Ophthalmic care can extend past eye to whole patient
Click Here to Manage Email Alerts
Leonardo da Vinci said it well: “The eye, which is called the window of the soul, is the chief means whereby the understanding may most fully and abundantly appreciate the infinite works of nature.”
As discussed in the accompanying cover story, the symptoms and signs of many systemic diseases are clearly manifested in the eye. When I attended medical school, after our second year we had to choose a surgery track, medicine track or pediatrics track. I chose a surgical track and therefore primarily rotated through all the surgical specialties. I had 3 months of internal medicine, 2 months of pediatrics and a month of neurology, but most of my clinical experience was focused on surgery.
When I chose to enter ophthalmology, I rotated for a month on the university teaching hospital ophthalmology service. I then organized as an elective to work with a very busy and prominent private ophthalmologist, Malcolm McCannel, MD, for another month. The four ophthalmologists at McCannel Eye were the busiest surgeons in Minnesota, yet I noted that they spent 4 days a week in the clinic and only 1 day a week in the operating room. The same was true for most of the university teaching hospital-based ophthalmologists. I learned that ophthalmology, while a surgical specialty, was first and foremost a primary care clinic-based practice and that a great number of patients were managed in collaboration with the individual’s primary care physician, regardless of age.
When it came time to pick an internship, I abandoned the surgical track and selected a high-quality rotating internal medicine program. With good advice from my mentors, I focused my electives on neurology, rheumatology, endocrinology and cardiology. As I look back 45 years later, that was a wise choice. Every day I am confronted with patients whose systemic diseases affect their eyes, and at least once a month, I find myself making a new medical diagnosis for one of my patients. In the past year these include newly diagnosed Sjögren’s syndrome, collagen vascular disease including lupus erythematosus and rheumatoid arthritis, one case of multiple sclerosis, several with transient ischemic attacks that after referral required carotid endarterectomy, endocrine abnormalities including thyroid disease and diabetes, and even a case of atrial fibrillation, which presented as a macular-sparing right homonymous hemianopsia that fortunately resolved with prompt thrombolysis after emergency transfer to a hospital-based stroke center.
The majority of ophthalmologists spend 80% of their time in the clinic and see 10 to 15 times as many patients in the office as they do in the operating suite. It is important to retain our general medical diagnostic skills and remain vigilant when we see manifestations of systemic disease in the eye. Our near total separation from our colleagues at the hospital has made this more challenging but not less important.
Disclosure: Lindstrom reports he is the founder and attending surgeon at Minnesota Eye Consultants and on the board of directors of Unifeye Vision Partners.