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.

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 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?

In medical school, we were forbidden to wear open toed shoes while in the hospital. After all, who wants to have ascites or a bloody mess on your feet? The potential consequences of walking barefoot in the operating room are even more severe. Imagine delivering a C-section without proper gowns! With needles and other dangerously sharp equipment lingering around the OR, who wouldn’t be wearing shoes?

Indeed, I was uneasy the first time my attending told me to take off my shoes when I was operating as primary surgeon. Since then, I’ve realized that it’s nearly impossible to control the microscope and the Infiniti (I’ve only used the cautery mode) while wearing shoes. The pedals for the operating microscope control the focus and zoom on the operating field. A four-way joystick is situated above the pedals. An additional four buttons are also on the platform surrounding the pedals. All of this is controlled using ONLY your LEFT foot. A similar configuration to control the phacoemulsification machine is  located on a separate platform for your RIGHT foot. Having tactile sensation on the pedals eases the difficulty of learning the machine, especially for newbies like me.

Still, I cringe every time we lose a needle (or #57 blade) on the ground.

I’ve begun to reconsider the notion that these academic centers are anything beyond extraordinary. For one, academic centers are training centers. There are residents of all levels caring for the ill; no matter how qualified the housestaff are, there will always be shortcomings. I’ve been at the blunt end of poor decisions too many times already.

One morning, I received a page at 5am from a medicine PGY-2 resident who noted that one of my colleagues had written “I/L: 2+ NS OU” on one of the consults but failed to address any intervention in the plan (The consult was for diabetes evaluation, which is already a dubious inpatient consult). The same resident called me again last weekend at 5:09am requesting a consult for a gentleman with multiple myeloma who was bleeding from his gums and was anemic. He had read of some reported complications of central retinal vein occlusions in hyperviscosity syndrome. The patient had absolutely no ocular symptoms. Moreover, the medicine resident congratulated me for recognizing that there were no pathognomonic ocular findings for hyperviscosity syndrome, but demanded a stat consult anyway. Since when does the “consultee” openly flaunt demands to a consultant? At the same time, I had a corneal ulcer that I was managing in the ED.

It is disgraceful for a notable academic institution to have such prideful individuals with limited insight. I trained at a community center during internship, and never called a stat ophthalmology consult. Most people knew their limitations. In fact, most cases never need emergent eyecare intervention.

Some might say that the mission of the academic center is different from that of a community center. In these differences lie a training and research center that necessitates inefficient consults and a higher operating overhead. Not so much. The community center I worked in certainly had a higher inpatient load than my current academic institution. The community center isn’t burdened by deadbeat unionized employees who show up to work half the time. Many workups are governed by protocol; those that are not are rightfully so. The profit that the community center–a non-profit organization–is converted to education and expansion of the hospital. Complicated cases are indeed transferred to the local academic center, but rarely so. The more common cases are managed far more efficiently than their equivalents in a large academic center.

Indeed there is a role for each type of hospital in every city. However, the discrepancy in the two is startling. Academic centers should excel in “complex case report worthy” medicine, but they should not have to sacrifice quality and efficiency of the entire hospital in doing so.

The selection pool was so rich that I wished we could accept 10 residents for the program. Some applicants had numerous publications. Others had worked on light detecting devices for disabled children. Everyone was gifted in his/her own way. I felt compelled to sell our program to the applicants. I wanted them to rank us high on their list. That said, I can only imagine how difficult it would be to decide how to rank applicants at all. Ultimately, we will only get a handful of newcomers. The rest will end up scattered across the hospitals in the country. I’m eager to await the match results at my program. In a way, I’m nearly as anxious as the applicants. I will be a senior resident the year these people start their residencies. While is would be great to have a highly qualified junior resident, it would be even better to have a highly qualified resident who will be reliable enough to handle the stress and pain of residency.

Best of luck to the ophthalmology residency applicants!

Bastard. What do people think I’m doing? I’m sure that everyone tries to be particularly alert, but there’s no reason to be paranoid.