BONUS TRACK--Deflating Debut

("Deflating Debut" was first published in "Reflections--The Human Side of Optometry" in the September 1995 issue of Optometric Management)

This student OD thought he knew everything--until his first day in the clinic.

I was a young, brilliant third-year clinician who, on my first day as a student doctor back in 1988, took great care to line my pristine clinic jacket with cover paddles, decorative tongue depressors, breath mints and reference cards.

I was looking good. And feeling better when I pondered my first clinical assignment. An automatic +2.50 add named Mr. Colombo was the only patient on my schedule, which meant I had four hours to grind away as I saw fit. But I was also sad that the curtain would rise on my career with a humdrum refraction when I had always dreamt of drugs, disease, diagnosis...

I checked visual acuities with his habitual correction of a +1.50 OU and a +2.50 add. I fogged each eye the requisite six lines and removed the fog in -0.25D steps in a slow, agonizing descent toward 20/20. I double-checked with the duochrome slide. Triple-checked with the clock dial. Threw in a balance and a final binocular best sphere. An hour later, I concluded that Mr. Colombo had suffered a (gasp!) +0.75 hyperopic shift. I demonstrated his supercharged prescription in the trial frame.

"I'll be able to see this tiny print? Even up to my nose?

I nodded. We were both impressed.

But my luck turned at the slit lamp, where I spotted brown speckles spread across the back of the cornea. I preset the tonometer to 20mmHg and began a long, careful approach. Even with near maximal effort, the mires remained far apart. I slowly wound the tonometer drum, pulling the mires closer. My rapid-fire serial tonometry left his corneas a little worse for wear, but the final score was in: OD 40 OS 38.

I then did what any rookie would do in that situation--freaked out and ran to my instructor.

"I've got a patient with IOPs of 40 and 38! He's gonna blow!" I shouted. My fellow students and their attendings who were in the "ready room" suddenly grew silent. All eyes turned toward my instructor and me.

"Calm down," my instructor said. "We'll deal with that in time. But what about this refraction? Is it possible that you're pushing too much plus?"

Refraction? Too much plus? What did they preserve this guy in?

He signed the glasses prescription with a sigh and examined my patient at the slit lamp before taking me aside.

"The 'brown stuff' is pigment--technically, a 'Kruckenburg spindle,'" he whispered. "Mr. Colombo has pigmentary glaucoma."

We referred Mr. Colombo that day to our disease clinic, where he underwent successful laser surgery and drug therapy. He had moderate optic nerve cupping and mild visual field loss. We'd caught the glaucoma in time.

A month later, he returned to our clinic. Was he going to thank me for saving his sight? No chance.

"I can't see with these glasses; I have to hold things too close to my face," he said frantically, waving them if front of my face. "I liked my old bifocals better. Fix them!"

My insides were broiling as I went to work. The +0.75 hyperopic shift was still apparent, but a +2.00 add restored his comfortable lap-top reading vision. That was the last time I saw my first patient, but I still carry the lessons he taught me seven years ago:

• Prescribe bifocals for the distance where patients want to read, not for where you think they should read.
• The cornerstone of optometry must remain excellence in refraction.

No matter how far we progress in disease diagnosis and management, we must continue to provide patients with crisp, comfortable corrections. Dazzle them with your diagnostic and treatment wizardry, but you better get the glasses right, or your name will be mud.

©2008 Dr. Michael Brown/20/40-Something. All Rights Reserved.