I almost finished my July 4th call week. Good news! Portland did not blow its face off this year. No open globes, no eyelid lacerations, no thermal injuries, no sclopetaria. Bad news: a Friday holiday means every unanswered call from every patient at every one of our offices lands on the on-call doctor, and I earned every one of them.

I walk through three cases. First, a cataract surgery my partner had to abort mid-procedure because the patient had six clock hours of zonule laxity. I explain what zonules actually do, why pseudoexfoliation ruins your day, and how a viscoelastic-driven pressure spike at 1 AM sent me to clinic to "burp the wound" instead of shipping the patient to the ED. Second, an inpatient consult for suspected optic disc swelling, and why nobody outside ophthalmology reliably examines an optic nerve. Third, the classic infectious disease vs. ophthalmology debate: does every asymptomatic patient with candidemia need a dilated eye exam? IDSA 2016 says yes. The American Academy of Ophthalmology says no. I'll tell you where I actually land and why I still show up anyway.

Also: my full case for licensing fireworks rather than banning them, and a little pushback on the once-a-year concern for veterans and dogs. Live shows coming up in Boston and at the Lebanon Opera House in September.

Takeaways:

Zonule laxity, loose or broken suspensory fibers that hold the natural lens in place, can force a cataract surgeon to abort mid-procedure and refer to a retina specialist for a safer staged approach; pseudoexfoliation is one of the most common causes

The viscoelastic gels used during cataract surgery can plug the eye's drainage system and cause an IOP spike that lasts up to 72 hours; oral Diamox is standard, but if the patient can't keep it down, options are IV Diamox in the ED or manually burping the wound in clinic

Ophthalmologists are effectively the only clinicians reliably trained and equipped to examine the optic nerve, which is why hospitalist consults for suspected disc swelling should be treated as a normal part of the job, not an imposition

The IDSA (2016) recommends dilated exams for all non-neutropenic candidemia patients within one week of diagnosis; the American Academy of Ophthalmology recommends against routine screening in asymptomatic patients.

Practical approach for 2026: consult ophthalmology for any candidemia patient with visual symptoms (floaters, blurriness, pain, flashes) or who can't reliably report symptoms (intubated, delirious); asymptomatic reliable patients likely don't need routine screening

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