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Intelligent prevention

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Last month, I wrote about the incredibly frustrating interaction I had with an internet-challenged dental hygienist over the prognostic value of screening x-rays. This month, I’m back to illustrate how clinical prevention can and should work.

Last week, I visited my optometrist. I started wearing glasses at age 8 or 9, for pretty bad nearsightedness. I wore glasses (increasingly thick ones) as I went through adulthood and then eventually bifocals, before I had a very successful Lasik procedure in 2004. This resolved my myopia almost completely and left me needing only 1.5 power readers for close-up work.

A couple of years ago, I noticed that my night vision while driving was not as sharp as I would like it to be and that occasionally I saw annoying halos around oncoming headlights. Since driving at night without clear vision is a really bad idea, my optometrist prescribed night driving glasses with an anti-reflective coating that completely eliminated the problem. Last week, I went back to have her tweak the prescription and also to dilate and examine my eyes internally because we had not done that for a couple of years.

She had two positive findings on dilation and internal exam. First, my left retina has developed an area of thinness, although not in a spot that is typically the locus of retinal detachments. Why does this matter? I do karate, and while we are a non-contact dojo, you do occasionally get clocked. It’s a combat sport, after all. She reassured me, however, that I need not run out to buy protective headgear (which creates a different set of problems) simply to avoid the (very low) prospect of a retinal detachment. The areas of my retinas where detachments are more likely to happen are not thinned. Hence, this is a positive finding that does not merit any specific follow-up.

The second finding was much more interesting, as was her advice. For the first time, she was able to visualize that my right lens is starting to ever so slightly get cloudy…a cataract is forming. Her reaction to it was exactly what you want in a competent and clear-headed health professional: “Vik, there’s nothing we can or should do about this slowly forming cataract. It’s probably going to be 15 to 20 years before it affects your vision (at the exam my vision without the corrective driving glasses was 20/20; with them it was 20/15). The only thing you should do is always wear a ball cap with a bill and sunglasses when you’re out during the day. By maximizing your protection against the UV rays of the sun, it’ll slow the formation of the cataract. It’s possible that with consistent eye protection, you’ll never develop a problem that requires lens replacement.”

That, my friends, is meaningful clinical prevention (to be technical, this is secondary prevention in both cases. The problems now exist; all I can do now is slow the formation of the cataract and stay out of the way of roundhouse kicks to my head that might cause a detachment where it should not happen). Two positive findings on exam, both potentially scary to someone who doesn’t know anything about the human body (which would include nearly everyone working in workplace wellness and most Americans generally) or the way problems progress. But, in reality, these don’t really even merit watchful waiting; she’ll observe both things in future exams and we’ll talk about how they are changing, if at all.

More to the point, I’ll know when the cataract is becoming a problem because, duh, my vision will start to get cloudy. In 20 years, we’ll see if my vision is impaired enough to diminish quality of life, and then maybe I’ll have the lens replaced.

This does, however, give me a reason to wear my Maui Jims more often. Best. Sunglasses. Ever.

Hats off to my optometrist and the people who trained her.


Note from Al: This approach to prevention should be contrasted to Health Fairs USA, where prevention consists of rounding employees up to tell them they have cancer when they don’t, and then recommending “preventive surgery.”


In the immortal words of the great philosopher Pat Benatar, hit me with your best shot.

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