First, Do No Harm
What are your numbers? It is a common question asked by residents interviewing for a glaucoma fellowship. In a field that is becoming more focused on surgery, training in a fellowship with a high surgical volume is enticing. Learning to manage intraoperative difficulties and postoperative complications and to cope with the inevitable stress is an important part of the glaucoma training experience. Likewise, the surge in angle-based procedures presents a new subset of skills that must be learned and mastered. The growing appeal of fellowships with substantial surgical training is therefore not surprising. Alas, an attitude that favors surgical intervention is bred, and therein lies the potential for harm.
My first encounter with Mr. S occurred 2 months into my fellowship. This 58-year-old African American man had been to the clinic many times. Previous doctors had recommended surgery, but the patient had been unwilling to proceed. He was monocular and had a visual acuity of 20/30 with only about 5º of central vision remaining in his sighted eye. The cup-to-disc ratio was 0.99. Mr. S was using timolol, dorzolamide, brimonidine, latanoprost, and pilocarpine. Because of renal disease, acetazolamide had not been prescribed. The IOP measured 20 to 22 mm Hg at clinic visits, and the patient did not know his maximum tonometry readings.
Particularly as a glaucoma fellow looking to increase my surgical experience, my impulse was to operate. It is easy to focus on the number and forget the patient. I told Mr. S what he had heard many times before about the risk of progressive blindness without surgery, but noticing his reluctance, I prodded, “What worries you the most with surgery?”
He opened up to me. “Doc, I live by myself, and I have no family around,” he said. “If I lose my vision with anything you do, my life will be over.”
The patient’s comments resonated within me. Pushing Mr. S any further and convincing him to undergo surgery could open the door to disaster. I took a step back. How did I know his disease was progressing at his current IOP? How high was his maximum tonometry reading? Could medical therapy be increased?
Mr. S and I developed a plan together. We would pursue all medical options first, and at any sign of real disease progression, he would agree to surgery. Furthermore, his comfort level increased after I informed him about social services my institution provides during the postoperative recovery period. I reached out to the patient’s nephrologist, who agreed to a reduced dosage of acetazolamide.
On return visits, Mr. S’s IOP has ranged from 16 to 18 mm Hg. More importantly, he has reported no dimming of vision, and his fields have been stable.
I suspect many physicians can describe cases that, in hindsight, would have turned out better with nonsurgical treatment options or, at the least, if they had ascertained the patient’s social support status in advance. The risk of blindness, temporary or not, with glaucoma surgery is real and significantly affects patients’ emotional state and their lives. Getting to know a patient is the only way to recognize his or her fear and to choose the most appropriate therapy.
Learning how to guide patients through difficult clinical decisions is a challenging endeavor. With fellowship training under the supervision of experienced attending physicians, however, this skill is attainable and, in my opinion, more desirable than high surgical numbers.
Section Editor Albert S. Khouri, MD
• associate professor and program director of the ophthalmology residency as well as director of the Glaucoma Division at Rutgers New Jersey Medical School in Newark, New Jersey
• (973) 972-2045; email@example.com
Arkadiy Yadgarov, MD
• recent glaucoma fellowship graduate of New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York
• private practice in Atlanta
• (404) 257-0814; firstname.lastname@example.org