Startling symptoms

Illustration Eoin Coveney Disturbed, I noticed the discomfort one evening after work; numbness, tingling, mild weakness. A little cramping pain. My hand, along the side and down towards my little finger, was not feeling right. What was causing it? Would it progress? I fast-forwarded, seeing myself developing a progressive weakness that limited the function of my hand, affecting my ability to do surgery. Eventually, ending my operating completely. I recalled one of my trainers, Shivona Chetty, had suggested that it was wise to have a non-surgical area of practice as a backup – just in case something unfortunate happened to stop you from operating. Her specialty is oculoplastics, but she also has a non-surgical area of practice, neuro-ophthalmology. I had felt that the issue was unlikely ever to come up, so I had not given it much thought, as I looked around and saw spry ophthalmologists in their 60s keeping up busy surgical practices. So these new symptoms were a little shock. I slept on it, and the next morning my hand felt back to normal. I forgot about the twinges then... Dublin had by now entered a higher tier of lockdown, but I was kept busy, on my glaucoma rotation. It was starting to feel like glaucoma could be straightforward. The patients coming in under the glaucoma umbrella were subject to the same basic questions – how far were they from their target intraocular pressure? Was the angle open or closed, and were there signs of progression or not? The answers to these questions guide the management decisions, and narrow down the suite of treatment options to offer the patient. But this, it turned out, was just the routine work, the everyday sorts of problems. More and more, in the tertiary referral service, there were stickier cases coming in. Aqueous misdirection, persisting with pressures in the 40s, even after pars plana vitrectomy. Complex anterior segment dysgenesis in children, when the risk of vision loss, but also the risk of surgery is high. As well as taking in the decision-making principles in the clinic, and learning about more thorny glaucoma problems, I was getting trained in the surgeries too. Trabeculectomy, I discovered, looks easier than it actually is. Fashioning a scleral flap, not too thin, and certainly not too thick, when you have about 500 microns of tissue to work with is challenging. Scleral flap sutures must be placed at just the right tension – not so tight that there is no flow, but not so loose that the eye will be too soft. And then when you're happy with your scleral flap closure, ready to relax, you still have the conjunctiva left to deal with. Prior to this, I had felt that I knew how to suture. I was happy with my skills honed doing squint and oculoplastics. But I quickly discovered that microscopic suturing was different, as I placed stitch after stitch of 10-0 nylon, more slowly, less smoothly than I would like. This was a skill I had better work at. Alongside the glaucoma in clinic, we also see general patients, including medical retina. One man I met in clinic had a central retinal vein occlusion. I was puzzled about what the aetiology could be. He was a builder in his 40s, and reported being healthy, no medications. He played football and had exercised regularly until recently, when chest pains had stopped him from pushing himself too hard. He said the pains had started in the months after he had been diagnosed with COVID. Investigations had shown signs of myocarditis. Long COVID was something I had vaguely heard about, but my impression had been that it was something like post-traumatic stress disorder. I had never imagined we would be seeing it in the eye clinic. Meanwhile, after my cycle home one evening, my hand developed the unpleasant weak, numb sensation again. I said it to my husband this time. We decided I should try to figure out what was going on, so I looked it up. Quickly scanning the possible causes of my symptoms, I sighed with relief after a few minutes research. One of the top hits was 'Cyclist's Palsy'. I read that gripping handlebars can cause pressure on the ulnar nerve in the wrist, leading to nerve compression. The next morning I paid more attention to my grip on the handlebars, making sure not to over extend my wrists, keeping them in a more neutral position. I realised that the wintry conditions were causing me to grip too tightly as I cycled to and from work in the cold, dark mornings and evenings. My skiing mittens came out of storage. The weakness and tingling have not happened since. I am delighted – you do not realise what you have till it's gone – or maybe till you fear you might be at risk of losing it. Clare Quigley is a resident at the Royal Victoria Eye and Ear Hospital, Dublin, Ireland

Tags: Inside Ophthalmology, training, Young Ophthamologists