It started late on a Thursday afternoon last May, when I noticed a wispy dark shadow in the lower left corner of my right eye. At first, I didn’t worry about it. But being 62 at the time — a baby boomer — I should have.
For years, I have had “floaters” in both eyes. Small moving spots that appear in a person’s field of vision, floaters typically occur when tiny pieces of the eye’s gellike vitreous humor break loose within the inner back portion of the eye. While annoying, ordinary floaters are very common and rarely are cause for alarm.
But a sudden burst of floaters can be a warning sign that a tear is starting to develop in the retina, the light-sensitive membrane in the back of the eye. An early-stage retinal tear can be treated in an eye doctor’s office with laser surgery that creates a weld around the edges of the tear and usually keeps the retina from detaching, according to Vinay Desai, an ophthalmologist with the Retina Group of Washington (RGW).
I should have called my regular ophthalmologist right away, but I didn’t have health insurance at the time for financial reasons. If this is just another floater, I told myself, I can live with it.
I hadn’t been hit in the eye or experienced any other eye-related injury, so the idea that my retina might be torn never crossed my mind.
But more than 90 percent of retinal detachments occur spontaneously, according to Gordon Byrnes, an RGW surgeon. The National Eye Institute says there are a variety of risk factors for retinal detachments, including being extremely nearsighted, having a family history of the problem and aging. (It also affects more men than women, the NEI reports.)
Many spontaneous tears occur in boomers who develop posterior vitreous separation. This degenerative condition occurs in 30 percent of people older than 50, according to William L. Rich III, an ophthalmologist based in Falls Church.
“Most people think retinal detachments come from trauma, such as being hit by an air bag in an auto accident or getting hit with a racquetball or tennis ball. In fact, most happen while you’re walking down the street or even sleeping,” Rich says.
“As we age, the vitreous jelly, which holds the retina in place, begins to liquefy,” Rich says. “When the vitreous gets less gel-like, it can detach from the back of the eye. As the vitreous starts to detach, it may pull on the retina and cause a tear.” The dark shadow I had dismissed Thursday was my retina starting to tear, the liquefied vitreous gel leaking through.
By Friday evening, the shadow had gotten bigger. By midnight, it was a reddish blob blotting out one-third of the field of vision. Then I started seeing flashes of light that looked like shooting stars. That’s when I called my ophthalmologist, Farhad Naseh at the Maryland Eye Institute in Gaithersburg, leaving an urgent message with the after-hours answering service.
Calling back within minutes, he said to get to the emergency room as fast as I could. The shooting stars, coupled with the reddish blob, are signs that your retina has detached, he said.
My wife and I arrived at the ER around 2:30 a.m. Saturday. Within the hour, an ER doctor had given me a preliminary exam and an ophthalmology resident was en route. By 5 a.m., the resident had examined my eye and the diagnosis was, as my ophthalmologist had feared, a detached retina. The retina had come loose from its supporting layers and the reddish blob was bleeding from blood vessels it had torn.
Even more worrisome, the macula — the part of the retina responsible for fine vision — was in the process of separating from the inside of the eye. Central vision becomes severely affected if the macula becomes detached. The resident spoke with the eye surgeon on call and relayed my diagnosis. The response was the last thing an uninsured patient like me wanted to hear: I needed a major eye operation — a vitrectomy, which removes part of the vitreous gel to get to the retina and repair it — as soon as possible. The surgery would have to be performed in a hospital operating room, under general anesthesia. The cost: more than $20,000.
I wanted to keep from going blind in that eye, but at what cost to my family? The ER charge and physicians’ fees already were estimated at around $1,000. So I called Naseh again, in hopes of finding a less expensive option.
He urged me to call Byrnes immediately. The retinal surgeon told me to meet him at RGW’s Fairfax office right away. He would take a look and see what he could do.
When my wife and I arrived at Byrnes’s office less than an hour later, I was totally blind in my right eye. But after examining me, Byrnes said, “I think we can fix this here.”
The retina had detached from the upper portion of the eye and an adjacent area was torn. Given the location and size of the tear, Byrnes felt I was a candidate for an in-office procedure known as pneumatic retinopexy. At around $1,000, it was a fraction of the cost of the hospital vitrectomy, though Byrnes warned me that it also had a lower success rate: 75 percent compared with 95 percent. I was willing to take that risk.
There was another factor that called for immediate action. “The macula was coming off, and the longer the macula is off, the more vision you lose,” Byrnes says. “We didn’t have time to wait for an operating room; we needed to do something right away.”
After applying numbing drops and injecting local anesthesia, Byrnes placed a small probe in front of my eye directly over the tear; when activated, the probe created a localized freezing spot within the retina. The process creates an irritation that causes a scar to form, and this scar tissue holds the retina against the wall of the eye.
Byrnes then injected a gas bubble into the vitreous jelly inside my eyeball. This would push against the frozen tear in the retina and help seal it in place. The tear has to be in the upper half of the retina for the bubble to be effective. Luckily, mine was.
The procedure was over in less than 10 minutes. Success would depend on keeping the gas bubble pushed against the back of the eye, which meant I needed to go home, put my head down on a pillow on the kitchen table, and sit that way for three hours. After that, for another six hours, I would have to sit still, looking down with my head tipped at a 45-degree angle. That night, I would have to sleep sitting up with my head held erect, using pillows and duct tape across my forehead to attach my head to the wall behind the bed.
Sunday morning dawned — and I could see out of my right eye. My vision was blurry and partially blocked by what looked like several bouncing, purplish balloons, but I could see. The balloonish spots were the gas bubbles, which Byrnes said would be absorbed gradually. When he reexamined me that morning, as he recalled recently, “I was satisfied that the procedure was working for you. It takes several days to form a really strong adhesion.”
Needing a follow-up exam on Tuesday, I went to Desai. After he looked at me, the news was not good. While the retina seemed to be attached, several new tears were now visible.
According to Desai, this is unusual but not unexpected, since whatever had caused the tears to begin can cause continuing and further separation of the vitreous gel.
There was now no getting around the fact that I needed immediate laser surgery. As it does with early-stage tears, the laser would cauterize the area around these new tears and form a bond preventing more vitreous fluid from leaking through and lifting the retina. Desai performed the procedure in the office, under local anesthesia. It took about 20 minutes.
An exam the next day showed the retina holding firm with no new tears. Within two months, my vision was back to 20-30, more or less where it was before the detachment.
I still see some waviness, something like the effect of looking through a pane of old-fashioned glass. “In retinal detachments involving the macula,” Desai explained, “even if the retina is reattached, there can be permanent damage . . . to our sharp vision.”
My out-of-pocket payments to RGW totaled $350: a $250 consult fee prior to the first procedure and a discounted $100 charge for a recheck following the laser treatment. The laser treatment, which usually costs $600, was free.
I asked Byrnes and Desai what prompted their generosity to an uninsured patient. “Our practice provides free care as the situation dictates, Byrnes said. “In your case, payment of the consult fee was sufficient.” “I would never let somebody go blind for financial reasons,” Desai said.
So what are the lessons learned, beyond the value of having health insurance (which I now do have)?
Anyone can suffer retinal detachment, but if you’re a baby boomer, your risk is higher and goes up every year.
The retinal detachment I had, caused by posterior vitreous separation, is “pretty rare” in people younger than 40, says Alexandria-based ophthalmologist Alan J. Pollack, but the risk of such a separation increases with age, to about 75 percent of those older than 65. “Most people who get vitreous separation are perfectly fine and don’t get a retinal detachment,” he said.
Even so, “when somebody has a lot of floaters and starts seeing flashes, we always recommend that they come in and have their vision checked,” Pollack says.
So what causes the flashes of light? According to Rich, pieces of protein in the liquefied vitreous jelly stay attached to the retina. When these particles pull on the retina, the flashes, which last only a microsecond, occur.
“Some patients who have flashes and floaters are okay, but a little tear left untreated can turn into a detached retina,” Pollack says.
“The earlier you detect a problem with the retina, the easier it is to get it fixed. By waiting, you can take a relatively simple in-office procedure and turn it into a hospital-based surgery.”
Holleran is a Gaithersburg-based freelance journalist and public relations consultant.