Republican Rep Dan Crenshaw (TX) received devastating news: A retinal detachment in his only seeing eye.

Crenshaw is a former Navy SEAL who lost his right eye due to an IED explosion in Afghanistan, hence his signature black eye patch. According to Politico, he began seeing “dark, blurry spots” in his remaining good eye a few days ago. He was told his retina was detaching and needed emergency eye surgery to repair his detachment.

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What does this all mean? As a practicing retina surgeon, I want to explain some of what he may be going through. The standard doctor caveat applies, which is that Rep Crenshaw is not my patient and I have not examined him or his records. I am instead piecing things together based on a good summary in Politico.

His spots are floaters, due to pigment or blood, common with a retinal tear or detachment, and an early warning of trouble.

Reportedly his better, left eye was also damaged in the IED explosion, but obviously not as bad as his right eye, which is blind, covered with an eye patch. He may have had retinal bruising or contusion in his good eye, increasing his risk of a late retinal detachment. He may also be predisposed by myopia, or nearsightedness, quite common and where the eye is more egg-shaped than round, putting the retina on stretch, increasing the risk of retinal tears or detachment.

His surgery was reportedly performed at the Houston VA hospital. Although VA hospitals often have a bad reputation, they are typically affiliated with and staffed by faculty from a local medical school and Rep Crenshaw’s surgery would have most likely been performed by, or closely overseen by, a member of the retina faculty.

The article states that, after the surgery, he would have a “gas bubble” in the eye serving as a “bandage” to hold the retina in place. This suggests he had a vitrectomy; that is, surgical removal of the vitreous gel inside the eye, which due to contracting and pulling on the retina, tore and detached the retina. During surgery, laser is used to tack down the retina, especially around where it tore, much like spot welding. A gas bubble is placed in the eye to hold the retina in place until the laser scars mature, forming a good adhesion to the back of the eye, after about a week.

Such surgery usually takes less than an hour, is performed under either general anesthesia or local anesthesia with sedation, and is done on an outpatient basis without overnight hospitalization.

The gas bubble seals the retinal tear and, during recovery, patients may have to keep a specific position to float the bubble to the location of the tear. Bubbles float upward but by positioning the patient’s head, and by necessity the rest of their body, the bubble can be positioned against any portion of the retina.

A retinal tear at the bottom portion of the eye is the most challenging as the gas bubble floats in the opposite direction. To counter the immutable laws of physics, the patient can be positioned on their side or face down so the retinal tear is then a higher point in the eye where the gas bubble will float and cover it.

Rep Crenshaw will be face down for a week for this purpose per the Politico story. It’s not 24/7 in that position but most of the time. I instruct my patients to be 45 min per hour in whatever position is needed for one week.

One cannot see through a gas bubble due to refractive indices and focusing issues. Like looking underwater, one has vision but extremely blurry. Once the bubble fills less than half the eye, one can see under the edge of the bubble, with central vision returning. That typically takes a week to ten days, depending on the type of gas.

My best guess as to the gas used is sulfur hexafluoride, an inert gas that takes longer to absorb than room air, but that the eye completely reabsorbs within three weeks. Longer-acting gasses can be used but that might leave Rep Crenshaw with poor vision for at least a month, which is not a good option in a one-eyed patient.

Patients with gas in their eye cannot fly or go to high elevation as the bubble expands under lower atmospheric pressure, raising the pressure inside the eye, potentially damaging the optic nerve – again, a very bad idea for someone with only one eye. Rep Crenshaw would miss any important House votes, unless he travels from Houston to Washington, DC by car or train, at least until the gas bubble is gone.

Even while positioning, face down or on his side, he can still speak to staff, colleagues, or constituents, meaning the wheels of government can roll on. Reading or television will not be feasible with the extremely poor vision looking through the bubble.

Most retinal detachments can be fixed with a single operation 80 to 90 percent of the time. If further surgery is needed, there are many options, and the ultimate success rate is in the mid to high 90 percent range. Final vision, however, can vary from normal to some loss, depending on the extent of the original detachment. Cataract development is expected as a side effect of this type of surgery, often within a year or two.

While Rep Crenshaw appropriately found the news of his retinal detachment “terrifying”, he wasn’t the only one terrified. I can assure you that his surgeon was also terrified, as I would be, operating on a one-eyed member of Congress, knowing that failure would doom this Congressman to a second black eye patch.

But such terror is part of being a surgeon and focuses us like nothing else to do what we are trained for and at our best. I’m sure Captain Sully faced similar terror as he safely landed his airplane in the Hudson River saving hundreds of lives.

I wish Rep Crenshaw the best after his surgery and am far more confident that he will have a good recovery than I am that his Congress will ever balance the budget.

Brian C Joondeph, MD, is a Denver-based retina surgeon and writer.

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