Scrubbing In: By defying doctor's advice, he would risk going blind

On a recent night in Atlantic City, a 59-year-old man had just left a restaurant when he felt a terrible pain in his eye. Then his vision became cloudy "like a Russian steam room."

He went right to the AtlantiCare Regional Medical Center emergency room where the doctor rightly suspected an acute attack of angle closure glaucoma. That's when the drainage system in the front of the eye closes off, causing a spike in eye pressure. This farsighted patient was prone to this condition due to the shape of his eye.

Sometimes the diagnosis is not so obvious because the pain and nausea accompanying these attacks can be confused with appendicitis or some other gastrointestinal emergency. But this ER doctor nailed it, and that's when the call came to me in the Wills Eye ER.

I told the doctor that the best thing for this patient was to start eyedrops and oral medications to lower the pressure and then send the patient to me to manage closely in our specialty eye emergency room.

"There may be a little problem here," the ER doctor said. "The patient wants to know if he can go home and come back to you later in the day tomorrow."

"He has the right to decide, but he should know that he could go blind in that time," I said. "I'd like to see him tonight."

The patient didn't like that answer and got on the phone. He told me he had a very important meeting in the morning that he couldn't miss. He would drive in from the Shore later that day.

I advised him to skip the meeting. I said I'd write a letter or talk to anyone he needed to excuse him medically.

"Are you sure? Do you really mean it, doc?" he asked, in a skeptical tone.

"I am sure."

How does a physician persuade a patient to follow her advice? This case was theoretically an easy one. The patient had severe pain and blurry vision and needed my help. Why was he so hesitant?

In medicine, we have a word for this scenario: compliance. If a patient follows advice, he is considered compliant. If he does not, he gets labeled noncompliant. The term is imperfect: It implies submissiveness and does not cut patients any slack. But still, it is a crucial concept.

Noncompliant patients have a number of reasons to explain their behavior. Patients who have chronic forms of glaucoma - different from what my patient had - may have to take eyedrops for decades. Cost is a big issue. Concern over side effects is another problem. And then there is stamina. Glaucoma patients have to endure one, two, even three drops in their eyes each day, often many times a day. It's easy to slip up.

Many patients who do not have symptoms can convince themselves that their doctors are overreacting. With chronic forms of glaucoma, it's a common pattern. Patients reappear years later in our clinic with permanent vision loss and a sad phrase written in their file: "lost to follow-up."

I was determined not to lose this patient. Angle closure glaucoma, which my patient had, is the leading cause of blindness in both eyes worldwide.

A couple of hours later, I got a call. "It's me again," my patient from Atlantic City said. "I decided to go home."

He had felt better after the drops and medication so he thought it could wait. Pain was no longer a motivator.

I tried one more time to get him in, using a blend of selling and scaring.

"You will most likely go blind if you are not treated," I said. "I am here all night so please come in."

By 5 a.m., he had arrived. We brought down his pressure with more drops. That morning I took him across the street to our clinic and lasered a hole in his iris to create a new drainage pathway for his eye fluid. I did the same to his other eye a week later.

My patient now knows the gravity of the situation. When I saw him last week for a follow-up visit, he asked: "Doc, when's my next appointment?"

Persistence can pay off. Every young doctor knows this skill. We persist to pass dozens of medical school exams. Now we persist for our patients. And many times we get through.

Rachel K. Sobel, a second-year ophthalmology resident at the Wills Eye Institute of Thomas Jefferson University, writes about her experiences every other week.EndText