The Eyes Have It

      Myasthenia gravis.

      Ocular myasthenia gravis, to be more precise.  It’s what the doctor said.

     It all began a little over two years ago when I could no longer focus on close up work, like reading the fine print, over the top of my glasses.  I had to resort to the bifocals for close up work and use more light.  Well, I am getting older, I thought.

      I called on a series of doctors, starting with an optometrist.  When, after new lenses and new frames, the conditioned worsened, I called on an ophthalmologist who made monthly visits to the local hospital.  He said I was suffering a condition that many people went through in their forties.  I didn’t much believe that.  He told me to come back next year.

       I got along for a year, but by that time, I was having trouble focusing both eyes in the upper portions of my glasses.  The inability to coordinate both eyes was working its way slowly down.  I could still see very well through the bifocals.  My right eyelid was beginning to droop by this time.

     The first ophthalmologist was no longer on the staff at the local hospital, so I made an appointment with a Loveland ophthalmologist.  Except I couldn’t see him until I had seen his optometrist first.  If there was a problem, I would be referred to the big guy, the receptionist assured me.

     No problem, the optometrist said.  They could correct my double vision with pyramids in my right lens.  My ability to read, which was still good, might be screwed up by the pyramids, but I could get reading glasses. 

     I am not so concerned with correcting my vision as I am concerned about what is causing it to deteriorate, I explained.  No answer, except the hint that I was getting older.  Was I having other problems?  Yes, thyroid issues.  So he wrote a report to be sent to the endocrinologist who was dealing with the thyroid problem.  Let him know if I wanted to try the pyramid lenses.  Come back in a year. 

      One more time the endocrinologist opined that the thyroid problem was not the cause of the eye problem.  For sure, I did not have Graves’ disease, a thyroid disease which does affect the eyes.  She referred me to another ophthalmologist.

     The one she referred me to was booked for three months.  Would I accept one of his associates, also an ophthalmologist?  Yes I would.  A few hours later, the office called back advising me that they would like to change my appointment to another doctor who was more familiar with the drooping eyelid problem.

      At that visit, a pair of young folks ran me through the standard visual checks, blinded me with piercing light beams, questioned me about my condition.  They departed saying the doctor would be in soon, except they returned in about ten minutes and said they would like to change whom I was going to see.  Another doctor was available who could address the whole eye issue, not just the droopy lid problem.  Yes of course, I concurred.

      This fellow got to the root of the problem and gave the best answers to my quest for a cause of my eyesight deterioration.  He said it could be a blood vessel problem.  If so, the body would eventually restore circulation and the problem cure itself.  

       He was diplomatic with his second possible solution:  I might have celebrated too many birthdays, he said.  The third possible cause was a disruption in communication between nerve and muscle.  He wanted to wait a few weeks to see if the condition changed.   

    I made an appointment for January 11.  In the meantime, I found a date to swallow a radioactive pill to destroy the growth on my thyroid, a date where I could be outcast and unclean for five days.  I had to stay away from others for five days while the radioactive stuff left me. 

      The date was January 6.  I was cleared to be around adults, but not pregnant ladies or young kids.   I called the ophthalmologist’s office to be sure none of the caregivers was pregnant.   “Oh,” the receptionist said, “Dr. Arnold is a pediatrician.  His waiting room will be full of kids.”  We cancelled my appointment.  She didn’t offer to reschedule and I didn’t insist.

      In the meantime, I did call on our “family” doctor for my first visit.  He heard my story, examined my eye, and ordered an immediate MRI, fearing there would be a tumor somewhere in my head.  An hour later I was in the imaging chamber being entertained by a chorus of jackhammers.  Loud jackhammers.

      Two days later, in a follow up visit with the doctor, he gave me the news my dad could have told him a half-century ago:  the examination had found nothing in my head.   (Whenever we did something stupid as kids, Dad always said, “You ought to have your head examined.”  I finally did, and sure enough, they found nothing in there.)

      Dr. Prows decided we needed a neuro-ophthalmologist to get to the root of my problem.  He found only two and sent me to one in Aurora in the University of Colorado system.  I thought I had an appointment with a Doctor Bennet, but when I checked in, the receptionist told me I would be seeing Dr. Pelak.

     This time, a young man came through the double doors, called my name, escorted me to an examining room where he checked my vision, asked me questions, and recorded my answers and his impressions by tickety-tacketeying a hundred words a minute on the computer keyboard.

     Dr. Pelak turned out to be a comely young lady who said she had 17 years’ experience as an ophthalmologist.  It is hard to believe she has been out of high school 17 years.  More to the point, she knows her business. 

     She looked at the MRI images and pointed out the muscles in my right eye, the lower muscle about twice the size of the upper one or either of the left eye muscles.  She thought the swollen muscle prevented the eyeball from rolling up, thus he focus problem in the upper part of my vision.  Later, she would ascertain that the eyeball was free to move by numbing the eye, then using a big Q-tip to force the eyeball up.  After she was done, she said many ophthalmologists would use a forceps to grip the eyeball and move it.  I thanked her for using a Q-tip.    

     Dr. Pelak suspected I had myasthenia gravis.  It was Dr. Arnold’s option three, interference between nerve and muscle.  Here is how I understood her explanation.  When the brain sends a message to a muscle, the nerve uses a juice to reach the muscle.  The muscle absorbs the juice and contracts.  The brain says “open eyelid” and the nerve sends the juice.  When the brain says “relax eyelid”, the nerve stops serving the juice.  Along comes the janitorial staff which mops up the juice and sends it down the body’s waste system.

      In myasthenia gravis, the body produces antibodies probably in response to another problem elsewhere, like my thyroid hyperactivity perhaps.  The antibodies ally with or stimulate the janitorial staff.  The nerve juice gets cleaned up and shooed away before the job is done.  So the eyelid doesn’t go up.

      The condition can affect other muscles, arms, legs, diaphragm (breathing problems) and swallowing muscles.  Statistically, I have about an 85% chance of having other muscles affected.  If other muscles haven’t been affected after two years from onset, the chances of other muscles being involved drops significantly.   If left untreated, the “gravis” part can come true.  A victim can end up in the grave.  Modern medicine to the rescue.  The antibodies have to be suppressed.     

     Dr. Pelak had me try pyridostigmine taken four to six hours as needed.  It helped get my eyelid open, but didn’t do much for my focus problems.  I still have double vision.  I also had to return to the MRI for better pictures of my “orbits” and because myasthenia gravis can be caused by a growth on the thymus gland. The thymus got a clean bill of health, but the image revealed a “nodule” on my adrenal gland.  I am referred back to Dr. Prows for that problem, if it is a problem.

      Irreparable muscle damage can occur if the antibodies aren’t suppressed.  Dr. Pelak demonstrated by using her fingers to represent the muscle surface where muscle and nerve interface.  The rough muscle surface allows a lot of area where the nerve juice can contact the muscle.  Left untreated, the antibodies can result in the muscle surface smoothing over like the surface of cold gravy.  There is much less surface for the nerve to contact the muscle.  The muscle function is greatly reduced.          

     She gave me two options to try in addition to pyridostigmine.  One is Imuran.  I will probably end up taking that or something similar for life.  It is rather slow acting.  I reluctantly elected to try prednisone for a time for a faster “cure” for the double vision.  The idea is that once the double vision is fixed, I will quit prednisone and go to another drug less harmful to the rest of the body, probably Imuran.

     I can only think that now if I want to try out for the Rockies, I won’t get past the drug test.  I am on steroids!  Plus, I have seen folks who are taking prednisone.  They don’t look healthy.

     For one glorious year, I went through the day without taking any pills.  Then I took a blood test.  My calcium was low.  Start taking calcium again. 

      I am in the early stages of getting the right dosage of Synthroid.  The radioactive iodine got rid of the thyroid nodule, and the gland’s ability to produce.  Add to the Synthroid the two pills for my eye, and the Zantac for stomach upset and the selenium to counteract the steroid, and I am a walking pharmacy.

      For now, it seems I have succeeded in my quest to find the cause of my eye problem.  In the process, I nearly lost my respect for the medical profession.  With the help of a couple of good doctors, my faith is partially restored.

     Now, if you have read this far, reward yourself with a gold star for listening to yet another old goat discuss his medical problems.  A bourbon and Seven might be in order, but I think you don’t need to dig out the Tylenol PM.  You are probably half-asleep already.