How tunnel vision can lead to bad medicine

The trend of increasing specialization in medicine may lead to unintended adverse consequences. There is an old saying, “We see what we recognize and we recognize what we know.” My wife’s recent adventures in ophthalmic care is such an example. I offer it as a cautionary tale.

She was born with granular corneal dystrophy (GCD). We would later learn that this autosomal dominant gene was thought to have originated in a small Southern Italian City of Avellino, just east of Naples. Since her grandmother was born not too far away, the epidemiology and genetics make sense. There are many types of corneal dystrophies. They are characterized by deposits in certain layers of the cornea and do not usually affect vision until the fifth or sixth decade of life. Her uncle and her mother both had corneal transplants. Some forms of dystrophy, such as Fuchs, are easier to treat than others. In my wife’s case, the best treatment for improved vision is corneal transplantation — either full or partial. Since my wife was an art teacher, loss of vision added to her decision to retire at age 65.

Shortly after her retirement, her ophthalmologist diagnosed her with cataracts and said they should be removed before addressing her corneal issue. The latter had been getting progressively worse, so her cataracts were removed in 2017. Her vision did not improve as much as he or we had hoped. Over the next two years, he continually checked the back of her lens for cloudiness. A common complication of cataract surgery is clouding of the part of the lens covering (capsule) that remains after surgery, called posterior capsule opacification. When my wife asked about her vision getting worse the ophthalmologist kept saying the cloudiness wasn’t bad enough to do surgery yet and at one point added, “We need to talk about the elephant in the room.” That elephant was her corneal dystrophy.

In 2018 her visual acuity became so bad she had to stop driving. Between fall 2018 and early winter 2019, she saw five corneal specialists. All of these doctors dilated her eyes and therefore should have been able to see beyond her cornea all the way to her retina (The importance of this will be detailed later.)

The first corneal specialist was a pioneering expert in corneal surgery. He was very pessimistic and said he would not even touch her right eye since she had had a stroke after brain surgery in 2008 for trigeminal neuralgia. He said the left eye could have laser treatment or transplant, but the corneal dystrophy would recur within five years. We then saw another corneal transplant specialist at the University of South Florida. He said her right eye could be operated on but first, we should see another physician in Miami who did laser surgery and was highly regarded and published in the field. We could not get an appointment until January 2019. We also saw the head of the ophthalmology department at a large university in the Midwest who also mentioned this physician. Finally, we saw another transplant doctor in Tampa.

Long story short: We were so impressed with this physician that she underwent bilateral laser treatment of her GCD in early February. Her vision did not improve much after six weeks, and recommendations were for scleral contact lenses that might help. About this same time, we had a routine follow-up with her primary eye doctor who had performed her cataract surgeries. He finally said that maybe she should have the YAG laser treatment for her corneal cloudiness. This was done, and her visual acuity in the operated eye went from 20/150 to 20/30 in just three days! She is now driving and seeing better than she has in years and will be having the other eye done shortly.

It is unbelievable that none of the five experts would mention treating the cloudiness of the lens before treating the more obviously diseased cornea. After all, the risks of YAG laser capsulotomy are quite low. To think she might have had a corneal transplant instead, (which at some point in hopefully the distant future she will still likely need), is frightening. However, in hindsight, (which of course is always 20/20 — pun intended), we cannot understand why none of these surgeons could see beyond their own area of expertise: that is, the cornea. Advances in medicine and surgery are wonderful and at times, life-saving. But too many times doctors can be lulled into error by not thinking beyond their narrow specific area of interest and practice. After all, there is a whole patient out there waiting to be diagnosed and treated.

David Mokotoff is a cardiologist who blogs at his self-titled site, David Mokotoff.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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