Ophthalmology off the Grid
Episode 62

The Patient Perspective

Kevin Waltz, OD, MD, talks to host Gary Wörtz, MD, about his recent experience as an ophthalmic patient. He shares his personal story as a way to help his fellow physicians better understand what their patients experience when undergoing surgery.

Gary Wörtz, MD: As doctors, it’s easy to get caught up in day-to-day tasks and lose sight of what our patients are experiencing. We tend to view things more objectively, and as a result, sometimes we aren’t mindful of the stress patients go through.

It helps to occasionally look at things from a different perspective. In this episode of Off the Grid, we hear from Dr. Kevin Waltz about his recent experience as an ophthalmic patient. Kevin had cataracts at an early age and had to have surgery. Nearly 20 years later, after experiencing some issues as the result of the surgery, Kevin had to undergo a second surgery.

He’s sharing his story to help his fellow doctors gain some insight into what patients and their families experience and what we can learn from putting ourselves in their shoes.

Coming up, on Off the Grid

Speaker 2: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full listing of podcasts for eye care professionals, go to eyetube.net/podcasts.

Gary Wörtz, MD: Welcome to another episode of Ophthalmology off the Grid. Today, we've got the opportunity to talk with Dr. Kevin Waltz, and Kevin and I go back quite a few years, and we've worked together, we've operated together outside of the United States on some projects that we've worked on together. But, today, instead of talking about our surgical techniques, our preferences, what we can learn from each other as surgeons, Kevin has a different story he wants to share. We were talking about it a few months ago, and I asked him whenever he was ready if he felt like it would be interesting for others to hear about. Kevin actually was an ophthalmic patient recently, and I feel like there's probably a lot to unpack inside of this. I think there's a lot we can learn from Kevin, and I think it is going to be a good reminder for us about what it's like to be the patient, not just the doctor. So, Kevin, thank you for coming on tonight and sharing a little bit about your story I really appreciate it.

Kevin Waltz, OD, MD: I'm happy to be here Gary. I think an important part of being a doc is to share your experience when you're a patient because it really helps your fellow doctors get a better idea of that perspective.

Gary: Yeah, it's so easy for us to put that patient perspective in the icebox so to speak because we have to be ready when we walk into a room to be totally objective, worry about the task at hand, but sometimes I think that can actually be a detriment if we don't occasionally remind ourselves of what the stresses are that the patient and their family are going through. And, one of my favorite corny jokes is the definition of minor surgery is surgery having anybody else. If it's happening to you, it's major surgery. So, why don't you just start by telling us a little bit about your initial experience as an ophthalmic patient yourself, and we can just kind of walk through the story.

Kevin: Sure. You know, I had your classic nightmare as an ophthalmologist. I'm a 40, 41-year-old ophthalmologist and all of the sudden I can't see. And, lo and behold, I've got cataracts at a very early age. It turns out they're congenital in my family, we didn't know, and I've got to have surgery in a relatively short order. I went from 20/25 in January to about count fingers by April.

Gary: Wow.

Kevin: And, I had my partner at the time do it. He's an awesome guy. He's a great surgeon. And, he inherently understood the key factor that the patient wants the surgeon to understand, and that is the patient wants to know that the surgeon is in there with you, not on your side, but they're sharing your tail risk. And, tail risk is something that can happen months or years later, and that's what we have insurance for, but that didn't really cover the problem. So, the ultimate compliment of the surgeon was, my partner at the time said, "Kevin," this was our final preop, he said, "Kevin don't worry. If the surgery goes bad, you're going to be the best paid medical ophthalmologist in the state."

Gary: That's a nice way to put it, I guess.

Kevin: Yeah, so he's accepting the risk with me. He's doing his utmost to do a great job, and that's ultimately what the patient wants. They want to know that surgeon is with them no matter what.

Gary: Right.

Kevin: Now, the other part is we tend to operate in terms of fashion. So, at the time it was quite fashionable to really aggressively clean the capture bag so that it maintained its flexibility over time. This was 1998, so that was a cool way to do it. Well, he cleaned it really well. He cleaned it so well that I got a dead bag syndrome, which we didn't know about at the time.

Gary: Well, Kevin, I'll be honest, that is a term that maybe I'm behind the curve on, and that wouldn't be the first time if that's the case, but explain dead bag syndrome because I think there's probably a lot of younger ophthalmologists who have not been around long enough to experience it in their own hands and maybe haven't seen it, so explain that to us.

Kevin: Well, one of the benefits of having at least a few epithelial cells is you get a little bit of epithelial fibrosis, and it seals the front and back capsule together, and it seals the IOL in place. My IOL never really fully sealed in place. Only the nasal portion of my capture bag sealed because the temporal portion had been cleaned so much.

Gary: Gotcha.

Kevin: And, that's kind of the definition of a dead bag, that you clean it so thoroughly it never really seals.

Gary: Gotcha.

Kevin: So, that was what we did, and it was a beautiful surgery, but there was no evidence that there were issues at the time, and I had 18 years of wonderful surgery. My vision for most of that time was uncorrected 20/10 minus the distance and J1+ near.

Gary: Yeah because you had the Array lens, correct? The original multifocal lens?

Kevin: That's correct.

Gary: Amazing.

Kevin: So, great surgery but essentially because of the technique some many years later my temporal haptic came loose. And so, as they say I had another learning opportunity.

Gary: Right.

Kevin: So, it happened in August of '16, and I woke up one morning, and I had diplopia. I was like, "What the heck, I didn't have it yesterday." And, we discovered very quickly that my IOL had sunsetted a little bit, not a lot. And, it's interesting because diplopia in and of itself is not that troublesome. It's not like you've got blurred vision.

Gary: Right.

Kevin: So, a little bit of diplopia is very tolerable. That's lesson number one for the surgeon. We don't like diplopia, but I was still 20/20, I was fine. So, I chose not to do anything. I kept operating, and I was fine, and it was actually during some of those times that we operated. Over time there were three separate episodes where I had a stepwise falling in my IOL until, ultimately, I had five images in my left eye, and that became a little bit more bothersome. As the images increased, the blurriness increased, which was much more bothersome than just the multiple images.

Gary: Interesting, okay.

Kevin: So, finally almost 2 years later, okay, it's not going to get better, it's going to get worse, and eventually it's going to fall out of place, so I've got to do something.

Gary: Right.

Kevin: The next thing I would encourage the docs to think about is, when the patient knows, without a doubt, they have to do something, the risk benefit issues go away.

Gary: Right.

Kevin: The only question is, “Do I have the right surgeon?” And, if there are issues, well there are issues. There were going to be much worse issues if I didn't something. So, I'm following my own advice to patients. I said, "Don't do it until you have to." I had to do it. I found a great surgeon. I talked to several surgeons about getting it fixed. People weren't that excited about it because it was a strange situation, it's a multifocal lens, etc. So, ultimately, I was going to be in Berlin in June of 2018 for a meeting, Burkhard Dick practices a few hours away by train. He's a fearless, amazing surgeon, and I asked him if he would do it, and he said, "Yes." So, after the meeting I went to Burkhard's place and he fixed me.

Gary: Before we get into that, I imagine you had, I mean, you're thinking all of the things I'm thinking, right? You're thinking, “Okay, are we going to be able to save the lens? Are we going to be able to suture the bag potentially? Is the lens going to have to come out? Are we going to do the Yamane technique? What lens are we going to put in? I've had a multifocal all this time, am I going to be able to keep my multifocality?” Walk me through your decision process on not only who you went with, because I think we would all agree that Burkhard Dick is an amazing surgeon and that's kind of if you have access to him that's an obvious choice, but walk me through those other nuance choices that you had to be sort of doing this pro con.

Kevin: I had originally hoped to have a light adjustable lens.

Gary: Okay.

Kevin: So, one of the reasons why I was putting it off was to get the light adjustable lens on board where I could get to it and get the treatments after the surgery.

Gary: Gotcha.

Kevin: I was part of the US FDA trial. I love the technology. I love the lens. It's a three-piece silicone lens, so it would be perfect in my situation.

Gary: Right.

Kevin: But, the way the Calhoun, now our ex-site, was developing, it just wasn't possible, and I couldn't wait any longer. So, that was off the table, but that was my first choice. Second choice was the IC-8.

Gary: Right. Explain that to people who may not be familiar with the IC-8. I agree. I think the IC-8 is phenomenal.

Kevin: It's a single piece acrylic with a mask embedded in it. Essentially, it's a pinhole mask within a single piece acrylic.

Gary: Right. It's like the camera inlay, but the inlay is in the IOL.

Kevin: Yeah.

Gary: Got it.

Kevin: It’s shrunk a little bit because it's closer to the retina, but yes.

Gary: Right.

Kevin: It's interesting. Burkhard and I talked. Burkhard has a lot of experience with the IC-8. He and I agreed that that was the best choice that was available for me. We decided that we would try to fixate my original lens because I was perfectly happy with my lens before it de-centered, because that was going to be less surgery, less traumatic, etc.

Gary: Right.

Kevin: If that wasn't possible, I would get an IC-8, even though he was going to have to tie some sutures to the single piece acrylic.

Gary: Like a cow-hitch suture with Gore-Tex?

Kevin: Yeah, something like that. That was the thought process. We considered other options. We considered a monofocal, which I wasn't very excited about. We had a process: try to keep the Array, if that doesn't work, do an IC-8, if that doesn't work, do a three-piece monofocal.

Gary: Gotcha. The strategy is set in place. Walk me through getting ready for surgery. What are you thinking as you're getting ready for surgery? You've been on the other side of it so many times. How is it different?

Kevin: As a knowledgeable patient, there's a bit of a religious experience aspect to it because you have to place your hands in somebody else's care. I stopped thinking about it. I made all the decisions that I could make. I was going to be asleep. I was totally at peace with it. I had to do it. I had the best surgeon in the world that I knew. I trusted him completely. At that point, there's nothing else you can do.

Gary: Why worry about something you have no control over at that point? You've made your decision. You've placed your bets. It's time to play the game. It's time to go to surgery.

Kevin: Yeah. That's also part of what's important for the surgeon to understand. Why does a patient get upset at a surgeon? One of the reasons why they might is that they don't know the surgeon. They don't really trust the surgeon. They're doing it for reasons that...who knows what they are. It might be there's only one surgeon option. In my case, I had tens of thousands of surgeons, literally, I could choose from.

Gary: I'm kind of offended you didn't call me, but we'll talk about that later.

Kevin: That's part of what the surgeon needs to do and have their staff help the patient understand why that surgeon's the one.

Gary: Right. That's a great point. That's a great point.

Kevin: The rest of it, if there's problems, there's problems and you deal with them.

Gary: Right. Right. You would never be able to look back and say, "I did not go through the process of choosing wisely." You could always have peace of mind knowing I did everything in my power to control the outcome to the extent that it was controllable, and now I can let the chips fall where they may because that's all we can do in life is shoot the averages and stack the deck in our favor.

Kevin: It's like my first surgery, that 18 years later didn't turn out exactly the way I wanted, but I had a fantastic surgeon who's totally on my side. I got no regrets. Here I am.

Gary: Right. Tell us, what did Burkhard find? What did he end up doing?

Kevin: Well, my capsular bag was more compromised than we had originally suspected. Originally, all we've got is examination. I've got serial photographs that show my lens dropping over time and what appears to be my capsule, but there was a rip in the anterior capsule, part of the peripheral capsule temporally was compromised. That probably led to some of the problems as well. Burkhard had to do a vitrectomy. He released the temporal haptic from...it was stuck in the ciliary body. He made a scleral flap temporally, exteriorized the haptic through the scleral flap, sutured the haptic within the scleral flap. He did that so that he could make it symmetrical with the nasal haptic, which was still very secure.

Gary: Gotcha.

Kevin: With asymmetrical placement he couldn't do a Yamane because it would be asymmetrical. Here he made basically an adjustable fixation of the temporal haptic and then he closed the pocket sealing on it and then closed the conj[unctiva] over that.

Gary: Wow. Have you had a YAG previous to this? Was your posterior capsule still intact?

Kevin: It was not.

Gary: He's really having to fight with anterior and posterior capsular remnants, asymmetric fibrosis, and a haptic that's meandered its way outside of the confines of the bag. Is that fair?

Kevin: Yes. You still want to do it?

Gary: No. I think you made the right choice there. I'm really glad. As a matter of fact, I may send some patients to Berlin after this call. Tell me about anesthesia. I know a little bit of this story, but it wasn't all just rainbows and sunshine.

Kevin: It was going to be a significant, long surgery. We agreed I was just going to get a general so he wouldn't have to worry about me moving or talking to me because he didn't really want to talk to me. He just wanted to work.

Gary: Right.

Kevin: I said, "No problem." I had my anesthesia. I'm getting up, waking up, and I'm going, "Whoa. What happened?" My eye feels fine. I'm really blurry, but I'm mentally deficient. My ability to do an abstract problem was drastically reduced. I'm a smart guy. I went to medical school, got into ophthalmology. So, I'm one into the bell curve of intelligence. I am certain that when I woke up that day and the next day I was way on the other side of the bell curve because normal things like, "What am I going to order at a restaurant? How am I going to get a taxi from here to there? Where's my room in the hotel?" I couldn't do it.

Gary: You think that was just anesthesia, just slowly coming off of anesthesia?

Kevin: I don't know. I sometimes get funny reactions to medicines. I can't explain it. I wasn't unconscious. I didn't have decreased consciousness. I had decreased mental function.

Gary: That's wild. So, you're in Germany trying to make your way home. I've been in Austria and Germany. People, for the most part, speak English, but everything is written in German, and trying to figure out which train to get on is not easy. That had to be terrifying.

Kevin: It was. Burkhard, again, was great. He arranged for me to have a taxi to the train station. I explained to the taxi driver — it was somebody that worked with Burkhard — I said, "I can't do it. Can you park the taxi and take me to the train?" The guy was kind enough to do it. I got on the train. I've got a first-class ticket because I've got two pieces of luggage. I've been in Europe for two weeks. Now, I have to get off at the train station, and Burkhard had made clear, "If you miss the train station with the airport you're toast."

Gary: Right.

Kevin: So, I'm sitting there, and all these people are looking at me funny because I've got too much luggage. I've crossed the line demarcating where you could be in second class, I am past that. I don't look German, and I felt threatened. Partly, I felt threatened because I couldn't process the clues.

Gary: Right.

Kevin: Looking at the exits, I am going “is this the one, is this the one?” So, I got off one exit early because I was afraid. I got back on the train to get off at the correct exit, and then I had to try to figure out how to get through customs and all the other rigamarole. It was absolutely frightening.

Gary: Wow.

Kevin: So, when we tell our patients “you can't drive home,” we should mean it because every once in a while, the medicine just reacts funny with the patients.

Gary: Right.

Kevin: I had surgery on Wednesday, I wasn't fully back into normal function until Monday.

Gary: Was it just like, when you woke on Monday, was it like the fog just lifted?

Kevin: There was a physical sensation of fog in my head. I had this pressure sensation in my brain that I was like “what the heck?” and then on Monday it was gone.

Gary: That is wild. So, Kevin, what takeaways, I mean you have been giving us little pearls along the way about decision making and why a patient would choose a surgeon or why a patient would be upset with a surgeon, but what are other takeaways would you give?

Kevin: Some of the things post-op that were really good. I had a lot of trouble with my ocular surface disease post-op, so my recovery was very slow.

Gary: Okay.

Kevin Waltz: I could tell that my lens was in good position early on, but my epithelium was so bad that eventually we scraped it all off to start over.

Gary: Okay.

Kevin: One of the things that was very interesting is people don't appreciate how important binocular summation is. I have got a good right eye. I am 20/15 uncorrected in my right eye, J1+. So, it sees great, even though it’s got a multifocal, and my left eye is my bad eye. I can tell you that I didn't really understand the difference between a really bad eye and an annoying eye.

Gary: Alright, explain that.

Kevin: When my left eye was really bad, when my left eye was open it decreased the vision in my right.

Gary: Because you are overlaying a bad signal on top of a good signal.

Kevin: Right, so then as my eye improved to about the 20/40 range, 20/50 range maybe, when I opened my left eye, it improved the vision in my right.

Gary: Gotcha, because now you can summate.

Kevin: There is a huge difference between that difference. So, when I opened up my left eye and it made my right eye worse, I closed it all the time.

Gary: Right.

Kevin: When I got to the 20/40 range, I opened it all the time. It was blurry, but it still helped.

Gary: Right.

Kevin: So, your feeling of well-being is much, much better when you get to that point. That also taught me that, sometimes we get into a situation where the first eye is not going great, and they say “well, why don't you just do the second eye?”

That's a doctor decision that puts the patient at risk because if you get up to poor vision in both eyes, it really is unsettling to a patient.

Gary: Let's put some meat on that. You mean, if someone comes in post-op, and they still have Descemet fold, or they have some epithelial edema, rather than just taking the other eye to surgery and potentially having the same issue with both eyes, give them a couple weeks to let the edema clear, so that when they wake up from their second surgery, if that’s the bad eye, they’re able to function.

Kevin: Exactly.

Gary: Okay, gotcha.

Kevin: Otherwise, it is just terrifying to the patient. When I was 20/15 in my right eye and 2200 in my left eye, I functioned okay.

Gary: Right, right.

Kevin: But if I drop to 20/50 in both eyes, I am not going to function okay.

Gary: Yeah, and you know, we have this perspective of knowing, okay it’s edema, it is going to clear, and you’re going to be fine, but you are exactly right, if you're a patient and you've gone through the first surgery, and you are not where you want to be or even close to it, it’s really hard to step into that second surgery just blindly trusting that it’s going to work out.

I think that is a good reminder to remember to put ourselves in the patient's shoes, making sure they have at least one eye that is going to function before we take on the next one.

Kevin: It gets back to that the trust factor for the patient. If the second eye goes great, surgeon’s excused, you move on.

Gary: Right.

Kevin: But, the patient’s going in, and I’m not so sure, and when there’s a problem, instead of breaking trust, and you’re more likely to end up with problems with the patients, both clinical and legal…

Gary: Right, right.

Kevin: …So, it’s good for everybody, if it’s not just right, or close to it, just take a breath.

Gary: Yeah. I agree. Any other life lessons on this? I am sure it has changed your perspective a little bit about maybe the fragility of our working career because this is a game changer for an ophthalmologist. Everyone needs their eyes, but I think we feel like we need them more than anyone else. Am I wrong?

Kevin: Even from the very first surgery, I was always concerned about what’s going to happen here. I am just getting started now, I want to keep going, and that is a big deal.

The one thing that I think is really important for people to understand is, our microscopes that we operate with these days are phenomenal. So, with a 20/15 eye and a 2200 eye, I can operate just fine. Normal rates, normal efficiency, normal safety because the optics and the brightness are so powerful with the scope, essentially you have the best pinhole system in the world with your microscope, and you see so well it’s unbelievable.

At work, it’s not an issue having some decrease in vision. If I want to work on the computer, or if I want to read, it slows me down tremendously, but if I want to do cataract surgery, I am fine.

Gary: Gotcha.

Kevin: That was a little bit of a surprise to see how much of a difference that was. I was worried about surgery, no problem, but I wasn't worried about reading, huge problem.

Gary: Isn't that funny?

Kevin, we are so glad that you are on the mend and so glad that you had access to Dr. Burkhard Dick and the great work that he did, so hats off to Dr. Dick for the fantastic work on fixing you up, and I will say this, we’ll continue to follow your progress, and if you have other lessons, both as a patient or an ophthalmologist, that you’d like to teach, you are always welcome.

Thanks a lot Kevin, really appreciate your time.

Kevin: Thank you, Gary.

Gary: Kevin’s story is a good reminder about what it’s like to be on the patient side. For his most recent surgery, he followed his own advice: “Don’t do it until you have to.” He also spoke to several surgeons before choosing one.

Once all of the decisions were made, he had to stop thinking about it and place his trust in the surgeon. As doctors, it’s important to realize how much we are asking patients to trust us and accept what they cannot control. We need to help them understand that we are with them throughout the process, accepting the risk along with them.

With that, thanks for listening to Off the Grid. Until next time.

Speaker 2: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full listing of podcasts for eye care professionals, go to eyetube.net/podcasts.

12/26/2018 | 28:18

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