A certain detachment

It really began with the ants. We’d returned from a Saturday shop to find an outbreak of the flying variety in our kitchen. I’d had a day or two of feeling that maybe the dry and dusty conditions in London had left a few more things than usual floating in my eyes, but it was then that I suspected something else might be the matter, as despite the deployment of powder, sprays and a vacuum cleaner to the invaders, I was still seeing little black things, moving into and out of sight in the periphery of vision. At this point, nothing else: I resolved to call in to the doctor on the following Monday.

However, by Sunday afternoon, there was more to be worried about. Namely a blot, growing from the lower corner of my right eye. This happened quite quickly — over the space of some thirty minutes. The obstruction bobbled a little, like a wave or black tide trying to creep over a beach. The penny dropped — I thought that this was what a detached retina should feel like. Two minutes on wikipedia confirmed it, and thoughts of the doctor the next day were replaced by — how do I get to Moorfields as quickly as possible. (Moorfields Eye Hospital is London’s specialist centre for eye conditions, and one of, if not the, leading institution of its kind worldwide).

It turned out that both eyes were affected - left, a small tear at the bottom of the eye; right, several tears and a larger detachment that had spread to encompass the macula - the part of the retina that deals with the centre of vision. We were lucky — a kind neighbour dropped everything and drove us to Moorfields, where we were lucky to hit a quiet hour or two in casualty. Examinations of various sorts confirmed the problem: after an hour or so it became clear that it wouldn’t be possible o have it treated immediately, so arrangements were made (via a doctor who was scarily like Stephen Mangan in Green Wing — hi, Zoltan!) to return the next day. Go home, go to bed, sleep on your right side…

So what is retinal detachment? Think back to your school biology classes: the eye is full of jelly — the vitreous humour — not liquid. (Such an evocative term. I remember being fascinated and puzzled by it at school. Humour? Why humour? What’s funny about it?) Though detachment can happen in a number of ways, in my case the vitreous shrank a little, pulling at the retina and tearing it. Think pulling blu-tack of a wall, and taking the paint or wallpaper with it. Liquid accumulates beneath these tears, separating the retina from the back of the eye. If not treated, it can deteriorate suddenly, and once completely detached, say goodbye to the sight of the affected eye.

Overnight gravity did its work, but it didn’t take long for the blot to return. It was an early start — we’d arrived at the clinic at Moorfields for 7.30, and reassuringly the first person we saw was the surgeon, on whose list I’d been placed for an operation later that day. Most of the day was then spent waiting — lying on the aforementioned right side, whiling the time by listening to music. Both eyes needed work, but the tear in the left would be dealt with by laser from the outside of the eye, with the serious business reserved for the right. Given both eyes would be operated on, I was offered as a matter of routine a general anaesthetic, but chose local. Partly because I really don’t like the woozy experience of waking from GA, but largely because I was interested in the operation, and didn’t want to miss anything. (You’ll have gathered I’m not squeamish… Well, maybe I am, but curiosity has always been a stronger impulse for me than discomfort). Late in the afternoon, the call came, I was togged up in the surgical gowns, and went to meet the anaesthetist.

WARNING at this point, if you’re nervous about needles, eyes, needles in eyes, it might be best to stop reading now…

The eyes were dealt with differently. The left, a quick jab on the inside of the lower eyelid, the right a more complex process. No needles, but a small cut in the membranes, beneath which a local anaesthetic was introduced. This spreads around the eye (all the touch and pain receptors in the eye are one the surface, so this is a very efficient way of putting the eye - and surrounding muscles, as it happens - to sleep). So far so good.

Then into the theatre. If you’re used to medical dramas on TV - well, this one was a lot smaller. Octagonal, with lots of light - in panels, where the ceiling and wall join. By this point, I wasn’t really able to take a good look around… and shortly thereafter more covering around the eye hid the rest from view. It struck me that the surgeon spent a great deal of time getting me, and himself, in exactly the right position - his chair, the angle end height of the trolley, my head just so. The theatre lights were dimmed, and work started on the easy part of the procedure - fixing the left eye tear with laser pulses.

This turned out to be the least comfortable part of the procedure, even though the tear was relatively minor. I was aware of flashes and streaks of red, which sometimes flared up as a bright green/white. After a while my eye ached, and the temptation to blink and turn the eye away was overwhelming, though the muscle had been immobilised. But after five minutes it was over, and the real fun could begin.

The procedure is called Pars Plana Vitrectomy with Gas. You’ll already have worked out this involves removing the vitreous, not by suction (that would pull the retina with it, and somewhat defeat the object) but with a little device that chomps or nibbles its way through the vitreous humour. Occasionally I would catch the shadow of the tip of the tool, and think of Arthur C Clarke’s Von Neumann machines, the sentinel consuming the gas of Jupiter … I digress! With the gel gone, the next step is to tack the retina to the back of the eyeball, either with laser again or (in my case) a cryo probe. Cue much hissing of liquid nitrous oxide, and again, as the procedure continued, some slight, dull pain at the back of the eye. Finally, a little fluid is reintroduced into the eyeball, and a quantity of gas, then stitches in the small openings made for the microsurgery.

All the while the surgeon spoke to his team, and to me, and I asked questions from time to time (hence my new-found expertise in the Pars Plana Vitrectomy). Some things made a particular impression:

a “timeout” at the start of the procedure where the surgeon spoke to the team about what he was going to do;

the fact that most communication was the surgeon asking, telling, requesting. This generated an edge, an urgency to proceedings, which after a while I found reassuring — it kept people focussed;

apart from the surgeon and anaesthetist, the team was not exactly a team (I got the impression that as a group they had not worked together before, though pairs and threes will have spent theatre time together), but more of a crew — roles, activities and procedures so well understood that strangers — with enough in common of shared practice and culture — could come together to contribute to a critical process;

the way he kept calling me “sir” (I asked him about this - he said that it’s not impoliteness, but the fact that when you’re thinking about the three or four things you’re doing inside a patient’s eye, its easier than trying to remember their name);

the bleeping of the blood monitor (what the team listen for mostly is the pitch, which indicates blood oxygen levels: the pulse reading is more or less a byproduct. I’m sure I’m not the only patient who found it useful as feedback, though);

the fact that at one point he reminded the team that they’d all been trained not to trust the surgeon, and to ask or call out if anything wasn’t clear to them, or seemed unusual or incorrect;

the way he asked a trainee theatre nurse to get involved in the suturing — straight out of Gawande!

It all passed very quickly — around an hour in the theatre — and surprisingly painlessly. I’ve had less comfortable visits to the dentist. I was wheeled back to my room, where for the next couple of hours I had to keep my head down: looking at the floor, so that the gas bubble in the eye rested over the repaired part of the retina, its buoyancy keeping the retina firmly pressed against the eyeball. In some cases, post-op recovery involves “posturing” — lying in the same position for several days, to keep the bubble in place. I was lucky: the tear was at the top of my eye, so normal upright posture would be just fine, though to help healing I would have to sleep on my left side for the next week or so. After the operation my eye was sore — gritty and itchy rather than out-and-out painful, somewhat like conjunctivitis. Eyedrops (antibiotic and anti-inflammatory — for a month) brought that under control in four or five days.

And slowly, vision returned. At first, you’re looking through the gas: there’s a small pool of liquid at the bottom (which you can just see at the top of the field of vision — don’t forget it’s inverted). The refractive index of the gas is all wrong, and you really don’t see much at all: light and dark, vague shapes. But even now, I could tell that I had all the field of vision back. Never have I been more pleased to see the end of my nose.

The gas is absorbed slowly by the bloodstream and the boundary line between gas and water moves down. Two weeks on, I’ve still got a small bubble (which a few days ago was acting like a lens in its own right, giving me really amazing close-up vision when I looked straight down). As the detachment was large, the vision is a little distorted: straight lines have a small kink, and the perceived image is slightly squashed compered with the left eye. It’s like using a pair of glasses that aren’t quite right: it’ll take a few months, but apparently the brain does get used to this eventually, to some extent at least. Until then, don’t be surprised if you see me reading, programming or playing with an eyepatch — and don’t worry, I won’t be upset if you’re moved to talk like a pirate when I’m around.

Complications? Well, there’s a 15%-or-so chance that the operation will not have worked, and will need to be repeated. If it’s failed, I think this will be clear pretty quickly, but at present it’s all looking good. The procedure’s also associated with an increased risk of cataracts (which can be dealt with surgically easily, if they arise. And it’s better than losing the sight of an eye.)

Lessons for my readers? Most importantly - be aware of the early symptoms! A steady or sudden increase in the number of floaters in your eye (if I’d known this, I may have gained a couple of days) is a giveaway. Something I’d noticed but discounted a few months before is apparently also an early sign: close your eyes or sit in a dark room, and shake your head. I’d seen a bright flash, like someone momentarily opening a door to a brightly-lit room, at the edge of my vision. It’s called photopsia, most commonly caused by shrinking of the vitreous, and might, particularly if you’re not as young as you were, or even as old as me, suggest you should have it checked.

Lastly, acknowledgements — firstly to Chau-Yee, who’s looked after me lovingly: kisses. And to my surgeon, Mr Paul Sullivan, with thanks for a job well done. To our neighbour Ollie Smith, for the first ride down to Moorfields! And finally, to John McIntosh, to whom I’d promised this blog.

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