Mrs. Brown is just 55 years old, but the vision in her only seeing eye is deteriorating. Perimetry shows a constricting island. Does she regret not having had an eye examination years ago? Should she blame herself for not having had health insurance that would have covered an eye examination earlier? Whatever the case, I admire that she accepts that the past is the past.
“Mrs. Brown, I think we're looking at surgery again,” I say. I cannot fault her for having a different reason for declining each time I make this comment. Today, it is her daughter's wedding. Her worry about the possibility of another surgical complication is understandable. Her last surgery, implantation of a Baerveldt shunt (Abbott Medical Optics), went perfectly. Postoperative IOP control was excellent, and it looked like we finally had the bull by the horns. Then, a rare complication occurred: a fibrin clot, treated with the Nd:YAG laser, led to iris obstruction of the tip of the tube. Eventually, the tube had to be explanted. That was her third glaucoma surgery.
I wish Mrs. Brown the best for the wedding, but when she returns to the clinic afterward with elevated IOP, we plan for the inferonasal implantation of an Ahmed Glaucoma Valve (New World Medical).
HUMILITY AND PRACTICE
I recall watching Wimbledon with my dad as Björn Borg was crowned champion. I remember my dad's telling me that what made Borg special was not his innate talent but his humility, which led him to practice and mentally rehearse every point of the match. Years later, I connected with my residency chairman, Jeffrey Henderer, MD, over our common fondness for Borg and his effortless grace. Dr. Henderer reiterated this principle of preparedness. The night before Mrs. Brown's case, I try to emulate Borg by rehearsing in my mind the steps and pitfalls that might arise.
Beside me in the OR the next morning is another great mentor, George Cioffi, MD. As we look at Mrs. Brown's eye under the microscope, we see the scars of past battles fought and lost. Every aspect of the case deviates from the script. The conjunctival exposure is minimal, the scarring and bleeding are excessive, and the corneal limbal scarring inhibits good visualization. I come to realize the full value of good training and the importance of the humility of which my dad and mentors spoke.
Dr. Cioffi had advised me, “Pass a thousand sutures. Pass them backhanded, with your eyes closed, with your left hand. Practice.” Today, although the tissue seems so scarred and friable, with a steady touch, one stitch at a time, we are able slowly to close up the conjunctiva.
CONCLUSION
So far, Mrs. Brown is doing well. Her IOP is controlled, and she has avoided any notable complications. Although this battle was won, given her young age, the war is far from over. Still, I feel a deep satisfaction from knowing that we were able to help her. Moments such as this one contribute to the most enjoyable and rewarding year of my career. I am grateful to my glaucoma mentors, Drs. Henderer and Cioffi as well as Lama Al-Aswad, MD, and Dana Blumberg, MD, MPH. Most of all, I am thankful for people like Mrs. Brown who remind me of the importance of human connection and inspire the courage to enjoy life no matter the setbacks.
Section Editor Albert S. Khouri, MD, is an assistant professor and program director of the ophthalmology residency, and he is an associate director of the Glaucoma Division at Rutgers New Jersey Medical School in Newark, New Jersey. Dr. Khouri may be reached at (973) 972-2045; albert.khouri@rutgers.edu.
Alex B. Theventhiran, MD, is affiliated with New York-Presbyterian/Columbia University. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Theventhiran may be reached at abt2001@cumc.columbia.edu.
