Lisa Sanders, M.D.,
is a contributing writer
for the magazine. Her
latest book is ‘‘Diagnosis:
Solving the Most Baffl ing
Medical Mysteries.’’ If
you have a solved case to
share, write her at
Lisa.Sandersmdnyt
@gmail.com.17nearby Fort Lee, N.J., Dr. Paul Shahinian.
If the star bursts were worrisome to the
young woman, Shahinian’s reaction to her
exam was terrifying. She needed to see a
neuro-ophthalmologist, he told her — a
specialist in eyes and brains — and she
needed to see one soon. All the informa-
tion collected by sight is transmitted to
the brain through a thick cable of fi bers at
the back of the eye called the optic nerve,
the doctor explained, and the nerve in her
left eye was hugely swollen. As she sat in
his offi ce, Shahinian called the specialists
himself. The fi rst two offi ces he called
had the same answer: She couldn’t get an
appointment for months. Then he reached
out to a neuro-ophthalmologist who was
new to the area, Dr. Kaushal Kulkarni, and,
after explaining the urgency, arranged for
the patient to be seen the following week.
↓
Communication Breakdown
Kulkarni listened to the patient describe
her strange visual abnormalities. Although
her vision was still 20/20, the intermittent
star bursts and the bent lines seen in her
peripheral vision — a phenomenon known
as metamorphopsia — suggested some-
thing was wrong with the way the brain
was getting and processing her visual
information. Kulkarni shined a narrow
bright light into the young woman’s right
eye. As expected, both pupils constricted.
He moved the light over to the left, and
both pupils immediately dilated. Moving
it to the right, her pupils again constricted;
returning to the left, again they sudden-
ly widened. Clearly the signal on the left
wasn’t getting through. The swelling was
cutting off the fl ow of information from the
eye to the brain. It seemed to be a one-way
problem, however: The fact that the left
pupil constricted when the light was shined
in the right eye indicated that information
from the brain was still getting through.
There are many causes of this kind of
optic-nerve injury. Shahinian had thought
that, given the patient’s age, this was likely
to be multiple sclerosis, an autoimmune
disorder in which the immune system
mistakenly attacks nerve fi bers that link
the brain to the body. Kulkarni agreed that
was a possibility and ordered an M.R.I. to
look for evidence of that or other abnor-
malities. Was this a tumor? Or a stroke?
Other autoimmune diseases also had to be
considered. It could also be the result of an
infection: Lyme disease could do this; so
could cat-scratch fever, an infection caused
by the bacterium Bartonella henselae; even
syphilis, often called the great imitator
because of its ability to manifest in so many
ways, could cause this kind of injury.
He sent the patient to the lab for test-
ing. The results of the blood tests came
in quickly. It wasn’t Lyme or Bartonella or
syphilis. None of the infl ammatory mark-
ers suggestive of an autoimmune disease
were elevated. It was the M.R.I. that held
the answer. Kulkarni didn’t see the bright
white smattering of dots and dashes that
would suggest M.S. Instead, a large round
object, a mass about the size of a plum,
dominated the middle portion of the left
side of her brain.
Kulkarni called the patient and told her
that the M.R.I. was abnormal. She came
back a couple of days later. He couldn’t
tell her based on the pictures just what
kind of tumor she had. The most common
would be a meningioma, a tumor of the
tissue that lines the brain. An acoustic neu-
roma was rarer but also possible. This is a
slow-growing tumor originating in the tis-
sue that connects the ear to the brain. She
was a little young for that; these tumors
usually appear in men and women over
40, and they usually cause problems in
hearing and balance rather than in vision.
Whatever it was, the tumor was so large
that it blocked the circulation of the spinal
fl uid through the brain, causing the nerve
to swell. It would have to be removed.↓
Occupational Hazard?
Kulkarni knew the patient didn’t have
health insurance. He called around to
the neurosurgeons he knew, trying
to fi gure out how to get this woman
the care she needed. The only answer
seemed to be for her to get in through
the emergency department. Thanks to
a law called the Emergency Medical
Treatment and Labor Act, all emergen-
cy departments are required to provide
stabilizing treatment to any patient who
comes in, regardless of insurance status
or ability to pay. The care provided isn’t
free; patients are billed, but they have
to be treated.
She went to the emergency depart-
ment at NewYork-Presbyterian Hospital/
Columbia University Medical Center,
and the mass was removed. The pathol-
ogist confi rmed that the tumor was an
acoustic neuroma. Reading up on this
type of growth, the patient noted that
hearing loss is a common symptom. She
had hearing loss in her left ear, but she
hadn’t made a connection between that
problem and the one with her eyes. She
thought that the constant exposure to the
sound from her violin might have caused
a little damage. She fi gured it was just
the price of doing what she loved. After
the surgery, her hearing didn’t change,
but the strange star bursts completely
disappeared. Straight lines still have the
tendency to buckle in her peripheral
vision, though.
Before her hair had even grown enough
to hide the scar, the bills began to roll in.
The numbers were even more frightening
than the images of the tumor. The ultimate
accounting totaled around $650,000. She
and her husband worried that they would
have to declare bankruptcy. They had some
money — they were saving for a rainy day,
but this was a tsunami. Salvation came,
unexpectedly, when a friend of a friend
asked if they had talked to the hospital about
fi nancial help. It turned out that Columbia
Presbyterian did have a fi nancial-aid pro-
gram. In fact, all nonprofi t hospitals are
required to provide fi nancial assistance to
people who need it; it’s mandated by the
Aff ordable Care Act. They didn’t have to
bankrupt themselves. They are grateful that
the ordeal ended well. And, two years after
the surgery, they are beginning to rebuild
their savings — because you never know
when it might rain again.