Psychiatrists have long been involved in the evaluation of organ transplantation candidates. These evaluations are crucial to determine potential psychosocial barriers to a successful outcome. Although most transplant psychiatrists have become familiar with psychosocial evaluation for commonly transplanted organs such as kidneys and liver, ongoing developments and advancements in surgical techniques have opened new doors. We present the case of a psychiatric evaluation for a new retinal prosthesis technology (Argus II retinal prosthesis system, Second Sight Medical Products, Sylmar, CA). Our goal is to increase awareness among psychiatrists of this new technology and the applicability and limits of existing pre-organ transplantation psychosocial assessment approaches to this procedure. We also aim to raise awareness among ophthalmologists about potential psychosocial barriers to successful surgical outcomes and highlight the need for more routine preoperative psychosocial screenings prior to surgery.
Retinitis pigmentosa is an inherited condition that is caused by degeneration of rod and cone receptors. Many patients with this condition suffer legal blindness by middle adulthood.1
The Argus II retinal prosthesis system is currently the only US Food and Drug Administration-approved retinal prosthesis in the United States. It is specifically approved for patients with bare light perception or no light perception vision and diagnosed with advanced end stage retinitis pigmentosa.2 This device consists of an external video processing unit which translates visual information from an eyeglasses-mounted video camera into electrical signals.3
Vigilant preoperative screening and counseling are critical for successful implantation and visual rehabilitation along with management of the patient's expectations. The vision produced by the device is different from the patient's premorbid vision. Patients must learn to process light patterns. The most challenging aspect of the perioperative course is the postoperative visual rehabilitation. These patients transition from a world of complete darkness to seeing new flashes of light that they must learn to interpret and use to better navigate their surroundings. This rehabilitation requires from 6 months to 2 years before a patient may benefit from the device. The rehabilitation process consists of two stages: initially within a clinic, and then in the community. The patients are taught the components of their new device, how to manipulate the controls, and basic visual skills. In the beginning, patients learn eye movement and localization awareness.3 In the community, the focus is on visual integration into functional activities of daily living and refining existing blindness skills. Inability to comply with follow-up and after-care is generally considered a contraindication to the implantation of the device.3
The patient was a man in his 50s with a medical history of retinitis pigmentosa-related blindness since adolescence, type 2 diabetes mellitus, hypertension, and kidney disease requiring dialysis. He was referred to a consultation-liaison psychiatry service for a psychiatric evaluation of his candidacy for a retinal prosthesis implant, given concerns that he had unrealistically optimistic expectations regarding the implant outcome, a history of poor adherence with the preoperative regimen, and concern for high risk of poor adherence with postoperative appointments and medications.
On arrival for his assessment, the patient reported that he came to the appointment because he understood that some transplant cases require a psychiatric evaluation. The patient related that he had been attempting to receive this implant for several years, calling multiple hospitals and providers. The patient initially related that he believed this procedure would allow him to obtain “20/20” vision. When asked about what he believed the procedure entailed, he gave an elementary answer, stating it would be a long procedure requiring intravenous access. The patient was asked about the preoperative and postoperative course; however, he stated that he had not yet had this discussion with the provider, contrary to collateral reporting from his ophthalmologist. The patient was scheduled for the procedure earlier that year, but it was cancelled as he did not comply with the preoperative regimen. The patient reported that he believed his medications had been tampered with in the pharmacy, resulting in the wrong eye drops being dispensed and preventing his adherence.
The patient's self-reported psychiatric history included depressive symptoms, for which he had been prescribed a selective serotonin reuptake inhibitor by his primary care provider. He denied prior psychiatric hospitalizations or suicide attempts. He denied using alcohol, nicotine, or illicit drugs.
The patient was raised by both parents. After developing blindness during adolescence, he continued school with special services. He had never been employed.
In obtaining collateral information from the family, one relative corroborated the patient's lack of understanding about the procedure and outcome, and another raised concerns about the safety of the device itself. The patient's primary supporter within the family, who had been strongly advocating for the implantation, shared the patient's unrealistically optimistic expectation that it would completely restore his vision.
On mental status examination, the patient appeared somewhat anxious but was cooperative. His speech was normal aside from occasionally becoming rapid when appearing anxious about a question. He reported a “good” mood, and his affect was appropriate during the interview. He was free of any hallucinations or delusions. His insight and judgement as related to the implantation were poor (as described above). Cognitive testing was limited due to the patient's blindness. He was alert and oriented to date, time, and place. He could recall 2 of 3 words at 5 minutes and had difficulties with the “serial sevens” test, although he was able to spell the word “world” backwards.
In this evaluation, the Stanford Integrated Psychological Assessment for Transplantation (SIPAT) was used as a tool.4 The instrument was designed to standardize the psychosocial assessment of organ transplantation candidates but had not yet been validated for nontransplant medical technologies. It evaluates multiple psychosocial risk factors, with higher scores associated with poorer outcomes. This patient's SIPAT score was 34, which suggested that he was a minimally acceptable candidate, and it identified risk factors that needed to be satisfactorily addressed before further consideration for organ transplantation. The patient performed particularly poorly on the readiness section, which includes understanding of the transplant process. We determined that to be a better candidate for the retinal prosthesis procedure, our patient should demonstrate a better understanding of the implant process, more reasonable expectations for the outcome, and better adherence to preoperative care.
In a literature search of PubMed to date, this is the first reported case of a psychiatric evaluation as part of the preoperative assessment for a retinal prosthesis system. The SIPAT was a useful tool in our evaluation and provided guidance to help determine the patient's overall candidacy. However, this case highlights that the rapid evolution of medical technologies may necessitate the development of modified psychosocial assessment approaches that reflect the unique behavioral and learning demands of those technologies. Such demands may differ from that required by solid organ transplantation. For example, whereas adherence to immunosuppressant medications to prevent immunological rejection is the primary behavioral task after solid organ transplantation surgery, learning to interpret visual information in the spirit of navigating one's surroundings is paramount to a successful implantation of the Argus II retinal prosthesis. Similarly, whereas successful solid organ transplantations may restore functioning to near premorbid levels, the Argus II retinal prosthesis does not restore vision to near normal levels, further raising the bar for the level of insight that would be expected before proceeding to surgery. In the case of our patient, his persistent unrealistic expectations and those shared by his primary support were of major concern to both the referring ophthalmologist and psychiatric team.
Despite the rigorous behavioral demands required by an Argus II retinal prosthesis implant, psychosocial assessment is as yet not a universally required part of the preoperative evaluation as occurs with solid organ transplantation. Routinely including such evaluations to identify and address potential barriers to successful long-term outcome may decrease potential complications as well as disappointment if unrealistic expectations are not met. Research to further study the association between psychosocial variables and outcomes of this new technology would further inform the development of specific psychosocial guidelines and tools to assist in the evaluation of candidates for retinal prosthesis surgery.
- Hartog D, Berson E, Dryja T. Retinitis pigmentosa. Lancet. 2006;368:1795–1809. doi:10.1016/S0140-6736(06)69740-7 [CrossRef] PMID:17113430
- Finn A, Grewal D, Vajzovic L. Argus II retinal prosthesis system: a review of patient selection criteria, surgical considerations, and post-operative outcomes. Clin Ophthalmol. 2018;12:1089–1097. doi:10.2147/OPTH.S137525 [CrossRef]. PMID:29942114
- Ghodasra DH, Chen A, Arevalo JF, et al. Worldwide Argus II implantation: recommendations to optimize patient outcomes. BMC Ophthalmol. 2016;16:52. doi:10.1186/s12886-016-0225-1 [CrossRef] PMID:27154461
- Maldonado JR, Sher Y, Lolak S, et al. The Stanford Integrated Psychosocial Assessment for Transplantation: a prospective study of medical and psychosocial outcomes. Psychosom Med. 2015;77(9):1018–1030. doi:10.1097/PSY.0000000000000241 [CrossRef] PMID:26517474