The big news

This whole thing started about a month ago, when I started seeing some strange flashes of light in the upper left quadrant of my field of vision in my left eye. A medium sized white light would appear, sometimes a circular shape, and sometimes shaped like a pancreas, and then it would fade away starting at the edges, until it was gone. I'm pretty sure that the last point of light was always in the same spot in space. Each flash would last about 1 second from first appearance until it had faded away. I didn't think much of it at first, but I made a mental note to pay attention to how frequently it happened, if anything about it changed, etc. It started out happening about once every hour.

Over the next couple of weeks the frequency had increased a little bit. A quick Google search made it seem like this sort of thing could be attributed to anxiety, fatigue, sleep apnea, whatever. I was a little concerned, but I didn't think that it was anything too urgent.

Then, about 4 or 5 days ago, I woke up to take our dog Duke out for a walk while Angel took a shower to start our routine for getting ready for work. When we got home from the walk I gave him his breakfast, then headed upstairs to stretch my lower back. I was laying on my back on the floor using my Spinal Stretch device (http://spinalstretch.com/, it's awesome, thanks Angel for getting it for me!) All of a sudden I realized that Duke was nearly hovering over my face, and I hadn't seen him coming. That really spooked me, because I know that I should have seen him out of the corner of my eye. I started experimenting a bit and realized that the vision in my upper left quadrant was not nearly as good as the other side. If I tried to look up and to the left with my right eye closed, the whole corner was a dark, fluttery gray. This realization scared the shit out of me.

I didn't even have a primary care physician, because I hadn't been to the doctor in a very long time. I looked on the website for United Healthcare to find a doctor in the area. After calling a couple who weren't taking new patients, I ended up with a Dr. Zwerin, a general practitioner in internal medicine. I got an appointment with him Friday morning. He did a thorough exam and asked me a bunch of questions about my medical history and my concerns. He ended up telling me that based on his exam I was "disgustingly healthy," but that my story about my eye was deeply concerning to him. He guessed that I had a detaching retina, which is treated as a medical emergency because it can quickly lead to blindness. His office assistant made a couple of phone calls and ended up getting me an appointment 4 hours later with a retinal specialist named Dr. DeSouza.

Luckily, Angel was able to leave work early to go to this appointment with me. During this appointment, a very friendly technician was testing my eyes in all sorts of ways that made me realize my left-eye vision was worse than I had originally thought. When my right eye was covered, she would ask me to tell her how many fingers she was holding up as I looked straight ahead. As long as she held her fingers up above my head, I couldn't see them until she dropped them down to virtually straight out in front of my eye. Because of how light enters the eye through the lens, this meant that something funky was definitely happening on the bottom half of my retina.

I got some drops to dilate my pupils, waited a while, had a couple more tests, then I got in to see the doctor. I lay back in his chair looking at the ceiling, and then he came over with a device to look at my retinas. The light he pointed at my eyes was much brighter in the right eye than it was in the left. He walked across the room to start up an ultrasound machine as he said "Well, it's not good news." Angel and I thought to ourselves that perhaps the retina was farther detached than what we were expecting to hear. He then followed with "It's a malignancy."

I just laid there and stared at the ceiling, because I was speechless for several minutes. I could tell that Angel, who was sitting off to my right, was beginning to cry, but she was doing a great job keeping it in check. She asked the doctor a couple of questions as he started rolling his ultrasound wand around my closed left eye, taking measurements of whatever it was that he was seeing. When we asked him how sure he was, he said "I'm 100% sure that it's a malignancy, and I'm 95% sure that it's a choroidal melanoma." The measurements told him that the tumor was about 5mm in diameter, just less than a quarter of an inch (correction: I now know that the tumor is 10.5 mm in diameter and 5 mm in depth). The tumor is growing underneath my retina, causing it to detach from the underlayers (the choroid and the sclera [http://en.wikipedia.org/wiki/File:Schematic_diagram_of_the_human_eye_en.svg]).

I looked over at Angel to see that she was visibly upset. The first thought in my mind was that I was so sad that she had to hear this news. Thinking about how upset this made her brought tears to my eyes. The doctor kept glancing over at her as he walked back and forth from a table in the room to my chair, so he could look into my eye once more. I could see that he felt bad, and a couple of times he said "I'm sorry, I know this is not what you expected to hear today." My mind was racing, but I couldn't help to think about some essays from a great medical author, Atul Gawande, in which he mentions how terribly many physicians perform when it comes to delivering bad news. I know Dr. DeSouza felt sorry for us, but both Angel and I agree that he did a pretty terrible job of delivering the bad news. I don't blame him for it, I know I couldn't have done any better.

We were escorted to the next room when another technician injected concentrated solution of fluorescein sodium into my arm so they could take some fluorescence angiography images of my retinas as the fluorescent dye passed through my blood vessels. She incorrectly told us that it is a vegetable dye rather than a synthetic molecule. She took a time course of pictures after the injection so they could track how the dye was flowing through the vasculature in the retina and the choroid. Here are the last two pictures they took...one of the right eye and one of the left. You can see the big, bright, highly vascularized blob that shouldn't be there.

There are no scale bars or anything, so there's no way to tell how much of the retina is being shown, or exactly how large the tumor really is.

The doctor came back in to talk to us a little longer. He told us that this tumor is considered a medium-sized tumor for this type of cancer. He went on to tell us that for large size tumors, the general treatment is to remove the eye, a procedure called enucleation. Medium sized tumors generally respond well to radiation, although there is still a small possibility that the eye will need to be removed. And if the eye does not need to be removed, it's hard to say whether the vision in this eye will be spared as a result of the radiation (more on this in the next post). He said that this type of cancer doesn't generally metastasize until its later and larger stages, so there's only a small chance that the cancer has spread up to this point. He said that I will need to see a radiologist to make sure the cancer is still only in the eye, and then that I will need to get started on radiation treatment as soon as I can. He said that no one in the Phoenix area specializes in radiation on the eye, but he knew of a good group in Tucson and one in LA that he wanted me to go to.

He wrote me a prescription for a chest x-ray (PA and lateral) and a panel of liver function tests, to make sure that the cancer hasn't spread, and told me that he would call Monday morning to see whether I've decided to go to Tucson or Los Angeles.

As we waited in the waiting room to see the doctor, time passed so slowly, and then once this news hit, everything seemed to happen so fast. It's just the way that Angel and I are to never be satisfied with enough information. We could have continued asking questions forever, but there wasn't enough time to do so. When we returned to the lobby to pay my $30 co-pay, there was a man furiously yelling at the staff about why he was having to wait so long, and threatening to report them to the medical board. I desperately wanted to punch this asshole in the throat and tell him that the doctor was spending a little extra time explaining to my wife and I that I have cancer, and that was partially why he had to wait a few extra minutes. Instead we just quietly walked out the door to head home.

More later...