Resident Diary

New Procedures

Clare Quigley

Doing new procedures is fun. I had observed this one many times, either watching through the assistant arm of the microscope, or looking at the screen in theatre. Recently, I had logged in for a webinar on the technical aspects of how to do it. Implanting a stent into the trabecular meshwork, as an adjunct to cataract surgery, seemed like a neat thing to do for patients with glaucoma. In theatre I practiced; after a stent had been implanted, I took the left-over injector, sliding back and forward the guard over the trocar, getting a feel for the grip and the injector button. And then finally, one afternoon there was a suitable patient.

Operating from the temporal side was a little awkward, compared to my default Doing new procedures is fun. superior seat. The operating I had observed this one many times, tables in the cataract unit have a bulky underside, so my left leg either watching through the assistant had to be stretched out straight arm of the microscope, or looking at the and over to the side to reach the microscope pedal. My right screen in theatre. knee was tucked tight against the table, a snug fit at best.

I started. My Consultant Barry Quill scrubbed, ready to swap in if necessary. Phaco finished and lens in, I injected a good fill of viscoelastic. Then the novel steps began. The circulating nurse started to turn the microscope, slowly angling it, and I tilted the patient's head. It seemed to take forever for the microscope to be turned to the right angle, and finally I took the goniolens, pressing just enough to coat its under-surface with the viscoelastic that sat in a blob on the cornea, not so hard as to indent or cause shallowing. Focusing down, the view into the angle sharpened, and its details emerged.

“That's a hypopigmented angle,” Mr Quill observed.

“Yes,” I hesitated, disappointed. What were the chances, on my first trabecular stent surgery?

Gonioscopy is a skill that takes time to learn. At the start, I found it difficult. Among all the different examination techniques that we had to master, in that steep early learning curve, it was tricky. One of my first Consultant trainers, Gerry Fahy, observed me having trouble. He advised me to buy my own gonio-lens, his rationale being that I would be more likely to do gonio regularly for my patients if I had a lens to hand with me all the time. If I was going to stick with ophthalmology as a specialty, I might as well invest in my own lenses, he said. It worked out—I realised that the only way for me to become proficient at gonioscopy was to do it regularly—and with my own lens I never had the excuse to forgo it because there was no lens available in clinic. After years of practice, I could judge angle depth, and pick up other signs. But that was not helping me right now. How was I supposed to implant a stent into a trabecular meshwork that was not pigmented, and was therefore pretty much invisible? “You see that red line? That line is Schlemm's canal,' Mr Quill said. 'You can see that when the eye pressure has been a little lowered. That's your target.” “Oh, perfect,” I sighed in relief. I could see the red band. It did not matter then that the angle was hypo-pigmented. I asked the scrub nurse to open the injector.

Not accustomed to operating under a gonio-lens, it took a moment for me to adjust my perception of angles and correct the trajectory of the injector. I pulled back the guard and exposed the trocar. Advancing right across the chamber, I gently indented the trabecular meshwork. Tip in position, apposed, but not too firmly, I pressed the button—the loud click was palpable—and wispy strands of blood refluxed into view, showing that the implant was in the right place. Conscious that I did not want to waste time and lose my clear view, while blood steadily swirled into the anterior chamber through that first stent, I swung the trocar a few clock hours away—click—the second stent was in.

During this case, and the other cases on the list, we had music playing. For some time, I have been having trouble getting my phone to connect to the cataract units Bluetooth speaker, so lately, instead of Spotify, I bring up a playlist on YouTube on the theatre PC. This is usually fine. Until I pick an innocuous sounding playlist, “easy 90s”, which starts promisingly. Then suddenly the theatre is filled with the noise of “Barbie Girl” by Aqua and I realise I've made a mistake. Mid-phaco I call out to the circulating nurse, and she moves quickly to the computer in the corner of the room, switching for “acoustic 90s”. I resolve to figure out how to get my phone connected to the theatre speaker.