Ayub Qassim | a1207985 University of Adelaide

Reflection on a self-created surgical elective

The Royal Victorian Eye and Ear Hospital (RVEEH) is one of the largest teaching
hospitals specialising in ophthalmology in the world. It undertakes half of
Victorias public general eye surgeries and up to 90% of special eye surgeries. It
is also a major ophthalmology training centre in Australia.
The ophthalmology elective program at the RVEEH allows interested doctors and
students to attend a busy 24/7 eye and ear emergency department; a variety of
speciality eye clinics; general and subspecialist theatres; imaging and laser
treatment facilities; and weekly tutorials and teaching clinics and meetings.
There is incredible depth to ophthalmology that one does not fully realize at a
general hospital. Attending a specialist eye hospital allowed me to grasp how
detailed and complicated ophthalmology really is. Subspecialties allow the
hospital to run like any other general hospital patients with complicated
ophthalmic issues are treated in a multidisciplinary team of ophthalmologists
from varying areas of expertise. It is not uncommon that a patient with uveitis is
managed by ocular immunologist, a glaucoma specialist, a retinal specialist in
addition to the rheumatologist and general practitioner.
Ophthalmology teachings as a medical student tends to be focused on conditions
relating to systemic conditions, or very common ophthalmic presentations.
Examination techniques taught are generally in context of a neurological
presentation and rarely specific to ophthalmology. The practical aspects, such as
using the slit lamp, are often skills foreign to the average medical student.
This is fairly understandable considering medical school prepares students to
become a general doctor with knowledge spread thin across all specialities. In
the scheme of overall medical problems, eye conditions are often not the
forefront of the patients health. However, this all changes when working at a
specialist eye hospital.
The first week of my elective at the RVEEH was spent almost entirely at the
emergency department. Taking small but steady steps is critical to the somewhat
steep learning curve of ophthalmic examination. There are so many techniques
and tools at the examiners disposal, most requiring a long time to master.
Ophthalmology is a very visual field; the examiner is usually able to see the
pathology and sometimes treat it all under the slit lamp. This makes experience
and a degree of pattern recognition all the more important.
Whenever I worked with a new person, I would often be asked: do you know how
to use the slit lamp and can you do a retinal exam. I always hesitated to say a
confident yes. While I had the theoretical knowledge and the narrow experience
to start me off, there was always a new technique to learn or a skill to improve
on. And this is what makes ophthalmology very rewarding the challenge and
the payoff are very closely held together. Being able to directly visualise the
pathology, grade it and monitor the treatment response is a very satisfying
experience, one that is seldom experienced elsewhere in medicine.

While the initial experience might have been daunting, once one gets hold of the
basics there is a plethora of things to see and do. From common signs of corneal
infiltrates, cells and flare in the anterior chamber, lens opacities and retinal
drusen, to the rarer vortex keratopathy, anterior segment dysgenesis, advanced
diabetic retinopathy and vitreous bleeds of Tersons syndrome. It is then really up
to the keen examiner eliciting, observing and interpreting the signs in putting
everything together and formulating a management plan.
One important and interesting aspect of ophthalmology is how well it ties to the
patients general health and quality of life. Not unfrequently the eye presentation
is a manifestation of an underlying, sometimes occult, systemic disease, making
the ophthalmologist a central piece in the multidisciplinary care of patients. Most
commonly, diabetes mellitus and seronegative spondyloarthropathies present
with ophthalmic complications, sometimes without prior diagnosis. Interestingly,
an ophthalmologist I was working with noted that one patients pupils were
reacting differently to light than to accommodation, a phenomenon known as
light-near disassociation. With keen observation of a subtle sign and a sharp
clinical deduction, she tested and diagnosed neurosyphilis in an otherwise
healthy elderly man. It was very fascinating, and really reinforces the critical role
of ophthalmology in patient care.
At the theatres, I attended some of the most astoundingly precise and skilful
operations I have ever seen. Peeling and dissecting into layers only a few
microns thick under the operation microscope would require immense
concentration and fine motor skills. Many operations are done under local
anaesthetic with sedation and it was most interesting hearing patients insight
and perception during the operation inside their eyes.
Overall, my elective at the RVEEH was an excellent overview into various aspects
of ophthalmology and its impact on patients quality of lives. The patients
recollection of the care they have received and its effects on their lives tells me
the unique privilege it is to care for ones vision. The skillset I have learnt lay a
foundation on which I will continue to build on.
I have gained a unique insight on the care of patients from an angle that is not
always at the centre of attention in everyday medicine. I believe this will make
me a better, more holistic doctor in caring for my patients in the upcoming years,
and I look forward integrating these skills in my practice.