Our monthly column on medical wonders, mysteries and amazing human stories in Cleveland's medical field.
Another month, another medical wonder
For many people whose eyesight is in peril, regular injections into the eyeball is the only thing that can prevent their vision from worsening. This is Greg’s new reality. Greg is a 60-year-old carpenter from Cleveland, who was recently diagnosed with macular degeneration. Approximately 200,000 people, usually older in age, are diagnosed with this condition each year in the US. Beyond maintaining good health, the harsh reality is that doctors don’t yet know how to consistently prevent it. The back of the eye is called the retina and is responsible for turning incoming light into signals sent to the brain – culminating in vision. The most important part of the retina forming our most detailed sight is the macula. It’s just smaller than Lincoln’s head on a penny but if it starts to degenerate, fluid accumulates and distorts the smooth surface. This causes a disconcerting blurriness and blackness in the center of your vision.
What amazes Dr. Jerry Schartman, a Cleveland retina specialist, is that some people let blurriness in their vision persist for months, simply attributing these changes to old age. But for Greg, things were starting to look better after going to one of Dr. Schartman’s partners. And then he started seeing unusual flashes of light.
Light at the End of a Struggle
Vision is the king of being taken for granted. Greg of course relied heavily on his sight while doing construction work and for his favorite hobbies- golfing and reading. So, while the prospect of an eye injection can be anxiety provoking, halting the effects of macular degeneration seemed a fair trade.
Dr. Schartman, a master of this procedure, says it takes around seven seconds to complete. He’s injected an astonishing 60,000 eye balls, and every one of his patients is grateful that he numbs the eye. No blood, no pain, and the gift of sight.
For Greg, the medicine injected into the fluid of the eye, called the vitreous, works by inhibiting small vessels growing into the macula where they don’t belong. His ophthalmologist would dilate his pupil to see the retina clearly, assessing the response to the injections. Six months in Greg’s sight had improved; no black spots, no blurriness. He was diligent with coming to the appointments, his wife helped with that. But now he was seeing light flickering in the corner of his vision a few times a day. At first they seemed like a glare from a window, or a flashing light, but when he turned to see it, there was nothing there.
At his next appointment, after hearing this, the doctor thought of what he might find in the back of the eye. What could be causing this new symptom? Sure, Greg had some other health issues, including stents in the arteries of his heart and high blood pressure, but flashing lights was his only symptom. If Greg’s blood pressure were out of control he might have blurriness in vision or headaches. Small vessels in the back of the eye can burst under high blood pressure too. But he had no headaches and his blood pressure was fine in the office.
Flashes of light typically mean a problem with the retina- a tear in it or it has become detached, like a wrinkle in a rug. But Greg hadn’t had any recent injuries to cause this so having a detachment would have been very unlucky. His eye doctor dilated his eye, creating that window to look through hoping to find some clues. What he found was mysterious. There were many small oval spots (as small as the thickness of a piece of paper), creamy yellow in color spread out across one part of the retina in a speckled pattern. Sometimes in macular degeneration there can be spots on the macula, but these looked different and weren’t even by the macula. It was time to call Dr. Schartman.
Seeing Things Differently
Like a carnival house of mirrors there are some confusing things about our vision. First off, we only perceive one “picture” despite having two eyes. Fine, toss that to some sophisticated processing in the brain. Next, what we see on the outside of our vision is actually the image that is projected on the half of our eyes that is on the inside of each of the retinas, closest to the nose. So, Greg’s flashes of light in his peripheral vision would correlate with something wrong with the inside portion of the eye, exactly where these spots were.
By the time Greg met Dr. Schartman, his vision had gotten slightly more blurry and he was still seeing the flashes of light. But luckily, Dr. Schartman had a hunch he knew what was going on. A physician is always recalling any similar unusual patients they’ve had when a diagnosis is unclear. This is the reason some people prefer an older doctor; experience. But Dr. Schartman isn’t old, he’s just seen many many retinas in his decade of practice.
He looked in, saw the pattern and size of the spots and thought “yep, birdshot.” Named for the scattered pattern of shotgun spray, this condition is much rarer than macular degeneration. It is an autoimmune condition where the body attacks a deep layer of the retina. Dr. Schartman made sure there were no other contributing conditions, which can cause similar issues, such as TB, syphilis and sarcoidosis- but as suspected Greg didn’t have these issues. While many autoimmune conditions can cause problems in many parts of the body, birdshot is restricted to the eyes. Without treatment, people most often lose their vision completely.
One Last Shot
Greg is doing well now. With a steady hand and a calming voice, Dr. Schartman provided encouragement to a situation fraught with fear and worry. He injected a small implant, the size of Washington’s nose on a quarter, which will float around and secrete a small amount of corticosteroid in the eye for 3 years, halting the body’s attack on itself. Greg’s vision has returned to normal and he is expected to keep his macular degeneration and birdshot under control, knowing all too well that no subtle symptom should be ignored by patient or doctor alike.
Dr. Corey Meador is a practicing family medicine physician in Cleveland who has written for PBS NewsHour and The Washington Post. He obtained degrees from Loyola Marymount University School of Film & Television in Los Angeles and Drexel University College of Medicine.