The Bubble Treatment

Image of retina/Credit: Immunofluorescence

A week ago today, my vision failed.  This was not subtle.  One minute we were driving along Post Street in San Francisco, looking for parking, anticipating a pleasant few hours in Japantown.  The next minute, a big black mass was engulfing my sight on the right side. I blinked.  Blinked again. I looked up, down, left, right.  It didn’t change. It was large, opaque, unmoving.  I’ve had floaters, which most of us do by a certain age.  This wasn’t that.

As a medical writer who spent a fair bit of time in ophthalmology, I suspected something was up with my retina.  You don’t mess with that stuff.  I called my ophthalmologist, who didn’t have time that day, but fit me in anyway.  Within an hour, she had escalated me to one of the ophthalmological surgeons she trusts.  Even in the medicine-rich Bay Area, we are not thick on the ground with ophthalmological surgeons.  Dr. James Palmer was at El Camino Hospital that day.  Off we went, Cal driving, to Mountain View.

Dr. Palmer didn’t really have time that day either.  But he also fit me in. We walked into a stuffed waiting room, every chair taken.  “Name?” asked the woman at the desk.  “Birthdate?”  I gave both, knowing they weren’t going to work.  “I don’t find you in our system,” she said, brow furrowed. “That’s because I’m not a patient here,” I replied.  “I have been referred on an emergency basis by Leslie Weil.”  “Oh, OK,” she beamed, glad to solve the mystery.  “I can give you an appointment in three weeks.”

“You know this is a detached retina, right?”  Dr. Weil had called ahead and covered all this. Apparently, this young woman had not been read in. Understandable in a busy practice.

“Oh,” she answered. “Just a minute.” She disappeared into the inner sanctum. Back in under a minute, she said “Dr. Palmer will fit you in as soon as he can.” 

“I’m guessing this is going to be awhile?” I asked, looking around the stuffed waiting room.

“Yes,” she said apologetically.  “Have a seat.”

We did. In another two minutes she came running out with a clipboard.  “I forgot to give this to you,” she said, even more apologetically.  “There’s a few things to fill out.” I couldn’t see all that well, but the stack of paper looked like 50 pages.  She hesitated.  “Do you need help with it?” I assured her we did not. Cal took the clipboard and started in, me chiming in when needed, him signing my name everywhere it was required.  I could barely see the clipboard, let alone what was on it.

Two hours later, I was up.  Vision tests, pressure tests, more dilation.  At this point, my pupil was the size of a beach ball. Any light hitting it hurt.  Dr. Palmer eventually appeared, at what had to have been a very long day for him.  It was after hours by now, and all the patients and all the staff were gone. Polite and professional, he confirmed that my retina was detached, but that the macula was still in place --- good news. He launched into the options.  I needed to decide now.

We writers tend to be pretty good researchers.  I’m curious about most things.  But when it comes to medicine and especially, the medicine my family and I consume, I am borderline obsessive.  I research exhaustively.  I spend hours looking at medical journals, various practitioners, pros and cons of each treatment.

Not today.  It was one of the most out-of-control feelings I have had in years.  Putting myself in the hands of somebody I had just met, knew nothing about, in a hospital I never went to with a set of procedures I remembered only dimly, having read about them in the distant past when they weren’t relevant to me. 

The tech who remained behind to assist thrust another document for me to sign into my lap.  “Is this me agreeing to allow you to save my vision?”  I asked, scribbling an unintelligible mark about where I was guessing the signature line was.  “I’m down with that.”

There was a guffaw from across the room.  Dr Palmer seemed to think this was funny. “You know who never reads these things?” he asked.  “Lawyers.  They know these don't really deter people who are determined to sue.”

Good to know, I thought, hoping it wouldn’t come up.  

Most retinal re-attachments involve two steps: getting the retina back where it’s supposed to be, and surgically repairing the damage. The first involves injecting a gas bubble into the eye.  If you’re lucky, the second involves either minimally invasive cryosurgery (freezing) or lasers.  If you’re not lucky, a more conventional surgery may be required. In my case, because I had a trip to Japan in a month and really, really wanted to be able to take it, we opted for the gas bubble and cryosurgery, right then. It gave me my best shot at a faster recovery.

Insertion of the gas bubble was not bad.  It involved the use of an ocular speculum to hold my eye way, way open.  I didn’t get to see this, obviously, but I think Cal was pretty scarred by it.  He muttered something about that cyborg in the Arnold Schwarzenegger film. 

Credit: The Guardian

On to step two, cryosurgery.  Except they couldn’t get the cryosurgery tanks to work. There was a sea of them in the procedure room, which Cal commented on.  “Oh, we have a lot of them because sometimes they run out of gas,” Dr. Palmer answered.  He was rummaging around, apparently looking for one that would work.  First, they couldn’t find the wrench to open the tops.  Then, they had trouble reading how much gas was in the various tanks.  It seemed the rubber gaskets on some of the tanks were old and dry, preventing proper operation.  At one point, Cal helped them find the wrench.  At another, he helped them try to open the tanks.  How fun, I thought.  Participatory surgery!

I am not a nervous patient.  I know what kind of training these people have and I tend to trust them.  But this was interesting. 

In the end, the tanks won and cryosurgery was off the table for that night.  “I think you might do better with lasers anyway,” said Dr. Palmer. “Come back tomorrow.  This office will be closed but just knock and I’ll come open the door.”

So, after hours in the face plant position, using gravity and a gas bubble to get the retina back where it belonged, that’s what we did.  We visited an empty office in El Camino Hospital, with an eye surgeon wearing street clothes, for a decidedly casual but insanely advanced technology using green wave-length lasers. Dr. Palmer was positively chatty this day.  He answered my many questions. We played the “do you know” game when it turned out I had worked with some of the doctors he trained with. He treated us to a fun lecture on the advancement of ophthalmological lasers, recalling the days when lasers were the size of a couch and the patient had to be in a prone position for the surgery, requiring that the doctor crawl under the table and operate lying on his back, looking up. 

This day, ocular speculum in place, Dr. Palmer zapped my eye about 100 times with a device roughly the size of a pen light. I worked very hard at staying absolutely still, hoping that he had the best hand-eye coordination in his medical class.  “You’re doing great,” he said, several times.   The actual surgery took six minutes. 

As I climbed out of the chair and tried to get my bearings, he asked suddenly: “How was this experience for you?”  It seemed an odd question, and I wondered if he was thinking of the night before, the tanks that didn’t work, and this odd Saturday, off-hours procedure in an empty hospital unit.

“It’s been fascinating,” I said after a pause, and it was true.  It was scary and at times painful.  There was discomfort and boredom ahead, as I would have to lie in an uncomfortable position for 45 minutes out of every hour for days, avoiding all screens and all reading.  The specific position would let fluid dissipate, and ocular structures settle back to where they belonged. The gas bubble created a black flying saucer hovering over my right field of vision, obscuring everything. That was disconcerting, and my poor brain had to work double time trying to keep up with the weird visual inputs. Over time, the flying saucer would shrink and disappear.

But on the other hand, think about it.  All the doctors and researchers and patients who came before, experimenting with lasers, operating upside down; trying, failing, trying again in a quest to perfect the technologies. I wondered who first asked: what if, instead of grabbing that retina and forcibly putting it back, we used a gas bubble, and let gravity do the work? 

This day—just 48 hours after the black mass appeared—I thought about all the people who got us here.  Where I could have a rupture in my eye one day, get it fixed the next. In an empty but high-tech office.  With one really skilled guy.  Using one of medicine’s most advanced technologies and—on the other hand—gravity. A force as old as time.   

“Actually,” I corrected myself.  “It feels kind of like a miracle.” 

And yes. I will be on that plane to Japan.