Now You See, Now You Don't

What Can Go Wrong
By Bob Guldin
Special to The Washington Post
Tuesday, June 3, 2008

"Wow!" I said. "Is that a psychedelic light show?" I was at a party, and I could see a bright shimmer of purple across the room. It reminded me of my misspent rock-and-roll youth.

My wife looked at me quizzically. "There's no light show; it's just a light," she said.

I looked at it hard and could tell she was right. So what had I just seen?

I didn't know it, but I had entered the unsettling sphere of retinal detachment, a Twilight Zone where you can't believe your eyes. And as I had yet to learn, recognizing the symptoms of a displacement of the light-sensitive tissue lining the eye could mean the difference between saving and losing your sight.

In the weeks that followed, I saw more flashes of light that I knew weren't there. I saw growing numbers of "floaters," odd shapes that drifted across my field of vision. Once, while washing dishes, I panicked at the sight of a swarm of them congregating around a basket of bananas. Surprise! My floaters were actually fruitflies. (Somehow, I was not comforted.)

When I got worried enough to visit my eye doctor, he told me my eye tricks might signal a developing tear or detachment of the retina, the layer of cells that receives images and sends them to the brain via the optic nerve. If you see something like a curtain crossing your vision from any direction, he warned, come in right away.

Three days later, I saw the dreaded curtain, rising from the bottom of my right eye's visual field. I went to the George Washington University Ambulatory Care Center, where retinal specialist Fadi Nasrallah put me on the retinal fast track.

I was diagnosed at 1 p.m. and told "we have to operate today." Once doctors explained the urgency, I dropped the idea of a second opinion. At 6 I was on the operating table, and by 10 that evening I was home. Who knew American medicine could move that fast?

The Need for Speed

The speed, I learned, was necessary. Unlike many eye conditions such as cataracts, a retinal detachment is fast-moving. If it's caught quickly, you have a chance of keeping your eyesight virtually intact. Wait too long and you're looking at blur city, maybe near blindness in the affected eye.

Nasrallah, the specialist who stuck sharp shiny objects into my eye (God bless him), acknowledges that there's an information gap. "There's no public awareness that flashes and floaters are to be taken seriously," he says. "We don't publicize it enough."

What's more, most people who have flashes and floaters are not in a retina emergency, says Sharon Solomon, an assistant professor of ophthalmology at the Wilmer Eye Institute at Johns Hopkins. "But if you never had floaters and wake up one morning and you have 20 new floaters, that's concerning."

Because retinal detachment causes no pain, too many people ignore their symptoms, hoping they'll go away, says Julia Haller, who heads Philadelphia's Wills Eye Center.

Others don't get prompt care because they lack insurance or access to an eye surgery center, or because medical gatekeepers don't recognize the need for quick action.

Patients with a detached macula (the central part of the retina, which gives us sharp, detailed vision) who are treated within a week have a 75 percent chance of retaining 20-70 vision or better (good enough to drive a car with restrictions), Solomon says. After a week, their chances drop to 50 percent.

Star Lawrence, a writer in Arizona, knows the cost of delay. In December 2006, she was diagnosed with a detached retina plus hemorrhage in her right eye. ("I saw things like big red branches." she says.) But her eye surgery wasn't until weeks later. Now, four operations later, Lawrence has lost almost all the sight in her eye.

How It Happens

To understand why speed is so essential, picture a retinal detachment in the making. Normally the retina adheres to the back wall of the eyeball. A clear gel called the vitreous humor (or just vitreous) helps it stay in place. But as we age, the vitreous becomes more liquid and pulls away from the retina.

In some cases, as it pulls away, it tears the retina. If vitreous liquid gets under that tear, the retina can detach from the eye's wall, causing floaters (actually, clumps of protein in the vitreous), flashes (quick bursts of light usually in the peripheral vision, caused by tugs on the retina) and vision loss. After a couple of weeks of detachment, the retina begins to lose function.

"A retinal doc can still reattach the retina to the eye anatomically, but after two weeks or more, reattachment does not guarantee an improvement in vision," Solomon says. "That's especially true if the detachment crosses into the macula."

In any given year, about one American in 10,000 suffers a retinal detachment. But if you're extremely nearsighted and in the 45-to-70 age range (boomers beware), the risk is much higher. (After 70, risk declines.)

Other risk factors: a family history of retinal detachment, having another eye disease such as glaucoma or cataract, eye surgery. Very nearsighted people can have detachment at an early age, because their eyeballs are elongated, which makes it easier for the retina to separate.

Despite a commonly held belief, vigorous exercise does not increase the risk of detachment, though it is true that welterweight Sugar Ray Leonard took several long timeouts in his boxing career to recover from detached retinas.

Sleep, more than aerobics, is likely to spur retinal detachment, Solomon says. "That's because during REM, or rapid eye movement sleep, your eyes are under most stress, whipping back and forth as you're dreaming."

How They Fix It

In recent decades, ophthalmologists have developed several repairs, said to work in more than 85 percent of patients, when a tear is caught in time. Those include the scleral buckle (a silicone band that pushes in the eyeball so the retina can reattach), injecting a gas bubble in the eye to press the retina back into place, and vitrectomy (replacing the vitreous gel in the eye with a clear liquid).

In almost all cases, these techniques are combined with use of a laser or extreme cold to weld the retina back in place.

I had the bubble cure. It wasn't painful, but it was extremely weird walking around with a large blue-green bubble bobbing around like a beach ball in my field of vision. Over six weeks, the bubble got smaller and eventually disappeared. I was also under orders to do no reading and no work. Very sad -- a month of TV and books on tape!

A month later, even before the bubble was gone, I was back to my regular life: working, reading, swimming and driving. The flashes and floaters were gone. My retinal detachment seemed like a bad dream that had come and gone in the blink of an eye.

Bob Guldin is a Washington area freelance writer.

© 2008 The Washington Post Company