A common question sheds light on ophthalmologists’ motivation.

Lightbulb or epiphany moments in life are rare. The paths we take are determined gradually and the source of your interests, motivations, and opinions are difficult to pinpoint. However, I can say that I did have a literal and figurative lightbulb moment during residency, after which I had a passion for ophthalmology.

I was following an adult patient with traumatic brain injury, debilitated after years of cognitive regression, who now relied on his sister to perform the most basic life functions. His cataracts were dense — at that time, extracapsular dense cataract. His sister (she served as his power of attorney) was told that he was too high risk for surgery, that he would not do well with anesthesia, that he would not tolerate the recovery, that he probably can see better than anyone thought, and that it would be safer to leave things alone.

After several visits she asked me, “Is he going to go blind?” He was blind, and likely reversibly so. She had noticed over the last several years he smiled less. He was eating less. Despite antidepressants, he was “not his usual happy self.”

I was fortunate to have a chief resident who would agree to push the limits when appropriate. He thought it would be worthwhile to perform an extracapsular extraction given the density, so we did. It was my first start to finish cataract surgery. The next day, when I removed his patch, a lightbulb went on for both of us. I had never seen him smile. But when he saw his sister across the room he lit up, ear to ear, waving at her for what seemed to be several minutes. She would wave back and he would return the favor. They did this even as she wheeled him out of the eye clinic. I realized that this is why we are ophthalmologists.

That lasting memory has molded my career and guides me to this day. His sister’s question, “Is he going blind?” was not unique. It seems as if in glaucoma I hear this from patients on a daily basis. Despite the frequency of the question, I don’t have a preset response. I sound like a broken record when discussing the disease, consenting patients for surgery, and teaching residents and fellows. But I still don’t have a cookie-cutter response to this simple question because it is so personal that it requires an individualized response.

From a population standpoint, fortunately most patients with glaucoma do not go completely blind. However, this is variable and case specific. A young patient with advanced vision loss is more likely to progress to worse than 20/200 vision or a constricted visual field <20o over their lifetime compared to someone in their 80s with minimal disease despite similar intraocular pressures.

In general, we discuss that over 15 years there is roughly a 15% chance of losing vision in 1 eye and a 6% chance of losing vision in both eyes. The rates of blindness from studies can be difficult to interpret as some studies include vision loss from any cause in glaucoma patients. Regardless, the rates of vision loss and/or blindness hover around 5-15% over 5-15 years from diagnosis.^1,2 These are numbers patients can remember. Although beyond the numbers, we must manage the patients’ concerns. It is our responsibility to educate and try to alleviate excessive fear. Despite the statistics, with proper treatment and follow-up the chance of blindness from glaucoma can be reduced — this is why we are glaucoma specialists. GP

References

1. Chen PP. Blindness in patients with treated open-angle glaucoma. Ophthalmol. 2003;110(4):726-733.
2. Stone JS, Muir KW, Stinnett SS, Rosdahl JA. Glaucoma blindness at a tertiary eye care center. N C Med J. 2015;76(4):211-218.

Arsham Sheybani, MD, is an assistant professor of ophthalmology and visual sciences at Washington University School of Medicine in St. Louis, Missouri. He reports consultancy to Allergan, Glaukos, Katena, and Alcon, and speaker's fees from Allergan and Alcon. Reach him at sheybaniar@wustl.edu.