My day usually starts at 8:30am for clinic, or 7:30am if I’m starting with an operating theatre session. On this particular day we have 7:30am morning teaching, so I make my way into clinic where one of the other registrars is waiting with coffee for everyone. Ophthalmology as a discipline is very subspecialised, with clinics and teaching sessions divided among seven or so sub-specialty areas including cornea and ocular surface, cataract and refractive, glaucoma, medical/surgical retina, neuro-ophthalmology, oculoplastics, and paediatrics + strabismus. Today is retina day, so we settle in and the consultant grilling session begins. Four difficult cases today, a rare variant of Stargardt’s disease (paediatric macular degeneration), Toxoplasma retinitis, surgical management of macular holes, and proliferative diabetic retinopathy. Fortunately, I’ve passed my fellowship exam already and can fade into the background while the upcoming exam candidates are thrust into the spotlight.
We rarely have inpatients that can’t be seen in clinic, and today is no exception, so we all move to the clinic rooms to start the morning session. The vitreoretinal surgeon whose clinic runs this morning was on-call last week for central Sydney and the NSW coast, so it’s a fully booked clinic. With a few ward consults and surgical pre-admission patients we have about 50 patients to see between the three registrars and one consultant. I see four postoperative retinal detachment patients who were operated on last week. All are progressing well, but still have a long road to visual rehabilitation ahead. One patient in particular had a complex detachment requiring vitrectomy and intraocular tamponade with silicone oil. He is very relieved that we can now relax his positioning instructions (strictly facedown 50 minutes out of every hour, with bathroom and meal breaks allowed). He is now allowed to be upright during the day but must not sleep on his back. I reassure him that count fingers vision is entirely expected while he has silicone oil in situ. Unfortunately, it will be at least 2-3 months until we can attempt to remove the tamponade, which will require another operation. My second patient is a young man who had a macular-on detachment with a single superior retinal break and required only scleral buckling and cryotherapy. I’m thrilled to find that his vision is almost perfect after a week. He will need updated glasses, as the buckling procedure always results in a myopic refractive shift, but he’s immensely thankful that his vision has been restored.
My other six retina clinic patients are a mixture of common retinal conditions – diabetic retinopathy, vitreomacular traction, branch retinal vein occlusion, and wet macular degeneration. The branch retinal vein occlusion patient has a small area of neovascularisation despite previous retinal laser therapy, so I take him to the argon laser and spend 15 minutes placing another 150 laser burns on the ischaemic area of retina driving the new vessel formation. The ability to perform quick clinic-based interventions that will make a real difference to a patient’s visual outcome is one of the most satisfying aspects of the job for me.
Finally, I see two preadmission cataract surgery patients who are on one of my upcoming operating lists. Our service has a standing policy that all Registrars will meet, consent, and examine any patient that they will be operating on in preadmission clinic prior to the day of surgery. Our patients are generally awake (and anxious) while we are operating on their eye, meeting the patient prior to the day of surgery helps to reassure them and generate trust between patient and surgeon. It also allows us to judge the complexity of the case and prevents surprises on the table – the word “oops” is banned in any theatre with a conscious patient.
With clinic done I head across the road to grab some lunch with the other registrars. They have 45 minutes until the afternoon Cornea clinic starts and are planning to sit in for a team meal. My lunch will be to-go today, as I have an operating theatre session at another hospital this afternoon. I eat my lunch in the car in the course of the 15 minute drive, then make my way to theatres to get changed. Once in theatres I meet up with the vitreoretinal surgery fellow who I am sharing the list with. There are four cases booked for the afternoon. The first two cases are cataracts which will be solo cases for me, then there is a vitrectomy + epiretinal membrane peel and a vitreous haemorrhage of unknown cause. I will be assisting the fellow for these last two cases. While our anaesthetist is performing the first eye block, I check my profile and settings have been loaded on the surgical microscope and phacoemulsification machine I will be using for my cataract cases The first cataract case is routine and is complete in about 15 minutes. The second case is a little more complex, with a small poorly dilating pupil that requires a mechanical dilating device called a Malyugin Ring. This slows things down a little but the case is otherwise uncomplicated. Both of these patients will go home this afternoon and I will see them in clinic tomorrow morning for a day 1 check. These visits are usually very satisfying, sharing in our patients’ reactions to their new vision really reinforces the impact that our work can have on quality of life.
With the cataracts out of the way we start on the vitrectomies. I prep the patient and put in the scleral ports before handing over to the fellow and taking the assistant position at the microscope. The first step in essentially any surgery on the retina is vitrectomy, the vitreous must be removed to relieve traction on the retina and to prevent inadvertent tears or injury to this delicate tissue. Epiretinal membranes are sheets of glial scar tissue that form on the internal limiting membrane of the retina. They are only a few microns thick, but are capable of stretching and distorting the fragile retina on which they grow. The deformation of the retina causes matching visual distortion termed metamorphopsia. The epiretinal membrane in our case is quite dense and it is a little tricky to lift an edge, but once the edge is started the membrane peels off the surface of the retina without too much difficulty.
The final case is a vitreous haemorrhage of uncertain cause. Once again we begin with scleral ports and vitrectomy, as the bloodstained vitreous clears we can see the tell-tale signs of a sub-acute central retinal vein occlusion. We search the retinal peripheries and don’t find any breaks/tears in the retina, so proceed to perform complete panretinal photocoagulation with an endoscopic argon laser to treat the ischaemia that caused neovascularisation and vitreous haemorrhage. This patient’s visual prognosis is guarded given the underlying central retinal vein occlusion, but without this treatment he will inevitably develop neovascular glaucoma and a totally blind and painful eye. As we noticed a degree of ongoing bleeding into the vitreous chamber during endolaser, we perform a fluid-gas exchange with sulfur-hexafluoride gas tamponade. This gas bubble will absorb much slower than air, and should provide tamponade for approximately two weeks while the laser scars mature and the new vessels regress.
Both of our vitrectomy patients will remain in hospital overnight for review in clinic and discharge tomorrow morning, as their risk of postoperative complications is higher than that of a cataract surgery patient. At the end of the list it is 4:45pm and time to head home.
Once I get home I settle in and then head to my desk to digitally sign off on the letters I dictated during the morning clinic, and to quickly add the details of my preadmission patients to my running sheet for next week’s operating lists. Once this is done I put my work away and head to the kitchen, as it’s my turn to cook tonight.
Ophthalmology offers a great balance of outpatient clinics and surgery. With the option of subspecialty practice it is possible to customise this balance to suit your individual preferences. I love that this specialty gives me the ability to make huge differences to quality of life in a very short timespan. I have had rural patients who come in bilaterally cataract blind, and then on day 1 after cataract surgery can see well enough that they could pass the vision exam for their driver’s licence. Ophthalmic surgery demands a high level of technical expertise and skill. The anterior chamber where most ophthalmologists spend their operating career has a fluid volume of 450 microlitres, and the working space between the lens and the back surface of the cornea during cataract surgery is between two to four millimetres. This is difficult to master, but immensely satisfying. We are privileged to be able to apply optical science and cutting edge technology to improve the lives of our patients and safeguard their vision.