Red Fog Rising

When an eye doctor goes blind, there are no special dispensations or exemptions. He does it just like everybody else–one eye at a time.

My recent self-diagnosis of a retinal tear in my right eye took a colorful, and ominous, turn on July 4th. I was driving around Huntsville when a blood vessel which crossed the area of the retina that was treated with laser burst open like a uncapped oil well. No black gold or Texas Tea, Jed, just blood.

It started with a single red ribbon which began to flow upward from my inferior visual field. Other scarlet streaks soon joined it, each dividing into tributaries and tendrils which filled my clear field of view with smoky-red smudge. As the blood mixed with liquefied vitreous, the rivers and streams began to break up into clumps and clots, which in turn, dissolved into even smaller individual red blood cells. Millions of them.

It was more impressive than any fireworks display in Huntsville that day. “Rockets red glare, the bombs bursting in air,” only it was my very own private show, inside my eye.

“I’m having a massive vitreous hemorrhage,” I said out loud. I remembered a story about a medical school professor around the turn of the 20th century who was lecturing to his anatomy class when he stopped and announced, “I believe I’m having a brain aneurysm,” and promptly keeled over dead. I knew what was happening, and most likely why, and in part was fascinated by the pathological progression. There was another part of me that was scared to death.

I pulled over and asked Eyegal to drive. By the time we reached home, I had gone from 20/20 vision to the point where I could barely see my hand move in front of my face, all in the span of 25 minutes.

When I got out of the car and stood up, my right knee nearly buckled, my right hand shot out, and I listed toward the left.  I tried to walk, but my legs lurched and stuttered, my body stalling in protest. Somewhere deep in my brain a warning signal, tripped by the lack of visual input, had sounded: “Slow Down! Proceed With Caution!”

Once seated, I carefully checked the sliver of my peripheral visual field which remained by counting fingers. All sectors were present and accounted for, meaning the retina was most likely okay and still attached. I had seen the photos of the retinal artery which crossed the tear, and I knew that the blood was probably coming from sections of that artery which were being ripped open by the ongoing vitreous traction. Since the laser repair was probably doing its job and keeping the retina in place, I decided to wait and call my retinal specialist the next day– I didn’t want to ruin anybody’s holiday. I chose to sit very still and see if the bleeding would stop.

The blood continued to flow, swirling and twisting into funky shapes and patterns, like a monochromatic kaleidoscope. Point sources of light, such as light bulbs, were headlights in a dense, red fog. Even sitting still, I became so motion sick that I had to cover the offending eye with an opaque pirate’s patch to stop the nausea. It was one of those rare cases when seeing nothing was better than something.

The next morning, I had adjusted to the motion and was able to go without patching. I decided to go into work and try to see my patients and check-in with the retinal specialist later in the day. Eyegal offered to drive me, of course, but I declined. I wanted to find out what it was like to drive with one eye. She wasn’t happy about this, but I knew that many of my patients drove with impaired vision, and for once, I wanted to see through their eyes.

When you suddenly lose half your vision, you must swivel your head like a beacon in order to compensate for the missing portions of visual field. Depth perception also suffers. Although there are “monocular clues” to depth, they pale in comparison to the 3D topographic map created by two eyes that are yoked and the fusion that results when their separate images meet up and marry in the occipital cortex, the visual processing center, at the base of the skull.

As I pulled out onto the main street near my home, I had more difficulty judging the speed and distance of the cars in the lane into which I was attempting to merge. As I drove along, I found myself drifting toward the right, and my adjustments to stay in my lane, normally micro-movements of my hand on the steering wheel, became larger and more abrupt. Had there been a police car behind me, I’m sure I would have been pulled over for a field sobriety test. Pulling into a parking space between two cars in my office lot, normally a confident, whip-like maneuver, became a slow, self-conscious crawl.

But it was in the office while seeing patients that the true extent of my visual impairment became apparent. The highest form of depth perception is stereopsis, the feeling of depth created by the eyes’ viewing of the same object from slightly different angles. The two slightly disparate images from each retina are fused in the occipital cortex, the same process that allows the impression of depth when viewing 3D movies or images like those in the old GAF View-Master.

With my right eye filled with vitreous blood, my stereopsis was completely gone. I had trouble finding and keeping a monocular image in the oculars of my various scopes. I could no longer distinguish the five, fine layers of the cornea or discern retinal elevations, capabilities crucial to making some very critical diagnoses. Had someone come in with a metallic corneal foreign body, I would have felt very uncomfortable with a 25-guage needle near a patient’s eye, and the patient might have felt even worse.

I was very agitated and frustrated at first, but as the day wore on, I seemed to adjust more to my circumstances. Our plastic brains can respond to a wide array of perceptual challenges, and I suppose if I had to adjust to becoming a one-eyed eye doctor, I could–but I didn’t want to.

But, then again, I knew I wouldn’t have to. I dilated my right eye after I finished my last patient and went to see my retinal specialist. He confirmed what I already knew (that my retina was fine) and that there were two options: 1) “Watch and wait” for the blood to reabsorb on its own, or 2) a vitrectomy, the suctioning out of the blood and rinsing of the vitreous cavity.

He thought that the hemorrhage might start clearing to my satisfaction in a few days and encouraged me to wait a week. But my gut told me this wasn’t one that would heal on its own. I needed my stereopsis back sooner rather than later. “If it hasn’t improved significantly by this time next week,” I said, “I’ll want the vitrectomy.”

Over the next few days, the hemorrhage would start to clear a bit (at times, an occasional pocket of clear vision would form; with the right head and eye movements, I could coax it into my line of sight). But every time more light would penetrate the red fog, the eye would start to bleed again.

After several rebleeds over the next three days, I called the my doctor’s answering service Sunday afternoon and relayed the message that I wanted the vitrectomy ASAP. A different doctor called me back, one who hadn’t seen me. But when I described what I was experiencing, he agreed with me that vitrectomy was indicated and told me to come in first thing in the morning and they would work me in.

On Monday morning, the retinal surgeon performed a 3-port, 23-guage, pars plana vitrectomy with prophylactic focal argon laser repair. Basically, the surgeon punched three small holes in the white part (sclera) of my eye through which he placed his instruments, suctioned out the blood with equivalent of a mini shop-vac, rinsed it with saline, cauterized the leaky blood vessel, and sealed the edges of the retina with a 360 degree laser spot weld. He’s probably done 10,000 of those procedures. He was in and out in about 20 minutes.

Tuesday morning, I took off my patch. The red fog had lifted. I knew immediately that I was already back to 20/40, maybe even better.

I’ll be on eye drops for a few weeks, but I should heal nicely. “I was blind, but now I see,” has new meaning. I recognize that my good clinical outcome is not shared by all who suffer these kinds of bleeds. Not all have my kind of connections. There are many who have no care at all. My blindness was temporary, but for some unlucky souls the fog never rises, and worse yet, night falls.

Like the red fog, I have risen as well, a full order of magnitude, from sympathy for my patients to empathy with them. Henceforth, I will take this sacred trust of mine–guarding the gift of sight–more seriously than ever.