More on cataract surgery and my prognosis

So, what was entailed in my cataract surgery, and how did it go? If you don't like hearing about surgeries or graphic things, don't read on :)

Before [cataract surgery] photos

Finally got photos from Dr. Shields back, so am retroactively posting these before photos so you can get an idea of how dense my cataract was :)

Trigger warning: basically none. Just close-ups of my eyes :)

The unavoidable cataract

A known side effect of plaque radiotherapy is that in 2-3 years, the patient will develop a cataract.

Well, as predicted, I now have a very dense cataract in my left eye (still working on getting the pics but if/when I do, I'll post them for those interested).

Basically, the radiation has caused the fluid inside of my lens to become cloudy.

The upshot is that the vision in my left eye has grown progressively worse.

I didn't do a good job tracking exactly when this started or how it progressed, but here's what I can say: my left I was formerly my dominant one. Sometime this spring, I switched from taking photos using my left eye to using my right. Over the summer, the cataract became visual to the casual observer of my face. In late September when I went hiking, I realized I had to go much slower than I was used to in order to avoid tripping. In early October, I realized driving might be something I want to do with extra caution (i.e. turning my head all the way around when merging from right to left).

At this point I am practically blind in my left eye. I can't see you if you're on my left side. More importantly to day-to-day life, I have almost no depth perception. This has led to some exciting scenarios in which I a) walk into people next to me or door frames, b) attempt to light a candle by holding a match 1.5 cm away from the wick, or c) pour water onto the table rather than into a glass (the trick for this one is to bring the pitcher in contact with the water first, as a double-check).

This is the closest I could find on google image search to what my vision is currently like in my left eye:

But actually mine's far worse. There is no distance at which I can read out of my left eye. I can only tell how many fingers you are holding up if you are within 6 inches of my face. I can see light and dark, ish, but the light has a yellowish tinge.

The good news is that it's operable! I am pursuing cataract surgery here in Denmark ("grå stær" means cataract in Danish) -- [much] more on that soon. Additional good news is that though the surgery will require a specialist, my lens looks ok. The radiation has weakened its elasticity, which is part of what makes the procedure a bit higher risk, but it is tight, not "wrinkly," which is a good sign.

Sorry for the long hiatus, and more coming soon!

2-month post-op update - addendum

Dr. Rumery called me back to ask that I come back in so he could test the pressure in my eye (a quick and simple test) so we coordinated and somewhat sketchily / awesomely met up at the Dean Clinic on the West Side after hours to get me checked out before he went on vacation (thanks again, Dr. Rumery, for being so flexible and awesome!)

For those interested, after a numbing drop, Dr. Rumery used a hand-held applanation tonometer, which I find to be vastly preferable to the puff of air method:

It didn't look exactly like this one, but this picture was too awesome not to include

Anyways, good news:

• left eye: 8 mmHg (the one of interest)
• right eye: 11 mmHg

Background on this measurement and why it matters from the Ocular tonometry wikipedia page:

Tonometry is the procedure eye care professionals perform to determine the intraocular pressure (IOP), the fluid pressure inside the eye. It is an important test in the evaluation of patients at risk from glaucoma.^[1] Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg).

It's all in the genes

As part of the surgery to implant the plaque, I opted into another procedure called a fine needle aspiration (FNA) biopsy. It's exactly what it sounds like. The idea was to:

1. confirm the original diagnosis and 
2. find out more about the tumor (such as its likelihood to metastasize or kill me)

The first was quick to determine: the cells from the biopsy were consistent with a low-grade melanoma. Glad we did that whole plaque thing then :)

The second required more lengthy analysis. 3 chromosomes were analyzed: 3, 6, and 8. The results for chromosomes 3 and 8 were normal ("disomy"); chromosome 6 was "amplified," however apparently this region of chromosome 6 (6p and 6q) is not correlated with increased risk of metastasis (which begs the question why are we testing it, but I'm sure this result was heavily diluted for the lay person so the question is moot). It seems that monosomy of chromosome 3 or amplification of chromosome 8q are changes that are associated with an increased risk for developing metastatic disease. *Whew*, amirite?

TL;DR: based on genetic makeup alone (i.e. discounting size and location of tumor), there is a low risk that this will metastasize elsewhere for me.

--------------------------------------------------------

Some definitions from the result materials I received:

Chromosomes: visible rod-like structures in each cell of the body that contain genetic material. Normal human cells have 23 pairs of chromosomes. The chromosomes are in pairs (two copies) because one copy of each chromosome is inherited from your mother and father. There are specific genes located on each chromosome, and the number of genes varies for each chromosome.

Somatic: refers to genetic material that is found in a specific tissue or cell-type in the body. In genetic testing, when a DNA mutation is defined as a somatic mutation, there is very little risk of passing on the mutation to children. Most cancers have somatic mutations meaning a mutation occurred in a single cell that disrupted normal cell growth, which allowed a tumor to grow.

Disomy: refers to the normal number of two copies of a chromosome.

Monosomy: refers to an abnormal number of only one copy of a chromosome.

2-month post-op update

Ok, it's not quite 2 months, but due to scheduling stuff, I had my 2-month post-op with Dr. Rumery today.

Stuff we discussed:

My current meds

1. Tobradex Ophthalmic ointment - 3x/day, this is for comfort and as an antibiotic
2. Atropine - 1 drop daily before bed, this is to keep my eye dilated*

*Why are we keeping my eye dilated? Great question! This helps to prevent synechia. Basically, after surgery or other eye trauma, it's possible for your iris to become sort of stuck to your lens (in my case) or cornea. This is bad because it can cause pressure that can led to glaucoma. Keeping my eye dilated means my iris is a bit more withdrawn from the lens, at a position where it's at a slight distance from it and therefore less likely to become stuck.

My vision

Pretty good! With glasses for correction, my right eye is at 20/20, which is expected. My left eye is still not back at 100%. I've been worried about this, but this visit reassured me a bit.

You're probably familiar with an occluder (see image below), even if you don't know it by name: it's the thing you use to cover one eye so you can use the other for a vision test. They had a nifty one at my eye doctor that had a flap that rotates into place over the eye of interest, adjusting the opening from a Sacagawea dollar-sized hole to a series of pinpoint openings. This is awesome because it reduces the amount of light entering your eye. Meaning...

*drumroll please*

It simulates your eye in a non-dilated state! In other words, looking through the occluder with this flap engaged meant I was seeing as I would if my eye weren't dilated. And hearteningly, this improved my vision a LOT. While I'm not at 20/20, I'm close. This alleviated my worry that maybe I wasn't recovering well, or that my cataract was already brewing.

Fancy occluder

My retina and overall eye health

Pretty good! Nothing in particular of note, in either direction.

My cornea moisture

After putting a drop and some yellow (fluorescein?) dye in my eye, Dr. Rumery examined it using blue light, with which the dye is most visible. The idea is that the yellow dye attaches to areas of lower moisture on the cornea, meaning those areas are dry and perhaps indicative of poor corneal health or recovery. Good news: while I had a couple of areas that showed up under the blue light, they were small and faint. This isn't worrisome.

Bonus: for those who looked at the surgery pics, there was one where I was not at all sure what layer was sewn shut. Well, mystery solved: it was the conjunctiva, which is a layer on top of the white part of your eye (the sclera) that helps with lubrication. It doesn't normally extend over the iris/cornea, but was stretched to do so during the time I was wearing the plaque (apparently). Anyways, ♪♫ The more you know! ♫♪

I've gone back and updated the photos post with this info, too :)

[Trigger warning] surgery photos!

The post you've all been waiting for!

Warning level: EXTREMELY graphic. If you don't like blood, needles, sutures, or thinking about things touching eyeballs, do not click the Read more link.

Details & plan

The exact wording the pathologist used was that the results of the biopsy are "suspicious for melanoma."

He therefore recommends plaque radiotherapy. Not sure what that is? It goes something like this:

<Philadelphia>
On a Thursday: I have surgery to have a radioactive piece of metal ("plaque") sewn to the surface of my eyeball over which I'll wear a lead patch (!)
On the following Monday: I have surgery to remove the radioactive plaque
</Philadelphia>

<Recovery>
Week 1: no driving
Week 2: no strenuous activity (no lifting anything more than 25 lbs), pools, or saunas
</Recovery>

I may have blurry, doubled, or distorted vision right away; I also may have flashes or floaters. These should subside as my eye heals from the radioactive intrusion.

I'll have follow-up appointments:

• at 2 months: here in Madison
• at 4 months: back in Philadelphia

Then, over the next year:

• I will develop a cataract
• I may develop cornea damage

I'll do a post on the science of plaque radiotherapy later (maybe). Nerds out there, this will have to suffice in the meantime:

• Radioactive Plaque Therapy
• Eye and Vision Sparing Radiation Therapy for Intraocular Tumors