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Fear factor

The tale of two brothers who had to overcome their phobia of needles in order to regain their sight

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Wave, November / December 2013

Reginald Piercey started noticing problems with his vision about four years ago.

"I would look up at the moon and see seven moons," explains the 57-year-old Winnipeg man. "Being the eternal optimist, I thought it would go away."

But the problem did not disappear. It just got worse.

"When my one eye went out, I told myself that as long as I still had one eye, I was good," he says.

But soon, that eye, too, would fail Piercey. In the winter of 2010 Piercey's vision deteriorated to the point of light perception, meaning he could tell if it was light or dark, but could not detect movement.

It was about this time that Piercey's younger brother, David, 50, also started to lose his vision in much the same way.

"He started complaining of it when he was watching TV. I knew what was happening to him was exactly what I was going through," Piercey recalls.

For most people, the slow but steady descent into blindness would be cause for grave concern and a search for medical help. But not for the Piercey brothers.

More than the loss of sight, the Winnipeg men feared something else far more: needles. Rather than seek medical assistance, they decided to live with blindness.

"I accepted the fact I was totally blind," says Piercey. "I had absolutely no problem at all feeling my way around."

And blind they might have stayed, were it not for some extenuating circumstances and the compassion of Winnipeg ophthalmologist Dr. Gdih Gdih. With his help, the two men would learn to overcome their fears, and regain their sight.
  
Reginald started to go blind shortly after losing his father to cancer in 2010. Living with his 86-year-old mother, Piercey was still able to do all the cooking and cleaning, even though he was slowly going blind. But eventually his inability to see cost him his job as a janitor, and he was forced to go on social assistance. And that was something he just could not accept.

"I knew where everything was in the house, and I could have lived with (blindness) forever if I hadn't become a social burden," he says. "I realized I was going to be dependent on family for the rest of my life if I didn't do something about it. I needed help and help was there."

Piercey made up his mind to seek medical assistance in 2011. He made an appointment with a general practitioner, who referred him to an ophthalmologist. The ophthalmologist realized that a specialist was required. In November of that year, Piercey met Gdih.

A staff surgeon at the Misericordia Health Centre's Buhler Eye Care Centre, Gdih completed his residency in ophthalmology at the University of Ottawa. He then completed a post-doctoral fellowship in glaucoma at the University of Toronto, where he also taught medical students and ophthalmology residents. Gdih has also attended the Srikiran Institute of Ophthalmology in India, where he was trained and certified in manual small incision suture-less cataract surgery (MSICS).

With eight years of experience in treating various eye conditions, Gdih has seen his share of challenging cases. But he says the case of the Piercey brothers is unique.

Usually, in medicine, the challenging cases are the ones that involve rare conditions or diseases. But in this case, the cause of the blindness was no mystery. It was due to cataracts - a common and easily rectified condition. What made it interesting was the brothers' fear of needles. As Gdih explains, people don't usually lose their vision from cataracts. But the Piercey brothers' intense phobia kept them from getting treatment for years. As a result, they both developed very severe cases of cataracts.

Upon meeting Reginald for the first time, Gdih realized the first order of business in treating him was to gain his trust.

Although fear of needles, which is also known as trypanophobia, is not unheard of, it is not all that common. "At first Reginald was apprehensive, but I told him he would see the world again and I promised him there would be no needles - that was key," says Gdih. "When I examined his eyes, his reaction wasn't that bad, so I knew he could do it. I have very good relationships with all my patients. I take my time, even if I have to take more time than usual."

Reginald says he has never been fussy about going to a doctor because of his dislike of needles. "If you tell me I've got a doctor's appointment, I run," he says. "This is what happens when you have a bad phobia."

Gdih suspects that the unusually severe cataracts were caused by the emotional stress of the Pierceys caring for, and then losing, their father. Ordinarily, cataracts are caused by age and are usually seen in  people in their seventies and older, he adds.

"He was young for the amount of cataract he had, and it was what we call a super dense cataract. Whenever we are very upset, it causes hormonal changes in the body. Nothing else medically could explain what happened to him. This type of cataract was first seen after the Holocaust, reported in people rescued from concentration camps (during World War II)."

Gdih knew Reginald could not wait. "He was completely blind - he couldn't even see his hand or any motion," says Gdih. "But his pupil reaction was very good. That told me the optic nerve was alive. I was 70 per cent confident he could regain his vision, but he had nothing to lose. His vision couldn't be worse than what it was."

"I tried to make it easier on him. I didn't want him to get delayed by the difficulties of the system," says Gdih. "I was bothered by his situation more than he was. I wanted to get him in as soon as I could."

Originally, Gdih had hoped to restore the sight to one of Piercey's eyes by Christmas of 2011. But that was too soon for the patient, who still had to work up his nerve. Even after being reassured that the outpatient surgery didn't require needles, Piercey was terrified.

But by January of 2012, Gdih restored sight to one of Piercey's eyes. The cataract was removed from Piercey's other eye in late March of the same year.

A cataract is described as cloudiness of the natural lens of the eye, which gradually hardens and will not transmit light. The lens is made of protein and cataracts are what occur when that protein becomes denatured. Most people develop cataracts with age, although diabetes, complications from chemotherapy, and the use of steroids can cause them as well.

Modern cataract removal surgery replaces the eye's natural lens with an intraocular lens implant (IOL), much like a contact lens, which can be folded and placed into a very small incision in the eye.

Phacoemulsification and standard extracapsular cataract extraction (ECCE) are surgical methods that remove the cataract as well as the front portion of the lens capsule (anterior capsule). Phacoemulsification surgery is most commonly used today. It is less invasive and the eye can heal without stitches.

Phacoemulsification surgery begins with the application of xylocaine, a freezing gel that is applied to the surface of the eye. It can cause a mild stinging sensation. This topical anesthetic is usually enough, although some highly anxious patients can opt for a local anesthetic that includes the injection of a light sedative. Piercey refused this option because of his fear of needles.

The patient is then taken into the operating room and hooked up to monitors. The eye is washed with antiseptic three times. The surgeon then dries the eye, eyelid, and the skin around the eye with a sterile towel. A plastic drape is placed over the patient's face, and a slit is cut in the drape to expose the eye that will be operated on.

A speculum is used to keep the eye open during the procedure. The patient will remain conscious and aware throughout the operation.

"They are aware of every single moment. I may ask them to look up or down. But after I turn on the microscope light, all they see is light. It's a very powerful light," says Gdih.

Once the patient is prepared and the microscope light is on, the surgeon makes a tiny 2.75 millimetre cut in the cornea where it meets the sclera, or white of the eye. He inserts a gel into the eye to ensure the eye doesn't lose its shape when the lens surface is removed. A circular opening is created on the lens surface (capsule) and a small surgical instrument (phaco probe) is inserted into the eye.

Since Piercey's cataracts were so dense, Gdih had to use a special stain called Vision Blue. "It helps me to see the capsule that covers the cataract so I can remove it first," Gdih explains.

Once the front portion, or anterior capsule, is removed, the surgeon uses sound waves known as ultrasound to break the cataract into small pieces. The cataract and lens pieces are removed from the eye using suction.

"I blend the cataract inside the eye and then drain it out until none of it is left inside," says Gdih. He then fills the eye with a viscoelastic material and injects the lens implant into the small incision he made. "Once the lens reaches the posterior capsule at the back of the eye, it opens itself," Gdih says.

The last step is washing the eye with a balanced salt solution that mimics the patient's natural body fluids. The speculum and draping are removed, and the patient is allowed to sit up.

"Patients start to see immediately, but their vision really clears in a week or so. Most people will be very happy after one week, and at six weeks, everything should be settled," says Gdih.

Surgery on Piercey's eyes took about eight minutes each time, although these types of procedures can run about 20 to 30 minutes.

The result was life changing.

"Eight minutes later, I was sitting up and could see perfectly out of that one eye. People were clapping and wishing me well. Now I can see better than I have in my entire life."

Post-surgery, patients use three different types of eye drops to help their eyes recover, and they are required to wear a protective shield while sleeping. Antibiotic drops are used once a day for one week, and anti-inflammatory drops are used twice a day for four weeks. After the surgery, patients feel no pain but a mild irritation, as if an eyelash is caught in the eye.

Patients must return for a follow-up appointment 24 hours after surgery. They are seen again after one week and then once more after four weeks. At the six-week mark, they should see an optometrist to have their vision assessed.

Cataract removal surgery has improved dramatically in the past 15 years. At that time, ultrasound was not used to break up the cataract, which was instead removed in one piece. This required a lot more invasive surgical procedure, explains Gdih.

"This type of surgery resulted in more pain and lots of stitches that could induce visual distortion. The stitches could also pop out and start bugging the patients. No one does it this way anymore in the developed world."

Before the IOL was developed, the surgery also involved a bigger wound, stitches, and a longer recovery time. Manitoba is the only province where cataract patients can receive an upgraded (Blue Light Blocker) soft, foldable lens for free, says Gdih.

He adds that everyone will eventually develop cataracts due to age, no matter their lifestyle. Cataracts usually develop slowly, with changes occurring every six months. Gdih recommends scheduling cataract removal surgery as soon as possible, before the cataracts become severe. "Cataracts that are left for a long time are the ones that tend to cause complications. If you have them removed early, they are easier to remove, there is less chance of complications, and a better recovery time," he says. "I don't recommend delaying the surgery for very long. In some people, cataracts progress very quickly. Some stay stable for a couple of years. Everybody is different, but one thing is certain - once you have cataracts, they're not going to get any better."

When Gdih learned that Piercey's brother, David, had the same condition, he was willing to visit David in his home to convince him to have the surgery. In the end, it didn't come to that. Once Reginald  regained his sight, it was easy to convince his brother.

"Within weeks of my second eye being done, my brother went in for his first eye. It was finished a lot quicker than I thought. When I was driven home from the first operation, I had a big smile on my face," says Piercey.

"Now I can see 100 per cent in both eyes with a simple pair of reading glasses. I'm so excited about the procedure and the success of it. I went through it without any anxiety or tension."

Piercey says neither he nor his brother would have gone through with the surgery if it hadn't been for the kindness and patience shown them by Gdih.

"It was very humane of him to be so kind. I have a natural-born fear that raised its head whenever I was shown a needle. Eventually I became an adult who panicked at the thought of going to the doctor," he says. "But if I'd realized how simple and painless the whole thing was, I wouldn't have waited - I wouldn't have gone completely blind."

Holli Moncrieff is a Winnipeg writer.

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