All about the eye love you

Not many people know about the eye.
They know about the cataract, heard about the glaucoma and subconjunctival haemorrhage and that is about it. The end point to an eye disease is... well... blindness. And that is about it. Nobody dies from an eye disease, medically.

Even those who are in the medical field, they don't know a lot about eye. Those who think you know, no.... No! You don't know anything! I am in ophthalmology department for *wow!* 4 years and I still don't know all about it. 😭The more I read, the more I feel like I don't know anything at all! Sometimes I feel like leaving the books untouched, just so my confidence won't falter that much... 😐


Ophthalmology is very specialised subject. There are a lot of learning curves that one have to learn and overcome before you can competently confidently walk around the hospital seeing patients, looking like the glorified robot with overhead light. I bring my specialist to sees some cases with me. At times, even my specialists bring senior specialist and consultant in to see a case. That's the beauty of hierarchy that provides a safety net for both the patients and doctors. That, and the fact that the eyes can't see what the brain doesn't know!

When I first joined the ophthalmology department, I struggled with the slit lamp. Trying to understand the mechanics of the optics in the slit lamp is one thing. Porro whatever double prisms. It is another thing trying to not get double visions or squints at the end of the day. I have spent my earlier days of my eye career, just looking at the iris. Just at the velvety smooth brown iris..... Totally mesmerised by it.... Yea, I know you may roll your eyes, but then I would know that you haven't looked at one yet. So I have the last laugh. ✌🏻

I moved onto the fundus examination. I actually squealed with excitement when I can handled that indirect ophthalmoscope, without it landing flat on my nose, AND see the whole view of a dilated fundus. Yes, I went like "YAY! OH WOW!!!! It is so beautiful!" in the busy clinic, in front of my bosses.  I ❤️beautiful things, I ❤️ to see beautiful things, so what...

And then I ventured into removing foreign bodies from cornea. The main bulk of A&E and polyclinic referrals to us. Trying to stabilise my hand while trying to adeptly remove the metal from one's eye while maintaining the grip of that needle (yes, needle to korek it out) while trying NOT to poke one's eye and all the same time having the patient's eye vigorously moving up and down and left and right, looking everywhere in the world except at the spot that I would really like his eyeball to be at, still. I know it is hard to maintain your macho when there is a needle that is coming right at your eye 👀

So, you people out there! WEAR THE FREAKING GOGGLES WHEN YOU ARE AT WORK! WELDING, CUTTING GRASS, NAILING AND WHATEVER!!! WEAR THEM!! You may not know, but I have seen people losing their vision and eyeball because of that... I have had a 30 years old otherwise healthy man, crying in front of me, when told that he may have become blind.  

Just one misfortune is all it need.  

Anyways, digressing... I haven't even start to talk about scrapping for corneal ulcers (ugh!), learning to not squish one's eyeball when checking the intraocular pressure, learning to read the intraocular pressure (IOP), trying to peep through the undilated eyes, doing the gonioscopy (and actually recognising the micro-anatomy is yet another thing), seeing if it is conjunctival injection or is it ciliary flush (😧), slitting the light beam and actually knowing that there are 5 layers of cornea (!!) and you have to  know which layer you are looking at, where the deposits sit, because each layer has their own clinical importance (😲), determining the types and severity of cataract because god forbid you miss a polar cataract or phacodonesis (😨), deciding if it is a cotton wool spots or a drusen or a whitish retinitis patch or is it actually a subretinal exudate because they are all freaking different pathologies which can look freaking the same in an untrained eye (😬), deducing if it's an intraretinal microvascular abnormality (IRMA) or a new leaky vessel or just a normal vessel (😛) and the list goes on. And on. Seriously. These are all just part of a slit lamp examination. I have not included the cranial nerves examination, ptosis, proptosis examinations and blah blah blah else... 😢

You have no idea how many times I have shown a fundus which I diehard thought had a retinopathy, and got this reply "This is a completely normal fundus" 😳 Or when I told a senior that I can't laser that particular patient because of hazy fundus view, only to be replied "This is so clear lah wey!" and he proceeded to laser 1000shots 😑. Therefore since then, I have learnt to tilt my lens to help me view better. This will come, with lots of practise and experience. 

And patient, compassion seniors and specialists to guide us along, no doubt 😍

In ophthalmology, we use a lot of instruments to help us see all the mini micro micro-anatomy things  that our naked eyes can't, that the optics of our eyes cannot possibly allowed. Thus, advancement of technologies, by some very clever people, have helped us overcome those limitations. Now we have Optical Coherence Tomography (OCT) machine to delineate the cross sectional of retina so that we can see in very detail all the 10 layers of retina (yes!! 10 layers!!) and detect all the pathologies of the retina. Each layer has different pathologies and we die die must know how to recognise and differentiate them. We can now even scan the thickness of the optic nerve head and see if it has thinning in any of its quadrants in glaucoma cases. So hebat right, I know! We have modalities (B-scan) to scan the back of the eye in cases of dense cataracts, to see if there is retinal detachment, choroidal pathologies, blah blah blah.... I haven't even talked about the FFA and ICG and other machines that are available in other states but not yet in Sarawak..

So.... not many people really, actually, know about the eye... And when other department people say, "your eye very easy wan ma, right", lagi wanna ask me to 'right' with you ah 😒, I can't help but feeling defensive. Why do you all out there have this idea? I know why. Because all of us were only briefly exposed to ophthalmology during our undergrad time. I had, hmmm a month? maybe, I think, of ophthalmology rotation, some of you maybe only 2 weeks rotation in that 5-6 years of studying. It is no brainer that people think ophthalmology equals conjunctivitis and CMC ointments. 

And oh, DR screeners. 😅 Just as I don't think of endocrinologist equals DM only. 

When you haven't know much about one's field in depth, don't assume. 

This is true that we don't really have a lot of inpatients to take care of. But that doesn't mean that we are 'free'. Take a stroll into our clinic during one of our clinic days... Take a whiff there, see if you pengsan or not.. You can congratulate yourself on your victory if you can find a place to stand and not be in our staff's way. If you can find a place to sit, you deserve a medal already! Eye clinic is our main bulk of our work load. They are those relatively 'stable' people, whom we can place them steadily on slit lamp for proper full eye assessment, and not tumbang over. We are divided into 3 teams now. And everyday there are at least 50-70 (the highest record that I personally seen in a team was 102) patients per team. In a day. These are those patients on follow up and were given appointments prior. And we have one active running clinic that screens and sees all the new cases and those who walk in without appointment. That active clinic sees roughly about 20-40 cases a day. That is just our daily routine warm ups. And I am not  kidding when I say we are one of the 'light-weighted' eye clinics in Malaysia. But that is due to the fact that every month, we have a visiting team that reach out to district hospitals (Lundu, Simunjan, Serian, Sri Aman, Betong) in Sarawak and help to cater to those rural eye patients follow ups. Therefore, our patients are actually all scattered all around. Also, we have one OT running every 1, 3, 5 days, operating 10-16 patients a day. Tuesdays are our GA days while Thursdays are our vitreoretinal surgery days. I have not even mentioned about our Klinik Katarak 1Malaysia (KK1M), a mobile bus service that provide cataract service (yes, including cataract surgeries) to the poor people in the district of Sarawak once a month, throughout the weekends. Medical and surgical cases, you have doctors out there in the district doing all the works for you, and referring only when they can't manage at a district hospital setting. Not us. Precisely because eye is such a specialised field, only eye doctor knows how to see/diagnose/manage those glaucoma, ARMD, VR cases.

So, no... We are not easy or free, like you may have assumed.
Those newly graduate MOs... I hope I have not scared you. 😇

There are many things people don't understand why we, eye team, do things the way we do.

Like asking us to ascertain diabetic retinopathy, on bedside of a very ill patient.... hmmm... it's like me asking you to check a patient without your stethoscopes. Difficult, no? Maybe you can hear the murmur or crackles by placing your ears very, very closely to their chests. Or asking neurosurgeons to tell exactly what is wrong without any CTs or MRIs. Possible? I like my slit lamp, I adore the slit lamp because it helps me to see all sorts of things, in a magnified view. With slit lamp, I can tell you with certainty the DR status. Sure, sometimes we do, do bedside DR screening, but it is not as accurate as seeing the fundus with the slit lamp or fundus camera. If it is a super big haemorrhage or super big lesion, we can obviously see them bedside with our BIO (that robotic overhead light thing that you always see us wear), but small-not-so-angry-looking lesions (IRMA/super fine new vessels) may be missed. And this is not fair to the patients nor us. DR is very delicate, and that's why we frequently ask if patient can sit on wheel chair because we would like to place them on the slit lamp/ in front of the fundus camera for a proper DR fundus examinations. Especially ortho patients, with their Ilizarovs and metal wires hanging around patient's limbs, it feels like performing bedside kungfu, trying to manoeuvre myself skilfully around them, so not to dislocate or fracture their fractures, again. I have developed fear of falling-onto-patients-phobia.

In case of papilloedema screening, yes... That, we can do and detect bedside with the BIO. But when you say the patient is cooperative (for your examinations of lung and heart auscultations), it doesn't mean that the patient is 'cooperative' for eye assessment! Why the hell not? you may asked. When a patient has severe headache due to, let say, IIH (idiopathic intracranial hypertension), do you think she would want to open her eyes and kindly let me shine bright strong lights into her dilated super big eyes? Or guai guai open her eyes and not move for me to check her IOP? Have you seen those IIH patients? They always have their eyes close shut tight with bad ugly wrinkles on their foreheads (okay not important) because they simply can't open their eyes without feeling dizzy or nausea. Some have vomited during my examinations. Some can't even cooperate long enough for a vision check bedside, no matter how hard they tried. Of course, eye will see... definitely.. But do help ease our work and for the patient's sake, relief her of some pain and distress first. I can't help you if she is not cooperative for me. I have had drunk men trying to punch me while I tried to assess their fundus (obviously he was angry right, people wanna mabuk sleep, I beria-ria dilate and see his fundus) and schizophrenic patients kept pushing and pushing me away during IOP checking. Some patients will open their mouths when we come near to check their IOP with the handheld Perkins tonometer and I unabashedly always tell them to close their mouths. 'Buka mata, tutup mulut'. You will be surprised how many people can't even follow that. So, don't be mad and say bad things about me when I documented 'unable to assess as patient not cooperative' just cause when you asked the patient to raise their hands and legs they could obey those simple commands with no problems, but the eye team came and suka2 said 'patients are not cooperative'. Now, you know why.

There are some things that can't be seen with a torch light. Simply cannot wan. Like, you want eye to help see got Kayser-fleischer rings (KF rings) because you want to rule out/diagnose Wilson, but the patient unable to sit up. How la wey... What makes you think I can see it bedside with my torchlight when the copper deposits in the Descent membrane, that is the 4th layer of the cornea? A slit lamp is needed to see that oh... 😅 How to "urgently stat-ly" help you see if got KF rings.. Tell me how?  If a torchlight is all you need to see that, then no eye referral is warranted because you yourself can see it! With your own torchlight! But you can't! And I can't too! So, wait till the patient is stable to sit at slit lamp la ya...👌🏻

I would like to add and say... subconjunctival hemorrhage... will go away on its own in 1-2 weeks without any special treatment. It is benign. You don't really have to refer eye for subconjunctival hemorrhage.. A specialist once asked me, why are we accepting so many subconj hemorrhages? Well, I don't know. 😌 We scare we may get complained if we don't? Most of the time they are idiopathic and if you die die want to find out the cause, I can list a few for you that I know: the patient sneeze too hard or cough too hard or constipate then did a Valsalva then the small capillaries in the conjunctiva burst. Or patient had high BP (that you need to help optimise) or the patient had bleeding tendency (that you need to find out why). If it is a trauma case, then fine, it is warranted to rule out any other sinister causes like globe rupture or posterior extension of the bleed or head fractures. Of course when you refer, we still accept and prescribe some lubricants.

I can humbly say that our eye team has always been quite keen to take on eye referrals. Even if it is partially not indicative. It is as I mentioned, we are all aware that untrained eyes may misdiagnose certain things. Even simple things like cataracts. It is in my opinion, one of the basic things in medicines to see and recognise a cataract. Yet, many times I have received referrals for cataracts which turned out to be posterior pole pathologies (advanced age related macular degeneration, vitreous haemorrhage, retinal vein occlusions, advanced diabetic eye disease, to name a few) with very mild or no cataracts at all. If the patients have no cataract but have very bad vision, why do you refer as cataract? It's okay, life still goes on. We don't stop taking cataract referrals. We take and we manage accordingly. This is a tertiary centre, and this is how it should be.

So then, I would like to ask, when we refer cases to you, even deemed indicated, why aren't you ready to accept ours and help us out? It is not in regards to my patient, or your patient. I am referring A PATIENT. Someone's father or mother or son or daughter or brother or sister, whom we are treating for their eye problem and found to have other concurrent medical/surgical issue too. Even things which deemed simple and basic in your opinion, like high BP or uncontrolled DM or abnormal ECG or low blood sodium or poor renal function or even UTI la, why won't you advise when consulted? You want me to adjust myself the cardiac patient's medications? Tsk tsk tsk.... I have never expected one to help me adjust glaucoma medications, to put it crudely.

It is accurate that all of us had done all 6 rotations. Let's be frank. Once you have left the main stream departments and enter ophthalmology or ENT or skin or rehab or nuclear medicine, you don't really manage/see emergency cases that much. I have forgotten how to fast correct a potassium. Or how to recognise a posterior MI. Or elbow fractures or Monteggio something fractures. I can flip the books, sure! But we work in a tertiary hospital! Why can't the patients get the best medical treatment from the one who knows and can handle and manage the best? Most eye patients are stable ones and my 4-month horsemanship experience are limited for with sepsis or IV adrenaline infusion or ventilator settings or deranged electrolytes.

I would like to remind you that I aspire to be an ophthalmologist, therefore I am here.  I spend many nights reading eye articles/journals, revising ophthalmology textbooks and googling about eye stuffs. I have stopped reading about ECGs and ABGs and ectopic pregnancies and types of rash and types of radius fractures and how to manage status epilepsy, if you care to realise. I do not want to be a physician or surgeon or orthopaedic or anaesthesiologist or paediatrician or radiologist but you do. You do! So, why when referred for a case that is your speciality are you so reluctant to see the patient? It's not like I'm referring myself for my own entertainment purpose. It is a patient in the hospital, for goodness sake. If you don't like to be referred and received calls, then don't be oncall la! If you are oncall and you will want to claim the oncall money, then oncall properly la! Stop pushing your responsibilities and liabilities away! Be professional... Septic unwell patients in other people's ward, go and see and help...

That's why we all need each other in the hospital. Just as we need plumbers and traffic polices and car mechanics and chicken rice uncles in our society. Everyone has their own parts and play their roles. Ophthalmologists don't intubate and anaesthesiologists don't perform C-section. Neurosurgeons don't do phacoemulsifications and obstetricians don't do K-wiring. Paediatricians don't do burr holes and dental surgeons don't scan your baby's gender. Radiologists don't adjust your insulin regime and orthopaedics don't give chemotherapies. Each of us have our own duties and accountabilities. Let's work together harmoniously and synergistically.

Plus, if you love your job, you would be eager to come to see and offer your expertise.

That being said, I have always tried to do some of the examinations (that I can remember to do with my often-forgetful brain) beforehand before I refer other disciplines. I would at least check the vital signs and even auscultate the lungs. I even check throats when necessary. Just so I don't irritate the oncall people that much. 😁 However, there will always be things that I did not examined as it is not part of my daily norm to check and thus quite simply slipped my mind, like checking dorsalis pedis artery pulsation. Therefore the referral, right? To you, the expert. I am lucky to have BFFs that I can ask to see CXR (often 'normal CXR' jerrr.. hehehe...) and CT scans, when I am not sure, to one who is in radio master and ask ENT stuff to another who is in ENT master. It is the ultimate awesomenest to be able to ask silly questions minus the snide remarks.

I would like to clarify that referrals in this context means referrals from MOs to MOs of other departments. If you can't be nice to your fellow colleagues, then.... tsk tsk tsk..  That is totally your choice, I supposed. But be nice, play nice, have some courtesy. You never know when you need their help in return and karma sure likes to bite. 

And some HOs really need SOS help in referring. Please do help them! 😜

Thank you for reading.

p/s: if you gedik2 perasan or terasa I am talking about you, that is your problem.