The Blister That Can Blind

The first thing Dr. Ronald G. Michels tells any patient with a detached retina is that he or she has suffered "one of the most serious things that can happen to the eye," and that if surgery isn't performed promptly, total blindness can result. Michels, 38, an associate professor of ophthalmology at Johns Hopkins University's Wilmer Eye Institute who performed the retinal reattachment operation on Sugar Ray Leonard, is one of the nation's most renowned eye surgeons and an expert on diseases of the retina. Approximately 20,000 Americans annually develop detached retinas, a condition usually associated with aging. Most of Michels' patients are well into middle age. Those as young as the 26-year-old Leonard have usually been victims of some sort of trauma.

In explaining a detached retina to a patient, Michels asks him to think of the eye as a rubber ball. The inside of the ball is filled with a clear jellylike substance called the vitreous. If the ball were sliced in half, the retina would be the thin, delicate layer of tissue that lines the entire inside of the back half of the ball. "The best way to understand the retina function," says Michels, "is to think of it as the film in a camera. It is the part of the eye on which the image is actually focused and from which that image is transmitted to the brain."

A retinal detachment usually begins when the vitreous gel for one reason or another pulls on the retina, breaking or tearing the retinal tissue. Fluid then seeps through the tear and accumulates as a kind of blister beneath the retina, causing more of the retina to become detached from the wall of the eye. The blister can begin as a tiny one, depending upon the size of the tear, but it almost always grows larger, with more retina becoming detached—like paint blistering off a wall.

There are two different sets of symptoms. When the initial tear occurs, the patient will see light flashes, and then "floaters"—spots, cobwebs, dots or squiggly lines. Once retinal detachment begins, part of the visual field is lost. Shadows, clouds, veils or dark areas begin to appear. In its least serious manifestation, the detachment occurs on the outer sides or bottom of the eye, and vision impairment appears in the peripheral field. But if the detachment spreads to the center of the back of the eye—the macula, which controls the sharpest part of the vision—the damage can be much more serious.

In any case, prompt surgery is the only means of correction. If the condition is caught as soon as the tear in the retina occurs, before detachment has begun, the tear can be sealed off relatively simply either with a freezing treatment, called cryotherapy, or with a laser beam. But if detachment has already begun—as in Leonard's case, in which 40% of the retina was reported to have been detached—a more complex operation, called scleral buckling, is required. In this technique, the surgeon makes an incision through the clear membrane that covers the sclera, the white part on the outside of the eye. Then he indents the sclera by attaching pieces of silicone rubber so that the wall of the eye comes in contact once again with the torn part of the retina.

After such an operation the success rate for complete anatomical reattachment of the retina is better than 90%, although some cases require more than one operation. However, Michels points out that this high rate shouldn't be misinterpreted. "We're talking about reattachment, not restoration of normal vision," he says. "How much vision can be restored depends on how long the retina had been detached and how extensive the detachment was. If the retina was detached for a long time—and long can be only a matter of days—there can be irreversible damage done to the retina, and total restoration of sight is impossible to achieve."

In fact, 100% restoration of normal vision after reattachment is not possible in most cases. When the retina is detached from the wall of the eye, it's deprived of approximately half of its blood supply, and its cells begin to deteriorate. Reattachment can stop, and partially reverse, the deterioration. A patient may have an inherited weakness in the eye that makes him predisposed to retinal detachment, or it may occur as a result of aging. The other most common cause is trauma, either from a severe blow causing an immediate and acute retinal tear or from continued blows that cause deterioration of the vitreous gel.

Michels declines to discuss the specifics of Leonard's case beyond saying that the symptoms were caught "early" and the detachment was "partial." Had Leonard defended his title against Roger Stafford last Friday in Buffalo, the damage to his left eye almost certainly would have become much, much worse. As for Leonard's future, Michels stresses that that determination can't be made for at least six months.

Michels advises all postoperative patients to avoid activities like skydiving and diving into swimming pools, as well as contact sports. "Jogging, swimming, tennis or golf would be rigorous activities a patient could resume without danger," he says. "You certainly want to avoid a situation where you might get a major blow to the eye."

What, then, of the professional athlete? "I think each case has to be individualized," Michels says. Though no scientific data exist, Michels acknowledges that athletes in contact sports are at a much higher risk than the general populace. Dave Bing suffered a detached retina in 1972 while playing for the Detroit Pistons and after surgery resumed his All-Star level of play. But of all athletes, boxers, who receive countless blows to the eyes a week while training for a fight—not to mention the fight itself—are the most susceptible to retinal damage. Since 1979 three U.S. boxers besides Leonard have suffered serious retinal injuries. Two resumed their careers; one didn't.

The one who didn't, Harold Weston Jr., 30, today is the matchmaker for Madison Square Garden. Three years ago he was fighting Thomas Hearns—and perhaps beating him—when Hearns thumbed Weston's right eye. His retina was literally torn to ribbons, and 80% to 85% detached. Even after an eight-hour operation that was considered more a miracle than a success, Weston was game to fight again. "I needed the cash," he says. "I was willing to lose the eye if the right price was thrown at me. But it wasn't, so I just said, 'Forget about it. I'll quit.' "

Earnie Shavers suffered a severe retinal tear when he was thumbed by Larry Holmes on Sept. 28, 1979, at the age of 34. He saw "specks" immediately, and within four days was at Johns Hopkins, where Michels sealed the tear with a laser. Shavers was back in the ring on March 8, 1980 and has had eight fights since then, including a second-round knockout of Joe Bugner on May 8.

"My first two, three fights I was a little leery," Shavers says. "But if I thought there was any danger of losing my sight, I wouldn't fight."

Hilmer Kenty, a 26-year-old former WBA lightweight champion, is scheduled to make his comeback June 11, less than 11 months after undergoing surgical repair of a retinal tear in his left eye, which he suffered while sparring. "You know the thought [of re-injury] is going to come, but it's going to go right back out," Kenty says. "It's going to have to or I'll get beat to death. I'm sure of that."

Weston feels there are two factors that cause boxers to be reluctant to acknowledge eye injuries. First, the vast majority of fighters are young, uneducated and unskilled, trying desperately to cash in on their only chance for financial success. "The only thing they know," Weston says, "is the baby needs milk, the rent's due, the car note is due, the insurance is due, and the only thing they know how to do is fight. They may know something is wrong with their eye but they won't tell anybody because they want to keep on going. And, O.K., say you got a kid with no money and no manager and he thinks he has a detached retina. Who pays for the operation?"

An excellent question, which leads to the second factor: the indifference of some managers, promoters and boxing commissions. No state requires a fighter to undergo an ophthalmological exam before a bout. "All they want is that body," Weston says. "The manager may not want to hear about a fighter with a detached retina, because he feels it's going to mess up his payday." The same presumably goes for many of the other boxing people.

Says Weston, "I feel that if they took all the fighters in the world today, they would find 30 percent have detached or torn retinas. Thirty percent! Anybody that gets their head jolted every day, day in and day out, something's got to be wrong with their eyes."

Michels will only go so far as to call Weston's feeling "an interesting observation." Although no studies have been done on the subject, Michels wouldn't say that Weston's estimate is off base.

As for the decision that Leonard will have to make, Michels will encourage him not to think about it for the next six months. "At that point," the ophthalmologist says, "I will have to decide whether the eye itself is as secure and strong as a normal eye. And Leonard will have to evaluate my opinion about his chances of [recurring] problems in the context of his career." As for what a recurrence might mean to Leonard, Michels says, "If you have performed a reattachment that hasn't held up, then in all likelihood the condition would be much more serious than it was the first time."

ILLUSTRATION

KIRK MOLDOFF

A detached retina begins when the vitreous gel that fills the eye pulls on the retina and causes it to tear. When fluid seeps behind the tear, the retina "blisters" and detaches from the pigment epithelium. Serious visual loss can occur if the macula, the central part of the retina, is involved. To repair the damage, a surgeon indents the sclera and reattaches the retina to the eye wall.

SCLERA

PIGMENT EPITHELIUM

RETINA (NORMAL)

MACULA

OPTIC NERVE

VITREOUS GEL

DETACHED RETINA

PHOTO

Three years ago Hearns thumbed Weston's right eye, detaching the retina. End of career.