Ophthalmology residency has been the most enjoyable, yet demanding, time of my academic career to date. Beyond first-year in-house call, the ever-increasing level of responsibility and expectation is true of many subspecialty rotations. Nowhere, however, did I appreciate the difference between first and second year more than in glaucoma clinic. Beyond attempting to understand what the disease actually is, learning the names of eye drops (or actually cap colors), and trying to interpret optical coherence tomographs and visual field tests, the most trying part of my first-year rotation was mastering applanation and gonioscopy.
Applanation is, in part, similar to attempting to quantify anterior chamber inflammation. One of my general eye clinic attendings described it as “having to attain a Zen state.” Doubt ensued, but reminding myself that every novice resident has undergone a similar struggle helped me to keep pushing forward. I began by spilling fluorescein on my patient's white sweater, followed by embarrassment and profuse apologies. I struggled to overcome the awkward slit-lamp positioning, and the patient sensed my frustration. I nevertheless remained determined and, somehow, eventually achieved the perfect union of crisp green mires. I thought to myself, maybe I can do this.
Gonioscopy was far more foreign. There is nothing natural about floating a multimirrored glass lens, creating perfect coupling with the tear interface, and overcoming total internal reflection to look into someone's angle. I based my approach to gonioscopy on the advice of a different attending. He said, “There is no wrong person to gonio. If at any point during the exam you wonder what the angle looks like, then gonio that person.” Struggle after struggle to overcome one orbicularis muscle contraction after another, I began to make out the angle structures. Comparing what I thought I saw to images online (gonioscopy.org is an amazing resource)—not once but countless times—I realized the progress I was making. Correctly identifying a cyclodialysis cleft and high peripheral anterior synechiae insertion in iridocorneal endothelial syndrome was one of the most memorable experiences of my first year. I thought to myself, I am beginning to enjoy this.
Second-year rotation was far different. Applanation and gonioscopy became second nature, but new challenges arose. I was expected to examine patients with complex diseases and adjust medical treatment regimens. I felt myself starting to develop a feel for when surgical intervention was necessary to preserve vision. I was no longer worried about correctly interpreting a visual field, and I started to become attuned to the many factors affecting my patients' adherence to prescribed medical therapy and follow-up, along with the effect of systemic diseases and medications on their eye disease. I was fortunate to manage patients with aniridia and uveitis-glaucoma-hyphema, Schwartz-Matsuo, and Axelfeld-Rieger syndromes. I thought to myself, I know I can do this.
Now, I look forward to my third-year glaucoma rotation with intense anticipation. I am encouraged by the progress I have made thus far and excited at the prospect of helping patients maintain their vision—and independence—for as long as possible. I know that it will not be easy, but learning to assimilate new information, technical skills, and surgical techniques is all part of the process. I think to myself, I am ready to be an ophthalmologist. n
Section Editor Albert S. Khouri, MD, is an assistant professor and program director of the ophthalmology residency, and he is an associate director of the Glaucoma Division at Rutgers New Jersey Medical School in Newark, New Jersey. Dr. Khouri may be reached at (973) 972-2045; albert.khouri@rutgers.edu.
Anton Kolomeyer, MD, PhD, is a second-year resident in the Department of Ophthalmology, University of Pittsburgh Medical Center. Dr. Kolomeyer may be reached at kolomeyeram@upmc.edu.
