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!