When I first started doing cataract lists, the consultant at the time, a Mr Brown from Carmarthen, used to say that phacoemulsification was more akin to flying a jet fighter for short dangerous bombing runs than a boring long haul flight which was the equivalent of a standard operation. These words have long stuck with me.

Hernia repairs may seem like more work with more potentially life-threatening complications but they are not stressful at all. If there is bleeding you can cauterise it. You can take your time and, as was usual in the days when I did do hernia operations, have long discussions with the boss or the anaesthetist about the political issues of the day as you were doing it. Appendicectomies were also on paper a more stressful operation but in practice I found the learning curve was short and if anything they were tedious rather than electrifying. Tonsillectomies were a bit more exciting due to the potential for bleeding, but there was something inherently stressful about cataract surgery which I detected from the very beginning and which others admitted to but the reason for which I could not easily determine. It was a good thing that my first cataract trainer was so open about this as many others have denied the phenomenon exists at all. 

Perhaps it is due to the fact that a high degree of hand eye coordination is involved and any small deviation is magnified in the glare of the operating microscope and beamed to a gigantic television on the theatre wall for all to see? Under such magnification it is surprisingly easy to come across as an elderly sufferer of Parkinson’s disease while making movements which otherwise would appear highly skilled. Perhaps it is because such tiny movements have such big consequences and the posterior capsule is so mind numbingly thin that the delicacy of the operation causes a high degree of stress? Perhaps it is because of the irreversible nature of the dreaded posterior capsule tear?

In most other operations problems can be solved, the situation returned to how it was previously and the operation completed. This is simply untrue in phacoemulsification surgery as once the posterior capsule ruptures no force on earth or in heaven can undo it, and the fact that the rupture took place will remain in the patient’s eye, the operation note, Eyelogbook and your own mind. Forever. 

Mr Brown, now retired, was correct on multiple levels, I surmised. Now being a consultant myself I was in a position to oversee registrars operate and noticed them have the same sort of difficulties that I had, both in actual operating and in the whole psychology of the operation itself. It is not uncommon for registrars, and consultants too, to have bad runs at operating and though not much is said, the look on their faces speaks volumes about the internal turmoil that is unleashed after a complication such as a capsule tear or a dropped nucleus. The registrars themselves were how I imagined pilots were during the Battle of Britain or in Vietnam. If all went well there was much bravado and tales told loudly and with much grinning of how a small pupil was conquered or a hard cataract was rescued from the jaws of defeat.

Often some British self deprecation is thrown in such as the admission of having caused a corneal abrasion after essentially saving the sight of a vulnerable elderly diabetic who doubtless without that particular level of phaco skill would otherwise have gone entirely blind and died the next day. A friend from Basingstoke calls this phenomenon, rather unflatteringly, ‘dick measuring’ but this is a very poor descriptive term as women are just as guilty as men of doing it.

If you swapped the setting to a steamy South East Asian jungle the stories could just as easily have been about how a bombing raid over a Viet Cong controlled village almost went awry due to the unexpected presence of batteries of anti-air guns but having dropped the explosives successfully all was well even though there were quite a few bullet holes over the tail and left wing that were only noticed afterwards. Likewise, the faces of those shot down over enemy territory tell of jungle horrors and wicked tortures inflicted by communist forces and their colleagues keep a respectful distance and try to talk about anything but the war. There is simply no other specialty that has this strange attitude to operating and within ophthalmology no other operation that has this stress associated with it.

It struck me that there is one group of ophthalmologists that don’t care one jot about the stress of phacoemulsification: vitreoretinal surgeons. After I realised this a bigger realisation came to me; the reason cataract surgery is inherently stressful may be because we cannot fix the ultimate complication and have to call for assistance. What my consultant colleague from Cwm Taf calls the ‘phonecall of doom’ needs to be made in the event of a dropped nucleus. Prior to making this call the caller needs to steel themselves and build up the courage before dialling the fateful numbers. “Forgive me father for I have sinned” we say with trepidation. “What sin have you committed my child?” “I have dropped a nucleus” a trembling voice croaks into the receiver. A sharp intake of breath is heard, followed by “How much did you drop?” Some respite perhaps. “A quarter!” we squeal into the phone, even though we know it was closer to a half. “It was a very tricky case. The trainee started it. The patient moved. Forgive me father I am a sinner in a world of temptation and I throw myself at your mercy and beg your forgiveness.” There might then be a pause as a diary is consulted or an operating list examined, then after what feels like an age but might actually only be three seconds we are told to send the patient over and all will then be well.

For a few weeks after this, copies of letters to the patient’s GP then appear in our pigeon holes with ‘complicated cataract surgery’ as the diagnosis, reminding us of our sins and our human status in a fallen world and how truly beyond redemption we are.

This makes vitreoretinal surgeons our own priesthood with the ability to forgive sin on behalf of the almighty. This is possibly why being cataract surgeons is so stressful. Even with the friendliest vitreoretinal colleagues in the world, the phonecall is still a confession to a terrible crime, or at least feels like it. During wars it is said (I saw it on a Youtube video) that those undertaking the riskiest missions with the greatest chances of being blown up or shot down were likely to be the most religious soldiers of all. If we are all jet fighters undertaking perilous missions as Mr Brown suggested we may therefore need all the priests we can find.

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CONTRIBUTOR
Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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