Medical Mysteries: A condition worse than migraine was causing woman's pain
Tuesday, March 23, 2010
After dropping her 12-year-old daughter off at school one morning last October, Kim Goodrich was driving to her job as a hairdresser while talking on her cellphone with her husband, who had recently arrived in San Francisco on a business trip. Her migraine, she told him, was getting worse and she worried that intense pain might require a trip later that day to the emergency room of the hospital she was driving past.
What she said next made Steve Goodrich's stomach drop: "I can't see out of my left eye. And something's weird with my right eye."
"Go to the hospital right now," he told her before hanging up to book the next flight home to Montgomery County.
Each was frightened, but for different reasons. Kim Goodrich, 39, had tried to endure the pain associated with migraines that had become more debilitating. Her husband had a more immediate concern: Kim, who had emigrated from Vietnam at age 16, sometimes had difficulty understanding what was being said to her and communicating effectively. He served as her interpreter in medical situations. Now he was 3,000 miles away, powerless to help her.
Things were about to get much scarier. Doctors soon discovered that a symptom of Kim's migraines was the vital clue to a problem that nearly had catastrophic consequences.
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The first migraine had come on suddenly. In October 2005 Goodrich had traveled with her family to New Hampshire when she developed a severe headache and pain in her eyes and began projectile vomiting. The next morning, after a good night's sleep, she seemed fine.
"We just chalked it up to a migraine," said Steve Goodrich, adding that his wife has long suffered from carsickness and occasional tension headaches.
Goodrich had noticed that her eyes sometimes seemed tired and achy at the end of the day; at times her vision wasn't clear. "Sometimes it seemed like I was walking through a smoke cloud," she recalled. An optometrist who checked her eyes in 2005 and 2006 told her nothing seemed amiss.
But early one morning in March 2008 Goodrich experienced such severe eye pain that her husband took her to a Maryland emergency room. "They hooked her up to monitors, saw that her pupils were dilated and said, 'She's on drugs,' " he recalled.
"She doesn't do drugs," he replied. The ER doctor gave her an injection of Dilaudid, a potent narcotic painkiller; within minutes the pain vanished and her eyesight returned to normal. She was discharged with a diagnosis of migraines.
A few weeks later the neurologist she consulted about the headache ordered a CT scan, which revealed no abnormality. He advised Goodrich to reduce stress and to take over-the-counter pain relievers if she felt an incipient migraine. "His advice was: 'Learn to relax,' " she recalled.
The migraines continued intermittently, increasingly accompanied by eye pain. In August 2008 she wound up back in the emergency room with symptoms identical to the first ER visit -- and a similar resolution.
The couple assumed that the stress of a new job that required battling heavy traffic might be partly responsible. "My wife is someone who, no matter what is going on, maintains her routine," Steve Goodrich said. He suggested she see an ophthalmologist, but she didn't think it was necessary. "I figured, well, she's got to make her own judgments."
The events preceding her sudden loss of vision in October 2009 were not unusual, although she had never before lost her sight.
But her third ER visit was different: Doctors focused on her eyes, not her headache, and discovered that her intraocular pressure, the fluid pressure inside the eye, was dangerously high. They sent her straight to a nearby ophthalmologist, who quickly diagnosed the problem: narrow angle glaucoma, the most severe form of a disease that is uncommon in people younger than 40. In Goodrich's case, farsightedness and Asian ancestry were risk factors.
Steve Goodrich, up in the air on his way home, knew none of this. "I had no cellphone access. It was absolutely nerve-wracking for me, and I knew how scary this was for her," he said.
The glaucoma was intermittent, which had made it harder to diagnose. Ophthalmologists believe it had been developing for at least four years, probably before the New Hampshire episode. But every time Goodrich's optometrist measured her eye pressure it was normal, and doctors did not check it on her first two ER visits. Nor did the neurologist consider it: He treated her for migraines.
Narrow angle, also known as angle closure, glaucoma is considered a medical emergency, according to the Merck Manual, one of the world's most widely used medical texts. It occurs when the fluid at the front of the eye becomes blocked by part of the iris, which causes an increase in eye pressure as well as severe pain, nausea and halos. The increased pressure can damage the optic nerve and reduce the visual field. Intermittent glaucoma can resolve spontaneously after several hours, usually after people fall asleep in a supine position.
The ophthalmologist later told the couple, who spent much of the next week in his office, that Kim's case was so advanced that she was within 48 hours of permanent blindness. He immediately began a series of treatments, which included various eyedrops and laser procedures; at one point he tried to drain the excess fluid using a needle inserted into her left eye, which was much worse than the right.
On Saturday, Oct. 24, Steve Goodrich said, he told the ophthalmologist that while he appreciated the doctor's efforts, it was time to call in a specialist. The ophthalmologist agreed and telephoned Howard Weiss, a Chevy Chase glaucoma expert, who met the couple in his office that afternoon.
Weiss administered stronger eyedrops and performed another laser procedure, which seemed to work. The couple left his office at 6 p.m. with plans to return the following day.
But five hours later, Weiss received an urgent call from Steve Goodrich. Kim was in the throes of severe eye pain and a bad headache. The eye surgeon sent them to the emergency room, where the pressure in her left eye was measured at 71. (Readings above 21 are considered elevated.) Weiss began assembling a team to perform emergency surgery.
After several middle-of-the-night conversations with the ER doctor, who managed to control the pain, stabilize her vision and send her home, Weiss called the Goodriches at 7:30 a.m. and told them to head to the Washington Hospital Center, where he operated on Kim, fashioning a new drainage channel in her left eye.
"She did great," Weiss said. Luckily, the pressure in her right eye seemed to be under control; Weiss planned to monitor it closely.
But at 6:30 Sunday night, Kim Goodrich called Weiss. Her right eye hurt, she had developed a headache and she was having trouble seeing.
Weiss was dumbfounded -- and alarmed. "I was really nervous about the second eye being in trouble so fast," he recalled. Although he has treated thousands of glaucoma patients in his 24-year career, he had never heard of both eyes requiring such emergency surgery, which doctors are loath to perform because of the risks.
He called two of his partners -- among them they had 65 years of experience -- and "no one had ever seen anything like this," particularly in a patient so young. His search of the medical literature and textbooks turned up nothing, either.
He told the couple to meet him at 7:30 the next morning in his surgery center. There he removed the patch covering Goodrich's left eye and checked the pressure: To everyone's immense relief it had dropped to 19. But the right eye measured 51. A few hours later Weiss operated, creating a new drainage channel for the right eye.
Both surgeries were a success. Two weeks later, the pressure in both eyes was normal. Goodrich's headaches and eye pain disappeared, and her vision returned to normal.
"In her case the eye symptoms were actually more important than the headache," said Weiss, who doesn't expect the glaucoma to recur. "The headache was due to the eye pain," rather than the other way around.
Although Goodrich's experience is very rare, Weiss considers it a valuable reminder to patients and doctors alike: Eye pain should trigger a full ophthalmological work-up, particularly in farsighted patients.
Kim Goodrich said that she and her family feel deeply indebted to Weiss, who considers her case among the most rewarding of his career. Sometimes she thinks about what life would be like if she could not see her 12-year-old daughter grow up.