From the Editor-in-Chief

Respect

In the complex and dynamic world of retina specialty care, where science meets humanity, the concept of respect plays a pivotal role in shaping the patient–doctor relationship and our overall medical practice. Respect is a multifaceted virtue that encompasses acknowledging the dignity, autonomy, and unique experiences of our patients and colleagues.

In the context of medicine, respect extends beyond mere politeness; it forms the foundation of compassionate and patient-centered care. From my perspective, respect is becoming a lost virtue in our society and our specialty.

One of the fundamental principles of medical ethics is respect for patient autonomy. In this context, autonomy refers to an individual’s right to make decisions about their own health care—including whether to refuse or accept treatment.

Respecting patient autonomy requires retina specialists to engage in open and honest communication, providing comprehensible information while directly involving patients in their decision-making process. In previous paternalistic approaches to medicine, the physician chose the “best” treatment for the patient. This approach simplified the physician–patient interaction by disenfranchising the patient from the decision on how to approach their own health condition.

In practice, respecting patient autonomy requires us to consider the patient’s values, preferences, and beliefs when formulating treatment plans. It acknowledges that our patients are not mere recipients of medical interventions but active participants in their own care.

A respectful approach empowers patients to make informed choices that align with their goals and values, fostering a sense of ownership and control over their health. This approach does not abrogate the physician’s responsibility to the patient and does require precise documentation of the discussion—especially when the patient chooses a nontraditional approach.

In my ocular oncology practice, these discussions can be difficult and fraught with real-world consequences for patients and their families. I am often amazed at my patients’ choices.

Effective communication is at the heart of respectful medical practice. Retina specialists must be proficient not only in conveying complex medical information but also in understanding and addressing patients’ emotional and psychological needs.

Very little of our formal medical training typically is focused on these critical interpersonal skills. Empathy is a key component of this skill set, involving our ability to comprehend and share the feelings of others, thus fostering a connection with our patients.

Photo courtesy of Kevin Caldwell Photography.

Significant focus has been placed on how cultural, racial, sex, and religious differences between a patient and a physician can impact patient care. A clinician should always put the patient first and provide outstanding care, regardless of patient demographics.

To be effective, communication about patient issues must be respectful, involving both active listening and targeted responding focused on maintaining empathy in often-complex situations. This approach helps build trust and rapport—essential elements for a successful patient–doctor relationship. When patients feel heard and understood, they are more likely to actively participate in their care and adhere to treatment plans.

Respect in medicine also requires valuing the diversity of our patients. In Miami, cultural competency is an integral aspect of health care, acknowledging that individuals from different cultural backgrounds may have unique health beliefs, practices, and preferences.

A respectful health care environment is inclusive and sensitive to cultural, religious, and linguistic diversity. Retina specialists and their teams are responsible for providing a clinical environment that includes a diverse team able to address these patients’ unique needs.

Ultimately, cultural competency for us as retina specialists includes educating ourselves on the norms and values of the populations we serve. It also requires adapting health care practices to accommodate potentially diverse needs, ensuring that every patient receives care that respects their cultural background. By doing so, we contribute to reducing health care disparities and promoting equitable access to quality care.

Privacy and confidentiality are critical components of the patient–doctor relationship. This trust in confidentiality is fundamental for patients to feel secure in sharing personal information necessary for accurate diagnosis and treatment.

Our health care team also must be diligent in safeguarding patient privacy, implementing secure information systems, and adhering to ethical standards. When patients know their personal information is handled with respect, they are more likely to be forthcoming about their health concerns.

In the realm of retina care—and for me in oncology—we as health care professionals often find ourselves navigating ethically and emotionally challenging situations. Respect becomes particularly crucial when addressing vision- and life-threatening diseases, discussing prognoses, or managing situations in which treatment options are complex.

I always strive to remember that patients fear blindness and cancer above all other conditions. In these instances, respecting patients’ dignity and autonomy becomes paramount.

Especially when addressing difficult topics, open and honest communication, coupled with empathy, is essential. Respecting patients’ autonomy means involving them in decisions about their care, even when faced with challenging circumstances. This approach acknowledges the value of each individual’s life and ensures that their preferences and wishes are considered, promoting a dignified and compassionate approach to treating both vision- and life-threatening diseases.

The field of medicine is inherently collaborative, involving many health care professionals working together to provide comprehensive patient care. Respect, a cornerstone of effective interprofessional teamwork, fosters symbiosis and a positive working environment. This requires us to recognize and appreciate the expertise and contributions of individuals from diverse health care disciplines.

Respecting colleagues’ input, regardless of their professional background, enhances the quality of patient care. Effective communication, mutual respect, and a shared commitment to patients’ well-being are essential for successful interprofessional collaboration.

This cooperative approach not only improves patient outcomes; it also contributes to a respectful workplace culture. I continue to focus on the importance of supportive specialty care, particularly where no single standard of care exists.

A focal point of collaborative care is to acknowledge that different approaches to care are reasonable in our field. As a benchmark of our differences, I turn to the annual ASRS Preferences and Trends (PAT) Survey, which clearly documents broad differences in approaches to care.

Always be respectful of your colleagues. Rarely do I find a retina specialist who does not believe that the care of their patient is paramount, but often I find major differences within that care.

Although the importance of respect in medicine is widely acknowledged, various challenges may impede its consistent implementation. Time constraints, burdensome workloads, and the pressure to meet performance metrics can create barriers to building strong patient–doctor relationships. Biases and stereotypes also may unconsciously influence health care professionals’ attitudes and behaviors, affecting the equitable delivery of care.

Addressing these challenges requires a multifaceted approach. Health care institutions can implement policies and practices that prioritize patient-centered care, providing resources for ongoing professional development in communication skills and cultural competence. Individual health care professionals can reflect on their own biases and actively work to counteract them, fostering a more respectful and inclusive health care environment.

Respect in medicine is not a mere courtesy; it is a fundamental principle that underpins ethical, compassionate, and patient-centered care. The implications of respect are far reaching, from respecting patient autonomy and cultural diversity to maintaining privacy and confidentiality.

As important, respect for our colleagues and an appreciation of our differences is key within our small society. I believe that this professional lack of respect is most notable in our legal system and is highlighted by our medical malpractice environment.

“Experts” immediately focus on differences in care practices and use these differences not to recognize the diversity of retina specialty care but to suggest that only one approach to patient management is “correct”—and that any deviation from this “standard of practice” represents malpractice.

In navigating the complexities of health care, the virtue of respect serves as a guiding light, shaping the patient–doctor relationship and influencing the quality of care provided.

In This Issue

Mohammed and Thompson ¹ update the application of the 2020 spectral-domain optical coherence tomography (SD-OCT) consensus to the preoperative classification of macular hole and other macular pathologies to determine whether SD-OCT classification can be useful in determining visual outcomes. Overall visual acuity (VA) improved in all 3 groups but declined from 1-year best vision in the lamellar macular hole cohort.

Tran et al ² address the outcomes of scleral buckle in eyes with failed pneumatic retinopexy and noted a surgical anatomic reattachment in 81.5%. Notably, in the failure after scleral buckle, all eyes were attachable with pars plana vitrectomy (PPV). This study adds information on the ongoing impact of scleral buckle vs PPV and suggests that scleral buckle surgery remains a viable option for repair of these initially failed pneumatic retinopexy eyes.

Baxter et al ³ evaluate rhegmatogenous retinal detachment (RRD) in eyes with presumed endophthalmitis and note an incidence of 12.9% in their study sample of 170 eyes. Primary vitrectomy was associated with a greater likelihood of RD compared with tap and inject alone or tap and inject followed by vitrectomy, but these numbers were small and bias to treatment may be a confounder in this series.

Mahmoudzadeh et al ⁴ address the question of outcomes of patients lost to follow-up after either intraocular or periocular steroid injection. In these 67 eyes of 53 patients, loss to follow-up was defined as no ophthalmologic examination for at least 6 months. Notably, no patient required incisional surgery—but only patients who returned to care could be evaluated, eliciting a clear potential selection bias. Patient follow-up remains a critical focus for complex eye disease.

Shaheen et al ⁵ present a pilot study of the impact of ocular perfusion pressure on the foveal avascular zone (FAZ) in 8 vitrectomy-repaired eyes; they found that lower intraoperative mean ocular perfusion pressure was associated with enlargement of the deep FAZ but not the superficial FAZ. As the authors note, multiple local and systemic factors have the potential to impact ocular microvasculature and OCT angiography may be a unique tool to assess these structural outcomes.

Zhu et al ⁶ describe a meta-analysis review of chandelier-assisted scleral buckling for repairing RRD. Overall, the primary surgical success rate was 91.7% in the 30 studies included in the review, but it was as low as 78.2% in Albalkini et al’s 2022 series and as high as 100% in Yan et al’s 2017 report. Chandelier illumination appeared to decrease surgical times but did not increase surgical success over this meta-analysis.

Yao et al ⁷ evaluate the impact of oral prednisone on both preventing and managing proliferative vitreoretinopathy (PVR) after open-globe trauma. In this series of 155 eyes, steroid use in 81 eyes was not associated with lowered PVR risk; in fact, it required more surgical procedures overall than the nontreated control arm. An ultimate VA benefit was noted for the oral prednisone group, but this study highlights the lack of benefit of oral steroids to reduce PVR/RD in these high-risk eyes.

Mansour et al ⁸ report the impact of deep sclerectomy in their case series of 5 patients with retinolenticular touch associated with nanophthalmos. Anatomic and visual improvement were noted with a shift from light perception to a median VA of 20/100. The authors suggest that this surgical approach may benefit adult patients with complex exudative total RD.

In our second case series, Thomas et al ⁹ report 5 patients with cryoglobulin-associated retinal vasculitis. The mean presenting age was 46 years, and the interval from the onset of uveitis to the presence of cryoglobulins was 9 years (although as early as 3 months in 1 patient). This rare presentation was managed with multiple approaches including steroids, antimetabolites, and biologic therapy.

Rai et al ¹⁰ update our understanding of treatments and outcomes in 36 eyes of 18 patients with incontinentia pigmenti. These children (median age, 11 months) were primarily treated with laser photocoagulation, maintaining retinal attachment in all eyes treated prior to RD. The authors correctly discuss the variability of presentation, the importance of examination under anesthesia, and the beneficial impact of laser photocoagulation to peripheral avascular retina. The importance and impact of ultra-widefield fluorescein angiography and antivascular endothelial growth factor (anti-VEGF) injection are both undergoing further studies.

Pereira et al ¹¹ present our first case report of subfoveal choroidal neovascular membrane secondary to idiopathic intracranial hypertension (ICH) in an obese 21-year-old woman who responded to oral acetazolamide for the ICH and anti-VEGF for the subretinal neovascularization.

Harbeck et al ¹² present a 47-year-old man with acute retinal necrosis secondary to varicella zoster virus with the unique presentation of perilesional pachychoroid. The patient required aggressive treatment with oral valacyclovir followed by progression with supplemental intravitreal ganciclovir and then oral prednisone. Laser was prophylactically applied. Resolution occurred over 3 months without complex RD but with resolution of the pachychoroid.

Bonafonte et al ¹³ report 2 cases of atypical large melanocytomas treated with anti-VEGF injections for vascular activity with extended follow-up over 5 years. The authors focus on the inclusion of malignant melanoma and retinal pigment epithelium adenoma/adenocarcinoma in the differential diagnosis and the critical nature of long-term follow-up including diagnostic echography.

Ahmad et al ¹⁴ report severe eye pain in a 41-year-old patient undergoing hemodialysis with known neovascular glaucoma. The authors suggest that severe ocular pain during hemodialysis requires urgent evaluation and targeted treatment. In this case, an intraocular pressure of 59 mm Hg was noted with neovascular glaucoma and the patient received urgent cyclophotocoagulation, intravitreal anti-VEGF, and laser panretinal photocoagulation to the fellow eye.

Abi Karam et al ¹⁵ report an 80-year-old woman with geographic atrophy from age-related macular degeneration who developed an occlusive retinal vasculitis after a single injection of pegcetacoplan. This single case further extends the ASRS Research and Safety in Therapeutics (ReST) Committee report in the January/February 2024 issue of JVRD. In this case, VA declined from 20/80 to 20/200 at month 3 with resolution of occlusive vasculitis and a plan for close observation.

Finger ¹⁶ reports the first use of yttrium-90 episcleral brachytherapy for choroidal melanoma. The 72-year-old patient was diagnosed with a posterior cT1a choroidal melanoma. The small tumor was treated with high-dose brachytherapy requiring an episcleral application time of 3 minutes 39 seconds. At 13 months, a reduction in tumor size and maintenance of 20/20 VA were noted.

Finger ¹⁶ discusses this unique high-dose rate brachytherapy and focuses on the elimination of the second surgery for plaque removal, the ability for outpatient surgery, the guided applicator ensuring appropriate treatment margins, and the potential in reduction of radiation exposure.

Shoji et al ¹⁷ conclude our case reports with a case of cytomegalovirus (CMV) retinitis associated with intravitreal dexamethasone implant injection. This 75-year-old man developed CMV retinitis after multiple dexamethasone intravitreal injections.

The patient, on presentation, was treated with intravitreal ganciclovir and foscarnet along with oral valganciclovir and trimethoprim/sulfamethoxazole. Aqueous polymerase chain reaction testing was positive for CMV, and 3 additional intravitreal injections of ganciclovir and foscarnet were given. At 18 months, the VA was 20/200 with significant macular atrophy.

_________________________________________

In a broader clinical spectrum, these infection cases remind us that novel treatments may incur unique complications. It behooves every retina specialist to respect both the benefits and risks of our treatments for these complex diseases and to remember that untoward events can occur even in the best hands.

As we continue to advance in our medical science and technology, it is essential to recognize that the human element—the interaction between health care providers and patients—is at the core of retina specialty care. Our cultivating a culture of respect not only honors the inherent dignity of each individual; it also contributes to a health care system that is empathetic, equitable, and genuinely patient-centered.

Sir William Osler eloquently stated, “The good physician treats the disease; the great physician treats the patient who has the disease.” Here’s to treating our patients, and our colleagues, with the respect they deserve.

Timothy G. Murray, MD, MBA, FASRS, FACS
Editor-in-Chief
Journal of VitreoRetinal Diseases