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Wednesday / May 18.
HomemicontactAssessing the Damage

Assessing the Damage

Professor Nathan Efron’s personal journey of retinopexy, cryopexy, vitrectomy and IOL surgery.

It was the morning after my scary ‘ink in the eye’ experience. I awoke feeling a little drowsy. I hadn’t slept well during the night, thinking about what had happened to my eye. It was time to get dressed, have a quick brekkie, and make my way to Bill’s clinic. I usually wear contact lenses, but left them out because I knew my pupils would be dilated.

I announced myself to the intercom at the entrance to the underground car park, made my way past the impressive line of Porches, BMWs, Mercedes etc., and found a spot. Convenient and complimentary basement parking was a useful benefit that I was going to avail myself of many more times subsequently.

On making my way in the lift up to the third floor, I noticed a sign listing about
six ophthalmologists who work in this group practice. It was going to be interesting to see how a large, private ophthalmology clinic operates in the modern age. All of my previous eye examinations over the past 20 years have been conducted by my optometrist wife, Suzanne, in optometry clinics, so I was unfamiliar with this form of ophthalmic clinical environment.

Bill explained that these tears were so far out in the periphery that he would not be able to deal with them adequately using a slit-lamp mounted laser; he would need to do this in a surgical theatre…

I presented to reception and was handed the customary medical history form on a clipboard. I sat down in a packed but comfortable waiting room of about 30 patients, all seemingly at least 60-something, and proceeded to fill out the form. No, I’m not pregnant. Yes, I have type 2 diabetes. No, I don’t have HIV or hepatitis, and so on. You know the drill.

Suddenly a young lady announced in a loud, clear voice “Professor Nathan Efron”. At once, everyone in the waiting room awoke from their slumber and looked around to see who among them was ‘the professor’. So, up I stood and followed this young lady to a small consulting room. She performed an auto-refraction, and then took me to a slightly larger room, and commenced a routine procedure that I was soon to become very familiar with.

First, the young lady took my ocular history relating to events over the past 24 hours. “And I believe you are a Professor of Optometry?,” she asked. I answered in the affirmative. She took my glasses away briefly to measure the prescription, before measuring my vision without, and then with, them. Whereas vision was a little hazy in my left eye yesterday following my ‘ink in the sky’ episode, visual acuity was good today: R6/4-3, L6/6-3, near R N5, L N6.

At this point, I started to wonder what sort of professional was examining me, so I politely asked, “What exactly do you do here?” She replied that she was a ‘tech’, which I took to mean technical assistant. On further questioning, I found out there were a number of techs assisting in this practice. They were typically orthoptists or had a biomedical science degree and were trained in-house to undertake basic eye screening examinations.

Rough and Ready

The tech then proceeded to perform a refraction using a trial frame. Now, every eye care professional knows that no one can do a better refraction than themself, and I am no exception. The tech seemed to do a rather ‘rough and ready’ refraction, using a minimum of bracketing. I was not particularly impressed. When she finished refracting my right eye, I wasn’t convinced that she had determined the ‘maximum plus power’ refraction end point, so I couldn’t hold back, and blurted out “Can you please put up an extra plus 050 just to be sure?” She obliged with a wry smile (who was she to argue with ‘the professor’), and it fogged me. So she was right. I’ll shut up in future.

The tech checked my pupil reactions then instilled topical anaesthetic, fluorescein and a mydriatic. Then (I assumed forgetting who she was examining), she explained to me these drops will make my pupils larger and that she needed to check the pressures inside my eye. I reminded her she didn’t really need to tell me that. After measuring IOP with a Goldmann tonometer, I was led to another waiting room.

Of course, the key logistical problem with ophthalmic examinations is that it takes a good 45 minutes for pupils to dilate, so I had to duly wait the mandatory 45 minutes before being called into another examination room, where I was greeted by Mike, one of three or four optometrists working for this group. My reputation had preceded me, and Mike told me that he was a QUT graduate and was aware of my background. He then quickly talked through and confirmed the tech’s findings, pulled across the slit lamp, did a brief scan of my anterior eye, and began a detailed examination of my ocular fundi eye with a Volk lens.

Mike wasted no time in getting around to the crux of the situation: he could see a large horseshoe-shaped retinal tear supero-temporally in my left eye. But there was a big surprise in store – he found an even larger horseshoe-shaped retinal tear supero-nasally in my asymptomatic right eye (see diagram). Mike asked the obvious question – if I had noted anything strange in that eye in recent times – but I could not recall anything untoward.

Just as we finished this discussion, Bill entered the room. A short, handsome chap with a pleasant smile, he welcomed me and in the process of exchanging pleasantries it became clear that he had been briefed about my ophthalmic background. He was also well aware that Suzanne had referred many patients to him. Bill then began to examine my eye with the Volk, and as he was doing this, Mike began reciting his own findings. Now this seemed like a really smart approach to me, and essentially resulted in Bill (and me) getting an immediate second opinion.

Bill confirmed Mike’s findings, and added that the retinal tear in my left eye was due to an acute vitreous detachment. ‘Schaeffer’s sign’ was observed (I had to Google this later; it apparently refers to the liberation of retinal pigment epithelial cells into the vitreous which often can be seen just behind the lens with slit lamp biomicroscopy). Bill also noted an ‘old posterior vitreous detachment’ in the right eye, and background diabetic retinopathy, in the form of a small number of microaneurysms, in both eyes. The latter was no surprise, and is related to my type 2 diabetes of about 25 years standing.

Bill cut to the chase. This was a very serious situation. He explained he had seen tears like this before, which can start small and in no time at all propagate to create a full detachment. Both eyes needed to be attended to immediately, one at a time, starting with my symptomatic left eye. Bill explained that these tears were so far out in the periphery that he would not be able to deal with them adequately using a slit-lamp mounted laser; he would need to do this in a surgical theatre, so that he could indent the sclera to perform retinopexy using a head-mounted laser on the proximal aspect of the tear, and cryopexy on the distal aspect.

It was Wednesday, and Bill’s next surgery list was not until Friday. But it couldn’t wait until then. Bill telephoned the operating theatre, which happened to be in the same building on the floor below, to see if a theatre was available that afternoon (it was being used by other doctors). Luckily, it was…

Nathan Efron is Research Professor in the School of Optometry and Vision Science at the Queensland University of Technology.

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