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.

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

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.

13. Treatment

14. Treatment

15. Discussion Utilization of limited health care resources Who makes the decision?