No, it’s not a typo. Didn’t mean to discuss pediatric ophthalmology, rather the type of ophthalmology where the shoe is on the other foot, as is the case with the 19 year-old who was my last patient Thursday evening.
Examining our 19 year-old, the history was strongly suggestive of the garden variety visual skills problem I see with these students. His mother noted that he had been examined by the family’s ophthalmologist two years ago and had been told everything was fine. A rabbi visiting from Israel who conducts vision screening said that they should look into the possibility of vision therapy for his difficulties in following along with the printed text.
As you can see, the text pages that these Yeshiva students follow is crowded and can pose a bit of sensory overload even to students with normal visual abilities. The crowding effects are exacerbated by varying fonts and columns and widths along with absence of puncutation rendering the text as if it were a run on sentence that has to be parsed based on careful visual inspection and linguistic as well as cognitive cues.
When our extern presented me with the automated visual field printout, there was significant dropout of the visual field that didn’t seem to fall into any recognizable pattern despite his fixation and responses being very reliable. Unaided visual acuity hovered around 20/25, a bit more of a struggle with the left eye. Our patient exhibited compound hyperopic astigmatism worse in the left eye, with binocular instability and intermittent suppression of the left eye. Although his functional visual problems might account for his difficulties “learning inside”, the expression Talmudists use for studying the text, there was something deeper going on. The answer was revealed in our 19 year-old’s dilated fundus examination.
By convention we examine the right eye first, and as I first looked at the retina there was mild pallor of the optic nerve and color alterations around the papillomacular bundle, but more strikingly a hint of pigment deposition where it didn’t belong. As I was examining the patient, his mother said: “You know, when I come back for the conference, I want to discuss his older brother with you. He’s been having alot of problems with his peripheral vision and difficulty with driving.” As I scanned further, particularly further into the nasal retina, our patient’s likely diagnosis became apparent.
I will be referring our 19 year-old patient out for further testing to establish baseline angiography and ERG, but his bony spicule formations, pattern of visual field loss, and progressive difficulty with Talmudic text is consisent with a diagnosis of Retinitis Pigmentosa. Changes in the left eye were a bit more advanced than the right eye, mirroring our patient’s perception and accounting for intermittent suppression of print under binocular conditions.
Although the classic description of progressive retinal degenerations of this nature is of “tunnel vision” with realtively preserved central vision, reading can be greatly affected even in the presence of decent acuity because of diminishing peripheral cues to saccades. Our treatment will include patient education, genetic counseling regarding his siblings and other family members once they’re examined, as well as any rehabilitative therapy we feel can maximize residual function in the face of this progressive disease. Now here is a final point to ponder.
This cartoon from The New Yorker is adapted from a line by Gore Vidal, indicating “It’s not enough that we succeed. Cats must also fail.” If you’ve been reading these blogs you’ll notice a recurrent theme in which I periodically take ophthalmologists to task – particulalry pediatric ophthalmologists as a group [though there are notable exceptions] – for willfully or unintentionally misrepresenting optometry to the public. Not satisfied with whatever degree of success they have, they seem to resent the success of optometrists, particularly those who practice vision therapy.
Consider this. Our 19 year-old’s parents are going to return for a conference in which I review my findings and recommendations, and I know they are going to ask me why the ophthalmologist who examined their son two years ago told them everything was fine. If you were me, what would you tell the boy’s parents? And further, if the shoe were on the other foot, and I had examined this boy two years ago but somehow missed his condition and an ophthalmologist subsequently picked it up, how do you think it would be handled?