John G. McHenry, M.D., M.P.H., P.L.L.C.

Appointments
214.753.8500

For Physicians

Country Doctorin’

My father started out as a country doctor in the 1930s. Later in life I learned all too well that you’d better be on your toes when a a professor would describe themselves as such. It’s much the same as an Austin attorney tellin’ a Yankee lawyer “aw shucks I’m just from Texas”. One day he said to me “Son, I’m going to give you two pieces of advice: Don’t raise dairy cattle and don’t do contacts.

You see the old country doctor also had done a residency in ophthalmology and a residency in otolaryngology and a fellowship in plastic surgery all after he finished his degrees in chemistry and agriculture. So I listen to him then as I did for many years. I became an interventional neuro-ophthalmologist and raise Herefords. As men my age will attest, we never stop listening to ourr fathers long after they are gone.

Since I’m an off and on professor myself, what I’m gunna try to do is pass on a little of his country knowledge: what I would call Desert Island Ophthalmology. Some self righteous sorts from some schools back east call it what to do ‘till the doctor gets there. Let’s just think of it as old west ingenuity, or what would McGiver do.

Temporal Arteritis

An 80 year old female comes into your office on a Friday afternoon complaining of visual loss and temporal pain. You look in her eye and her disc looks like that Icelandic volcano no one can pronounce: it’s swollen and pale.

What' y'all gunna do?

Get some blood, start her on steroids and give us a call. My mentor Tom Spoor would say ”the bell’s gotta ring’. This of course is giant cell arteritis or temporal arteritis. Send her to the pharmacy for 120 mg of prednisone stat and in the AM and continue it till we prove it is not giant cell arteritis. You may not be able to save this eye, but eyes come two by two for just this occasion. Get her to the lab for an ESR, C Reactive protein and Platelets. Then get her to me.

I took care of a wonderful older gentleman in his 90s for many years with giant cell arteritis who never stopped raving about one of my ex-residents who while in private practice would not take no for an answer. To the old man’s later delight he saved his vision. He actually drove the old man to the lab and deposited him on my doorstep. There is nothing like being a real doctor. The gratitude of your patients keeps you going through the tough times

Papilledema

A 22 year old obese female comes into your office. She is complaining of headaches and transient visual obscurations. You look I her eyes and she has bilateral swollen nerves. In the old days, bilateral swollen nerves were brain tumors until proven otherwise. Believe me this is still the old west. Until you have reviewed an MRI the patient with the swollen nerves has a brain tumor.

What' y'all gunna do?

Get an MRI and give us a call.

When I was a first year resident I was a persistent cuss (as opposed now to being persistently cussed at} who saw a patient in our emergency walk-in clinic with a little bit of disc swelling and a whole lot of headache. I convinced Dr Spoor to get a scan on the patient and he turned out to have a malignant glioma. I was very proud of myself until Dr. Spoor reminded me there was no useful treatment (at that time). That episode constantly reminds me that diagnosis is for academics and helping others is for real doctors. I started him on acetazolamide, steroids and narcotics and worked on helping his headaches.

Most patients with papilledema will not have brain tumors. The next most important test to do is to perform computerized static perimetry to determine if there is visual loss. If there is any loss or there are headaches then a lumbar puncture is crucial.

Pupil involved third nerve palsy

So its four o’clock on a Friday afternoon and a patient comes in with double vision and a droopy lid. You note that the pupil is larger and poorly reactive on that side, the eye is down and out and he is complaining of headaches.

What' y'all gunna do?

Get a stat MRI and MRA and give us a call. This patient has an aneurysm until proven otherwise. I’ve had the misfortune of seeing several patients whose aneurysms were progressing while in my office. Once again you get to be a real doctor here. Your patient will never forget who it was who got them to the ER.

I’ve followed many of these patients over time and eventually completely rehabilitated their diplopia and ptosis with surgery. They will require sequential eye muscle surgery when the strabismus has stopped improving and then a ptosis repair.

Anterior ischemic optic neuropathy

A 50 year old male comes in with a cloud over the vision of one eye. When you look into his eye there is segmental swelling an hemorrhages of the disc.

What' y'all gunna do?

This of course is ischemic optic neuropathy. You need to lower the eye pressure and start them on aspirin. Get an ESR a CRP and a Platelet level and give us a call.

In one of the great ironies of life this happened to my father while he was operating. Back then patients were given a trial of steroids. It didn’t help his vision but it did give the cows a companion in the early morning because he couldn’t sleep and was up at 4 AM. He also got a case of prostatitis.