1. The ward
The day starts with the ward round. This is usually a civilised affair; the patients are brought to us, and there are never more than four of them. These patients will have complex and serious eye conditions which need intense treatment and input. For example, there are those with severe corneal ulcers requiring antibiotic drops every 30 minutes (in an ideal world this would literally be up to 48 times per day (!!), however we do recognise our patients’ need for uninterrupted sleep!). In these patients, we are trying to stop the infection destroying their cornea and causing a corneal perforation. Another example of a patient we might see on a ward round are patients who have really high intra-ocular pressures who need a combination of eye drops, IV medications, laser treatments and surgery. There is always something to learn from managing these patients, and there is really good Ophthalmology consultant input to make sure they are managed appropriately.
2. The clinic
Following the ward round I head down to clinic. This is where the majority of the Ophthalmology patients are seen. Clinics are split into subspecialty and are usually very full-on. I find my allocated room, and get all the equipment I am going to need ready, including the all-important lens. I check the list of patients that are booked to see me and go through all their notes, requesting the tests that I would like them to have before I see them. An eye condition, called glaucoma, because of its frequency and risks, will have its own clinic. Glaucoma is a condition where the intra-ocular pressure inside the eye is too high which can damage the optic nerve and affect sight (see left picture). In the glaucoma clinic the patients often have visual field testing to help assess whether their glaucoma has got any worse and whether they need an increase in their treatment. Visual field testing is a difficult test to get used to, both as a medical student (performing the test), and as a patient (whose visual fields are being tested). I would recommend asking an Ophthalmologist to demonstrate it to you on your Ophthalmology attachment as a medical student, to find out what the patients have to go through. Another specialised clinic is the macular clinic, for patients with macular degeneration, which is age-related, and causes blurring of the centre of someone’s vision, and can lead to partial blindness. Patients in the macular clinic will need an OCT (optical coherence tomography), a scan which has really improved the macular service. It uses infrared light to produce a really detailed picture of the macula and you can see if there is any fluid present, which can be affecting the vision in these patients.
The first patient has had their tests and is ready to be seen. I take their history and then manoeuvre them into the awkward looking slit lamp. This is the Ophthalmologists’ best bit of kit. It enables us to get a really good magnified view of the patient’s eyes. We most often use it with a slit of light, hence its name. We can look at the anterior segment of the eye, including the cornea, the anterior chamber, the iris and the lens. I may be looking for signs of infection in the cornea, tiny white blood cells floating in the anterior chamber, fine new blood vessels on the iris or evidence of a cataract (opacification of the lens of the eye). There is really a lot that can go wrong with the eye, and each condition has a different physical sign. The slit lamp also lets us look at the back of the eye using a special optical lens. There is no difficult direct fundoscopy required (a less advanced technique, which non-specialists use, where you usually end up bumping into the patient’s forehead in your attempt to peer into a tiny pupil and guess whether the optic disc and the retina look normal or not). The patient has had dilating drops put in, so their pupil is nice and big, and you can easily see all round the retina and the optic disc. I am checking the optic disc, looking for any signs of glaucoma or disc swelling; looking at the macula to see if there is any evidence of macular degeneration; and checking the peripheral retina to make sure there aren’t any retinal tears or detachments. There are loads of other tests that we regularly carry out in clinic, depending on the patient’s condition. The most common is checking the patient’s intra-ocular pressure. This is done with a device that touches the front of the eye. Again I would recommend having your own eye pressure measured when you are on your Ophthalmology attachment to see what it is like from the patient’s perspective – not the most comfortable examination in the world! Each patient will have a focused examination and I will collect all the information I need to decide how best to manage the patient. Depending on the findings, I can assess if the patient is doing well on their current treatment, or if they need more treatment. This can take the form of eye drops, laser therapy, injections or surgery. The clinic is fast-paced and good fun. I get to make the majority of clinical decisions myself, as a registrar. For the complicated patients, there is always someone more senior available to ask for advice.
After clinic, it’s time for lunch and to prepare for the afternoon. There is plenty of variety in the Ophthalmologist’s workload. The afternoon could be spent doing laser treatments for patients with diabetic retinopathy or glaucoma. Laser is as close to a video game as I imagine you will get in Medicine! You have a target and you shoot it using the firing button on the top of your joystick. Another option is doing injections. There are a lot of injections in Ophthalmology for the treatment of age-related macular degeneration. However, today is the best of the lot, as it is theatre day.
Cataract surgery is almost always done under local anaesthetic, which itself adds certain challenges, including keeping the patient calm and making sure they keep their eye still. The patient’s eye is cleaned and a sterile drape is used to cover the face. I get myself comfortable, a key part of the operation, making sure the chair and table are at the right height, and that I can reach the foot pedals easily and the microscope is focused on the eye. Now my heart rate starts increasing. The operation starts with a 2.4mm incision in the cornea, which has a thickness of about 800µm in the periphery. I make a completely circular incision in the anterior lens capsule, which is only a few micrometres thick. This lets me get at the cataract. I use a phacoemulsification machine to chew up and suck out the cataract using ultrasound energy. This is the scariest bit because the posterior lens capsule is behind the cataract and if I make a hole in it, the cataract can fall to the back of the eye and the patient will need another emergency operation. This time I manage to get all the cataract out successfully. I can take a breath at this point, but the operation is not over yet. Next I inject a new lens in through the same incision. It comes folded so it can fit through the incision and it unfolds when it’s in the eye to sit nicely in the right position. I check that the wound to make sure it is not leaking and that’s it. Hopefully one happy patient. Only five more to go… I really enjoy Ophthalmology theatre because the surgery is so fine and precise, and there are lots of gadgets and kit that we get to use. Theatre finishes without a glitch. If I am on call then I would have to head to the Eye Casualty to see any remaining patients there, as well as going to see any ward referrals that I had got during the day. I am on call overnight but can spend that at home unless I get called in, which doesn’t happen very often. Today I am not on call so I can catch up with my admin, work on any projects that I am doing but also get home at a very reasonable time.