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| Why Was the Woman Having Trouble Seeing, if Her Eyes Were Fine? | Why Was the Woman Having Trouble Seeing, if Her Eyes Were Fine? |
| (5 days later) | |
| “You look awful,” Esther Sarid, a psychiatrist in Toronto, told her patient. She’d been seeing the 46-year-old woman for nearly a year, after the sudden death of her brother. Despite her grief, the patient continued to work hard as a professor at a Canadian university. But Sarid knew it had been a tough time for her. | “You look awful,” Esther Sarid, a psychiatrist in Toronto, told her patient. She’d been seeing the 46-year-old woman for nearly a year, after the sudden death of her brother. Despite her grief, the patient continued to work hard as a professor at a Canadian university. But Sarid knew it had been a tough time for her. |
| The trim, middle-aged woman nodded sadly. She looked tired. And the right side of her face was a little droopy. “My Bell’s palsy has come back — again,” she said with a sigh. It was just one medical problem among many that year. | The trim, middle-aged woman nodded sadly. She looked tired. And the right side of her face was a little droopy. “My Bell’s palsy has come back — again,” she said with a sigh. It was just one medical problem among many that year. |
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| Blurry Images | Blurry Images |
| Nine months earlier, she woke up to find the world looking a little fuzzy. She had always enjoyed perfect vision. And she had seen the eye doctor just a few months earlier, who confirmed she was still seeing 20/20. But that morning, everything was a bit out of focus. Worst of all, she couldn’t read. She rubbed her eyes. She blinked hard. The letters on her screen looked smeared. | Nine months earlier, she woke up to find the world looking a little fuzzy. She had always enjoyed perfect vision. And she had seen the eye doctor just a few months earlier, who confirmed she was still seeing 20/20. But that morning, everything was a bit out of focus. Worst of all, she couldn’t read. She rubbed her eyes. She blinked hard. The letters on her screen looked smeared. |
| It was late afternoon before she had time to go to the North York General Hospital emergency room. A doctor there was worried enough to contact the on-call ophthalmologist. When she went for the appointment, the technician did the usual vision tests. The doctor came in and told her that her eyes were fine. It was probably presbyopia — the loss of near vision common in middle age. But the reading glasses he prescribed didn’t help. She saw two more eye doctors over the next week. No one had an answer. | |
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| In the Shadows | In the Shadows |
| She went to her primary-care doctor. Every image, every letter had a fainter replica overlapping and just off to the side, she told him. The doctor asked her to hold her head steady and follow his pen tip as he moved it back and forth in front of her eyes. You have diplopia, he said. Each eye was seeing correctly, but they were not working together. The result was that she was seeing two images instead of one. | She went to her primary-care doctor. Every image, every letter had a fainter replica overlapping and just off to the side, she told him. The doctor asked her to hold her head steady and follow his pen tip as he moved it back and forth in front of her eyes. You have diplopia, he said. Each eye was seeing correctly, but they were not working together. The result was that she was seeing two images instead of one. |
| That suggested a serious problem, he told her, and he immediately sent her to the neurologist on duty. That doctor also noted the diplopia and sent her for a CT scan. When the scan was normal, he ordered an M.R.I. It would take a few months, he warned her. In Canada, getting an M.R.I. takes time. There are fewer than 350 of the machines in the entire country — a fraction of the number in the United States. How was she supposed to work when she couldn’t see? she asked. Let’s just see what the M.R.I. shows, he answered. | That suggested a serious problem, he told her, and he immediately sent her to the neurologist on duty. That doctor also noted the diplopia and sent her for a CT scan. When the scan was normal, he ordered an M.R.I. It would take a few months, he warned her. In Canada, getting an M.R.I. takes time. There are fewer than 350 of the machines in the entire country — a fraction of the number in the United States. How was she supposed to work when she couldn’t see? she asked. Let’s just see what the M.R.I. shows, he answered. |
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| Compensating at Work | Compensating at Work |
| In the meantime, she struggled to keep up with her work. A magnifying glass helped. She bought the widest computer monitor she could find. And she gave herself more time to get things done. | In the meantime, she struggled to keep up with her work. A magnifying glass helped. She bought the widest computer monitor she could find. And she gave herself more time to get things done. |
| When the M.R.I. was normal, the neurologist told her it was stress. That didn’t make sense to her; the most stressful thing in her life at that point was the fact that she couldn’t see well. He had nothing more to offer. She asked her primary-care doctor to refer her for a second opinion. Maybe she should talk to her psychiatrist about her stress before seeing another doctor, he suggested. | When the M.R.I. was normal, the neurologist told her it was stress. That didn’t make sense to her; the most stressful thing in her life at that point was the fact that she couldn’t see well. He had nothing more to offer. She asked her primary-care doctor to refer her for a second opinion. Maybe she should talk to her psychiatrist about her stress before seeing another doctor, he suggested. |
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| Problem With a Nerve | Problem With a Nerve |
| It was around that time that she first noticed the facial droop. It was subtle. The normal upward curve of her lips was lost on the right side. Indeed, it looked as if she were sad, but only on that half of her face. She went to a walk-in clinic. Bell’s palsy was the diagnosis. She had Bell’s palsy some 20 years earlier. Back then, she was told that it was from an injury to the facial nerve and that there was nothing to be done; it heals on its own. She waited, and within a week it was gone. A couple of months later it was back, but again, for only a few days. It had just come back for the third time that year, days before her appointment with Sarid. | It was around that time that she first noticed the facial droop. It was subtle. The normal upward curve of her lips was lost on the right side. Indeed, it looked as if she were sad, but only on that half of her face. She went to a walk-in clinic. Bell’s palsy was the diagnosis. She had Bell’s palsy some 20 years earlier. Back then, she was told that it was from an injury to the facial nerve and that there was nothing to be done; it heals on its own. She waited, and within a week it was gone. A couple of months later it was back, but again, for only a few days. It had just come back for the third time that year, days before her appointment with Sarid. |
| She had never felt this tired, she told her psychiatrist. Sometimes she felt so weak, she had to do her work lying down. Even sitting was a struggle by the end of the day. Her diplopia came and went with no discernible pattern. Maybe my doctor was right, the middle-aged woman suggested. Maybe it is all stress. No, Sarid replied. I’m not sure what you have, but I am certain it’s not due to stress. | She had never felt this tired, she told her psychiatrist. Sometimes she felt so weak, she had to do her work lying down. Even sitting was a struggle by the end of the day. Her diplopia came and went with no discernible pattern. Maybe my doctor was right, the middle-aged woman suggested. Maybe it is all stress. No, Sarid replied. I’m not sure what you have, but I am certain it’s not due to stress. |
| “I have a friend, a colleague, who I bet can figure this out,” Sarid told the discouraged woman. She called Robert Yufe, a neurologist she’d known for decades. She outlined the symptoms she’d seen and heard about over the past year, then offered her own diagnosis: Could she have myasthenia gravis? | “I have a friend, a colleague, who I bet can figure this out,” Sarid told the discouraged woman. She called Robert Yufe, a neurologist she’d known for decades. She outlined the symptoms she’d seen and heard about over the past year, then offered her own diagnosis: Could she have myasthenia gravis? |
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| An Unusual Condition | An Unusual Condition |
| Myasthenia (from the ancient Greek meaning muscle weakness) gravis (from the Latin meaning severe) has been puzzling physicians for at least three centuries. It was first described in 1672 by the physician Thomas Willis, who wrote (in Latin) of people who “are able at first rising in the morning to walk” but who later in the day “are scarce able to move Hand or Foot.” We now know that myasthenia gravis (M.G.) is a rare autoimmune disorder in which antibodies interfere with the message the brain sends to the muscles. The hallmark of the disease is weakness that worsens with activity and improves with rest. In many patients, M.G. will affect the muscles of the face first. | Myasthenia (from the ancient Greek meaning muscle weakness) gravis (from the Latin meaning severe) has been puzzling physicians for at least three centuries. It was first described in 1672 by the physician Thomas Willis, who wrote (in Latin) of people who “are able at first rising in the morning to walk” but who later in the day “are scarce able to move Hand or Foot.” We now know that myasthenia gravis (M.G.) is a rare autoimmune disorder in which antibodies interfere with the message the brain sends to the muscles. The hallmark of the disease is weakness that worsens with activity and improves with rest. In many patients, M.G. will affect the muscles of the face first. |
| Yufe saw the patient a few weeks later. On that day, she had no symptoms, except her persistent fatigue. Her diplopia and facial droop had resolved. She told him about her peculiar symptoms and normal tests and how other doctors thought it was stress. In a woman with symptoms that wax and wane over time, two uncommon diagnoses came to Yufe’s mind: multiple sclerosis (M.S.) — a disease that causes asymmetric weakness that can come and go and is usually progressive — and myasthenia gravis. Each is seen more often in women than in men and strikes young adults. A normal M.R.I. made M.S. unlikely, because that disease usually attacks the fatty myelin sheath that surrounds the nerves. The sites of those attacks are seen on an M.R.I. as bright silvery white spots against normal dark gray brain tissue. | Yufe saw the patient a few weeks later. On that day, she had no symptoms, except her persistent fatigue. Her diplopia and facial droop had resolved. She told him about her peculiar symptoms and normal tests and how other doctors thought it was stress. In a woman with symptoms that wax and wane over time, two uncommon diagnoses came to Yufe’s mind: multiple sclerosis (M.S.) — a disease that causes asymmetric weakness that can come and go and is usually progressive — and myasthenia gravis. Each is seen more often in women than in men and strikes young adults. A normal M.R.I. made M.S. unlikely, because that disease usually attacks the fatty myelin sheath that surrounds the nerves. The sites of those attacks are seen on an M.R.I. as bright silvery white spots against normal dark gray brain tissue. |
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| An Unusual Test | An Unusual Test |
| Because M.G. doesn’t show up on imaging, it is often hard to diagnose. Yufe asked the patient to roll her eyes upward for as long as she could. With M.G., usually the muscles of the upper eyelid will tire, and the lid will drop no matter how hard the patient tries to keep the eye open. Not this time. He had her raise her arm over her head and keep it there. Like the eyelid, the shoulder and arm muscles should tire. They didn’t. Still, a normal exam didn’t mean she couldn’t have M.G. The symptoms are often erratic. | Because M.G. doesn’t show up on imaging, it is often hard to diagnose. Yufe asked the patient to roll her eyes upward for as long as she could. With M.G., usually the muscles of the upper eyelid will tire, and the lid will drop no matter how hard the patient tries to keep the eye open. Not this time. He had her raise her arm over her head and keep it there. Like the eyelid, the shoulder and arm muscles should tire. They didn’t. Still, a normal exam didn’t mean she couldn’t have M.G. The symptoms are often erratic. |
| He sent the patient for a blood test to look for the antibodies associated with M.G. and referred her for a test known as a single-fiber electromyography study — an up-close look at how the nerves speak to the individual muscle fibers. Not everyone with M.G. will have these antibodies, but nearly all will have an abnormal nerve study. She didn’t have the antibodies, but her nerve study was strikingly abnormal. She had M.G. | He sent the patient for a blood test to look for the antibodies associated with M.G. and referred her for a test known as a single-fiber electromyography study — an up-close look at how the nerves speak to the individual muscle fibers. Not everyone with M.G. will have these antibodies, but nearly all will have an abnormal nerve study. She didn’t have the antibodies, but her nerve study was strikingly abnormal. She had M.G. |
| An M.G. specialist put her on a medicine that counteracts the antibodies, so that her nerves and muscles can communicate as they should. These days, her symptoms get worse if she gets sick, but otherwise she has a full life. She has learned to pace herself — a skill she recommends for everyone. | An M.G. specialist put her on a medicine that counteracts the antibodies, so that her nerves and muscles can communicate as they should. These days, her symptoms get worse if she gets sick, but otherwise she has a full life. She has learned to pace herself — a skill she recommends for everyone. |
| Sarid wonders if the fact that her patient was seeing a psychiatrist made this difficult diagnosis even more difficult. When a patient in therapy with a psychiatrist has a complaint, it is all too easy for the doctor to attribute the symptoms to something emotional, something in her head. It’s the mark of a great doctor to see past the limits of her own specialty to identify the true cause of a patient’s symptoms. | Sarid wonders if the fact that her patient was seeing a psychiatrist made this difficult diagnosis even more difficult. When a patient in therapy with a psychiatrist has a complaint, it is all too easy for the doctor to attribute the symptoms to something emotional, something in her head. It’s the mark of a great doctor to see past the limits of her own specialty to identify the true cause of a patient’s symptoms. |
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