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!

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.

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.

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.

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...

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.

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...