reflections THE HUMAN SIDE OF OPTOMETRY
Caught in the Act
A routine exam turns into a life-saving experience.
BY ADAM P. RUBIN, O.D., GAITHERSBURG, MD.

When a nine-year-old boy came into the office complaining that he hadn't been seeing too well out of his right eye for about two weeks, a lot of possible diagnoses ran through my mind. When Jimmy's mother, Mrs. Summit, said she thought he was "okay because I've been testing his vision around the house," I was not too concerned. Jimmy had experienced bouts of headaches several months earlier, but after thorough testing, including a CT scan, his physician attributed the headaches to sinus problems. Therefore, I thought that this would be a quick, routine exam; perfect for 5:30 p.m. after a long Monday. Besides, I'd examined Jimmy's eyes last fall and everything then was completely normal.

	PHOTO BY ANDERSEN ROSS

A not-so-routine exam

However, behind the phoropter, I couldn't correct Jimmy's right eye, while he could easily read the 20/20 line with his left. I figured the phoropter wasn't aligned properly or Jimmy wasn't sitting up straight so I tried again. He still couldn't see the big E. Next I used loose lenses, but still no improvement -- just counting fingers. Immediately I checked his pupils. There was an unmistakable positive right afferent pupillary defect. Then I looked at his optic nerve heads and found pale nerves, worse in the right eye than in the left.

Bringing bad tidings

Based on the case history, I presumed that Jimmy would possibly be slightly myopic in the right eye, and I would have to break the news to him and his mother that he might occasionally need glasses. Or maybe I'd find perfect vision, and I would just need to reassure Mrs. Summit. Instead, I had to tell them some difficult news.

I told Mrs. Summit that I was concerned about her son and moreover, that although I wasn't sure exactly what was wrong with him, there was a serious problem behind his eyes that needed immediate attention. She could tell by the tone of my voice that I was worried and pressed me on what the exact diagnosis was. Not wanting to scare her, I told her that we would have to wait for that. I set up an appointment with a neuro-ophthalmologist for the next day.

I suspected the worst and I went home thinking about Jimmy. Within the week he had a visual field, MRI and brain surgery. He was diagnosed with a craniopharyngioma, a benign tumor located near the pituitary gland, in which the survival rate is approximately 85% with complete resection or surgery and radiation.

Early diagnosis pays off

After spending nine days in a children's hospital, Jimmy is back in school and on his way to recovery. Because the surgeon couldn't remove the entire tumor, Jimmy's now undergoing radiation. Unfortunately, craniopharynigiomas can recur, so Jimmy's doctors will monitor him carefully for the rest of his life. These days, he's tired. But he can walk, talk, see and he spent Thanksgiving with his family.

I'm thankful that Jimmy forced his mom to bring him in. And I'm thankful that I could help them. I'm also thankful that this career we've chosen can prove rewarding.

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. OM OFFERS AN HONORARIUM FOR PUBLISHED SUBMISSIONS.