Ophthalmic Surgery and Lasers

Ophthalmic Surgery and Lasers

[About Ophthalmic Surgery and Lasers ] [Table of Contents]

Volume 31 (2) * March/April 2000 * Editorial (full text)

The Operation was a Success, But the Patient Died

George L. Spaeth, MD

It is easy to forget what we are trying to do as physicians. We are not trained to keep focused on our primary task. In fact, many of us get through medical school, residency, and fellowship, without having our primary task pointed out to us. Of course, we knew it when we went to medical school, but since it is rarely mentioned during medical school training and is almost never mentioned during specialty training, we forget. The consequence of forgetting is unnecessarily poor patient care. Two patients seen by me recently reminded me of this.

The first was a 56-year-old business executive. He had been seen by his ophthalmologist for his routine annual checkup and was noted to have optic nerve changes that were thought to be glaucomatous. A visual field examination was performed and showed, what was interpreted as probable nasal loss in both eyes. The patient was started on Alphagan in both eyes. When the pressure did not fall from its original 15 mm Hg in each eye, Xalatan was added. When it still did not fall, Timoptic was added. When it still did not fall, a laser trabeculoplasty was advised. At this point, the patient came to me for a second opinion. The vision was 20/20, the pressure was 14 mm Hg, and the anterior chamber angles were normal in both eyes. The discs had large cups and the width of the rim of approximately 0.2 inferiorly and 0.1 superiorly and temporally. There was no pallor, notching, hemorrhage, or other specific abnormality of glaucoma. A repeat visual field examination with a proper correction in place showed no loss in either eye.

The second patient is an elderly woman, who was found to have an intraocular pressure of 25 mm Hg in one eye and 26 mm Hg in the other. A diagnosis of glaucoma was made and she was started on treatment. Initially, she was given Timoptic 0.5% in both eyes twice daily. The pressure did not seem to change so Propine 0.10% twice daily was added. Again, there seemed to be no change in pressure. Consequently, Iopidine three times daily in both eyes was added. The intraocular pressure did not seem to change. Consequently, Xalatan once daily at bedtime was added. The pressure seemed to fall to about 22 mm Hg, but was not judged low enough. Consequently, pilocarpine 1% four times daily was added. The pressure fell to 18 mm Hg and the patient was continued on all of those medications. The eyes became inflamed and uncomfortable and, consequently, Patanol four times daily was added. The eyes continued to be uncomfortable and the patient came to see me for a second opinion. The pressure was around 19 mm Hg in each eye. The fields were full. The optic discs were healthy appearing with small cups, without notches, hemorrhages, or other signs of glaucoma. Over the next six weeks medications were gradually reduced from each eye until she was on no therapy. On no therapy, the intraocular pressure was around 25 to 26 mm Hg, which was judged to be satisfactory for her, given the health of her nerves and the life expectancy of around 10 years.

The operation was a success, and the patient died.

In both of these instances the patients received care that was less than optimal because the physicians forgot what the purpose of their care really was. Their job was not to lower the intraocular pressure. Their job was to enhance, or maintain, the health of the patient. In both situations the health of the patient was made worse by the therapy.

In summary, it is essential to remember that our primary responsibility to our patients is to enhance or maintain their health.

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Copyright 2000, SLACK Incorporated. Revised 14 March 2000.
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