A Bad Case of Congestion
Friday was unusually hazy, hot and humid for our northern location. My last patient before lunch was a “double book”. Nat Bruehl, an infrequent visitor to our clinic, had called about congestion and an irritated eye. Probably a case of conjunctivitis, everyone involved had concluded, and he was given an appointment within an already filled time slot for a “quick look”.
“I brought my daughter to her high-risk obstetrician’s appointment in Capital City Monday, and she made us drive with the blasted air conditioner on the whole way there and back. Ever since then my eyes seemed irritated”, Nat explained. “I figured I got a cold in them. I took some cold pills that didn’t do any good. Then, last night my right eye started to hurt like a son of a gun and now everything is a little blurry. I even had a hard time driving myself here in this rain storm.”
I looked at his face. His right eye was red, and as I looked closer, I noticed his pupil was enlarged. As I directed my wall mounted light at his eye, the pupil remained dilated and I could see that the fluid behind his cornea was gray and cloudy, barely letting the light through.
I brought him out in the hallway to look at the vision chart.
“Start with your good eye”, I asked him. Outside, lightning struck not far from the office. The earth shook and the fluorescent lights blinked.
He squinted and strained, and missed two letters on the 20/40 line. With his right eye, he couldn’t even do 20/100.
“You’ve got a true emergency”, I explained. “I think you’ve got a dangerous buildup of pressure in your eye because of an internal blockage – a case of acute glaucoma, and I want you to see an ophthalmologist today.
“But I couldn’t drive to the city”, Nat protested. “Not in this weather.”
“I wouldn’t want you to”, I warned him. “You need to find somebody else to drive you.” I also asked for his permission to bring in our head nurse and my own nurse, Autumn, to look at his eye. “I would like everyone here to see what you’ve got”, I explained.
He agreed, and I showed his abnormal eye to our nurses.
I made a call to the nearest ophthalmologist, Mike Dube, but he was off and had signed out to Jeremy Sweet over at Cityside Hospital. After hearing my case description, Dr. Sweet’s assistant gave Nate a 3 o’clock appointment.
“Now, don’t try to drive all the way there yourself”, I warned him. He agreed to find someone to drive him. I gave him directions and went back to my office to catch up on charts and grab a bite of my sandwich. Outside, the sky darkened as if night had already fallen.
The afternoon was a whirlwind. Other places may wind down on Friday afternoons, but not our clinic. Just before 5 o’clock there was a call from Dr. Sweet’s assistant.
“You were right”, she said. “He has a bad case of angle closure glaucoma and we are having a hard time getting his pressures down. It’s 50 even in his good eye. That antihistamine-decongestant he took for three days is probably what did it. Good thing you caught this – we often see people like this bounce around a bit before getting diagnosed.”
I thanked her and made sure to let the staff know about the callback. Flashes of lightning lit up the darkness outside, the thunder roared almost continuously, the floor vibrated and the rain beat hard against my office window as I finished my charts for the week.
About 10 years ago, when I lived in Michigan, my optometrist told me to go see an ophthalmologist because he could see a “possibility in the future” of getting closed angle glaucoma. I went to the ophthalmologist recommended most often by colleagues and friends and he agreed and suggested that I get iridotomies (little holes) lasered in my eyes as a preventive measure. I read up on it (had access to excellent research, working at a health services research company) and the possible side effects worried me greatly. So I made an appointment with another ophthalmologist for a second opinion. She also said that she felt it was a good idea after she examined my eyes. I told her that she was the second doctor to tell me that. She asked me who my first consult was and when I told her it was Dr. Katz she say. “Dr. Katz is an expert in this, you should have him do it.” I sat on the fence. I told my PCP about it and I told her that statistically I only had a 10% chance of developing closed angle glaucoma without the surgery. She said “I’d feel a lot better if that was 1%. Gosh, three strikes against my opinion by three (four?) respected doctors! Although I’m a proponent of less is more when it comes to medical treatments, I’m not stupid. We were planning on retiring and moving to New Mexico so I bit the bullet and had it done a few months before our move. I had none of the bad vision side effects mentioned as possible. The iridotomies are still there, safely protecting my eyes according to my current optometrist. He did say that he’d never seen the particular placement of them that I have in my eyes, and that they are placed differently in each eye. I will assume that Dr. Katz chose where to make the holes based on the many iridotomies he’d performed.