Wednesday, August 22, 2007

Subjective experience two weeks after surgery

A. The remaining gas bubble. The bubble appears to be opaque (black) around edges, and that tapers off pretty rapidly to a somewhat greenish-grey translucent center. It is now small enough that, if I hold my head parallel to the ground, it becomes a circle in the center of my field of vision and I can see all around it. It shrinks noticeably every day. (One notices the difference after sleeping).

B. The sides are relatively clear; however, there is a milky white haze relative to my left (good) eye. Focus is poor, but I could easily read the larger letters on the eye chart.

C. The central area above (from my perspective) the bubble is similar to B in focus and color, but adds reflections as if being viewed under a little water. I suspect that is reflection from the bubble and that once the bubble is completely gone, my vision will be like area B.

As the bubble recedes, I see some very faint floaters -- particularly if I jiggle the bubble -- for example in brushing my teeth or walking. The surgeon is not concerned -- no need to panic, but check with your surgeon if you see any.

Saturday, August 18, 2007

Check out Joe Henderson's weekly commentary on running

Joe Henderson writes about running and life in books and as a columnist for Runner's World magazine. He also publishes a weekly commentary which you can subscribe to by email. Joe has been around long enough that much of his writing is about older athletes.

For example, the current commentary is on author Paul Reese who ran into his 80s. Another commentary is a tribute to George Sheehan who ran competitively and wrote eloquently about it until age 74.

(It seems that some old runners are also inspiring writers. Does running induce reflection? Do thoughtful people tend to turn to running for exercise?)

Friday, August 17, 2007

Recovery begins

This blog has been hijacked by my detached retina. Time to change the subject.

I walked 2.4 miles today. I walked slowly, kept my head down a lot, and kept an eye on my eye. Pretty lame, but it was my first exercise since this began.

Obsessive observations

The surgeon asked me to report changes, and I spend a lot of time observing my vision. I hope this diminishes with time.

The gas bubble in my eye now covers about half of the field of vision. The transparent portion has a distinctly white haze over it relative to my good eye. I don't think it is getting denser, but cannot be 100% sure. I wonder if that is caused by poor focus, the clouding of the back of the lens that I have read about or something else. Will it pass?

The clear area is full of reflections -- like being under water -- which I hope will clear up when the gas bubble is gone. The gas bubble also jiggles whenever I move, even when I brush my teeth.

I also noticed that when my face is parallel to the floor -- so I am seeing through the bubble -- and I have a patch over my eye, I can see a faint discoloration where the detachment was. It shows up a bit stronger when I move my eye or take a step. This is a subtle change, but, as I said, I am kind of obsessed for the time being.

Thursday, August 16, 2007

The long term looks good, but for now I remain a couch potato

I saw the surgeon today, and she says the retina is attached and doing well. She also assures me that I can go back to heavy training at the end of the process. I mentioned things like dead lifts and leg presses on a machine where one's feet are elevated, and she said "no problem."

For the next three weeks, I am to remain a couch potato. I am slipping rapidly out of shape. The only good part of that is that I will get a chance to see how fast and how completely I can recover.

Her advice is to do nothing that will elevate my heart rate. I guess I will start taking some long, slow walks.

I asked her what the risk mechanism is -- is she afraid of elevated blood pressure, temperature, intra-ocular pressure, acceleration, etc., but got no answer -- just repetition of the admonition to keep my heart rate low. I think I could be a more effective and less worried patient if I had a better understanding of her model of the eye and healing process, but the system does not allow her time to teach me.

Wednesday, August 15, 2007

Can I remain "athletic?"

My vision is still very blurry, but I am assuming that is due to correctable focus problems, not retinal disease. So, my attention is turning to the future -- will I be able to remain "athletic?" The following questions come to mind:
  1. Given the nature of the detachment and its cause, is my right retina more likely to detach now than it was before?
  2. Will there be some time period after which detachment is no more likely than before?
  3. I was told that the risk of detachment from cataract surgery was less than one in one thousand. Assuming that that is the overall rate, what is the rate for someone my age, with my degree of myopia and level of physical activity? (I have even read that being of Jewish descent increases the probability of retinal detachment).
  4. It has been a couple of months since my left eye was operated on. Is my risk of retinal detachment still elevated? Will it ever be as low as it was before the cataract surgery?
  5. Is it certain that walking home from UCLA did not precipitate the second detachment? Is it safe to walk now? At what rate and for what duration?
  6. What are the mechanisms through which various forms of exercise cause detachment -- jarring, straining, physical contact, etc? Specifically, I am interested in the risks of heavy weight lifting, running, swimming and hard bike riding. What about a sport injury such as a bike crash?
  7. Are some weight lifting exercises more dangerous than others -- for example using a squat machine in which one's legs are elevated or dead lifts where one lifts a weight from the floor?
  8. Have there been studies of masters athletes, for example members of national track or swimming associations or senior Olympic competitors?
  9. Are there warning signs that I could watch for during exercise, and, if so, would immediately stopping be sufficient?
  10. Are there warning signs that can be detected during a retinal examination? If so, would it be possible to resume vigorous exercise and have regular (quarterly? monthly?) retinal exams?
  11. I was told there was close to thirty percent chance that the capsule behind my implant would cloud over. If that occurs, would fixing it be likely to detach either retina?
  12. What sort of fluid will fill my eye and what is the effect of that? Might it reduce/increase traction -- lower viscosity? greater velocity when accelerated? Are there fluid dynamic models of the inner eye? Have ophthalmologists collaborated with mechanical engineers on this?
  13. What is the effect of the scleral buckle on the likelihood of recurrence?
  14. Why have my physical restrictions been less stringent than anticipated before the surgery? Does that indicate a lower likely hood of re-detachment?
  15. I have been told that there are several types of cataract procedure, each with differing levels of retinal risk. If this is the case, what are those alternatives, and which did I have?
  16. Has the vitreous gel in my left eye shrunk away from the retina, and, if so, what are the implications of that?
  17. Before the cataract surgery, there were more floaters in my right eye than my left, and they were larger and darker. Did that indicate more risk for my right eye?

Tuesday, August 14, 2007

A non-problem, but let's use the Net

Post-operative patients are a bit compulsive, noticing every change. Yesterday, I noticed that if I stood up fast, slightly diminishing the flow of blood to my head, my right (bad) eye went black for a few seconds. I was afraid that might be the signal of a vascular complication, and called the doctor just to be sure. Her secretary called back about 20 anxious hours later saying it was to be expected and not to worry.

That was a relief. But, what if it had been a problem? How long did it take for my message to get to the surgeon? How long did it take for her to reply? Shouldn't we use the Internet to speed communication between a surgeon and her currently convalescing post-operative patients?

Sunday, August 12, 2007

How it looks from in here

The problem began with a milky, irregular shape in the left-lower quadrant. After the first surgery, that area was regular and opaque (a). Just before the second surgery, the opaque area had grown (b). After the second surgery, there were two translucent areas (c). Today there is only one translucent area (d).

My retina seems to be healing

I can only see very blurry colors and shapes -- can barely count the fingers on the hand in front of my face -- but I believe the retina is healing. While the dark area of the bubble remains translucent, the previously opaque area where the retina was detached is nearly transparent now.

Furthermore, I have an eye shield with small perforations. When I look through those perforations, things are a bit sharper, indicating that the problem is in focus, not the retina. Finally, at about 2.5 inches, I can resolve considerable detail -- I can read black letters on a white background. Since I am using drops that dilate my eyes, have swelling, have had the shape of my eye distorted with a scleral buckle, have a lot of liquid on the surface of my eye, etc., it is not surprising that things are out of focus. I wonder what the long term effect of having had my vitreous gel removed will be? What is replacing it?

Something positive

I've been complaining like crazy -- time for something nice. During my second surgery, I was sedated, but could hear the surgical team converse. The highlight for me was hearing them discuss a recent journal article in the context of my surgery. I've been seen by doctors who struck me as non-intellectuals who practiced handbook medicine and probably got most of their continuing education from drug companies. Doctors who had not read the articles I had found on-line, and were not interested in my sending them copies. These young physicians are involved professionals.


I should not have had the cataract surgery on my right eye in the first place. The cataract on my left eye had grown quite bad, and really did need to be removed, but my right eye was not so bad. After the first surgery, I could see well with my left eye, and my right eye was myopic. I could read, work at the computer, drive, etc. just fine. I should have questioned the surgeon's assumption that the right lens should be replaced.

Prior to the operation, the risks were outlined in message video taped by the surgeon. In the section of the tape labeled "Risks and Complications" he states:
Cataract surgery is surgery, and there is a small chance that things can go wrong or not turn out the way we want them to. The two most significant risks of cataract surgery are infection and retinal detachment. The numerical odds of those problems are in the one in a thousand range. In my hands the actual risk of infection has been lower than one in a thousand and the same for retinal detachment, but they are in that range and they are real serious problems. If they occur, we have to take care of them, there is no option. We cannot sort of sit on them and watch them, we have to manage them. And even with a complication we can get good results.
I understood that there was a risk of detachment with cataract surgery, but was not told that the risk increased with age and degree of myopia. What is the detachment rate for 67 year-olds who are as myopic and physically active as I was? I still don't know.

The video mentions several other possible complications including "the capsule behind the implant clouding over -- in fact that one is almost a 30 percent chance and that is a simple thing to fix." I wonder if that fix, if necessary, will risk re-detachment of my retina.

I went for a two-week follow up examination after cataract surgery on my right eye. I told the surgeon that my vision was significantly worse -- blurrier and less bright -- than the left eye, and had been plateaued since a few days after the surgery. I suggested that this might be due to manufacturing variance in the implants, which he said was extremely unlikely. My relative inability to read the eye charts confirmed that my vision was both dim and out of focus. I told the surgeon that I was not able to read using the drugstore reading glasses he had recommended. He was puzzled by that, but did not follow up. Was that an indication that the problem was not due to a faulty lens or swollen eye, but the retina? I also mentioned that I thought I was catching "glimpses of my nose" in my peripheral vision.

The surgeon said the poor vision was probably caused by inflammation and prescribed different eye drops. He shrugged off the mention of seeing my nose -- said he had never heard that one before. In retrospect, that was the start of a detached retina. Should he have been suspicious and sent me for a retinal exam?

The surgeon's reaction to my "seeing my nose" or not benefiting from reading glasses reflects inattention to the patient's subjective state. He has never had the subjective experience of a retinal detachment. Did his training attempt to convey that experience to him? He should have read descriptions of retinal detachment by patients. He should have looked at patient's drawings of what it looks like.

Cataract patients should read the same accounts and see the same drawings. Like the surgeon, we are unfamiliar with the subjective experience of a detached retina until it is too late.

Why didn't my poor vision worry the surgeon? I suspect that is a combination of hubris, "knowing" the statistics, and inattention exacerbated by the fact that he does many operations each day, and schedules only about five minutes for the two-week post operative examination.

One or two days after my two-week follow up, I woke up seeing a watery-opaque area in the lower-left quadrant of the field of vision in my right eye. I went to the clinic, and received an emergency scleral buckle. Since then, I have read that a scleral buckle may be accompanied by the draining of the fluid from behind the detachment and the injection of a gas bubble into the eye. Would one or both of these steps have prevented my second surgery?

I went for an early-morning post operative exam a few days later. The surgeon was worried about the lack of improvement. She contemplated injecting a gas bubble at that time, but decided instead to wait two days. When I asked her whether I could walk home or should call my wife to pick me up, she replied that there would be no harm in walking as long as I did not exert myself to the point of elevating my heart rate. I walked home (downhill) very slowly. Might that have caused the detachment to spread?

A few hours later, the opaque area extended into the upper left quadrant of my field of vision, and a second emergency surgery was performed. Could that have been avoided by injection of the gas bubble earlier in the morning?

The first night after the second surgery, I was instructed to lie on my stomach with my face parallel to the floor until I returned the next day for a post operative examination. That is a very uncomfortable position, and maintaining it all night was very difficult. But I was able to do so with the help of some foam rubber cushions my daughters picked up at a drug store. It would have been impossible otherwise. Why didn't they give me such a cushion when I went home after the surgery? They would have given me a crutch if I had a broken leg wouldn't they?

The patch was removed from my eye the day after the second surgery. The area that had been opaque -- the left side of my field of vision -- was improved. It was still discolored, but translucent, not opaque. However, a second translucent area had appeared across the top of my field of vision. That scared the shit out of me. I told the surgeon, but she said she could see nothing wrong and told me not to worry. (Right). The next day, the original area showed some improvement, but not the new area on top. I called and left a message to that effect. Many hours later, another doctor called to say that I should quit worrying. The next morning I made a subjective discovery. The darkened area was not fixed at the top of my field of vision -- it moved to the side if I tilted my head. It was the gas bubble! That was a great relief, but why hadn't I been told that in the first place? I don't think the surgeon was being insensitive. I think she had not been trained on the subjective experience of the patient. I am better trained to support post operative patients than she in some ways.

I have also encountered a small "catch-22." I was frightened after the second surgery, and worried that I might not be able to sleep well. I asked the surgeon for a sleeping pill prescription, but she said I would have to ask my general practitioner. The general practitioner also refused, telling me to ask the surgeon. I ended up taking a Tylenol PM. Who is my "physician?" I wonder how Paris Hilton gets her drugs?

Every day, many people have retinal detachments repaired. We are experts in the subjective experience. The Internet excels in providing a meeting place for communities of common interest. Why was I not given the address of an online patient-support group before I agreed to cataract surgery? Why was I not given the address of an online patient-support group once my retina was detached? Why doesn't the surgeon use the Internet to stay in contact with the dynamic group of currently convalescing post-operative patients?

Saturday, August 11, 2007

Feeling old

No two ways about it -- a side effect of a serious injury or illness is that it reminds you that you are old, frail, and mortal. There is a saying -- "if you want to hear God laugh, tell him your plans." I can touch envy of youth for the first time. Adios, denial

Anxious dreams

This detached retina has invaded my dreams. Last night I dreamt I was at the Senior Olympics, but expected to finish last and also kept getting mixed up on the schedule and missing events. Finally, I dreamt I ran a dash, and woke up afraid that the excertion may have damaged my retina. Total anxiety and fear dreams.

Use it or lose it

I have been a gym rat since my undergraduate days at UCLA. I stopped working out for a few years after graduation, but came back to the gym in the early 1970s and have worked out regularly -- typically 6 hours per week -- ever since. Until my retina detached, I don't think I went more than one week without at least one heavy workout in all that time. On off days, I would typically jog or do a hard training ride on my bike.

The most strenous thing I have done in the last two weeks is walk a few blocks.

Well, I am going a bit nuts. I was addicted to exercise. I always felt great -- rejuvenated -- after a workout, but the addiction was not all positive. I think I was also afraid to skip workouts -- afraid to lose it. If my eye heals, and I can resume training, it will be interesting to see if I can come back and, if so, how long it takes.

If things go well, I have to wait two months to resume training. Hopefully I will be able to do some exercise before that. Right now I am not allowed to bend over, lie on my back, lift anything heavier than five pounds or walk fast enough to raise my heart rate. (The first night I had to stay up all night lying on my stomach with my face parallel to the floor to keep the gas bubble floating against the retina).

Two weeks of inactivity have already taken a toll -- most notably on my legs. They are smaller and the thigh muscles are less defined. Abs too. Less deterioration of the upper body. More important, my legs feel very weak. I think this is also bad for my heart. I feel some arrhythmia and a little bit of the effect of being low on oxygen. That may contribute to the feeling of weakness in my legs. It might be in my head too. I will monitor the comeback if I am able to resume working out. We'll see how long it takes to reach the level I was at two weeks ago, if I can do it. That will be most interesting.

Detached retina

I had a cataract in my left eye repaired at UCLA's Jules Stein Eye Institute about 8 weeks ago. The results were good. Then I had the right one done about three weeks ago. At my two-week post operative visit, the results were poor -- things were a bit dim and out of focus. The surgeon examined me and sent me home with a prescription for different eye-drops. The next day, the lower-left quadrant of my vision clouded over. I went back to UCLA, and a few minutes into the examination, the retinal specialist asked me when I had last eaten. My response was "shit" -- I knew she was thinking emergency surgery and I new my retina was detached.

I was frightened in the pre-operation area. My usually 130 mmHg systolic blood pressure went to 178. I was trembling inside my body. My veins receded, making insertion of an IV needle difficult. It was fright, not flight.

The surgery went well. They installed a scleral buckle -- a flexible band placed around the equator of the eye behind the tear, but did not drain the fluid under it or insert a gas bubble. The cloudy area became opaque. A few days later -- hours after a retinal exam -- it began to grow. I went back for a second emergency surgery -- a vitrectomy, replacing the vitreous with a gas bubble. That is where I am now. I can only see shapes. One is the bubble, floating at the top of my field of vision. The detached area has faded from opaque to fairly transparent. If nothing goes wrong, I will see the doctor again in five days.

I am still frightened. The prognosis is good, but far from certain. I now know I am prone to retinal detachment -- they keep checking my good eye. My right eye will be even more prone to re-detachment. I could end up blind in one or both eyes. Not many blind athletes around.


The benefits of being an old athlete are clear -- we are fit and capable, look as good as can be expected, and have energy for all sorts of activities -- we trick our minds and bodies into feeling and acting young, and the feedback systems within us tend to make it so. We hide from the knowledge that it will not go on forever -- we will not still be competing triathlons if we live to be 100. And the odds that we live to be 100 are not all that hot.

I was able to think about that hidden knowledge, and still repress the bad feeling until two weeks ago, when I suffered a detached retina as a side effect of cataract surgery. I am now afraid of being blind, and feeling my age. If the surgery is effective, and my sight is restored, will I revert back to a child-like state of forgetful denial, or will I be changed?

I can speak with my head -- going back to denial is a good idea -- it is rational -- there is no use making myself miserable by imagining a grim future. With a little help from Shakespeare, Julius Caesar said it a long time ago -- "The valiant never taste of death but once. Of all the wonders that I yet have heard, it seems to me most strange that men should fear seeing that death, a necessary end, will come when it will come." Well, that was my head talking -- the logic is unassailable -- but good luck controlling my feelings and imagination.

I hope I have the chance to reread this in a year and see whether I have returned to denial, and pushed awareness of my frailty down. The other option is really frightening.

Wednesday, August 01, 2007

Is competion worth it?

Although I train regularly, I have only entered two competitions -- the Carpinteria Triathlon and the Senior Olympics in Pasadena, California.

In the triathlon, I did the sprint course -- 5K ocean swim, 15K nearly flat bike ride and a 5K run. In the senior olympics, I did the 5 and 10K bicycle time trials and bench pressing.

Barring injury, I will do the triathlon again this year, but I am not so sure about the Senior Olympics. I love bike riding -- for training and transportation -- but the bike races were kind of serious. For example, Fritz Tomasello, shown here, is a California State champion. Like Fritz, most of the folks had a couple of expensive racing bikes and other equipment in their trucks and vans. I was the only one with an old steel frame bike. Even worse -- I didn't have a spandex riding outfit -- just a t-shirt and shorts.

Jewett Pattee was another notable competitor. Jewett is a hall of fame racer who has completed the Race across America and five Furnace Creek 508 races. Jewett is a pretty amazing guy -- out on his bike with artificial hips at 83 years old!

The bench press contest was easier going. There were more competitors, and they did not seem quite so focused on winning -- maybe in weight lifting the contest is more against yourself than the other athletes. We ranged from first timers like me to AAU champions, but everyone seemed to cheer everyone else on. Unlike the bike races, equipment is not a factor in weight lifting.

The triathlon is open to all ages, but we were grouped in the starting area by age, so all of the older men got to hang out before the race. There only a few of us, but it was a friendly group. Again, I had the only old bike and rode in running shoes, but I did have a cool wet suit. I was nervous about the swim, having just started swimming a few months earlier, but that turned out to be the most enjoyable part. We started in a bunch, and you could feel the others around you -- like a school of fish. The bike ride was pretty easy -- I paced myself, but still passed a lot of people. The run was tough -- I had to stop and walk to catch my breath frequently. Looking over my split times, it is clear that I need to work on running.

I got a couple of medals from all this, but they are no big deal -- surely not enough to keep me coming back for more. I am hooked on training -- daily workouts -- the way I feel afterward is all the reward I need. The competition is a footnote.