I consider myself a better than average ocular diagnostician. Whenever my technician or an intern comes into my office and tells me a patient’s history and describes the patient’s signs and symptoms, I usually know what is wrong without even looking. I am like Carnac the Magnificent, only with a white coat and head-mounted ophthalmoscope instead of a cape and feathered turban.
In my head, I generate a list of three to four possible diagnoses and rank them according to their probability. If it is my technician, I tell him what I think is most likely going on and perhaps ask him to perform another test or two and then dilate the patient’s pupils. If it’s an intern, I might quiz them Socractically for a few minutes in a attempt to jump-start their thinking, but I don’t tell them what I think is wrong. I want them to figure it out on their own.
Over the past 20-plus years as an optometrist, I’ve put my diagnostic skills to good use, helping save the sight of thousands of patients. Today, I had the opportunity to save my own.
About 10 o’clock this morning, I was discussing my findings with a patient when I casually looked down for a second. When I looked back up, a large shadow passed in front of my vision. I literally jumped, thinking that I had just been buzzed by a fly or gnat. I reflexively swatted at it with my right hand.
My patient and my tech had noticed and looked at me funny. A second later, the “bug” returned, hovered in front of my line of sight for a second, then flew away. I remember thinking Focus on finishing the exam! You can deal with this later.
Muscae volitantes (from the Latin, meaning “flying flies”) are not real insects, but instead vitreous floaters. The vitreous humor, a gel-like substance that fills the inside of the eye, is normally transparent and goes unnoticed. It is composed of collagen and hyaluronic acid, which can shrink over time, a process called syneresis. Depolymerization causes the hyaluronic acid to release water, which in turn causes the vitreous gel to become more liquified. The collagen fibrils start to clump together and move about in the liquified vitreous, and when light hits them, they create shadows on the retina that can appear as cobwebs, spots, threads, “germs,” or, in my case, “bugs.” Since there are actual objects in the eye causing the effect, vitreous floaters are not an optical illusion but instead are classified as entoptic phenomena.
I’ve had vitreous floaters since college. I’m moderately myopic (nearsighted), so they developed earlier than normal. But this one was not among those that I have lived with and grown accustomed to all these years. This one was darker and more ominous, like the shadow cast by a large bird of prey.
I sat at my desk and moved my right eye around. The floater flitted about like a lightning bug dancing in a jar. My eyes were feeling a little dry, so I tested an alternative theory. Thinking that what I was seeing might not be a new vitreous floater but instead a strand of mucus skating across the cornea, the eye’s clear front surface, I put a few drops of artificial tears into my right eye. I blinked a few times and waited. A few seconds later the “bug” was back, drifting slowly past my line of sight like a raft on a lazy river.
I noted that I had not seen any photopsia or flashes of light. Flashes are like warning flares, indicating that the vitreous might be collapsing and tugging at one of its several tight adhesions with the retina. Sometimes, the traction can cause retinal tears which create an opening through which liquified vitreous can seep, detaching the retina from its moorings and filling it like a billowy sail.
I thought little more of it for the rest of the day, occasionally noting the floater’s presence, thinking to myself that I needed to find a colleague to check it out sometime this week. I didn’t feel a particular sense of urgency.
At 4:00PM, I left the office a little early to go by Office Depot for some envelopes and mailers. I noticed that my right eye was a little blurry and felt a little “full” and achy. Entoptic phenomena are more noticeable against a blank surface like a white sheet of paper or an open monochromatic space such as the cloudless, cerulean blue sky of an Alabama summer’s day. As I drove west on Governors Drive, I looked up at the sky and saw something that I had never seen before–a dozen tiny black donuts pirouetting in the air.
That’s when I knew I was in trouble.
I knew instantly that what I was seeing were the tiny, biconcave bodies of red blood cells in my vitreous. The human erythrocyte pushes out its nucleus as it matures, forming a discoid-shaped cell that is centrally depressed on both sides but not so much so that the two sides meet in the middle. I was seeing the shadowy afterimages of such cells–black donuts–which are a welcomed presence in most places in the human body, but not the vitreous. I was most likely experiencing a vitreous detachment which had torn the retina and perhaps a blood vessel as well, setting the stage for a retinal detachment.
I pulled into the Office Depot parking lot and cut the engine. I faced a crucial decision. Should I just wait until tomorrow to get it checked out, or should I get help immediately? What would I tell one of my patients to do? It was late in the day, and I know what it’s like having a patient call near closing time with a so-called “emergency.”
I knew I probably had a retinal tear, but I had no idea how large it was or where it was located. I asked myself, “What’s the worst thing that could happen?” I decided that the worst case scenario would be waiting and waking up in the morning with half or more of my vision completely gone from a retinal detachment which would then require general anesthesia and major ophthalmic surgery.
I turned the engine back on and made a U-turn toward my office.
I arrived back at my office at 4:10PM and headed straight to the exam room and instilled one drop of proparacaine, one drop of tropicamide 1% and one drop of neosynepherine 2.5 % in each eye to dilate them. I called the front desk at Retina and Vitreous Associates on Meridian Street. I spoke with an appointment clerk and told her that this was Dr. Michael Brown and that I needed to refer a person with an acute posterior vitreous detachment and a high likelihood of a retinal tear. She asked for the patient’s name, and I said, “It’s me.”
She told me to come straight there and that they would be waiting for me.
I called Eyegal and told her what was going on. “Do you need me to come over and drive you?” she asked, the concern evident in her voice.
“Nah,” I replied, “I’ll be fine. If they have to do something and think its unsafe for me to drive home, I’ll call you.”
I left the office at approximately 4:20PM and arrived at the retinal specialist’s office 5 minutes later. I popped a few breath mints in my mouth, walked inside, and rode the elevator to the 4th floor.
The clerk was waiting for me with a clipboard full of paperwork. I started filling it out, but I was having a bit of a hard time seeing small print because the dilation was taking full effect. A few seconds later, my friend Dr. Tarek Persaud came into the waiting room and greeted me.
Tarek is Indian, in his early to mid-30s, and just a few years out of training. He is my go-to consultant when retinas go really bad, and my patients love him. He is courteous, conscientious, and conservative, like a good retinal surgeon should be. His letters back to me are always extremely thorough, explaining fully what he has found and what he plans to do (or has already done). He never fails to complement me on my accurate diagnoses and always thanks me for allowing him to share in the patient’s care. Tarek is a gem of a person and a physician, and I was very glad to see him.
I explained to him what had happened, how I had jumped and swatted at a bug that wasn’t really there and that I had started home, thinking that it could wait until tomorrow, but that all those little black donuts had changed my mind.
“You did the right thing,” he said. “You don’t have to finish filling out the paperwork. Just come on back.”
His technician took over, leading me to a pretesting room where she checked my visual acuity and intraocular pressure (both were normal). I had to chuckle at the way she explained everything to me. “Okay, now I’m going to put some numbing drops in your eyes.” Yes, I know, I know.
Next she led me to the exam room where I waited for Dr. Persaud. He entered the room like the biggest gunslinger in the bar and had me place my chin in the cup and my head against the headrest of the slit lamp. He picked up a small, biconvex lens, the same one I used just an hour before on a patient of my own, and began. I knew the routine: Look up, down, left, right as far as you can.
He called off his findings to his tech. “Cornea clear, AC deep and quiet, lens clear. Shaeffer’s sign negative, condensed vitreous centrally.”
When I looked up in the 12 o’clock position he said, “Right eye, horseshoe retinal tear at 12, blood along the edges, bridging vessel, no RD.”
He had me lean back. He looked at me, smiled, and said, “Brilliant call. With a tear in that position, if you had waited until tomorrow, the retina would most likely have detached. We should go ahead and treat that with laser today.”
I texted Eyegal and told her that they were taking me to the laser room to spot weld the tear so that it would not progress any further.
At approximately 4:50 PM, the tech led me to a room filled with several table-mounted lasers. I thought she was going to seat me at one, but instead she pointed toward a small cot with a pillow that looked like it might belong in a psychiatrist’s office and told me to lie down and make myself comfortable. She instilled another set of “numbing drops” and said the doctor would be with me in a moment (Where exactly does he go during these interludes? I thought). That’s when my cell phone rang.
It was Number One Son. He was accepted at UAB School of Medicine a few weeks ago and was jonesing for a little early clinical action. “Can I come watch?” he asked.
“Sorry son,” I replied, “I think this is going to go pretty quickly. I don’t think there’s time for you to get here.”
A few seconds later, Dr. Persaud walked into the room, placed a lid clamp in my right eye, and strapped on a head-mounted argon laser. He explained to me that there would be a series of fast-flickering lights and that I might feel a little pain, like the “brain freeze” that you get from eating ice cream too fast. He offered me a retrobulbar block to numb my eye, but I declined. I had places to be, and so did he.
He called off the laser settings to his technician who dialed in his commands. The first time he brought the condensing lens close to my eye and started to fire the laser, I blinked hard in protective reflex. The lid clamp popped out.
“Sorry,” I said.
“No worries,” he replied, “you’re fine.”
He wedged the clamp in my eye and tried again. Like before, I squeezed hard and popped it out. He turned toward his tech and said, “I think we’re going to need a stronger clamp.”
Once the industrial-strength, titanium-reinforced clamp was in, I looked as far up as I could and he began. The laser clicked and whirred, bathing my eye in pulsating green light. I saw another entoptic phenomena, the branching limbs of the Purkinjie Tree, the afterimage of the eye’s vascular bed.
I thought about the movie The Tree of Life, and I felt for a moment that I was a prisoner of some primeval time, a small, insignificant specimen suspended in ancient amber. I kept telling myself to look straight up and not straight ahead, but after awhile, I seemed to lose all sense of direction.
In the middle of the procedure, Dr. Persaud’s cell phone rang.
“Sorry Dr. Brown,” he said, his foot continuing to jam away on the laser’s pedal, “that’s probably my wife. She always seems to call when I’m in the middle of something.”
I wanted to say, “I feel your pain,” but I didn’t dare move.
Finally, he stopped. “There,” he said, apparently satisfied. “That should do it.”
He explained to me that my eye would ache a little today and that a little tylenol should help. He told me the signs and symptoms of retinal detachment not because he thought I didn’t already know them but because the speech for him was pure reflex.
I shook his hand and thanked him. “Come back and let me look at it in two weeks,” he called out as he walked out the door, his finger already pressing his wife’s number in his cell phone’s “Contacts.”
I left the office at approximately 5:00PM, a little dazzled, but no worse for wear. I stopped by my office and picked up a small bottle of steroid drops to help with the postoperative inflammation in case the tylenol wasn’t quite enough.
I arrived home at about 5:25PM. Eyegal met me at the door, hugged and kissed me, and said, “You poor thing.”
Number One Son and his friend Zach, another recent medical school acceptee, were in the living room and dying for all the details. I regaled them with the story.
By 5:30 PM, I had my feet up and was sipping a beer. It had been a long day’s work, and I thought I deserved one.