Article

MEMORABLE PATIENT ENCOUNTER

A farm worker’s 30-year “thank you”

I met “Anna” more than 30 years ago, and since that time we haven’t forgotten each other.

She was referred to me at my Fresno, Calif., practice in 1988 due to severe bilateral uveitis and only counting finger vision in each eye. Accompanying these were severe headaches, tinnitus, hair loss and the loss of patches of skin color. The diagnosis of Vogt-Koyanagi-Harada (VKH) disease was made.

As a 26-year old farm worker in the San Joaquin Valley who picked oranges during the winter and tomatoes during the summer, Anna needed to see to earn a living. She was immediately put on a large dose of prednisone as well as intensive topical steroidal and cycloplegic drops. Each time I tried to taper off the prednisone, her disease flared up. After six months of close follow-up, her disease quieted down. But, by then she developed dense bilateral cataract and had only “hand movement” vision.

NO GOOD OPTIONS

It was clear she needed her cataracts removed, otherwise her disease’s chronic inflammation would require her to keep using steroid drops to keep her eyes quiet. After getting an opinion from the University Uveitis Clinic, at the University of California, San Francisco, the recommendation was to remove the cataracts without IOLs; in the 1980s, the general consensus was that IOLs would only make inflammation worse due to poorer quality materials and less experience with implantation.

Doing so, though, would require her to use contact lenses or thick aphakic glasses, both of which would make it incredibly difficult for her to work in the fields. She would most likely need to continue the frequent eyedrops, and it would be impossible for her to do so over the contact lenses.

REMEMBERING MY FATHER

I pondered the problem for a few days and asked myself what I would do if in her place. I also recalled my own father’s struggles with his contact lenses, which he started using after his cataract surgery. He had mild uveitis and his ophthalmologist decided against IOLs. I decided that, if it were me, the IOLs would be the only practical option, even with the risks. If the inflammation got too severe, the IOLs could still be removed.

I discussed all the options with Anna. She was intelligent and understood the pros and cons of each option and why I recommended the IOLs. She agreed with my suggestion, and her cataracts were removed and IOLs placed without incident. In the end, her vision was 20/30 in both eyes and the symptoms of VKH disease never bothered her again.

ANNA NEVER FORGOT

To this day, Anna continues to do well. After 30 years, she never forgot me. Even to this day, after I retired and moved to Hawaii, I still get a card from her each Christmas with a photo of her family and a handwritten letter thanking me for helping her. While I’ve gotten many cards from patients in the past, Anna is the only one to do so for such a long period of time. And, while I was still in practice, she would regularly drop off a box of fresh fruit for the office.

If Anna did not have the IOLs placed, her life would probably have been much more difficult. It always makes me feel good thinking about how I made a difference in her life. OM