We all have those patients that stand out because we really learned from them. Maybe we learned a clinical pearl or we saw a retinal condition for the first time or sometimes it is as simple as learning how to talk to a patient with empathy and compassion.
One in particular comes to mind for me: a 4 year old with severe amblyopia from a constant exotropia. Because the child’s vision was so poor, we decided to start treatment with patching and some visually-guided activities. We spent the first visit explaining the patching regimen and associated activities, as well as discussing the importance of proper compliance. However, at the next visit, the child’s visual acuity had not improved! As a student, we learn about all of the Amblyopia Treatment Studies (ATS). The evidence clearly indicates that vision should improve with patching, even in cases of severe amblyopia. It is easy to be discouraged when we do not see the progress that we expect.
Instead, we gathered ourselves ready to explore the reasons why this child was not improving. We turned to our detective mode and began asking relevant questions. Wanting to consider the parent’s role in establishing a consistent approach to the patching, we began asking questions about how often and how long the child was wearing the patch. This is where the wheels came off the bus! The parent broke down sobbing in the exam room. Her daughter was getting rashes from the patch and would scratch her face so hard she would bleed. Mom just couldn’t seem to find a way to “enforce” the patching that didn’t make her feel that she was causing harm to her daughter.
I had to take a step back and realize that this parent was not noncompliant because she didn’t care, it was because she cared too much. So as a student, how do you approach an emotionally-conflicted parent while maintaining the integrity of treatment?
One of my professors taught me that our first priority is the child so we discussed the different options for this child instead of the stick on patches. Together with the parent, it was decided to try using a pirate patch that the little girl got to decorate herself! She loved arts and crafts so this was a perfect option. We also educated mom about short-term vs. long-term goals. Focusing on patching and improving the visual skills of the amblyopic eye (short-term) was likely to make it easier to begin binocular treatment and maintain gains long-term. She began to understand that the discomfort her daughter felt now was a short-term problem, but the overall treatment plan would help her daughter succeed in many activities as she was growing up, including school, sports and appreciating a 3-dimensional world.
So what did this case teach me and what should students take away from this story? Remember that though we are learning and we understand the processes that occur to create amblyopia and the associated visual deficits, parents do not know what they have not learned. It is important to spend time educating them so they feel comfortable with the treatment for their child, even if the child does not enjoy it. We must encourage parents to step up and do what is best for their child and their future. Not everything we learn occurs in a classroom. Sometimes these interactions with patients and their families allow us to learn to think outside the box and gain their trust.
O.D. Candidate Class of 2018
Pennsylvania College of Optometry
Villanova University Class of 2015
August is Vision & Learning Month and this year we want to help parents Keep Summer Learning in Sight! With fun activities that help develop visual skills and acomprehensive vision exam in time for back-to-school, we aim to ensure each student starts the next school year with the best vision possible. Learn more!