My decision to become an ophthalmologist was the source of the some of the most profound blessings in my life, whilst at the same time being the source of the some of the most profound pain.
By way of explanation I would like to describe my experience with three patients I was involved with during the 21 years I spent working in the field:
It’s Saturday night, just after 11pm. I’m reading in bed but I keep losing my place, and Jonathon Franzens’ The Corrections is too well written to be hypnogogically stumbled over. I reach over and turn out the bedside light, fluff my pillow, and settle down to drift off to sleep.
My mobile phone rings.
I recognize the number immediately: “Hello X. It’s late, what’s up?”
“Hello Dr Leppard. I’m so sorry to bother you on Saturday night, but I’ve been in a fight. I can’t see out of my right eye. What should I do?”
“Oh, that doesn’t sound good. What hit you, how hard, and can you see anything at all?”
“He punched me pretty hard. It’s all black.”
“OK. Where are you, and who’s with you?”
“I’m in Kogarah. I’m by myself.
“Call your mum. Straight away! Get her to pick you up, and I’ll meet you at the Hurstville office in 30 minutes. OK?”
“Yes doctor. Thank you so much . . .”
As I drive to the office that night I recall the day, five years earlier, that I had first met X. He had been on his hands and knees in the middle of the David Jones store in Hurstville, feeling around carefully for something with one hand, his nose just inches from the floor. I had been walking past on my way back to the office from lunch in the food court: chicken laksa. I don’t know what urged me to stop and ask X if he needed help, intuition I guess, or you might call it fate:
“I’m looking for my contact lens. It just popped out of my eye.”
“Keratoconus?” I ask.
X’s head swivels toward me, and he peers, unfocusedly, in my direction: “How did you know?”
“Educated guess. Let me help you.”
It doesn’t take me long to find the rigid gas permeable contact lens; I know what I’m looking for. As X puts the lens into his mouth to clean it, I hold back an objection – his oral bacterial flora are almost certainly less pathogenic than those lurking on the floor of this particular David Jones store. After reinserting the lens and restoring at least a little vision, X stands and shakes my hand. I slip a business card into his shirt pocket:
“You should come and see me. Soon. I think I can help you . . .”
Over the next four years X underwent 6 operations on his eyes, including a corneal transplant to each eye performed 18 months apart. The follow-up visits after corneal grafts are frequent, weekly initially, and, beginning about a year after the initial procedure they include progressive removal of the microscopic sutures used to suture the graft into the circular opening left in the eye when the diseased corneal button has been removed. This process attempts to minimize the post-operative astigmatism.
Within a year of our meeting, X is able to obtain glasses that allow him to start driving for the first time. He is also able to resume studying; he enrolls in a law degree. He has just turned 19.
About 18 months after the second corneal transplant we decide to improve the quality of his vision further with a newly available technology: customized toric iris-clip phakic intraocular lenses. It would take too long to explain what this mouthful means, but within a few weeks of the surgeries X has regained 20/20 vision in both eyes for both distance and near, and he now needs no contact lenses or glasses to achieve this. We are both very pleased. For me it is the most complex eye surgery I have undertaken to date . . .
“Are you going to tell me what the fight was about, X?”
“I’d rather not doctor, if that’s OK.”
“Sure, but I hope it was worth it. The graft has been ruptured along the suture line. It looks like I can salvage it, but only time will tell if, or when, it may fail and need to be totally replaced. Half of your iris has been torn from its root and expelled from your eye as it ruptured. The special lens I inserted is gone too. It’s pretty messy; there’s a lot of blood. Luckily it looks like your natural lens is still intact. I need to clean everything up and re-stitch the graft into place. It's going to take me a while, maybe 90 minutes or so, and I' like to do it under local anaesthetic right now. Would you like me to call the anaesthetist in to give you intravenous sedation?”
“No doctor, go ahead. I trust you completely . . .”
X went on to become a barrister. His right eye regained about 50% vision after the assault: a good result given the severity of the injury he sustained that night. He is now married with two little girls. Unfortunately, only in his mid-30’s, X now faces major challenges with cancer.
I love you dearly X. You are a beautiful man, and I wish you all the best . . .
“Well Y, you’re lucky to be alive.”
“I SAID YOU’RE LUCKY TO BE ALIVE. THAT BUS YOU DIDN’T SEE ON THE KINGSWAY ALMOST FINISHED YOU OFF, DIDN’T IT?”
“I DON’T KNOW WHAT YOU’RE TALKING ABOUT. WHO ARE YOU?”
Y has been delivered to my Miranda office, unexpectedly, by the Police after he walked in front of a bus on a busy road, narrowly avoiding being run down and killed. He has some bruises, including a black-eye, and a few grazes on his face and hands, but otherwise he is intact.
When questioned by police after the incident it is revealed that Y is virtually blind, profoundly deaf, and that he lives alone in a tiny caravan in the local caravan park. They also discover that he has no friends, that he is estranged from his family, and that he has no regular doctor: “ALL DOCTORS ARE CHARLATANS!!"
Y is 98 years old . . .
“Now Y, you have very advanced . . .”
“I SAID, YOU HAVE VERY ADVANCED CATARACTS. IT’S NO WONDER YOU DIDN’T SEE THAT BUS, THE CATARACTS SHOULD HAVE BEEN REMOVED YEARS AGO. YOU ALSO HAVE A BIT OF MACULA DEGENERATION, BUT THAT’S NOT CAUSING TOO MUCH OF A PROBLEM FOR YOU. HOW WOULD YOU FEEL ABOUT ME REMOVING ONE OR BOTH OF THE CATARACTS FOR YOU?”
“NO. BUGGER OFF.”
“You’re a grumpy old bastard, aren’t you?”
“WHAT DID YOU SAY?”
“I SAID COME OUT TO THE WAITING ROOM AND ANNIE WILL MAKE YOU A CUP OF TEA . . .”
After much coaxing, and not inconsiderable effort on the part of my wonderful staff members Annie and Pat, Y had both of his dense, rock-hard cataracts removed. His post-operative visual result was modest—R 6/12, L 6/24, to those of you who know what that means—but the vision he achieved was extremely beneficial. Y received an unexpected burst of life as a result of his newly restored vision.
In the months that followed, again with not insignificant assistance from Annie and Pat, Y sold his caravan, disposed of an illegal firearm (!), moved into a local retirement village, made a few friends, got his first telephone, and reconnected with his daughter and grand-daughter.
I later heard Y had said: “My 99th birthday was the happiest of my whole life.”
A few weeks after his second cataract operation, Y appears unexpectedly at the Miranda office a second time, this time under his own steam. He is smiling, and is carrying a large box.
“I’VE JUST BEEN INTO CHINATOWN ON THE TRAIN, AND I’VE BEEN TO THE CAKESHOP THAT I USED TO VISIT 30 YEARS AGO. IT’S STILL THERE, CAN YOU BELIEVE IT? HERE, THIS IS FOR YOU. I HOPE YOU LIKE LEMON.”
Inside the box is Y’s favorite lemon cream cake, decorated with the words:
ANNIE, THANK YOU. PAT, THANK YOU.
Y died peacefully in his sleep a month short of his 100th birthday . . .
“How was your night, Z? Any pain?” I ask tentatively.
“Not really. Just a little irritation on and off.”
“Oh, that sounds good,” I say, relieved.
I gently remove the eye pad and shield that I had placed over Z’s right eye at the end of her operation the previous afternoon.
I cover her left eye with my right hand, and ask if she can count the three fingers of my left hand I am holding up less than a metre from her face.
“Nothing doctor, it’s all foggy. In fact, it’s quite dark. Should it be like that?”
“Well . . . no, but let me take a closer look here at the slit-lamp and see what’s going on before I say anything more,” a nauseous, sinking feeling settling heavily into the pit of my stomach as I reach over and turn off the overhead lights . . .
I took over an established ophthalmology practice in 1998 from a surgeon who was one of my mentors in my final year of training at Royal Prince Alfred Hospital in Sydney. His health was failing and I was a suitable candidate to fill his shoes. This was a wonderful opportunity for me in terms of my career path, with many years shaved off the usual progression that unfolds after completing the four year post-graduate ophthalmology training program.
The down side of such a decision: inheriting any difficult and challenging long-term management problems, as well as any angry, unhappy patients amongst the former surgeon’s client base. Z fell into the challenging category (she also happens to be one of the nicest, kindest, and strongest human beings that I have ever had the great fortune to meet).
Z was born with a congenital cataract in her right eye, the cataract reducing her vision to around 50% that of a normal seeing eye. Her left eye was highly myopic from birth—a most unusual finding, and given the cataract in the other eye, points to likely intrauterine developmental issues as the cause of both abnormalities—but this was not recognised when she was a child, more attention being given to her cataractous right eye. As a result of not receiving the appropriate optical correction at a young age, Z’s left eye is now densely amblyopic (lazy), and even with her full glasses correction the vision does not improve very much at all: 6/60 with a -6.50D sphere. That's less than 10% vision in this eye. It’s safe to say that Z was not dealt a good hand in the vision department.
About eight years prior to my first meeting with Z, my predecessor had attempted to remove the cataract from her right eye. This operation had gone very badly. A broken lens capsule with vitreous loss meant that the intraocular lens he had inserted at the time of the operation was poorly supported, partially dislocated, and was becoming progressively more mobile. As a result, Z was experiencing more distortion and fluctuation of the vision in her better seeing eye, and her vision wobbled whenever she moved her head or eyes. There was also a lot of debris around the intraocular lens that caused her to see large floaters all the time. Finally, her pupil was fixed and dilated causing her to experience excessive glare, both indoors and outdoors.
Initially I met with Z twice a year and we monitored her symptoms. We would discussed how she was coping with her vision at the level she had, and I would spend time each visit discussing the various surgical options that were available to her to try and improve her vision. After a about three years of this it became obvious that things were deteriorating, and that Z was finding it increasingly difficult to carry out her work as a school guidance counsellor. Z’s husband had died a number of years earlier, and as the mother of three young boys she was the bread-winner of the family; I started the discussion with Z about improving her vision.
I proposed removing the old intraocular lens, clearing away the vitreous and debris from inside the eye, suturing a new intraocular lens to the sclera (the wall of the eye) to support it, and finally, suturing her widely dilated pupil to restore normal pupil size, which would reduce glare. She agreed without hesitation.
The procedure went perfectly. It took over 2 hours—that’s long for an eye operation—and I was on a high afterwards; the same euphoria you might experience after a particularly exhilarating roller-coaster ride. I had employed a number of advanced surgical techniques during the procedure, and I was extremely pleased how it had all come together . . .
“Z, there’s been a wound leak overnight and your eye has lost pressure. I’m so sorry, but I’m going to have to take you straight back to the operating room to re-suture the wound and re-inflate your eye.”
“That doesn’t sound good. Will I be able to see afterwards?”
“I certainly hope so, but right now we just need to get your eyeball inflated again. I’m so sorry . . .”
As the weeks passed into months after the surgery, the situation with Z’s right eye stabilized. The good news: the intraocular lens was nicely centred, stable, free of debris, and her floaters were gone. Z was able to read better than 20/20 on the eye chart with this eye, without glasses. Great!
The bad news: the overnight loss of pressure in the eye had caused the choroid and retina (the internal layers in the back of the eye) to swell and fold. As a result, everything that Z now looked at was wavy and distorted. I knew that over months – or perhaps years – Z’s brain would rewire and adjust for this new challenge, but in the short term it was extremely disorienting for her. The other bad news was that with the overnight deflation of her eyeball, the fine polypropylene suture I had placed in her iris to create a normal sized pupil had torn through the iris tissue. As a result she now essentially had four pupils, a little like a four-leaf clover: one large leaf pointing downward at the bottom of the clover leaf, and three smaller leaves fanning out above it. This unplanned arrangement meant that Z now saw three ghost images around everything that she looked at. Damn! In time this issue was partially corrected with a contact lens painted to obscure the extra iris apertures, but this solution has never been fully successful.
Throughout this period I became progressively more depressed as a result of her ongoing troubles. There were other factors involved in my depression, of course, but this was the biggest one. By late 2002 I was clinically depressed, taking anti-depressant medication (with no effect) and I had considered suicide on a number of occasions. The only solution that kept presenting itself to me – stop seeing Z.
I referred her to a colleague, and admitted defeat. Z, I adore you. I am so sorry . . .
The Enneagram is a wonderful tool I recommend to anyone interested in self-investigation. One of the principles of the Enneagram states that there are three core emotions that human beings do anything to avoid feeling: anger, fear, and shame. As a result of this avoidance we are, unknowingly and paradoxically, slaves to them. Everyone avoids all three of these emotions to some degree, but in any individual one is always predominant. In my case it was clearly shame.
From 2003 onwards, with the mysterious arising of the spiritual urge to know the deeper meaning of my life, I turned the focus of my attention inward and became familiar with self-inquiry as a way of analysing my moment to moment experience. Here I discovered a deep well of worthlessness, unlovability, and shame waiting to be met; emotions that I had run from my whole life.
Upon the realization that this particular emotional avoidance was at the core of all of my unconscious actions, and the indirect cause of all of my suffering, I came to see that in my role as an ophthalmologist my primary concern, though unconscious, was to be seen, appreciated, and admired for the work I was doing for others. Consequently, it was extremely important for me to be very good at my work, which I was, or else my patients would have nothing to appreciate me for.
The very nature of surgery in general, and ophthalmology in particular, however, is that it is impossible to be perfect, and impossible to make everyone happy. Human beings are simply not perfect: we make mistakes, and sometimes unexpected outcomes occur. Year after year I would perform my work as perfectly as I possibly could, but there was always a small percentage of intra-operative complications, as well as a small group of patients who would develop unexpected post-operative complications. Dealing with these complications is extremely challenging for both patient and surgeon alike, and the cause of much angst and heartache. For me they were my worst nightmare.
Then, there was the small group of patients who would have a perfect surgical procedure, have no post-operative complications, and have a perfect outcome on paper, yet they would still be unhappy with their vision and angry with me as a result. Everything that went wrong in their lives from that moment forward became my fault. It wasn’t until years later that I was able to recognise the mechanism of projection, and realise that these angry people were projecting their venom not only onto me, but onto the world in general, all the time; it simply wasn’t personal.
Throughout the course of my 21 years working as an ophthalmologist, I would routinely have 99 out of 100 people give me exuberant praise and thanks for the wonderful results they had achieved from their surgery. Frequently I would hear that I had changed their lives for the better, and I regularly received cards and gifts to show this appreciation. In the early years, however, the only voice I would hear as I drove home from the office at the end of the day was the one disappointed or angry patient that was unhappy with my performance. This would convince me that I just wasn’t good enough, and that I would never be good enough.
Over time, these angry, negative, voices accumulated, and they became a great burden that I carried around with me wherever I went, proving to me, and to the world, that I truly was inadequate, worthless, and forever unlovable. In the years prior to 2003, the way that I dealt with this increasing burden of failure and shame was to get angry myself. Occasionally this anger would be directed back at a patient, but mostly it was directed inappropriately at innocent people in my life, people I loved and cared about. The result: more shame, and more suffering. The other way this burden of negativity was increasingly dealt with in these years was through indulgence in addictive behaviours (see The Shadow) . . .
I consider myself incredibly fortunate that in this lifetime I have found the way out of this spiral of negativity, and rediscovered causeless joy, and true unconditional happiness. This discovery, which occurred through Grace, was powerfully assisted by my wonderful spiritual teachers, and years of dedicated spiritual practice on my part.
Throughout the 10 years of self-inquiry I embarked on to discover the truth of who I am beyond all my mind's definitions, my work as an ophthalmologist continued to confront the unhealed parts of my psyche; there was never a lack of angry, negative patients to provide these triggers. Pleasingly, this heavy burden slowly started to lift from 2003 onwards, and I found that I was able to swim with my head above water more and more of the time. I was actually able to hear the praise, and experience the loving positivity that had been there all around me through every step of this dark journey. More importantly, it became possible for me to feel compassion for the pain being experienced by these same angry patients, and to start to love them unconditionally.
Then, in 2014, after my second cancer diagnosis, it was clear—enough. I no longer needed to be at this coalface where the world continued to push my buttons to find out where I was still vulnerable and unhealed. I was done. Ophthalmology had served its purpose.
Elvis has left the building . . .
January 24th, 2015.
I worked as an ophthalmologist from 1993 - 2014.
See a video of me performing cataract surgery here: