Sunday, August 12, 2007

Mistakes

I should not have had the cataract surgery on my right eye in the first place. The cataract on my left eye had grown quite bad, and really did need to be removed, but my right eye was not so bad. After the first surgery, I could see well with my left eye, and my right eye was myopic. I could read, work at the computer, drive, etc. just fine. I should have questioned the surgeon's assumption that the right lens should be replaced.

Prior to the operation, the risks were outlined in message video taped by the surgeon. In the section of the tape labeled "Risks and Complications" he states:
Cataract surgery is surgery, and there is a small chance that things can go wrong or not turn out the way we want them to. The two most significant risks of cataract surgery are infection and retinal detachment. The numerical odds of those problems are in the one in a thousand range. In my hands the actual risk of infection has been lower than one in a thousand and the same for retinal detachment, but they are in that range and they are real serious problems. If they occur, we have to take care of them, there is no option. We cannot sort of sit on them and watch them, we have to manage them. And even with a complication we can get good results.
I understood that there was a risk of detachment with cataract surgery, but was not told that the risk increased with age and degree of myopia. What is the detachment rate for 67 year-olds who are as myopic and physically active as I was? I still don't know.

The video mentions several other possible complications including "the capsule behind the implant clouding over -- in fact that one is almost a 30 percent chance and that is a simple thing to fix." I wonder if that fix, if necessary, will risk re-detachment of my retina.

I went for a two-week follow up examination after cataract surgery on my right eye. I told the surgeon that my vision was significantly worse -- blurrier and less bright -- than the left eye, and had been plateaued since a few days after the surgery. I suggested that this might be due to manufacturing variance in the implants, which he said was extremely unlikely. My relative inability to read the eye charts confirmed that my vision was both dim and out of focus. I told the surgeon that I was not able to read using the drugstore reading glasses he had recommended. He was puzzled by that, but did not follow up. Was that an indication that the problem was not due to a faulty lens or swollen eye, but the retina? I also mentioned that I thought I was catching "glimpses of my nose" in my peripheral vision.

The surgeon said the poor vision was probably caused by inflammation and prescribed different eye drops. He shrugged off the mention of seeing my nose -- said he had never heard that one before. In retrospect, that was the start of a detached retina. Should he have been suspicious and sent me for a retinal exam?

The surgeon's reaction to my "seeing my nose" or not benefiting from reading glasses reflects inattention to the patient's subjective state. He has never had the subjective experience of a retinal detachment. Did his training attempt to convey that experience to him? He should have read descriptions of retinal detachment by patients. He should have looked at patient's drawings of what it looks like.

Cataract patients should read the same accounts and see the same drawings. Like the surgeon, we are unfamiliar with the subjective experience of a detached retina until it is too late.

Why didn't my poor vision worry the surgeon? I suspect that is a combination of hubris, "knowing" the statistics, and inattention exacerbated by the fact that he does many operations each day, and schedules only about five minutes for the two-week post operative examination.

One or two days after my two-week follow up, I woke up seeing a watery-opaque area in the lower-left quadrant of the field of vision in my right eye. I went to the clinic, and received an emergency scleral buckle. Since then, I have read that a scleral buckle may be accompanied by the draining of the fluid from behind the detachment and the injection of a gas bubble into the eye. Would one or both of these steps have prevented my second surgery?

I went for an early-morning post operative exam a few days later. The surgeon was worried about the lack of improvement. She contemplated injecting a gas bubble at that time, but decided instead to wait two days. When I asked her whether I could walk home or should call my wife to pick me up, she replied that there would be no harm in walking as long as I did not exert myself to the point of elevating my heart rate. I walked home (downhill) very slowly. Might that have caused the detachment to spread?

A few hours later, the opaque area extended into the upper left quadrant of my field of vision, and a second emergency surgery was performed. Could that have been avoided by injection of the gas bubble earlier in the morning?

The first night after the second surgery, I was instructed to lie on my stomach with my face parallel to the floor until I returned the next day for a post operative examination. That is a very uncomfortable position, and maintaining it all night was very difficult. But I was able to do so with the help of some foam rubber cushions my daughters picked up at a drug store. It would have been impossible otherwise. Why didn't they give me such a cushion when I went home after the surgery? They would have given me a crutch if I had a broken leg wouldn't they?

The patch was removed from my eye the day after the second surgery. The area that had been opaque -- the left side of my field of vision -- was improved. It was still discolored, but translucent, not opaque. However, a second translucent area had appeared across the top of my field of vision. That scared the shit out of me. I told the surgeon, but she said she could see nothing wrong and told me not to worry. (Right). The next day, the original area showed some improvement, but not the new area on top. I called and left a message to that effect. Many hours later, another doctor called to say that I should quit worrying. The next morning I made a subjective discovery. The darkened area was not fixed at the top of my field of vision -- it moved to the side if I tilted my head. It was the gas bubble! That was a great relief, but why hadn't I been told that in the first place? I don't think the surgeon was being insensitive. I think she had not been trained on the subjective experience of the patient. I am better trained to support post operative patients than she in some ways.

I have also encountered a small "catch-22." I was frightened after the second surgery, and worried that I might not be able to sleep well. I asked the surgeon for a sleeping pill prescription, but she said I would have to ask my general practitioner. The general practitioner also refused, telling me to ask the surgeon. I ended up taking a Tylenol PM. Who is my "physician?" I wonder how Paris Hilton gets her drugs?

Every day, many people have retinal detachments repaired. We are experts in the subjective experience. The Internet excels in providing a meeting place for communities of common interest. Why was I not given the address of an online patient-support group before I agreed to cataract surgery? Why was I not given the address of an online patient-support group once my retina was detached? Why doesn't the surgeon use the Internet to stay in contact with the dynamic group of currently convalescing post-operative patients?
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