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Residents & Fellows Corner | Sept/Oct '20

More Than the Eye Can See

An early exposure to the other side of clinical ophthalmology.

She has advanced glaucoma and might need surgery in the future, so it would be better not to use a multifocal IOL,” the glaucoma attending said. “Her pressures are on the higher side, but we can’t use timolol because of her asthma.”

This was not an ophthalmologist-to-ophthalmologist phone call about any ordinary patient. The patient being discussed was Sarah, my mother’s best friend whom I have known since I was 3 years old and who often comes to me with medical questions. Eight years ago, she began seeing a glaucoma specialist, who explained to her that years of steroid use for her uncontrolled asthma had contributed to her glaucoma and that her disease was advanced.

Like all patients with glaucoma, Sarah had to try to come to terms with her diagnosis and embark on a lifelong journey with a chronic eye disease. Although difficult, her experience has guided me as I progress through my ophthalmology residency. Having a close family friend with glaucoma has taught me to focus on addressing three important questions that typically fall outside of the clinical examination but that directly relate to the patient’s journey with this complex disease.

KEY QUESTIONS TO ADDRESS FOR COMPASSIONATE GLAUCOMA CARE

To Answer: “How did this happen?”

Even ophthalmologists often cannot explain why some patients develop glaucoma and others do not. When Sarah was initially diagnosed, she was in disbelief and sought multiple opinions before accepting her diagnosis. Sarah is someone who takes meticulous care of her health, and talking about her disease often makes her sad. She knows that there is little she could have done to prevent her steroid-induced glaucoma and that, ultimately, she does not have as much control over the disease as she does over other aspects of her health.

Many patients with glaucoma share these feelings of sadness and lack of control over the development of the disease. Educating these patients about their illness can help them to cope with their diagnosis and may motivate them to take care of their eyes. When I detect anxiety in a patient, I take extra time to check in and help him or her cope with this progressive disease.

To Answer: “When will I lose my sight?”

I have found this question to be the trickiest to address with patients. It is a question that I have asked of Sarah’s physicians in the past, and it is one that patients may be afraid to ask because, for many, loss of vision means a loss of independence and a decrease in quality of life. Discussion of this subject requires a good dose of honesty. I always strive to help patients understand that, even as their vision declines, I will do my best to help them maintain their quality of life. Further, a loss of vision does not mean that a patient cannot be helped. Counseling patients on low-vision services and helping them understand how I can best improve their remaining vision to fit their individual needs has become an essential part of my practice in residency.

To Ask: “How are you taking your drops?”

When Sarah was first diagnosed with glaucoma, her life began to revolve around her medication regimen, as is often the case with chronic diseases. Observing the difficulties she experienced in acquiring her drops, administering her drops on time, and dealing with various side effects has helped me understand the burden that is placed on patients with glaucoma who are tasked with administering eye drops multiple times per day indefinitely. For patients like Sarah who have realized the true implications of having a progressive eye disease, any therapy that can stop or slow progression becomes vital to their future quality of life.

Seeing Sarah struggle with her medications changed the way I approach the topic with my own patients. I always ask them to tell me exactly how and when they are instilling their drops; whether they are able to obtain their drops from their pharmacy; and, most importantly for older patients, who is administering their drops. I have learned that my job is not necessarily to prescribe the newest or most potent drops on the market but rather to give patients the product that will work for them, whether that is one that requires less frequent administration or one that is less potent but also less irritating. The goal is to remove as many barriers as possible so that the patient will use his or her medication as prescribed. I have learned through Sarah’s experience, and now through the experiences of my patients, that I am treating the whole person, not simply lowering his or her eye pressure.

TREAT THE WHOLE PATIENT, NOT JUST THE DISEASE

As an ophthalmologist, I am first and foremost the patient’s physician. Thus, in treating a chronic condition such as glaucoma, I try to treat the overall illness and not just the biological disease. This involves trying to my best to address the external factors that inhibit patients’ access to proper care, educating patients about their disease, and helping them understand their prognosis. Watching Sarah’s journey with glaucoma has helped me develop a better understanding of the true impact that chronic eye diseases can have on a patient’s life. I have realized that a small investment of my time may have a major impact on a patient’s ability to care for his or her disease. My goal as a physician

author
Rabia Karani, MD, MPH
  • Ophthalmology Resident, Harkness Eye Institute, Columbia University Medical Center, New York Presbyterian Hospital, New York
  • rabiakarani@gmail.com
  • Financial disclosure: None
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