Decision time

“I'll take the lens please.” Lyndon, the scrub nurse, handed me the lens injector. I was relieved to be at the end of the case; this cataract had been a white marble. The patient was under anaesthetic, as he could not lie still for surgery; his pre-op vision had been reduced to hand movements. His procedure had gone smoothly with the help of vision blue dye and intracameral phenylephrine initially, a good volume of viscoat to protect the endothelium and then a stop and chop approach to the phaco. Throughout, there was a medical student by my side, tracking my every move in the eye. As I watched the lens implant unfold in the bag, my heart sank. There, towards the centre of the optic, was a jagged dark line. A full thickness crack in the lens. “There's a problem,” I exhaled. “The lens has a scratch.” At least the patient was asleep, and he did not have to listen to this. I took the BSS and used it as a pointer, indicating with the cannula tip the irregular scratch visible in the optic, showing it to Lyndon and the medical student. “Ooh, I see it,” said Lyndon. “You'll need the lens cutter, and holder?” “Yes... and a new lens, another twenty-three point five,” Nicola, the circulating nurse, went to fetch the lens and the explantation instruments. Waiting for her to come back, I recalled a recent discussion I'd had with one of my consultant trainers in cornea, Billy Power, on lens explantation. He had talked about a nice approach to improve the safety of removing a lens; make a scaffold. First, fill the eye with plenty of viscoelastic, and dial the lens for explantation up into the anterior chamber. Leave this lens for now. Next, insert your new lens into the bag, directly underneath the old one, which is still in the anterior chamber. At this point you have two lenses in the eye; your lens for removal, but also your new lens that is in the bag now, that will act as a barrier scaffold, keeping the bag distended back and out of the way. You can cut and remove the lens from the anterior chamber, without worry that your scissor could nick the capsule. It sounded like a neat technique. Dialling up the cracked lens into the AC was straightforward – it flopped up out of the bag, and then on top of the iris after I nudged it up and out with a drysdale. Next, I enlarged the wound slightly, and got the fresh lens injector. There was a tense moment while I pushed the plunger, and watched the new lens emerge; it slid in under the damaged lens, into the bag, no problem. Nice clean optic. But now I had two intraocular lenses in the eye, one of which I did not want. Actually cutting and removing the cracked lens was the more awkward task to complete – I held the lens with the forceps, and started cutting with the scissors, but the forceps grip was not strong enough, and the pressure from the scissor blades were causing it to slip away in the anterior chamber. At this point my Consultant trainer Barry Quill, who was watching my movements on the screen, gave me a useful pointer – I could take the Sinskey hook to stabilise the lens from the opposite end. With the hook giving counter-traction, I was able bite down on the lens with the scissors, without it sliding away from me. I was elated when I finally cut through and pulled the slices of the cracked lens from the eye. Between theatres and clinics, we are happy to be back to a more normal pace of work. The country is still in level 5 lockdown, but the Royal Victoria Eye and Ear is a specialist hospital where we look after only eye and ENT problems, and all the staff are now vaccinated. That means we are able to see patients, including routine cases and emergencies. People are presenting with a miscellany of different eye problems in the emergency department, a mix of more serious problems than pre-COVID. That's because the nurses now do a telephone triage of those wanting to come in – to ensure that they really do need to be seen – meaning less blepharitis and dry eye, more traumas and retinal detachments. I see those in the year ahead of me getting ready to leave for fellowship jobs. Next year that will be me, which means I should really start applying soon. I find that it is not such an easy decision, considering the range of excellent specialty options we have in ophthalmology. Some of my colleagues have known from the start – definite VR. Definite paeds... Not me. But decision time is nigh. Clare Quigley is a specialist registrar in Royal Victoria Eye and Ear Hospital, Dublin, Ireland

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