Friday, December 15, 2017

Everything You Never Wanted to Know About Eye Diseases and Procedures to Repair Them

This week has been far from the most focused week of my education in regard to my training in the specific domain to which I have been assigned. My supervising attending physician has been contracted Type A (H3N2) influenza. He was vaccinated, but we know that none of the vaccines are 100% effective; such is particularly the case with the H3N2 variant, which has mutated to some degree from the deactivated version of the virus in the vaccine.

The attending physician began showing slight symptoms Saturday night, but shrugged them off. By Sunday morning, He was feverish with chills, sore throat, cough, headache, body aches -- all the classic flu symptoms. He did the nasal swab test and found that he had type A H3N2, and immediately began taking Oseltamivir, otherwise known as Tamiflu.  Because he started the antiviral drug so soon after symptoms, he will be able to return to work in order perform his scheduled surgeries today.  Even though I had the flu vaccine, because I had spent a large portion of Friday, when he might already have been contagious even though he wasn't yet displaying symptoms, I began taking Tamiflu.  I will stop this weekend because it's not the end of the world if I come down with the flu during my time off; I just couldn't afford to miss any more work due to illness.

I spent Monday and Tuesday in the emergency room. Wednesday I scrubbed in for the surgeries of  two ophthalmologists who presumably owed favors to my attending ophthalmologist.  I certainly was doing no one any favors by being there, but part of the job for physicians and surgeons at a teaching hospital is teaching, so such doctors have little choice but to tolerate the likes of me. If they hate operating while medical students  stand on tiptoes to look over someone's shoulders, then ask what are probably stupid questions, they find other jobs at non-teaching hospitals, because we're not going away at any time in the foreseeable future.

The ophthalmologist whose work I observed and assisted deals with neuro-ophthalmology, a sub-specialty relating to diseases of the nervous system that affect the eye, typically  involving control of eye movements, vision, and pupillary reflexes.  The surgeries with which I assisted Wednesday were mostly corneal and retinal surgeries. It's all mostly very delicate work, but I don't find the corneal and retinal procedures to be quite so interesting as are the neuro-ophthalmological procedures.

I did get to see a corneal transplant (penetrating keratoplasty) on Wednesday.  I was very lucky to get to view the procedure. The doctor I observed typically only does maybe four of such surgeries a month spread out over ten days of surgery for a given month. Corneal transplants aren't quite like vital organ (or bone marrow) transplants whereby tissue compatibility is a major issue.  With a kidney transplant, for example, tests are run to locate specific antigens in the tissues. Six particular antigens are likely to cause rejection of the organ if they are not well matched. Such is not usually the case with corneas. The cornea isn't naturally a particularly vascular area unless disease has caused new blood vessels to form in the area, which introduces immune cells to an area that normally wouldn't have them.  The corneal transplant procedure is most often successful with compatible blood type between donor and recipient, but further cross-matching has been found to be irrelevant.  If a person has had one failed corneal transplant, his or her odds of tissue rejection are considerably higher for future transplants. The corneal transplant I saw was a first-time procedure for the patient, and all appeared to go well. He will take steroids for several weeks, which reduce the risk of tissue rejection.
Is there anything we don't treat with steroids these days?

My attending physician told me to stay at home and to sleep yesterday. I am finally off steroids and am able to sleep.  I'm not sure why i needed a day off two days before I begin a three-week break, but
I didn't want to look into the mouth of the proverbial gift horse.  It felt almost decadent to sleep so much.

I'm now at the hospital anxiously awaiting the arrival of our first surgical patient of the day.  we have a few eyelid surgeries, a few eye muscle surgeries, one orbital decompression, and one lower lid blepharoplasty. In this procedure, tissue from the roof of the patient's mouth will be harvested and transplanted to the patient's lower eyelids. This is usually a cosmetic procedure, but in this case, thyroid ophthalmopathy has caused the lower lids to partially retract, causing considerable discomfort and lack of eye closure and excessive corneal exposure in addition to the obvious cosmetic issues.

We should be finished with surgeries by mid-afternoon, at which time I will be singing along with the late Rev. Dr. Martin Luther King, "Free at last! Free at last!" Thank God almighty I'm free at last!"
I'll be free for three weeks, anyway.


  1. I'm wearing glasses again because my freakin' contacts started hurting yesterday. My eyes are okay now, but it's too late in the day to put contacts in. Good thing I like my new glasses.

    Do you like the eye specialty?

    1. I sort of like it, though I would not want to look at retinas all day. I'd probably sub-specialize in corneas or neuro ophthalmology if I were to go into that field. It's one of those fields for which I have no tremendous passion but could be happy enough working in it if it were necessary.