Roulette

Thomas J. McGarrity, M.D.

Ihad this spot. A freckle, which for me is not unusual. When I was young and the sun was shining, my freckles would blossom, erupting across the bridge of my nose. Every year in grade school, I was in the running to win the Freckle King contest. I had a pretty good shot. This one freckle was in my right eye.

“Has anyone ever mentioned this to you before?” asked the ophthalmologist.

“No,” I said, not confessing that this was my first eye exam. Ever.

“Rarely, rarely these turn into something bad.”

So began my multidecade oph-thalmology surveillance dance. My attendance was laissez-faire. The ophthalmologist’s office had no recall system. The pupillary dilation wrecked my day — I was unable to work or read. Each almost-annual exam concluded with “No change.” My eye exams fell in December, a busy time of year for my gastroenterology practice. Patients get caught up in the holiday rush securing colonoscopies before their deductibles are reset in the new year. This past year, I was double-booked, for my eye exam and the endoscopy suite. I chose endoscopy and canceled ophthalmology. Saving me from myself, my secretary rebooked my appointment.

The slit-lamp exam took longer than usual. “Look up, right, down, left,” the ophthalmologist commanded. The blinding white light made my eyes water. Tears ran down my cheeks. There was less free conversation between us, then silence. “Let’s get another look with optical coherence tomography, a second opinion at Philadelphia Eye. I see some activity in this lesion that wasn’t there before.”

My freckle had become a lesion.

My last case the day before my Philly eye appointment was an endoscopic ultrasound. On the gurney was a cheery 74-year-old woman with a meticulously made-up face, vague abdominal pain, and a CT scan suggesting a “fullness” in the head of the pancreas. As I explained the consent form, she mentioned, “Finally I am going to be a grandmother come March.” Her two daughters, she stressed, were “not getting younger!”

The fullness was an irregular 2.8-cm mass with a loss of interface with the portal vein. The on-site preliminary cytology report said “likely malignant.” I told the woman I saw a tumor, a cancer. My words stunned her like a sedative. However, she quickly recovered. “I have a lot to do,” she reminded me; “I am going to be a grandmother” — revealing an insulation of innocence that I dared not disrupt. Then I raced to the commuter train bound for Philadelphia.

I had danced with this devil before, in college. My right testicle had grown painlessly. Surgical excision. Teratocarcinoma — not the type to have. Chemotherapy. Abdominal aortic lymph node dissection. More chemotherapy. Bald as a cue ball on my 21st birthday. But I was younger then, more confident of my strength and stamina. I felt less sure today. I contemplated my long and happy marriage, two strong sons, gratifying 40-year career. Had I made my Faustian bargain way back then? My roulette wheel was in spin.

The train lurched to a stop, floors below street level and my hotel. The next morning, I walked through a wet snow to the eye hospital, oncology, 8th floor.

The waiting room overflowed with people bundled in winter coats, like wet sheep sheltered in a barn. Registration, insurance cards. Then the long, slow wait. Sit, wait, name called, wait, test, have a seat, wait. Visual acuity, formal visual fields, a slit-lamp exam, ultrasound, optical coher-ence tomography, fluorescein an-giogram. My urine flowed a psychedelic yellow. I munched on power bars, sipped tepid tea. All tests completed, results pending. Melancholy squeezed my temples like a vise. My train had left the station, my ticket was punched.

Late in the afternoon, I was placed in a small, narrow exam room. Soon I would hear the results and learn my fate. The slit lamp’s metal frame caged me off from the rest of the room. A disassembled model of an

Roulette

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eye lay on the desk. Silently, nurses, aides, fellows filed in and positioned iPads on the desk, each showing a different test result for efficient viewing.

One iPad showed a picture of my right eye, a fiery red background impaled by a dark brown-black hulking mass like a Death Star from Star Wars. The attending came in with an entourage. “Sit forward.” My chin and forehead pressed against the plastic harness. The searing white light blinded me. “Look up, right, down, left.” She then sat at the desk dictating with precision the result of each test. “Impression: 62-year-old male with choroidal melanoma, right eye.” Pause. “Comma, early stage.”

She faced me. I remained seated behind the cage. “We don’t need a biopsy, we know what it is. We don’t need to remove your eye. We treat this with plaque brachytherapy. You’ll lose some vision and might develop a cataract from the radiation. When we take the plaque out, we can biopsy for abnormalities in three chromosomes, which will determine your prognosis. The biopsy is $1,200, not covered by insurance.” She left, having answered all my questions without asking if I had any. The next week is melanoma treatment day. After surgery, four of us patients are bundled together and shuttled to a hotel. Like disabled war veterans at a parade, we line up to register with our bulging eye patches. We’re quarantined for 72 hours. Three days later, we return for a second surgery. The plaque is removed.

Six weeks pass. I am at work and the phone rings. Cancer genetics counselor calling. She explains that my tumor was analyzed for abnormalities in chromosomes 3, 6, and 8. If all three are abnormal, I have a high risk for metastasis. Like a seasoned game show host, she teasingly goes through each test result. “Chromosome 3, no abnormality. Chromosome 6, no abnormality. Chromosome 8, no abnormality.” I exhale. In the blink of an eye. For me, for now, the roulette wheel is no longer in spin.

I get to live. Blind luck or blessed from above?

In my right eye where my freckle was, I have a visual field defect. If I am in a hurry when I’m driving, I make mistakes. When I am careful, I stop before making a left turn. Look left once. Then turn to my right, look once, then twice, and then a third time, each turn in a widening arc to compensate for my blind spot.

My scar is etched in survivor’s guilt. What I do know is that I get to sit on the edge of my patient’s bed. I lean toward him into that space with everything I know and have experienced. It is my duty to help him play his cards, whatever they may be.

In my peripheral vision, I glimpse his wife, standing sentry, beseeching with watery eyes. I turn to face them eye-to-eye. I say we will all do our best to get him better, and if we cannot make him better, we will make him feel better. Then I sit for a while in their silence. I focus directly on my patient’s eyes. I look once, then again, and then a third time in an ever-widening arc to see what I need to see.

Disclosure forms provided by the author are available at NEJM.org.

From the Departments of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA. This article was published on February 5, 2022, at NEJM.org. Reprinted with permission from the Massachusetts Medical Society.