The surgical eye

Robert came to us from southern Africa He had had surgery on his cervical spine one year ago for a compression of his spinal cord that had made it difficult for him to use his hands and legs He made an exemplary recovery from his symptoms and regained his lost function in a span of eight monthsHowever he began to notice something funny His voice began to undergo a consistent change it started developing a nasal twang the kind that would make one believe he was from the PhilippinesWithin a few weeks he also found it arduous to swallow food and even drink water He choked on tiny morsels of grain food would sometimes make its way down the windpipe instead of the food pipe which would cause him to asphyxiate The doctors back home inserted a nasogastric tube prohibiting him from consuming anything orally They even made a hole in his wind pipe doing a tracheostomy to safeguard him from suffocating in his own secretions He lived this way for an entire year before they sent him to us to figure out what was wrong It was puzzling an MRI of the brain was clear and the spine too had been adequately decompressed at the level they operated on but there was some mild stenosis above They told him he might need more surgery and put him on a planeAlso Read The surgical footballWhen I first saw him he looked emaciated with a tube stuck in his nose and another one popping out of his throat which he blocked with a finger for his voice to be audible He was sixfoottall and weighed about 50 kg he had lost half his weight in the past few months ldquoWhy does one of your eyes look a little smaller than the otherrdquo I asked after listening to his entire ordeal His wife jumped off the couch to check on my observation and after peering closely agreed ldquoThe left one correctrdquo she asked surprised at how she hadnrsquot noticed it in the past year ldquoDoes that mean anythingrdquo she continued perturbed I explained that there is always some subtle asymmetry in the human body often one breast or testicle is slightly smaller than the other or one half of the brain is slightly larger than the other and then there are people who have an indistinct difference in the size of their hands or feet and sometimes even the eyes The key is in understanding what is clinically significant to our diagnosisldquoDo any of your symptoms worsen as your day progressesrdquo I enquired further ldquoYesrdquo he said emphatically once again blocking his tube to be heard the voice becoming more nasal the fatigue more pronounced I told them I had an idea of what we were dealing with and that I needed to check with our neurologist who confirmed the diagnosis in a few minutes of seeing him ldquoWithout a doubt this is myasthenia gravisrdquo he said with an air of authority explaining to Robert that the disorder indicated grave or serious muscle weakness ldquoThis is a disease in which antibodies are made by a personrsquos immune system to prevent certain nerve muscle interactionsrdquo he continuedldquoThis affects certain groups of muscles causing them to get weak more so as the day progressesrdquo Turning to me he announced ldquoWersquoll give him a few drugs to block the antibodies and hersquoll be okay in no timerdquo his excitement palpable as he snapped his fingers at meThere is an exhilaration in recognising what is staring you in the face The joy of making a concrete clinical diagnosis in medicine in todayrsquos AIdriven metaverse is a simple example of that We now live in a time where images and investigations show us the way forward but once in a while a Robert comes along to keep the light aflame one clear look at his eye told us what was going onSenior clinicians look back lamentingly on the days when they spent hours getting to know a patient sitting at their bedside and talking to them gently examining them with excruciating detail until they were able to discern what was going on only to be thrilled at making the correct diagnosis and seeing the results of their treatment pan out in front of them Today most of us glance at reports and films to know how to move forward and focus on technical nuances After all it is also imperative that we use all the modern technology available to us to enhance our surgical outcomesThe eye is a direct extension of the brain Looking into someonersquos eyes gives us so much informationmdashmedically emotionally and spiritually You can diagnose something as simple as a cataract conjunctivitis or jaundice copper deposition indicating liver disease or thyroid dysfunction or something more sinister such as a retinal detachment or neuritis Looking into the eye can tell you if there is raised pressure inside the brain and if you look a little deeper you can even diagnose increased pressure inside the heart The important thing is to look hard enough Looking into patientsrsquo eyes while talking to them builds trust and confidence It allows them to share their real story It tells us parts of their story that words fail to expressThe eye is also a surgical corridor to the brain Instead of sawing through the skull bone for certain pathologies we can make a tiny incision behind or through the eyelid and then make a small hole through the eye socket to reach the brain We like to call it lsquonatural orificersquo surgery Irsquom not sure if this makes the idea of brain surgery less or more terrifyingRobertrsquos diagnosis was confirmed with a few lab tests and nerve conduction studies He was started on a cocktail of medication by the neurologist that improved his voice and strengthened the muscles he needed to eat chew and swallow within a matter of days His eye opened up like it was ready to bloom We removed his nasogastric tube and closed his tracheostomy over the next two weeks His smile had never been broader because he was able to eat like a normal human being for the first time in a year he even polished off the food that came for his wife He put on 9 kg while he was admitted with usIt was the perfect start to the new yearThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals