CLINICAL: the back
Retinal Surgery – A Personal Reflection
Use my story to help manage patients who have retinal tears.
BEZALEL SCHENDOWICH, O.D., F.I.A.C.L.E., JERUSALEM, ISRAEL
To my dismay, I experienced a retinal tear roughly a year ago. Many friends, relatives and colleagues commented on the irony — an eye doctor hit with an eye problem.
However, a problem like this can happen to anyone, and my story can aid fellow optometrists who co-manage patients who undergo retinal surgery.
Originally, I discovered a new floater in my left eye. This new dimension in my vision was accompanied by a couple small peripheral flashes of light.
Being the professional I am, I was worried enough to undergo dilation and have my retina examined by an ophthalmologist. The result of the examination was benign, though my insight was that I had a rather large posterior vitreous detachment. Five days later, the vision in my left eye suddenly misted, or clouded over. I found no loss of comparative, confrontation visual fields and suddenly and painlessly lost my 6/6 BCVA.
I attended my hospital’s ophthalmology clinic and was dilated and more thoroughly examined by a retina specialist. The diagnosis: a small retinal tear at 12 o’clock with an adjacent hemorrhage into the vitreous. My visual acuity was finger counting at about one meter.
The doctor provided my first experience with retinal laser photocoagulation within the same hour that the tear and hemorrhage had occurred.
Here are the “highlights” of the treatment:
▸ Up, up and ouch. To allow the surgeon access to the peripheral tear in the superior retina, I was required to look up until it hurt. Most of us don’t stretch our extra-ocular muscles, and mine ached by the time the treatment concluded.
▸ Turn down the lights. Remember the last time a colleague scanned your fundus through a dilated pupil with a binocular indirect ophthalmoscope — bright, right? Now, turn the light source bright green and up the power many, many times. It was bright on a scale hard to imagine.
▸ Energy overload. The laser pounded physically on the inside of the eye with each burst of energy.
Immediately after the laser treatment, I experienced the greatest trial of all: I was restricted to bed rest and sleeping with my head raised — essentially sitting upright — for the first two and a half weeks. Reading was limited, and my observations while in bed consisted of trying to see around the blood filled bag of vitreous, practicing comparative confrontation visual fields testing on myself to ease the boredom and seeing bits and pieces of visual improvement hour by hour. At times, I could perceive the painting on the wall opposite my perch on the bed or flowers in the garden.
During this period, my eye was examined several times, and laser therapy was completed in two additional sessions: one, a day later, and the second, four days after that. This created a ring of scar tissue around the retinal tear and effectively sealed it from further deterioration or fluid leakage that could detach the retina.
As my vision slowly improved, I began to notice (with trepidation) that I had lost binocularity. But, as I was regaining clarity, I found a distinct hyper/exoprojection that required a great deal of effort to overcome — a feat worthy of note, as it seemed to be based on accommodative-convergence in a 59-year-old.
As my vision continued to clear and binocularity returned around four weeks later, I noticed a fascinating monocular phenomenon, which I have termed the “spinning chandelier” sign.
When I viewed a large, and quite stable, crystal chandelier with the hazy eye, it appeared to spin first in one direction, then the other, depending upon the position of my head.
My tentative explanation: The spinning came from a micro-strobe effect caused by the migrating blood cells in my vitreous.
Initially, the retina specialist estimated my vision would return in roughly three weeks, which was very accurate in terms of acuity and the clearing of the majority of the blood. My vision was a hazy 6/6 with a couple of large, hairy, spidery floaters interfering with my retinoscopy and general mesopic function. Nevertheless, the improvement was remarkable. Gradual clearing occurred as the blood in the vitreous settled and began to absorb.
Roughly a month and a half after the original tear and bleed, I returned to my pre-event lifestyle. My visual acuity was in the range of 6/6+, though when I view monocularly through my left eye I see as though I am submerged in a murky lagoon. The floaters became “old friends,” as they continue to roam aimlessly across my left eye’s visual field. I wished they would also go away, but, as my surgeon advised me when he first treated me, I had to be patient.
Experience: a Powerful Teacher
Empathize with your patients who are going through similar treatments.
Here’s a list of tips you can provide to aid their healing and recovery:
▸ Diagnosis by telephone is impossible. Patients, family and friends occasionally call with complaints of flashes and floaters, and I always advise a thorough examination before giving any advice.
▸ Expedience is a necessity. When patients present with sudden loss of vision, large floaters or flashes of light, advise them to see a retinal specialist promptly. These signs indicate potentially serious retinal problems or benign vitreous changes. Waiting to act could cause significant detachment, which leads to more serious care, such as full anesthesia, cryopexy, vitrectomy, injection of silicone oil and air and posture stabilization.
▸ Patience is essential. For full and rapid recovery, emphasize the need for bed rest and stability by insisting that full recuperation for a tear with hemorrhage is far more difficult than a tear without the bleed. The blood needs to settle, and the eye must be kept stable.
▸ Movement should be limited and reading prohibited. Boredom may be extreme during recovery, but its price is small compared with the gain.
In my years as adviser to keratoconus patients, both in clinic and via the KC-Link of the National Keratoconus Foundation, I have advised patience to those dealing with the tribulations of contact lens fitting and adjustment or healing post-penetrating keratoplasty. Now I had to practice what I’d preached.
Roughly 10 months have passed since my retinal tear, vitreous bleed and subsequent laser treatment. My surgeon has assured me at periodic follow-up appointments that my retina is flat and in place, I have no more tears or bleeds and the blood that had filled my vitreous has absorbed. Also, I am still bothered by my various floaters, so my surgeon has suggested undergoing a vitrectomy, though he doesn’t recommend it. I return to him every four-months, and he continues to be happy with my healing. OM
Dr. Schendowich is a member of the Medical Advisory Board of the National Keratoconus Foundation, USA, a fellow of the International Association of Contact Lens Educators and a clinical supervisor to Israeli optometry students in the ophthalmology clinic at the Sha’are Zedek Medical Center. E-mail him at firstname.lastname@example.org, or send comments to email@example.com.
Optometric Management, Volume: 49 , Issue: February 2014