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

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

I saw a guy in the clinic several weeks ago who sprayed Hongo Killer in his eye. He had a 100% epithelial defect with descemet’s folds. The cornea was pretty much in endothelial shock, although he was not hypotonous.

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.

medicine medicine, ophthalmology