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