Off the Cuff: More Than Meets the Eye

I have a patient who at 6 years old was diagnosed with an orbital rhabdomyosarcoma. He had surgery that successfully removed the cancer but disfigured his orbit yet saved his life. Amazingly, the eye was still sighted. You can only imagine the difficulties of navigating his childhood as a cancer patient who looked different and what kind of lifelong impact that would have on him. After undergrad, he was finally able to undergo a long-awaited reconstruction of the orbit. Unfortunately, during this surgery his optic nerve was “nicked” instantly blinding that eye. He now has so little eyelid tissue that the nasal half cannot close, subsequently leaving him with chronic exposure, blepharitis, trichiasis, meibomian gland dysfunction, and an inability to be fit with a scleral shell, so the resulting recurrent corneal ulcerations and scarring was not surprising.

One weekend when another of these ulcerations recurred, he was seen at one of our not-so-friendly corneal specialist's office. He was given a prescription for antibiotics along with a referral for enucleation. The next day I got a panicked phone call from his wife. Was this his only option? Was there anything else that could be done? The patient's history with surgeries and his left eye were far from stellar so neither he or his wife were prepared when this was the recommendation given. When I saw the ulcer later that day, it was bad but salvageable. An amniotic membrane healed it quickly and after another discussion stressing the importance of maintenance care for that eye, that he admittedly would get lax on, he still has the eye.

Was the enucleation recommendation the wrong call? Not really. I had had a discussion with him in the past about blind painful eyes and the potential for enucleation, so the procedure would make sense. However, for this patient, his case was more than treating recurrent ulcers on a blind eye. His eye represented a physical and emotional journey that started in childhood, and the idea of losing the eye, even if it was essentially nonfunctional, would be another in a long series of traumatic events. Cases like these act as reminders that we need to take into consideration the whole patient—including their psychological and emotional, as well as their physical, well-being when recommending a course of treatment.

 

Shannon L. Steinhäuser, OD, MS, FAAO Chief Medical Editor ssteinhauser@gmail.com

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Write to Dr. Shannon L. Steinhäuser, OD, MS, FAAO at ssteinhauser@gmail.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.