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The Need for Social Service Work in Glaucoma*
T H E NEED FOR SOCIAL SERVICE W O R K IN
GLAUCOMA*
AUGUST F. J E N S E N , M.D.** Grand Forks, North Dakota AND
HARRY
S.
GRADLE,
M.D.
Chicago Number Both Eyes Type of Cases Involved R. Acute incompensated . . 33 4 19 Chronic incompensated . 3 1 2 Compensated 161 113 141 Absolute 41 11 30 Hydrophthalmos 1 1 1
This is a study based on new cases of glaucoma admitted to the Illinois Eye and E a r Infirmary in-patient department be tween J a n u a r y 1, 1933, and J a n u a r y 1, 1937. None of the patients admitted be fore that time is now coming for treat ment. All diagnosed in the out-patient de partment as glaucoma patients were sent to the hospital for admission; but many refused to go and, consequently; no out patients are included in these statistics. This study was made to determine how many returned to the clinic for treatment and how long they continued treatment. Only the primary glaucomas are consid ered.
In 130 cases both eyes were involved and in 109 only one eye was involved. Of patients with both eyes involved, the majority were over 50 years of age. O u t of this group, there were only 33 cases of acute incompensated and 3 cases of chronic incompensated glaucoma. Six of the patients were totally blind in both eyes when first seen; several were blind in one eye, and had only light per ception in the other. In the 239 cases, 369 eyes were involved. Of t h o s e :
During this period 239 patients were admitted to the in-patient department of the Illinois E y e and E a r Infirmary. Of these, 133 were males and 106 were fe males. Their ages were as follows: Age Between 1 and 10 years Between 10 and 20 years Between 20 and 30 years Between 30 and 40 years Between 40 and SO years Between SO and 60 years Between 60 and 70 years Between 70 and 80 years Over 80 years
L. 18 3 133 22 1
Vision . Totally blind Light perception Hand movements to 20/200
Number of Cases 0 4 0 12 25 82 67 42 7
T h e greatest number were in the fifties and sixties and consequently had a life ex pectancy of 15 to 20 years. T h e cases were grouped into five types as follows: * From tlie Illinois Eye and Ear Infirmary. ** Formerly Senior Resident at the Illinois Eye and E a r Infirmary.
Number 74 86 104
In every case, the best possible vision with correction was recorded. There was considerable variation as to the time the patient had noticed the on set of the condition before coming to the clinic. Many of them could not give a definite statement, for there had been a gradual loss of vision over a considerable period of time. T h e younger the patient the more definitely was the time of on set determined. T h e length of time that elapsed between subjective onset of symptoms and first visit to the infirmary was found to be as follows:
993
994
A U G U S T F. J E N S E N A N D H A R R Y S. G R A D L E
Time Less than one month One to six months Six months to one year One year to two years Two years to three years Three years to four years Four years to five years More than five years
Number of Cases 19 50 28 40 24 19 14 5
Most of the patients had noticed that they had to have their glasses changed more often and finally they were not able to obtain sufficient visual improvement with a change of glasses. Quite a number of them were referred to the clinic for cataract operation, or had been diagnosed as cataract patients elsewhere and told to wait for operation until the cataracts were "ripe." There were 296 hospital admissions. Of those: Number admitted Only once Twice Three times Four times Five times Six times
Number of Cases 195 36 0 0 1 1
Of the 239 patients admitted, 171 were operated upon and 68 underwent no opera tion. There were 215 operations per formed. Twenty-nine percent of the patients operated upon were observed less than one month. Sixty percent were observed less than six months subsequent to opera tion. Of the 239 patients treated at the hospital during this time, 172 were treated less than six months. Of the patients treated, the duration of observation was as follows: Number Observation of Cases Less than one month 88 One month to six months 84 Six months to one year 22 One year to two years 16 More than two years 19 Still coming to the clinic for observation . 8
One hundred and seventy-two or nearly 72 percent of the patients were observed less than six months. They were probably not going elsewhere for treatment, for in this group only one had been treated for glaucoma elsewhere before coming to the clinic. This patient had been treated at a private clinic and hospitalization was advised. She was unable to pay for the hospital care, so was referred here. Three patients did not remain in the hospital long enough to be studied. In all of the cases admitted, the tension was con trolled at the time of discharge. Only eight of the patients admitted dur ing this time are still coming to the clinic under observation. These have been com ing regularly and have kept up their treat ment. Out of the 239 patients admitted to the hospital during the period from January 1, 1933, and January 1, 1937, only 67 re turned to the clinic for observation follow ing their hospitalization. One hundred and seventy-two patients received no fur ther treatment. We have no way of knowing of what value our treatment has been unless our patients return for follow-up work. One hundred and seventy-one patients were operated upon, 40 percent of whom were not seen at all after their discharge from the hospital. There is no way of knowing what operation gave the best results nor how long it was efficient. Of the entire group admitted during this time 72 per cent did not receive care after discharge. No matter how thorough our study or how well we were able to classify the case and outline the procedure of treatment, the patient has not been benefited as far as we know. These figures prove that our clinical cases of glaucoma are not receiving the aftercare necessary to pre vent almost certain blindness. The per centage of blindness due to glaucoma varied throughout the world from 6.5
SOCIAL SERVICE AND THE GLAUCOMATOUS
percent in the United States to 18 percent in some of the European countries. Such blindness is due to: (1) Lack of recogni tion of the disease until permanent dam age has been done; (2) inadequate medi cal or surgical care; (3) failure to observe the patient sufficiently long to insure against the further loss of vision from hypertension. This is not the place to discuss the first two aspects, although the third table in this paper could open the way. The ques tion here is, "How can the third phase be eliminated as far as is humanly possible?" The failure to observe glaucoma pa tients over a sufficient length of time must be attributed partly to the attending phy sician and partly to inherent negligence on the part of the patients. In a busy clin ic, the physician has not the time nor the patience to sit down and explain painstak ingly to the patient the character of the disease, the impossibility of improvement of vision beyond the existing conditions, the necessity of long-continued observa tion, and the importance of following medical or surgical directions implicitly. On the other hand, clinic patients are apt to be of a lower mental caliber and con sequently cannot comprehend the situa tion. Furthermore they are apt to find no improvement in vision after weeks of
995
use of drops or after operation and they drop the whole matter, accepting the loss of vision as something inevitable. In addi tion, if the patient is the support of the family, a visit to the clinic consumes near ly a whole day, causing a loss of one fifth or one sixth of the weekly income, which is an economic factor that must be given serious consideration. Much discussion along these lines is possible, but unnecessary, for the remedy is at hand, thanks to George Derby, who showed us the way. Adequate medical social service is the answer and thereby well over 80 percent of the third aspect of the problem can be solved. Only in that or some similar way can we keep under necessary observation the cases of glaucoma that seem doomed to ultimate blindness from neglect. Medical skill can prevent a large share of blind ness from glaucoma, but only if the pa tients are there for the doctors to work upon. No physician can prevent loss of vision from hypertension by absent treat ment. Four years from now, we will make a similar report upon the management of glaucoma under the added control by Social Service, and we think it will be more cheerful. 904 West Adams Street.
GLAUCOMA*
AUGUST F. J E N S E N , M.D.** Grand Forks, North Dakota AND
HARRY
S.
GRADLE,
M.D.
Chicago Number Both Eyes Type of Cases Involved R. Acute incompensated . . 33 4 19 Chronic incompensated . 3 1 2 Compensated 161 113 141 Absolute 41 11 30 Hydrophthalmos 1 1 1
This is a study based on new cases of glaucoma admitted to the Illinois Eye and E a r Infirmary in-patient department be tween J a n u a r y 1, 1933, and J a n u a r y 1, 1937. None of the patients admitted be fore that time is now coming for treat ment. All diagnosed in the out-patient de partment as glaucoma patients were sent to the hospital for admission; but many refused to go and, consequently; no out patients are included in these statistics. This study was made to determine how many returned to the clinic for treatment and how long they continued treatment. Only the primary glaucomas are consid ered.
In 130 cases both eyes were involved and in 109 only one eye was involved. Of patients with both eyes involved, the majority were over 50 years of age. O u t of this group, there were only 33 cases of acute incompensated and 3 cases of chronic incompensated glaucoma. Six of the patients were totally blind in both eyes when first seen; several were blind in one eye, and had only light per ception in the other. In the 239 cases, 369 eyes were involved. Of t h o s e :
During this period 239 patients were admitted to the in-patient department of the Illinois E y e and E a r Infirmary. Of these, 133 were males and 106 were fe males. Their ages were as follows: Age Between 1 and 10 years Between 10 and 20 years Between 20 and 30 years Between 30 and 40 years Between 40 and SO years Between SO and 60 years Between 60 and 70 years Between 70 and 80 years Over 80 years
L. 18 3 133 22 1
Vision . Totally blind Light perception Hand movements to 20/200
Number of Cases 0 4 0 12 25 82 67 42 7
T h e greatest number were in the fifties and sixties and consequently had a life ex pectancy of 15 to 20 years. T h e cases were grouped into five types as follows: * From tlie Illinois Eye and Ear Infirmary. ** Formerly Senior Resident at the Illinois Eye and E a r Infirmary.
Number 74 86 104
In every case, the best possible vision with correction was recorded. There was considerable variation as to the time the patient had noticed the on set of the condition before coming to the clinic. Many of them could not give a definite statement, for there had been a gradual loss of vision over a considerable period of time. T h e younger the patient the more definitely was the time of on set determined. T h e length of time that elapsed between subjective onset of symptoms and first visit to the infirmary was found to be as follows:
993
994
A U G U S T F. J E N S E N A N D H A R R Y S. G R A D L E
Time Less than one month One to six months Six months to one year One year to two years Two years to three years Three years to four years Four years to five years More than five years
Number of Cases 19 50 28 40 24 19 14 5
Most of the patients had noticed that they had to have their glasses changed more often and finally they were not able to obtain sufficient visual improvement with a change of glasses. Quite a number of them were referred to the clinic for cataract operation, or had been diagnosed as cataract patients elsewhere and told to wait for operation until the cataracts were "ripe." There were 296 hospital admissions. Of those: Number admitted Only once Twice Three times Four times Five times Six times
Number of Cases 195 36 0 0 1 1
Of the 239 patients admitted, 171 were operated upon and 68 underwent no opera tion. There were 215 operations per formed. Twenty-nine percent of the patients operated upon were observed less than one month. Sixty percent were observed less than six months subsequent to opera tion. Of the 239 patients treated at the hospital during this time, 172 were treated less than six months. Of the patients treated, the duration of observation was as follows: Number Observation of Cases Less than one month 88 One month to six months 84 Six months to one year 22 One year to two years 16 More than two years 19 Still coming to the clinic for observation . 8
One hundred and seventy-two or nearly 72 percent of the patients were observed less than six months. They were probably not going elsewhere for treatment, for in this group only one had been treated for glaucoma elsewhere before coming to the clinic. This patient had been treated at a private clinic and hospitalization was advised. She was unable to pay for the hospital care, so was referred here. Three patients did not remain in the hospital long enough to be studied. In all of the cases admitted, the tension was con trolled at the time of discharge. Only eight of the patients admitted dur ing this time are still coming to the clinic under observation. These have been com ing regularly and have kept up their treat ment. Out of the 239 patients admitted to the hospital during the period from January 1, 1933, and January 1, 1937, only 67 re turned to the clinic for observation follow ing their hospitalization. One hundred and seventy-two patients received no fur ther treatment. We have no way of knowing of what value our treatment has been unless our patients return for follow-up work. One hundred and seventy-one patients were operated upon, 40 percent of whom were not seen at all after their discharge from the hospital. There is no way of knowing what operation gave the best results nor how long it was efficient. Of the entire group admitted during this time 72 per cent did not receive care after discharge. No matter how thorough our study or how well we were able to classify the case and outline the procedure of treatment, the patient has not been benefited as far as we know. These figures prove that our clinical cases of glaucoma are not receiving the aftercare necessary to pre vent almost certain blindness. The per centage of blindness due to glaucoma varied throughout the world from 6.5
SOCIAL SERVICE AND THE GLAUCOMATOUS
percent in the United States to 18 percent in some of the European countries. Such blindness is due to: (1) Lack of recogni tion of the disease until permanent dam age has been done; (2) inadequate medi cal or surgical care; (3) failure to observe the patient sufficiently long to insure against the further loss of vision from hypertension. This is not the place to discuss the first two aspects, although the third table in this paper could open the way. The ques tion here is, "How can the third phase be eliminated as far as is humanly possible?" The failure to observe glaucoma pa tients over a sufficient length of time must be attributed partly to the attending phy sician and partly to inherent negligence on the part of the patients. In a busy clin ic, the physician has not the time nor the patience to sit down and explain painstak ingly to the patient the character of the disease, the impossibility of improvement of vision beyond the existing conditions, the necessity of long-continued observa tion, and the importance of following medical or surgical directions implicitly. On the other hand, clinic patients are apt to be of a lower mental caliber and con sequently cannot comprehend the situa tion. Furthermore they are apt to find no improvement in vision after weeks of
995
use of drops or after operation and they drop the whole matter, accepting the loss of vision as something inevitable. In addi tion, if the patient is the support of the family, a visit to the clinic consumes near ly a whole day, causing a loss of one fifth or one sixth of the weekly income, which is an economic factor that must be given serious consideration. Much discussion along these lines is possible, but unnecessary, for the remedy is at hand, thanks to George Derby, who showed us the way. Adequate medical social service is the answer and thereby well over 80 percent of the third aspect of the problem can be solved. Only in that or some similar way can we keep under necessary observation the cases of glaucoma that seem doomed to ultimate blindness from neglect. Medical skill can prevent a large share of blind ness from glaucoma, but only if the pa tients are there for the doctors to work upon. No physician can prevent loss of vision from hypertension by absent treat ment. Four years from now, we will make a similar report upon the management of glaucoma under the added control by Social Service, and we think it will be more cheerful. 904 West Adams Street.