Tuesday, 4 November 2008

Next steps

I had another visit to the hospital yesterday, starting at 4.30am when the alarm woke me with time to drive to Bangor and catch an early train. This visit was rather different for I was to see a new consultant (in a different clinic) who deals with intra-ocular lenses and retinas. For the time being, the glaucoma is controlled by the tube implant.

After preliminary examinations by a junior doctor, I saw Mr Charles, the consultant, a very busy man who is constantly being interrupted by juniors seeking advice about the patients they are examining. The same sort of thing happened with Miss Fenerty.

Mr Charles had a very close look at both my eyes, pronouncing my normal one to be healthy as he did so. That's good news. As for my troublesome eye, he laid out the options. Option 1 was do nothing which would result in poor vision getting worse as the dispaced lens inside does ever more damage to the cornea's internal surface, causing increasing cloudiness - oedema - and resulting in time in virtually no vision. The lens might even slip round to the back of the eye, causing retinal detachment. Option 2 was to undergo a rather complicated operation under general anaesthetic during which he would perform several things:
  • vitrectomy: removal of the vitrous jelly which fills the back of the eye. It was shreds of this which blocked the tube a while back
  • an injection into the macular to clear the swelling which gives me the sea urchin effect I described in my last post
  • removal of the displaced lens
  • insertion and suturing of a new lens to replace it, a difficult thing to do given the state of my eye but, in his opinion, worth having a go at

He was quite open about the chances of success which are no more than good for an eye like mine. He's done many of these lens operations, he said, and none have gone wrong but there would always by a chance of various complications. My eye is, as he said, a very difficult problem. Even so, he seemed to think the risks worth taking, given the alternative. I agreed and the operation is to be in about 2 months. If the operation is successful, I should gain better vision but the cornea will not recover and so I may need a complete corneal graft in a year or so.

Before leaving, I had to have the usual pre-operative check-up: blood samples, ECG, MRSA swabs and so on. I also had to have some measurements of the eye to enable them to order a new lens to the specifications needed by my eye. These measurement were not easy, as it turned out, since the normal laser machine couldn't record anything because of the cloudy cornea. So the operator of the machine had to use an ultrasound proble pressed against the eye surface repeatedly. Her aim was to get consistent results and it was some time before she managed to do this.

I arrived home in the evening to an empty and dark house because Val had left that same morning to visit Suzanne in Sheffield for 3 days. I was rather tired having had a poor night's sleep - as one does when needing to get up very early. I had a good sleep last night and today, reflecting on what will be happening, feel fairly positive about it all.

Saturday, 11 October 2008

One damn thing after another

Sea urchins and soreness: I visited the Manchester Eye Hospital yesterday for a 2-month checkup. I was ready for it because my eye has been becoming increasingly sore - especially in the evenings - for some weeks. This was despite putting in various drops and ointments which make dry eyes more comfortable. But the eye didn't seem to be dry. For all the world, it felt as though there was a badly-fitting contact lens in there but without the remedy of being able to remove the lens. There's more: when I first open my eye in the morning, I see a strange black object right in the centre of my vision. It looks like a rather flattened black sea urchin, complete with spikes. I close the eye again and there's a negative after-image. As the day passes, this manifestation becomes less obvious but I notice that I can see more clearly (that's a relative term; the vision is just a total fuzz) when I don't look at an object directly.

Some good news: Those were the symptoms which I recounted to Miss Fenerty. Firstly, though, she checked the pressure. It was 10 (and had been 12 three weeks ago when I had it checked at the local optician). So there's some good news: it really does look as though the glaucoma problem which has affected me since Fiji days in the early 1970s (though I didn't then know it) is solved. Big plus for Miss Fenerty's surgical skills and knowhow.
The soreness seems to be related to the loose ACIOL (anterior chamber intraocular lens) about which I am being seen in early November by another specialist. This is constantly causing low-level damage to the eye which then reacts by becoming inflamed. Some steroidal eye drops, she thought, would help: Prednisolone. Twenty four hours later, as I write this, it looks like she's right. I'm using the drops and, so far, the eye has stopped being sore.

Introducing a new player: macular oedema To get a diagnosis of the 'sea urchin' issue, Miss Fenerty at once sent me off for a laser scan of the affected area of the retina. This remarkble procedure, which took about 20 seconds, resulted in weird-looking 3D images and cross sections of my macular (the central area of the retina which is packed with cone cells giving the acute vision we all need for detail like reading) which I then whisked back to Miss Fenerty. I have fluid which has accumulated underneath the macular, lifting the retinal layer like a hill (in the images) where no hill should be. The result is the symptoms I have described. The first line of defence is a non-steroidal anti-inflammatory called Acular - which I am now also using. The likely cause of this oedema (aka 'edema' [US] meaning 'waterlogging' and which already affects my damaged cornea) is this lens and the inflammation it is causing.
So I await my next visit in just over 3 weeks to see the ACIOL specialist, Mr Charles. By that time, we'll know whether the oedema is reduced and, if it's not, I would expect that another operation to remove the injurious lens and, I hope, replace it with a new and stable version, will be very soon after. The saga will continue...

Saturday, 9 August 2008

Success, but what happens next?

In my latest trip to the Manchester hospital (phew, it's getting tiresome, all this travelling but at least most of it is on the train), I got to see Miss Fenerty, the senior consultant who has been so helpful to me and who has placed this drainage shunt implant in my eye. The pressure was a remarkable 10mmHg which is the lowest it's ever been since records began! It's the bottom end of the normal range now instead of way up above it. This means that the laser zapping last time to unblock the tube has worked. It also indicates fairly clearly that the pressure is properly controlled for the first time - and all without drugs. In fact in 3 weeks, I shall be completely off eye drops, the last one I'm using (an anti-inflammatory) being tailed off to zero over this period. Then I shall be drug-free for the first time since the glaucoma was originally diagnosed back in 1976. I took the opportunity to congratulate Miss Fenerty. I'm pleased to be off the drops not least because they may have affected my mental state, pushing me into depression, a known side-effect of some of them. I will now find out if this theory is correct.

But what now? At present, the vision remains very poor and I have double images too. What can be done about it? There are several options and another specialist, Mr Ho (I think), joined us to discuss what to do. Or rather, they discussed and I listened mostly. Mr Ho specialises in corneal transplants (see figure) and I shall probably need one soon. The inner lining of my cornea - called the epithelium - is damaged. This means it can't pump water out of the cornea into the anterior chamber of the eye from which it would drain through the tube. So the cornea is waterlogged which gives me vision like looking through a fog. The damage has been due to the glaucoma and also because of the intra-ocular lens implant I had done about 12 years ago which has become loose and has moved and is physically damaging the epithelium. The epithelial cells cannot regenerate themselves when they are compromised in this way. (The cornea is said to be 'decompensated'.) Hence the probably need for a donor cornea some time in the near future.

The issue is the lens, known as the ACIOL (Anterior Chamber Intra-Ocular Lens). This needs to be removed soon and replaced, but by what? Because my iris was partly removed in the original cataract operation back in 1972, there are no proper anchorage points for a lens - which is why there's trouble with the one in there now. Further damage has been done by the 10 subsequent operations. So how do they fit a new lens and anchor it? There are various possibilities, none sounding ideal, but Miss Fenerty is arranging for me to see a lens specialist at the hospital so he can take a look and see what would be the best option. The results of that consultation will be my next post in a few weeks time.

Monday, 28 July 2008

A nasty shock and some zapping

Once again, I trekked to Manchester last Friday for a check 2 weeks after removal of the supramid suture (previous post). It was a hot day and the hospital outpatients pretty busy. This time, I saw Miss Lewis who is a highly competent and professional member of Miss Fenerty's team who I've seen before. She checked the pressure which had previously been an acceptable 20. This - for me - was the moment of truth: had this Ultimate of glaucoma operations been a success? The pressure reading was, rather shockingly, 38. Way too high! I was in despair but the brisk Miss Lewis had a very careful look around the eye and brought in Miss Fenerty (always available to see intractable patients like me) who confirmed what she thought was going on.

Because my original lens was clumsily removed with its capsule in 1972 - a procedure called intracapsular extraction and not now carried out - there is nothing save the inserted artificial lens to separate the aqueous humour at the front of the eye from the vitreous jelly which fills the eyeball. Because the artificial lens inserted at Torbay hospital about 12 years ago has moved out of place slightly, shreds of the jelly are actually being sucked into the tube draining the eye and had, like a cork in a bottle, blocked the entrance to the tube. Not surprising, then, that the pressure had rocketed.

But there was a solution, albeit temporary. Miss Lewis conducted me to their YAG laser room almost immediately. Because this was a sort of operation, I had to sign a 'consent' and then she began the process of zapping (and it really sounds like that) the blockage using a special large contact lens pressed gently into my eye. It's not a painful procedure; just uncomfortable and I find I jump slightly with each zap, not knowing when she was going to do it. She had a little trouble with air bubbles under the contact lens but ended up zapping the blockage about 30 times. Then she pressed my eyeball with her finger and declared that she thought it was softer and that she had been able to see little zapped bits actually being sucked through into the tube which suggested it was now clear and draining rapidly. A pressure check back in her room quickly confirmed that the pressure had plummeted to 20. Phew! She asked me to come back in half an hour before leaving to see if the pressure had stabilised.

Half an hour later, she whisked me into her room again, measured the pressure and said, with a half smile, "It's 18. Now get out of here before there's any more trouble!" I did, feeling much relieved because it is now fairly clear that the tube implant operation is doing its job properly just so long as it doesn't block again. Of course, it could block again and Miss Fenerty said that what they will probably do now - and she needs to consult other specialists about this - is go in to the eye and remove the displaced lens, replacing it with one properly suited to my difficult eye and at the same time, clear out these shreds of debris. Whether they'll be able to do the proposed corneal graft at the same time I don't yet know. I'm going back, yet again, in 2 weeks and should learn more. I'm all for getting all these things done as soon as possible because my vision is still very poor. Miss Lewis advises me to go to a local optician to get the pressure checked this week - in case of further blockages. If it's high again, I'll be summoned back to the hospital and something will be done fairly quickly. Unfortunately, there are no symptoms of high pressure, the insidious thing about glaucoma. Permanent damage is done to the optic nerve and you're unaware of it.

So who knows what will happen next? I am heartily sick of all this travelling but there is light at the end of the tunnel...

Saturday, 12 July 2008

Can there be good news with glaucoma?

I went into the Manchester Royal Eye Hospital last Wednesday for another operation to be performed on Thursday morning, returning home on Friday. For once, travel was very easy. There was a direct train in both cases. I was even able to get a (free because I am over 60) bus back most of the way home. My stay in hospital was boring so I read a lot and listened to the radio on my mp3 player. Knowing how noisy things can be, I went equipped with ear plugs, very necessary since the man in the bed next to me specialised in gargantuan gurgling snores. There were four people in my room and the staff were efficient and cheerful but, because of the ethnic mix, sometimes a little hard to understand because of the potpourri of accents.

Read on for full details, but not if you're squeamish in which case, skip to the final paragraph.

The operation was to remove the supramid suture from the tube and plate implant in my eye. This is essentially a thin bit of string which partly blocks the tube implant so as to moderate the flow of liquid from the front of the eye. Although it sounds daft to have it there at all, there are good reasons for it. It is far more dangerous to the eye to reduce the pressure dramatically - a condition called hypotony - than to keep the pressure fairly high whilst everything heals up. For some people, the tube with its supramid thread is enough to relieve the pressure and nothing more need be done. Naturally, I am the difficult one who needs this extra tweak.

It was slightly bizarre lying on the operating table chatting to Miss Fenerty (surgeon and senior consultant) about wind turbines, green manures and her recent installation on her house of a 1.8kW photovoltaic device. We share many interests apart from eyes! I should add that this chat went on whilst she was anaesthetising the eye, not during the actual procedure which wasn't as easy as it should have been due, basically, to the fact that my eye has been cut open so many times that it contains a great deal of scar tissue which made inserting the original drainage tube and plate quite tricky. The process is in itself quite painful in some of its procedures like injecting anaesthetic into the tissues surrounding the eye which help immobilise the eye.

The supramid suture end normally lies under the conjunctival membrane (the clear covering over the white of the eye, the sclera) but it was difficult to locate because of the profusion of blood capillaries in the inner corner of the eye. Needless to say, Miss Fenerty and her assisting registrar finally spotted it and made a tiny incision and slowly, not without a little difficulty, reeled out the suture. They also removed several other stitches from other parts of the eye from the previous operation. All that remained to be done was for a dissolvable stitch to go in to close the incision.

Having an operation of this sort under local anaesthesia has its advantages. I was able to simply stand up and walk back to the ward after it was over and I get to hear all that goes on... which can be a disadvantage too. I found myself constantly having to consciously relax because I was so tense. Occasional sharp intakes of breath from me because of sudden intense pain resulted in instant reactions from Miss Fenerty who quickly added more lidocain. My eye is difficult to anaesthetise because, once again, of scar tissue and the location of the plate and suture which would normally be elswhere in the eye. But it was good to be able to ask the odd 'what are you doing now?' question and have it answered right away.

In my follow-up the next morning, the pressure was 20, top end of normal, and this without any glaucoma medcation. It had been 22 on the morning of the operation but that was with every single medication available including Diamox, the last resort which I've been on for 6 weeks when it was clear that the pressure was becoming way too high. Diamox has unpleasant side effects but it did allow me to go on holiday. So for the first time for decades, I am actually not on any glaucoma medication, some of which have side-effects of their own. In fact, I am still using eye drops, 4 times per day, but these are anti-inflammatory and antibiotic and are standard after your eye has been cut open.

My eye at present looks a little grotesque - all red as capillaries swell and grow to repair the damage done by the surgery. It's a bit sore and there's often a noticeable pricking sensation in the inner corner where the dissolvable suture is located. All this is normal and to be expected. The suture will dissolve and the soreness will dissipate. I have anti-soreness ointment and artificial tears to add when I feel the need of them.

I feel I should be celebrating this apparent success but I am hesitant to do so until I've been for my next follow-up appointment. Long dismal experience tells me that my glaucoma is an intractable condition and every effort to stop it in this troublesome eye is doomed to failure. I am optimistic though because I know I am in the hands of one of Europe's best glaucoma surgeons. The fact that Miss Fenerty has sent me off without medication suggests she is pretty confident that all should be well. The anti-inflammatory drops themselves cause an increase in pressure which should fall when I stop using them in a few weeks. On the evening of operation day, I met one of her deputies, the charming Mr Gandhi who I always ask to see when I go for checkups. We had a long chat about Green issues and about my eye, details of which he remembered perfectly even though he didn't have the notes and wasn't formally seeing me about it. One thing he said was that in his experience, removal of the supramid suture was usually sufficient to control the pressure and he knew of only two cases where further intervention had been needed. For further intervention is possible and, if necessary, can be repeated over and over again to keep the pressure controlled. It's a process called 'needling' in which the scar tissues blocking the exits from the plate are broken up to improve drainage. So it really looks like, one way or another, my glaucoma will be controlled.

There's more. At present, all I can see with my troubled eye is a fuzzy double image. Miss Fenerty and Mr Gandhi have told me of all the incredible procedures which can now be carried out to improve vision in people like me with 'compromised' corneas (the 'front window' of the eye). Miss Fenerty is optimistic that one or more of these will be suitable for me to regain some reasonable vision from this badly knocked-about eye. I will be learning more about these in the next few weeks. Meanwhile, one thing I have learnt from all this is patience!

Thursday, 27 March 2008

The Big Operation

I returned yesterday from my 2 days sojourn in horrible Manchester. No complaints about the treatment though. The 'suite'; (not called wards anymore apparently) was pleasant enough and the staff efficient and helpful. The 'wonderful Miss Fenerty' (as Val calls her) who is the senior consultant and the woman who conducted the operation with her team came to see me before the ordeal and answered my odd remaining questions. We then discussed planting our potatoes. I've done mine; she's still not got hers in.

Twenty minutes later, I was clad in my gown and whisked down to the anaesthetic room. This was where panic bubbles up to the surface and I had to resist a strong urge to do a runner. I didn't, of course. But this was the culmination point of all my endless nervous re-runs of how horrible it would be. They were all very kind, reassuring and professional as they plugged me in to various sensors and stuck a needle in a vein. Then, ever so slowly, the room began to spin and I muttered something about feeling drunk before passing out.

Some time later, I returned to the world of consciousness. The operation had taken 2 hours, Miss Fenerty later told me. Soon, I was back in my room,shared with another man who was in a state of near panic, this being his first ever eye operation. I think I was able to reassure him a little beforehe was whisked off for his operation. Certainly, he came back later much happier that it was all over. It was nowhere near as bad as he'd thought itwould be. As for me, my principal discomfort was my back aching after enforced lying for several hours. Assisted by Val, who had braved trams and getting lost in the big city to come and be with me, I moved to a chair and was soon pacing the corridors, much to the amusement of one of the black nurses who laughed with delight every time Val and I paced past, arm in arm, as if promenading on the deck of a ship. The jolly nurse said she wished she had a camera.

A little later, Miss Fenerty came to see how I was and Val was able to meet her 'wonder' at last. She said the operation had gone well though she'd had difficulty finding a suitable site for the plate and tube because of all theprevious failed operation sites. She'd had to patch up some leaky bits of thin tissue from these at the same time as locating the drainage plate (called a Baerveldt plate, pictured). Then she had patched that all over with donor sclera. This is slightly weird, knowing about and being able to see this piece of sclera (the white of the eye) which came from someone who died and had generously agreed to donate their eyes so that others like me might retain their sight. I shall never know who this was but I feel thankful for this ultimate gift. I shall, in a few months, probably receive a donor cornea too, once the glaucoma trauma is all healed and working properly.

I spent a second night in hospital so that Miss F and her team could examine me before discharge. All seemed to be well and in due course, I got a massive bag of drops and pills which I have to take at, depending on what they are, 1,2 3,4,5 and 6 times per day. I also have to swallow 15 steroid tablets. I think this is to suppress any immune reaction to the donor tissue which could theoretically be rejected, and helps keep inflammation minimal.

The eye is not a pretty sight at present but I can see out of it in a blurry fashion. Val nobly braved the scary city traffic and came in to collect me and it was with relief that we were soon speeding from a grey, rainy Manchester into a mostly sunny Wales. It was so nice that we went to Bodnant Gardens and had a brisk walk amongst the camelias and daffodils and a welcome cup of decent coffee in the National Trust cafe.

Coming home was wonderful. It was mild, still and sunny and all the birds were singing for spring is in the air. Snowdon looked wonderful in its cover of snow which fell last week.

I have to return for regular checks, starting on 4 April but I shall be ableto do this alone and go by the much more relaxing train. Today, I have been semi-back-to-normal, helping Val with veg packing (she did the bending; Idid the bagging) and assembling all the bags when Jill came with her contribution. I've also sown all my tomatoes - in heat. So, even though dosed up - literally - to the eyeballs with drugs, I feel fine. I'm being very careful as you'd expect. Obviously I don't want to jeopardise in anyway this 'last chance' operation and I won't. I won't know how successful it's been for another 4 weeks or so because the drainage device is designed to come into proper operation when a securing stitch dissolves away. And if the drainage isn't sufficient, then Miss F can tweak the device in a very small operation so that more fluid drains through the tube to be dispersed under the conjunctival membrane and thus absorbed into the blood stream.

It is, I think you'll agree, incredible what can be done with malfunctioning eyes. The eye is obviously tougher than you'd think and able to take a lot of damage. My eye is certainly an old hand at being cut up! And I think that's enough of this gruesome stuff. Meanwhile, full marks to the wonderful National Health Service. People love to grumble about it, but it works pretty well under often difficult conditions. And thanks to Miss Fenerty and her excellent team.