Comparison of 2 20G trocar systems

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As I was thinking of a surgery I did, (360 degree retinectomy on a PVR C A-12 with anterior loop contraction). It got me thinking.... again. I emailed a friend of mine, Dr. Jeff Gale, my co-fellow during our UofT/SMH stint as retina fellows, just to have someone sympathize on a really terrible case, and this article came up while I was reading the news letters from the ASRS (American Society of Retina Specialists). I forgot who wrote this (I think it was Dr. Giampaolo Gini an Italian VR surgeon), but it gave me some comfort in the cases we do in our career, things that other colleagues actually take for granted.

The patient, who had light perception vision, is now seeing counting fingers 3 feet, to 20/400 with a +8.00. I think I now have to write up my case series, if only I have the time. :)

A PAUSE FOR REFLECTION

By any standard a vitreo-retinal surgeon’s life is a strange one to most people. Indeed, they are looked upon as peculiar individuals even by other ophthalmic specialists, who many times wonder what drives them to lead such compelling lifestyles - long hours spent on what seem hopeless cases, the willingness to enter the operating room whenever needed, be it day or night, a work day or a holiday.

What makes a retinal surgeon do what they do, instead of dealing with predictable anterior segment procedures or more lucrative refractive surgery? Ask the same question to any vitreoretinal surgeon and chances are you will get the same answer.

It is an endless love for this kind of surgery. Love for the challenge that goes with it and love for the patient. It is about being conscious that there is an enormous difference between restoring sight and having no sight at all. It is about knowing that there is a job to be done that few are willing or capable to do. Finally, it is about faith. An unwavering faith that each procedure performed, each experience gained and shared will ultimately lead us towards perfection. Idealism? Perhaps.

No doubt, vitreoretinal specialists are unique individuals. And as such they can be pretty lonely too. Most times you are likely to be the only surgeon doing retina in your hospital, so it is difficult to share your doubts, fears, plans and enthusiasm with your colleagues. They cannot share these feelings because they have not had these experiences. They have not “been there”.

Thus it makes me feel good to know there are people out there that I can discuss my experiences with. To know these people are friends. To know that as I walk into the operating room each morning these friends are doing the same in so many other parts of the world.

Here we go again, I have a 62 year old female patient who had cataract surgery almost 2 years ago, done by a colleague. So happened that the vision did not improve as it was still counting fingers. When she was referred to me, she presented with a dense vitreous hemorrhage. Scheduled her for a vitrectomy. Intra-operatively, I saw a ruptured retinal macroaneurysm. (One of the common causes of vitreous hemorrhage in the elderly). Vision improved to 20/70. After a few months, she began complaining of distorted vision on the operated eye, with the vision going down to 20/400. Examination reveals the presence of a neovascular AMD developing on the same eye (How unlucky can she get). Advised intra-vitreal Avastin (bevacizumab), vision improved to 20/100 with diminution of the subretinal fluid. On follow-up, the membrane became more pronounced (I think it's a type 2 membrane, well delineated and no PEDs) and Avastin doesn't seem to take effect anymore (after 3 doses). Now, I'm contemplating on submacular surgery. Guarded prognosis for AMD I might say (SST says it is no different from natural course or PDT, though no direct comparison to anti-VEGF treatment)

I've had this blog since 2003, during my fellowship at St. Michael's Hospital, University of Toronto. My first intention was to make this as a personal forum for vitreo-retinal cases that I may encounter during my training as a clinical fellow. As luck would have it, I was too busy even to write my first entry on this blog, that I have, well, forgotten that it existed, until now. So now, I'll probably start to publish some of the cases that I see in my own private practice, so I can keep a record to the things I have been doing since coming back from training on 2004.

It has been a very fruitful endeavor on my part, as I learned a plethora of things during my fellowship. But, things I have really learned are that:

1) I am only a doctor, not a god.
2) I can do my best, but God will do the rest
3) Retina surgery is not carpentry. (Unlike what somebody I know used to say).

I can do retinal detachment surgery in record time, repair seemingly impossible cases of proliferative diabetic traction detachments, do macular hole surgery, peel any membranes imaginable, but still, I am limited by the abilities that was given to me.

I guess as a fellow under the tutelage of such excellent mentors (Drs. Filiberto Altomare, Alan Berger, Louis Giavedoni, and David Wong in alphabetical order), has opened my mind and developed my skill to the point that it will be the basis of my future practice. However, 4 years after, looking back, I still remember those words that reverberated when I was doing surgery with their guidance. Words like:

1) "Your pressing the eye too much"
2) "Are you sure you know what you're doing?"
3) " That's not the way I taught you how to do a vitrectomy."

and the occasional pat in the back words such as:

1) "Excellent membrane peel Natz"
2) "That's the way to laser the retina!"
3) "What? You're finished already?"

Had so much fun then that up to now, I still keep in touch with them, and my co-fellows. Anyways, will be placing more and more things here as time passes by.