Still More Tears

Am I referring to ‘tears’ in the title of this blog, as in ‘emotional lacrimation’ or as ‘ripping something’? Well, grammatically speaking, I am using the word ‘tears’ as a deliberately ambiguous heteronym, so as to produce a double entendre.

‘What is a heteronym?’, I hear you ask. Heteronyms are a particular form of homonym, which are groups of words that share the same spelling but have different pronunciations and meanings. Now I bet you’re totally confused… it took me an hour searching through Wikipedia to sort this out… read on, and you will soon see what I mean…

When I presented to Bill, my ophthalmologist, for a routine check six months after my bilateral retinopexy and cryopexy, I brought along print-outs of fundus photographs that were recently taken of my eyes at an ophthalmic trade exhibition in the United Kingdom. These images were captured with an Optos ultra-widefield retinal imaging camera. I had also prepared a blow-up of the superior tears surrounded by the multiple laser photocoagulation marks. The laser marks looked like they nicely surrounded the tears, but just to be provocative, I half-jokingly suggested to Bill that in trying to circumscribe the tears with the laser, he missed a few spots.

I wondered whether this was going to be a recurring theme – that every time I presented for a routine examination, more tears would be discovered and another round of lasering required…

I don’t think Bill quite got the joke. He responded with a considered “hmmm…” while he studied the images. Then he eased me down into the supine position, donned his binocular indirect ophthalmoscope, and proceeded to examine my eyes. He reported that my retina was nicely attached in both eyes. However, he declared he was not entirely satisfied that he had achieved full demarcation of the large superior tears in both eyes, and decided to seal these tears even more with additional ‘green laser’ treatment. I was left wondering whether by showing him these images of the lasered tears, I had impacted his decision to resort to the green laser.

Six months later, Bill noticed further small tears in the peripheral retina of both eyes, which were particularly evident upon scleral indentation. The verdict? More retinopexy was required in both right and left eyes.

These additional laser procedures were performed in Bill’s consulting rooms rather than in hospital. That’s because there was no further need to perform cryopexy as well, which is generally more involved and requires extensive anaesthesia. Some of these procedures were performed with me in a supine position with Bill using a head-mounted laser delivery system. At other times I found myself sitting at what appeared to be a specially designed slit lamp biomicroscope that had laser delivery capabilities built in. I am not sure what dictates which system is used for the particular region being lasered, and I didn’t bother quizzing Bill about this.

These in-office lasering procedures were not without discomfort! At various times during lasering episodes, which were performed through a dilated pupil and with topical anaesthesia, the bright flashes were followed quickly by considerable discomfort, bordering on pain. My slight yelps served as a signal to Bill that he was perhaps becoming a little over-enthusiastic in his lasering, but I knew this was all for the greater good (my ocular well-being), so I stiffened my resolve and put up with the discomfort as much as possible. After all, I was keen for Bill to do a thorough job.

Despondency Sets In

As you might imagine, all this additional lasering, 12 to 18 months after my initial round of treatment, was somewhat disheartening. Inwardly, I was shedding tears about my tears (get it now?).

I wondered whether this was going to be a recurring theme – that every time I presented for a routine examination, more tears would be discovered and another round of lasering required. I suspect Bill sensed my despondency, so he gave me his take on the situation. Bill said, in his experience, when patients present with large tears such as mine, it is usually a single catastrophic event. It is as if the retina in a myopic eye is stretched to its limit and gives way by tearing. Bill suggested that, once the initial event is dealt with, it is the exception rather than the rule that patients suffer further tears.

So, I guess that means I am the exception… Anyway, Bill said this was unusual and he did not expect me to present with any more retinal tears in the future.

He was right. When I presented for a follow-up examination six months after all this additional lasering was over, Bill carefully examined my eyes and declared that my retinas were firmly attached and there was no evidence of any further tears. He observed a few scattered microaneurysms, consistent with my diabetes of 25 years standing. He also reported that there was no sign of cystoid macula oedema in either eye.

I mentioned to Bill that I was noticing lots of floaters, and that they were becoming troublesome, especially when reading (I will have a lot more to tell you about floaters in my next blog). Bill declared he was not surprised that I was being troubled by floaters, because he could see a somewhat murky vitreous when he looked into my eyes.

So, what was causing the floaters? Probably a combination of two factors. First, blood and other extravascular factors had entered my vitreous, and remained embedded there, following my catastrophic retinal tears. Second, vitreous syneresis is now setting in – my 59-year old vitreous gel is shrinking and slowly becoming liquefied, freeing up collagen fibrils that are also floating about.

Another Bombshell

It was at this point that Bill landed a huge bombshell. He said while my retinas were secure and my eyes overall were stable and affording good vision (R&L 6/5), there was another potential problem looming, aside from the floaters. That problem was the formation of an epiretinal membrane in each eye. He said these membranes were only very slight at present and not immediately problematic in terms of eye health, but they were likely to develop further and may have to be dealt with surgically in due course, via an epiretinal membrane peel.

He was basically saying we could kill two birds with the one stone, by performing an epiretinal membrane peel and vitrectomy in a single operation.

The final sting in the tail was still to come. Bill told me that if a vitrectomy is performed and the removed cloudy vitreous replaced with silicone oil, a further operation would be required four to six weeks later to remove the silicone oil. All of this would almost certainly result in the formation of posterior subcapsular cataract, requiring cataract surgery. So, if these procedures were going to be performed in both eyes, I was looking at six possible operations over the next 18 months or so.

Bill reiterated that there was no need to act now – he just wanted to alert me as to what might lie ahead. He said I should just see how things go, and he would review me in another three to four months.

All of this came as a bit of a shock because I hadn’t really thought about such issues since graduating from optometry school.

My whole career has been involved with researching the anterior eye and contact lens wear. That’s a good 23mm or so away from the retina! So now I had some thinking – and reading – to do…

Professor Nathan Efron is a researcher at the Institute of Health and Biomedical Innovation and School of Optometry and Vision Science, Queensland University of Technology.

He is currently president of the Australian College of Optometry and is the only person to have served as president of both the British Contact Lens Association and the Cornea and Contact Lens Society of Australia.