The trouble with eye specialists

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A patient of mine recently underwent surgery for a massive pituitary macroadenoma. Don’t worry, I will explain the meaning later!

Story, story

The story is that she has been having progressive visual failure for years and diagnosed with all sorts, by both opticians and ophthalmologists before the penny dropped. After a long period of prescription glasses and treatments for glaucoma, Malaria and Typhoid, she finally got a brain scan performed which unfortunately revealed the tumour.

This pituitary tumour was the cause of all her previous complaints of headaches, pain behind the eyes, tiredness, irritability, head fullness and of course, blindness. This was misdiagnosed by eye specialists for several years as she went from one to another, receiving pretty designer glasses and eye shades!

Opticians

An optician, or dispensing optician, is a practitioner who designs, fits and dispenses corrective lenses (glasses) for the correction of a person’s vision. Opticians determine the specifications of various ophthalmic appliances that will give the necessary correction to a person’s eyesight.

In effect, opticians are technical specialists who make glasses for your eyes. They are also trained in the recognition of eye diseases. However, they are not trained to treat patients (apart from issuing corrective glasses). For example, they are not to undertake treatment of patients with a pituitary tumour, or even glaucoma for that matter.

Their job remit includes referral of patients to the ophthalmologist, immediately, if they suspect you have an eye disease not requiring glasses. Or an eye disease that could be potentially harmful with or without the prescription of glasses!

Ophthalmologist

An ophthalmologist is a physician (doctor of medicine, MD) who specializes in the medical and surgical care of the eyes, the visual system, the prevention of eye disease and injury. They can make diagnosis and carry out the treatment of many eye diseases referred to them by the optician.

In effect, the way this works is that the optician sees a patient with a serious eye disease that does not require glasses and refers to the ophthalmologist for further diagnosis and treatment. The other way works as well: that the ophthalmologist refers patients to the optician for corrective glasses as needed.

Not in Nigeria

Opticians are almost independent of ophthalmologists and the training programs devoid of synergy. Therefore, a lot of mistrust exists with opticians abrogating more responsibilities to themselves and ophthalmologists performing the job of opticians in their practices.

Ideally, the optician and the ophthalmologist should work hand in hand collaborating to treat patients with eye diseases effectively. They should both understand their job description and limitations as described above. Unfortunately, this teamwork rarely obtains in Nigeria as each jostles for money and supremacy, while the patient goes blind.

Follow the money

The money in eye business comes from issuing glasses and prescribing eye ointments. You would find opticians and ophthalmologists will some sell you ‘simple water’ for close to N5, 000 in many instances. They will sell you unnecessary glasses and designer shades if you stay too long in their examination chair!

Fancy spectacles do not help blind people. Opticians should refer to the Ophthalmologists who must have a low threshold for obtaining imaging especially if there are symptoms and signs of blindness. But, I appreciate the poor level of eye care delivered is because opticians especially, make their living from prescription glasses. However, we might soon have a nation of the blind leading the blind!

Anyway, let’s wrap this up with some education.

Pituitary gland

The pituitary gland is a very small gland (like a pea!) in the base of the brain which helps to regulate very important elements in the body called hormones. It is an important gland in the middle of our brain: just behind the eyes. In fact, it is sitting just underneath the nerves that supply vision and this is the reason why the eyes are easily affected by tumours of the pituitary gland.

Pituitary tumour

Pituitary tumours sometimes called adenomas start in the pituitary gland. They are usually and almost always benign (not cancerous). A few though can be cancerous and highly malignant. Symptoms can be caused by a tumour producing too much of a hormone, or by not producing enough hormones. Other symptoms are headaches and often vision problems caused by big tumours pressing on the optic nerves (the nerves that control vision). This can lead to blurring of vision, seeing things through a tunnel and complete blindness.

A patient with a pituitary tumour will need different tests, such as eye tests, blood tests, a brain scan (CT or MRI). The scan gives information about the size of the tumour and the important structures in that area. The blood tests determine if the tumour is producing hormones or not and the hormone levels in the body.

Treatment

Doctors sometimes treat a special kind of these tumours that produce a hormone called prolactin with drugs that reduce prolactin levels. Surgery is however the most common treatment. Radiotherapy is often used after surgery. Some people with very small tumours may have a specialised type of targeted radiotherapy called stereotactic radiosurgery.

Pituitary surgery

Many patients with a symptomatic pituitary tumour require surgery. We can perform the operation to remove the tumour by either going through the nose to the base of the brain or in a few instances by opening up the skull. Either way, the objective is to remove the entire tumour if feasible and prevent further damage to the eyes, or to remove a tumour producing excessive hormones.

If the whole pituitary gland is removed, you need to take drugs to replace the hormones that are normally produced (hormone replacement). This may be for life.

NB: Contact me for further information about pituitary tumour surgery or just to bitch about eye specialists……

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