Finding the Right Path

Published in Wilmer - Summer 2023

On a Thursday evening in the summer of 2022, Patrick Richard, Ph.D. experienced a sudden headache and severe eye pain — the worst pain he had felt in his life. He would later learn that he had suffered an attack of acute angle-closure glaucoma, a medical emergency that can lead to blindness within a few days without treatment.

The attack was an intense experience and Richard developed a close clinical relationship with Jella An, M.D., M.B.A., associate professor of ophthalmology. “At my age, I’ve interacted with a number of physicians in different specialties, and I do not remember having such a positive experience,” says Richard, who is director of the Health Services Administration Division at Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Richard first came to Wilmer about six months before that fateful Thursday. Since 2019, his vision hadn’t been as sharp, and his glasses weren’t helping. At Wilmer, Richard learned he had developed a cataract, or a clouding of the lens, in his left eye. In this case, the cataract had caused his lens to become larger, and it was closing off the angle, or drainage system, in that eye, increasing the risk of angle-closure glaucoma.

This relatively underdiagnosed condition, often caused by the growing size of the lens (in the form of the cataract, in this case), progressively narrows the drainage angle. Once the drainage angle completely closes, fluid gets trapped, which leads to high eye pressure.

“This was the first time I was learning about glaucoma and cataracts,” he says. “I’d been having all these issues with my eyes, and they were never diagnosed until I came to Wilmer. That’s when I felt like I was on the right path.”

After this diagnosis from a Wilmer optometrist, Richard was referred to An, who initially had good news: His angle-closure glaucoma could be addressed by cataract surgery, which would also improve his vision that had been affected by the cataract. During the surgery, An would remove his hazy natural lens and replace it with a clear artificial lens that would also be thin enough to create space to open the angle. Richard scheduled the surgery for the fall of 2022.

Then that summer, Richard, who had been taking two medications for glaucoma, woke up on a Wednesday and noticed some pain in his left eye. He went to urgent care and then the emergency room, and was diagnosed with high pressure again. Richard received a third glaucoma medication, and he made an appointment with An for Friday morning.

It was the next day that Richard suddenly felt the most horrible headache he had ever had. The acute angle-closure attack — a relatively rare development that affects less than 1% of the population — caused his eye pressure to soar, suddenly reaching 50 when it should be in the mid-teens.

Richard spent all day that Friday at An’s clinic. He urgently needed cataract surgery, but An first needed to address his swollen cornea, a complication of the attack. “When the cornea swells, the view gets very hazy, so you can’t really look through the eye and do the cataract surgery safely,” she says. “That was a limiting step because we wanted as clear a view as possible while also not delaying the surgery any more than necessary.”

At the clinic, An went through every treatment to lower Richard’s eye pressure, including performing laser surgery by cutting a small hole in the corner of the iris to allow the trapped fluid to flow into the angle. But because Richard’s angle was completely closed, this only reduced his pressure to around the mid-30s. An prescribed drops to reduce the inflammation in Richard’s eye, and, within a week, the swelling had subsided enough that she could perform the surgery.

But there would be another complication. During the surgery, Richard’s cornea swelled up again. “I couldn’t see anything inside of the eye,” An says. In cataract surgery, ophthalmologists need to make sure they don’t puncture the membrane that divides the vitreous and the anterior chamber, as this could cause vision-threatening complications, such as retinal detachment and infection. But because An couldn’t see the membrane clearly, she needed to rely on her past surgical experiences to guide her through the surgery.

“I had to imagine where my hands are normally supposed to be and where my instruments are supposed to be, and observe the dynamics of the fluid,” says An, who later performed cataract surgery on Richard’s right eye as a preventative measure. “Despite the challenges, the surgery went well, without complications. Without the natural lens, the angle opened up, and his pressure went down. His vision was restored to baseline without the need for any medication.”

An was also surprised and elated to see that Richard’s optic nerve wasn’t damaged despite days of very high eye pressure — and that he no longer had glaucoma. “That was a celebratory moment,” she says. “After that experience, he became a very special patient in my mind.”

Richard appreciates An’s approach to treating her patients like people instead of only seeing them as a diagnosis. “From a clinical standpoint, she’s very talented, and she pays attention to details,” says Richard, whose wife, Nancy Richard, also became one of An’s patients after this experience. “But there is also this feeling that you’re not just a patient, that she sees me. I feel very lucky and fortunate that I went to Wilmer.”