reflections THE HUMAN SIDE OF OPTOMETRY
The Ones That Get Away
Take time to listen -- not only to the patient, but to your own intuition.
BY ANDREW S. GURWOOD, O.D., F.A.A.O., AND DENISE L. WHARTON, O.D

He was a 63-year-old black mailman. His chief complaint was blurry vision at near. All ocular and systemic histories were unremarkable and he denied taking medications. His best uncorrected distance visual acuities were 20/20 at distance and his corrected acuities at near (through his +1.75 reading glasses) were 20/20 at distance and near. Biomicroscopy revealed normal anterior segment structures and applanation pressures measured 16 mmHg, OU. Dilated fundoscopy demonstrated healthy grounds and normal peripheries with increased cupping (.7/.7) in both eyes.

That said, I don't know what made me do it. I'm familiar with literature reporting that those of African descent have a greater incidence of larger, disease-free optic nerve cups than Caucasians. This man's intraocular pressures seemed reasonable, yet something inside kept saying, "Get the field today." I did.

The defect I uncovered was a congruous, right-superior, wedge-shaped quadrantanopsia. I ran the test again, but this was real. I'd seen a field like this before in a textbook and it represented damage to the lateral geniculate body via cerebrovascular accident (stroke).

I referred him to our neuro-ophthalmic specialist, who soon confirmed the diagnosis: Cerebrovascular accident with significant carotid artery stenosis on both sides. The specialist said I saved the guy's life.

	ILLUSTRATION BY JOHN PATRICK

Pay attention to the seemingly irrelevant

A 65-year-old man presented for a follow-up visit concerning his previously diagnosed nonproliferative diabetic retinopathy OU. During the history, he explained that he was having trouble with his hemorrhoids. I gave him the number of a proctologist and encouraged him to call, which he did from my office. He scheduled an appointment and the resulting exam exposed the beginnings of colorectal cancer.

A 54-year-old black woman came in for her yearly exam with a chief complaint of intermittent blurred vision at distance and near OU. With the exception of systemic hypertension, the remainder of her history, external and internal exams, refraction and dilated fundus exam were uneventful. Acting with nothing more than an urge to be complete (and so I could sleep at night), I decided to run an automated threshold visual field to rule out potential neurologic sequelae.

The visual field demonstrated an early, incongruous bitemporal hemianopsia more dense from the top down -- a classic chiasmal field. The neuro-ophthalmic specialist to whom I referred her uncovered a prolactin-secreting pituitary macroadenoma. Her symptoms subsided and her fields normalized after its surgical removal.

Catching what you can

We've come to believe that similar stories are common. In this upside-down world where healthcare management systems cater to the healthy, practitioners are virtually strong armed into choosing increased exam speed and increased patient volume to keep pace with inflation. Given that both have the potential to undermine quality, it makes us wonder how many of our colleagues could tell similar tales about "the one that almost got away." It also makes us sad -- because the victories we've won in the cases that almost got away are dampened by the prospects of the ones that did.

DO YOU HAVE A MEMORABLE EXPERIENCE YOU'D LIKE TO SHARE? DISCUSS YOUR STORY WITH RENÉ LUTHE, SENIOR ASSOCIATE EDITOR OF OPTOMETRIC MANAGEMENT, AT (215) 643-8132 OR LUTHER@BOUCHER1.COM.