Within the first week of Optometry school in Southern California, we walked as a class down the hall to a large laboratory set up up with 10 black exam chairs, phoropters and biomicroscopes. Each of these were arranged as separate exam stations, separated by curtains. We spent many days, nights, weeks and months in this dark room, taking turns being doctor and patient, learning to measure vision and see inside the eye. It was 1992 before the first pop-up restaurant or makeshift hospitals like we are seeing for COVID-19.
The biomicroscope is by far my favorite piece of eye equipment. It allows you to see the front and back surfaces of the eye in rich color with different lights and magnification. It sits on a table that slides in front of the patient and aligns their eyes with yours. As you peer inside, it feels as if you are landing on the moon or the bottom of the sea.
The first recognizable landmark is the iris, the colored part of your eye that surrounds your pupil, which just a big black hole. You drop immediately into craggy views, webby tissues, and almost volcanic or coral looking types of creation. The terrain of each iris is like a fingerprint, only 3D and never touched. You hold your breathe a little, because you are very close to your patient and it is an awesome sight. Short of a runaway blood vessel or a mineral deposit, there is lots to see in the iris but little that is clinically relevant.
The most important part of the front of the eye is the cornea. It is the clear dome front of the eyeball where you might place a contact lens. It is completely transparent which is good because otherwise you could not see clearly out of it. You know you are looking at the cornea when you swing your microscope light at a side angle to illuminate it’s nothingness. It looks like…Nothing. This was so frustrating to me. How do I know I am seeing the nothing when I see nothing? Everyone clucked their “ooh’s” and “aah’s”, and I did as well, but I could not for the life of me see the damn thing.
“It’s okay, just click up the magnification”, said my patient partner. It’s always great when your patient knows more than you. I click the magnification up. The sounds are how I knew I was getting close but all the clicking and clucking around me made me feel like a fraud. I was convinced that this first surface where light bends to enter the eye, travel the optic nerve, and create the miracle of vision was lost on me. Nothing there usually also means nothing is wrong for the patient but it did not feel right to me.
Pretty much the only time you can see something in the cornea is when there is a problem: a scratch, a fog, a degeneration. It was exciting when we could finally see some pathology so we knew we were focused on the right tissue but it also meant the patient was in pain, blurry and maybe even going blind. I much prefer the artistic view of the iris to the pathology that most doctors live to treat (I am thankful they do, as well).
Years later, as a Counselor, you would think I see less visual problems and solutions, but I actually see them more than ever. The same terms I learned then also apply now. I see and hear patients as they discover their unique and deep awareness, like their stunning iris, and their shifts in perspective, however invisible at first. It is a joy to build a personal narrative from a nothingness place, both for myself and now my clients.
I was never happy to be a doctor who had to inform patients of a dire diagnosis. I am much more alive showing up in creative ways, with vision and insight, in my makeshift guest-room-now telehealth office, with lots of hope as we build a vision for the future together.