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Second opinion helps make better surgeons

A trainee can see what the trainer misses, writes Leigh Spielberg

Leigh Spielberg

Posted: Tuesday, December 6, 2016

Leigh Spielberg

 

“So, Dr Spielberg, did you see the lesion?” asked Jean-Baptiste Willemot 
after I had examined his patient.
“No, actually. I didn’t notice anything unusual,” I answered. I had taken my time and had performed a thorough fundus examination, but I had seen nothing out of the ordinary. Jean-Baptiste always performs a very thorough and deliberate retinal examination. Like most first-year residents, he doesn’t want to miss anything, not even in the extreme periphery of the retina, especially when he knows I’ll be double-checking the patient afterwards.
“That little pigmented lesion at 6 o’clock?…” he asked, with an insistent tone in his voice, suggesting that he would prefer me to look once again, just to be certain.
I knew for sure that there was nothing of importance to be seen. The rest of the fundus was normal, there was no tobacco dust in the vitreous, no haemorrhage, no subretinal fluid, no schisis.
But I was curious to find out what he might have seen. I was also interested in helping him learn the difference between clinically significant and insignificant findings. He stood in my doorway with his new shiny blue fundus lens in his hand.

FANCY EQUIIPMENT
“Let me take a look with that blue diamond,” I said, teasing him a bit for having such fancy equipment. I put down my SuperField lens, and he handed me his Volk Digital Wide Field as I summoned the patient from the waiting room.
Once the patient had settled into position behind the slit lamp, I asked him to “Please look down as far as possible”, while I looked for anything abnormal. I caught a glimpse of an unusually large ora bay that I had missed with my SuperField.
Jean-Baptiste had been correct in noticing the physiologic abnormality. Fortunately, I had also been correct in not having missed anything that required treatment, follow-up, or even documentation in the patient’s file.
This experience mirrored one that I had had several weeks earlier. My colleague and one of my vitreoretinal surgery mentors, Fanny Nerinckx, had been speaking highly of the Volk High Resolution Wide Field lens that she had purchased at the last international conference.
“The wide-angle view is just like the SuperQuad, but without the distortion. And it’s tiny, so you never have the problem of fitting it under someone’s brow.”
I wondered whether it was time to upgrade my own lens set. I hadn’t previously given much thought to my lenses. What’s funny is that I obsessively research other, arguably less important, purchases ahead of time. I’ve spent whole evenings online looking for a perfect pair of skis, a rugged new mountain bike, top-notch open-back headphones, and a sharp camera lens to capture it all for later… But fundus lenses? No.
I decided then to approach the topic like I research my leisure-time toys. After all, I spend more time with my lenses than with my outdoor gear and electronics, so I might as well select what I think is best. The High Resolution Wide Field: no-distortion, with a 165° dynamic view of the periphery despite a tiny profile. Excellent.
As for the Digital Wide Field: it increases the field of view at the same dioptre power as the 90D, which enables me to see more anatomy in one glimpse. This allows the exam to proceed more quickly while reaching out into the periphery.
What I had been thinking about a lot was my examination technique. “Wow, you’re really making it difficult on yourself,” Marc Veckeneer had said to me recently, while I performed an exam in a room with the blinds open. The patient had a highly atypical, bilateral foveoschisis. I hadn’t expected Dr Veckeneer, a consultant in my university hospital, an expert diagnostician, and my other vitreoretinal mentor, to require such a strictly controlled environment in which to work.
So, a year after the completion of my vitreoretinal surgery fellowship, I felt I had to step it up. It seems we have the tendency to stick to what we’re used to.
After having done my research, I obtained the two lenses at the EURETINA/ESCRS Congresses in Copenhagen and have been using them ever since. The Wide Field lens instantly became my go-to lens for examination of the periphery, particularly for an overview of retinal detachments or when I suspect a retinal tear.
The Digital Wide Field has also replaced my SuperField. It not only has a wider field of view, but it also produces a higher quality image. The image quality is comparable to the difference between regular and high-definition TV.
So, now that I’ve got these two wide-angle lenses, what’s next? I’ll soon test the Digital High-Mag, which I suspect will sharpen my view of the posterior pole. I would hate to miss something that a trainee might see!
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium. leigh.spielberg@gmail.com