For all its green-scrubbed glory and ceaseless, smile-lit tides of recovery, eye care can have its depressing moments. Down here, it’s easy to soak in the sun of our successes. After all, cataracts and pterygium and allergic conjunctivitis and other mild ocular prey comprise a Texas sized portion of the cases we see. Ophthalmic nurses probably have “book her for cataract surgery” and “tetra and gutt. chlor” (ointment and drops) tatooed to their tongues by now because they are the remedy to nearly every case seen on outreaches. For weeks now we’ve seen treatable cataract case after treatable cataract case, flecked with a few glaucoma, corneal scar, and pterygium (a net of broth-colored phlegmish tissue crawling from the corner of the conjunctiva toward the pupil) to keep the crew on its toes.
Blindness, we were told, was lurking in and around these rural chiefdoms; Ali often reminded us that we must fight blindness with “machine guns” and blast its insidious mercenaries out of their foxholes. Not to contradict General MacArthur, I used to think, but the stuff we’ve seen is hardly insidious. The sluggish cataracts, the pterygium slouching like snails toward a pupillary Bethlehem, the conjunctivitis that EVERYONE (and I do mean everyone on account of the unrelenting dust) had—it all seemed so insipid, feckless, senior citizens brandishing walkers at Green Berets. With a good surgeon on board, we could wipe it all out while brushing our teeth before bed.
Then there was a patient who I will call Niya. She wore a green school-issued skirt and flitted around the consultation room like the white furs on a dandelion. Her mother followed behind her with an infant no older than 10 months yoked to her back by an overbearingly technicolored shawl, the child’s trio of tight ponytails sprouting like black vines from the mothers nape. For all of her wildness and excitement, Niya turned out to be a wonderful patient. As Dr. Wanye collected patient history from the mother, a few of us took turns examining Niya’s eyes through an oscilloscope and listening as the mother described the “shiny thing” she saw in her daughter’s pupil. This is not nearly as innocuous or “oooooh, interesting!” as it sounds. A glint in the eye, particularly in the pediatric eye, is the first lead for retinal blastoma. Retinal blastoma is a highly vascular, cancerous growth on the retina that, if untreated, expands, explodes, and metastasizes to the brain through the optic nerve. And sure enough, as each of us closed in on a circular slice of the retina, we saw it, bulbous and opaque with raspberry arteries sprawling from its center, a set of pumping highways converging in a dull white cloud. Standard protocol for treatment is chemotherapy and, depending on the size and nature of the tumor, surgical measures to excise what is otherwise a highly lethal pathology. Dr. Wanye explains this to the mother as her daughter wanders near the black and white examination device, stretching her fingers toward its gadgetry only to have them slapped away by a nurse whose wound braids must carve canyons into her scalp. Wanye tells the mother to go to Accra, explains the treatment options softly, VERY softly because the usual recourse for an American child with RB is quite different from that of a Ghanaian child with RB. The unfortunate truth is that chemotherapy is expensive, wildly expensive, and yet all that expense can be repackaged and forcibly shrunk given a proper insurance policy. This family, the mother and her wonderful daughters, had no such insurance policy, making monthly payments on chemotherapy a practical impossibility. And Unite For Sight can’t cover it either, since we don’t raise and allocate funds for retinal blastoma treatment. So we go to option number 2, which surely can’t be much worse than option number 1, but it is. The only way to keep an untreated blastoma from spreading to the brain with any level of comfort is to remove any tissue that could potentially play concierge to the cancer’s metastatic desires. This includes a large segment of the optic nerve, the retina, and, as one would naturally, but regrettably predict, the orbit (eyeball). Option three is do nothing, to observe the cancer’s slow spread through the optic nerve, across the chiasm into the other eye and the brain, until it kills her. Option two it is, then. By bloodless, lugubrious default.
For all the machine guns we wield to fight blindness, the war at our door is at times miles out of our league. Typically this is not the situation, but as in Niya’s case, we are not exempt from feelings of futility. The more pervasive scenario that grinds our gears as healthcare providers is the one where the war doesn’t meet us soon enough. My first day in Karaga, a village outside of Tamale, we saw a young woman blinded by absolute glaucoma—had she visited four years earlier when the symptoms became apparent, we could have started treatment and saved both eyes. Yesterday I saw a kid no older than my brother carrying the grotesque result of an untreated corneal laceration. The wound was left untreated for months and in that time much had changed about the eye; the cornea had melted off, the iris had prolapsed like a misshapen bead, and the sclera had turned meat red with inflammation. There was nothing we could do to save the eye and without an evisceration of the bad eye (the scooping out of the iris, pupil, sclera, etc. to prevent infection), the other eye would become sympathetically infected as well. Had we seen him immediately, we would have repaired the corneal laceration and sent him on his way. Oftentimes we find victims of a procedure whose outrageous price is only outdone by its incredibly frustrating result: couching. Sparing the gory details, the practice of couching (falsely) claims to ameliorate a patient’s cataract by poking the lens out of place and into the back of the eye. This can present a very real difficulty to cataract surgeons, especially if the lens is not pushed fully out of place and sits cockeyed like a phase of the moon peeking out from the pupil. How these ignorant charlatans, no more skilled than a pub regular twirling a toothpick, are not immediately wiped clean from village premises is beyond me. But they’re not and sometimes they get their first and botch any shot we have at resolving the most resolvable medical dilemma in the optic world (aside from farsidedness in adults). The list of clouds floating over our sun keeps growing the longer I stay here—patients with blinding infections from local “eyewashes,” patients that disregard post-operative care and needlessly end up with infections, the number of patients that refuse surgery because some “taboo” was spread throughout their village wagging a finger at Dr. Wanye and his pragmatic, secular approach to fighting blindness. Easy to get pessimistic over, that’s for sure. And yet, I’ve learned here that medical situations aren’t perfect, that our patients are not perfect, and that we certainly are not perfect either. That is the reality of a profession that demands constant, predictable results in a storm of chaotic causes. Atul Gawande once said that it is not assumed nor expected that a doctor be perfect in his profession—“only that he strives to be.” And though I saw it first in Gawande’s book, the guiding phrase is taking on a much deeper meaning here with every sun-lit day that passes.
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