A Tale of Two Cities

The frail, elderly man, who came to my office with his frail, elderly wife, knew he had lost most of his sight due to glaucoma and that his vision was continuing to fade. I wondered whether he could tolerate surgery, and that it would be very hard – perhaps insurmountably – for him to return for postoperative visits. He had already had two laser trabeculoplasties performed by the referring ophthalmologist. I advised him to add another drop to his regimen. When he returned a month later, his intraocular pressure seemed about the same; he had not noted any improvement in vision. He was not using the new drops. Why are you not using the new eye drops?” I asked in, I fear, a critical tone. “Well,” he answered softly in a scratchy voice, “It was either buying food or buying drops.”How could I have been so unaware, so totally living in the City of Doctors, unaware of his life in the City of Patients? 

The resident told me about the patient he had just examined, mentioning that we needed to lower the IOP further, as it was above TP and the patient had a thin CCT (speaking in the strange language only heard in the City of Doctors: LMD, OD, OS, c/d, NVG, OCT, CRVO, NVI). I asked, “how do you know the target pressure is correct?”  He was quiet. I asked “What difference does it make to that patient that her cornea is thin?” Of course, the compliance of the cornea affects the tonometric measurement of the IOP, but precisely by how much, is not known. Yes, studies have shown that groups of people with thin central corneas are more likely to have visual field deterioration than groups with thicker corneas, but there is no knowledge that a particular person with a thin cornea is more likely to become symptomatic than a person with a thick cornea. How can we doctors be unaware of that? Of course, the idea of personalizing the level of eye pressure that might possibly be fine for a patient is an advance over just using the standard distribution curve, but target pressures are just a useful guess – a “guesstimate.” How can it be that today we are unaware that the best way to establish stability versus deterioration of health is by documenting stability or deterioration of health?

I dread going to medical meetings where I hear about the latest, greatest surgery or medication, where I am titillated by totally confident surgeons demonstrating their techniques in videos enhanced by Mozart’s 23rd piano concerto. I dread being told authoritatively that patients need to have hysteresis and the flow of blood measured with OCT-A. There are other positions also presented, such as that of a truly thoughtful colleague talking about “AS-OCT.” Afterwards, I asked him privately, “How can you recommend anterior segment OCT when you know it’s a poor substitute for gonioscopy?” “But George,” he replied, “AS-OCT is better than nothing. You know few doctors gonioscope their patients routinely, and even if they do, they often are unsure what they’re seeing.” Of course, he is right. But is the solution to that problem to start using an expensive test that is not as good? Or should we learn and perform gonioscopy well?

At the same meeting, a young doctor presented a paper noting that half of the patients developing angle-closure glaucoma had apparently been  gonioscoped during the two years prior to their attack. He wondered why the doctors apparently were not concerned about the angle appearance. And I know from the patients with both open-angle and angle-closure glaucoma I see in my office (and in the clinics at the many medical schools) that the anterior chamber angle evaluation is often made by physicians unaware of their relative incompetence at gonioscopy. 

The graph in the refereed journal article indicates that when the intraocular pressure is lowered to a mean of 12.3 mmHg (Group A), there is no loss of visual field after 84 months in patients with “glaucoma,” but when the mean pressure is 20.2 mmHg (Group D) there are 2.32 units of field loss (1). But who is aware that is a misrepresentation of what happened? Fourteen percent of the subjects in Group A actually lost as much field as the average amount of field lost by kksubjects in Group D (the group with the higher pressure), and the fields of half of those in Group D did as well as those who had stable fields in Group A with the lower pressure. That must be known. Who is aware that the range of field loss in this study is 1–20 units? So, the group doing “worst,” lost an average of 3 out of 20 units of visual field in seven years. Is that amount enough to make people more symptomatic? For some probably “yes,” and for some probably “no.” Are we treating pressure or Mean Defect or a particular person?

We, eye doctors, carry on, often not hearing what needs to be heard, or not examining well what needs to be examined, sometimes testing what does not need to be tested and not testing what should be tested,  sometimes not treating what needs treatment or treating what does not need treatment, unaware of our unawareness – because we soldier on, living in our isolated City of Doctors. When we were college students, we chose the challenging career of a physician because we wanted to help people feel better; that desire has been supported by good studies. What causes the transformation from that intention to focusing on findings such as central corneal thickness and target pressure, and becoming unaware of the person? By the time we start medical practice too many of us have left the City of Patients for the City of Doctors. Why do some of us we become unaware we are following a standard of care irrelevant to many of those living in the City of Patients?

 It is as if we are caring for ourselves.