Touch of Gray - September / October 2005

Losing My Right Eye
Cyclists

Losing My Right Eye
   I am an 85-year old retired college professor living for the past eleven years with my wife, Dot, in Carolina Meadows, a Continuing Care Retirement Community in Chapel Hill, North Carolina. In 1983 I had stage D1 carcinoma of the prostate which was successfully treated with radioactive implants. I am in reasonably good health for my age. As to my eyes, everything seemed fine on my annual visit to my ophthalmologists, Drs. James A. Bryan III & Mark W. Scroggs, at Carolina Ophthalmology Associates, P.A. in Chapel Hill in October, 2003.

   One thing I had to watch was a benign mole – or nevus to give it its correct name – which I had in the choroid or inner lining of my right eye. This had been under observation for twenty years or more and it had not changed or grown materially in all that time.

   By December 2003 I was having difficulty squinting to read small print and my field of vision appeared to be greatly reduced on my right side. I went to see Dr. Bryan on December 10. “What’s the matter?” I asked. “Am I developing a cataract in my right eye?”

   Dr. Bryan immediately noted significant discoloration and changes in the size and shape of my nevus. He referred me overnight to the specialists at UNC Hospitals Ophthalmology Clinic.

   I was examined on December 11 by two senior men in the Clinic, Professors Jonathan J. Dutton & Travis A. Meredith. Both doctors confirmed that my nevus was no longer benign, but now appeared, in their considered opinion, to be a malignant melanoma. Sonogram tests indicated a spreading of the melanoma towards the optic nerve. In their view, normal methods of treating it with radiation would be difficult because of its proximity to the optic nerve. In any case they explained to us that such treatments would never restore the sight in the eye to its original level, but would hopefully stop the spread of the tumor.

   Dr. Dutton explained that if the melanoma was not removed the cancer would spread into the eye socket (orbit) and through the blood system to other organs and eventually be fatal. Both he and Dr. Meredith recommended complete removal of the eye.

   Before I left the Clinic that morning, I had x-rays taken of both my chest and my abdomen. Blood was also drawn for a liver panel check to make sure the cancer had not spread beyond the eye. Both specialists felt that such was unlikely but they did recommend that I not wait too long to have the eye removed.

   We saw Dr. Dutton and his staff again on December 17 and we arranged for enucleation (eye removal) on December 29 under general anesthesia at the Ambulatory Care Center. This was same day surgery that did not require an overnight stay.

   The total procedure on December 29 was not particularly stressful. It took about 45 minutes, and there was very little bleeding. A later biopsy on the removed eye confirmed the presence of an active melanoma.

   When my eye and socket tissues had been removed, Dr. Dutton inserted in the socket a spherical orbital implant, which was only slightly smaller than the original eye. The eye muscles were then connected to the implant to increase mobility and allow for up and down and side to side movement of the artificial eye when in place.

   The inserted implant is known as a Bio-Eye Implant. This unique patented implant was first approved by the Food and Drug Administration in 1989. To date some 25,000 people worldwide have benefited from it. It is made of hydroxyapatite, a natural coral-like substance with the same structure and composition as natural bone.

   Why the implant? It replaced the area in the orbit (the bone cavity) that had been occupied by the eye. The implant maintains the natural structure of the orbit and provides support for the artificial eye. It is not visible because it is covered externally by the conjunctiva, the pink surface tissue that lines the eye, similar to the inner lining of the mouth.

   Last but not least, the surgeon slipped a clear plastic disc called a conformer– similar to a contact lens, but slightly larger – under the eyelid to occupy the space in the orbit where the artificial eye was eventually to be inserted.

   Following enucleation, a pressure pad was applied over the eye socket and held in place with adhesive tape. This was intended to keep swelling of the socket tissues to a minimum. After four days, when the pad was removed, the eyelid was still a little swollen and remained black and blue. So I wore an eye patch, which gave me a distinguished – if different – look. Compresses were helpful as well as nightly application of an antibiotic salve.

   During that time we ran into occasional problems when the conformer tended to pop out. We returned to the Clinic several times to have the staff slip it back in, as it is a good idea to have the conformer in place till the new “eye” is in place. Eventually my wife, Dot, learned how to slip the conformer back in place under my eyelid so we could take care of it ourselves.

   We saw Dr. Dutton again on January 12. At least six weeks is suggested between the surgery and fitting of the artificial eye. He noted that healing was going very well and edema was lessening. He recommended that I go ahead with plans to see the ocularist and get my “new” eye.

   So an appointment was made to see the Boyd brothers, Michael W. & Patrick L, who run Carolina Eye Prosthetics. Inc., in Graham, North Carolina, one of sixty such firms in the United States providing state of the art customized eye replacements. Ocularists do not go to Medical School. They are members of the American Society of Ocularists (ASO), one of the smallest health care providers in the nation. They undergo long and intensive training under a working ocularist in the scientific and artistic skills needed in their work. It is very often a family business, where father and son or siblings work together, as do the Boyds.

   The history of artificial eyes is an interesting one. The first ocular prostheses were made by Roman and Egyptian priests as early as the fifth century BC. Those “eyes” were made of painted clay attached to cloth and worn outside the socket. It took about twenty centuries for the first in-socket artificial eyes to be developed. At first they were made of gold and colored enamel. Late in the sixteenth century the Venetians started making artificial eyes of glass. These were crude, uncomfortable to wear, and very fragile. Even so, the Venetians continued making them and kept their methods secret until the end of the eighteenth century.

   The center for artificial eye-making shifted to Paris for a time. But by the middle of the nineteenth century, German glassblowers had developed superior techniques and the center for glass-making of artificial eyes moved to Germany.

   Soon after that, glass eye-making was introduced to the United States. Material for making glass eyes was in short supply during World War Two since it had to be imported from Lauscha in Germany. Fortunately the plastics industry had already developed a medical grade acrylic in 1941. The time was ripe for its application as a replacement for the glass eye.

   The Dental Corps, Army of the United States, was first to publish details of the fabrication of the impression molded plastic eye in 1945. Needless to say, it became the material of choice when it became available to the general public.

   The advantages of plastic over glass were numerous. There was no longer the fear of breakage, the “eye” would not roughen with wear and if it became chipped or scratched it could be easily replaced. Most importantly the curvature and thickness of the impression molded plastic prosthesis could adapt to the irregular configurations of the orbital tissue. The glass eye, with its smooth concave posterior shape, allowed tears and secretions to accumulate behind it so that the eye would roughen and discolor. It had to be removed nightly. This was no longer necessary with the better fitting plastic product.

   What did our visits to the Boyds involve? My plastic custom-fitted prosthesis took two days to manufacture. On our first visit on February 16, three hours were spent fitting the prosthesis, based on an impression of the socket. Here was how Patrick did this. He took an impression of the space in the eye socket .For this he used an alginate, with a consistency similar to the white of a hard-boiled egg. This set up in about three minutes. After removal from the socket the impression was encased in dental stone, rather similar to plaster of Paris. The impression material was then removed from the mold and a hard type of molten wax was poured into the mold and allowed to cool and harden. This resulted in a wax piece that constituted a pattern for the artificial eye. The wax allowed Patrick to make changes for comfort as well as for cosmetic reasons.

   A plastic piece similar to the pupil, iris and cornea of the front of the eye was chosen and built into the wax pattern. Checking against my good eye, this was adjusted in order to give the proper effect of direction of gaze as well as vertical and horizontal positions. No two person’s eyes are the same, so it becomes necessary to custom fit for each individual. This took several hours and involved a series of trial fittings in the eye socket. The object was to give the desired prominence to the artificial eye and create the proper opening and contour of the eyelids.

   After we returned home for the day, and Patrick was satisfied with the wax pattern, he made a final mold of dental stone around it in a bronze flask. The pattern was removed and after placing the pupil, iris and cornea piece back in the mold exactly in position, he packed a dough of white plastic into the mold and processed it in a heated water bath until it had cured.

   Ten days later, February 26, when we returned to the Clinic, a winter storm was threatening. The morning’s procedure began with Michael filing a thin layer of plastic from the surface of my plastic eye. He then made a painting lens by placing a clear polyethylene sheet between the artificial eye and a new layer of clear plastic which then had to be cured. The painting lens afforded Michael a way to judge the color of the prosthesis with all optical effects present. When placed over the surface of the eye the painting lens brought the form back to the shape of the original wax pattern.

   The hand coloring of the artificial eye was done with the greatest of care to match the companion eye and faithfully duplicate the appearance of my living tissue. I sat for several hours that morning while Michael painted at his easel and we chatted about the news of the day.

   Every so often Michael would put the painted prosthesis in my eye socket and carefully check its appearance against my left (good) eye. So, painstakingly and carefully, he was able to match the colors with all illusions present and then touch up and alter tints as desired until we were both completely satisfied with the match.

   At this point we would normally have waited around for the several hours needed to return the eye to the final mold while the layer of transparent acrylic was cured on the front surface to protect the color during final polishing and subsequent wearing. But the winter storm was growing nearer so we decided it was best to make our thirty mile trip home quickly to Chapel Hill and not wait for the finished prosthesis. The Boyds promised to ship it to us that afternoon via special delivery with the U.S. Postal Service. I put my eye patch back on and we went home just ahead of the snowfall.

   Delayed by the storm, my new “eye” finally arrived two days later via the US Postal Service. It was delivered to our door carefully packed in a shatterproof container.

   Inserting the new “eye” was easy. My wife, Dot, slipped it right in without any discomfort. Thanks to the impression molding techniques originally developed by Lee Allen at the University of Iowa and so successfully followed by the Boyd Brothers my “eye” seemed to fit like a glove. Everyone remarked how beautifully it matched my good eye.

   I do not expect to take the “eye” out for a year – not until I return to the Boyds to have it checked and cleaned. It will of course be necessary for me to report back to Dr. Dutton every six months to make sure there has been no further spread of the cancer.

   Little care is need for my new eye. It tears normally and can be opened and shut at will and I do have adequate turning ability of the prosthesis and consequently of the eye also. I apply a salve nightly inside the lower lid to make sure the socket stays moist when I sleep. Washing the eyelids gently with a mild cleaning agent first thing every morning keeps the eyelids free of grainy matter.

   Is living with one eye difficult? In the words of one authority, “Monocular vision is basically an inconvenience, but it is certainly not a handicap.” But there are some problems.   

   When both eyes are working, your brain examines each separate image from the right and left eyes and computes the object’s size, distance and variety. The brain then merges each of these separate images into one clear picture. With just one eye working, this is no longer possible.

   There are two major problems for the one-eyed man. First is the loss of depth perception. The second disadvantage is the loss of some 20% of one’s field of vision on the side of the lost eye. You need stronger light and sometimes a magnifier to read the small print.

   I seriously doubt if I will do much more auto driving. With loss of peripheral vision on the right side, it would be difficult for me to observe following vehicles. Besides, accurately gauging the distance from the right curb becomes more of a problem.

   I have been busy learning some tricks to get over these problems. Slightly tilting my head up and down and from side to side as I walk varies the angles and apparent size of the viewed object, creating a perception of depth. Another thing I now realize is that I must turn my head more fully to the sightless side to accommodate the narrowed field of vision.

   I have to be careful when I pour liquids or try to plug in an extension cord in an electric socket. For liquids I found that touching both rims helped me to line things up and not spill. When walking, using a cane became a good idea to keep my balance. Stepping off a curb has to be handled with care or I miss my step! I have done this a couple of times already.

   The Boyds assured me that with time and readjustment my old brain will become reprogrammed and my body readjusted for my monocular vision. They promised me that my good left eye will in time develop its own depth perception as my visual system becomes reeducated and as I redirect my head movements. I can’t wait!

   So maybe living with just one working eye is not going to be so bad after all. -- Des Reilly, Resident

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Cyclists
    In Carolina Meadows, a continuing care community where the average age of residents is close to 85, a small contingent likes to leave their cars and golf carts at home and get around as much as possible on bicycles. Most of the cyclists have ridden bicycles since childhood, and never saw a reason to abandon their two-wheelers to dust and rust. Carolina Meadows maintains a battery of stationary bikes in an exercise room, but some of the residents make more use of the bike parking racks maintained for active riders just outside the Club Center.

   Almost surely the highest-mileage rider at Carolina Meadows is Bob Kent, 84, who got a bike for Christmas when he was 12 or 13, and lived in Oklahoma City, Oklahoma. When hard use and old age overtook his first bike, he abandoned two-wheeling until the early 1970s, when he and his wife, Betty, were living in East Orange, NJ. A worldwide squeeze on crude oil led to gasoline shortages in the U.S. and to long lines at gas stations.

   “Buying gas was a real pain in the neck,” he recalls, so he and Betty bought a matching pair of green Schwinn bikes to ride around town. Bob found that the exercise helped him keep in good physical condition, and his rides became longer as the months passed. Then one night while visiting friends, the Kents parked their bikes in a screened-in porch. The next morning, they discovered that someone had slit a screen, unlatched a door and made off with their bikes.

   After a move to High Point, NC, the Kents were once again pedaling around town and to nearby towns when Bob’s employer, American Bell International, asked him to move to Teheran, Iran. As it happened, their two bikes contributed to a weight of household goods in excess of their allowance for moving, and with some reluctance, the Kents shed the bikes and headed for Iran.

   “It’s probably just as well we didn’t take the bikes to Iran,” says Bob. “The streets were really rough and the traffic was wild.” It was also just as well not be overloaded in 1979; that was the year of the Iranian Revolution, when the Kents were compelled to abandon some of their possessions and leave the country along with other Western business executives almost literally at gunpoint.

   They returned to High Point, where they were soon two-wheeling it around town again. It was there that Bob encountered a hazard familiar to many bikers, a curious dog. For reasons unclear to human riders, some dogs regard bikers and their feet on rotating pedals as either threatening or edible, and a temptation to attack. A dog ran under Bob’s front wheel, pitching him over the handlebars and breaking his wrist.

   His only other significant accident occurred twenty years later, within a few yards of his Carolina Meadows villa while he was carrying a payload in his pannier and not wearing a helmet. For reasons not completely clear to him, he took a serious spill, found himself sprawled on the pavement with a sprained finger on one hand, a broken finger on the other, a large scrape on a knee, and a banged-up head (concussion?). After several hours in a hospital emergency room, he returned home with a firm resolution that now he never breaks: to wear a helmet whenever he rides. His helmet is equipped with a rear-view mirror, which helps him keep track of whatever traffic may be gaining on him.

   Unlike some riders, Bob says, “I spend very little time riding with groups. “ But in High Point, he sometimes rode with a group consisting mostly of firemen, who loaded their bikes on trucks and rode to distant points like the Blue Ridge Parkway. It was while descending a slope on the Parkway that Bob set a personal speed record, 39 miles per hour according to his bike speedometer.

   Mentioning that statistic leads Bob to comment on one of his favorite sport heroes, Biker Lance Armstrong, seven-time winner of the Tour de France. “Lance completed the last Tour de France with an average speed—uphill and downhill—of 27.31 miles per hour over a distance of 2274 miles,” says Bob with something close to awe in his voice. “Even to reach that speed I need a downhill slope and a tailwind.”

   A meticulous record keeper these days, Bob calculates that from 1989 to September 2005, he logged 53,643 bicycle miles on all surfaces and in all kinds of weather. Stretched end to end, this mileage was more than enough to carry him twice around the world at the equator. These days he sometimes adds to his mileage in big gulps. Often a volunteer subject for medical studies at the Duke Medical Center, Bob sometimes bicycles from Carolina Meadows to Durham and return, a 30-mile round trip.

   Like Bob Kent, resident Bob Newton started young as a biker, getting his first bicycle at age five or six. His hometown of Maywood, IL was in flat country, well suited to bicycling. As a high school student, he rode a mile or so to school most days, and after graduating from college with a degree in pharmacy, worked in a Veterans Administration hospital in Detroit. “We lived close enough to the hospital where the pharmacy was located that I could bike to work –about seven miles each way. I spent 20 years riding to work.”

   As every Michigander understands, Detroit is not known for its resort-like winter climate; that offered some challenge even to a hardy rider. “In the winter, you rode when it was ice-free, no matter how cold,” he recalls. There was one day when the car wouldn’t start and the wind chill was minus 47 degrees.“ He shivered a little, but pedaled to work on his bicycle. His riding costume for the coldest weather rose from light-weight rubber boots, to tight-fitting Gore-tex leggings, a fleece-lined jacket with a couple of sweaters inside, mittens rather than gloves, a ski band around the ears and a wool-lined helmet.

   Riding to work gave him a chance to think through the day ahead, and the ride home a time to work off any frustrations built up at the office. “When you got home in the evenings,” he recalls, “you had worked out any anxieties, dislikes of the day and you didn’t have to kick the cat around, you had pedaled it all off.”

   Since rush-hour traffic moved at a fairly leisure pace, Bob was able to move right along with the cars, keeping an eye on traffic ahead and as viewed through a rear-view mirror. Streets were usually scraped and sanded in snowy weather. “Under law you are a vehicle,” he notes, “and as long as you behave like a vehicle, obeying the same laws and rules, you rarely have any trouble.” In winter and darkness, he often attached ankle lights to improve his own visibility.

   “In the 1970s and 1980s,” Bob recalls,” I got into a bicycle club in Dearborn, MI. They were always getting involved in what they called Century rides in the summer, 100 miles out on Saturday, 100 miles home on Sunday, with a sag wagon to carry baggage and look after stragglers.” With another group, he rode a tour of the Scioto River Valley, from Columbus Ohio, down the Scioto river to the Ohio River, and back, about 105 miles each way.

   These century rides are not a walk in the park even for experienced riders. Says Bob: “Three months before, you would start taking 10-mile, 20-mile rides up to 30 and 40 miles a day. On the century rides, if you didn’t sleep in somebody’s camping area with bunks, the floors of a gymnasium were surprisingly comfortable, especially after a dinner of spaghetti and Gatorade.”

   Newton, who has a sensitive touch with tools, prefers to build the wheels he uses from hubs, spokes and rims purchased separately and carefully assembled and balanced in his garage. He occasionally provides repairs and solves maintenance problems for his bike-riding neighbors. He says he once was able to remove and patch a leaky inner tube, refit it and be on his way in ten minutes. Now, he says, it takes a little longer.

   The biking contingent at Carolina Meadows includes several women. Beverly Inchalik got her first bike when she was in the sixth grade and used to ride it from her home in East Rutherford, NJ, to Hackensack, about four miles away, to visit her grandmother. She still rides her bicycle around Carolina Meadows and the nearby Governor’s Village.

   Carolyn Kozelka recalls, “I first borrowed my sister’s bike, which was much too big for me and I wound up with skinned knees and elbows.” In time she got her own Elgin bike, with 28-inch wheels and took to the sport with enthusiasm that lasted into adulthood. She is especially fond of recalling a biking trip designated as an Outdoor Vacation for Women Over Forty. Her party numbered about a dozen women who toured Prince Edward Island, north of Nova Scotia. Aside from biking, the women hiked and went kayaking. She would like to work up interest among her friends and neighbors to go biking in North Carolina’s beautiful state parks, but so far has not been able to get a project off the ground. She is convinced that for riders of all ages, biking provides good exercise, stimulates the brain, and improves coordination and balance.

   She reminded Marge Miles of the pleasures of biking, and Mrs. Miles (who is also Dr. Miles, with a Ph.D.) visited a Chapel Hill bicycle shop for advice on selecting a bicycle suitable for her skill and life style. Mrs. Miles recalled that she and husband Lew used to bike around Kansas City, MO, when their daughter was small, and she biked to classes at the University of Missouri, Kansas City. All the old skills quickly returned, and now that she has retired from full time teaching at the UNC School of Nursing she cruises around Carolina Meadows and the nearby Governor’s Village, and along the nearby roads, breathing deeply of the clean fresh air. -- Bob Parker, Resident

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