Ophthalmologists take risks every day, not only in surgery, but also at home and at play, says Dr Leigh Spielberg
What is an acceptable level of risk? By which I mean, what is the risk-benefit trade off for a particular situation. That seems to be the primary question in my life these days, wherever I am and whatever I’m doing. The question poses itself when I’m in the clinic. It’s in the back of my mind in the operating room. It is a recurring theme when I’m at home with my kids. It pops into my mind when I’m doing any of my hobbies.
In the clinic, I can usually manage the question quite well. Most of the surgical indications are fortunately quite straightforward, so the risk of operating is usually clearly outweighed by the expected benefits. But what about vitreous floaters in a middle-aged phakic patient with -5D myopia? Is the decision to operate too risky? Who’s to say?
Similarly, in the operating room, almost every step of a vitrectomy is the result of calculating the risk. How closely should I shave the vitreous in this eye to make sure enough is removed but not so much that I risk an iatrogenic retinal tear. How much peripheral laser do I apply? Just a little, to absolutely minimise the risk of macular pucker, or a bit more, to allow me to sleep better tonight, knowing that a micro-tear won’t end up as a retinal detachment. Do I suture the sclerotomies, with the knowledge that sutures can irritate for days to weeks, or do I risk the potentially dangerous but very unlikely postoperative hypotony?
METAL OR PLASTIC?
The risk-benefit calculations continue at home too. Do I allow my little chefs-in-the-making use a metal knife to slice a banana for breakfast? Or do I insist on them using a plastic kid’s knife, which is perfectly safe but results in a banana that is mashed rather than sliced? Can Philippa (5 years old) and Raphael be trusted with metal scissors (currently: no! But when does the answer change to: yes)? Ocular trauma, whether personal or professional, gives me nightmares. And, on a less serious and dangerous note, can I accept the risk of them dropping my (wife’s) iPad while they watch a video that keeps them busy long enough to allow me to finish writing this blog?
My hobbies all pose some level of risk. Do I always have to protect my big camera and its fancy lenses if it not only decreases the chance of an expensive fall but also the chance of capturing that perfect shot? A nasty fall off my mountain bike could result in a broken hand or wrist, with serious implications for my operating future. But riding ultra-cautiously somewhat defeats the purpose of riding at all. Is riding a motorcycle an acceptable risk for someone with a wife and two young children? Clearly, not if it’s rush h hour and raining? But what if I only ride down country roads on sunny Sunday afternoons?
I’ve made it to where I am now, so I guess I’ll continue as I’ve done since day one.
Dr Manish Mahabir, winner of last year's prize, reflects on his achievement
The 11th September 2016 was an auspicious day for me.
I was in Copenhagen, Denmark at the XXXIV Congress of the ESCRS to receive the John Henahan prize for Young Opthalmologists.
I wore a white linen kurta-pyjama with a brown stole. The prize giving ceremony was held in a grand hall which was well-lighted and packed with people. After all the Video Awards had been presented , which seemed like infinity, my name was announced for the prize.
My heart skipped a beat. I walked on the dais with folded hands and received the prize amidst a roar of clappings. A woman came up to me and said that she was so happy to see me in a traditional Indian dress. It was a matter of pride for all the Indians.
So what has winning the prize meant for me?
It has helped me grow as a person. It has validated my faith in my ability to create value through my writings. The prize sitting on my desk reminds me to look upon myself as a global citizen and aim for loftier goals in life. It has strengthened my resolve to work at an international level, in a multi-cultural environment.
Due to my busy schedule, I hardly get time to visit my parents. They never get to see my (smiling) patients. The picture of me holding an international prize with the president of the ESCRS , Professor David Spalton, is something they hold on to.
They feel happy that all the sacrifices they have made have borne fruit. It gives immense pleasure to my teachers when they see their teachings being echoed in my words and their student achieving great success.
There is no better time to publish and manifest the unlimited potential already within us
Since I won the prize, many of my colleagues have been inspired to write. They have read my essay “Why Should I Publish” and discussed its unconventional style with me. As they say in the movie Kung Fu Panda, there is no secret ingredient…It’s just you!
The process of entering the competition, writing the essay and then winning the John Henahan Prize has been profound and even soul-stirring. It makes you think and study, understand the profession and society and even re-discover yourself.
The journey is thoroughly enjoyable and rewarding in itself. If you win, a prestigious international prize and will add five stars to your résumé. You will love the attention and accolades that come with it. The EuroTimes editorial staff and the staff of ESCRS is full of amazing people. They will go to great length to make you feel comfortable as well as special. Winning the prize will open new doors and mark the beginning of a new journey.
There is no better time to publish and manifest the unlimited potential already within us.
For information and to enter the 2017 John Henahan writing prize for Young Ophthalmologists visit: http://www.escrs.org/lisbon2017/henahan-prize.asp
Streamlining a process eliminates the confusion involved with extraneous tasks and concerns
I couldn’t believe it. An elderly patient who I had seen in the clinic an hour or two earlier was walking into my operating room, a relieved smile on his face. This patient, who I knew to suffer from vascular dementia that led to extreme agitation when he was confronted with stressful situations, was the picture of calm, despite his very recent diagnosis of endophthalmitis. Here he was, about to receive a vitreous tap and intravitreal antibiotics under local anesthesia, and there was nothing about his demeanor to suggest that anything had progressed anything less than perfectly since I had planned his surgery.
We had worked long & hard for this moment. What caught me by surprise when I started working as a full-time university staff ophthalmologist is the amount time and energy that needs to be devoted to coordinating logistical processes.
As a resident and fellow in another institution, I took the organisational aspect of the whole process for granted. That’s the way I’ve always known it, so it must have always been that way. And anyway, I had other things to worry about, like learning how to be an ophthalmologist and a retinal surgeon.
But once I graduated from training, started working elsewhere and inherited another system, I started looking critically at the organization in which I work. Identifying and eliminating inefficiencies became a top priority of mine. This is in part because a more efficient system is a safer system. Streamlining a process eliminates the confusion involved with extraneous tasks and concerns so that the focus can be placed on what’s important. But also because it’s more pleasant for everyone involved.
A more efficient system is a safer system
I have been concentrating on what happens from the moment I plan a surgical procedure to the moment the patient leaves the operating room. A clear, concise, 1-page surgical planning document has, I think, helped everyone involved know what’s going on (What’s the diagnosis? What’s our plan? What do we need to carry it out? Vision blue? ILM blue? Membrane blue?) and how we’re going to achieve it. My colleagues in the planning department have received clarified instructions on how to plan procedures, with unambiguous documents and materials lists for each specific operation.
The nurses in the operating room greatly appreciate this simplification. Everything moves more quickly, despite less effort being expended.
I’ve had a lot of help. My colleague, Thierry Derveaux, returned from his phaco fellowship full of insight into how a well-run and highly professional clinic works, along with the energy and motivation to make it happen. The resident currently rotating through the operating room, Geraldine Accou, is highly organised, well-prepared. As we say in NY, she gets the job done. No procrastination, no forgetting, no nonsense.
Ever since I spent many of my first days in the university hospital working until 7pm, either supervising the clinic or operating, two of my (many) goals have been the following: first, to finish the workday earlier. Second, to see more patients every day. My goals have seemed to many to be mutually exclusive. I disagree.
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium
A cocktail party or wedding is not necessarily the best opportunity to dispense medical advice
“So you’re an eye surgeon?” is a frequent question that we are often asked in social situations. It opens a conversation that is generally quite standard, but occasionally takes an interesting turn.
Usually, the question that follows is, “So why do you still wear glasses? I thought all eye doctors would definitely get their eyes lasered? Do you not trust the procedure? I guess you’ve seen all the ways it can go wrong, huh? Do you think I should get my eyes lasered? I’ve always wanted to get my eyes lasered, because I’m tired of dealing with contact lenses and I don’t look good with glasses. But I’m too scared! I can’t imagine a laser shooting my eyeball while I’m awake. There’s no way I could keep my eyes open for that long. But so many of my friends have had it done, so it can’t be that bad. Who’s a good surgeon? I’d only want the best to treat my eyes. Do you do laser surgery?”
I frequently can’t even get a word in, so I’ll just stand and listen, to see whether this new person delivering this monologue is actually interested in hearing my opinion on refractive laser surgery, which is very positive, or is instead simply interested in discussing it without forming any conclusions. But I don’t find a cocktail party or wedding to necessarily be the best moment to dispense medical advice. And anyway, refractive surgery isn’t my field of expertise.
“I do a different type of laser surgery, a type that I hope you never have to undergo,” I’ll say, referring to retinal lasers in the context of a retinal tear or a vitrectomy for retinal detachment.
PLEASE PASS ME THE WINE
Another route of inquiry involves the details of how eye surgery is performed, which to most people, especially the young, is unbearably grisly. “How do you take the eye out to operate on it? Do you remove it completely, or just pull it out of the patient’s head so that you can get behind it? When you make holes in the eye, how come everything inside doesn’t just leak right out? And how do you see what you’re doing? It’s all so small! What if your hand trembles? Eye surgeons must have really steady hands.”
I tell them that we use microscopes that make the eye look the size of a large dinner plate. Seeing everything is no problem at all. I suppose most eye surgeons were born with reasonably tremor-free fine motor coordination. But tremor also something that simply wanes with experience, confidence and a relaxed state of mind.
The eye fascinates most people, and is right up there with the heart as an organ that captures peoples’ imagination. And yet it remains a mystery for most people, something that they prefer to think about in more abstract terms.
“The eye is a beautiful thing,” I’ll sometimes say to end this line of conversation on an uplifting note. “So, do you have any interesting vacations planned? And can you please pass me the wine?”
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium
Another year is almost over and a new one will soon begin
Wikipaedia defines Ephemerality (from Greek εφήμερος – ephemeros, literally “lasting only one day“[) as the concept of things being transitory, existing only briefly. The term ephemeral is frequently used to describe objects found in nature, although it can describe a wide range of things, including human artifacts intentionally made to last for only a temporary period.
Ephemeral can also be used as an adjective to refer to a fast-deteriorating importance or temporary nature of an object to a person.
William Dean Howells (March 1, 1837 – May 11, 1920) was an American realist novelist, literary critic, and playwright, particularly known for his tenure as editor of The Atlantic Monthly as well as his own prolific writings, including the Christmas story Christmas Every Day, and the novels The Rise of Silas Lapham and A Traveler from Altruria.
His work can be read in The Complete Works of William Dean Howells which includes the following musing: “…I am impatient of the antiquated and ignorant prejudice which classes the magazines as ephemeral. They are ephemeral in form, but in substance they are not ephemeral…”
This was written long before the development of the internet which has completely transformed the nature of magazine publishing. While many of the readers of EuroTimes may keep the printed magazine in their offices for months, even years, they will eventually have to free up space and reluctantly dispose of their back issues.
And one day, they may regret this act when a colleague says: “Did you read the article in EuroTimes which talks about the downturn in LASIK procedures?”. The answer is no because that issue of the magazine has been binned.
But there is redemption. Howard Larkin’s article in December/January EuroTimes points out that global LASIK volume peaked at about 3.8 million procedures in 2007, and has struggled to break 3.6 million since.
In the USA, volume peaked at 1.4 million procedures in 2000, and has bumped along around 600,000 for the last five years, according to Market Scope data presented by Richard L Lindstrom MD at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA.
“We are in a no-growth market globally and in the USA. The question is, why is that?” asked Dr Lindstrom, founder of Minnesota Eye Consultants in Bloomington, Minnesota, USA.
To find out the answer to this question you can read the latest issue of EuroTimes but you can also go online and find the article at http://www.eurotimes.org/lasik-growth.
But you want to research further, so you can then another article from November EuroTimes http://www.eurotimes.org/lasik-studies, which is also written by Howard Larkin.
And the more you surf www.eurotimes.org , the more you will learn about LASIK and patient satisfaction.
Another year is almost over and a new one will soon begin and I wish all of our readers a happy and successful 2017.
* Colin Kerr is Executive Editor of EuroTimes, the award-winning news magazine of the ESCRS.
The great ophthalmologists are like the Arctic explorers and adventurers of old
The great ophthalmologists are not just surgeons. They are like the Arctic explorers and adventurers of old who went boldly where no man or woman had ever gone before.
They had an insatiable thirst for knowledge which laid the benchmark and foundations of modern ophthalmology as we know it.
But let’s digress for a moment.
Some of you old enough to remember may remember the old Buggles hit “Video Killed The Radio Star” which lamented the demise of radio in the new video age.
The song, recorded in 1979, had a catchy chorus with a bittersweet message:
“Video killed the radio star
Video killed the radio star
In my mind and in my car, we can’t rewind we’ve gone too far
Pictures came and broke your heart
Put down the blame on VCR”
As Wikipedia notes, although the origin of music videos dates back to the 1920s, they came into prominence in the 1980s when MTV based their format around the medium
The first pop music video aired on MTV (Music Television) was, yes, “Video Killed The Radio Star” and the rest is pop music history.
So, what about the first ever ophthalmology video? This year, ESCRS launched a new online museum which shows historic videos from some of the great innovators in the field. The videos, which are submitted by ophthalmologists are studied, verified and curated by Dr Richard Packard and Andrzej Grzybowski and date back to the 1930s.
The videos are featured on the ESCRS player at http://player.escrs.org/category/online-muesum
The online museum includes a treasure trove of material including the first LASIK procedure in 1990 by Prof. Ioannis Pallikaris, a video of the logbook from 1949 showing a summary of Sir Harold Ridley’s operations from 1949 and 1950 and a fascinating video from Prof. H.J.M. Weve showing an Intra-Capsular Extraction in late 1930s.
We have lot more material which is being reviewed by our curators and we plan to publish these online in the coming months.
Like all museums we are always on the look out for rare artefacts and maybe some day we will find the first ever ophthalmological video.
We cannot publish every video but we will do our best. All videos that we receive and publish will be fully credited, downloaded by users and the originals returned to their authors.
So submit your videos to email@example.com and maybe some day you too will be standing on the shoulders of giants.
The convention centre at McCormick Place, Chicago
If you’re an ophthalmologist travelling to international conferences, you’ll know all about Chicago.
The convention centre at McCormick Place is hosting the 2016 American Academy of Ophthalmology meeting from October 15 – 18.
The centre is comprised of four state-of-the-art buildings with 11 exhibition halls providing a combined total of 2.6 million square feet of exhibit space and attractsclose to three million visitors annually.
Of course, the centre isn’t just for eye doctors, although over the years it has become a regular host to AAO and ASCRS conferences.
When the AAO moves out of the centre on October 18th, work will begin on getting the centre ready for the American Society of Anesthesiologists annual meeting which takes place from Saturday October 22nd to Wednesday October 26th.
As my colleague Leigh Spielberg once observed, a large conference centre is like the Olympic Village that’s always built in the Olympics’ host city. with a collection of like-minded individuals separated from the rest of the population, separated from friends and family, and the rest of the world.
What makes McCormick Place special is that its on the doorstep of downtown Chicago. Even the best convention centres can become claustrophobic so its a big relief at the end of the day to walk out the doors and rejoin the real world.
And Chicago is as real as it gets. As Doris Day observed in that wonderful musical Calamity Jane, the windy city is mighty pretty, with its towering skyscrapers and wonderful bars, restaurants , shops, museums and art galleries.
The ESCRS/EuroTimes team flys into Chicago on Thursday and once we arrive we’ll keep you posted on everything, or almost everything, that moves inside and outside McCormick Place.
So let’s get in the mood by listening to another great song about Chicago, “My Kind of Town”.
And each time I leave, Chicago is
Tuggin’ my sleeve, Chicago is
The Wrigley building, Chicago is
The union stockyard, Chicago is
One town that won’t let you down
It’s my kind of town
Songwriters: CAHN, SAMMY/VAN HEUSEN, JAMES