Inside Ophthalmology

Startling symptoms

Unexpected pains can lead to serious reflections. Clare Quigley reports

Disturbed, I just the right tension – not so noticed the tight that there is no flow, but discomfort not so loose that the eye will one evening be too soft. And then when after work; you’re happy with your scleral numbness, tingling, mild flap closure, ready to relax, you weakness. A little cramping still have the conjunctiva left to pain. My hand, along the side deal with. Prior to this, I had and down towards my little felt that I knew how to suture. I finger, was not feeling right. was happy with my skills honed What was causing it? Would doing squint and oculoplastics. it progress? I fast-forwarded, But I quickly discovered that seeing myself developing a microscopic suturing was progressive weakness that different, as I placed stitch limited the function of my after stitch of 10-0 nylon, more hand, affecting my ability to slowly, less smoothly than I do surgery. Eventually, ending would like. This was a skill I my operating completely. I had better work at. recalled one of my trainers, Alongside the glaucoma Shivona Chetty, had suggested in clinic, we also see general that it was wise to have a non- patients, including medical surgical area of practice as a retina. One man I met in backup – just in case something clinic had a central retinal vein unfortunate happened to occlusion. I was puzzled about stop you from operating. Her specialty is oculoplastics, but she also has a non-surgical area of practice, neuro-ophthalmology. I had felt that the issue was unlikely ever to come up, so I had not given it much Illustration by Eoin Coveney what the aetiology could be. He was a builder in his 40s, and reported being healthy, no medications. He played football and had exercised regularly until recently, when chest pains had stopped him thought, as I looked around from pushing himself too hard. and saw spry ophthalmologists Dublin had by now entered a higher He said the pains had started in their 60s keeping up busy surgical practices. So these new symptoms were a little shock. I tier of lockdown, but I was kept busy, on my glaucoma rotation. It was in the months after he had been diagnosed with COVID. Investigations had shown slept on it, and the next morning my hand felt back to normal. I forgot about the twinges then... starting to feel like glaucoma could be straightforward. signs of myocarditis. Long COVID was something I had vaguely heard about, but my

Dublin had by now entered impression had been that it was a higher tier of lockdown, but I was kept busy, on my something like post-traumatic stress disorder. I had never glaucoma rotation. It was starting to feel like glaucoma could imagined we would be seeing it in the eye clinic. be straightforward. The patients coming in under the glaucoma Meanwhile, after my cycle home one evening, my hand umbrella were subject to the same basic questions – how far developed the unpleasant weak, numb sensation again. I said were they from their target intraocular pressure? Was the angle it to my husband this time. We decided I should try to figure open or closed, and were there signs of progression or not? The out what was going on, so I looked it up. Quickly scanning the answers to these questions guide the management decisions, possible causes of my symptoms, I sighed with relief after a few and narrow down the suite of treatment options to offer the minutes research. One of the top hits was ‘Cyclist’s Palsy’. I read patient. But this, it turned out, was just the routine work, the that gripping handlebars can cause pressure on the ulnar nerve everyday sorts of problems. More and more, in the tertiary in the wrist, leading to nerve compression. The next morning I referral service, there were stickier cases coming in. Aqueous paid more attention to my grip on the handlebars, making sure misdirection, persisting with pressures in the 40s, even after not to over extend my wrists, keeping them in a more neutral pars plana vitrectomy. Complex anterior segment dysgenesis in position. I realised that the wintry conditions were causing me children, when the risk of vision loss, but also the risk of surgery to grip too tightly as I cycled to and from work in the cold, dark is high. As well as taking in the decision-making principles in mornings and evenings. My skiing mittens came out of storage. the clinic, and learning about more thorny glaucoma problems, The weakness and tingling have not happened since. I am I was getting trained in the surgeries too. delighted – you do not realise what you have till it’s gone – or

Trabeculectomy, I discovered, looks easier than it actually maybe till you fear you might be at risk of losing it. is. Fashioning a scleral flap, not too thin, and certainly not too thick, when you have about 500 microns of tissue to work Clare Quigley is a resident at the Royal Victoria Eye and Ear with is challenging. Scleral flap sutures must be placed at Hospital, Dublin, Ireland