20th Annual Meeting Abstracts - 2007
Ocular Pathology as a Freestanding Subspecialty: Rise and Fall
David J. Apple
Introduction or purpose: Ocular Pathology began to flourish in the mid-late 19th century and two “Golden Ages” can be readily identified, one in the late 19th century and one in the 20th century. Prior to ca 1990, it continued to flourish. Today, however, one may say it is a dying field. Why is this so?
Historical approach or resources: I will present a brief overview of the evolution of ocular pathology with special reference to the various luminaries who helped make important advances in identification, diagnosis and treatment of many eye diseases. By tracing the status of ocular pathology practitioners decade by decade over the past century, one can trace the external/environmental influences that may have had in deleterious effects on one’s ability to freely practice in his or her specific laboratory.
Body of paper: After reaching a final peak in the years post World War II, a rapid decline relative to eye pathology occurred by the turn of the 21st century. Many established pathologists moved to clinical careers, retired, or passed away, thus leaving a shortage in the overall number of practicing eye pathologists. Only a few self-supporting pathologists now remain. Despite repeated warnings I have given in one lecture after another at various meetings and in various publications over the past 5 years, a substantial “demise” has occurred.
Summary or conclusions: General ocular pathology is now being taken over by general anatomic pathologists. Also today’s young academics-in-training are failing to fill the void in this important highly specialized field. Very few people are entering the new complex subspecialties of the future such as pathology of ocular biodevices—subspecialties that could be easily funded and provide a long term source of research material and funding and financial support for pathologists of the future.
Ophthalmology in Fin-de Siècle Vienna
Everything glittered in Habsburg Vienna. Yet conventional wisdom has it that nothing there was what it seemed. However grand the Blue Danube Waltz and the Radetzky March, Vienna in the fin-de-siècle is considered to have been the center of European social political disintegration. We will examine Viennese ophthalmology at a time and in a city where science was celebrated for its humanistic value while government and culture below the surface were in decay and decadence. Could a society which no longer desired to see things as they really were, a society whose vision was so enamored of surface ornament host a group of exemplary ophthalmologists whose passion it was to restore vision and explain if not conquer ophthalmic disease? Was ophthalmology part of the transition if not dissolution of human values? Ferinand von Arlt allows us pride as ophthalmologists when we contrast his unshakeable sense of duty, his accomplishments, his deep compassion for the indigent and his extraordinary modesty when contrasted with all those in Habsburg Court. But his appointment as Professor of Ophthalmology at the University of Vienna caused a rift with Eduard von Jäger-a rift no less virulent than between emperor, son, and nephew. The rift between the physicians would splinter European ophthalmology and give the specialty a “black eye”. That within the imperial family would lead to WWI and the loss of millions of lives. But there was the discovery of cocaine as a topical ophthalmic anesthetic by Carl Koller and the first penetrating keratoplasty by Eduard Konrad Zirm. The impressive careers and significant contributions of Austrian ophthalmic legends such as Stellway, Czermak, Harner, Dimmer, Schnabel, Mauthner, Elschnig, Fuchs, and von Graefe all contrast sharply with the elaborate emptiness of the aesthetic and intellectual world across the prater from the Algemeine Krankenhaus and down the imperial strasse from the University of Vienna’s eye clinics. As the Austro-Hungarian Empire was about to collapse, Viennese society was stifling to creative thinkers: composers, painters, philosophers, and writers. But apparently not so for the ophthalmologists. These scientific and medical innovators prospered, in and cared, for a disintegrating society. Their names we honor.
The Ophthalmology of Hieronymus Brunschwig
Donald L. Blanchard
Introduction or purpose: Hieronymus Brunschwig was a wound surgeon in Strasbourg, who in 1497 published the first major German text on wound surgery with colored illustrations. (Dis ist das buch der Cirurgia) It is best known for its discussions about amputations, gunshot wounds, and general anatomy. His ophthalmology section is a good indication of what a non ophthalmic surgeon of that time knew and dealt with as regards the eye. His life and work will be discussed. The first modern day English translation of the eye chapter will be presented.
Historical approach or resources: After reading Brunschwig’s book in the original German, I translated the eye chapter. I read the texts of the authors he quoted. My goal was to determine the types of eye injuries encountered by a wound surgeon in the late 1400s and specifically to learn more about him.
Body of paper: Brunschwig for the most part described wounds that would result from physical conflicts. Gunshot wounds as well as arrow and sword injuries were emphasized in his dealing with periorbital trauma. His methods of treatment mostly come from Galen but a flowering of surgical texts one to two hundred years before his time were also extensively quoted by the well read Brunschwig. These ophthalmic treatment plans and his life in general will be discussed.
Summary or conclusions: Brunschwig frequently quoted from the 14th century French surgeon, Guy de Chauliac, who said at the end of his eye section according to the Old English translation7, “The helping and the maneres of the which beeth more specified in Ali ibn Isa ‘Of Eyzen’ and in Alcoati and in the special bookes of eyzen. Neverthelatter be these inough to a cirurgen”. Or in modern English, that is all a surgeon needs to know about the eyes. The same held true for what was in Brunschwig’s book and was presented in this talk.
“He Sees Alcor, But Not The Full Moon”: The Arabian Eye Test Using The Stars
George M. Bohigian
Introduction or Purpose: An ancient test of excellent vision was the ability to see an “optical double star”, the second star from the end of the handle of the Big Dipper in the constellation Ursa Major, which usually was seen as a single star. This presentation describes the history, practicality and correlation of this “Arabian Eye Test” to the present Snellen eye test measurements.
Historical Approach or Resources: Resources are based on original Arabic writing, Smithsonian Institute, Library of Congress, and books/journals on astronomy.
Body of Paper: The Arabian eye test, the ability to distinguish the two stars Mizar and Alcor--the second “star” from the end of the handle of the Big Dipper. These two stars are separated by 11.8 minutes of arc which would be equivalent to Snellen 20/200 based on the angle. However, the perception of these two stars’ points of light depends also on other optical physical qualities such as magnitude of brightness, contrast, white on black and other factors. The history and use of this test is described. An optical experiment was done using human volunteers to demonstrate that this test is equivalent to the present day equivalent of 20/20 on the Snellen chart. There is an old Arabian saying, “He can see Alcor but cannot see the full moon.” This describes a person who could see trivial details but not the big picture. In addition, vision tests using stars, constellations, and planets will be discussed.
Summary or conclusions: The Arabian Eye Test, which challenges one’s ability to observe the separation between Mizar and Alcor, the “optical double star” in the constellation Big Dipper, provided the ancient observers a convenient and practical test for assessing visual acuity, which is still a practical measurement of visual acuity today.
The ReNu®-Related Fusarium Keratitis Outbreak of 2005-2006:
What Would the Reverend Henry Whitehead and Doctor John Snow Have Done?
John D. Bullock
PURPOSE: Compare/contrast two infectious outbreaks
RESOURCES:  site visit;  literature search;  internet search
BODY OF PAPER: In 1849, almost three decades before Robert Koch proved the germ theory by growing Bacillus anthracis in the aqueous humor of the ox’s eye and producing a lethal anthrax infection in mice, Snow proposed his theory of waterborne transmission of cholera, then a severe disease of unknown etiology. Although his data was obvious, most public health experts believed in the “miasma” theory: odors arising from decomposing organic matter combined with a weak constitution, due in part to immorality from overindulgence in alcohol and sex. In 1852 England’s Parliament mandated that water companies relocate, at great expense, their intakes upstream to a non-polluted region of the Thames. In 1854 a cholera epidemic occurred near the corner of Broad and Cambridge Streets in London. Various governmental agencies later inspected the interior of the well and the nearby sewer and detected no abnormalities. Even though Snow had noted that the pump water had a normal appearance, taste, and smell, he recommended removal of the pump handle to stop the epidemic, thereby making him the central iconic figure in the history of public health. Soon thereafter, Whitehead, believing instead that the epidemic had been caused by divine intervention, performed the first ever case-control study to disprove Snow. The results of his study [odds ratio = 19.6], however, confirmed Snow’s theory.
In July 2005, the Hong Kong health department noted an increase in Fusarium keratitis associated with ReNu® contact lens solutions and on 20 October asked Bausch & Lomb [B&L] to investigate. On 21 February 2006, 39 cases were reported in Singapore. 35 of these individuals had used a ReNu® solution [market share = 40%], 1 had not, and the remaining 3 were uncertain [odds ratio = 52.5]. On 8 March, 3 cases from Newark, New Jersey, and on 10 March, 2 additional cases from Dayton, Ohio, were reported to the CDC. In spite of an obvious association with ReNu®, B&L’s experts considered it safe and effective, because its fungal cultures were negative. Subsequent reports blamed infected consumers for “poor contact lens hygiene practices.” FDA reports from 2002 later surfaced which had raised serious concerns about B&L’s quality control. Sufficient governmental action had apparently not been taken.
SUMMARY / CONCLUSIONS: Although these outbreaks were separated by over 150 years, located on different continents, involved different organ systems, and occurred by different mechanisms, they are strikingly similar. In both episodes: serious consequences resulted (death / blindness); the etiologies were initially unknown; obvious scientific data (odds ratios) were either ignored or unappreciated; the transmission media were considered normal; significant financial resources were involved; the victims were blamed; and, imperfect governmental oversight had occurred. With respect to the Fusarium keratitis outbreak, Whitehead would have calculated the elevated odds ratio on 2/21/2006 and Snow (like removing the pump handle) would have issued an immediate recall of ReNu® to protect millions of consumers.
IVY and the Early History of Ophthalmic EMR
Robert C Drews
Introduction or purpose: To document the history of the IVY approach to electronic medical record-keeping (EMR) - while it is still possible to do so.
Historical approach or resources: Memory of hands-on involvement with this project, supported by what few documents and lecture materials remain. Consultation with the other key, original member of the team.
Body of paper: An historical analysis of the background and development of a successful turn-key system of medical record-keeping and office management, with insights into the philosophies and contributions of the key people who made the project possible and successful.
Summary or conclusions: IVY had obvious shortcomings, but its successes as a system of EMR have been overlooked in subsequent attempts to develop practical solutions to what is an enormous problem in documentation and communication, not only in ophthalmological and other medical record-keeping, but in all fields where case/client, time-referenced records are kept and used as the basis for analysis and communication.
Silas Weir Mitchell and Ophthalmology
Doctor Mitchell, known as the father of American neurology, was an experimenter, an unsurpassed clinician, and a thinker. He realized the importance of careful eye examinations, he appreciated that eyes were often the source of symptoms, and had some understanding of physiological problems we are still learning about.
There is a wealth of material about Silas Weir Mitchell and writings from his prolific pen. He wrote about the need for eye examinations (“Cases Illustrative of the use of the Ophthalmoscope in the Diagnosis of Intracranial Lesions” with Wm. Thomson). “Headaches From Eyestrain”, written in 1876, is a classic. Instrumental precision in medicine was an interest of his. The report “On the Production of Cataract in Frogs by the Administration of Sugar” is referred to in many places.
Instruments and mechanical devices have come a long way from the “Chess Automaton” Mitchell once owned, and his own knee-jerk meter. Eyestrain is with us again in the plethora of articles on “computers and eyestrain”. Education in ophthalmology is currently inadequate or absent from medical school curricula. The 2003 Nobel Prize in Chemistry went to Peter Agre for work on water transport in the lens.
The Civil War era is not properly appreciated in regard to medical care and accomplishments. Silas Weir Mitchell’s accomplishments are better understood with some facts about those years. Mitchell’s widely known rest cure might have been derived from reading John Hilton’s “Rest and Pain”.
Hans Goldmann’s Golden Year in St. Louis:
Daily Research Bench Rounds with The Master!
Jay M. Enoch
Abstract: The late Prof. Dr. Hans Goldmann took a well-earned year of sabbatical leave, shortly after having stepped down as Rector Magnificus of the University of Berne, Switzerland and from his Chairmanship of the Department of Ophthalmology. Hans spent that year at the Department of Ophthalmology at Washington University Medical School in St. Louis, MO. He and Bernard Becker (and many of us in the Department) were long-time associates and friends. And what a year it was! Those who were present still speak of it with awe and respect. What fun, what excitement – what work!
Each of us had a variety of fascinating personal interactions with Hans. However, a single set of salient experiences stands out in all of our memories! Early-on, Goldmann established a daily routine of going from laboratory to laboratory on the 10th and 11th floors of McMillan Hospital in order to conduct daily bench rounds with each of the individual faculty/investigators. Mornings, he would appear in a well pressed and fresh lab coat, greet us with a gleaming smile, and upon entry into your lab, he would ask, ”Huh, Huh, so what’s new today?” And it was expected that you would have new data, or experimental results to show to him! He would then ask penetrating questions about your work, techniques employed, the data presented, etc., as well as make suggestions for improvements. He also usually had some kind words of encouragement. If you did not have something new, he had something new and exciting to tell you of his own! Questions on the latter were almost always considerably more difficult to answer, than if you had something new to offer!
As a result, the research faculty and staffs were literally driven to a creative frenzy in order to have something new to discuss or to demonstrate when the good Professor made his anticipated daily entry into the laboratory. The faculty operated in high gear. Every morning, the techs would lean out of our doors, and indicate to their investigator toiling away, “He is coming very soon; he is in the next lab now!” Oh, to finish in time!
Also described is a sample question awaiting an individual if he had nothing to report! Hans posed the following query to JME: “If I shine a light into one of your two eyes, and you were not told which eye had been stimulated, could you state properly which of the two eyes had been stimulated/excited?” Hans explained that in species not having binocular vision, the individual animal’s survival depended upon making such judgments. With evolutionary advance of the eyes forward in the head, and both eyes facing forward, binocularity evolved. Hence, there was reduced need for this capability.
Goldmann properly raised the question, “Did modern humans retain this particular ancient skill?” As a result, JME and Goldmann performed studies on this topic (reported in Investigative Ophthalmology). Simply, these judgments are made properly by most observers with some practice.
Oxygen, Prematurity, Blindness: The Early Years
Introduction or purpose: In some unfortunate ways, the published historical record is incomplete or misleading in describing the years between the time when Terry’s first paper appeared in 1942 on what was later named retrolental fibroplasia, and the publication of the large collaborative study report by Kinsey in 1956. We propose to remedy this.
Historical approach or perspective: Review of the pertinent American and British literature from this period placed in perspective and added to with first-hand commentary by one of the crucial players, Dr. Arnall Patz, who later was given the Lasker Award for his contribution during that period.
Body of paper: Part of the presentation will be a DVD of Dr. Patz presenting a lecture on this material which was used to open the international meeting on Retinopathy of Prematurity held in Vilnius, Lithuania in September, 2006 (and which is a historical artifact in itself). Dr. Fishman will then provide some added commentary.
Summary or Conclusions: Scientific medical discoveries do not come simply or inevitably, especially when clinicians are faced with such a cruel dilemma as balancing the survival of premature infants with the likelihood of blindness. Recognition of the great utility of a large scale prospective and well-designed clinical trial was a by-product of this time.
The Philosophic, Physiologic, and Metaphoric Blind Spot of Mariotte
John W. Gittinger
Introduction or purpose: In the 17th century the optic nerve was thought to be focal point of the eye. An autodidact French clergyman, the Abbey Edme Mariotte (1620-1684), put this assumption to the test and found that there was an ordinarily imperceptible scotoma--the blind spot--where the optic nerve projected in visual space. This observation has fascinated scientists, philosophers, and the laity.
Historical approach or resources: Out of the political and social disturbances of the mid-17th century—plague, fire, wars, and religious strife—arose the Royal Society of London for Advancement of Experimental Philosophy, chartered in 1662 by the restored King of England, Charles II. The first English language scientific journal, the Philosophical Transactions of this “invisible college” disseminated Mariotte’s observations.
Body of paper: The English Civil War and the Protectorate of Oliver Cromwell set the stage for the Restoration and the intellectual explosion that ensued. Charles II, the “Merry Monarch,” valued scientific discovery, although the legend that he attended the Royal Society meeting where the blind spot was demonstrated and then used his own to “behead” members of his court appears apocryphal. Mariotte is also credited with originating the trichromatic theory of color vision, the wind tunnel, and the relationship between pressure and volume of a gas. He concluded erroneously that the choroid was the light sensitive tissue of the eye.
Summary or conclusions: The “filling in” of the blind spot has intrigued many subsequent observers. Measurement of the blind spot became one of the major goals of perimetry and the subject of much discussion even into the 20th century.
Ludwig Laqueur’s Introduction of Physostigmine
For Intraocular Pressure Lowering in Glaucoma
Robert F. Heitz
In 1863, Douglas Argyll Robertson was the first to publish in ophthalmic literature the miotic effect of physostigmine (eserine), the alkaloid extract of the Calabar bean. This effect had been noticed one year before by Thomas R. Frazer.
Its clinical use as a miotic and an antagonist of atropine was immediately recognized. Albrecht von Graefe recommended it to obtain a miosis before the iridectomy procedure to prevent iris-prolaps, but he erroneously contended that atropine lowered intra-ocular pressure and that physostigmine could provoke acute glaucoma.
The importance of physostigmine as an intra-ocular pressure lowering topical drug in glaucoma was not recognized until 13 years later, when Ludwig Laqueur established it in 1876. Laqueur, noting that atropine could precipitate acute glaucoma, reasoned that miotics could be helpful and advocated its use in this disease.
In the same period of time, Adolf Weber described the effect of physostigmine on the ciliary processes of rabbits.
Ludwig Laqueur (1839-1909) was Professor of Ophthalmology from 1872 to 1907 at the University of Strasbourg. He was himself affected by glaucoma. In 1876, he personally learned of the hypotensive effect of physostigmine before undergoing a bilateral iridectomy four years later.
Stereoscopy During the Civil War; News, Entertainment or Propaganda?
Richard W. Hertle
Introduction: A stereograph is a pair of photographic images of the same object, presented on a single sheet, each at a slightly different angle. They were made by using a dual lens camera, or two cameras side by side. Stereographs were mainly albumen prints, but were produced by every photographic process available during the 19th century. The images were viewed through a stereoscope, a binocular-like device that produced a three dimensional effect. Stereographs were introduced at the Crystal Palace Exhibition in London in 1851. The stereoscope was a common fixture in parlors well into the twentieth century. Civil War stereographs cover the entire period of the Civil War, from the first Battle of Bull Run through the surrender at Appomattox. Most of the images were stereographs and made in the eastern theatre, with scenes in Virginia by far in the majority
Historical approach: Using multiple books, on-line and library resources stereographic civil war stereoscopic images will be used to discuss how this medium and its images of the war attempted to inform, entertain and influence public, political and religious groups.
Body: Three basic forms of photography existed during the war. The most common were individual portraits of soldiers taken by itinerant army camp photographers and small-town photographers called ambrotypes. The second basic form of photography was the carte de visite also primarily a portrait photograph, except it was made with a glass, wet-plate negative. The third basic form of Civil War photography were the photographs taken in the field by nationally known photographers and firms such as M. B. Brady, Alexander Gardner, George S. Cook and the E & H.T. Anthony Co. The majority of these were 3-D photographs taken with a twin-lens stereoscopic camera. Views in northern states include naval shipyards in Massachusetts and Philadelphia, the battlefield at Gettysburg, and a rally and parades in New York City. Compelling images of death on the battlefield, and the destruction of cities, railroads and bridges show the devastating effects of the war. Individual and group portraits of soldiers relaxing in camps, drilling in the field, and ready for attack in trenches and other fortifications. There are images of African Americans fleeing slavery by crossing the Union lines, and of African Americans on southern plantations as well as serving in the Army and Navy. Civilian religious groups, artists, journalists, photographers, politicians and political rallies also appear in the photographs.
Summary: In addition to providing entertainment and visual representation of battles, soldier’s life and far away places, stereoscopic photographs during the American civil war were a source of propaganda distribution for social, political and religious ideologies.
The History of the Search for a Comprehensive Theory of Extraocular Muscle Functions: From Donders to Pulleys
Robert S. Jampel
Purpose: to review the history of the ideas that dominates current thinking concerning ocular motor function. To answer the question what does the earth, the gyroscope, and the head have in common with the eye?
Resources: The abstracts and introductions to 30+ scientific papers all of which contain some information of historical interest. Chapter 27 the “Movements of the Eyes” in Volume III of Helmholtz’s “Treatise on Physiological Optics”, the internet, and Wikipedia.
Body of paper: There is as yet no cohesive theory of ocular motor function despite over two hundred years of experimentation and speculation. Donders (1818-1890) and Helmholtz (1821-1894) believed that all eye movements are commutative (eye orientation is independent of order of rotations around axes) and that there is no static ocular counter rolling. The ideas that dominate current thinking are in disagreement with those of Helmholtz and Donders. They are (1) that 3D eye movements are necessary in order to see depth, (2) that because the eye is capable of moving in 3D, it always moves in 3D (3) that eye movements are noncommutative (eye orientation is dependent on order of rotations) and noncommutativity produces the possibility of an infinite number of eye orientations (4) that static ocular counter rolling produces the result of otolith stimulation caused by head inclination (5) that bioengineering produces significant insights into ocular motor behavior (6) that complex number and vector analyses are needed to understand the function of individual extraoclar muscles (7) that a pulley mechanism exists in the orbit, that is not under the control of the brain, and which determines the location of the rotational axes of the extraocular muscles.
The scleral coil method was introduced in 1963 and is considered the “gold standard” for measuring eye movements. The hope was that this bioengineering method would provide data that would enable mathematically precise calculation of the surgical treatment needed for ocular motor defects. The promise is yet to be fulfilled for reasons I will speculate on.
Martinez-Trujilio summarized most of the latest ideas of ocular motor function cited above (Noncommutativity of Eye Rotations and the Half Angle Rule. Neuron 2005; 47:171-173). He used the terrestrial earth to describe noncommutativity. From his paper: “Imagine we are holding a globe of the earth positioned to face the African continent. If we rotate it 90° to the left around a vertical axis, we will face the Americas, and if we then rotate it 90°up around a horizontal axis, we will face Antarctica. On the other hand, if from the same initial positions, facing Africa, we rotate the globe first 90° up and then 90° to the left, we will end up facing a tilted view of the Americas. This demonstration that “left and then up”≠ “up and then left” i.e., rotations are noncommutative. It is important to note that in both cases the axes were similarly, only the order of rotations changed. This principle, applied to the study of eye rotations by Tweed and Vilis (1987), made existing commutative models using simple integrators of angular velocity to position insufficient to predict oculomotor behavior”.
I read his description of noncommutativity and had a sudden revelation (epiphany) by asking myself how the earth and the head really move! I think I now understand eye movements and want t share that understanding with you and obtain feedback. Simple is sophisticated!
Otfrid Foerster (1873-1941)
Danny H.- Kauffmann Jokl
Introduction or purpose: The cortical representation of pain and motor function was poorly understood at the onset of the 20th century. As a consequence of the investigation of war wounds, an insight into the representation of the visual cortex had been described by Inouye and Holmes. At about the same time, neurosurgeons Horsley, Cushing and Bucy were drawing similar insights regarding cortical control of motor function and pain from the neurological outcomes resulting from their novel surgical techniques of tumor extirpation.
Historical approach or resources: Foerster wrote over 300 scientific papers and, along with the recollections of co-workers and biographers provides us with abundant evidence for his contributions to neurology and neurophysiology.
Body of paper: In Breslau, Germany, Foerster, a superb neurologist and innovative neurosurgeon, evolved novel surgical techniques as anterolateral cordotomy that led to the mapping of the human dermatomes.A superb linguist and humanist, he drew international investigators to Breslau among whom were Wilder Penfield and Harvey Cushing at a time when they and others were active in the mapping of the motor representation of the human cortex.
Summary or conclusions: Otfrid Foerster, German neurologist and innovative neurosurgeon, was a precise investigator and clinician to whom we owe our understanding of the cortical control of pain and muscular function.
Oculist to Queen Victoria
Introduction or purpose: Ophthalmology in Great Britain from the beginning of Queen Victoria’s long reign beginning in 1837 until her death in 1901 was transformed from being a branch of general surgery, with a poor reputation, to a specialty in its own right. Some of the oculists to Queen Victoria were responsible for this transition. This paper will explore the lives and contribution of some of the oculists to the Queen especially that of William White Cooper.
Historical approach or resources: Recent access to the personal archive, including diaries, of William White Cooper, not seen by anybody outside his decedents, reveals the intimate details of his relationship to the Queen and her household from 1859 to 1886. There are profiles of some of his famous patients such William Gladstone, the Prime Minister and Thomas Carlisle. There are also letters from the knights Sir William Lawrence, Bowman, Wilde, Jenner and Richard Owen the great anatomist.
The paper will include brief profiles of other oculists to Queen Victoria such as Henry Alexander, Benjamin Travers and Sir George Lawson whose letters from the Crimean War as a young surgeon make fascinating reading.
Body of paper: The paper will trace through these oculists, mainly William White Cooper, the transition of the general surgeon performing eye operations without anesthesia to the start of the 20th Century when the oculist had had fifty years experience of the ophthalmoscope and was working as a specialist from the many eye hospitals which had been established in the period.
Summary or conclusions: With the limited tools to hand, the early Victorian oculist was a remarkably able surgeon and diagnostician. By the end of the Queen’s reign her oculists were at the forefront of international ophthalmology. This was exemplified by her favorite oculist Sir William White Cooper whose life and contribution to ophthalmology will be explored.
Historical Treatments of Demyelinating Optic Neuritis
Jacqueline A. Leavitt
Introduction: Optic neuritis associated with Multiple Sclerosis (MS) remains an enigma. The topic is presented in the context of an in-depth review of the management of this disease using a historical perspective. Understanding the historical treatment of this disease places current treatment modalities into context.
Historical approach/resources: The first well described episode of optic neuritis was in 1822 by Augustus D’Este (King George III’s grandson) as part of an autobiographical discussion of his multiple sclerosis in his diary published in 1989. His prescribed treatments consisted of everything from horseback riding to valerian (Valeriana officinalis). A step-wise progression of treatments for ON in MS are presented using a chronological approach from this earliest report.
Body of paper: A review of treatments for optic neuritis will be enumerated. The therapies will be grouped together according to the predominant theory of pathogenesis of optic neuritis of that era. Previous interventions have focused on eliminating infection and improving nutrition; eliminating allergic responses to toxins; improving blood supply and decreasing venous blockade; protein shock or fever therapy to promote natural defenses and most currently steroids. Many other treatment modalities occur in the literature without adequate explanation as to the primary motivation behind their use. Summary/conclusions: The treatment of optic neuritis has had a long and varied history. Given that optic neuritis spontaneously recovers without therapy, treatments that improve on the natural history need to be subjected to vigorous study. Despite the lack of case-controlled, double-blinded masked studies, multiple therapies in the past have been proven ineffective. Time will tell how long the current standard of care will last.
Erasmus Darwin and his Curious Corneal Trephine
Mark J. Mannis
Avi A. Mannis
Erasmus Darwin (1731 – 1802), the grandfather of Charles Darwin, was one of the foremost physicians of his era and one of Europe’s leading intellectuals. With extraordinary insights into physics, chemistry, geology, meteorology, and all the biological sciences, Darwin planted the seeds of biological evolution that were nurtured and developed into the modern theory of evolution by his grandson. Poet, botanist, and prodigious inventor, Darwin’s encounter with matters ophthalmological was, at best, tangential. However, he conceived of a corneal trephine for creating a transparent window in a leukomatous cornea. He developed his concept of this instrument in a quaint, illustrated correspondence with Thomas Wedgewood, a member of the famous English pottery family. Thus, this master physician scientist became the first modern scientific history to conceive of corneal trephination for the restoration of vision.
Evolution of Therapy for Retinal Detachment
Michael F. Marmor
Introduction or purpose: To review the history of the recognition and treatment of retinal detachment (RD), from ancient times to the vitrectomy era.
Historical approach or resources: Articles and books about RDs and by the key figures in the evolution of modern therapy.
Body of paper: RDs were not recognized clinically until ophthalmoscopy developed. Early mechanical approaches had little success. Gonin was the first to recognize the importance of breaks, and to seal them with moderate success. Innovators such as Rosengren, Schepens, Custodis and Lincoff brought new and better technology to extraocular tamponade. The development of vitrectomy by Machemer made an internal approach possible for the treatment of complicated RDs.
Summary or conclusions: The treatment of RD has been primarily an evolution of mechanical manipulations outside and inside the eye. In the future, physiological and pharmacologic knowledge about the mechanisms of detachment may lead to less invasive therapies.
How Glaucoma Affected Four Artists from 19th and 20th Century France.
James G. Ravin
Introduction or purpose: How glaucoma affected four artists from 19th and 20th Century France.
Historical approach or resources: Review of the art historical literature. Interpretation and application from an ophthalmologic point of view. The works of each of these artists have been exhibited many times and each artist has been the subject of monographs. Although the general public may not know of them, each is represented in major museums.
Body of paper: Jules Cheret (1836-1932), probably the most important poster artist ever, tragically became blind from acute angle closure glaucoma.
Louis Valtat (1869-1952), a pre-Fauve painter, suffered near total loss of vision at the end of his life, and was forced to stop painting. Auguste Ravier (1814-1895), a landscape painter, lost one eye from neovascular glaucoma. He was able to continue working, but suffered from a cataract in the other eye. Roger Bissiere (1886-1964), and abstractionist, lost extensive portions of his visual field before undergoing surgery to control his glaucoma. Post-operatively he was overjoyed to know that he would still be able to see.
Summary of conclusions: Different forms of glaucoma have affected artists in different ways, sometimes tragically. Glaucoma cannot be diagnosed from examining their works of art.
Ophthalmology in Afghanistan: Past and Present
Introduction or purpose: Present Eye Care in Afghanistan
Historical approach or resources: 2 visits to Kabul during 2004 and 2005 on missionary trips.
Body of paper: Prior to the 1930’s, there was hardly any professional eye care in Afghanistan. Several Afghan physicians received some ophthalmology training in Germany and France and returned to practice in Kabul. Despite the great obstacles of a war-ravaged country, many international organizations are at work – personal experiences of two visits to Kabul will be presented (2004, 2005)
Summary or conclusions: Eye care in Afghanistan needs help. Eye Foundation of America is committed to help.
The Axenfeld-Rieger Anomaly in Retrospect
William H. Spencer
Introduction and Historic approach: The reports and investigative methods utilized by Axenfeld, Rieger, Burian and Shields are reviewed with respect to their contributions to our understanding of the morphology, clinical manifestations and presumed genesis of the Axenfeld-Rieger (A-R) anomaly.
Photomicrographs and goniophotographs depicting salient clinical features of the anomaly and its associated corneal opacity are evaluated and a scenario is offered for its genesis and secondary structural alterations.
Body of paper: 1920: Axenfeld introduces the term - embryotoxon corneae posterius,and provides a concise description of the basic components of the anomaly. 1934-35: Rieger reports the familial occurrence of the anomaly and additionally describes iris stromal hypoplasia and hole-formation with corectopia as well as an association with non-ocular anomalies. 1954-55: Burian, Braley & Allen provide the first slit-lamp photographs of the corneal opacity in the Axenfeld variant of the anomaly as well as an artistic rendering of the gonioscopic appearance of the anomaly. They erroneously attribute the opacity to the presence of a “prominent anteriorly displaced Schwalbe’s ring”. 1983: Shields reports in-depth analysis of 24 patients with the A-R anomaly over a 7 year period; 14 have glaucoma. He catalogs continued progression of the iris abnormalities during the first 2 years of life in 3 children and histologic studies reveal the presence of ectopic corneal endothelium over the iris and trabeculae. He attributes the presence of a “prominent” Schwalbe’s line to the production of excessive basement membrane by primordial endothelium and secondary glaucoma to arrested development of the trabeculae.
Suggested scenario and conclusions: 1. The narrow width of the unique corneal opacity with its surrounding lucid zone, its peripheral location and the absence of primary abnormalities in adjacent anterior segment structures suggests that differentiation of the anterior chamber and trabeculae proceeds normally until a late stage of intrauterine development when a gene directed defect transiently induces failure of a narrow band of the peripheral iris to separate from the posterior corneal surface and produces a clinically visible adherent corneal leukoma – Axenfeld’s line . The normal recession process then continues and does not interfere with development of the trabeculae. 2. Post-natal differential growth of the anterior segment of the eye gives rise to progressive, gonioscopically visible, stretching and/or separation of tenuous adhesions from the posterior corneal scarred surface. The iris stroma is not innately hypoplastic but stretching, thinning and shredding of the stroma with subsequent hole formation - with or without corectopia –may result from reactive proliferation of ectopic contractile endothelium and its basement membrane over the clinically visible inner surface of the adherent leukoma onto the iris surface, where it effaces the iris crypts, distorts the stroma and may induce ectropion uvea. Similar endothelial proliferation over the outer aspect of the adhesions may extend over the trabeculae and obstruct aqueous outflow. Additional stromal alterations may be initiated by traction associated with repetitive constriction of the pupil upon narrow or broad zones of firm iris stromal adhesions.
A Personal Reminiscence about the Ridley Implant
Introduction or purpose: To review my personal experience with complications of Ridley Implants.
Historical approach or resources: Comments on Ridley’s original publication as well as a listing of complications.
Body of paper: Results of retinal repairs in 7 eyes of 6 patients between 1959 and 1964 including complications such as dislocation of the implant, glaucoma, fixed miotic pupils, and corneal edema. A brief film clip of a December 1952 Ridley Implant operation will be included.
Summary or conclusions: Even when there were complications that hindered retinal repair some retinas could be reattached.
The Refractions of George Milbry Gould
Abstract: George Gould (1848-1923) was a prominent essayist, editor, lexicographer, and practicing ophthalmologist in Philadelphia. At age 32 he was given, for the first time, a careful cycloplegic refraction and got a pair of glasses that cured his headaches and allowed him to read in comfort. He was so impressed by his new glasses that he wanted to spread the good news. He went to medical school in Philadelphia, and then spent much of his professional life doing super-careful refractions on difficult patients.
Presented at the AGS Joint Session
Glaucoma Treatment: Drugs
Evolution of Disease Concepts
Glaucoma in Art
Glaucoma Treatment: Lasers
Glaucoma Treatment: Surgery