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    Eyecare March Madness: When teamwork goes wrong

    It’s March Madness time, and the next few weeks will take college basketball fans on a roller coaster ride of synchronous alley oops and ill-timed, dribble-off-the-foot turnovers. I’m always looking for an apt sports metaphor to help pass the time and get me through the day. A guy can dream, can’t he? Recently, I found myself playing point guard to a streaking, gravity-defying vascular surgeon.

    Setting up the play

    A 79-year-old patient presented with a complaint that always causes my ears to twitch: “For a few weeks now, I’ve been losing my place when I try to read.” In someone that age, I immediately think “scotoma” and start looking for one and working down the list of possible causes. His best-corrected visual acuity (BCVA) was OD 20/25 and OS 20/20. Amsler grid testing showed a small, dense scotoma near fixation in the right eye. There was no afferent pupillary defect (APD), but ophthalmoscopy revealed the problem: a silvery, translucent sliver of Hollenhorst plaque had clogged one of the arterioles adjacent to the superior border of the foveal avascular zone. I could see a small, well-circumscribed spot of whitish, retinal infarct, which correlated perfectly with his Amsler grid defect.

     

    My patient had no history of diabetes, hypertension, or other vascular disease. I didn’t check for a bruit, but I knew the right internal carotid (ICA) was the first place to look for the root cause of the “twig” branch retinal artery occlusion (BRAO). There was a hungry-for-the-ball vascular surgeon just a couple of buildings over from me, but because my patient was going to see his primary-care provider (PCP) soon, I decided to pass to another player. I jotted down my findings in a note to the PCP, including the test my patient needed ASAP (carotid Doppler). When my patient visited his PCP a short time later, he gave the note to her staff.

    Related: A closer look at central retinal artery occlusion

    Dropping the ball

    And then, as was explained to me later, they “misplaced” it. My patient probably did his best to explain the situation to his PCP, but she apparently never saw my note. A lot was lost in the translation. She ordered a cholesterol test and lipid panel, and that was it.

    His cholesterol and lipid findings were normal, and there was no follow-up scheduled. My patient told me what had happened, and I was pretty miffed. He mentioned to me that one of those mobile health-screening sessions, which included carotid Doppler, was coming to a church near his house very soon. I told him to go, get the ultrasound done, and get the results to me.

    He did, and the carotid Doppler showed at least 70-percent blockage on the right side. My patient had already called his PCP by then and set up an appointment for a few days later. This time, he would hang on to the envelope containing the test results for dear life until he was in the exam room and could hand it directly to the PCP. I told him the name of the vascular surgeon with the best reputation in the community. I also composed another note for him to hand to the surgeon, just in case.

    Next: The dream team

    Michael Brown, OD, MHS-CL, FAAO
    Dr. Brown has practiced medical optometry in a comanagement center and with the U.S. Department of Veterans Affairs Outpatient Clinic in ...

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