Hollow victory: Why our glaucoma victory felt meaningless

January 14, 2016

It’s an oft-repeated mantra among those of us who treat glaucoma: The goal of glaucoma therapy is to maintain adequate functional vision until the patient dies. Like a lot of mantras, we spout it almost glibly.

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It’s an oft-repeated mantra among those of us who treat glaucoma: The goal of glaucoma therapy is to maintain adequate functional vision until the patient dies. Like a lot of mantras, we spout it almost glibly. After all, we’re seldom actually there when the patient dies, so the full import of what we’re saying doesn’t hit home.

And then there are those times when you nearly are, and it finally does.

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A textbook win

Paul (not his real name) was a 58-year-old, tall, handsome, and gregarious African-American gentleman who reminded me of the actor and singer Paul Robeson with his broad chest and booming bass voice. Every time I saw him I could imagine him breaking out into a chorus of the poignant lament “Ol’ Man River,” and for the rest of the day I couldn’t get the song out of my head.

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He had moderate open-angle glaucoma that was diagnosed early enough in his life to prevent blindness from ever being an imminent theat. His intraocular pressure (IOP) over time was well controlled with two topical meds, his optic nerve stable, and his visual field unchanged. A classic, textbook “win” if there ever was such a thing.

When I saw him in August of last year for an IOP check, all had seemed fine. But somewhere between that visit and the time he returned for his annual visual field in early December, he had been diagnosed with terminal, Stage IV pancreatic cancer.

Next: An intense tutorial on mortality

 

An intense tutorial on mortality

But when Paul entered the clinic that afternoon, I wasn’t aware of that. My lead technician is superb and normally the first to audible a time-out in the middle of a busy clinic if he spots something out of the ordinary. But we were cruising at full speed and altitude that day, and my tech was on autopilot. He proceeded with the IOP check and visual field, and it wasn’t until afterward that I found out that Paul had mere days to live.

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“I felt really bad making him do the visual field,” my tech said, his head hanging in regret as he brought the printout into my office. “He’s in a lot of pain.”

My first thought was: I wish I had known that before we did the visual field. My second was: Why did he even come? Then I remembered how conscientious he was, how he’d never missed a follow-up visit, following all my instructions and guidance to a tee. We spend our careers riding herd on compliance, but in a few cases, perhaps we do our jobs too well.

I gently reminded my tech to “go with his gut” and ask me first if he thinks there is a situation that might call for aborting the plan for a visit. I then looked at Paul’s IOP and visual field. His pressure was in the low teens and his visual field was stable with good reliability indices all around.

My life has been punctuated with episodes of attending the dying and the dead (I held my mother’s hand and whispered “Love, love, love” in her ear as she passed), and I know how I should, in the words of the biblical Book of Psalms, “number my days aright.” Even so, here I was in line for yet another intense tutorial on mortality.

Next: Goodbye and Godspeed

 

Goodbye and Godspeed

When I entered the room, I drew in a sharp breath at how “The Emperor of Maladies,” as Dr. Siddhartha Mukherjee coins cancer in his book of the same title, had conscripted another subject and reduced him to a shell. Paul’s tall, robust frame had shrunk, his erect spine now bent into a small “c,” and his legs were drawn sideways against his swollen abdomen. I had read enough of his recent chart entries to know that his doctors had drained his ascites several times but had now stopped, relying only on palliative measures to address the pain.

Those clearly were no longer working. His eyes were closed and his face scrunched in what appeared to be deep concentration. His niece stood at his side, one hand on his shoulder, the other stroking the hair he had left.

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I sat, rolled my stool in close, took his hand, and said, “I’m so sorry.”

Then I pulled back a bit and addressed both of them. “Is there anything I can do for you, and what questions do you have?”

His niece took the lead. “Does he still need to use his eye drops?”

“No.”

“If he doesn’t, will he go blind before he dies?”

“No.”

“Will his eyes hurt more if he stops?”

“No. The pressure will go up some, but not high enough to cause any significant discomfort.”

I then looked at Paul. “Don’t worry about your drops. You did a great job when it counted, and you kept your vision. Spend your time on more important things.”

When it was time to go, his niece reached for the handles of his wheelchair, but I held out my hand and said, “Allow me.” She walked beside him, her hand never leaving his shoulder, as I wheeled him down the hall, the spokes of his chair spinning like sweep second hands.

When we reached the waiting room door, I leaned and whispered into his ear, “Goodbye and Godspeed” and let him go for good.

I turned toward the hall, filled with rooms, in turn filled with patients; the afternoon schedule, like “Ol’ Man River,” would “just keep rolling along.” For a moment, I held Paul’s and my “triumph” over glaucoma to the light and discovered that there was no iridescence or solidity. Only shades of gray, and a vague, but nagging, sense of hollowness.

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