♎️ 🥂 👇🏾 Everyday life of an ophthalmologist at the clinic: when doctors are not enough 🏉 🏇 🌅

You asked not to put scary pictures with needles in the eye before kat. An

ophthalmologist in a clinic receives about 25-35 thousand rubles in the region and a little more in Moscow (about 20 salary, the rest are floating allowances: length of service, intensity, category, etc.). This work is considered boring: career growth lies either in science or in surgery. If we are talking about science, then we need to write a work on some kind of pathology, from which hundreds of thousands of people die. In ophthalmology, this is difficult, and research on the patient’s quality of life is not so quoted in world practice.

Today I will tell you what the profession of an ophthalmologist is, what they are and what new things have appeared in our clinics and hospitals in recent years. And why exactly this situation allowed Russia to get some advantages in the global medical device market.

But let's start with the fact that everything is scary in the clinic. And it's not about COVID-19 coming now, no. Right now, the scheduled appointment in all clinics is closed, and you can get through to specialized specialists only in case of emergency through a harsh nurse with a ~~rectal~~ infrared thermometer. The doctors themselves are sitting on their suitcases and expect a possible urgent re-profiling into infectious disease specialists if they are missed.

I would like to talk about the fact that in some places the branch of hell is constantly open. To begin with, there are not enough doctors.

How many doctors do we have?

The correct answer to this is sorely lacking.

The specialists are so lacking that there are already quite formal plans to replace the shortage of doctors with migrants from other countries . Moreover, the situation is very uneven in different specialties. For example, the same ophthalmologists now have 0.9 people per 10,000 population, judging by the official statistics of the Ministry of Health .

There are even more rare ophthalmic directions, for example, ophthalmologists-prosthetists. There are five, according to the same data. I mean five people all over Russia. These are the same people who can choose the best version of a prosthesis made by glass blowers to people who have lost their own due to illness or injury.

Here they show how polymer eye prostheses are made.

In addition to polymer prostheses, we also make non-individual glass prostheses. They look very natural and are well tolerated by patients. But they have to be taken from the place of production immediately in large quantities to choose the perfect one. Left, right, small and not very, brown, green or with a pronounced pattern of blood vessels.

Glass eye prostheses. No, they are not in the form of a ball, as many think

A good friend of the ophthalmologist shared details of how this happens. Within a week, she selects the necessary shapes and colors in the production, and then everything is carefully packed and transported in hand luggage. Almost every time it ends with mild attacks of angina pectoris at the airport, when hundreds of eyes blindly stare from the screen of the fluoroscope. They contrast very well on x-rays. And often there are funny stories about classmates of a son who decided to rummage without demand in a box and find very creepy deposits of human eyes.

But such specialists are a rare exception. The bulk of the people who came to work in ophthalmology first fall into a continuous stream of outpatient admission, where one patient is given no more than 15 minutes of strength. In district clinics in Moscow, the reception can be only ten minutes if there is a nurse assistant. Moreover, according to feelings, the doctor should spend most of this time on paperwork and other formal procedures. Well, if ten minutes remain on the examination itself and the appointment of treatment. Young specialists usually either try to escape from the clinic to science, where it is more interesting, or to private practice, where at least they pay more. One of the many studieson this subject confirms that the main reason for leaving the private sector is wages, and the profession itself pleases all respondents, and they do not want to leave it. Only 45.2% do not plan to leave the public sector anywhere.

So what do ophthalmologists do?

In fact, if you do not go into the differences in helping children and adults, in Russia there are two main areas - the outpatient unit and hospitals. The most routine and conveyor work usually occurs in clinics.

Outpatient doctors have several main tasks.

They can help in solving a small but urgent problem. For example, get a tick, which for some reason fell into the eye and does not want to go anywhere. If they come with a nail in the eye, then such a person will immediately be sent to be operated on in a hospital. Nevertheless, my mother once brought a child to a colleague who looked very strange, holding an eyelid with his hands so as not to blink. When they looked, it turned out that he had found the old Soviet kaleidoscope. They were made with thin colored glasses. I don’t know what dried out in the cardboard case, but when turning, all the glass neatly spilled out into the eye and remained stuck with sharp triangular pieces from the cornea. They took out the glasses, threw away home kaleidoscopes just in case.

Barley, commonly caused by staphillococcus.

The clinic deals with the treatment of mild inflammatory diseases. For example, a patient with barley - acute inflammation of the hair sac of the eyelash or Zeiss sebaceous gland. People with acute conjunctivitis due to a virus or allergy may also come. If there is a creeping corneal ulcer, then again - to the hospital.

Of course, in the clinic they can still pick up glasses and check vision. But this part of the work has already flowed quite firmly into private optics salons, where optometrists with secondary medical education carry out the initial assessment of visual acuity. Nevertheless, a tough and experienced doctor will be able to pick up glasses much better in the case of, say, non-standard astigmatism and a big difference in vision between the left and right eye. But just keep in mind that the selection of points in the clinic will take ten minutes. If due to rush the doctor makes a mistake, then optics will not be responsible for someone else's prescription.

Well, the main part of the work is the observation of chronic patients, mainly the elderly. This type of patient exists in two versions: “Your cataract has not matured enough yet” and “Well, why did you pull so much?” Patients for the most part are fairly typical, the main pathology is cataract and glaucoma. Plus, a certain percentage of people with age-related or diabetic retinal degeneration, which really cannot be treated, unfortunately.

Therefore, it is the clinic doctor who will sort patients for the purpose of further hospitalization. It all depends on the number of quotas and the power of the stationary link. With the same cataract, there is an understanding that it can be operated on as soon as the patient begins to interfere. From the point of view of budget financing and preferential programs, first of all, the most difficult patients will go for surgery, and not those who have less than 50% visual acuity. Resources, of course, are always limited, although everyone is trying to help.

As I said, the main problem of the clinic is the lack of time. This is, first of all, the link for the mass sorting of patients into light ambulatory and heavy inpatients. Therefore, many problems that are not related to immediate loss of vision are given a minimum of time. For example, the same notorious dry eye syndrome, which we will talk about a little later.

What interesting happens in hospitals?

No, this is not a hairy eye with holes. This is the result of a complex donor cornea transplantation operation on a titanium substrate.

In ophthalmological hospitals, the most complex, non-standard work is performed. It is very difficult to pay attention to all possible options, therefore, I will try to focus on a few key ones.

Cataract

Lens opacities due to age-related changes, endocrine diseases, or trauma. The hospital primarily includes elderly patients who have a loss of visual acuity of more than 50%, who were referred from the clinic. According to quotas, we put quite good lenses, not of the cheapest category. So, old people get quite good visual acuity in the end. Of course, this can be greatly complicated by concomitant age-related problems with the retina, but vision will be better anyway.

Injuries

Here you can talk endlessly. One story of hospitalization is “more fun” than another. Typically, Darwin Award candidates who work with a rotating tool without goggles and guards usually lead. Extraction of fragments of grinding disks somewhere at the level of the posterior wall of the orbit is a fairly common problem. Surgeons swear, but the next day they bring the same immortal, who decided that cowards had invented safety precautions.

Often these are the consequences of road accidents. Sometimes it turns out to maintain at least partially vision, if the injury did not destroy the eyeball. Sometimes not. A friend of mine, an ophthalmosurgeon, told me how she had been picking gravel out of a motorcyclist’s eye for several hours, who decided that he didn’t really need a helmet, but had unsuccessful braking on the gravel. In general, 90% of all such injuries are prevented by at least minimal brain involvement and basic safety.

Glaucoma

Atrophy of the optic nerve due to a chronic increase in intraocular pressure. Over the past few years, there have been a number of breakthroughs associated with the development of minimally invasive laser technologies. For example, the same YAG lasers have spread. Now a very large percentage of operations are performed on an outpatient basis. The patient rests his head on a counter that looks like an ordinary slit lamp. The ophthalmologist surgeon makes spot iris perforations with a laser in the right areas, improving the outflow of intraocular fluid. Further, the patient is observed at the place of residence in the clinic. A very important change in recent years - earlier, due to the great invasiveness, they dragged it to the last with surgery and prescribed only drops with supporting drugs. Now, on the contrary, they immediately perform a minimally invasive operation and then they are carried out on an outpatient basis with drops.

Vitreoretinal Surgery

This is aerobatics. It is this segment that accounts for a significant share of all new developments. Surgeons of this direction perform operations on the retina of the eye, working with microscopic manipulators. There is no right to error as a sapper. If you tactually felt the resistance of the retina with your fingers, you already irreversibly damaged it. But the tasks are really complicated. For example, removal of the epiretinal membrane - the thinnest layer of cells that pathologically begin to grow on top of the retina. The surgeon literally needs to capture a film with a thickness of one cell by the manipulator and separate it from the retina without damaging anything.

Other strange cases

Well, there are always strange situations that are difficult to classify. For example, a friend of the ophthalmologist told how they removed a fairly frequent congenital cyst of the eye. It was located in the area of the limb - the transition of the cornea into the sclera. Usually they find fat or hair inside. But after the next operation, when a cyst was cut, a milk incisor was found. Such a beautiful one, with vascular nutrition and well-mineralized enamel. The child had a full set of teeth, but this one simply turned out to be bonus.

New in clinics

Of course, the bulk of the new technical solutions goes primarily to hospitals. There it is really in demand. However, until 2014, there was a massive wave of re-equipment of diagnostic equipment. Prior to this period, a typical clinic had a room painted black, old chairs, a table lamp and skyscraper rulers for eye examination. And separately, Sivtsev’s table for checking eyesight somewhere in the staff room.

Now, even in district clinics, modern refractometers have appeared that allow you to quickly assess visual acuity and features of refraction. Finally, electric ophthalmoscopes appeared that help to examine the anterior segment of the eye under high magnification and identify pathologies of the cornea and iris.

And also sets for measuring intraocular pressure according to Maklakov began to disappear en masse. This slightly intimidating method is still one of the most accurate, but it is long and unpleasant for mass diagnostics. Polyclinics now most often have non-contact tonometers that measure intraocular pressure by photographing the curvature of the cornea under the influence of a dosed air stream. For patients, it is much more comfortable.

"Not a serious enough problem"

Unfortunately, even such assistance in automating routine procedures leaves very little time for problems that do not threaten vision in the near future. Almost nowhere do they specifically deal with the dry eye syndrome, although at least one billion people are affected to one degree or another . Only a couple of acquaintances come to my mind who write scientific papers on this topic and take those patients who have not been paid attention to in other hospitals. In the clinic, there is usually no time to do this, but for the hospital this problem is most often not serious enough. They save lives and eyesight.

Moreover, dry eye syndrome is a relative contraindication for many surgical interventions. These include all types of corneal surgery for correcting vision and elective surgery for treating keratoconus. Prior to the restoration of normal tear film production, surgery is highly undesirable. Especially considering the fact that many manipulations with the cornea themselves can provoke a worsening of the situation. For example, patients after removal of the lens through a wide incision have high risks of developing this syndrome.

It is not necessary to consider that this problem is characteristic only for elderly patients. Yes, indeed, most often people of middle age suffer, mostly women. But even at a young age, wearing is identified as the key risks of developing the syndromecontact lenses and prolonged work behind the monitor , leading to a decrease in the normal blinking frequency. A lack of vitamin A may also contribute. We often eat so-so, and many do not have enough retinol.

Therefore, if you constantly work at a computer, and even more so wear contact lenses, it makes sense not to reach the grave consequences. Yes, at first it is just a slight discomfort and a feeling of sand in the eyes, but in the future, a small percentage of patients may begin to erosion of the cornea and pathological proliferation of capillaries, which may already threaten vision.

Our laboratory developed Blefarogelto solve this problem. Moreover, when developing this drug, we did not follow the path of an artificial tear, which is quickly washed out, but decided to stimulate the production of our own meibomian glands located in the ciliary region of the eyelid. When applied regularly to the eyelids in combination with massage, they begin to produce a more stable tear film, which prevents the cornea from drying out. Actually, starting with the sales of Blefarogel at international exhibitions (we are now almost completely loaded with the production of media gels for ultrasound and other studies in pneumonia, but before that peak, large quantities of Blefarogel were shipped abroad). So, the specificity of the same United Arab Emirates turned out to be that there the doctor takes care that the patient recovered. The quality of life is not very important. Well, as in a regular clinic:few people are interested in making you more than the minimum, because it will take more time, and then more reception. Therefore, the entire market for medical devices for the patient’s quality of life was ten years behind ours (subjective assessment, of course). So we were in the right place at the right time.

Unfortunately, a lot of problems often come with a not-so-high salary. Patients have been waiting for their turn for an appointment for weeks, but receive little attention, because the doctor works on the site alone, they can’t find a new one, and today he needs to take 20-25 people without the ability to really go to the toilet. Or generally 60, if there is a medical examination. Naturally, in addition to the people recorded in advance, there will be several urgent patients who need to be taken out of turn. Some will dump a stack of tests a couple of centimeters thick on the table, sincerely hoping that in the seven remaining minutes the doctor will get into and solve all the problems. When his official working day is over, the doctor will sit down to rewrite patient cards, paste tests and printouts. An electronic document management system does not imply a rejection of the paper part. She goes in addition.

Then the doctor will deal with the claims of compulsory medical insurance, which may refuse to pay for the slightest typos or unnecessary prescribed tests. Somewhere in the process, the doctor will listen to many complaints that he is a scoundrel, and "I am a veteran of the Kulikovo battle and everyone owes me." Undoubtedly, our grandparents need attention and care, but it’s very disappointing when jerky doctors who are forced to work with a load of 149% find themselves in extreme situations between complainants and management. Just do not forget about it when you come to the reception and do not receive a detailed analysis of your problem. The doctor does not always have time for this.

Pandemic - no reason to forget about your health

The fact that now everyone is locked up in their homes does not mean that all other health problems have disappeared somewhere. The same conditional cataract itself will not resolve and the other pathologies of vision have not been canceled. Colleagues from the infectious diseases hospital noted that people finally stopped licking their dirty hands after public toilets and getting into the hospital with dysentery.

Judging by the communication with many familiar specialists from the IT sphere, many, after switching to a remote site, began to work longer and more intensively. The boundaries of the working day and rest time are very blurred.

I’ll say a banal thing now, but please do not forget about your health. Take breaks and try to walk at least on the balcony. Find an online yoga or pilates course. Your back, joints and eyes will thank you. You can also go tous in the telegram channel (@geltek_cosmetics). There we tell interesting things about the chronicles of our cozy laboratory.

Take care of yourself.

Everyday life of an ophthalmologist at the clinic: when doctors are not enough