There are these things in Ophthalmology that are the bane of my existence.
They are called retinal tears.
Can I please tell you about how they haunt me and torture me?
So, the way our residency program works is that for the first 4 months, all 4 of us first years work in our ER eye clinic. It’s an urgent clinic, so anyone with an acute eye complaint can be seen.
The clinic is run by the first years, and then staffed by the chief residents and consultants.
So basically, anything can walk in the door and we get to see it first, diagnose it, and make a plan to treat it.
I’ve seen tons of run-of-the-mill things like corneal abrasions, foreign bodies, conjunctivitis, episcleritis, dry eye, HSV and shingles.
I’ve also seen lots of not-so-run-of-the-mill things like perforating corneal ulcers, endophthalmitis, uveitis, hyphemas, end stage glaucoma, diabetic retinopathy, and more.
The clinic is so amazing because I get to see all these things and learn how the present, how to diagnose them, and how to treat them. The patients are my patients so if they need daily follow-up, I will see them every day. I love the autonomy I get in clinic and how much I learn from seeing so many patients every day.
One of the most common symptoms that brings patients into the clinic is “flashes and floaters.” Meaning, they are seeing flashing lights and/or new floaters in their vision.
The biggest thing to rule out when someone comes in with flashes and floaters is a retinal tear. The retina is like a little piece of tissue paper along the back of the eye. When the jelly that fills the eye shrinks and separates away from the retina with age (which happens in about 60% of the population as we age) it can tug on the retina hard enough to put a little tear in it. If that happens, the tear can progress to a full retinal detachment, which is visually threatening and requires an extensive surgery and LONG recovery period to fix. So if someone has a tear, you want to find it before it becomes a detachment.
In order to find a tear, you basically scour the retina with a thin little beam of light until you see something like a ripped piece of tissue paper flapping around. Once you find the tear (which could be anywhere) you can laser it so that it will scar down and not extend into a full detachment.
But here is the problem: Lots of times, there isn’t a tear.
And for me, in these past 4 months, I haven’t seen one single tear.
My co-residents have all seen 10+ tears and are even lasering their own tears now.
But me? Oh I’m just chilling over here in no tear land and I’ve never even seen one!!
Here is how this works:
A patient comes in with flashes and floaters. I see their chief complaint and I think, “Yay! It’s going to be my first tear! I will find it and see it and it will be great.”
Then I take the patient into my exam room and look at every nook and cranny of their retina and don’t find a tear.
I go get a chief resident or a consultant to re-check and they look at every nook and cranny of the retina too. They say, “well, no tear!” And I send my happy patient on their way.
Meanwhile, I am dying on the inside. The fact that I still haven’t seen a tear, now 4 months into residency is practically statistically impossible. For every 10 patients with new floaters and an acute PVD or posterior vitreous detachment (meaning the jelly separated from the retina) there should be one tear. I have seen close to 30 PVDs and not a single tear.
My lack of tear-seeing has now turned into a complex for me. I have so many self doubts and worries because I haven’t seen a tear. It’s hard not to think that I am somehow missing them, and I’m just not capable of finding one of my own. Every time I start to do a posterior exam in someone who I think might have a tear, I get overwhelmed with anxiety. Will this be my first tear? It’s agonizing!
I’m writing about this now because tomorrow is our last day in the emergency clinic. Starting next week we all go our separate ways to subspecialty rotations. I am headed to oculoplastics, so my likelihood of finding a tear there is basically zero.
I know the day will come when I will see a tear, but I just wish it would come NOW!
Have you ever waited for something monumental to happen to you at work? Did you ever have to wait longer than your peers?