A TINY DARK ROOM

Some diagnoses elevate you, hold you aloft for a moment of wonder, and then drop you like a brick, leaving you flat on the pavement, crushed. I was working in the emergency room when we received a referral from an ophthalmologist: I hereby refer to you Mr Smits with an inferior “ablatio†retinae. That was it. The quotation marks around ablatio caught my interest. Had they been used because the doctor in question found it quaint that our hospital uses the old Latin term for a retinal detachment (RD)? Or was there something else going on? The patient was in his early 40s, fit, wellgroomed, and particularly inquisitive and curious. The left eye saw 20/200 and the right eye 20/20. A quick look through a semi-dilated pupil of the left eye showed a large, bullous RD in the inferonasal quadrant. Macula on. Wait, what? Macula on and 20/200 vision? 'Did you see flashes?' 'Nope.' 'Floaters?' 'Nope.' 'Trauma?' 'Nope.'

The autorefractor showed +2 D hypermetropia OD and 'no target' OS. Not myopic, not syndromic, no family history of RD. Okay, I thought, RDs can happen in hypermetropic eyes. Sometimes. Rarely. But why 'no target'? Why couldn’t the autorefractor refract? Interesting case! I took a closer look at the posterior pole and saw fluid under the fovea. I dropped mydriatics in both eyes, sent him to photography for an OCT. I moved on to the next patient on this busy Friday afternoon. When I continued with Mr Smits, dilated exam showed no tobacco dust in the vitreous. Okay, I thought, that can happen sometimes. But wait, no horseshoe tears either? Okay, a macula-on RD with submacular fluid in a young, hypermetropic eye with no flashes, no floaters, no retinal tears and literally not a single risk factor for detachment. This doesn't make sense. Look closer Spielberg, you must be missing something. Wait, what's that under the retina? I looked at the patient and cleared my throat. 'I'd like to do another test to get some more information,' I said. 'It's an ultrasound, like what the obstetricians use to see a baby in a pregnant woman.' 'Okay,' he replied. 'The more information, the better, right?' 'Right.' Our hospital is highly focused on open communication, transparency and continual, up-to-date information for the patients.

Simply said, the Dutch don't beat around the bush. This is reflected in the hospital's architecture. There are big, wideopen white spaces and few closed doors to be found. The ultrasound room is an exception. Tiny and dark, the room is so small that the ultrasound is behind the patient, who can't see the screen while we're making the images. I love Dutch straightforwardness, but at this moment, I was happy that the patient was still in the dark. I began the imaging. I’m not yet an experienced ultrasonographer, but this pathology was like a goal without a keeper: I couldn't miss. It was huge, this thing under his retina, like a big grey hilltop loosely covered in cloth. 'Look up,†I said. “Down, left, right, straight ahead.' It was visible from every angle. I thought to myself, I've never seen a choroidal melanoma, much less diagnosed one. Or is it maybe just a spontaneous choroidal haemorrhage? Spontaneous choroidal haemorrhage? Does that even exist? Okay, concentrate. Low internal reflectivity, biconvex, homogenous. Obviously a melanoma. Or is it a metastasis? Or a haemorrhage after all? Wishful thinking. While the pictures printed, he asked me, 'Do you have the information you were looking for?' Yes, I thought, I now have more information. But no, this is not the information I really wanted to see. A few moments later, images in hand, we were on our way to the retina department. It is always a nice feeling to be able to consult the senior staff when confronted with serious or rare pathology. The retinal specialist examined the patient and suggested we consult the ocular oncologist. After studying the medical file, the ultrasound images and the fundus, the oncologist said, 'I'd like to get some additional information, so we'll plan a few more tests within the next few days.' “Is it serious?†the patient asked. “That’s unclear at this point. We’ll have to wait until we have the results of all the examinations before we can say anything for sure.â€

Despite the Dutch tradition of upfront disclosure, our hospital believes that a serious diagnosis like ocular melanoma should be conveyed to the patient under the best possible circumstances. We have a special consultation for this. It is run by the ocular oncologist and supported by specially trained nurses and staff who all take the time to explain the nature of the disease, the process of enucleation, the postoperative follow-up and the cosmetic aspects of the prosthesis. The patients are given the contact information of past patients who are willing to share their own stories. Coffee is served. The goal is to soften the impact of the whole ordeal, and it works well. Nevertheless, cancer is cancer, and it's never a joyous occasion. I had arranged to see the patient after this appointment. Two years of residency isn’t long, but it’s long enough for me to have discovered that the doctor who leads a patient into the deep, dark regions of a tragic diagnosis is often the only one who can bring him back to the realm of the living, psychologically speaking. He was taking it relatively well, considering these circumstances, but whether that clear drop under his left eye was gel from the fundus lens or the result of emotion, I didn’t dare to guess. Today was, after all, the first day of the rest of his life. * The patient’s name has been changed to protect his privacy.