Ever since I became the pediatrics consult resident for the hospital, I’ve often been ending my days with a headache. This may be the reason:

The full link to the website is here.

medicine ophthalmology

I wrote about my feelings of receiving inappropriate consults on a previous post. Since then, I tallied an additional list of observations I’ve noted in consultation requests. Some of these are absurd:

Me: This is ophthalmology returning a page.

Consultee: You have to see this consult…

Others are even more direct:

Me: This is ophthalmology returning a page.

Consultee: Five-One-One-Eight… [reading medical record number of presumed patient needing consult]

On other occasions, the interaction becomes insulting:

Consultee: (At 3 am) Sorry to wake you. This isn’t an official consult yet, but can I borrow your Tonopen? (Device to check eye pressure). This guy with a history of glaucoma fell and hit his head last night….

I suppose that direct blow to the eye could cause an eye pressure spike, but there are a few other incongruities in this consult request (We take home-call).

The ultimate insult:

Me: Can I borrow your stethoscope?

Consultee: Do you even know how to use one? (I was one year senior to this guy in medical school, and I taught him about renal failure in a review group)

Sometimes I just want to scream.

medicine ophthalmology, rant

Most grocery stores now discourage the use of plastic grocery bags in favor of reusable canvas totes. Apparently plastic bags require too much energy to produce, and are unsightly populating landfills. Stores like Whole Foods even give a 10-cent discount when we opt out of a plastic bag. Others like Aldi, don’t even have plastic bags to offer. Years ago many stores in East Asia already began charging for use of plastic bags.

While it is true that plastic bags are produced from natural gas and recycling them can cut down on crude oil usage, we need plastic bags. Aren’t those large garbage bags we use in the kitchen made out of plastic (polyethylene)? What about the black bags lying on sidewalks of NYC awaiting transport to the landfill?

Plastic grocery bags are perfect as trashcan liners. They are the right size to help isolate your garbage from within your large 13-gallon kitchen trash bags. It typically takes me an entire week to fill a 13-gallon bag with trash. Do I want my watermelon rinds, chicken bones, and avocado pits lying in my kitchen for a entire week? Hell no.

Small grocery bags are also great for cleaning up pet litter, especially in the park.

Indeed, it would be a sad day when all plastic grocery bags are gone.

misc economy

Retinoscopy is one of the more difficult exams to master in ophthalmology. It allows us to obtain one’s refractive error objectively. This is useful in children who are too young to be tested subjectively on an eye chart, or in those who are not verbal.

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…

medicine ophthalmology

For the entire last year, the only true surgeries that I’ve performed as primary surgeon were pterygia–those bat-winged conjunctival growths on the medial bulbar conjunctiva. I would typically rip the entire bat-wing off with some Westcott scissors and scrape down the cornea with a #57 blade. Most of the time, I used a battery-powered diamond burr to smooth out the cornea–that’s how the wimps do it. Afterward, I transpose a part of the superior bulbar conjunctiva over to cover the exposed wound. It typically took me 30 minutes (on a good day) to finish the case.

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.

medicine ophthalmology