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One of the highlights of the medical retina fellowship programme at Moorfields is the Tuesday morning 8am fluorescein round. It is both exhilarating and terrifying. Exhilarating because they are slick presentations of the most interesting cases that each of the retinal consultants have spent weeks selecting and working up for the most perfect images. Terrifying, because the modus operandi of the meeting is getting a hapless fellow to describe the images whilst slowly building up towards the diagnosis through various trial and error wrong paths that can either be gently humorous or openly humiliating.

The selection of the fellow to be grilled is by the movement of a laser pointer passed hand to hand around the room. The terror can be so great as to prevent some fellows from attending the meeting lest the ‘pointer of doom’ be handed to them, resulting in potential group humiliation in front of all their colleagues. Not attending such an interesting and informative meeting would be such a great sorrow that I here present handy tips on how to survive these meetings, as well as all such similar ones that take place in eye departments up and down the country on a weekly basis.

Tip 1: Go first. The easy ‘warm up’ cases tend to be first so biting the bullet and volunteering for the pointer early on can prevent you being landed with the rarest case in all Christendom later on. There is nothing worse than seeing your colleagues eloquently describe type 2 choroidal neovascular membranes and central serous chorioretinopathy for you to be lumbered with a picture of a fundus so unusually abnormal as to cause you to develop a supraventricular tachycardia. The pointer belongs to Professor Bird so situating yourself as closely as possible to the Great Man without arousing suspicion will result in an early case.

Tip 2: Avoid the pointer. Another strategy is to attend the meeting but avoid being handed the pointer of doom so you get the education value without the terror. Openly refusing the pointer or passing it on without presenting has to be discounted immediately. Fellows when not presenting are acutely aware of the position of the pointer in the room, almost like a sixth sense, and anyone doing this will forever be branded as cowards and traitors. No, the best way is to avoid the pointer through situating yourself in the optimum place in the room. There are several strategies that can be employed to achieve this.

Tip 3: Sit behind a group of North Americans. Fellows from the US and Canada by and large are knowledgeable, confident and love the pointer. They can talk and cite papers and choosing a seat behind them will enable you to sit back, relax and enjoy the meeting safe in the knowledge that it will run out of time before the great gushing forth of information taking place before you will cease.

Tip 4: Avoid the Greeks. As a general rule Greek fellows hate the pointer and tend to congregate in a group towards the back of the lecture theatre. This is almost like a Roman testudo where the shields of their soldiers act as one to deflect all assaults. The pointer tends to pass around the edges of any Greek accumulations and never penetrates it so sitting next to such a group can lead to disaster. It is also impossible to position yourself inside a group of Greeks without being one as doing so will cause a movement around you resulting in reformation of the group elsewhere and you will find yourself excluded.

Tip 5: Sit amongst the consultants. The passage of the laser pointer around the room is a fascinating phenomenon that is worthy of further study. Through a year of attending the fluorescein round I have realised that the pointer is passed from a fellow, usually relieved after finishing their turn at the questions, to another in the immediate vicinity an arms length or less away. It can go lengthways down the isles or backwards (rarely forwards) and doesn’t tend to go down any dead ends. So if you sit more than a chair width away from any other fellows safely surrounded by a protective coat of consultants you will be pointer free till the end of the meeting. If there are many fellows present the pointer movement can otherwise resemble a game of Q*bert.

Tip 6: Watch out for the obligatory normal picture. Once or twice in every round a fellow is presented with a normal picture. Usually it is because the other eye is the affected one but the desired effect, usually achieved, is to create a sense of panic in the unlucky presenter causing all kinds of normal features and artefacts to be described as pathology. If the picture looks normal a good tactic is to stay quiet and nod your head knowledgably with a wry grin. Even if it turns out there was pathology after all you can adapt your grin into a ‘I knew about the pathology all along’ grin, as the two grins are in fact quite similar.

Tip 7: Acute macular neuroretinopathy (AMN). Every single fluorescein round since the dawn of time has included a patient with this diagnosis. If you think for even a second that AMN is a possibility, you can sit back and relax. Even if it isn’t AMN, suggesting it might be is always respected in the fluorescein round. Much like Father Ted’s ‘that would be an ecumenical matter’ as a means of answering any poorly understood theological question. If saying AMN in a knowledgeable and all-knowing manner is not enough to win admiration, a good alternative is paracentral acute middle maculopathy (PAMM). Nobody ever scoffed at PAMM.

Whilst the meeting can indeed be terrifying it is undoubtedly the most useful part of undertaking a medical retina fellowship. I have seen people humiliated, always at their own hand, which vastly increases the effect, and been humiliated myself. But I have learnt much, and not all of it medical retina. There is honour in taking a chance and speaking up. There is dishonour in refusing the pointer. People respect those trying and getting it wrong much more than those who avoid their share of responsibility in the drama of the fluorescein round. A long serving Moorfields colleague remarked over lunch that people’s behaviour in that meeting was representative of what kind of consultants they turned out to be. It was a microcosm of the earthly trials of life, the book of Job condensed into a weekly hour. So I suggest a seat next to Prof Bird, a look of enthusiastic derring-do on your face and a diagnosis of either AMN or PAMM at the tip of your tongue, and you’re already more than half way towards fluorescein based success.

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CONTRIBUTOR
Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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