A Stye Caused My Presbyopia

Though there is no argument that culture influences a patient’s perceptions, fears, beliefs and concerns regarding her healthcare, patients, regardless of cultural origin, will be patients. We are all human, and with that comes the same human tendencies that stretch across cultural boundaries. In the following case, I highlight one such tendency – that is, for patients to make associations between symptoms that may not correct. My patient presented with a swollen eyelid, which was the immediate obvious reason for her coming to the office, but as you will soon see, it masked the real reason for her visit:

Doctor: So what brings you to the office today?

Patient: <pointing to eyelid> I have this lump on my lid.  It started two weeks ago.  I tried soaking it and it hasn’t helped.  I even tried over-the-counter allergy drops.

<after examining the eye>

D: What you have is a very common eyelid problem, it’s a hordeolum, better known as a stye.  It’s a blocked oil gland in the eyelid that has become infected.

P: Okay.

D: You have to continue doing the warm soaks with eyelid massage several times a day.  In addition, I’m going to give you a medicated eye drop that will help bring down the swelling and treat the infection.  Do you have any questions?

P: Yes, why can’t I read? I haven’t been able to read anything since this all started.

D: <looking at the patient’s age, and last chart note which was 10 months prior> It is not unusual for a person in her mid-forties to start experiencing ‘presbyopia’, or the problem with reading things in a near-range.  Have you tried using the over-the-counter reading glasses?

P: Yes, that’s what I’ve been doing, but my vision wasn’t like this before I had this stye on my eyelid.

D: It’s not unusual to make associations like that: when something is actively going on in our eyes, like a stye or infection, we focus on our eyes more, and may start to notice things we previously overlooked.  But it is very normal to start to need readers in your early forties.

P:<getting increasingly more agitated and frustrated> This problem did not start until I got this stye! My stye caused this! What are we going to do about my vision? I was fine the last time I was examined!

D: <looking at the last note’s date> Yes, but that exam was almost a year ago now, it is common to have vision changes in this time period, I assure you.  Please, try these +1.25 magnifiers on now, and see if you can read this pamphlet.

P: <looking at the pamphlet with the readers on> Yes, I can see everything, but it wasn’t like this before—I know the stye did this.

D: A stye is a blocked oil gland in the eyelid, it doesn’t affect the vision.  Here is some reading material on ‘presbyopia’ or the need for reading glasses.  Reading this information will help you understand more about the natural visual progression of the eyes over time.  We can recheck your stye in approximately 1-2 weeks from now after you’ve started treatment.

P: <doubtful> Humph, ok.<walks out, still disbelieving the doctor>

This is a classic case of a patient coming into the office with a pre-conceived idea of her medical condition and not being able to come to grips with the fact that she may be wrong in her self-diagnosis. Maybe this particular patient equates trouble reading with getting older, and doesn’t want to accept that she is getting older. It is easier to project blame onto a stye rather than aging. Maybe her difficulties with  reading remind her of a family member who lost vision and she fears she could be going down the same path. Maybe this patient truly believes an eyelid infection can cause loss of vision and simply needs to read more on the topic to understand the pathogenesis. It is hard to know exactly what factors were at play in her mind, but encounters like this are frustrating, for both doctor and patient. Both stand on different platforms of a dialogue that never truly reach a level plane of understanding. The following is another example with a Spanish-speaking patient of mine:

D: ¿Por qué Usted está aquí en la oficina hoy? Se dice aquí que Usted necesita un examen completo de los ojos.

P: Sí, necesito una examinación, y lentes nuevos, pero, tengo problema. Todos los días los ojos me arden, son rojos, y tengo lagrimeo – especialmente cuando voy afuera de la casa.

D: <después del examen> Bueno, Usted tiene sequedad de los ojos – especialmente cuando está afuera, cuando el viento sopla, o cuando está concentrando en la pantalla de la computadora todo el día en el trabajo, las lágrimas naturales en la córnea se evaporan- y el ojo se vuelve seco.

P: ¿Y por qué tengo este problema?

D: Sequedad de los ojos es muy común con el envejecimiento. Particularmente hoy día, con vídeos, móviles, computadores y todo, nuestras lágrimas se evaporan, y hay mucho más sequedad para personas de todas edades.

P: Sí pero, yo trabajaba por una fábrica que hacía aislante para hogares y, el cuarto donde me estaba estacionado era muy polvoso y sucio. Los síntomas que tengo empezaron allí.

D: Es posible cuando hay contaminantes en el ambiente medio donde trabajaba, que los puedan causar más molestía de los ojos – sí – particularmente si una persona tiene sequedad u otro problema de la superficie del ojo, pero los contaminantes no causan sequedad.

P: Bueno, pienso que el trabajo causó los problemas que tengo ahora, porque nunca en el pasado antes tenía los síntomas de ojos rojos, picazón o ardor.

D: Sí, pero tiene que recordar que sequedad de los ojos es una enfermedad que es una parte del envejecimiento. Entonces, los síntomas podrían empezado, no importa si trabajaba por esa fábrica o no.

P: <mascullando> Sí, es de la fábrica. Sí, los síntomas empezaron allí.

In one of my earlier blog entries, “The Art of Convincing”, I touch on a very similar topic, how it is difficult at times to convince a patient to be compliant with a treatment regimen, especially if the medical problem he has is virtually symptomless and not affecting the vision. When there is no pain or vision loss, it is hard for a patient to accept there is something wrong that needs daily, long-term medical care. That entry shares a common point with today’s topic: that the key to getting past these misunderstandings and incorrect associations is education. Regardless of a patient’s language, culture or medical problem, it is our duty as physicians to provide the facts to the patient through whatever means necessary to allow the patient to come to the most informed conclusion as possible. We can achieve this through thorough conversations, informational pamphlets, medical website references and second opinions with other professionals. Some patients may still come to the wrong conclusion, but through education I believe we plant a seed in their minds that they can further reflect on and question in their own time.  

 

Broken Castle, Sv. Mihovil, Hrvatska

Am I Part of the Problem?

In my October 2014 blog entry, “Now You’re Speaking My Language”, I presented a dialogue I had with a patient of mine. The patient talked to me about how he tried learning English when he first came to the U.S., and confessed he knew more of the language then than he does now. He said that he used English only at work, but when he got home at the end of the day, he surrounded himself with his family and friends—with whom he spoke only in Spanish. Since being retired, his exposure to English has dwindled to almost zero, and as a result he lost any previous knowledge in English that he had.  He stated he would be too embarrassed to speak it now, fearing he would sound foolish at best.

I was reminded of this particular conversation during a very similar encounter I just had with another patient of mine yesterday. She told me she’s been living in the U.S. for 29+ years, but doesn’t have any English language skills because she made it a point to isolate herself only with Spanish-speakers in her community. She works for a friend’s family-owned business where she only speaks Spanish. Her family and acquaintances only speak Spanish. Her education ceased back in her home country, and not exposing herself to any classes here in the U.S. keeps her speaking, reading, writing, watching T.V. and listening to the radio in Spanish. But she told me that despite all this time that has passed, she still has a hope and desire to learn English because she doesn’t want to be limited to interactions only in her small community. And she told me all this in Spanish, with me listening and responding, of course, in Spanish.

This patient’s frankness about the difficulties she’s been having made me start to think, when does a service that we provide for people become less a help to them and more a hindrance? There is an immediate need now for health care for Latino immigrants fresh to this country that are functionally illiterate in English. For these people, I can do the entire ophthalmologic exam and assessment, greet them and explain to them, diagnose, treat and provide follow-up, all in Spanish. And this is a good thing – for doctor and patient! However, for the Spanish-speaker who has been living in the U.S. for several years, who may be earnestly trying to become more proficient in English, he is greeted everywhere he goes (his community, the doctor’s office, signs in department stores) in his native language.  How does that help and encourage him to accomplish his goal of learning English? From my own personal experience with language learning, I can say that the less practice a person has in a language, the less likely he is to try and push himself to communicate in it, for fears of sounding and looking foolish. Some people are confident enough to push past this fear, but many people are not, and will just continue to communicate in what is comfortable for them-their default, native language.

As a result, I personally think it is important to communicate in both languages when possible. If I’m speaking with a patient, and I notice she seems to know a few words or phrases in English, I will interject some English when speaking with her. Or I will introduce the word for whatever we’re talking about in both languages. “Bueno, Usted necesita usar una toalla con agua tibio – a towel with warm water – para limpiar los párpados.” “Usted tiene un rasguño de la córnea – a corneal scratch – donde el palo le golpeó.” “Una catarata ocurre cuando el cristalino natural del ojo- the eye’s natural lens – se vuelve nuboso-cloudy.”

I have said before that, just as English in the U.S. has been influenced by the Spanish language, Spanish in America, too, is influenced by English. There’s no rule in the book that says that our conversations can’t reflect that- a little bit of both –un poco de los dos idiomas – to encourage learning and understanding. Let’s build a bridge across linguistic barriers and foster growth in both languages.

Blog Reference Links:

“Now You’re Speaking My Language” http://www.eyesayinspanish.blogspot.com/2014/10/now-youre-speaking-my-language.html

“Spanglish”http://www.eyesayinspanish.blogspot.com/2013/10/spanglish.html

“The Only Foolish Question is the One That Isn’t Asked” http://www.eyesayinspanish.blogspot.com/2013/12/the-only-foolish-question-is-one-that.html

Hopi Tribe wall engravings, 300-1300 AD, Utah

Letters & Numbers

When I was a resident working at Bellevue Hospital in Manhattan, the majority of my patients were immigrants freshly arrived to the U.S. from all parts of the world. Most did not know English, and required the intervention of a third party interpreter for the completion of their health care exams. Of course, it was always easier for me to communicate on a one-on-one basis with those patients from Spanish-speaking countries, because I had a fair command of the language and didn’t need to use the LanguageLines telephone interpreter otherwise provided. 

During my time there, one experience that I would come across time and again was a patient who would struggle to read the letters I put up on the screen. I would look at their age and think to myself, ‘it’s probably nuclear sclerosis, or perhaps some macular chorioretinal scarring, or corneal scarring or astigmatism, that is contributing to their difficulty’. And I would proceed to do the refraction and find no improvement. And then I would do the exam which revealed no cataracts or corneal or retinal scarring, and I would wonder why I was not getting a better visual acuity measurement. Was it amblyopia?

Many times the patient didn’t say anything to me. He would just struggle through the lines. Or he would  ask me if he could say the letters to me in Spanish, but still struggle through. One or two letters would come in loud and clear on the 20/80 line, but not much else. Just for good measure, I would put numbers on the screen.  All of a sudden, a break-through occurred. The 20/80 line plunged down to 20/30, as the patient quickly read the numbers on the wall. 

There were patients who would even struggle with the numbers, and for those I would use the tumbling E’s which, when the patient pointed out all the line directions correctly, would confirm my suspicion. That is, that I was dealing with a literacy issue and not a visual one. 

According to Wikipedia, the definition of functional illiteracy is “ having inadequate reading or writing skills in a language, as would be required for daily living and employment tasks that require reading beyond a basic level”. The article goes on to say that a foreigner living in a country with a language non-native to his own which he cannot read or write is considered functionally illiterate.

My blog has been born from the fact  that the majority of patients in the community where I work are functionally illiterate. Outside their very insular Latino community within the borders of their town, they cannot communicate with the English-speaking world. But, the majority are literate in their own native language of Spanish.

However, there are still some patients that I come across who, unfortunately, may not have had access to education in their home country. Although they can communicate easily orally in Spanish, which does not give any indication of a deficit, when confronted with reading tasks such as visual acuity taking, the problem emerges. If a doctor is not thinking about the possibility of illiteracy, then it is very easy to assume that the problem is solely visual.

A literacy chart provided by the United States CIA Factbook from 2003 looks at the literacy rates of various Central & South American countries and compares them to those of the U.S. at that time. ‘Literacy’ was defined as ‘age 15 and older that can read & write’.  In 2003, the literacy rate in the U.S. was 99% of the total population. By comparison, Puerto Rico was 94.1%. The highest rates behind the U.S. came from Uruguay 98% and Argentina 97%. The lowest were Nicaragua 67.5%, Guatemala 70.6%, Honduras 76.2%, El Salvador  80.2% and Peru at 87.7%. More recent estimates from 2012-2015 show an increase for all said countries, but still trailing behind the U.S.: Uruguay 98.5%, Argentina 97.9%, Nicaragua 82.8%, Guatemala 83.4%, Honduras 88.5%, El Salvador 88% and Peru 94.5%. 

With better access to education for all citizens, literacy rates will continue to improve world-wide. This is still an ongoing work-in-progress. Until literacy is achieved for all, doctors working with an immigrant population need to think about not only functional literacy in their multicultural practices, but also the general literacy of their patients. This issue needs to be considered, particularly if the eye exam points to a 20/20 eye, but the visual acuity result says otherwise.

References

http://latinostories.com/Latin_America_Resources/Latin_American_Literacy_Rate.htm

https://en.wikipedia.org/wiki/List_of_countries_by_literacy_rate

https://en.wikipedia.org/wiki/Functional_illiteracy

 

čitaj znakove, Hrvatska

Do as I say, and as I do

“¿Por qué Usted está aquí en la clinica hoy?”

“Hace seis meses ahora, tengo ojos rojos, ardor, particularmente cuando leo, tengo lagrimeo, no puedo ir afuera de la casa sin lagrimeo cuando sopla el viento. No sé lo que pasa, pero, los ojos están molestándome.”

(después del examen)

“Tal vez esto va a soñar poco extraño, pero Usted tiene ojos secos.”

“¿Cómo?”

“La manera en que el ojo mantiene una córnea lubricada es muy complicada, pero en su caso, las glándulas que normalmente producen bastante lágrimas para cubrir la córnea no están funcionando completamente. Las células de la córnea se vuelven secas, y  algo sucede que se llama en íngles “reflex tearing”o lagrimeo reflexivo.

“¿Qué es lo que tengo que hacer para curarlo?”

“No hay una cura. Tiene que mantener un régimen diariamente lo que se incluye lubricantes artificiales tres veces al día al menos, un limpiador para los párpados y una crema para usar cuando se acuesta por la noche.”

“¿Cúanto tiempo tengo que hacerlo?”

“Por siempre.”

<expresión abatida>

Patients are looking for a fast cure-all. It doesn’t matter what the problem is, or how long it’s been going on. I have found in my experience working with patients over the last 10 years, that if an easy fix isn’t provided, frustration results. For something like dry eye or glaucoma, which are chronic diseases, I work to present a doable treatment regimen that the patient can follow on a daily basis. Still, the fact that the regimen is not finite and requires a commitment over a lifetime is oftentimes not the resolve the patient is looking for.

Some might say, well, so what of it? You’ve presented the diagnosis and a treatment plan. You’ve explained the logic of it, based on their symptoms and signs, and what has to be done to alleviate the condition, temper it or control it. That should be enough to encourage compliance! Well, it isn’t. From those patients I cannot give a quick treatment fix, I detect a sense of frustration, disappointment, sometimes anger and/or sadness, and all of these associated emotions inevitably lead to a lack of compliance. Patients may start the treatment plan and stick with it for a while, but then their commitment wanes and not surprisingly, symptoms return full-fold.

There are and always will be certain personality types of patients that, despite every means of encouragement, will still fail to fully commit and comply. But one mechanism I have found to work for a majority of people falls under the “misery loves company” motif.

It is human nature, that in our suffering we look to others who are suffering similarly for support, hope and a camaraderie found only in a combined struggle. As doctors, we’re patients, too. Sufferers of the same afflictions. I personally use this to my advantage with my patients.

I have dry eyes. My symptoms started in my late twenties, when I was an ophthalmology resident. The end of a long day in the clinic used to leave my eyes stinging and burning, and I couldn’t understand why. I would run to the small sink in the back of the clinic and flush my eyes, for relief. It wasn’t until we started covering anterior segment pathology that I began to realize what all my signs and symptoms were pointing to: dry eye! ¡sequedad de los ojos! And then I began to understand the concept of evaporative tear loss, the function of the meibomian glands, or lack, thereof, in a person already suffering from acne rosacea.

Putting together my own daily treatment of dietary Omega-3, hot compresses and artificial tears helped my symptoms tremendously. Having gone through the not-so-pleasant experience of dry eye myself made me more exquisitely in-tune to the symptoms of my patients suffering from it. But again, when I identified these patients and told them that they need to follow a daily schedule of artificial tears, dietary changes and the like chronically, I was met with dissatisfaction and worry. I wondered, how can I encourage these patients? How can I try to make them dedicate themselves to a treatment plan?

The free dictionary of idioms on-line describes “misery loves company” as “fellow sufferers make unhappiness easier to bear”.  I decided to share my own story.

“¿¿Tengo que usar las lágrimas por siempre??”

“Sequedad de los ojos es, desafortunadamente, una enfermedad crónica, y que es más, tiene una tendencia empeorar con tiempo. Yo también tengo ojos secos.”

“¿De veras?”

“Sí. Y yo también tengo que usar lubricantes, a veces tres o cuatro veces al día, particularmente por lo que miro la pantalla de una computadora todo el día diariamente. Esa actividad, le he explicado, tiene una tendencia a secar los ojos.”

“Pero Usted es joven.”

“Síntomas de ojos secos pueden empezar a cualquier edad. Especialmente hoy día, la edad de celulares y computadores, juegos de vídeo y cosas así, la gente más y más joven está sufriendo de sequedad de los ojos.”

“¿Sólo tengo que usar los lubricantes?”

“Bueno, Usted debe tratar de hacer el tratamiento de ojos secos una parte de su rutina diaria. Por ejemplo, por la mañana, cuando se levanta, y normalmente se lava la cara, use una toalla de agua tibio para frotar y limpiar los párpados – y puede repetirlo cuando se acuesta. Durante el día, debe usar una gota de <su marca favorita> de gotas artificiales, dos o tres veces, antes del trabajo, en el mediodía en la oficina, cuando regresa a la casa, y a veces, cuando mira la televisión por la noche. Trate comer comidas con el aceite del pescado, ‘Omega-3’, durante la semana, o puedo tomar el suplemento de la vitamina.”

“Está bien. Voy a tratar mantener el horario.”

“Hago una cita para Usted en 6-8 semanas, para reexaminar los síntomas y monitorear su progreso.”

“Está bien. Gracias, muy amable. Me ha explicado todo claramente.”

“De nada.”

Of course, providing some samples of artificial tears always helps, in addition to making an appointment in the near future to check on and encourage progress.

Mexican Hat, San Juan County, Utah