May 2010

 

OPHTHALMOLOGY NEWS

 

All patients welcome?


by Matt Young EyeWorld Contributing Editor

   

Given that people living with HIV are leading longer and healthier lives, what implications does this have on whether they are refractive surgery candidates? A new study, published in the January 2010 issue of the Journal of Cataract & Refractive Surgery, suggests the issue is a complex one. There are many surgeons performing refractive surgery on HIV-positive patients. There are fewer doing so on patients with AIDS. The Food and Drug Administration (FDA) has not traditionally supported the concept. But litigation has caused at least one physician who denied care to an HIV-positive person to settle. “There is a lack of consensus among refractive surgeons regarding practice patterns for elective refractive surgery in persons with HIV or AIDS,” according to lead study author Ahmad A. Aref, M.D., Penn State Hershey Eye Center, Penn State College of Medicine, Hershey, Penn. “Lack of a standard of care may have medical and legal consequences for the physician and patient.”

Dr. Aref’s study, therefore, is important in examining the landscape of this tricky issue and hopefully guiding physicians to, if not standardized decisions, personal ones that are better informed.

The results

Dr. Aref surveyed members of the International Society of Refractive Surgery to determine whether they considered people with AIDS acceptable candidates for elective refractive surgery and whether any precautions were taken for the operations. Of 285 respondents, 143 (50.2%) said they considered people with HIV (without definitive AIDS) to be acceptable candidates for elective refractive surgery. Meanwhile, 94 (33%) considered HIV-positive patients to be relatively contraindicated for surgery. And 46 (16%) considered HIV positivity an absolute contraindication. U.S. practitioners were somewhat more liberal in their consideration of HIV patients. Among these surgeons, 109 (58%) considered HIV-positive people to be acceptable candidates for elective surgery. A further 54 (29%) considered HIV a relative contraindication. And 26 (14%) deemed HIV to be an absolute contraindication. Interestingly, factors associated with considering HIV-positive patients acceptable candidates included more surgical years in practice and a greater clinical surgical volume. “The odds of considering HIV-positive individuals acceptable candidates for elective refractive surgery were 2.2 times higher for surgeons who practiced in the U.S. or Canada than for those who practiced outside this geographic region … 2.3 times higher for surgeons who had been practicing for more than 10 years than for those who had been practicing for fewer than 5 years … and 3.7 times higher for surgeons who performed more than 1000 refractive surgeries a year than for those who performed fewer than 100 refractive surgeries a year,” Dr. Aref reported. In considering AIDS patients for refractive surgery, U.S. ophthalmologists did not differ much from their international colleagues in that only a small minority considered this acceptable. However, other factors did matter. “The odds of considering individuals with AIDS acceptable candidates for elective refractive surgery were 3.7 times higher for surgeons who had been practicing for more than 10 years than for those who had been practicing fewer than 5 years … 3 times higher for surgeons older than 60 years than for surgeons aged 35 to 45 years … and 2.9 times higher for surgeons who performed more than 1000 refractive surgeries a year than for those who performed fewer than 100 refractive surgeries a year,” Dr. Aref noted. Of those who considered HIV positivity a relative or absolute contraindication, they reported they were concerned about virus transmission to the surgeon or operating room staff, virus transmission to other patients, and post-op complications including post-op keratitis, delayed wound healing, and dry-eye-related complications. Ophthalmologists looking for guidance from the American Academy of Ophthalmology (AAO) or the FDA, meanwhile, may not find what they are looking for. “The AAO Preferred Practice Pattern for Refractive Management & Intervention does not mention HIV positivity or immunodeficiency as a contraindication to refractive surgery,” Dr. Aref noted. “The U.S. Food and Drug Administration, however, lists patients with immunodeficiency as an absolute contraindication to all approved excimer laser devices and advises patients that ‘certain conditions, such as immunodeficiency states (e.g., HIV), may prevent proper wound healing after a refractive procedure.’”

The issue is complicated further by potential legal consequences of refusing refractive care to HIV-positive patients. “In October 2003, a complaint was filed with the Colorado Civil Rights Division by a patient who was denied consideration for refractive surgery based on his HIV-positive status,” Dr. Aref noted. “The patient’s attorney claimed that there was no medical evidence to support the surgeon’s decision to refuse to perform the procedure and cited the Americans with Disabilities Act, which requires physicians to perform an individualized health assessment before refusing a patient service, as further support for his argument. The case was settled under undisclosed terms in 2006.”

For those concerned about HIV transmission to surgical staff, Dr. Aref cited research suggesting “an HIV-infected patient is unlikely to pose a health hazard to the surgeon.” Scheduling an HIV-positive patient last on a day’s surgical schedule was suggested as a precaution to prevent transmission to other refractive patients. William B. Trattler, M.D., cornea specialist, Center for Excellence in Eye Care, Miami, meanwhile, said every patient should be treated the same way. “We don’t treat patients any differently if they have HIV,” Dr. Trattler said.

He noted that not all patients with HIV even know they have it. “Certainly, some patients may disclose that they have HIV,” Dr. Trattler said. “Others may have HIV and have no idea. So really we have to treat every patient the same way.” Because a complete and sterile cleaning of all instruments after surgery is required, Dr. Trattler said there is no risk of transmission from one patient to the next.

Editors’ note: Dr. Aref has no financial interests related to this study. Dr. Trattler has no financial interests related to his comments.

Contact information

Aref: ahmadaref@gmail.com
Trattler: 305-598-2020, wtrattler@earthlink.net

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