Eyeworld

EW NEWS & OPINION 30 September 2017 Weighing in Although the findings are relevant for ophthalmologists, Dr. Thyssen thinks it's his colleagues on the dermatology side who may benefit more from the findings. "[They] should refer more patients with ocu- lar complaints to ophthalmologists, since complications are frequent, sometimes severe, and may be over- looked among the many comorbidi- ties of atopic dermatitis," he said. Adrian Jachens, MD, EyeCare 20/20, East Hanover, New Jersey, found the discussion on biologic treatment interesting if not a bit per- plexing in terms of how much AD treatment can help patients. "The hypothesis discussing eosinophils was interesting and may sufficiently explain this phenomenon, but it's still not a great situation to be in where you're fixing one's eczema and creating another worsening hy- persensitivity elsewhere," he said. One pearl Dr. Jachens found was to become more familiar with newer biologic treatments coming down the pipeline and their associated in- creased risk of conjunctivitis. "Oph- thalmologists should consider asking patients with allergic conjunctivitis if they have had atopic dermatitis and if they are on those drugs," he said. Additionally, ophthalmolo- gists should refer any patient with suspected dermatitis, usually defined by a severe itch or a family history of atopic disease, to a dermatologist, Dr. Thyssen said. Such referrals also are valuable if a patient has estab- lished atopic dermatitis but it is not under control. Dr. Jachens has no problem making such referrals. "Since der- matology and ophthalmology are distinctly different subspecialties, each should readily refer to the other when diseases overlap," Dr. Jachens said. EW Reference 1. Thyssen JP, et al. Incidence, prevalence, and risk of selected ocular disease in adults with atopic dermatitis. J Am Acad Dermatol. 2017;77:280–6. Editors' note: The physicians have no financial interests related to their comments. Contact information Jachens: ajachens@eyecare2020.com Thyssen: Jacob.p.thyssen@regionh.dk Insights by J.C. Noreika, MD, MBA perplexing contradiction to a physi- cian's need to fix, mend, and heal, it may be best to respect her choices, to understand, to empathize as best as one can who too will someday die. My mother is 86. She survives in ways I cannot fathom. In death, she will secure that peace and serenity found wanting in advanced age, existential angst and a childlike fear. She will die, I know not when, but her memory will live on intense- ly in the minds of those few who know her best and later in abstract myths and fictions passed along by others at funerals, weddings, and gatherings where life is celebrated in both tenses, past and future. In the end, there will be nothing, just carbon, nitrogen, iron, silicone, the star-stuff of this universe's life. If there's an incomprehensible unknown when she does shuffle off, I hope she takes better care of herself, listens to her doctors, and always chooses Jeopardy's Daily Double. Above all, I pray she finds God's bounty of the tranquility of timelessness so elusive in life. Until that appointed time, I will support her as she will permit. I'll be kind, compassionate, and most of all, patient. As a doctor, I can't fix her. As her son, I'll respect her judgment. EW Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Contact information Noreika: JCNMD@aol.com a window, and television's compan- ionship. Drew Carey beckons her to lunch; Pat Sajak reminds her to sit for supper. She has succumbed to aging nei- ther precipitously nor contentiously. Her trajectory to death has been an inevitable slowing, a glacier's sub- tlety with sentient avoidance of pre- vention. It's been years since she was fully functional—perhaps her early 70s, I think. Her days are no longer vital and they pass seamlessly, rou- tinely. She has senile aortic stenosis; her doctor's record says so. Her once elastic valve leaflets, opening and slapping shut somewhat regularly as lifeblood courses from heart to the far reaches of her being, are calcified, stiff, sclerotic, exhausted. Surgery is unthinkable. She is frequently short of breath at rest. This symptom predicts her mean life expectancy at 6 to 24 months. It's a statistic. We all struggle for the coveted right leg of the Gaussian curve, that diminished area that extends mortality without regard to function, cognition, or whatever happiness looks like to a human being whose day is measured in "I want to buy a vowel" and "Who is Kübler-Ross, Alex?" She re- buffs all efforts at medical interven- tion, shifting any such discussion quickly and adamantly to a house wren on her windowsill. Rational? As rational as one who feels too poorly to keep a doctor's appoint- ment, yet religiously takes her daily ration of another 90-day supply of medication. What to do? I'm not certain there is anything to do. Although in accounts for most of this accretion. The number of U.S. citizens older than 90 has more than tripled since 1980. Women older than 90 out- number men 3 to 1; more than 80% are widowed. Despite infirmity and disability, most live alone. An academic literature has developed around growing old. Eric Erikson's Vital Involvement in Old Age and George Vaillant's writings on Harvard's Grant Study offer valuable treatises on late adult development. Marcus Tullius Cicero's Cato Maior de Senectute (On Old Age) is the arche- type. Citing Plato, Sophocles, and others, the Stoic's advice resonates today. None of us get out of here alive. I'm not clever enough to be one of those doctors professing an insider's privilege to life's great design and death's mystery. Physicians first as- semble data culled from their obser- vations and then interpret it based on experience, knowledge, and bias. When it comes to life's end, many find it best to under promise and over perform. After all, we've all heard of people who walk the streets years after their doctor informs them they have a month, 3, 6 to live. We ophthalmologists learn this in our daily work. We also encounter it in our personal lives as we and our loved ones must confront life's end. Our medical knowledge is inade- quate when it becomes this person- al. I think of my mother. She is 86 years old. She will soon die. My mother has lived a full life, a "good run." Feigning indepen- dence, she chooses to live alone. Her interests are her dog, sitting by Ophthalmology's waiting rooms are crowded with the aged and infirm. Sharing a common fate, eye surgeons might reflect on what it means to grow old to better empathize with their patients' challenges "Last scene of all, That ends this strange eventful history, Is second childishness and mere oblivion, Sans teeth, sans eyes, sans taste, sans everything." —As You Like It, Act II, Scene 7 A mericans have little diffi- culty inviting their own mortality. The internet is rife with news with death's methods as varied as an opioid Neonatal Intensive Care Unit, the killing fields of Chicago's South side, the wrack and ruin of Afghanistan, and the elderly's lethal depression and decay. Yet medical science continues to prolong life's longevity to lengths unprecedent- ed in the history of Homo sapiens. Since 1950, the average American life expectancy has increased from 68 years to more than 80 years in women, less in men. Decreasing mortality of the oldest of the old Life's seventh and final act J.C. Noreika, MD, MBA Delving continued from page 28

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