soon should the surgery be performed? For diabetic retinopathy: was there edema within a certain distance from the foveal center and when should we schedule the laser if the ETDRS criteria were met? In AMD, the choices were even simpler: was there a well-defined membrane outside the fovea that could be thermally coagulated in the hope that severe vision loss could be prevented?

In the last 15 years, fundamental changes have occurred in the way that we practice ophthalmology, both from the medical and surgical viewpoints. An explosion in therapeutic options has increased the complexity of decision making, as well as placed an added the burden on us to offer appropriate choices for our patients. Something as simple as fixing a retinal detachment now invokes an extensive decision tree beginning with the choice of scleral buckle vs vitrectomy vs pneumatic retinopexy. This is followed by a choice of standard vs small incision surgery, selection of an ocular tamponade, and determining the extent to which epiretinal membrane and ILM tissue should be removed. In the case of diabetic detachments, there is even the issue of whether preoperative pharmacologic agents should be utilized to stabilize the eye prior to surgical intervention. This issue of Retinal Physician focuses a great deal on these surgical dilemmas that confront us today. The information will hopefully be of value to you in your clinical practice.

Making the best choice

So where does that leave us? How do we know what the right choice is for our patients? Perhaps we should all return to old doctrine of �First, do no harm.� Personally, I prefer to use the �family member� approach: Imagine it is your wife/husband, mother/father, sitting in the chair before you and then decide what you would recommend for them and let that guide you in how to select the proper approach for your patient.  Even better, what if you were the one sitting in the exam chair? What would you choose?