CLIMBING HIGHER

Now that I’m no longer a resident, I have to make the transition to being a vitreoretinal surgery fellow. Residency itself is a transformative experience. A good fellowship builds upon this experience, taking the freshly-minted ophthalmologist from the base camp of general ophthalmic skills and hoisting him or her into more rarefied air. Fellowship mentors are entrusted with guiding their fellows into what might be termed the high-altitude peaks of performance, encouraging them to leave the comfort and safety of base camp behind. 

Or so, it feels to me. “All the serious problems end up at the vitreoretinal surgeon’s doorstep,” said one of my mentors. “And if you can’t solve them, no one can. So, pay attention and make sure you know what you’re doing, because you’re the patients’ last chance. Once you enter the eye with your trocars, there’s no turning back. And beware. Any problems you create… you have to solve them yourself.”
When a nucleus is dropped, the cataract surgeon’s main priority is to clean up as much of the mess as possible, limit the damage and refer the patient to the VR surgeon. The same thing applies to postoperative endophthalmitis and pseudophakic retinal detachment. But a retinal surgeon has to fix whatever goes wrong during or after surgery. On the other hand, a retinal surgeon has the luxury of having more control during a procedure. Missteps can often be fixed. This is due to the varied and versatile instrumentation, continual fluid infusion with oversight of IOP, and diathermy to treat haemorrhage. 

AN UNUSUAL EXPERIENCE
But how does one become a VR surgeon? Fellowship. 
Being a fellow is an unusual experience. A fellow embodies an unusual combination of authority and subordination, ability and inadequacy, knowledge and ignorance, respect for skills previously obtained and the realisation that there’s so much more to learn. The residents with whom I trained find it quite impressive that I’m doing vitrectomies on my own. While they’re worrying about completing their first phaco, I spend my days in the OR doing phaco as simply the first step of a combined procedure for a retinal detachment or macular hole. 

This is a great feeling. On the other hand, a VR fellow spends most of his time with his surgical mentors, who can simply do so much more. ‘How did they get so advanced?’ I often find myself wondering. ‘Are they naturals?’
Although prior ophthalmic surgical experience is a major plus for a VR fellow, it does not all translate into VR success. There are so many variables. 
VR surgery training is also very different from cataract surgery training. Most cataract mentors will scrub into every one of a resident’s first 150 or so phacos, watching every step of every procedure through the microscope. The mentor will be there, offering advice and guiding the trainee through the whole ordeal.

PAY ATTENTION
Why? Because cataract surgery can go very wrong at any moment. This makes it not only worthwhile to pay attention, but also somewhat exciting. On the other hand, watching a VR fellow perform a core vitrectomy is boring. A new fellow operates so slowly that watching the procedure is like watching grass grow: almost nothing happens. So, once a mentor realises that a fellow is competent enough to avoid damaging the lens or the retina with the vitrectome, (s)he will tend to recede into the background to do something useful for the next hour. 

In the heat of the moment, simply remembering the correct order of the steps of a long operation can be difficult. I often find myself asking myself questions like: ‘Is it best to first cauterise the horseshoe tears in a retinal detachment, so I can find them later, or first shave the tractional vitreous so the tear doesn’t enlarge?’ There is no single correct answer, but which will work best for me? 

Once I get through an operation, my attention shifts to tomorrow. Seeing vitreoretinal post-ops early in the fellowship is emotionally crushing, and it has been a difficult part of my fellowship to get used to. An eye often does not look particularly good after VR surgery. Subconjunctival haemorrhage, anterior chamber flare and cells, a bit of hyphema and wild fluctuations in IOP are all common. Patients are generally not in good spirits. 
After phaco, most patients are enthusiastic to have the second eye operated as soon as possible. Not so during the first few weeks after retinal surgery. 
I imagine most fellows have a moment during which they think: ‘Should I continue climbing up into the peaks, or shall I settle for the relative comfort of base camp?’ 

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital, Belgium