A disease or health condition is the doctor’s initial care delivery compass, guiding us through the health care forest. We often have an accurate assessment of the patient’s problem within minutes of the initial encounter. I frame my thinking before entering the exam room by first stratifying the individual into a familiar patient subpopulation – one that over time I’ve recognized follows an evidential course with some predictability. While this initial strategy gives focus, I’ve learned never to assume ‘usual care’ associated with a particular cohort will mirror a relevant clinical guideline or established chain of events. I’ve learned to suspect the outlier. One powerful experience honed these clinical and critical thinking skills.
I’m an eye doctor who specializes in chronic vision impairment. I care for people with vision loss whose surgical, therapeutic, and other conventional options are exhausted. I diagnose the impairment, quantify remaining vision, and recommend treatment options so patients can best use remaining vision for optimum function through highly specialized optical systems and other prescribed treatment. I provide care to maintain critical activities like reading small text, self-managing medications, and mainstreaming with classroom peers. As a mentor told me, “the buck stops with us”. I await patients with help at the end of the road. It’s an incredibly rewarding eye specialty and the best kept secret in health care.
Sadly, my clinical world has no dearth of underlying causes of chronic vision loss. Macular degeneration. Diabetic retinopathy. Vascular disease. Retinopathy of prematurity. Glaucoma. Stroke. Cerebral palsy. Optic neuropathy. Cardiovascular disease. Systemic or ocular infection. Endocrine disease. Multiple sclerosis. Cancer treatment side-effects. And traumatic brain injury, just to name a few. As a doctor dedicated to treating chronic vision impairment for over 25 years it’s difficult to identify something I haven’t encountered, including injury from firearms.
I still can vividly recall one patient who survived a gunshot injury to the head. He had been referred by his neurologist early in my private practice days. According to the doctor, I was his “last hope”. He walked with a limp but without assistance. He had full use of one arm and hand. One eye was intact. He had sustained a shot to the left side of his head at eye level, destroying the globe on that side along with surrounding orbital, cranial, and sinus structures. Most of his pinna was preserved, but the injury had inflicted related neurological and visual system damage in addition to other sensory impairment. Since his injury he had undergone a myriad of reconstructive surgeries attempting to normalize his face and cranium.
During the examination, I diagnosed his deficits, examined the remaining eye, and quantified the status of his visual system. Together we discussed recommendations for treating his complement of vision impairments – he had a loss of visual acuity and restricted visual field, decreased contrast sensitivity, a loss of oculomotor function due to cranial nerve paresis, and sensitivity to light from a blown (a.k.a. fixed and dilated) pupil, among other changes. He had seen a multitude of doctors and had an extensive health care team, but I was the first team member to tackle the issue of how his vision and function related to vision could improve.
His care and treatment plan were not unusual. Prescription safety lens to address his irregular refractive error and protect his remaining eye and vision. Prosthetic contact lens with custom designed pupillary aperture to replace lost pupil function and control the light entering his eye. An R seg (bifocal) microscopic system for returning him to reading newspaper-size text and providing comfortable orientation vision. A bioptic telescopic system to distinguish faces, see distance targets, ambulate safely, and comfortably watch TV. Field enhancement to improve his environmental mobility. Therapeutic filter in lens form to selectively absorb wavelengths of light causing him glare and discomfort and improve light-to-dark-to-light adaptation. Clinical therapy targeting his oculomotor dysfunction. Ongoing integrated follow-up care to monitor his physiological and psychological health and progress. Over time, along with his initial priorities and preferences, our shared clinical decision-making discussions took all into account. I can still see his smile when he realized he could live seeing better than how he did when he first entered my office.
He and I worked hard, and over time addressed his needs with clinical solutions. Together we made good progress over several years in meeting targeted outcomes, until he moved out of state and I referred him to one of my colleagues in the new area to continue his care. But progress didn’t come easy to either of us – he struggled through his multi-faceted recovery, and I struggled to meet his eye and health needs. I learned a great deal from him regarding the science and art of my clinical care, what I could and needed to do, and how best to use my skills in integrating his care. We were keenly aware of the visual and health benefits he would realize from the treatment I prescribed, including the spectacle-mounted systems and optical technologies to meet his individual needs. These outcomes were clear and clinically attainable, and even after 20 years the details remain vibrant in my mind.
Engineering his treatment options, however, emerged as my biggest challenge. The issue that became the tipping point in his care involved frames. In the clinical treatment of vision impairment, a spectacle frame has immense importance. It serves as the ‘carrier’ and key component of the final prescription and specialized optical system it supports. The frame allows me to incorporate additional important options for patient-centered treatment. Developing the proper systems for this patient became a barrier to his success, and this experience taught me to overcome through tenacity and resourcefulness. I’m certain his other doctors didn’t fully appreciate the gravitas of this important piece of his story, but as an eye doctor on the health care team I certainly did. His injury was also responsible for the loss of something often taken for granted, and certainly not the first thing most would identify as a treatment priority after injury from a firearm.
The gunshot had left him without a nose. He was without a nasal bridge, or any functional structure on which to position a spectacle frame bridge or nose pad. There was no possibility of further reconstructive surgery in his immediate future. His only eye and remaining vision were vulnerable, and his highest priority needs were in spectacle form. He had survived a life-threatening situation, yet he still faced the mortality of his eyesight. His health care, path to rehabilitation, and ongoing recovery would continue to evolve around the devastating impacts left from his injury. He forced me to find new ways of modifying almost every needed treatment option to attain desired outcomes and ensure his visual welfare. And I’ve since become a better navigator of many different forests.