Looking Forward to 2020: The Year of Vision a Self-Reflection

By Stephen D. Anesi, MD, FACS

This time of year is always a time for reflection, but also a time to look to the future. As we enter into this new decade, starting with the year 2020, I wanted to share some of the thoughts I have had during my 10 years spent at MERSI. First and foremost, I have had the immense pleasure of meeting and getting to know the people of New England, a place I am very proud to now call my home. And I also have been very fortunate to be called upon to help those who have traveled from distant states or countries to Boston to seek our care. Our patients, whether afflicted with the myriad of problems we are known to specialize in treating as a tertiary care center in ocular inflammatory disease, or suffering from other significant eye disease that may rob them of vision just the same, are the reason we keep doing what we do. We have been entrusted with their care, and there is no greater joy I have found in my career than each moment when a patient is helped to the point where they are able to now go about their lives without concern for their eyes or vision. And there is no greater frustration than when, despite my best efforts, a patient is still unable to experience this.

For many, the prospect of 20/20 vision is a goal they aspire to achieve. “Perfect vision.” What does this mean? It means that at 20 feet, a patient can see things that another person with “normal” or “perfect” vision can see at 20 feet. The same as 20/40 means they must come up to 20 feet to see what “normal” vision allows at 40 feet, and 20/15 means they are able to stand back at 20 feet to see what “normal” vision allows at only 15 feet. These numbers are so critically followed by many who come through our care, and small changes, which may not necessarily be medically “significant”, may make a very large difference to the person directly affected by those changes.

As physicians we are often expected to shoot for the stars, to be perfect, to fix everything – but in truth many MDs are often satisfied if the result achieved is at least up to the “standard of care”. For us physicians, I actually believe it is critical that we also remember that it is neither our needs nor expectations that are the only ones that matter, but those of the patient as well. And those needs and expectations may vary considerably… If a patient is left with near but not quite 20/20 vision, despite a very difficult course or prognosis, they may still be disheartened for not reaching that seemingly crucial endpoint. As if they somehow fell short. Yet there are others who become overjoyed to finally be able to see something recognizable at all. And then what if those needs go beyond vision?

What many do not know or come to realize is that 20/20 IS just a number… just one metric by which we as ophthalmologists judge how well an eye is able to function. The key word here is function, for vision is not the only problem we as ophthalmologists strive to manage. The overall well-being of the eye extends far beyond being 20/20, or even vision for that matter. One may reach the 20/20 level while being tested in the dark with a white background, but go out into the real world and be functionally incapacitated by some other deficit. Having 20/20 vision may not help someone see inside a darkened room after coming in from outside because of retinal disease or glaucoma, or gain back the independence of driving at night or in the rain because of overwhelming glare and haloes from cataract or astigmatism, or even still relieve debilitating ocular discomfort that prevents one from being able to concentrate or do anything at all. And these are only a few of the problems we, as doctors and patients together, face in the fight against eye disease.

Another thing many don’t come to realize is how much of an effect patients have on their doctors. I continue to learn from the people I have helped, sometimes years after I have met them. The strength, the courage, and most of all the will to continue on even when it seems there is no hope. It’s an inspiration. On both sides of the spectrum.

A patient of mine with uveitis for several decades presented to me with one remaining eye with any potential for vision, legally blind with severe astigmatism and a dense inflammatory cataract no other surgeon wanted to remove due to the risk involved. Despite the difficulty of the surgery, and the low chance it would even improve his vision due to previous retinal and optic nerve damage, he was motivated to achieve the best possible outcome, including pursuing correction of the astigmatism with a special lens. Today he regularly visits with 20/60 vision in his only seeing eye with minimal correction – and is absolutely thrilled because now, even though far from 20/20, his eye is able to function to allow him to see more, and do more, than he had been able to in many years. Needless to say, this is an outcome that would leave any doctor or patient ecstatic, as it continues to do for both he and myself each and every visit since that outcome was achieved.

Another patient of mine has had 20/20 vision in both eyes for as long as I can remember, but this was not her major concern. For despite the number, her vision was not clear, and worse, she has constant pain from scleritis and orbital inflammation. Pain to the point where life often comes to a standstill because of the inability to think or do or feel anything else, often leaving her unable to function in any capacity at all. Worse still, her case is among the most difficult to treat I can also remember. The thought of even coming to visits is at times an overwhelming burden, but a strong will and motivation to improve continues to prevail. And as she continues to battle this difficult disease, I too am motivated to continue, absolutely without end, to try to find some means of achieving relief for her so that one day she can again enjoy the life she greatly deserves.

These two brave patients help me remember some important lessons I have learned. No two patients, nor their eyes, are the same. Nor is any outcome taken for granted. Their needs are their own. What they value, crucial. What we may call routine care is a “miracle” to another. And what we consider a heroic effort may end in failure. As long as motivation remains, by both patient and doctor, to improve upon the hand dealt, I will continue moving toward that end in any capacity I am able. My goal as an ophthalmologist and ocular immunologist moving forward will remain thus… to help each patient and eye, not only just to see, but to function in a way that makes life easier and more enjoyable for the person who has entrusted me with their care. No matter what.

On behalf of myself and the other doctors and the entire staff at MERSI, I thank you for your continued faith in us to be there to help you however we can in whatever struggle you face, and I wish you all a very happy and healthy new year and decade to come!

#ophthalmology #uveitis #scleritis


C. Stephen Foster, M.D., F.A.C.S., F.A.C.R.

What is episcleritis?

Episcleritis is inflammation of the episclera, which is the thin vascular outer coating of the eye wall, the sclera. Episclera lies underneath the more superficial layers of conjunctiva and other connective tissues. Unlike the more severe disease scleritis, episcleritis is a benign condition and is usually not associated with other systemic inflammatory diseases. The vessels that appear inflamed in either episcleritis or scleritis actually run through the episclera. It can appear in one section of or diffusely over the eye, or as a nodule of inflammation on the eye. It can occur in both eyes simultaneously, but more often occurs just in one, and almost never causes any permanent damage. Most often it is seen and treated by general ophthalmologists or even primary care physicians, unless the problem becomes more frequent or severe.

What are the symptoms of episcleritis?

Redness is the main symptom of episcleritis. Patients will sometimes also complain of irritation or even burning. Symptoms can start and stop abruptly, and can recur often. Frank pain is not present and the eye should not be tender to the touch nor be significantly sensitive to light. Any of these symptoms suggest another disease process is taking place.

Do I have episcleritis or scleritis?

This is the most common point of confusion for most patients who have been afflicted by inflammation of the eye wall, and unfortunately, also for many eye care specialists who see these patients when their disease presents for the first time. Redness is common to both, but in episcleritis it involves the more superficial blood vessels in the conjunctiva and episclera, where as in scleritis it involves the deeper episcleral vessels. In episcleritis, this redness will mostly disappear when your ophthalmologist puts certain kinds of dilating eye drops in your eyes, but in scleritis, the deeper vessels will still appear red and inflamed despite use of these drops. Episcleritis is typically painless, or at best annoying. Pain and tenderness, however, are hallmarks of scleritis, especially pain that worsens with eye movement or radiates to different parts of the head, mimicking headache, sinus disease, or tooth ache. Bottom line: if the eye is significantly painful and red, it is probably something other than episcleritis.

What causes episcleritis?

Unfortunately, this is not known. It is thought to involve inflammation of the small vessels that run along the eye wall, a disease process known as microangiopathy, similar to scleritis. The level of inflammation present in episcleritis and the immunologic driving-force behind it are much less severe than in scleritis.

What other medical conditions are associated with episcleritis?

Episcleritis is usually not associated with any systemic disease. Only about 3 out of 10 people with episcleritis have an associated systemic disease. It can, however, present in a wide variety of conditions causing ocular surface inflammation, including connective tissue or vascular disease (such as lupus or rheumatoid arthritis), infection, rosacea, gout, or allergy. A work up is not always done for episcleritis unless it is more stubborn or severe.

What are complications from episcleritis?

Thankfully, episcleritis does not cause permanent damage to the eye. Rarely, it can be accompanied by mild inflammation of the peripheral cornea or inflammatory cells inside the eye. There are times, however, when a patient may later develop scleritis after first having episcleritis, and at that point vision threatening complications become a concern. Sadly, complications from episcleritis sometimes occur from treatment of episcleritis because of long term use of steroid eye drops.

How do you treat episcleritis?

Treatment of episcleritis is most often conservative. Observation without treatment may be all that is necessary for episcleritis that does not cause significant redness or irritation. Lubricating drops can help both soothe irritation as well as surface inflammation. More often a topical non-steroidal anti-inflammatory drug (NSAID) is used on a daily basis, either until symptoms resolve, or can be used safely long term in cases of recurrent episcleritis. Corticosteroid eye drops may help to relieve episcleritis but should never be relied on long term due to inevitable complications of cataracts and glaucoma. If episcleritis is particularly stubborn or severe, oral NSAID therapy can be used. Eye redness, irritation, or pain requiring treatment more aggressive than this should be reevaluated by a specialist for the presence of a more serious disease process, like scleritis.