The optics behind retinoscopy is elegant. In a perfectly round cornea without refractive error, light entering the eye is focused directly onto the retina. The reflection of light appears as a homogeneous red reflex to the examiner. In a hyperopic eye, the cornea is underpowered–light becomes focused behind the retina. As the examiner streaks the light through the pupils, the retinal reflex moves in the same direction as the light beam from the retinoscope–this appearance is dubbed “with motion”. With-motion is created from uncrossed light rays traversing the surface of the retina.

Conversely, myopic eyes focus light in front of the retina. Light rays on the retina are crossed, and produce a red reflex that moves in the opposite direction of the the streak (against motion).

For many people, against motion is difficult to discern, especially if there is with motion in another axis. I have probably overlooked this finding in dozens of kids with small amounts of myopic astigmatism, hopefully without dire consequences.

Last week, however, I successfully identified myopia through retinoscopy in a 5 year-old. The refraction was -1.00 + 4.50 x 085 in the right eye.

A celebration for this momentous event is in hand…

In these cases, I never entered the eye (intentionally).

Last week, I performed an anterior capsulotomy on a 10-month old girl. This involved loading up the Accurus vitrectomy surgical system to chew up the phimosis that developed after cataract surgery. This was a relatively simple procedure, involving an anterior chamber maintainer and another 23G port for instrumentation. However, it was my first attempt at intraocular surgery. The feeling is different. When you’re working inside the eye, there is a sense of uncertainty, even when you have direct visualization of your work. The eye is like a ball–you’re working on the inside without opening it up.  It was an even stranger feeling to run the vitrectomy system without ever having performed cataract surgery.

Running the vitrector (without having broken a posterior capsule) was a blast. The little pieces of capsule eddied toward the probe head at different rates, depending on how much I depressed the foot pedal. Before I knew it, I had chewed up the phimosis, and the case was completed.

I feel that I have been initiated.

Interesting use. Could someone elaborate?

I try to explain to them that there is no need to arrive so early, especially if the normal wait is already painfully long. Apparently there is a loss of communication. I suspect that there is a rumor among the patients that arriving early at an appointment translates to leaving early. This is as likely to happen as winning at Pai Gao Poker.

I once had a patient who I needed to follow daily for a herpetic corneal ulcer. After four days, he simply stopped showing up. Later, he told me that it was impossible for him to work if he spent hours at the eye clinic daily. Other patients of mine come to clinic ad lib, for prescription refills only. Then there’s the majority of them who sit patiently for 3 hours in the waiting room to be sent to fluorescein angiography for 2 more hours for a proliferative diabetic retinopathy (PDR) workup.

Indeed, to be a clinic patient is to be a special patient.

Unfortunately, I have yet to receive any surveys in the months that I’ve enrolled. Perhaps they are a front to harvest physician data? Or have they run their fund dry?

In actuality, I think that there is a limited market for ophthalmology-based medical opinions. The service appears to mediate data harvesting. In order for the physician to receive a survey, there much be a client investor on the other end to field medical questions. No funding, no money. Simple as that.

Are there any other physicians out there who have actually received surveys or been paid by TruthOnCall? Let me know!

I chuckled when he showed me the bottle. I suppose that it was entertaining only because of my limited Spanish knowledge and I had been basking in our underground clinic’s flickering fluorescent lights the entire day.

On my first few cases, I used a traction suture on the cornea to help rotate the globe for access. To minimize trauma on the cornea, I now ask my assistant/attending to help rotate the globe with a muscle hook. This is impractical, since most surgeons operate solo in practice. To remedy this problem, I’ve come up with three solutions:

1. Practice more–the obvious solution, but not elegant.
2. Use my LEFT hand to drive the sutures when operating on the LEFT eye. Use my RIGHT hand to drive sutures when operating on the RIGHT eye. Switch hitters in baseball do it, right? While I am not completely ambidextrous, I’m sure that my triple-digit hours playing Quake III and other FPS‘s might have helped my dexterity.
3. Operate only on RIGHT eyes. After all, there are already too many subspecializations in ophthalmology. Why not specialize on just one eye?

Which one is your favorite?

“Bullshit,” I initially thought. The ED frequently calls me about corneal abrasions and other minor trauma at obscene hours.

The photo on the left does not do justice to the severity of injury. Apparently, the patient had left a pot of boiling eggs on the burner, and exploded in her face. A shard of eggshell pierced the cornea through the stroma, nearly penetrating through Descemet’s membrane/endothelium.

The eggshell was removed in the operating room the next day. Unfortunately, I did not get to do the operation (but exciting nonetheless).

In aviation design, there is no room for chance. Every detail serves a purpose. For instance, the design of airport runways required efficiency to the finest detail. Chicago’s Midway Airport is a prime example. Considered the “busiest mile”, the airport roughly consists of a square mile of runways closely surrounded by local businesses. Its longest runway runs approximately 6000-ft, which limits the size of aircraft the airport can handle. A fully fueled Boeing 747 with maximum payload requires a minimum ground speed of 200-mph for a safe take-off, not considering incoming winds. Approximately 13000-ft of runway is needed to achieve this speed. Furthermore, airfields with limited land area implement displaced threshold airstrips.

The area of the runway marked with chevrons is the displaced threshold region. This region indicates that no aircraft is to land directly on that portion of the runway. The designation applies often when noise ordinances or structural buildings prevent a gradual aircraft descent onto the runway from a particular direction. In many cases, the displaced threshold section also offers less structural support than the opposite end of the runway; the ground on which an aircraft touches down must be able to withstand a greater pressure (force / area) than the rollout region.

How the hell does air travel function with airports working the way they do now? It is futile to seek out an explanation. Airports operate the same way our eye clinic does–despite all the mis-scheduled patients, missing charts, absent technicians; all the patients are remarkably cared for at the end of the day.

In particular, I learned about ophthalmology training in Portugal. As with most professional training outside of the United States, specialization begins directly after high school. Medical school totals six years of schooling, although they do not have an equivalent to “college” as we do in the U.S. During the last year of medical school, students rotate through certain medical specialties much like we do in our 3rd year of medical school.

During this 6th year, students prepare for a cumulative exam on Harrison’s Principles of Internal Medicine. It is a 100 question exam on minutiae. Several of the Portuguese residents have told me they studied for over six months for the exam. Others have taken it 3 times. Your score on the exam allows you preferential ranking into the specialty and hospital of your choice.

That’s right. No application essays. No interviews. No traveling. Your career is determined by how well you do on one single exam. Mind you, this isn’t like the SAT’s that Toby-the-school-jock (who happens to have a reasonable grasp on English) can get a 1600 (or 2400 now) without preparation. Any sort of all-inclusive exam on internal medicine borders insanity.

As far as I understand, ophthalmology training in Europe has great variability. What you learn is certainly dependent on which hospital you train at. It seems to me that much of the cerebral knowledge comes from independent learning from textbooks. Surgical training, however, can be impressive. One of the first year residents I spoke with had already performed over thirty pterygia and over ten phacoemulsifications! I would be fortunate to clock even 15 pterygia this year. A vitreoretinal fellow from India had told me he did over 500 phaco’s in addition to hundreds of extracapsular extractions during his residency.

In a way, it is humbling to hear about experiences outside of the U.S. Indeed, we have an overwhelming amount of funding and resources, yet our training isn’t necessarily superior. Where do our investments go? Research labs? Lawyers? Administration and unionized workers? The abyss?