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Approach cases from the patient’s perspective
Taking the time to understand the issues from the patient’s side can go a long way to ease his or her mind.
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Because we have spent so many years studying ophthalmology, the subtleties of our field become second nature to us. We can glance at a person from across the room and instantly come up with a differential diagnosis. Sometimes we can even discern the correct diagnosis from history alone.
We are also able to instantly understand the prognosis of ocular pathology and the potential risks and complications of surgical procedures. Our patients do not have this level of knowledge and it is our job to educate them and share our expertise.
Prognosis of disease
For the past 2 years, a 30-year-old patient noticed a gradual decline of vision in his right eye. The other eye functioned fine, and due to lack of insurance coverage, he decided to defer medical treatment.
What started as a shadow in his vision eventually turned into a partial blockage of his vision and then finally resulted in his vision dropping to no light perception. He did his own online research and figured that he had a cataract that could be fixed without much problem in the future. Unfortunately, he was wrong.
Examination of his right eye (Figure 1) revealed no light perception vision and a corresponding afferent pupillary defect. The anterior segment had extensive rubeosis iridis and a ciliary flush with scant anterior chamber cells. The retina was detached and adherent to the posterior capsule of the crystalline lens, which was relatively clear.
Figure 1. At first glance, it appears that the patient has a whitish cataract (A), but in fact that white structure is the retina up against the posterior capsule of a relatively clear crystalline lens. Further examination showed extensive rubeosis iridis (B) and hyperemia in a ciliary flush pattern (C).
Images: Devgan U
Figure 2. MRI scan shows a bright lesion inside the vitreous cavity of the right eye on the T1 image (A), which then appears dark on the T2 image (B). This bilobed lesion is approximately 10 mm × 15 mm in size and appears attached to the scleral wall. Fortunately, there were no brain lesions detected on this study.
B-scan ultrasound showed a complete funnel detachment with a large mass in the vitreous cavity. An MRI study showed the mass as 10 mm × 15 mm in dimension, bilobed and attached to the scleral wall (Figure 2). After consultation with a colleague who specialized in ophthalmic oncology, it was confirmed that the diagnosis was a choroidal melanoma. Surgery to enucleate the eye was performed, and the histopathology showed an aggressive tumor that began to invade the scleral wall.
In this case, the patient was completely shocked, and justifiably so — we do not normally expect to see these kinds of diagnoses in young and healthy patients. Hours were spent in detailed discussion with the patient and his family. This is a situation where the seriousness of the diagnosis must be conveyed but, at the same time, care must be taken to treat the psychological state of the patient, as well. Consider a team approach involving the patient’s family and block out enough time in your schedule to address all of the issues.
Fortunately, the patient is doing well, and the systemic work-up and consultation with a medical oncologist did not reveal metastasis of the melanoma. Although this case of choroidal melanoma is rare, even more common ocular diseases such as glaucoma and macular degeneration can have serious prognoses and resultant loss of vision. This can lead to loss of mobility and independence and can have a deleterious effect on the patient’s outlook on life.
Risks and complications of surgery
Another patient was referred to me for a complicated cataract surgery. He had been involved in a blunt-force trauma that resulted in subluxation of his cataract, zonular damage and vitreous prolapse into the anterior chamber. Surgery was performed, during which a limited anterior vitrectomy, cataract removal and suture fixation of the IOL was accomplished.
The patient did very well, achieving 20/25 vision with a −0.50 spherical refraction. To ensure that there were no areas of retinal weakness, the patient was sent to a vitreoretinal colleague for detailed examination of the posterior segment after cataract surgery.
Everything looked great, and the patient did well for 6 months. He then noticed a shadow in his vision and a shower of new floaters. The patient waited to see if it would resolve on its own; however, after his vision declined to the count-fingers level, he decided to go back to the retina doctor for evaluation.
The patient presented with a macular-off rhegmatogenous retinal detachment with a peripheral horseshoe tear. A combined vitrectomy and scleral buckle was performed and the retina remained attached, but only for 1 month. He had a redetachment and then underwent silicone oil placement.
The risk of a retinal detachment in this case is higher than for a routine cataract surgery, but it is still relatively low, particularly when the patient was confirmed to have a normal retina without breaks a few weeks after the primary procedure. However, complications like this do still occur, and even if the risks are one in 500, if your patient is that one patient, the odds do not matter.
This patient asked me, “Why would this happen to me?” There is no great answer other than complications happen. Although we try our best to avoid problems, every surgery has some element of risk, no matter how small. Even avoiding surgery altogether is not risk-free, as this patient could have still suffered detachment as a complication of his original trauma.
I feel for patients, and I try my best to see things from their perspective. I was fortunate to have great mentors during my training and their words still echo in my mind as I interact with patients today. Sometimes, there is no explanation for why a patient is struck with a grave diagnosis or a complication from surgery.
The physician can empathize with the patient and simply say, “I’m sorry that you’re in this tough situation, but just know that I am here to help you any way that I can.” We should also remember that one day we will all likely be in their shoes, listening to our physicians explain the diagnoses, risks or prognoses of our own personal medical and surgical challenges.
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