Details have been changed to preserve patient anonymity.
“The neighbours were arguing,” he explained. “Stupid fight. I was trying to calm things down.”
“Right,” I said. “What happened?”
“A bowl, one of them threw a bowl….” He lapsed into silence. His seeing eye was looking off and away, recalling.
I imagined it too. My patient had been the good Samaritan, stepping in to cool heated tempers and talk some sense between quarrelling neighbours. I had read the triage nurse’s notes, but I wanted to hear the story in his own words.
“A piece flew?”
He nodded, indicating with his finger jabbing towards his traumatised eye, the trajectory of the shard that had hit him.
“You’ve had a very severe injury,” I started.
“At the moment, you cannot see anything; you’ve lost the vision in the eye.” I continued, talking about surgery. I explained that at this stage his eye was open, leaking. We wanted to reduce the risk of any infection getting in, as if that happened, he could lose the eye altogether. Primary repair was the first procedure he needed, involving stitches to seal the eye. He would need further surgery down the line, as there was a high likelihood intraocular structures had been disrupted—the retina being our biggest fear.
He shook his head, signing the consent form.
Within a few hours, he was on the table asleep, and I was operating. My Consultant, Professor Lorraine Cassidy, scrubbed to assist and advise when it emerged that the perf went far posteriorly. I had to take off the lateral rectus to even start to visualise the scleral laceration. Hooking and taking off the muscle (with care so my hook did not go right into the eye), I was thankful for my squint surgery training. With the muscle off and out of the way, we could finally see the tear. Unfortunately, it extended back past the equator of the globe. In this position, placing sutures was very awkward; as I went further and further back, the pressure we could put on the eye reached a maximum—it was not possible to displace it further to reveal the end of the lac. Already we had seen a little spurt of clear fluid—liquefied vitreous—coming out. After some gentle cryotherapy, I put the muscle back on and closed the conjunctiva.
Some weeks later, he still comes back to clinic, with hand-motions vision. Serial B scan ultrasounds reveal a retina still in position, though it is not visible behind dense sheets of vitreous haemorrhage. We liaise with the vitreo-retina team and hope that he improves.
That patient had been unlucky. What were the chances, of all the possible flight paths the shard could have taken—it had to rip a tear in his sclera?
But I see lucky patients too.
“Remind us of what happened,” I asked recently, for the benefit of the Oculoplastics fellow and Senior House Officer, who had not heard the story. Georgios, Mehera, and I were gathered in the theatre for this man’s surgery.
“Well, I was in the parlour—”
“The milking parlour,” I interjected. This injury had not happened in an elegantly turned-out reception room.
“Yes, the milking parlour”, our patient, a dairy farmer, agreed. “So, in the parlour, hooks hang from above, from the ceiling. They’re used to hang equipment for milking. That day, the day it happened, I was a little distracted. Busy you know, under pressure. I turned, ’course forgetting there was an empty hook right there behind me.”
He paused, like that explained what had happened.
“And the hook?”
“Yes well,” he continued, “the upturned end of the hook just caught me, slid right in under my eyelid, against the eye. And I pulled back straight away when I felt it…”
I remembered seeing him later that day on call. Lid lacerations are not uncommon, but this one was more dramatic than the others I had seen. The upper lid was torn in half, hanging down in a curved line that extended from the medial canthus up and out. When he blinked, the lid flapped about freely. I knew the levator had been at least partially transected and hoped he did not have an ocular injury behind it.
That evening on call, I had done a primary repair of the eyelid, closing the lid margin and suturing the skin, but without dissecting out and re-attaching levator.
Now he was back, a few months later, for an exploration and advancement of his levator to treat his ptosis. His eye itself was perfect.
“I was unlucky, but I suppose I was lucky,” the patient conceded, at the conclusion of his story. We agreed with him, reassuring him that he was lucky overall to be coming back for a ptosis repair. There are worse things.