“Oh, my God, look at Miss Salmon,” Wendy whispered to Jennifer, nodding across the boat toward a woman in her early thirties. “Is she real?”
The woman seemed to have been assembled by a team of male pubescents. Her tiny waist gave way in one direction to a pair of tanned and taut legs that seemed taller than half the men around her, and in the other to a chest so full and eager that no bra could have contained it anyway. Her heels coaxed out unusually perfect calf muscles, while the strip of salmon-colored gauze she used for a dress coaxed out all the rest. Hers was the face of a 1940s movie star. Her long blond hair beckoned men from every era.
“I’ve got to tell Mike about her,” Wendy said. “I’ve got to tell Mike about Miss Salmon.”
“He’ll love it,” Jennifer said.
Wendy pulled May aside and described the scene. She spared no detail. Jennifer could not discern most of the conversation, but every few seconds she heard her husband say, “Really?” or “Wow!” or “How do you know that?” And she could hear him ask her sister, “You can see all that just from sitting across the boat?”
The next day, the families gathered in one of the hotel rooms to take a break from the sun. They checked the pay-per-view movie lineup and came across a film called At First Sight, starring Val Kilmer and Mira Sorvino, about a blind man whose vision is restored. It seemed a natural, especially as May had mentioned his chance meeting with Dr. Goodman to Jennifer’s family. He took a position on the king-sized bed, flanked on one side by his wife and on the other by her sister, as the movie began.
Eyes rolled just a few scenes in. The main character seemed dull and frightened. He became derailed by everyday circumstances. He smiled goofily.
“This guy is a downer,” May said.
When the blind man’s girlfriend pressured him into pursuing a miracle cure for his blindness, Jennifer fidgeted and mumbled to herself, “Why would someone pressure another person like that? It’s so personal.”
Halfway through the movie no one was paying attention.
“I’d be back at the pool looking for Miss Salmon if I weren’t already sandwiched between two such beautiful women,” May said.
The sisters asked if he was still watching the film.
“Not much,” May told them. “The main character’s not a real person.”
When May returned from this trip he asked his office assistant, Kim Burgess, to help him search the Internet; the speech-synthesized screen-reading software he used on his computers worked well for word-processing or spreadsheet tasks, but it bogged down trying to decipher complex Web pages. He told her he wanted to research stem cell transplant surgery for the eyes.
At the same time, he submitted a query to an Internet newsgroup dedicated to issues that concern the blind, asking if anyone knew of such a procedure. He told Jennifer that he still expected to find nothing—if the minds at the universities he’d contacted knew nothing, if Dr. Fine had known nothing, he expected to come up empty on his own.
Soon, information trickled in—a foreign Web site here, an e-mailed answer there. It appeared that there did exist a procedure involving stem cells and vision, one referred to as “corneal epithelial stem cell transplantation.” When May used that language on the Web and in queries, the information began to flow. Much of it was bound in the private vernacular of scientists and surgeons; they spoke of “limbal allograft,” “existing symblepharon,” and “cicatricial keratoconjunctivitis.” May panned the literature for colloquial nuggets and used a dictionary to machete through the rest. He determined this much to be certain about the procedure:
• It was indicated only for very special cases—but a chemical burn was among them.
• Its evolution was recent and its implementation rare—fewer than four hundred had been performed worldwide.
• Very few doctors knew of the surgery, and almost none had attempted it.
• If successful, it could restore vision to the blind—even to those who had been assured they would never see.
May briefed Jennifer on his discoveries. It felt strange to him to think about vision—he could remember doing it only once before. In his late twenties, he’d heard a man on the radio describe using hypnosis to help people recover childhood memories, and he’d wondered if a hypnotist might make him see what he’d seen before his accident. It was a fascinating proposition and one he’d entertained for a few days before returning to his busy life.
“The stem cell surgery is really interesting,” he told Jennifer. “I’d like to know more about it. I still don’t think it would change my life, but I have to say, it seems like it’s for real.”
Vision begins at the cornea. When light enters the eye, it passes first through the cornea, a transparent, circular layer one-fiftieth of an inch thick at the very front of the eye. The cornea has no color, but its job is critical—to allow light in and do the majority of focusing. The cornea must stay clear; otherwise, trying to see would be like trying to look through a frosted shower door or a dirty car windshield.
But how are corneas kept clear? People can’t run wiper blades over them as with car windshields. The body, it turns out, has its own ingenious method for keeping the corneas clear. It begins with special cells known as corneal epithelial stem cells. These are not the controversial stem cells taken from embryos or fetuses, but rather cells that exist in every person for a lifetime.
These stem cells reside along the edges of the cornea. If you imagine the cornea as a round window, the stem cells—about a thousand of them—live along the area where the frame would be. The stem cells produce millions of daughter cells. These daughter cells have a single mission: to converge toward the center of the eye, covering the cornea in a transparent protective layer.
This protective layer of daughter cells is the cornea’s main defense against dirt, scratches, bacteria, and infection. It also prevents blood vessels and cells from the white part of the eye (known as the conjunctiva) from growing over the cornea. The protective layer itself might get dirty, but every few days the daughter cells that compose it fall off and are replaced by new ones, thereby ensuring perpetual freshness and clarity. The stem cells around the edges of the cornea never tire of making new daughter cells—they do it for as long as the person lives.
But what happens if these stem cells are destroyed—perhaps by disease or burn or trauma to the eye? In that case, they can no longer produce the daughter cells that form the protective layer over the cornea. Soon, blood vessels and conjunctiva cells grow over the cornea, clouding it and then making it opaque. Light is no longer able to pass through the cornea on the way to the pupil, iris, lens, and retina. That means the person is blind. A chemical explosion—like the one that happened to Mike May when he was three—can destroy corneal epithelial stem cells instantly.
Before 1964, scientists had little idea that the edges of the cornea play a role in keeping the cornea clear. And they certainly didn’t know of the existence of corneal epithelial stem cells and how they protect the cornea. When surgeons encountered a grown-over cornea, they removed it and transplanted a clear donor cornea in its place. That worked most of the time, because the patient still had stem cells around the edges capable of producing protective daughter cells. It failed, however, in cases when the patient lacked those stem cells. Ophthalmologists believed those failures to be caused by the body rejecting the donor cornea. They never suspected that the patient’s lack of stem cells was the cause of the donor cornea going bad.
In 1964, a Colombian ophthalmologist named José Barraquer treated one of his patients—a man who had suffered a chemical injury to one eye—in a new way. He transplanted a section of the edge of that patient’s healthy cornea onto the edge of the injured eye. The patient’s vision improved. Barraquer didn’t realize it, but he had performed a stem cell transplant. Science now knew that, somehow, the edges around the cornea were important to corneal health.
Research along these lines was advanced in the late 1970s in Pittsburgh by Dr. Richa
rd Thoft, who refined Barraquer’s techniques and also began transplanting the edges of cadavers’ eyes into patients. But it wasn’t until 1989, through the work of Drs. Kenneth Kenyon and Scheffer Tseng, that science fully understood the role of corneal epithelial stem cells and how best to transplant them. The process, it turned out, required two surgeries and a good deal of technical skill on the part of the surgeon.
When a donor dies, an eye bank dispatches a volunteer to remove the donor’s eyeballs. The eyes are placed in a preservative solution and sent back to the eye bank, where the corneas and surrounding stem cell areas are cut from the eye and placed back in solution. They are then sent to a surgeon for transplantation, preferably within five days of the donor’s death. (Surgeons prefer to use corneas and stem cells from donors no older than age fifty.)
The first surgery is to transplant the donor stem cells. After the patient is placed under general anesthesia, the surgeon scrapes away any conjunctiva cells and blood vessels that have grown on top of the patient’s cornea. That alone requires an artist’s touch, but the hardest parts are yet to come.
The patient is left sleeping while the donor cornea and its surrounding doughnut of stem cells are placed under a nearby microscope. The surgeon uses that microscope—and a midnight-still hand—to cut away the center part of the donor cornea, leaving just the doughnut of stem cells. His job now is to place that doughnut on top of the patient’s existing cornea, thereby providing the cornea with a new supply of stem cells.
In its current state, however, the doughnut is too thick to transplant. Still using the microscope, the surgeon thins the doughnut by shaving it from underneath, narrowing it from one millimeter to one-third of a millimeter, all without damaging the stem cells on top. His movements are a tiny ballet of precision and nerves.
After the ring of stem cells has been thinned, the surgeon places it on top of the patient’s existing cornea and sutures it into place. The entire process takes between ninety minutes and two hours.
The stem cell transplant by itself produces no vision. That’s because the patient’s existing cornea has been too badly damaged by overgrowing cells and blood vessels and no longer functions properly. He needs a new cornea, but before he can receive one, he must allow his new stem cells to produce waves of new daughter cells to forge a clear path to the cornea. Without that clear path, future protective daughter cells cannot reach a new cornea.
It takes about four months for the daughter cells to clear that path. Once the surgeon confirms that this has occurred, he removes the patient’s damaged cornea and replaces it with a healthy cornea from a second donor. If all functions properly, that new cornea will be protected by the new stem cells and the daughter cells they produce. And that can mean long-term vision.
By 1999, only fifteen or twenty surgeons in the United States had performed corneal epithelial stem cell transplants. It is likely that the procedure had been attempted fewer than four hundred times worldwide.
May’s days stretched from dawn to midnight as August drew to a close. Still, during his free moments, he found himself digging. He called ophthalmologists to ask if they had performed corneal epithelial stem cell transplants—he wanted to know how Goodman’s experience ranked among his peers’. He could not find a single doctor who had performed any. He dug into Goodman’s reputation and discovered a nationwide respect for the man. When he checked with his insurance carrier, he discovered that Goodman was a preferred provider and that a stem cell transplant might be covered.
In the Caravan one night, with Carson and Wyndham asleep in the back, May told Jennifer that he was thinking of scheduling the B-scan—the ultrasound that would look behind the surface of his eye to determine whether or not he was a good candidate for the surgery.
“It seems like it wouldn’t hurt to find out,” May said.
“That sounds right,” Jennifer said. “It’s not like it’s a decision to get vision. It’s just a step to see what’s there.”
The next day, May called Goodman’s office and asked to schedule the B-scan. He was referred to a San Francisco specialist in ocular ultrasound, who would perform the scan, after which Goodman would interpret the results. The receptionist scheduled May’s follow-up consultation with Goodman for September 23. He thanked her, called the specialist, and made an appointment.
On the afternoon of September 9, 1999, May walked with his Seeing Eye dog, Josh, to the local bus terminal, boarded an express to the Vallejo ferry, took the boat to the Ferry Building in San Francisco, then took a taxi to his appointment. The trip took ninety minutes.
The specialist explained the B-scan to May. He would anesthetize the eye and keep it immersed in a tiny bath of coupling fluid. Then he would place a small electrical probe on the eyelid that would broadcast and receive sound waves. The instrument would image the internal anatomy and structure of the eye in much the way an ob-gyn’s machine uses sound waves to image a fetus. The idea was to detect gross pathologies or abnormalities. It would be up to Goodman to explain the results.
The procedure lasted fifteen minutes and was painless. All that was left was to wait for the answers.
May’s appointment with Goodman was two weeks away. Sendero didn’t care. Its needs were insatiable, its problems always in bloom. Daytime stresses trickled into May’s nights. He had never been a sound sleeper—he was often restless, and would sometimes lie awake for hours thinking through business and life. Wrestling Sendero to the starting line did not improve his slumber.
Every so often throughout his adult life, lying awake at three A.M., May would find his thoughts drilling down through the everyday and into the eternal. He would contemplate dying and mortality, try to get his arms around the idea of what it meant to be extinct. He considered what it meant to have no awareness—not even the ability to touch something—and how a person who made jokes and missed his kids by noon every day could disintegrate in the dirt until there was nothing left of him. These thoughts bore no relation to his everyday fears—of flying in bad weather, of sudden explosions—the kind that could be defeated by logic and guts. These were terrifying ideas, the type that lay in wait while he tended to business concerns and bickered with Jennifer about staying organized but that found him before dawn, when his mind had quieted and Davis had gone silent. They were the kind that could shake his core.
He rarely spoke of dying. Recently, however, May had found himself in just such a discussion with his father. Now living in Denver, Bill May had lost another job to alcoholism. Doctors could not promise that he would survive. May flew in to visit his dad. The elder May told his son that he had been thinking about what it meant not to be anymore, that he tried to imagine what it felt like to be gone. “I’m petrified of dying,” he said. May told his father, “Me, too, Dad.”
A few nights later, May was awake with these ideas. His usual antidote was to think about his accident, about how easily he might have died. Everything after that, he’d tell himself, was icing on the cake. On this night, however, he had a different thought. He wondered if, when he died, he would die bravely. He hoped that he would. Others, many of whom considered him the embodiment of courage, would have bet on it. But there was really no way to know until he got there. And it struck him that this was true about knowing oneself in general. It wasn’t who a person believed himself to be or what he predicted he would do in a given situation. It was what he did when he got there that defined him.
On the morning of September 23, 1999, May set out for his appointment with Dr. Goodman. He packed an early working version of his GPS product—complete with laptop and hockey puck–sized satellite receiver—for testing along the route. He was to receive the B-scan results that would determine his suitability for the rare corneal epithelial stem cell transplant surgery. Jennifer kissed him good-bye and wished him luck.
May and Josh took their usual route to the city—by bus, ferry, taxi, and foot. He made business phone calls on the way. He still believed that if vision restoration was possible, Dr.
Fine would not have pronounced his case forever hopeless. But as his GPS guidance system delivered him to Goodman’s doorstep by tuning in to satellites that orbited the earth, he couldn’t help but wonder for a moment if nothing was impossible.
After he signed in, a nurse showed him to a room down the hall and asked him to sit in an examining chair, a request that seemed odd to him given that he was there to discuss test results. Goodman entered a few minutes later and shook May’s hand.
“Great to see you again, Mike,” he said.
“Great to see you, too. May I call you Dan?”
“Of course,” Goodman replied. “I want to take a quick look at that eye.”
Goodman dimmed the lights. He opened May’s right eyelid with his thumb and forefinger and used the penlight and biomicroscope to look inside. He tested the pressure inside the eye. Then he pushed his stool back and flipped on the lights.
“I’ve read your B-scan,” Goodman said. “The results are excellent. It shows no gross pathology in the back of your eye. Your retina and optic nerve look normal. The back of the eye is anatomically intact and healthy. It’s a normal scan.”
“What does that mean?” May asked.
“It means we have a good chance to restore your vision,” Goodman said. “It means that we can try this.”
Goodman understood the magnitude of his words. He watched closely for May’s response to the idea of new vision. He paid careful attention to the psyches of all his patients—he considered it part of the gestalt of his practice—and would not move forward with even a routine Lasik procedure unless he believed a patient was emotionally grounded and had realistic expectations. He had a keen gut instinct for such matters, but even so, the analysis was always more art than science.
Crashing Through Page 5
