Inside Ophthalmology

Decision time

Dealing with the here and now and looking to the future. Dr Clare Quigley reports

I'll take the lens please.” Lyndon, the scrub nurse, handed me the lens injector. I nudged it up and out with a drysdale. Next, I enlarged the wound slightly, and got the fresh lens injector. There was a tense moment while I was relieved to be at the I pushed the plunger, and end of the case; this cataract watched the new lens emerge; had been a white marble. The it slid in under the damaged patient was under anaesthetic, lens, into the bag, no problem. as he could not lie still for Nice clean optic. But now I surgery; his pre-op vision had two intraocular lenses in had been reduced to hand the eye, one of which I did movements. His procedure not want. had gone smoothly with the Actually cutting and help of vision blue dye and removing the cracked lens intracameral phenylephrine was the more awkward task initially, a good volume to complete – I held the lens of viscoat to protect the with the forceps, and started endothelium and then a stop cutting with the scissors, and chop approach to the but the forceps grip was phaco. Throughout, there was not strong enough, and the a medical student by my side, pressure from the scissor tracking my every move in blades were causing it to slip the eye. As I watched the lens implant unfold in the bag, my heart sank. There, towards the centre of the optic, was a jagged dark line. A full thickness crack in the lens. “There's a problem,” Illustration by Eoin Coveney away in the anterior chamber. At this point my Consultant trainer Barry Quill, who was watching my movements on the screen, gave me a useful pointer – I could take the Sinskey hook to stabilise the lens from the opposite I exhaled. “The lens has a scratch.” At least the patient “There's a problem,” I exhaled. end. With the hook giving counter-traction, I was able was asleep, and he did not “The lens has a scratch.” At least the bite down on the lens with have to listen to this. I took the BSS and used it as a pointer, indicating with the patient was asleep, and he did not have to listen to this the scissors, without it sliding away from me. I was elated when I finally cut through cannula tip the irregular and pulled the slices of the scratch visible in the optic, cracked lens from the eye. showing it to Lyndon and the medical student. Between theatres and clinics, we are happy to be back to

“Ooh, I see it,” said Lyndon. “You'll need the lens cutter, a more normal pace of work. The country is still in level 5 and holder?” lockdown, but the Royal Victoria Eye and Ear is a specialist

“Yes... and a new lens, another twenty-three point five,” hospital where we look after only eye and ENT problems, and Nicola, the circulating nurse, went to fetch the lens and the all the staff are now vaccinated. That means we are able to see explantation instruments. patients, including routine cases and emergencies. People are

Waiting for her to come back, I recalled a recent discussion presenting with a miscellany of different eye problems in the I'd had with one of my Consultant trainers in cornea, Billy emergency department, a mix of more serious problems than Power, on lens explantation. He had talked about a nice pre-COVID. That's because the nurses now do a telephone approach to improve the safety of removing a lens; make a triage of those wanting to come in – to ensure that they really scaffold. First, fill the eye with plenty of viscoelastic, and dial do need to be seen – meaning less blepharitis and dry eye, the lens for explantation up into the anterior chamber. Leave more traumas and retinal detachments. this lens for now. Next, insert your new lens into the bag, I see those in the year ahead of me getting ready to leave directly underneath the old one, which is still in the anterior for fellowship jobs. Next year that will be me, which means chamber. At this point you have two lenses in the eye; your I should really start applying soon. I find that it is not such lens for removal, but also your new lens that is in the bag now, an easy decision, considering the range of excellent specialty that will act as a barrier scaffold, keeping the bag distended options we have in ophthalmology. Some of my colleagues back and out of the way. You can cut and remove the lens from have known from the start – definite VR. Definite paeds... the anterior chamber, without worry that your scissor could Not me. But decision time is nigh. nick the capsule. It sounded like a neat technique.

Dialling up the cracked lens into the AC was straightforward Clare Quigley is a resident at the Royal Victoria Eye and Ear – it flopped up out of the bag, and then on top of the iris after Hospital, Dublin, Ireland EUROTIMES | MAY 2021