The Ethiopian Assimilation of an Asian-American

There seem to be two phases to living in a different culture.  Phase I is essentially the "outsider" phase in which one feels like one is completely removed from the culture in which he or she is living in, an observer looking through a glass pane in a museum.  Everything about the culture seems radically different, from the way people interact, to the conditions in which they live their lives, to their everyday habits.  For me, at least, a sense of "other-izing" occurs, in which all people of a different culture are lumped together as somehow different from me yet nearly identical to each other.

In Phase II, all that reverses.  One begins to see past the superficial differences between cultures and realizes that one was only viewing things through a filtered lens.  The outward differences are no longer so pronounced as one comes to understand that there are many elements of this new society which closely resemble one's own- from intergenerational conflict to community events.  Even the once seemingly homogenous people of the new culture become strikingly different from one another as distinct personalities emerge- there are selfless, good-natured people, but also womanizers, misanthropes, and connivers.

It was in my last few weeks in Ethiopia that I began to more fully embrace Phase II, spurred on, no doubt, by the weekends I spent with my local friends in the community.

Watching the local soccer games came to be one of my regular weekend pasttimes.  Though these were casual games played by the residents of Dembi Dollo, the level of competition surpassed the average pick-up soccer game held in the US.  The fact that a large crowd of local kids and many adults came out to the games and would often rush the field and perform victory dances after a goal only added to the excitement.  In fact, the weekly games struck as me as analogous to a weekend little league game or high school football game in that they were simultaneously sporting events as well as events which brought the community together.

One of the characters I met during one of these soccer games was two-year old Robera, son of my Ethiopian friend Gabayo.

Robera was a two foot tall agent of chaos, delighting in pushing chairs over, stuffing sand in his shoes, and running anywhere his two small legs could carry him.  He might have been insufferable if not for the fact that he radiated infectious joy in everything he did, and he generally left a smile on the faces of all those in his presence.

One of Robera's companions was one year old Wabi, the son of Sister Evelyn's driver.  Without fail, Wabi would begin bawling everytime he saw me.  I guess I should've worked on looking less scary.

Wabi crying because he saw me

Apparently I succeeded in shedding my intimidating demeanor over the next few weeks as the kids who had previously only stared at me from afar began to approach and sit next to me.  A few kids even reached out to touch me- my face, arms, boots- apparently intrigued by this foreigner who looked so different from the Ethiopians they were used to.

 

One Saturday, the local youth association put on a performance featuring skits, sermons by local pastors, comedic roasts, and short talks by members of the community.  In one skit, the town bully was humiliated when a robber who attacked him turned out to be a little girl in disguise while in another, a smoking womanizer realized the errors of his ways and became a pastor.

The pastors addressed a number of topics, from the trappings of materialism and wanting luxuries such as nice cars, to the ways in which technology such as Facebook can be both beneficial and detrimental to our spiritual lives.  I was struck by how prescient these sermons seemed, as they very well could have been delivered to a church youth group in the US with little modification.  The slapstick humor in the day's skits and the lighthearted jabs during the roast also resonated surprisingly well with my American-developed sense of humor. 

costumed students before the performance

On my last day at the eye clinic, the clinic staff hosted a farewell dinner, complete with the requisite injeera, meat, and coffee.  As bittersweet as it was to be leaving my friends and coworkers of the past two months, I was thankful for the impact they had had on me- from lessons in ophthalmology to their warmth and generosity to instruction in Ethiopian culture and the Oromo language.

 about to eat nashif- minced lamb and garlic between two sheets of injeera (the word nashif means "good")

 farewell dinner

 receiving a traditional Ethiopian shirt as a thank-you gift from Mitiku on behalf of the eye clinic

 Ethiopian assimilation complete!

Roller Coaster

One afternoon, I accompanied Dr. Samuel on a trip to the nearby town of Guliso.  If the road in Dembi Dollo was the Indiana Jones ride at Disneyland, the road to Guliso was Goliath at Six Flags.

Over the course of the ride, we were slammed against every side of the vehicle.  We zipped along tortuous hillside roads, blazing past cornfields and young children shouting as we passed.  Our driver floored the van at 70 kilometers per hour through the rocky unpaved road only to slam on the brakes at the sight of an upcoming puddle or hole, sending us hurtling forward.  As the van careened through muddy ditches, we were hurled back and forth from left to right, with feet flying high in the air.

If I ever wondered why there were no amusement parks in Ethiopia, I now wonder no longer.

Master Classes with Dr. Samuel

 

"If you do not remind yourself why you are practicing medicine, you will become angry, frustrated, and say things you don't mean."
-Dr. Samuel

the ophthalmology department

The town of Aira sits northeast of Dembi Dollo, roughly a three hour car ride away.  A small agrarian town, Aira also happens to be the birthplace of Dr. Samuel- he was the first child in town delivered by C-section- and the site of one of Ethiopia's major hospitals.  Founded and supported by the German Lutheran church, the hospital at Aira serves as a sort of tertiary care center for western Ethiopia, in that patients whose conditions are too difficult to treat in their hometowns are referred to Aira.  

By its very nature as a higher-level hospital, Aira Hospital allowed me to learn about a variety of conditions I hadn't previously seen.   One such condition was a case of Elschnig's pearls, which is when grape-like growths made of cells from the outer eye appear on the lens, typically after cataract surgery.  I had the chance to observe trabeculectomies to treat glaucoma, and combined trabeculectomy/manual small-incision cataract surgeries for patients with glaucoma and cataracts.  In the trabeculectomy procedure, the ophthalmologist creates a small pouch or "bleb" in the eye to allow aqueous humor, the fluid in the front sac of the eye, to drain, thereby reducing eye pressure.

 creating a "bleb"

I also observed a number of surgical patients with arcus senilis- fat deposits in the ring around the iris- which occurs most commonly in the elderly.

Dr. Samuel also showed me how to differentiate between vitreal detachment and retinal detachment on ultrasound, and discussed Mooren's ulcers and peripheral ulcerative keratitis- two conditions which present similarly, but which stem from unknown causes and autoimmune diseases such as lupus, respectively.


One case which shocked even Dr. Samuel was that of a young boy who had an abscess, or collection of pus, under his left eye.  When Dr. Samuel went in to drain the pus, the fluid strangely did not leak out.  Upon further investigation, Dr. Samuel realized that it wasn't pus that had accumulated under the boy's eye, but rather a mango fly making a rather comfortable home for itself!  As the fly wriggled out of the boy's head, I couldn't help wondering how such a fly had entered in the first place.

mango fly crawling out from under the boy's skin

On other days, I was able to witness an evisceration and an enucleation.  The evisceration, essentially a drainage of the eye which leaves the outer layer and ocular muscles intact, was performed on an elderly man who was awake and alert throughout the procedure.  The man had lost vision in his left eye, and had it drained in order to avoid any risk of sympathetic ophthalmia, a condition wherein trauma to one eye results in inflammation in the opposite eye.

An elderly woman underwent an enucleation, which went one step further than an evisceration in that the entire eyeball was removed, including the outer layer.  The glaucoma in this lady's left eye had progressed to the point where her vision in that eye was irreparably damaged.  Dr. Samuel had found a potentially cancerous mass in her left eye, and advised her to undergo an enucleation to not only determine if the cells in the mass had spread to other parts of her body, but also to prevent such an occurrence.  Upon removing the lady's eye, Dr. Samuel sliced it open and determined that, thankfully, the potentially cancerous cells had not spread anywhere else in her body.

[no pictures shown of the two procedures described above for obvious reasons]

the hospital's guesthouse, where I stayed

the guesthouse caretaker's children- the middle kid always burst into tears whenever he saw me

During our daily tea time break from surgery, Dr. Eric, a Danish orthopedic surgeon who had served at Aira Hospital for over 10 years, regaled us with stories of his most trying cases in the early days of his time in Ethiopia.  Conversation would generally drift to current events, and Dr. Eric engaged me and the doctors in some much-appreciated debate over Edward Snowden, the current political situation in Egypt, and the causes of the 2008 recession.

Dr. Eric, Sister Sennait, and Dr. Samuel

One evening Dr. Eric and his European-raised, Eritrean-born wife Sennait had Dr. Samuel and me over for dinner.  Sister Sennait was as kind as Dr. Eric was entertaining, and together they made very enjoyable hosts.  We enjoyed soup, fresh baked bread, and Danish fish egg paste in a Western-style home overlooking mountains and valleys that almost made me feel as if I were in Hawai'i.


Every evening after all the patients had been seen, Dr. Samuel and I would take walks around the town of Aira, and he would reflect on how this town that he had grown up in had changed over the years.  As we trekked up hills, through abandoned air fields, and into churches under construction, he would note how much he enjoyed the simplicity and tranquility of the town.

 tree in front of Aira Hospital

 Aira's "airport"- a small airstrip for planes to land on

A new Mekane Yesus (Lutheran) church being built- the two-story sanctuary shown here, with a floor of offices and meeting rooms underground

 

 kids sliding down the hill

My first week in the Dembi Dollo eye clinic, a shy but pleasant seven-year old boy had come in with trauma to his right eye.  Unsure of what course to take, we had recommended he see Dr. Samuel at the eye camp in Gambella.  Once there, Dr. Samuel determined the boy had a traumatic cataract, and advised him to travel to Aira, where he could perform cataract surgery.  On one of my last days in Aira, as Dr. Samuel and I passed by the inpatient ward for ophthalmic patients, a man standing near the entrance reached out and shook my hand, saying, "Dembi Dollo."  Confused, I turned to leave when Dr. Samuel explained to me that this was the father of the boy I had seen in the Dembi Dollo eye clinic.  I entered the ward and found the young boy lying in a bed, recovering from surgery, but with a healthy eye and vision restored.

It seemed the boy's path had intersected mine at all of the major points of my time in Ethiopia, and I found it fitting, in a way, that near the end of my trip, I had seen his condition resolved.

Days of Being in Clinic Redux

One morning in the exam room of the clinic, a familiar tune entered the room via the window facing the restaurant next door.  In a town where I never heard English unless someone was intentionally trying to communicate with me, it was quite a shock to hear the recognizable bars of Jesus Culture's "Your Love Never Fails."  Initially, I was certain it was a fluke- the restaurant next door regularly played Afan Oromo songs for its customers, and I reasoned that the American worship song must have slipped into the playlist by accident.  Yet when "Oh Happy Day" played next, followed by the Newsboys' "I Am Free," and Jeremy Camp, I knew the worship songs were no fluke.  Throughout the rest of my weeks working at the eye clinic, the music streaming in from the restaurant next door served as a constant reminder of why I was there in Ethiopia.

 

 Using a slit lamp tonometer to measure a patient's eye pressure

My eye clinic experiences in the second half of the trip were no less remarkable than those in the first half.  One noteworthy case was a man who came in complaining of temporary vision loss in one eye, which led us to suspect he had amaurosis fugax, essentially a mini-stroke in a blood vessel supplying the eye.  On another occasion, an elderly man who had recurring pain in his eye proclaimed that I was a "god-man" after I gave him some anesthetic drops in order to take his eye pressure!  Even though we were only midway through the exam since we hadn't figured out the underlying cause of his pain, the man was ready to leave, having been temporarily cured of his ailment.

A week and a half after the Gambella eye camp, Mario returned to the US to prepare for a new research job at the University of Miami.  The clinic sent him off with a traditional Ethiopian shirt, and Sister Alganesh at the Daughters of Charity compound had him perform the obligatory coffee ceremony before his departure.

 Mario busting a move in his new Ethiopian shirt

 Mario and Peace Corps volunteer Trudie bidding farewell on Mario's last night

In my last few weeks at the clinic, some of the kids of the clinic nurses and assistants began to stop by to visit their parents.  Whether they were playing, climbing mango trees, or trying to help their parents, their presence always made the day just a little more enjoyable.

Ophthalmic nurse Mitiku's son at the top of the mango tree

 

 

 Kids of the clinic staff

 

Mitiku's daughter (Mayti), son (Lanejo), and niece

One evening after clinic, I accompanied Mitiku to the Dembi Dollo hospital, where his sister-in-law was preparing to give birth.  The hospital, which had started as a Christian mission hospital, had in more recent times been taken over by the government.  One doctor there told me most adults were admitted for diabetes, congestive heart failure, and tuberculosis, while many of the children were admitted for pneumonia.  The hospital offered services from baby deliveries to psychiatric counseling to eye care, though they were lacking in doctors in many fields, most notably ophthalmology.  A small wing was devoted completely to ophthalmologic services, but because the hospital could not entice any of the few Ethiopian ophthalmologists to work there, it was manned entirely by an ophthalmic nurse, Sehai, who split her time between the hospital and the eye clinic.

Mitiku's sister-in-law hours from giving birth

hospital cook serving lentil stew on injeera

pediatric unit

In my second to last week in Ethiopia I learned that the eye camp planned for the next week in Kamashi had been canceled because a corruption scandal had landed many of the town's government officials in jail.  Hoping to work with Dr. Samuel one last time before I left, I asked him if I could work with and learn from him at Aira hospital, four hours northeast of Dembi Dollo.  He graciously agreed, and the next day I was zipping along in the Toyota Landcruiser on my way to Aira.

Return to Samaro

A few weekends after returning to Dembi Dollo from the Gambella eye camp, I journeyed with the girls who live with the Daughters of Charity back to Samaro.  The four girls who were there for the summer- Anane, Senna, Ayantu, and Letu- had all either lost their parents or left homes where their parents either neglected or abused them.  We ventured first to the district of Anka, which Sister Evelyn had dubbed "the end of the world," since it contained a wide, elevated plateau from which one could see Samaro, Addo (location of the podo clinic), and other towns even further out.  From there, we headed down the steep drop-off past the plateau, down to the road which led to Samaro.

Alex, the Irish permaculturist, had long since left the million dollar fields, but Sister Kaffa still oversaw the kindergarten, animal life, and plant life in Samaro.  We stopped by the chicken coop and picked some mangoes, but sadly missed out on visiting the young calf, which had recently died due to lack of milk.  At the day's end, we slowly trudged our way back up the mountain to the sisters' compound despite six year old Letu's worries that we might not have enough energy to make it.  We returned rejuvenated and revitalized from the agrarian paradise we had had the opportunity to enjoy.

Letu with her "umbrella"

Sight

"When you restore sight, you restore hope."

-Dr. Samuel

What is it like to become blind?  Over the week of the Gambella eye camp, I had ample opportunity to ruminate on this question.  I can only imagine the gradual loss of vision which occurs with the more common causes of blindness, and the hopelessness that ensues as the darkness slowly creeps in.  With glaucoma, one loses vision from the outside in, first being unable to see out of the corners of the eye until eventually one can no longer see anything at all.  When a nuclear cataract first develops, one's reading vision actually improves to the point where some people no longer need to use reading glasses.  This joy quickly turns into worry, however, as the nuclear cataract matures and gradually blocks out all sight.

I tried to grapple with the emotions which the blind experience- the depression from realizing that you will never be able to see the faces of your children again, the loss of self-worth from being unable to work or do any meaningful activity, the complete and utter dependency of being reliant on someone else to help you perform even the most basic functions.  We even heard stories about some blind people who would cry out at the top of their lungs for help because they desperately needed to use the toilet but had no way of finding it and no one to help them do so.

One morning, a young man wearing a UCLA t-shirt pulled me aside.  His ten-year old brother, he told me, needed to be seen by Dr. Samuel.  His brother had been born blind in one eye, and had recently become blind in the other and desperately needed help.  As Dr. Samuel came down the line screening patients for operable cataracts, he reached the young boy and gave his verdict- the boy had extensive corneal scarring from trachoma which could not be reversed with cataract surgery, or any surgery available in Ethiopia.

In desperation, the young man grabbed me again.  "Have him recheck!" he burst, unable to believe there was nothing to be done for his brother.  I calmly re-explained Dr. Samuel's diagnosis, trying to avoid my own conflicted feelings about the boy's case.

As the young man and his little brother dejectedly collapsed on the benches along the hallway, I sat down with them.  A wave of hopelessness washed over me as I felt the despair and anguish of the brothers sitting next to me.

"We tried to get him an appointment in Juba, we tried to get him an appointment in Khartoum," the man wailed [Juba is the capital of South Sudan, Khartoum is the capital of Sudan].

The tragedy of this boy's blindness was compounded by the fact that even though they had sought medical care earlier in three different countries, there simply were not enough doctors available to treat everyone who needed care.  The young boy's life had been irrevocably altered because of this simple fact, and he was relegated to a lifetime of blindness.

Yet there was still hope amidst the tragedy.  Anne-Berit brought up Shashamane school for the blind, which Larry, Sean, Joey, and I had visited near the beginning of the trip.  I strongly urged the young man to visit the school with his brother and family- they had the resources to help his brother get an education and could help him live his life to the fullest, despite his visual limitations.

The disappointment of being unable to aid many of the patients was outweighed by the joy of witnessing patients from the previous day regain their sight.  As we arrived at the hospital each morning, forty to fifty patients who had undergone cataract surgery the day prior sat in the courtyard just outside the operating room.  We would slowly make our way down the line, removing the patches covering the healing eyes and distributing post-op medications, while Dr. Samuel checked the eyes for any complications and, most importantly, for restored vision.

Dr. Samuel checking visual acuity

Patients typically didn't react immediately once the eye patches were removed, but as they began to look around and as the realization that their sight had returned crept in, smiles erupted on faces all over the courtyard.  Some patients would point at their grandchildren, finally seeing their faces again, and a few even belted out worship songs and shouted prayers of thankfulness to God.  Mario and Sean followed one elderly patient named Gideon back to his house, where his pastor presided over a ceremony and his church choir offered up songs of praise for the transformation in Gideon's life.

One woman who had had her sight restored grabbed my hand and gestured toward the sky, saying something I couldn't understand.  "She is saying, 'I thank God for you,'" my friend Jango explained.  "I didn't even do anything!" I laughed.  I suppose I should be thankful none of the patients licked my hand, which was an experience that befell Sean when an overjoyed woman wanted to express her gratitude.

a post-op patient

 family and friends gather excitedly around a man who has regained his sight

At the end of each day, despite being drenched in sweat, despite being covered in mosquito bites, despite having to eat meals covered with flies, despite the fatigue of 12-hour days, despite the frustration with argumentative patients or the inefficiencies of Ethiopian healthcare, I felt this unshakeable sense that somehow- somehow -it was all worth it.

Manual Small-incision Cataract Surgery

Cataract surgeries performed at the Gambella eye camp:  276
Highest number of surgeries performed in one day of the camp:  49
Cost of each cataract surgery:  $50 US dollars (cost to patient is free)
Average duration of a single cataract surgery at the eye camp:  < 15 minutes

 Dr. Samuel's notes explaining manual small-incision cataract surgery

The manual small incision cataract surgery (MSICS) procedure which Dr. Samuel regularly uses reflects the incredible resilience of the human body.  To perform the operation, the surgeon essentially cuts open the eyeball, replaces the lens, and patches the eye- without sewing or suturing the cut in the eyeball!  After one day, the eye actually heals itself and the patient has his or her vision restored.

Of course, the details of the procedure add additional layers of complexity.  A step-by-step guide to MSICS-

Prep- Dilation, Sterilization, and Anesthesia

Before the operation can begin, the patient's pupil must be dilated in order to give the eye surgeon the largest possible area in which to work.  Because the lens lies behind the iris, the further the pupil is dilated, the less the iris will obstruct the exit of the lens.  We used a mixture of tropicamide, cyclopentolate, and phenylephrine to achieve dilation.

As with any other surgery, the surgical field must be sterilized prior to operation- at the eye camps, Dr. Samuel uses a povidone-iodine mixture.

Finally, the eye must be numbed and rendered immobile.  This was accomplished with a lidocaine-adrenaline injection.  The adrenaline works by delaying the absorption of lidocaine, the anesthetic, into the body so that the numbing effect can continue throughout the duration of the surgery.

Step 1- Conjunctival Dissection

eye as seen from the side

Once the patient is lying on the operating table, under the eye of the ophthalmologist's microscope, the real fun begins.  The ophthalmologist grabs hold of the outer layer of the white of the eye (the conjunctiva) and makes a careful horizontal cut a few millimeters above the iris.  Though this step is referred to as the conjunctival dissection, it is technically a dissection of two layers- the conjunctiva and the layer of the eye below it, called Tenon's capsule.  In dark-skinned people, such as those in Gambella, Tenon's capsule is much thicker, and sometimes the ophthalmologist must make a second cut to dissect Tenon's capsule instead of taking the two layers out with one blow.

After pulling away an area of the conjunctiva and Tenon's capsule, the surgeon then seals (or "cauterizes") the blood vessels he or she has exposed.

Step 2- Linear Incision

eye seen face on

Next, the ophthalmologist makes a careful horizontal cut in the sclera, the layer underneath the conjunctiva and Tenon's capsule.  Some surgeons prefer the "smiley face" cut or the "frowning face" cut, but Dr. Samuel's incision of choice was linear.

Step 3- Scleral Tunnel

eye facing up as seen from the side

Thirdly, the eye surgeon creates an upward sloping tunnel from the incision he has just created all the way to the area in front of the iris (the anterior chamber).

Step 4- Capsulorrhexis

Now that the ophthalmologist can reach the lens, he can peel off a circular area of the front part of the "bag" (or capsule) holding the lens.  In other methods of MSICS, doctors peel off the front of the bag in other ways, such as in a "V" shape.

Step 5- Hydrodissection

 eye as seen from above

Once the front of the capsule is removed and the nucleus (or center) of the lens is exposed, the ophthalmologist shoots a stream of water at the nucleus, rotating it about 180 degrees to completely detach it from the rest of the lens.  


Step 6- Nuclear Extraction

 eye as seen from above- pulling the nucleus through the scleral tunnel

Next, the surgeon can reach into the capsule and pull out the nucleus of the lens.  Dr. Samuel's preferred technique was to use a fishhook, which he created by reforming the needle of a syringe into a hook shape.  Not all nuclei are created equal, and there was a huge amount of variability in the consistency of lens nuclei at the eye camp.  Dr. Samuel deemed the fairly mature cataracts "delicious," as they were solid, hard, and dense, and relatively easy to extract.  Hypermature cataracts, on the other hand, have progressed further than mature cataracts and are also known as Morgagnian.  In Morgagnian cataracts, the outer part of the lens (the cortex) actually turns from solid to liquid though the inner part of the lens (the nucleus) remains solid.

According to Dr. Samuel, the nuclear extraction step is the hardest part of the operation, as the lens is in danger of falling further back into the eye.  To me, this seemed like the most exciting part of the surgery, as the removal of the lens from the eyeball was almost like the delivery of a baby (albeit a tiny baby that you throw away immediately after the surgery).


Step 7- Aspiration

Since the lens is composed of both the center portion (nucleus) and the outer portion (cortex), even after the nucleus has been extracted, the less rigid peripheral portion of the lens remains.  Typically, the surgeon aspirates or suctions out the cortex using a device called a Simcoe cannula, essentially vacuuming behind the iris to pull out the strands of lens remaining.  Sometimes, fragments of cortex remain behind the iris on the same side of the eye that the incision was made.  In this case, it is impossible to reach the last pieces of cortex, so an additional incision must be made about 120 degrees counter-clockwise from the initial incision.  From there, the ophthalmologist has the perfect angle from which to suction out the last of the lens.


Step 8- Inject Viscoelastic

Normally, the space behind the cornea (the anterior chamber) contains a water-like liquid called aqueous humor which, among other things, helps to maintain a sort of pressure equilibrium in the eye.  During MSICS, this equilibrium is disrupted and thus the ophthalmologist injects a similar (but synthetic) material called viscoelastic to help restore the appropriate pressures.  The surgeon can choose between dispersive and cohesive viscoelastic.

Cohesive viscoelastic, as its name suggests, tends to clump together, making it easier to remove.

Molecules of dispersive viscoelastic, on the other hand, separate from each other making removal more difficult.  The benefit of dispersive viscoelastic is that it coats the inside of the cornea (endothelium), providing a nice protective coat.


Step 9- Lens Implantation

 inserting the new lens through the tunnel and under the iris

Finally, the ophthalmologist inserts the new lens into the spot where the old lens used to sit- behind the iris and within the "bag" (capsule).  Two curved prongs on either side of the new lens called haptics ensure that the lens hooks snugly into the capsule.  To my understanding, the viscoelastic helps create the right pressure in the front of the eye so that the surgeon has an easier time placing the new lens.

artifical lens with hooks (or "haptics") on either side

Step 10- Removal of Viscoelastic


When the surgeon removes the viscoelastic using the vacuum-like tool called a Simcoe cannula, he can also use the opportunity to "polish" the newly inserted lens along the patient's visual axis.  This helps to lessen any blurriness the patient might otherwise experience.


Step 11- Closing the Wound

applying water pressure to the incision to seal it

Finally, the ophthalmologist fills the space behind the cornea with water to restore the pressure lost after the removal of viscoelastic, then shoots water along the linear incision he made in Step 2.  If all has gone according to plan, when the surgeon lightly taps the patient's cornea, no water leaks out of the incision because a flap of eye is holding it shut.

Throughout the surgery, the ophthalmologist must make numerous decisions as he goes.  If the surgeon senses the patient is tense, he will typically make his initial dissections further from the intersection of the white of the eye and the cornea (the limbus), thereby creating a longer scleral tunnel.  Tense patients are at greater risk of their irises leaking out through the incision, so creating a longer tunnel helps prevent this.  Patients who have a condition called pseudoexfoliation, in which protein deposits appear in the iris and/or lens present as riskier surgical cases because the strands encircling the lens and holding it in place (zonule fibers) are more fragile.  Thus, the ophthalmologist must be especially delicate in his surgical actions.


After drying the eye and injecting an antibiotic mixed with a medication to reduce inflammation, the patient's eye is patched up and he or she is sent home to rest until the next morning, when- if all has gone well- the patient will regain sight.