Reliving the joy of your first corneal foreign body

March 4, 2016

The euphoria that comes with removing a corneal foreign body never fades. With a nod to Foreigner, whenever I pluck a painful piece of metal from a patient’s eye, “it feels like the first time” every time.

The euphoria that comes with removing a corneal foreign body never fades. With a nod to Foreigner, whenever I pluck a painful piece of metal from a patient’s eye, “it feels like the first time” every time.

Removing a corneal foreign body is an “Androcles and the Lion” moment. Just like the lion that thanked Androcles for removing the thorn from his paw by later saving his life in the Circus Maximus, patients whose pain you relieve immediately are grateful. They don’t usually lick you in the face like the lion did-thanks be to Irv Borish-but you just might score a box of donuts out of the deal.

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My first time

My “first time” was during my residency in ocular disease at VisonAmerica of Nashville in 1990. It was the perfect setup for a newbie: recent metallic foreign with a little rust; temporal cornea of the left eye; ripe for the plucking with my natural right hand. Dr. John Potter, my residency mentor, was supervising me that day.

“Where’s the foreign body spud?” I asked.

“We don’t have any,” he replied. “We use needles around here.”

Gulp. This was long before optometry students stuck each other with sharp objects in procedure classes. I felt like protesting, “A drop is not a needle,” just like ODs used to say, “A lens is not a pill” back in the day. But I knew it wouldn’t do any good.

John explained to me that that with the bevel of the needle away from the patient, the doctor could use the edge to remove the metal with more precision and less epithelial disruption than spuds.

“Just remember,” he lectured, “keep the needle tangential to the cornea. It’s almost impossible to penetrate the cornea without intentionally trying.”

And then he paused for effect. “But anything can happen, so be careful.”

I had the patient close his eyes and brought the needle close to the lashes while spotting outside the slit lamp oculars. Then I had the patient open wide as I looked in and guided it home.

Contact! The puckering of the patient’s endothelium from the pressure (he hadn’t told me about that) caused a little puckering of my own. The faint “snap, snap” from the tip of the needle occasionally snagging Bowman’s membrane startled me (he hadn’t told me about that, either).

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I don’t recall if my hand shook or not. I’d like to think that it didn’t, but I’ve probably blocked that part from my memory. I took out the majority of the metal in a few swipes and then discovered there was more rust there than we first thought. Fire up the Alger brush.

You can tell by the car I drive that I’m no dentist, but that poor patient listening to me drilling out his rust ring wasn’t convinced. Once done, I dutifully cyclopleged, put in a larger-than-needed dollop of antibiotic ointment, and pressure patched with a clump of gauze and tape that spilled over the orbital rim by a good inch.

After the patient was led to his car, I asked John how I did.

“You did fine,” he said. “But next time-breathe.”

 “Remember to breathe.” Those were the first words out of my mouth as I led students and residents over the years through their “first time.” Altering tissue for the better and relieving pain with the deftness of one’s own hands is a rite of passage for those who long to practice the healing arts. It instills confidence and enables one to sit up a straighter with the posture and bearing of a “real” doctor. Watching the smile and extra spring in the step of a student who had just taken out her first corneal foreign body never got old.

Next: Something was off

 

Something was off

But there came a time when my own confidence in performing delicate procedures around the eye began to wane. It was during that period a few years back when my retinas started to go rogue. A vitrectomy had given me a runaway nuclear cataract and myopic shift which produced several diopters of anisometropia.

I tried compensating for my decreased stereopsis with contact lenses and by adjusting the oculars, but something was off a hair. It gave me sympathy for those patients who couldn’t put their nagging symptoms into words.

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My tech would watch through the teaching scope while holding the lid with a cotton-tip applicator and the patient’s head against the headrest. We had a code: whenever I started to miss the mark, he would clear his throat-“Ahem!”

Two cataract surgeries and a scleral buckle later, the induced anisometropia and retinal aniseikonia made me wonder if I’d have to give up procedures for good. I didn’t have to wait long to find out.

Next: Got it

 

Got it

A couple of months after I returned from surgery at UCLA, a burly man walked in wearing a leather biker jacket and chaps and holding a rag against his eye. Yes, he had been sawing aluminum without safety goggles; no, that had not kept him from riding his Harley to the clinic-Roll Tide.

A silvery clump of aluminum was lodged in the anterior corneal stroma at about four o’clock in the left eye. Moment of truth, I thought. With my tech watching wide-eyed through the teaching scope, I dove in. A couple of needle passes later, I flicked out the metal in one piece and held it in magnified view on the tip of the needle, like a scientist examining a rare specimen.

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“Got it,” I whispered under my breath. I looked up and my tech was grinning ear to ear.

No pressure patch this time; just a topical antibiotic and NSAID, plus a pat on the shoulder. Motorcycle man wasn’t content with that. He grabbed my hand and pulled me into a tight bro hug.

For the rest of the day, I sat up a little straighter and had an extra spring in my step. And yes, that song played in my head-“It feels like the first time, it feels like the very first time.”

Because in some respects, it had been.

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