Wednesday, 28 October 2009

Hard graft

I've just returned from what just might be my last eye operation at the Royal Eye Hospital in Manchester. Why the last? Because if this one does as it should, reasonable vision should return to my troublesome eye within the next few days or weeks.

The run-up: I wrote about what was to be done in my previous post. Mr Au, the specialist, had already determined that I should need a full-thickness (or penetrating) keratopathy (graft). Mr Au was fully prepared to video my operation - at my request - but in the event was unable to do so because the video cables in the brand-new hospital were not compatible with his laptop. For the curious, I've added a YouTube video below of the entire procedure showing how the damaged cornea is cut out and the donor one is placed in the hole and sutured. There's no blood and I find the whole proceedings fascinating and incredible.

What happened? Val and I drove to Manchester on Sunday where I was admitted to be ready for action on Monday. Mr Au bounded into the ward on Monday morning and directed me to an examination room with the usual slit lamp and tonometer (for examining and measuring pressure in the eye respectively). He remarked that the old cornea had deteriorated noticeably since he'd last examined me and gave me a run-down on what he would be doing, knowing that I was very interested in the procedure. Then there was the interminable period of waiting, made more endurable because not only was Val there, but Suzanne and her new baby boy, my grandson, Aaron, were there too. The wonderful new hospitals have plenty of space for walking about, sitting, eating and drinking. Aaron sat on my knee and smiled and gurgled for quite a while.

I was last on the list for the afternoon and was not allowed anything to eat or drink after my breakfast at 6am. Finally, I was gowned-up and checked several times to make sure there were no mistakes
and walked the long walk down the long, brightly lit corridors to the operating theatres and anesthaesia room. It helps to have been through this before but it's always scary. A while later, I came round in recovery and was soon back in the ward. A remarkable thing about modern anesthaesia is that within minutes of coming round, you're ready to walk about and have a good meal. It used to be that you felt horribly nauseous. Not now. So I had my tea and Suzanne helped me out of the gown and into my normal shirt again. They all had to leave by early evening since Suzanne had to get a train back to Sheffield and Val, after seeing them onto the train, had to get a tram and bus back to nephew Dale's house where she was staying. (Thank you, Dale and Debs!)

And the results? I'm sure everyone reading this will want to see what my eye looks like now(!). So here it is:
Not a brilliant self-portrait but you can see the clear central cornea from the donor and just make out the tiny sutures - there are 16 of them - anchoring the graft in place. The white patch on the right was placed there 18 months ago by Miss Fenerty as part of the glaucoma tube operation she performed. This is also from a donor. So my right eye now contains two pieces of other people's eyes. Thank goodness for donors! What a noble thing to do when your life is cut short: bequeath useful parts of your body so that others might see (and many other things) again. Both Val and I are registered donors.

Mr Au examined me yesterday (Tuesday) morning after I'd had a surprisingly good night's sleep with little pain, and pronounced me fit for discharge. The graft was looking good and the pressure was normal. The operation had gone smoothly, he said, and although my vision was - and still is - quite poor, this is perfectly normal. But it is better than it was before and should slowly improve over the next few days and weeks.

And so I was discharged but, owing to some sort of procedural cock-up, Val and I weren't able to actually leave until nearly 5pm because my prescribed eye drops hadn't been sent down by the hospital central pharmacy. A small matter but irritating at the time. It meant Val had to drive back in the dark, through heavy rush-hour traffic and jams because of an accident on the motorway and, later, heavy rain after we entered Wales. She managed supremely well but was quite exhausted when we got back.

I have to sleep with an eye shield covering the eye for a month and not do any heavy work which could damage the slowly-developing seal between the new cornea and surrounding old corneal periphery. The sutures may need to remain in place for 1-2 years and there is a slight possibility that the donor cornea will be rejected by my immune system. I have to be very careful to avoid infection because, when you think about it, there's quite a large cut surface which bacteria would just love to invade. Accordingly, I'm using antibiotic and anti-inflammatory eye drops 4 times a day for the time being. As I write, the eye is a little sore and scratchy when I blink but this should quickly pass. I go back for a checkup in a week when I will find out how things are going. So back to long train journeys again... but at least I can see.

So hoorah for the eye hospital staff and hoorah for the good old NHS!

Saturday, 18 July 2009

Eye Phase 3: the cornea

I've had two visits to the eye hospital within 7 days, not because there was anything untoward but because I had appointments with different specialisations. The first was the retinal clinic where I had various tests which showed that the swelling of the macula had 'dried out'; the oedema has gone. I don't notice much improvement because I can't see much anyway for a different reason: my compromised (it's called 'decompensated' in the jargon) cornea. So the macula appears to be normal again.

A week later, I went to see Mr Au who is the specialist in corneas and corneal transplants. The cornea is the 'front window of the eye'; the part that does most of the focusing of the image which it projects onto the retina. Mine is severely damaged from all the operations I've had and because of years of glaucoma. The endothelial cells on its inner surface, if damaged, cannot renew themselves but are vital as they pump water from the cornea. If this pump isn't working, the cornea becomes waterlogged causing the blurry vision - like looking through a ground-glass screen - that I have. The only cure is to replace the endothelial cells with a graft, a new and delicate operation called a DSEK or to replace the entire cornea (full-thickness keratopathy). In either case, the graft comes from a donor, someone who has died young and generously left their eyes to be used for helping the likes of me. I already have a piece of somebody else's eye in my eye, the result of the patch graft which Miss Fenerty placed over the tube and plate she inserted to control the glaucoma - which, I am happy to say over a year later, it does effectively. As a result of this anonymous post mortem generosity, I have registered as an organ donor; the least I could do.

I had only a short wait to see Mr Au himself. He is very brisk and efficient and pleasant with it. He did several tests on different machines to enable him to determine with precision what exactly would be the best option for my eye. For various compelling reasons to do with the geometry of my 'difficult' eye, the intra-ocular lens and pupil, he feels that the best course is for me to have a full thickness keratopathy. In this operation, he makes a circular cut - using an instrument like a cookie-cutter, though a little more refined - to actually bore out a hole in the front of my eye about 7mm in diameter. Into this, he inserts a donor 'button' - the replacement cornea - which he then sutures firmly into place using very fine radial stitches. The sutures remain in place for around 18 months and I will need steroid eye drops to prevent rejection. But the new cornea should mean that I can see clearly again. At present, the image quality is so poor that I get no image fusion, no stereoscopic vision, and can barely make out the biggest letter on the standard eye chart. If I don't have this graft, the outlook is worsening vision and pain associated with the oversaturated corneal tissue. I've already had a lot of pain with this cornea and I know how unpleasant it is. The operation is not without risk but the benefits are significant.

So the choice is easy! I'm on the waiting list for an operation in about 3 months.

Thursday, 29 January 2009

Good eye news... for now

It's Thursday evening and I can see better with my damaged eye than I've been able to do for months... and that just over 24 hours after being out for the count in the operating theatre at the Manchester Royal Eye Hospital. Yes, I've had my operation and it went better than expected.

Val and I drove to Manchester on Monday early evening, a horrible busy drive when you're just used to seeing the postman and a few sheep. We stayed with my nephew Dale and his partner Deb, as previously when I was to have a major operation nearly a year ago. They live within easy public transport access (walk, tram, walk or bus) of the hospital to which I had to report by 12 noon the next day. Being there a day early made the journey much less nerve-racking. Val stayed with them while I was in hospital.

After being admitted on Tuesday, Mr Charles, the consultant examined me and we talked about the gravity of the operation. I fully understood that there were a whole raft of horrors which could occur because of my tricky eye which has been so much damaged by earlier operations. I reckon this was my 12th! There were three things to be done: an injection of Avastin to arrest the swelling of the macula (the central spot of the retina with the greatest concentration of light-detecting cells) which had been causing a semi blind spot in my central vision; removal of the old and displaced anterior chamber lens (ACIOL) and its replacement with a new one to be supported by suturing to the sclera which would also require the removal of all the jelly-like vitreous humour at the back of the eye (vitrectomy) which would be naturally replaced by the salty aqueous secretion from the ciliary body close to the iris.

Operation day came and I was gently knocked out by a very kind anaesthetist who was, he said, exactly the same age as me. A short time later, I came round and was soon back up in the ward amid rumours that things had gone rather differently than expected. I was puzzled by the lack of pain for a start and the short time in which this long and complex operation had been carried out by Mr Charles and his team. Later in the afternoon, Mr Charles appeared and after being introduced to Val - who was, of course, there with me - told me what had happened. He operates on the principle of 'do no harm' which could be paraphrased in my case as 'if it ain't broke, don't fix it'. After making one small incision with which to remove the misplaced lens, he found that the lens would actually very easily slip into the place it should have been and seemed quite secure. He was very happy at this point to not open up the eye any further for, as he had explained to me, every time this is done, more damage is done to the non-repairing endothelial cells of the inside of the cornea. This damage causes oedema, or waterlogging, of the cornea which results in the vision being variably foggy. So he decided to leave well alone, administered the Avastin injection to the macula and patched me up. And that was it. The incision, I understand, is so small that no stiches were needed. Hence the almost total absence of pain.

How long this will last is unknown. It could become displaced again in a few weeks or go on for 10 years. We just don't know. Mr Charles saw me again this morning for a final check before discharging me. All seemed to be well and no damage had been done to Miss Fenerty's fine handiwork (the tube implant, done nearly a year ago to control the glaucoma) with the pressure coming in at 10 (it is now normally between 10 and 15 whereas it used to hit the upper 30s when the glaucoma was out of control). I return to see him in 2 weeks for a routine check. I'm on the usual antibiotic and antiinflammatory drops and have to not stoop for about a week only. The eye - as I write - is painless and for the first time for months, I don't see multiple images. This means that the images from both eyes fuse properly and I get some rudimentary stereo vision. I can also just about see the letters on my laptop's keyboard. I couldn't before and as the Avastin does its job, I hope my central vision will improve some more. But with this much improvement already, I feel very pleased.

When I was waiting to be discharged this morning, I heard a cheery, "Hello Mr Lynas" in a familiar voice: it was Miss Fenerty who has so successfully sorted out my glaucoma. She remembered all about me (astonishing in my view since she must see dozens of patients every month) and we chatted briefly about her photovoltaic panels which are successfully feeding electricity into the grid. She wanted to know about the vegetables and how the weather had been for them. The upshot of this chat is that she plans to take up my invitation, proffered some time back, to come and visit Mur Crusto farm. I would, I said, be honoured!

Finally, I have to record with pleasure that my stay in hospital was made almost enjoyable by the kindly staff, male and female of all races and creeds. The food wasn't bad either, not something you hear many people say. There's lots of laughter on this eye ward, good therapy for any patient.