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Ophthalmic Surgery and Lasers
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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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