OPHTHALMOLOGY AS ART

Like sport, ocular surgery demands mastery of equipment, technique and performance to succeed where others have failed Extreme sports have long interested me as an art form. Videos of out-of-bounds skiing, big-wave surfing, alpine hang-gliding and open-ocean speed sailing have always been able to grab my attention and hold it until the athlete crashed or the video ended, whichever came first. There’s something visually magnificent about a skier flying down a mountain peak through waist-high powder, or a mountain biker soaring through the air between the trees and into the valley below. Just like Quentin Tarantino is a master at exploiting the aesthetic qualities of violence to produce beauty – witness the fantastic samurai sword fights in Kill Bill – extreme sports movie directors take advantage not only of the scenery but also of the fluid movements of the athlete to create a beautiful whole. Recently, I’ve come to recognise the same splendour in ocular surgery. Witness an experienced surgeon reattaching an uncooperative retina or replace an ailing cornea with one of crystalline clarity. This is to behold elegant performance art with a higher purpose than perhaps any other: the restoration of health, happiness and vision to what would otherwise have become a dark and painful life. So if extreme sports and ocular surgery can both be exciting and beautiful, there must be other similarities between the two. Surgery and extreme sports both start with a mastery of basic technique.

The basics form the underpinning of performance and a foundation to fall back on in case of trouble. And the ambitious surgeon/athlete must be willing to enlarge this foundation and go beyond the normal boundaries of standard practice and develop deep knowledge of the many potential pitfalls as well as the ability to get out of unexpected situations with minimal harm to one’s patients – or, in the case of extreme sports, to oneself. Extreme sports might be defined as activities in which there exists a realistic possibility of serious bodily harm. Put an average skier on the top of a black diamond slope and (s)he will likely end up in trouble. This possibility also applies to the complications of surgery. Ask an inexperienced young ophthalmologist to replace a severely diseased cornea with a new one and the patient will likely not fare much better. Of course, surgical risk applies primarily to the patient rather than to the surgeon, but for the practitioner they are to be avoided with equal fervour, for uncontrollable variables abound. Surgical risk factors like high myopia, vitreoretinal traction, anticoagulants and tamsulosin, just like their environmental counterparts – wind, rain, rocks and snow – make the terrain unpredictable, dangerous, interesting… and ultimately worthwhile.

Of course, specialised equipment helps. It builds one’s confidence to get started on a vitrectomy with the newest trocars. Forget about starting a corneal transplantation without a very precise trephine. And who knows where the current developments of the femtosecond laser will lead cataract surgery? But it might well be spectacular. Cutting-edge of athletic performance has attracted people for ages, and great athletics preceded medical progress by thousands of years. While the ancient Greeks were sprinting their way to Olympic glory, their contemporary, the Greek physician Alcmaeon, postulated that the eye contains not only water but also fire. That is very poetic, and our patients with a burning sensation in their eyes might be inclined to agree with him. But reliable restoration of sight would have to wait until modern times. Fortunately, ophthalmology has come a long way since then, and has consequently come to attract some of the best and brightest in medicine and research. Thousands of people have dedicated their lives to the field of ophthalmology, and millions of patients have benefited from their efforts. But in the end, medicine and surgery are solitary pursuits. Only one surgeon has the blade in hand, ready to enter the anterior chamber. The solitary aspect of both extreme sports and ocular surgery can either attract or repel. The thrill of solo success can be counterbalanced by the anxiety of lonely failure. If a suprachoroidal haemorrhage occurs during your procedure, or if your rope fails during a rock-climbing ascent, you’d better know what to do, because you’re all alone at that point. Saving the eye and saving your life boils down to secondnature knowledge and rapid execution of what needs to be done.

In other words, it’s back to the basics. Encouragingly, a big advantage of ocular surgery is that we can practise it far longer than we can practise extreme sports. We can continue beyond the moment at which our knees no longer tolerate icy ski trails, beyond the time when our wrists can no longer take the pounding of bike handlebars on a rutted mountain trail, and beyond the time when we might truly fear that something might go wrong while we are all alone in some distant corner of the Earth. Extreme sports are for the young and agile, while ocular surgery can continue to be performed as long as we’ve got our wits, our vision and our fingertip precision. So, as residents, we can take comfort in the idea that the effort we make now will continue to pay dividends for several decades to come, after we’ve passed the baton of extreme sports to the next generation. If we’re lucky, we can continue working along with a talented and dedicated team of colleagues, anaesthesiologists and nurses who will support our ambitions and will pick us up in the unlikely event that we fall.