32nd Annual Meeting Abstracts 2019  

 

Snyder Lecture

The Sociology of Refractive Errors: The Good, the Bad, and the Mysterious

         David G. Harper

This paper discusses the evolution of attitudes surrounding refractive error science during more than 20 centuries. From the time of Pliny the Elder in the 1st century AD to the evolution of 21st century refractive surgical techniques, erroneous concepts have often strongly influenced clinical practice. Myopia and presbyopia were the earliest recognized refractive errors because of the associated diminished visual acuity that was obvious to everybody. However, myopic individuals encountered negative attitudes that limited full societal participation. 

Presbyopia was not controversial as it happened to the virtually every aging person. However, eye practitioners did not understand that apparent presbyopia occurring in younger people was secondary to a significant underlying hypermetropia. The resulting blurred vision and headaches after prolonged close work defined asthenopia in this population group into the 20th century. For unknown reasons, fear of causing irreversible amblyopia in individuals using convex lenses for close work became commonplace. The use of convex lenses was denied to many while some even encountered recommendations to emigrate to Australia where ranching activities didn’t require prolonged reading. Donders, in his 1864 text book, strongly refuted this erroneous concept, stating that he had never seen amblyopia develop secondary to the use of convex lenses for close work. However, generally poor communications in the latter 19th century assured their slow adoption. 

Practitioners noted that myopia, apparently associated with school work, was increasing in frequency in the 19th century. Bizarre ideas about the causes were common, but everybody agreed with the need for a prevention or cure. However, serious attempts at myopia prevention would await the 20th and 21st centuries, and currently the evaluation of topical drug therapies, convex lenses, bifocals and various highly specialized contact lenses all remain under intense study. Meanwhile, corneal surgical techniques for refractive error correction, especially in young people, have become commonplace. However, recent attempts using corneal surgery to provide superior vision for athletes, in the belief that this will enable them to excel at various sports, are probably doomed to failure. 

 

 Special Guest Lecture

The Great Bear Rain Forest

Patrick Freeny 

 The Great Bear Rainforest, the largest, remaining intact temperate rainforest on our planet, is home to First Nations cultures and a complex, elegantly co-dependent marine and terrestrial ecosystem. The origins of this unique place, the cultural traditions of the local First Nations who have lived along the coast for over 10,000 years, and the animals of the ecosystems, from herring to humpback and orca whales, to the fish-eating coastal rain wolves, spirit bears, and grizzlies, will be seen through the video and camera lens of Patrick Freeny taken over the past 20 years that he has sailed, hiked, and kayaked along this magnificent coast. 

 

Clyde Keeler and the Dark Side of Genetics 

     Daniel Albert

This presentation recounts events in the early years of retinal genetics by reviewing the activities of Clyde Keeler (1900-1994), one of its pioneers. Keeler was a geneticist strongly influenced by the eugenics movement, who, in 1923, discovered the first inherited structural abnormality in the nervous system based on a single gene mutation: the “rodless mouse,” an important murine model for retinitis pigmentosa.

As an undergraduate at Denison University, Keeler was selected to work summers in the Eugenics Training Corps at the Cold Springs Harbor Laboratory. As a graduate student at Harvard, he prepared microscope slides of an eye from one of the mice he was breeding, and discovered it lacked the rod and photoreceptor cell layers. 

In 1927, Keeler became the first researcher hired in Harvard’s new Howe Laboratory, where his interests centered on genetics and eugenics. In 1936, Keeler wrote a section in a book entitled “Eugenical Sterilization,” advocating voluntary sterilization for various hereditary eye and neurological disorders. In 1938, he visited a genetics/eugenics laboratory in Berlin and gave it a positive review.

Moving to the University of Pennsylvania in 1939, Keeler developed his theory of “pigment gene pleiotropy,” claiming that the pigment gene also regulated the phenotype of other organ systems, as well as behavior. Keeler considered this theory to be his most important scientific contribution. He was discharged from Penn in 1942 and then moved through a number of different positions before retiring in 1962. During these years, he studied the Cuna Indians of Panama, who had high incidences of albinism. 

In 1981, Matthew LaVail, in his Friedenwald Lecture at ARVO, reminded vision scientists of Keeler’s early discovery, and the following year, Keeler was ARVO’s guest of honor. 

The significance and impact of Keeler’s work on rodless mice is assessed.

 

Milton's Blindness

     Jennifer Arch  

The English poet John Milton (1608-1674) began noticing weakness in his vision in the mid-1640s. By 1652 he was completely blind. In his most famous sonnet, Milton asks God—though “fondly”—how such a barrier to his work as a poet and scholar can have been presented to him. In later works, especially Paradise Lost, he made full poetic use of the idea of blindness as insight and prophecy, integrating it into a larger argument about passivity as heroism. As reconciled as this language makes him appear, however, Milton actively sought a physical explanation for his condition, and he acknowledged the suffering it caused him. In my presentation, I will summarize modern speculations about the cause of Milton’s blindness, and I will give an overview of how Milton used the irony of blindness as insight to achieve remarkable effects in both poetry and argument, especially in Paradise Lost. In Book 3 of that poem, though Milton is cut off from the “cheerful ways of men” by “ever-during dark,” the Celestial Light of God shines “inward,” giving Milton the power to see what it invisible to other mortal men: God’s reasons for his treatment of mankind.

 

Dr. Bacteria, or Dr. Santiago Ramon y Cajal

     Donald Blanchard  

Dr. Santiago Ramon y Cajal, the renowned anatomist, was also a science fiction author under the pseudonym of Dr. Bacteria with an early novel about an explorer on Jupiter, who encountered humanoid monsters 10,000 times larger than men. Upon graduation with a Licentiate in Medicine he was drafted to serve in Cuba. He contracted malaria, dysentery, and tuberculosis and was discharged home. When he recovered, he found himself sullen, unsociable, and passed-over for advancement at his medical school. 

He won the Nobel Prize in Physiology or Medicine in 1906 for his new work in the neuronal theory of the nervous system. The previous year in a limited edition under his pseudonym, he had published five science fiction stories.

The main character in “The Corrected Pessimist” is Juan Fernandez, a 28 year old sullen and pessimistic doctor in Madrid, recovering from a severe bout of typhoid fever. He had few friends or patients, his fiancée was drifting away, and he was passed over for an academic chair.  
Juan asked The Spirit of Science, ”Why were bacteria created; why does the unlucky flight of spores become the fate of civilizations?” He wished for vision sharp enough to see these virulent germs.

The Spirit of Science agreed to a one-year trial of amplifying all objects 1,000 times. Working at his home laboratory, as did Cajal, Juan discovered unrecognized germs, with his naked eye, but, alas, no one believed Juan. 

The term of new vision ended with a pleased Spirit of Science. Equanimity returned and his pessimism was cured. Juan returned to the clinics and married, happily. Cajal also enjoyed life more, realizing “that any man could, if he were so inclined, be the sculptor of his own brain.

 

The Caduceus vs. Staff of Aesculapius - One Snake or Two?

  George Bohigian  

There is much confusion about the true symbol of medicine.  The single staff with one snake entwined is the current AMA logo. The history of this ancient symbol, with a heritage stretching over two millennia, is shrouded in the fog of history. Many physicians, as well as the public, are unaware there are two distinct symbols commonly used, which have two different origins. The Staff of Aesculapius is a rough-hewn branch entwined by a single snake, while the Caduceus has two snakes wrapped about its slender staff and the addition of a pair of wings. Aesculapius is the god of medicine. He is seen with a traveling wooden staff, which represents plants and growth. The staff is entwined with one snake.

The popularity of the Caduceus with two snakes is probably attributed to being more aesthetically appealing than the Staff of Aesculapius. The symmetry is more balanced than the single snake version.

 

Leonhard Euler: The Mysterious Oculopathy of a Mathematical Genius     

     John D. Bullock; Ronald E. Warwar; H. Bradford Hawley

Posthumous diagnosis of historical figures with ocular defects, based on portraiture assumed to be anatomically accurate, is both interesting and intellectually challenging, requiring an intimate knowledge of ophthalmology, general medicine, and biography.

The Swiss polymath Leonhard Euler, who spent the majority of his adult life at the St. Petersburg Academy of Sciences, is considered one of the most famous mathematicians of all time and themost prolific. In 1735 (at age 28) he developed a near-fatal febrile disease. Euler’s portrait in 1737 shows a normal appearance of both eyes. The following year Euler suffered a febrile relapse and began to lose his right-eye vision. His fevers continued. A 1753 portrait shows a partially ptotic right upper eyelid with miosis (consistent with Horner’s syndrome) and a right hypertropia (consistent with a CN-IV palsy). In 1766, Euler developed a left cataract, the unsuccessful 1771 extraction of which left him virtually completely blind, but still able to perform highly complex mathematical calculations in his head. In 1783, Euler suddenly sustained a fatal cerebrovascular accident.  

 A recent publication suggested a CN-III palsy due to a(n): 1) “septic cavernous sinus thrombosis” from either “paranasal sinusitis” or “stye;” or 2) “aneurysm of the right posterior communicating artery of the circle of Willis.” These are incorrect. He did not have a CN III palsy. Typhoid fever, tuberculosis, epidemic typhus, syphilis, and the Tolusa-Hunt Syndrome can also be excluded. 

 An essential part of the 18thcentury Russian diet had been raw milk, the consumption of which is a significant risk factor for brucellosis (undulant fever). This condition is a long-standing, recurrent febrile disease which can be associated with optic neuropathy, retinitis, cranial and peripheral neuropathy, cataract, phthisis bulbi, and mycotic aneurysms. Thus, brucellosis was the most likely cause of Euler’s mysterious systemic disease, oculopathy, and intracranial hemorrhage.  

 

 From Trinity to Today - The Evolution of Military Head and Neck Trauma Teams 

  Michael Deegan; Robert Enzenauer

The current treatment of military head, face, and neck trauma patients – provided by teams of neurosurgeons, ophthalmologists, otolaryngologists, and plastic surgeons -- traces its origin to the turn of the twentieth century. The development of dramatically-increased explosive effectiveness resulted in a greater incidence of traumatic injuries to the head, face, and neck during the First and Second World Wars. The need to treat these compound injuries led the British to develop designated teams of specialized surgeons to care for patients suffering from a constellation of complex wounds. The so-called “Trinity” of World War I was quickly adopted by American physicians from their British counterparts and laid the foundation for treatment on subsequent battlefields.  The success of multispecialty treatment teams in Afghanistan and Iraq further validated the concept of dedicated practitioners caring for head, face and neck trauma.  As the explosive capabilities of armaments increase with each ensuing conflict, the importance of “head and neck” treatment teams in modern combat medicine is becoming increasingly relevant.

 

An Obscure Eye Surgeon and a Very Famous Son [poster]

       Ira Eliasoph

Ophthalmologists have made many contributions to our world by their direct work or indirectly in different ways. An eye surgeon from Wills Eye Hospital, many years ago, resigned at a peak level of his career. He and his wife, at her insistence, went off to Europe and there raised their son, John. That son became a painter and in time did a group portrait of four physicians we all recognize. That ophthalmologist was FitzWilliam Sargent. Learn the whole story and companion items when you see it all. 

 

Charles Joe Snyder: Architect of Our Ophthalmic Heritage [poster]

       Ira Eliasoph; Pamela C. Sieving

Charles Snyder, 1914-1996:  the librarian and archivist of the  Massachusetts Eye and Ear Infirmary from 1951-1982, and a medical historian in ophthalmology and otolaryngology, he set standards for both the fields of ophthalmic history and vision librarianship.  Snyder is known for a series of 50 papers published in Archives of Ophthalmologyunder the rubric “Our Ophthalmic Heritage,” later the title of a book in which they were compiled. He also wrote a history of the MEEI, published in 1984.  He was a speaker at national and international conferences and such occasions as the dedication of the Cecil S. O’Brien Ophthalmic Library at the University of Iowa; he was elected to honorary membership in the New England Ophthalmological Society and the New England Otolaryngological Society.  The Snyder Lecture, presented at the annual meeting of the Cogan Ophthalmic History Society, honors both Charles Snyder for his accomplishment and those whose own achievements in the field of ophthalmic history are of note.

 

William Wallace (1860-1940): British Ophthalmologist and Classical Music Composer 

     Robert M. Feibel  

William Wallace (1860-1940), a Scotsman by birth, received the degrees MB, MCh, and MD from the University of Glasgow and spent several years as a house surgeon at the Royal Infirmary and Glasgow Eye Infirmary. He continued his training as a clinical assistant at Moorfields (Royal London Ophthalmic Hospital), qualifying as an ophthalmologist in 1888. Even as he was training in eye surgery, he was already composing music, and eventually, Wallace became more attracted to the ear than to the eye, and he left medicine to become a composer. 

 He apparently never practiced ophthalmology after 1889, except during World War I, when he volunteered (at age 55) to serve in the Royal Army Medical Corps for four years, 1915-1919. He spent these years examining thousands of patients and treating ocular injuries from the war.  
He studied briefly as a Fellow at the Royal Academy of Music in London, but was mostly self-taught. Wallace was influenced by the music of Franz Liszt and Richard Wagner, and, following their lead, became a champion for late Romantic music.

He wrote many types of music. His most successful were symphonic or tone poems. These compositions were programmatic, which is a genre in which music relates to or is inspired by history or the visual and literary arts, subjects of interest to Wallace. He also wrote songs and music for the theater. He was a painter, playwright, music critic, translator, and advocate for composers’ copyright interests in Parliament.

After the War, he never again composed, but held important positions in organized music such as Professor of Harmony and Composition at the Royal Academy of Music. Only about 30 percent of his compositions were performed or published in his lifetime, but recently, there has been increased interest in performing and recording his music.

 

The Genius of Art Tatum, a Blind Black Pianist: His Impact on The Development of Jazz

     Gerald A. Fishman; Marlene Fishman 

The presentation focuses on describing Tatum’s blindness, personality, musical genius, and his impact on the field of jazz music. Art Tatum was born on October 13, 1910 in Toledo, Ohio and died in November, 1956 in Los Angeles of uremia.  Art was born with congenital, “milky” cataracts. He underwent 13 eye operations in his youth.  Also in his youth, he was mugged and hit in the left eye with a blackjack. The eye was damaged beyond repair. His right eye progressively worsened until it was left with limited sight.  

Art was compulsively independent and competitive. As such, he shunned assistance. He was generous toward other musicians, particularly younger ones. Temperamentally he was reserved and entirely consumed by playing the piano. Tatum possessed an extraordinary memory for music and people. One additional extraordinary trait was his ability to consume large amounts of alcohol while playing his music.  

Tatum was trained in the New York stride style of jazz playing. He was influenced by P.J. Johnson, who helped develop the technique, and Fats Waller, who highly promoted and advanced it further. Art took this style of playing to another height by incorporating elements from early and late 19thcentury classical music. It was Tatum’s unique approach to improvisation that set him apart from the contemporary modern jazz sound. He set a new standard for jazz pianists as to what was possible on a keyboard instrument. Art developed distinctly unique harmonizations with rapid arpeggios and complex runs. Tatum influenced the playing of George Shearing, Oscar Peterson, Duke Ellington, Erroll Garner, Teddy Wilson, and Louis Armstrong, among others. Even Vladimir Horowitz and Arturo Toscanini were in awe of the immense talent of the black pianist Art Tatum. 

 

James Lind and the Scurvy Treatment Trial

      Ronald Fishman 

In 1753, James Lind published his Treatise on Scurvy, describing his attempt to identify the best means of preventing and treating scurvy aboard ships of the British navy. He had divided a group of sailors with active scurvy into six groups, each of which received a different diet. Only the group receiving citrus juice or a similar source of vitamin C showed a clear, prompt resolution of scorbutic signs and symptoms. This event is frequently referred to as the first controlled clinical trial, leading directly to the consistent use of lime juice in the Royal Navy and the conquest of scurvy. The story is presented as a milestone in the history of medicine, not only regarding scurvy, but as the progenitor of scientific, evidence-based medicine. But many elements of the standard version are misleading, particularly the inference that the scurvy problem was solved.  It was not solved at that time, and the reasons tell us something about how medical discoveries are made and generally accepted into practice.

 

The Story behind Amsler's Grid

     Albert Franceschetti 

Amsler was not the first to use what became known as the Amsler’s grid, but because the original inventor never had the time to publish his findings, Amsler happened to make a presentation to the Swiss Society of Ophthalmology in 1943, explaining how to use the grid. And thus he became world-famous.

 

Why are Spectacles Depicted on the 1582 Siege Coins of Audenarde?

      Jay M. Galst 

The 1582 siege coins of Audenarde will be described along with a brief history of the town in the 16thcentury. Audenarde was a wealthy town in Flanders, which became Protestant following the Reformation and allied itself with Ghent against Charles V. The prolonged siege of 1582 by the Spanish resulted in the subsequent flight of nobles and merchants, resulting in the town to never recover to its former glory.

As rare siege coins, those of Audenarde have been collected by prominent numismatists for centuries. The depiction of spectacles on these coins has also made them popular collectables by ophthalmologists and other optical collectors since the 19thcentury. Some of the previous theories as to the reason for the depiction of spectacles on these coins will be discussed, as well as the discovered reason.

  

Night Blindness in Soldiers and Sailors: From Malingering to Malnutrition

    John Gittinger

The medical study of loss of night vision, nyctalopia—often paradoxically call hemeralopia in older literature, has a long history. Hippocrates recognized it and offered a remarkably prescient treatment: raw calves’ liver dipped in honey. The implications for soldiers and seamen of poor night vision are particularly serious. The inability to perform sentry duty or keep watch at night severely limits their function. The attitude of military and ship’s physicians toward this disability has evolved with advances in the knowledge of retinal physiology and disease, but the possibility of malingering to avoid duty was often raised, with potentially grave consequences. For reasons to be discussed, malnutritional nyctalopia was often prevalent in men in wartime and at sea.

 

The History of Eye Movement Recording: 200 Years of Investigation

     Richard Hertle  

Introduction/purpose: To describe the evolution of relevant techniques, and their inventors, used to investigate the ocular motor system over the last 200 years.

Methods: Medical libraries, the internet, multiple ocular motor physiology laboratories’ historical records, and the author’s collection were used in combination as source materials.

Summary: This paper will summarize the history of eye movement recordings from the 18th century until today and will discuss the technical principles of the early forms of modern recording devices. Eye tracking devices developed in the late 19th and early 20th centuries resulted in new insights into the true nature of eye movements and underlying brain mechanisms. These technological advancements allowed novel questions to be addressed, resulting in new and unexpected discoveries in the neurophysiology and neuropsychology of eye movements, as well as their relation to orbital mechanics, brainstem function, cognition, and visual perception.

Conclusions: Eye-tracking technology continues to evolve, and with it, so does our investigative flexibility and creativity. Increasingly, eye movements can be measured simultaneously with other brain functions during complex visual, vestibular, and gross motor tasks. These innovative applications will have new and profound influences on our understanding of visuo-motor integration and treatment of ocular motor diseases.

 

How Did Implementation of Medicare Affect Ophthalmologists?

     Erich P. Horn 

Medicare, the federal social insurance program that pays for hospital and medical care services for Americans age 65 and older, was passed by Congress and signed into law by President Lyndon Johnson in 1965. While politically popular, the legislation was opposed by many physicians and their professional organizations. The effect of this landmark legislation on the private practice of ophthalmology has been little-studied and is the aim of this investigation.  By examining practice financial records, patient logs, and recollections of surviving office staff and ophthalmologists and their spouses through the archives of the Alachua County Medical Society, I hope to illustrate the effects of Medicare on particular ophthalmologists in north-central Florida, which may apply to American ophthalmologists, in general. I hypothesize that patient volume increased over the ensuing three years after implementation, that ophthalmologists’ income rose, and that difficulties with collection of fees from elderly patients were diminished in this large segment of ophthalmologists’ practice.  

This investigation is relevant today because the next phase of health care reform is being considered. Ophthalmologists, their professional associations, and political lobbying organizations are very interested in the results and highly motivated to influence regulatory agencies and regulatory agendas to further their own interests for high income and to minimize interference with medical practice, much as they were two generations ago when Medicare was first implemented.

 

Eyes of Gold – Incorporating Gold into Eye Care: A History

     Michael Hughes 

Introduction: In the last 70 years since PMMA has been utilized, there has been a rapid change in materials used in medicine, including ophthalmology/eye care. Gold’s inherent qualities suggested its early use; its historical uses in ophthalmology and eye care are presented here.

Methods:Few materials have the history, value, and dependability of gold. Such terms as “gold standard,” “golden,” and “the Golden Rule,” all demonstrate the value and mystique of this legendary element. Gold has been the international standard of luxury for millennia. In addition, the metal has many practical uses, including some in medicine and prosthetics.

Gold’s chemical symbol (Au) is from the Latin aurum(glowing), and its atomic number, 79, places it just between platinum and mercury in the periodic table of the elements. It is a noble metal with a valence of 1 or 3. A highly sought-after metal, this naturally occurring mineral is found in grains, nuggets, and underground veins in rock and deposited in river sand. It has several crystalline structures, including wire, leaf, branch, and tree forms, often within quartzite formations.

Conclusion: Although gold still has some uses in ophthalmology (and eye care), it is unlikely to be widely used again as its cost increases.

Hermann Knapp and Herrmann von Helmholtz at Columbia College of Physician & Surgeons October 3, 1893

     Danny H.- Kauffmann Jokl

In 1868, Professor Hermann Knapp resigned his Heidelberg Professorship, sailed for New York, and, within two years, opened a private Ophthalmic and Aural Institute, founded the Archives of Ophthalmology and Otology, was admitted to the American Ophthalmological Society, and, in 1888, was appointed Professor at Columbia College of Physicians & Surgeons (P&S).

On October 3, 1893, Hermann Knapp hosted his Heidelberg colleague Hermann von Helmholtz on the occasion of the opening of the Knapp Ophthalmology Clinic at P &S.

Helmholtz was the preeminent scientist of his era, comparable only to Albert Einstein,  a student and admirer of Helmhotz, in the 20th century. Helmholtz, best known for his ophthalmoscope, also was renowned for unique achievements in the field of optics, otology, color vison, electrical conductivity, and energy conservation – all objects of his genius and his original observations. 

Visiting with his old friend Knapp, he addressed an audience of ophthalmologists and phsicians. He recalled in 1851, as lecturer in Physiology in Koenigsberg, explaining that the glow in cats’ eyes at night is due to reflected light from the tapetum. As practicing physician, he recognized how utilizing this reflected light could permit physicians to visualize the retina, until then invisible. “I intended to show the ophthalmoscope as a useful explanation for reflected light to prove that light emanated from reflection from the retina and just needed a converging lens to image the retina itself…Its use for disease was an afterthought…I had merely taken previous work and completed it; they had stopped in the middle of the way without going on to the end.” He admonished his audience “to go to the end when investigating natural phenomena.”

 

Ophthalmic Pathology in the Parable of the Blind Leading the Blind by Pieter Bruegel

     Zeynel Karcioglu 

Pieter Bruegel the Elder (c.1525–1569) was a well-known 16th- century painter who created many realistic canvases related to daily activities of common people of his time. The degree of realism he utilized in his paintings provided a great deal of information about life in the second half the 16th century. He was very talented in detailing the surroundings and life styles of those times, as well as the human appearances. Bruegel’s minutiae have allowed physicians over the years to critically analyze medical conditions in his paintings. This presentation summarizes certain ophthalmologic diseases depicted by Bruegel, focusing largely on his masterpiece The Parable of the Blind Leading the Blind(1568), with a new twist.

 

Celebrating Frans Donders’ 200th Anniversary

     Richard Keeler 

The 200th anniversary of the birth of Franciscus Cornelis Donders (1818-1889) was celebrated with several lectures and events during 2018. 


Donders was foremost a physiologist and teacher, but from the early 1850s he took up ophthalmology. He was greatly influenced in doing this after he met Albrecht von Graefe and William Bowman in London in 1851, while attending the Great International Exhibition. The announcement of the invention of the ophthalmoscope by Hermann von Helmholtz in the same year spurred on all three young men, who became life-long friends, to explore the secrets of the fundus with great urgency and enthusiasm.


Donders set up the first ophthalmic hospital in the Netherlands in Utrecht, and soon many students and ophthalmologists came to study under him and listen to his lectures. One of the students was Herman Snellen, who joined Donders at the hospital as an ophthalmologist, eventually taking over the running of the hospital.


Donders published many articles and books, the most famous being On the Anomalies of Accommodation and Refraction of the Eyein 1864.


Donders’ anniversary provided an opportunity not only to review his life and contribution to ophthalmology, but also to investigate closely many of the ophthalmic treasures stored in the University Museum that he -- and Snellen -- used in their experiments on the optics and physiology of the eye.

 

Aspiration of Cataract in 1815 in Philadelphia, Pennsylvania [poster]

    Christopher T. Leffler; Charles E. Letocha; Kasey Pierson; Stephen G. Schwartz

We present and discuss the previously unrecognized evidence for the possible introduction of cataract extraction by aspiration into modern Western medicine on March 26, 1815, in Philadelphia, Pennsylvania, by surgeon Philip Syng Physick. On this date, he successfully extracted a cataract by suction through a tube, according to newspaper reports written by the patient, an attorney who sought a patent on the suction device. Aspects of the patient’s account are confirmed by supporting evidence from the medical community and by a cataract instrument set attributed to Physick, which includes a cannula attached to a syringe. The evidence suggests that Physick was the first to reintroduce cataract aspiration to Western medicine.

Published as: Leffler CT, Letocha CE, Pierson K, Schwartz SG. Aspiration of cataract in 1815 in Philadelphia, Pennsylvania. Digital Journal of Ophthalmology 2017; 23(4):95-98. PMID 29403333

 

Why an Eye Hospital, Mr. Wills?

     Charles Letocha 

Wills Eye Hospital has been in existence since 1834 and is one of the premier ophthalmic institutions in the world. But little is known about its origin. This paper will explore what biographical information is known about James Wills, Sr. and James Wills, Jr. and make some conjectures about why they might have wanted to found an eye hospital.

 

Novels, Storytelling and the Eye: Creative Writing Viewed Through the Ophthalmologist’s Lens

     Veronica Lucian; Robert Enzenauer

When asked why he pursued careers as both a writer and physician, Dr. David Hellerstein answered, “For me it was hardly a matter of choice…I became passionate about writing…and I decided that I wanted to become a doctor as well.” Throughout history and into modern times, ophthalmology has shaped a large cohort of physician writers, many of whom have written primarily fictional works with historical background. In the19thcentury, Sir William Robert Wills Wilde, father of famed writer Oscar Wilde, published five non-medical works, the first of which, The Narrative of a Voyage to Madeira, Teneriffe, and Along the Shores of the Mediterranean,combined science and folklore. Around the same time, Sir Arthur Conan Doyle gave the world Sherlock Holmes.

The trend continues with a new wave of ophthalmologist writers. In recent years Robin Cook has become a New York Times bestseller for his novels combining medicine with the thriller genre. Andrew Lam has published two historical novels and is working on a third. In 2015, Gita Bhandari published a novel portraying the experiences of a Hindu family post World War II. Joseph Reich has published multiple fiction novels. In the last two years, Gene Helveston produced two historical/political thrillers. This writing trend will be examined through the respective works of past and modern authors, with special focus on the influence of ophthalmology.

  

Electrotherapeutics in Ophthalmology: A Shocking Tale

     KieuYen Luu; Mark J. Mannis

The history of employing electrical current as a therapeutic agent in medicine spans the past 200 years.  Practitioners of ophthalmology have long been fascinated with the application of Galvanism (continuous current resulting from a chemical reaction) and Faradism (magneto-electric current) to diseases of the eye.  The range of diagnoses managed with electrotherapy is broad: from blepharitis and trichiasis to degenerative retinal disorders and optic neuropathies. While electrotherapy may not be of proven efficacy in many eye disease states historically, it has proven efficacy in several disorders and continues to fascinate contemporary vision scientists with applications to retinovascular optic nerve disease as well as to corneal wound healing.  We will review the intriguing history of electrotherapy in ophthalmology:  past, present and future.

 

X-linked Ocular Albinism – Mapping and Cloning the Gene

     Ian MacDonald 

Introduction: Albinism is typically divided into conditions that affect the eye, skin, and hair (oculocutaneous albinism, autosomal recessive conditions) and those that predominantly affect the eye (ocular albinism, an X-linked disorder, XLOA). XLOA is characterized by iris transillumination, nystagmus, foveal hypoplasia, and macro-melanosomes. Early mapping studies with blood groups allowed assignment of the XLOA gene to the short arm of the X chromosome. Only with the advent of molecular genetic techniques was the gene cloned from a critical region on Xp22.

Methods: Interviews with two senior colleagues in Canada (William G. Pearce, Emeritus Professor, U. Alberta) and the USA (Dr. Richard Lewis, Baylor College of Medicine, Houston) were undertaken to provide insights into the early investigations of XLOA, to understand how initial progress was made and how molecular techniques allowed cloning of the gene.

Results: Blood samples from XLOA patients with newfoundland pedigrees were collected by Dr. G.J. Johnson and sent to the MRC Laboratory of Dr. R. Sanger in London. Analysis of the segregation of Xg (a+/a-) blood group polymorphisms was used to assign the gene for XLOA to the short arm of the X chromosome (1971). DNA from the same large Newfoundland pedigree was further investigated with the use of DNA polymorphisms to localize XLOA more proximal than Xg on the X chromosome (1992). Finally, in 1995, a multi-disciplinary group from Italy, the Netherlands, and the USA (Baylor) identified the XLOA gene at Xp22.3-22.2.

Conclusions: Careful clinical examination of patients and the aggregate study of many families with affected males and carrier females resulted in identifying the XLOA gene. The major advances in gene discovery re XLOA occurred in a short period of time in the early 1990’s. Key intragenic deletions in the putative gene enabled confirmation that the gene for Nettleship-Falls ocular albinism had been found.

 

From Starch to Misfolded Protein. Milestones in the Scientific Understanding of Amyloid

     Curtis Margo  

Amyloid is ubiquitous in ocular and ocular adnexal disease. It can be found in eyelids, conjunctiva, cornea, vitreous, uveal tract, retina, and orbit. Although the term amyloid implies a singular condition, this pink amorphous material is a shared feature of many unrelated diseases. Rokitansky provided the earliest comprehensive description of amyloidosis in 1842, but promulgated the unflattering name “lardaceous disease,” which other physicians used to describe these waxy deposits for roughly 50 years. Rudolph Virchow coined the term amyloid in 1854, thinking it was starch. But Virchow was looking at corpora amylacea in the brain, which have nothing to do with amyloid. Amyloid is now considered a protein misfolding disorder arising from over 20 different precursor proteins. The physicochemical properties of amyloid responsible for its unique optical properties (and famously popular for their diagnostic utility) were elucidated during the 20th century. Major advances in deciphering the molecular properties and pathogenesis of amyloid have depended on the development of sophisticated technologies, such as electron microscopy, immunohistochemistry, and X-ray diffraction. This presentation will examine milestones in scientific discovery that have led to our current understanding of amyloid. Perhaps no other single misshaped molecule illustrates the interdependence of technology with scientific discovery than amyloid.

 

Franciscus Maurolicus Revisited

     Harry Mark  

In writing of 1554, Maurolicus was the first to assign to the retina the site of the optical image. His anatomy of the eye was, however, quite ancient. The erect image is shown to fall at the entry of the optic nerve. It is upright rather than inverted. He described the lens as not spherical, but more compressed on the front side than the back. The aqueous humor is said to be a discharge of the lens. The vitreous humor feeds nourishment to the lens. It is, itself, nourished by the retina. People with deeply curved lenses are nearsighted; a flat lens leads to farsightedness. The lens flattens with age, causing hyperopia (presbyopia).

 

Did Leonardo have Strabismus?

     Michael Marmor 

Purpose: A recent article in JAMAOphthamologypresented an analysis of attributed portraits of Leonardo, asserting that he had divergent eyes. This issue had been raised (questionably) for Rembrandt a decade ago on similar grounds, and thus revisits the larger questions of what one can learn about artists’ eyes from the examination of art historically, and whether strabismus has any effects on art. 


Methods: Portraits of Leonardo and the points raised in the article are analyzed critically.


Results: The attribution of these portraits is admittedly questionable, and the portraits clearly show different people. Thus, it is specious to argue they all show Leonardo’s eyes. Many of these portraits also have obvious errors, such as a hypertropia or eccentric pupil, which the author dismisses as style -- but one should not dismiss some features as style while accepting others as worthy of measurement. Furthermore, judging ocular angle by the amount of visible white of the eye is a faulty technique because of artistic license and because even normal eyes can appear divergent in side gaze. 

Conclusions: There are many reasons to question the “evidence” in this report, and the implicit argument that intermittent exotropia would enhance an artist’s ability to paint in two dimensions seems equally indefensible. We have no trouble enjoying photographs with full stereopsis, and artists with severe strabismus (like Barbieri) do not portray depth in any special way. Diagnosing eye disease from artwork is always hazardous, whether from an artist’s paintings or painted portraits of the artist. We will never know for certain whether Leonardo has straight eyes, until he comes in for examination -- but it wouldn’t make a bit of difference to his art.

 

It’s His Fault! The Complications of Dieffenbach’s Primacy

     Norman Medow; Anita Goyal; Gabriel Rand

Johann Friedrich Dieffenbach performed the 1st known strabismus operation on October 26th, 1839. The surgery transected the medial rectus muscle in a case of esotropia. This operation was performed in order to cure the patient of this “unbecoming infirmity. “ Surgeons throughout the world rapidly followed Dieffenbach’s lead, and books on the subject soon appeared. In 1842, Dieffenbach wrote his own book analyzing the 1,200 surgeries for esotropia that he had performed in the three years since his origin operation. He indicated that tenotomy is an operation NOT without complications. At times, the cut muscle could reattach in an “unfortunate position, far back, resulting in the fact that the formally dominant muscle was too weak to counter balance the strength of its antagonist.” That is, an outward turning or exotropia would result. Other unwanted positions were also noted: hypertropias, hypotropias or -- the worst of all “complications” --  little or no improvement!!

This talk will discuss the complications of the Dieffenbach Tenotomy Operation, the surgeons who recognized these complications, and the solutions they offered to correct them.  It was these situations that lead to the development of the field of strabismus surgery-NO GOOD DEED GOES UNPUNISHED -- but -- PUNISHMENT CAN LEAD TO REHABILITATION!!

 

The First Published Ophthalmoscopic Illustrations by A. C. van Trigt, MD 

     Fraser Muirhead 

Very rarely does someone do something no one has ever done before. In his M.D. thesis, Adrien Chistophe vanTrigt did just that. His 1853 images of the interior of a living human eye are generally considered to be the first ever published.

Although van Trigt is widely recognized for this accomplishment, virtually nothing has been written about him. He was born in Dordrecht in 1825 to a very prominent surgeon, aquarellist, and ornithologist and his wife. He died in Amsterdam 39 years later.

F. C. Donders assigned van Trigt the new ophthalmoscope as his doctoral-thesis subject. After graduation he worked in Amsterdam as a doctor in the local hospital and in a syphilis and skin diseases clinic. His personality was very retiring. He published very little, preferring to present papers at the Amsterdam Medical Group. However, the variety of subjects he addressed was remarkable, varying from trichinosis to progressive locomotor ataxia. His non-medical interests included painting and ornithology. His artistic skills were well-known; Christies’ sold a painting of his in 2001.

Van Trigt’s life, the ophthalmoscope he used and helped design, the variations of his three 1853 fundus illustrations, along with a conjecture as to which of the three was published first, are the subjects of this presentation.

 

 Observation of the Microfilariae of O. Volvulus in the Anterior Chamber of the Eye 

     Rolando Neri-Vela; Luis Vicente Sánchez-Fernández

One ocular disease that causes blindness is onchocerciacis, whose historical origin has not been determined. In Africa Leuckart observed the subcutaneous nodules produced by Onchocerca Volvulus, and in Mexico Larumbe, Ochoterena and Torroella became interested in O. Volvulusafter discovering endemic areas in the states of Chiapas and Oaxaca, where the disease had been mentioned in writings as early as the 16thcentury. In 1929, some onchocercosis patients were taken from Chiapas to Mexico City, where they were examined -- and the microfilariae of this disease were observed for the first time ever anywhere.
In this paper we will discuss what Mexico has done to contribute to the study of this evil.

 

Evolution of Modern Cataract Surgery

     Steven Newman 

Introduction: Phacoemulsification and implantation of intraocular lenses have revolutionized cataract surgery, in a greater fashion that anything since Daviel. It is quite clear what we owe to Harold Ridley, and Charlie Kelman (1967).  Less clear, however, has been the evolutionary changes that have occurred since then that have made cataract surgery into what it is today.  

Materials and Methods: Review of primary and secondary sources concerning the development of cataract surgery over the last half century.

Results: Although Ridley introduced intraocular lenses in 1947, the lack of ability to stabilize them with standard intracapsular cataract surgery, or for that matter current extracapsular surgery, delayed general adoption.  Hyaluronic acid (Healon) reintroduced by David Miller and Stegman in the 1980s, originally as a way of protecting the corneal endothelium at the time of intraocular lens implantation, gradually was accepted as routine in surgery. 

Howard Gimbel’s continuous tear capsulorehexis immediately showed superiority in stabilizing placement of intraocular lenses in the bag. Howard Gimbel remarkably improved cataract surgery by introducing nucleus disassembly by the divide and conquer technique with movement of fragmentation of the lenses into the central anterior chamber, where they could be more safely emulsified.  There has been a parallel improvement in the engineering of phacoemulsification units with increased power and decreased repulsion (torsional phaco).  The ability to see the capsule has improved, with indocyaine green, and later trypan blue staining.  Additional improvement was the development of foldable intraocular lenses to allow them to be inserted through a standard phacoemulsification port without expansion pioneered by Thomas Mazzocco.  Recently, the development of toric lenses has also permitted reduction of corneal astigmatism.  

Conclusions: Modern cataract surgery owes a substantial debt to the innovators who have improved intraocular lenses and phacoemulsification since its original introduction.

 

A View of Baltimore Ophthalmology before the Wilmer Eye Institute [poster]

  Michael Piorunski

Baltimore has long been regarded as one of the finest medical communities in the United States. In 1807, the University of Maryland opened the first Baltimore medical school. Many general hospitals and specialty eye and ear hospitals opened and later expanded to meet the needs of the population. When the railroad became operational, a large number of patients were referred to Baltimore from the West. There were fifteen medical schools operating in Baltimore prior to 1910, some of which were actually quite good.The Johns Hopkins Hospital opened in 1889, the Medical School in 1893. Most people know Baltimore ophthalmology by way of the Wilmer Eye Institute, which opened in 1925, butits early ophthalmic community took to a back seat to no one as many advances in the practice and teaching of ophthalmology occurred here beginning in the early 1800’s.

 

The early ophthalmologists of Baltimore produced the first American text on eye diseases, created new instruments and made helpful modifications on existing ones, accepted new concepts and procedures such as local anesthesia and early ambulation following cataract extraction. They also made significant contributions to ophthalmic education and held leadership roles in national ophthalmic societies. 

 

With the establishment of the Wilmer Eye Institute in 1925, Baltimore became the “official” leading center of ophthalmology in the United States, preserving and continuing the legacy established by those early pioneers.

 

Louisa May Alcott:  Celebrating 150 Years of Little Women

     James Ravin  

By 1920 only the Bible sold more copies than Little Women. This famous book by Louisa May Alcott (1832-1888) describes the conflict in young women’s lives between devotion to family and developing a career. It has been made into a movie several times. The 1933 version is the best- known. It won an Academy award for best writing and Katherine Hepburn was awarded a golden medal for best actress

Less well-known is that Alcott also wrote sensational literature under a pseudonym, including the story “A Pair of Eyes.”

Alcott served as a volunteer nurse at Georgetown Hospital in Washington, DC, during the Civil War, but became severely ill from typhoid. Treatment with calomel (mercury) only made her worse.

She died at age 55 from an undiagnosed multisystem disease, which may have been lupus.  She was treated with many medications that are no longer prescribed, including gelsemium, the toxin investigated by Sir Arthur Conan Doyle, which was undoubtedly the toxin used by the Russians to kill Alexander Peripilichy in London in 2012.

In 1870, she and her sister May travelled to Europe, where May developed an eye disease, probably trachoma, and was treated by a famous ophthalmologist, Henri Dor. (Dor’s library was bought by J.P. Wayenborgh and is now in the Norton Library of the Bascom Palmer Eye Institute.) The Alcotts and Dor knew the famous Boston ophthalmologist Hasket Derby.

Although the medical therapy used to treat Alcott has not stood the test of time, her writings certainly have.

 

The History and Physical of the Medical Record

     Joseph Sassani

From its earliest history, the message of the medical record (MR) has been impossible to separate from its physical medium. The seeds of the MR are contained in the writings of Sumerian, Egyptian, and Greek authors, although some might suggest that paleolithic cave painters could be cited in this regard. (If you think charting in the electronic health record (EHR) is tiresome, try scribing on clay tablets.)

The contribution of case histories and case books to the development of the MR will be presented, including one of the largest such collections from the 17th century, encompassing 80,000 cases. The development of the MR will be documented through the contribution of 19th century clinicians until its metamorphosis to the 20th century document that moved from hospitals and academic institutions to more widespread use. The role of organized medicine in fostering the adoption of the 20th century MR will be cited.

The EHR as a culmination of previous goals for the MR and its potential as a disruptor in the history of medicine will be discussed. In this regard, one wonders if Dr. Lawrence Weed and the early EHR pioneers thought they were capturing lightning in a bottle, letting the genie out of the bottle, or opening Pandora’s box. Today, there are advocates for each of these positions and key ones will be presented. The EHR also will be cited as an example of paradigm shifts in medicine, and the role that forces internal and external to medicine have played in their adoption will be reviewed. Ethical issues and unintended consequences of the EHR will be discussed with a focus on ophthalmology as a lightning rod for these issues. 

Finally, implications for the future of the MR from an historical perspective will be presented

 

The Evolution of Accommodation

     Ivan R. Schwab 

Accommodation is the ability to vary the focal power of the eye. It permits accurate, sharp detail to be focused on the photoreceptive elements of the eye. The methods of accommodation include changes in lenticular size, shape, contours, and density, as well as direct and indirect muscular adjustments. Invertebrates rarely have, or need, the ability to accommodate, although some lineages, such as the cephalopods, do have vertebrate-like accommodation as an example of convergent evolution, suggesting plasticity. Vertebrate accommodation has followed an evolutionary trail that began with hard crystalline lenses that are moved in one or two axes to focus near or far in aquatic animals. As creatures came ashore as tetrapods, a stem animal established the cotylosaurs, which was the first amniote evolved from an amphibious predecessor. These terrestrial creatures would develop a thinner, lentil-like lens with an elastic capsule and softer, more pliable cortex. This stem animal likely had accommodation using striated muscular attachments to the lens, but probably developed attachments via zonular fibers. This stem lineage divided into two groups—including the diapsids/anapsids and the synapsids. The diapsids/anapsids would radiate into the reptiles, dinosaurs, birds, and eventually the snakes. Each such lineage developed similar accommodation mechanisms with special adaptations for their niche. The synapsids would radiate into dinosaur-like creatures and eventually the mammals. Early mammals became nocturnal with little need for accommodation and would lose most of the striated muscular fiber characteristics.  Accommodation would be recovered, but not with the same speed and accuracy of the diapsid lineage.  Mammalian accommodation muscles would have subtle hints of its cotylosaurian background, suggesting their origins. In general, accommodation is “plastic” and promptly responds in a manner that relates to the niche the animal fills.

 

Famous Monocular Warriors 

     Stephen Schwartz; Christopher Leffler; Andrzej Grzybowski 

The loss of an eye can be associated with many negative and lifelong consequences to a patient. Interestingly, some of the most successful military commanders in history have been monocular. These include Philip II of Macedon, who established control over Greece in 338 BC; Federico III da Montefeltro, the Duke of Urbino, who is perhaps better known as the subject of a famous painting; and Horatio Nelson, the British naval commander who is generally depicted as having lost an eye, although the evidence that this actually occurred is questionable. Their life stories are interesting and may prove inspiring to ophthalmologists and to their monocular patients. 2019 Famous Monocular Warriors (with Christopher Leffler and Andrzej Grzybowski) 

Published as: Schwartz SG, Leffler CT, Grzybowski A, Bermudez D. Famous monocular warriors. Historia Ophthalmologica Internationalis 2018;2:161-7

 

 Samuel Mackenzie Elliot: New York City Oculist 

     Peter van Alfen 

Samuel Mackenzie Elliot (1811-1875), a Scottish immigrant and graduate of the Glasgow Royal College of Surgeons, established ca. 1835 highly-regarded ophthalmological clinics in Manhattan on William Street and in New Brighton, Staten Island. He practiced as an oculist, which is what he called himself, because his medical degree from Scotland was not recognized in the United States. Later, in 1851, he graduated with an M.D. from New York Medical College. For four decades, he attracted numerous well-known patients, such as Henry Wadsworth Longfellow and James Audubon, in addition to the family of Francis Shaw and others who eventually settled in what became known as Elliotville in Staten Island. This paper explores Elliot’s career as an ophthalmologist, an abolitionist, and, along with the Shaw, a participant in the Underground Railroad, and his brief career as an officer in the Union Army during the Civil War.

  

The Expansion of Clinical Syndromes as Emphasized by the Story of the Urrets-Zavalia (U-Z) Syndrome

     Charles Pat Wilkinson 

Introduction: Clinical syndromes typically expand as criteria for specific entities grow, and (more recently) as molecular diagnostic studies identify an ever-increasing number of clinical and laboratory abnormalities. The U-Z syndrome (post-operative persistent mydriasis) was initially described following penetrating keratoplasty, but the term was subsequently applied to many ophthalmic surgical procedures, even though the pathogenesis of all could not have been identical. 

Methods: The literature regarding both the ophthalmologist Alfredo Urrets-Zavalia, Jr., (1920-2010) and the establishment of his syndrome were thoroughly reviewed, and the likely mechanisms for the syndrome were studied. 

Results: The pathophysiology of the U-Z syndrome must have been different among reported cases. 

Conclusions: A correct diagnosis of the U-Z syndrome depends upon the view of the observer: “Lumpers” might continue to consider all postoperative permanent mydriasis as the U-Z syndrome, but “splitters” would likely insist on limiting the term to cases with findings literally consistent with the original description.

 

 

Page last updated April 5, 2019