Article Date: 1/1/2006

reflections - the human side of optometry
When You Can't Fix It
Being a doctor can sometimes mean being helpless in the face of tragic news.
ROGER BLANK, O.D., VERNON HILLS, ILL.

Last Thursday started as a typical day filled with general exams for glasses and CLs. Then towards the end of the day in comes a just-turned 40-year-old white female that I had last seen two years ago. She was diagnosed with breast cancer two and a half months after that last visit. She went the whole distance with partial mastectomy, radiation and chemotherapy. A year later she is doing well, just on tamoxifen (Nolvadex, Astra Zeneca). No other health issues.

Lisa is a petite, pretty preschool teacher with an upbeat attitude and a quick smile. Chief complaint: distortion in vision in O.S.

She said that she wasn't in pain and that the problem had started about six days earlier.

"Is it getting better, about the same, or getting worse?"

"Getting worse." (My stomach becomes queasy.)

Visual Acuity was 20/20-1 O.D.; 20/30-2 O.S. Direct ophthalmoscopy showed a grayish haze in the left eye temporally. (My queasiness is worsening.) Her best corrected visual acuity was 20/20 O.D.; 20/25-1 O.S., but letters and chart are slanted.

Dilated Fundus Exam: I'm searching periphery for a retinal detachment. Nothing. Optic nerve: no problem. Posterior pole: foveal reflex is present, but so is a huge, gray-white, fuzzy, oblong lesion just inferior, temporal to the reflex, about 7dd in size and bulging up 3-4dd.

No easy way to say it

Never a good poker player, I feel my face draining of color. I hung up my headset, flicked on the lights, sat in my chair three feet from her so we are eye to eye ... and became speechless. I've been practicing for 24 years and I'm speechless. I had really expected to see a retinal detachment, so my mental script had to be rewritten. She looks at me, knows something is wrong. Then she reaches out and holds my hands. Calmly, with a smile, she says, "Just tell me what you saw, Dr. Blank. This is why I came to you. I knew you would be honest with me."

I'm feeling my eyes start to mist up and say "Lisa, I am so sorry. You have a growth in your eye."

Bad deja vu

I'm thinking back to 1987 when I saw a similar lesion in a 62-year-old white female patient who'd just received a clean bill of health from her primary doctor. I'd sent her to a retinal specialist because of an unusual lesion. She was dead within nine months — after she'd gone blind from radiation.

I'm thinking about that time and in front of me sits a young woman and I'm fearing for her future. She asks, "Is it cancer?" I say, "It may be." Immediately, she asks, "Do you think it is?" I say, "Yes, I do."

She is pulling this information out of me and I do not want to tell her. She asks, "What kind is it?"

"I suspect it may be a metastasis." She thinks about that and then asks, "What should I do now?"

I tell her to go to her oncologist and he'll work with a retinal specialist to take care of this. I'm praying that I sound confident enough to give her hope. I tell her that I will call the doctor tomorrow morning with my findings. She looks at me, reads my sorrow and tells me that not to worry, she'll be fine; that I did the right thing in telling her. She gives my hand a little squeeze and then goes to the front.

I felt a lot more humble that night.

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@LWWVISIONCARE.COM OM OFFERS AN HONORARIUM FOR PUBLISHED SUBMISSIONS.



Optometric Management, Issue: January 2006