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Well our time in Vancouver has come to an end and it has been a superb 6 months. I have had an amazing training experience with loads of hands-on surgery and a continual flow of interesting oculoplastic, lacrimal and orbital cases.

This should set me up well to start back as a Consultant in Cardiff but I am under no illusion that this increased responsibility will be an enormous challenge.

We cannot fault Vancouver which has been an incredible place to live, a vibrant, cosmopolitan, family friendly place with unparalleled access to the great outdoors. We arrived in deep snow and left in 30 degree sunshine with a beautiful Spring in between.

So onto Africa and Northern Kenya where I am headed for the Samburu tribe to provide practical help for the people who are blighted by trachoma in the form of surgery, antibiotics and environmental improvement. We are also hoping to do some research on how to better treat this disease.

We’ve just had our fellowship graduation which was a great evening enjoyed by all and I’m almost finished in this beautiful city. It was a combined academic and clinical evening recognising the trainees who have passed their final exams, the clinical fellows and the postgraduates completing their higher degrees.

As the sun really starts to shine, the city really springs into life with the beaches packed, the open-air swimming pools open, skis hanging in the garage while the kayaks, mountain bikes and sailing boats come out. Great place to be!Graduating Fellows Vancouver 2009

I am primarily working with Dr Peter Dolman but also spending some time with Drs Rootman, Buffam and Rossman. They all have offices within the Eye Care Centre which is adjacent to Vancouver General Hospital near the middle of the city, but we also spend some time operating at the Children’s Hospital and the University Hospital.  Apart from becoming proficient with general oculoplastic techniques, there are many weird and wonderful tertiary referral cases from all over Canada and the rest of the world. The schedule is pretty gruelling with long days and emergency cases out of hours but with usually four days a week in the operating theatre there is plenty of hands-on cutting experience. There’s also night skiing less than half an hour from the hospital, which makes up for any long day!

The case load is very similar to any other centre around the world, entropion, ectropion, ptosis etc but we also see some more unusual pathology.  Similarly the emergency cases are comparable to those seen in the UK, Canadians also like to get drunk and punch each other in the eye with beer bottles, although eyelid laceration from a bear’s paw is not so common at home.

Dr Dolman has developed the VISA classification system for thyroid orbitopathy, which is a useful tool in the management of this difficult disease so we see many thyroid patients and regularly perform orbital decompressions both for rehabilitation and optic neuropathy secondary to apical optic nerve compression.  The timing of intervention for these patients is critical and watching how other people treat thyroid patients has been very useful.

Dr Dolman has also championed the non-endoscopic endonasal approach for dacryocystorhinostomy (DCR), which I thought would be very difficult. In fact, the anatomy is well displayed and accessible without an endoscope so that learning the technique has been very satisfying; it also helps that I have a teacher with endless patience. This low-tech approach has excellent results and is fast to perform with minimal instrumentation so I hope it will benefit my patients back in the UK.

Dr Rootman is well known worldwide as an authority on the orbit; he is an excellent teacher and has an encyclopaedic knowledge of all things orbital. Particularly impressive is his management of orbital varices, notoriously difficult to deal with because they are often large with many vascular connections and they bleed heavily. He has developed techniques to image and glue them with the help of the interventional radiologists which makes them much easier to remove.

Working with these internationally recognised people has been an amazing experience. More importantly, they are good teachers and have an excellent bedside manner with their patients. Plenty to think about for the future!

Spring has arrived in Vancouver, the snow is melting and the cherry blossoms have bloomed! A bit of background on Vancouver itself…

Vancouver is on the Pacific coast of Canada in the province of British Columbia. With a population of 2.5 million people it is the largest city in Western Canada and it was named after the British explorer George Vancouver. Originally settled in the 1860’s as a result of the Fraser Canyon gold rush it rapidly became a metropolitan centre and a major seaport. The economy traditionally relied heavily on forestry, mining, fishing and agriculture but now has diversified into software development and biotechnology, an ever growing tourism industry and has also become one of the largest film production centres in North America, earning it the nickname Hollywood North.

Vancouver jostles with Sydney for the accolade of most desirable city in the world to live in. Unfortunately this makes housing very expensive but quality of living is high and access to outdoor pursuits is unparalleled. You can ski in the morning and sail in the afternoon, making it very attractive to those who love the great outdoors and earning it the sea to sky nickname. Ice hockey is the Canadian equivalent of football back home; the local premier league team are the Canucks, followed obsessively by most locals. Jogging appears to be a popular city pastime, but with such close proximity to ocean, mountains, rivers and lakes, you can take your pick of activities, from big wall rock climbing at Squamish, skiing at Whistler to some of the best salmon fishing in the world.

Vancouver’s climate is unusually temperate by Canadian standards with mild wet winters and warm summers, similar to the UK, perhaps explaining why so many Brits choose to emigrate to Vancouver.

Vancouver is a city of neighbourhoods, each with a distinct character and ethnic mix. Historically people of Scottish, English and Irish origins were most common and elements of British society and culture are still highly visible. Nowadays the Chinese are the biggest ethnic group in the city. Getting around Vancouver is easy and everyone is encouraged to leave their car at home with a good electric bus network, a sky-train, a sea-bus and a dedicated network of bicycle routes, which is how I get to work now it has stopped snowing.

Spring has arrived in Vancouver, the snow is melting and the cherry blossoms have bloomed! A bit of background on Vancouver itself…

Vancouver is on the Pacific coast of Canada in the province of British Columbia. With a population of 2.5 million people it is the largest city in Western Canada and it was named after the British explorer George Vancouver. Originally settled in the 1860’s as a result of the Fraser Canyon gold rush it rapidly became a metropolitan centre and a major seaport. The economy traditionally relied heavily on forestry, mining, fishing and agriculture but now has diversified into software development and biotechnology, an ever growing tourism industry and has also become one of the largest film production centres in North America, earning it the nickname Hollywood North.

Vancouver jostles with Sydney for the accolade of most desirable city in the world to live in. Unfortunately this makes housing very expensive but quality of living is high and access to outdoor pursuits is unparalleled. You can ski in the morning and sail in the afternoon, making it very attractive to those who love the great outdoors and earning it the sea to sky nickname. Ice hockey is the Canadian equivalent of football back home; the local premier league team are the Canucks, followed obsessively by most locals. Jogging appears to be a popular city pastime, but with such close proximity to ocean, mountains, rivers and lakes, you can take your pick of activities, from big wall rock climbing at Squamish, skiing at Whistler to some of the best salmon fishing in the world.

Vancouver’s climate is unusually temperate by Canadian standards with mild wet winters and warm summers, similar to the UK, perhaps explaining why so many Brits choose to emigrate to Vancouver.

Vancouver is a city of neighbourhoods, each with a distinct character and ethnic mix. Historically people of Scottish, English and Irish origins were most common and elements of British society and culture are still highly visible. Nowadays the Chinese are the biggest ethnic group in the city. Getting around Vancouver is easy and everyone is encouraged to leave their car at home with a good electric bus network, a sky-train, a sea-bus and a dedicated network of bicycle routes, which is how I get to work now it has stopped snowing.

Medical training in Canada is similar to the American system where students do a University degree before entering medical school for 4 years, then doing a residency in the specialty they are interested in. Medical students are a little more earnest than their British counterparts, possibly because they are older and have to work hard to get through in 4 years.

Exposure to ophthalmology in medical school is as bad as it is in the UK, about a week if they are lucky but it is still a highly competitive residency to get into, especially in a desirable place like Vancouver.

The training takes 4 years and is equivalent to our 6 year specialty training so the residents are busy, typically having teaching at 7am every morning and regular assessments throughout their training. They often then do a fellowship although many become general ophthalmologists doing mainly cataract surgery; during their training they usually do a couple of hundred cataract operations, more than American residents but less than British trainees. They seem to see a fair bit of trauma, averaging about 50 penetrating eye injuries, a lot more than I saw!

All in all, a good training and pretty equivalent to the UK.

One good thing about working in an internationally renowned unit is that you get some really interesting cases, often requiring multi-disciplinary input.

We recently saw a gentleman who had a bulging left eye and some loss of visual function. The scan showed a growth at the orbital apex which looked benign but was causing some pressure on the optic nerve and affecting his vision. Our usual approach is from underneath the eyelid but with a tumour that far back it is very difficult to access.

The scan showed that it was very close to one of the sinuses so we asked one of the ENT surgeons who specialising in functional endoscopic sinus surgery for his opinion.

We decided on a combined approach mainly through the nose, but with us on hand to push the tumour out from the other side out and advise on the best place to enter the orbit causing the least collateral damage.

The ENT surgeons were using a new electromagnetic guidance system so they knew exactly where they were in relation to the scan and we eventually removed a sizeable benign haemangioma.

The patient was delighted and made a full recovery. Technology and cooperation at its best!

Operating with the ENT surgeons and their new guidance system

Operating with the ENT surgeons and their new guidance system

Tumour removed from the patients orbital apex

Tumour removed from the patients orbital apex