Tag Archives: history

Solving the Puzzle of History

 

Our profession enjoys a long and rich history, one that has seen dramatic advancement in technology and techniques that aid in the documentation and diagnosis of eye disease. My personal interest in the history of ophthalmic photography stems from participation in multiple history symposia sponsored by the  American Academy of Ophthalmology’s Museum Committee. In 2011, I was quite honored to be invited to co-chair the symposium Imaging and the Eye, but I think I drew the short straw when we were assigning lecture topics. I was given the task of covering the origins of photography and ophthalmic photography – in a ten minute presentation!

It seemed like a daunting task to somehow cover all that history in such a short talk. But when I started to research the topic, a common theme began to emerge when I came across rivalries, controversies, mistakes, and inconsistencies in the historical accounts related to several important discoveries. Rather than try to force every important milestone or event into a timeline format, I decided to concentrate my lecture on a few important controversies and rivalries. This approach worked well for the symposium, but I ended up with far more material than I could hope to cover in several lectures. And I had barely scratched the surface.

The Pencil of Nature is the first collection of photograph works published in book form by Fox Talbot in 1844.  The photographs were printed separately and then mounted or “tipped in”. Talbot claimed that his photographic process preceded that of Daguerre’s in 1839. A digitized version of this book is available through Project Gutenberg.

During the research process, I found that reconstructing history is somewhat like completing a puzzle. Professional historians traditionally have had access to original source documents to support their historical research. Thanks to digital technology, many of these obscure resources are now publicly available through advanced search engines and extensive online collections of scanned historical journals and documents. New pieces of the historical puzzle often become apparent when you can access these primary documents. The accounts in this series benefit from the availability of newly digitized documents, many of which were originally published over 100 years ago.  The Internet Archives, Project Gutenberg, and Google Books provide access to digitized, publicly accessible books, periodicals, and journals that are now in the public domain by virtue of their age and expiration of copyright.

Advertisements in The Philadelphia Photographer from June, 1886. Jackman and Webster’s landmark article on the first successful fundus photograph is included in this issue of the photographic periodical. It can be accessed and downloaded from the Internet Archives.

Even with access to these amazing resources, there are still some missing pieces of the puzzle. The available literature sometimes contains conflicting information or apparent mistakes between different historical accounts. Some publications have also proven to be difficult to locate, either online or in print. These hard to find references were often published in the decades just prior to routine digital publication (1960’s & 70’s) and may not yet be eligible for inclusion in public domain collections.

Covers from vintage journals accessed through Google Books. The 1894 Transactions of the Ophthalmological Society of the United Kingdom includes a paper on fundus photography by one of the early pioneers, Lucien Howe. The American Journal of Ophthalmology from 1899 includes a description of Thorner’s reflex-free ophthalmoscope. Thorner and others soon adopted the same optical design to build improved fundus cameras.

In piecing this puzzle together, I found that it pays to read all referenced documents that other historians have cited rather than rely on a citation of a “fact” actually being accurate. Mistakes are sometimes made and then blindly repeated or misinterpreted in other accounts. For example, a non-existent reference title was accidentally published in multiple historical reviews. Listed as “Barr E.: Drs. Jackman & Webster, Philadelphia Photographer June 5, 1886”, it combined fragments of two separate references and was most likely an author’s note to search for them both. 1,2

After searching the online archives, I was able to confirm that the combined title doesn’t exist, yet multiple authors include it in their reference list.3,4  The authors may have also been confused because of a typographical error in multiple references. Elmer Barr was listed as author of an 1887 paper in the American Journal of Ophthalmology, as well as another article in the Scientific American Supplement from 1888.1,5  Both of these articles describe the successful capture of a human fundus photo with more recognizable features than previous investigators. The author’s real name was Elmer Starr, but the typographical error was repeated several times causing an early pioneer in fundus photography to fade into obscurity and lose his rightful place in history. Being able to detect these mistakes and correct the historical record of our profession has been fascinating.

Die Photographie des Augenhintergrundes by Friedrich Dimmer is an atlas of fundus photographs, published in 1907. It contains several amazing reflex-free photographs taken with a one-of-a-kind camera of Dimmer’s own design. This book represents a major milestone in ophthalmic photography. It was digitized by The Internet Archives in 2011 with funding from Open Knowledge Commons and Harvard Medical School.

In piecing these puzzles together, what stood out the most were the often bitter rivalries that seemed to overshadow many of the most important discoveries. Photography was born in the Victorian Era, a time of great discovery, invention, and advancement in science and medicine. The Victorian Era roughly coincided with the Belle Epoch in Continental Europe and the Gilded Age in the United States. It was during this period that Darwin, Babbage, Pasteur, Maxwell, Morse, Helmholtz, and many others made important advancements in science, medicine, and technology. As you will see in future installments of this series, it was also a time of fierce competition, rivalry, and controversy. The brilliant minds of the day often had egos to match their great intellect. The race to be listed as the “first” to discover a scientific breakthrough could become an obsession. Eponyms were popular, and just about every important new discovery was named for the person that first described it.

A classic example of this competition and controversy occurred in the feud over the discovery of anesthesia in the 1840’s when American dentist Horace Wells and his former apprentice William Morton both claimed to be the first to discover the use of inhaled anesthesia. Wells had successfully used anesthesia on several occasions, but was discredited after a famously failed public demonstration. Humiliated after this one failure, he became deeply depressed, began abusing chloroform, and eventually committed suicide. Morton didn’t fare much better. He remained obsessed with recognition throughout his life. He tried to patent ether under a different name, and eventually died penniless. The American Dental Association honored Wells posthumously in 1864 as the discoverer of modern anesthesia, and the American Medical Association recognized his achievement in 1870. Morton was similarly recognized later in life and again posthumously. Both were instrumental in this major medical advancement, but their egos prevented them from sharing in recognition of their achievement.

The next few episodes in this historical series explore similar relationships, rivalries, feuds, and debate surrounding several important milestones in the evolution of ophthalmic imaging. Fortunately the ending of each of these stories is slightly less morbid than the anesthesia saga:

The Priority Debate looks at the frantic race for recognition as the inventor of photography in 1839.

Stereo Photography examines the nineteenth century development of the stereoscope and competing theories on stereo vision that resulted in a bitter feud between Wheatstone and Brewster.

The First Human Fundus Photograph will explore the early days of fundus photography including several controversies and professional rivalries, including how Elmer Starr lost his place in history.

From there we will continue to explore the evolution of ophthalmic imaging by taking a look back at important individuals and events that shaped our profession – and hopefully fill in a few more pieces of the historical puzzle.

References:

  1. Barr E. On photographing the interior of the human eyeball. Amer J Ophth 1887; 4:181-183
  2. Jackman WT, Webster JD. On photographing the retina of the living eye. Philadelphia Photographer 1886;23:340-341
  3. Van Cader TC. History of ophthalmic photography. J Ophthalmic Photography 1978; 1:7-9
  4. Wong D. Textbook of Ophthalmic Photography. Inter-Optics Publications, New York, 1982
  5. Barr E. Photography of the human eye. Scientific American Supplement 1888; 650:10388

World Photo Day

August 19th is recognized as World Photo Day, an international celebration of photography. This date marks the anniversary of the public unveiling of the Daguerrotype by the French government in 1839. It is an important milestone in the history and evolution of photography.

The story surrounding the invention of photography is both compelling and controversial. Several individuals claimed to be the true inventor of photography. The series of competing announcements by Louis Jacques Mandé Daguerre, William Henry Fox Talbot, and several others became a frantic race filled with secrecy, surprise, jealousy, financial reward, political maneuvering, and legal action.

To this day it’s still not entirely clear who was first to invent photography or exactly when, but history ultimately crowned a winner. Although Talbot (and others) made several significant early contributions Daguerre is generally given credit as the inventor of photography and August 19, 1839 is often recognized as the day that photography was born. Whether or not this is accurate is open to debate, but it seems a good a day as any to celebrate the history and evolution of the photographic arts.

You can join the celebration of World Photo day by taking and sharing some photographs on August 19th. If you want to know more about the controversial history surrounding the  invention of photography, visit: Milestones, Rivalries and Controversy: The Origins of Photography and Ophthalmic Photography

Ocular Autofluorescence – More Than Just the Fundus

Over the past decade, fundus autofluorescence imaging has become a commonly used diagnostic technique to document the presence of fluorescent structures in the eye.1-2 The term “autofluorescence” is used to differentiate fluorescence that may occur naturally from fluorescence that is derived from application of dyes such as fluorescein or indocyanine green.

Autofluorescence is most commonly used to document fluorescence of lipofuscin, a fluorescent pigment that accumulates in the retinal pigment epithelium (RPE) as a normal byproduct of cell function.3 Lipofuscin deposition normally increases with age, but may also intensify in certain retinal abnormalities. It is used to document progression of macular degeneration, central serous chorioretinopathy, Stargardt disease, drug toxicities, and several hereditary retinal dystrophies.

In addition to the documentation of lipofuscin in the RPE, there are other fluorescent findings that may occur in the eye. One of the initial uses of autofluorescence was documenting optic disc drusen and astrocytic hamartomas as early as the 1970’s.4 Both of these entities are calcified lesions that are highly fluorescent and can be documented with standard fluorescein excitation and barrier filters.

Fig 1 small
Left: optic disc drusen. Right: astrocytic hamartoma, a calcific tomor associated with tuberous sclerosis

The aging crystalline lens is also known to be fluorescent. In fact, lens autofluorescence was the inspiration for the development of fluorescein angiography by Novotny and Alvis.

LENS faf2
Dense cataract that fluoresces with the standard fluorescein excitation and barrier filter combination in a fundus camera. This image illustrates how fluoresence from the lens can compromise the qulaity of a fluorescein angiogram by adding unwanted fluorescence.

In addition to these well-known entities, there are some additional autofluorescent findings you may encounter in the eye. In 2009, Utine et al reported autofluorescence of pingueculae on the ocular surface.5 This finding may interfere with photo-documentation of topical fluorescein staining patterns in patients with conjunctival lesions.

pinguecula2
Autofluorescence image of a pinguela taken with a fundus camera in external mode. Note that the crystalline lens of this eye also fluoresces.

Certain emboli, presumably calcific, exhibit fluorescence.

plaque3
Patient with a branch retinal artery occlusion. Left image demonstrates classic retinal whitening from the occlusion. Right image identifies the fluorescent calcific plaque associated with the arterial blockage.

We’ve also had a case of corneal blood staining that fluoresced. As it turns out, hemoglobin and hemosiderin are known to be fluorescent and that’s what fluoresced in this case.

hemosiderin
A case of corneal blood staining after a long standing hyphema. Autofluorescence is presumably from either hemoglobin or hemosiderin.
angioid
Another case where blood is hyperfluorescent in a patient with angioid streaks.

There may be other ocular findings that exhibit autofluorescence when excited with light of specific wavelengths. Have you noticed anything else that fluoresces? If so, I encourage you to share them.

  1. von Ruckman A, Fitzke FW, Bird AC. Distribution of fundus autofluorescence with a scanning laser ophthalmoscope. Br J Ophthalmol 1995;79:407-412.
  2. Spaide RF. Fundus autofluorescence and age-related macular degeneration.
    Ophthalmology 2003;110:392-9.
  3. Delori FC, CK Dorey CK, G Staurenghi G, et al. In vivo fluorescence of the ocular fundus exhibits retinal pigment epithelium lipofuscin characteristics. Invest Ophthalmol Vis Sci 1995;36:718-729.
  4. Kelly JS. Autofluorescence of drusen of the optic nerve head. ArchOphthalmol 1974;92: 263-264.
  5. Utine CA, Tatlipinar S, Altunsoy M, et al. Autofluorescence imaging of pingueculae. Br J Ophthalmol 2009;93:396–399.

Camera Heritage Museum

camera museum small1On a recent trip through Virginia, I stumbled across a gem of a museum tucked away in historic downtown Staunton, VA. I had been browsing brochures of local attractions on a stand in the lobby of my hotel and spotted a photo of a vintage view camera. The brochure was for the Camera Heritage Museum. The non-profit museum bills itself as the largest camera museum on the East Coast. It wasn’t far from my hotel, so I decided to visit, not knowing what to expect.

I walked into what obviously had once been a camera store jam-packed with cameras of all shapes, sizes and vintages. There was a gentleman sitting behind a counter in the back, busy doing some maintenance on a camera. He looked up briefly, said hello, and went back to his work while I browsed through the impressive collection. I saw everything from miniature spy cameras to large format portrait view cameras.

I recognized some cameras that I had used in my early days in photography including a Crown Graphic 4×5 press camera, a Graphic View (first monorail view camera design), several early polaroid cameras, a 16 mm Minox and many others.

After a few minutes of browsing, I asked the man behind the counter a few questions about some cameras that I recognized. When I showed genuine interest in the cameras on display, he stepped out and started describing the history, significance and stories related to many of the items on display. His name was David Schwartz, and he is the curator of the museum. He’s a wealth of information. As more people entered the museum, he recounted some of the same stories several times over, each time with the enthusiasm of someone that clearly loved cameras and the history of photography.

The collection includes vintage view cameras, military cameras, spy cameras, aerial cameras, stereo cameras, underwater cameras, Kodak Brownies, Hasselblads, Leicas, Voigtlanders, Nikons, and some truly unique cameras including a 40″ long baseball camera with lever activated focus stops preset for the distance to each of the bases on the diamond.

Folmer Graflex Baseball Camera

David and I talked about some of the stereo cameras on display and I told him that as a medical photographer I regularly take stereo photos of human retinas. He nodded and directed me to a case which held a collection of Topcon 35mm cameras including a body from a vintage Topcon fundus camera.

OLYMPUS DIGITAL CAMERA
A Topcon 35mm camera back from a fundus camera is tucked in the back of this glass case.

When I explained a little bit more about fundus photography, he listened intently and I can imagine that he’ll include some of what I told him about this equipment in explanations to future museum visitors.

The venue for this museum is a little quirky, but it houses a serious collection of over 2000 cameras, photos and accessories. A unique feature is the fact that it is an open and accessible to the public, rather than a private collection. The museum also has an online presence. Their website contains a wealth of information on the history of photographic equipment, especially the online gallery of some of the many cameras in their collection. It’s a great resource for history buffs and vintage camera enthusiasts.

museum4

The museum can be found at the old Camera and Palette store at 1 West Beverley Street in Staunton, VA. If you are travelling through the area, it is definitely worth a visit. Better yet, if you have some old film cameras collecting dust in a closet you might want to consider contributing to the collection by donating them to the museum. They are always looking for cameras, photos and accessories with historic significance.

 

Eponyms in Ophthalmology

Did you ever wonder how ophthalmic diagnostic findings get their names? If you feel like there is no rhyme or reason to the naming conventions used in ophthalmology, you are not alone. Ophthalmology (and medicine in general) does not have structured system of nomenclature like some other sciences.

For example, the field of chemistry utilizes the periodic table of elements to organize and classify fundamental information. Biology employs Linnaean Taxonomy, which is an organized hierarchical system of classification including kingdom, phylum, class, order, family, and genus, to differentiate and name species. It was established and organized by Carl Linnaeus in the mid 1700’s and results in a naming convention known as binomial nomenclature.

eponyms 2

In binomial nomenclature, this common Tiger Swallowtail butterfly is known as Papilio Glaucus. It was classified and named by Linnaeus himself in 1758. Papilio is latin for butterfly and glaucus means blue.

Human anatomy and medicine is a different story however. Historically there has been controversy, disagreement, language differences, and confusion amongst anatomists regarding universal terminology. To address this, there have been attempts to standardize terminology in human anatomy. Nomina Anatomica was the international standard on human anatomic terminology from 1956 until it was replaced by Terminologia Anatomica in 1998. But in ophthalmology, as in much of medicine, there is no universal system of classification for ocular anatomy, clinical findings, or diseases. It’s a bit of a “free-for-all”. In the late nineteenth century some 50,000 terms for various body parts were in use. The same structures were described by different names, depending on the anatomist’s background: school, language, culture, traditions, etc.

Let’s take a look at some of the ways that diseases are named in ophthalmology. Clinical findings may be named for their anatomic location, clinical appearance, etiology, disease process, or end result. They may also be based on etymologic roots or finally, eponyms.

eponyms 3

A common and logical diagnostic naming convention is simply descriptive of a disease process like vitreomacular traction or corneal erosion.

eponyms 4

Or it could be the anatomic result of those processes such as a macular hole that results from vitreomacular traction or a corneal ulcer that arises from erosion.

eponyms 5

Some terms are based on clinical appearance, either the literal appearance or a resemblance to something else. Pink eye or floppy lid syndrome are conditions that are literally descriptive of their appearance.

eponyms 6

Conditions like bear tracks, bullseye maculopathy, cotton wool spots, morning glory nerve, birdshot choroidopathy, and several others often bear a resemblance to something that would be commonly recognized or understood.

eponyms 7

Other names may be based on etymology, which means they originate from traditional Greek or Latin root words. Heterochromia is a good example as it comes from the Greek roots heteros which means different, and chroma which means color.

eponyms 8

Cataract is an interesting term that may be related to the opaque lens’ resemblance to rushing water of a waterfall, or possibly to one of the earlier etymologic roots meaning a covering or impediment.

Some conditions are probably better known by the acronym representing the full name: ARN, CHRPE, APMPPE, etc.

Finally, many conditions are based on eponyms meaning they are named for a person, usually the person that first identified or described the condition in the literature. Eponyms are a longstanding tradition in science and medicine, and being awarded an eponym is considered an honor.

Anatomists seem to have been especially fond of naming structures for themselves as seen by the many eponymous anatomic terms in ophthalmology: Bowman’s Membrane, Descemet’s Membrane, Canal of Schlemm, Annulus of Zinn, Schwalbe’s Line, Tenon’s capsule, and Bruch’s Membrane to name just a few.

eponyms 1
Purtscher’s retinopathy is an example of a well-known eponym in ophthalmology. In 1910, Austrian ophthalmologist, Otmar Purtscher (1852-1927) described a retinopathy of bilateral peripapillary patches of retinal whitening and hemorrhages after compression injury to the head.

Eponyms extend beyond anatomy into diagnoses as well. Conditions have been named for Sjögren, Krukenberg, Stargardt, Marfan, Elschnig, Thygeson, Vogt, Cogan and countless others. We certainly shouldn’t overlook Austrian ophthalmologist Ernst Fuchs, who described several conditions and has his eponym associated with many of them. Eponyms may also be proper names of places ( Lyme Disease, North Carolina Macular Dystrophy) or famous patients: Lou Gehrig’s Disease (amyotrophic lateral sclerosis) or Tommy John surgery (named for Major League pitcher, first person to undergo the procedure).

With all these names and egos involved, there has often been confusion and controversy over who was  the first to fully describe a condition. Bergmeister’s papilla and Mittendorf dot are eponyms given to remnants of opposite ends of the embryonic hyaloid artery. Vogt-Koyangi-Harada disease is named for three investigators who independently described different manifestations of the same underlying condition. Stevens-Johnson syndrome, named for pediatricians Albert Mason Stevens and Frank Chambliss Johnson, also has several other eponyms associated with it including names such as: Baader, Fiessinger, Rendu, Fuchs, Klauder, Neumann and Hebra – whew! Further confusing things are hyphenated or double surnames such as Robert Foster-Kennedy (Foster-Kennedy syndrome ) and Roger Wyburn-Mason (Wyburn-Mason syndrome).

eponyms 9
Dilated and tortuous retinal vascular abnormalities are a hallmark of Wyburn-Mason syndrome. Findings also include arteriovenous malformations in the midbrain in this rare condition named for British physician Roger Wyburn-Mason who described it in 1943. It is also known as Bonnet-Dechaume-Blanc syndrome, named for the group that described it in 1937.

In fact, Wyburn-Mason syndrome had been previously described in the French literature and is also known as Bonnet-Dechaume-Blanc syndrome. So the correct eponym may depend on what language you speak.

Eponyms are often controversial, especially when questions arise about the moral and ethical character of eponymous honorees. There has been sparring in the literature for years over the use of eponyms and the worthiness of some of the individuals that have conditions named for them. Pulido and Matteson ask the question, “Is it worth having eponyms at all?” in an editorial in Retina in 2010. They go on to state, “Although they can function as a memory aid, they do not enhance understanding of disease…. It is best henceforth to not name new diseases with eponyms and to start moving away from their use completely.

 

stargardt composite
Stargardt disease was described by Karl Bruno Stargardt in 1909. In 1997, researchers identified a mutation in the ABCA4 gene as the cause for this hereditary retinal disorder. Many hereditary diseases are now being referred to by their identified gene mutation rather than an eponym.

Wikipedia lists some of the pros and cons of eponyms in eponomously named diseases and briefly talks about current trends:

“The current trend is away from the use of eponymous disease names, towards a medical name that describes either the cause or primary signs.”

“The scientific and medical communities regard it as bad form to attempt to eponymise oneself.”

Then there is Stigler’s Law of Eponymy, which states, “No scientific discovery is named for the original discoverer.” As proof, Stigler freely admits that others postulated the idea before he named it for himself! In describing Stigler’s Law, Malcolm Gladwell stated, “We think we’re pinning medals on heroes. In fact, we’re pinning tails on donkeys.”

David Cogan talked about the pitfalls and limited life of eponymous designations in an editorial in the Archives of Ophthalmology in 1978. Yet Cogan-Reese syndrome was named for him and Algernon Reese many years ago.

eponyms 10When a new designation, ICE syndrome, was suggested as a unifying term to replace Cogan-Reese syndrome, Chandler syndrome, and essential iris atrophy, Cogan was quoted by William Spencer in another editorial in Archives: “Better a descriptive name, if that is possible, and an eponym if it is not possible. Now the syndrome described by Al Reese and me is characterized by nodules, unilateral glaucoma, Descemet’s membrane and endothelial extension; why not call it by the acronym NUDE syndrome? This would give it sex appeal and put the Archives right up there with Esquire.” Cogan’s response suggests he thought eponyms still have their place – especially when it came to one named for himself!

Surprisingly, these trends and opinions haven’t prevented the coining of new eponyms in ophthalmology. In 2013, a new anatomic layer of the human cornea was first described by Harminder Dua in the journal Ophthalmology. There was even a big splash in the mainstream scientific news and social media about this exciting new discovery and the investigator who identified it. As you may have already guessed, the finding  is called Dua’s layer. He named it for himself!

Despite all the controversies, confusion, and egos involved, it seems as if eponyms in ophthalmology are here to stay, at least for now.  So try not to be confused or frustrated when comparing Fuchs’ corneal dystrophy with Fuchs’ heterochromic iridocyclitis, or if you have difficulty remembering whether it is Best’s or Behcet’s disease that has macular vitelliform lesions. We might as well embrace these long-established eponyms – warts and all.

Resources
Here are some great resources to look up information on eponyms in medicine and ophthalmology:

Whonamedit? A dictionary of medical eponyms
http://www.whonamedit.com/

Doyne’s Hall of Fame, Faces behind ophthalmic eponyms
http://www.mrcophth.com/ophthalmologyhalloffame/Doynehalloffame.html

Wikipedia list of eponomously named diseases
https://en.wikipedia.org/wiki/List_of_eponymously_named_diseases

References:

  1. Whitmore I. Terminologia anatomica: new terminology for the new anatomist. Anat Rec. 1999 Apr 15;257(2):50-3.
  2. Lamy R, Dantas AM. [Anatomical nomenclature in ophthalmology]. Arq Bras Oftalmol. 2008 May-Jun;71(3):446-58. Portuguese.
  3. Pulido JS, Matteson EL. Eponyms: what’s in a name? Retina. 2010 Nov-Dec;30(10):1559-60.
  4. Grzybowski A, Rohrbach JM. “Eponyms: what’s in a name”. Retina. 2011 Jul-Aug;31(7):1439-42; author reply 1442-3.
  5. Grzybowski A, Rohrbach JM. [Should we abandon the eponym ‘Wegener’s granulomatosis’? A historical excursion]. Klin Monbl Augenheilkd. 2011 Jul;228(7):641-3.
  6. Dua et al.: Human corneal anatomy redefined: a novel pre-Descemet layer (Dua’s layer) (Ophthalmology 2013;120:1778-85).
  7. Cogan DG. The rise and fall of eponyms. Arch Ophthalmol. 1978 Dec;96(12):2202-3.
  8. Eagle RC Jr, Font RL, Yanoff M, Fine BS. Proliferative endotheliopathy with iris abnormalities. The iridocorneal endothelial syndrome. Arch  Ophthalmol. 1979 Nov;97(11):2104-11.
  9.  Spencer WH. Proliferating terminology and the NUDE syndrome. Arch Ophthalmol. 1979 Nov;97(11):2103.

 

Ophthalmic Photography: Where Science Meets Art

Ophthalmic photography has long played an important role in the documentation and diagnosis of ocular diseases. Ocular photography is used to record medical conditions, track disease progression, and create illustrations for publication and education. The primary role of ophthalmic imaging however goes well beyond documentation in its ability to aid in diagnosis of a broad range of eye conditions. Treatment plans derived from the diagnostic information provided by ophthalmic images have benefited countless patients, as ophthalmologists use images for decision making purposes on a daily basis, and in some cases, rely on photographs as a “road map” to guide therapy.

The history of ocular photography dates back to the late 1800’s when Jackman and Webster described a technique for photographing the retina of a living human subject. The next fifty years witnessed a slow advancement in instrumentation and techniques. Photographic results were mostly inadequate due to slow film speeds, long exposures, and inconsistent light sources. In the 1950s electronic flash and 35mm cameras were adapted to ophthalmic instruments and modern ophthalmic photography was born.

slit1

There is a compelling connection between this photographic discipline and our subject, the human eye; a connection that goes beyond the obvious parallels between eye and camera, cornea and lens, iris and aperture, retina and film. We use the visual art of photography to identify problems in another visual system – the eye itself. Optical instruments used to examine or photograph the eye often utilize the optics of the subject eye to help in visualizing the target pathology.

CarterR4

Ophthalmic photography can at times be simple or incredibly complex. Ocular tissues can be opaque, translucent, or transparent and may require different strategies to record these structures photographically. Enhancement of anatomic features is sometimes necessary, and can be achieved by using fluorescent dyes, monochromatic light, or specialized optical devices and techniques to adequately document subtle pathology that would otherwise not be visible.

Bennett Cataract

Creativity and aesthetics have their place in this field and many ophthalmic images transcend their scientific purpose and achieve artistic merit, but it can be heartbreaking when the most photogenic or aesthetically pleasing subjects present themselves because a patient’s vision is severely compromised. Enthusiasm for creative imaging can suffer in the context of tragic loss of vision. This is balanced however, against those times when an imager captures great images that help preserve a patient’s vision. Unfortunately not all images will be of sufficient quality to warrant public display or publication. The challenge for ophthalmic photographers is to provide consistent clinical images of adequate diagnostic quality, even under adverse conditions.

RD Barr

By providing support for education, research, and clinical eye care activities, ophthalmic photographers have been an integral part of the professional eye care community for decades. As new diagnostic imaging and treatment modalities are developed, the role of the ophthalmic imager will evolve and continue to play an important role in the preservation of sight.

bennett slideshow17

The Eye is Like a Camera

“The eye is like a camera.”

I first heard this expression many years ago when a retina specialist was explaining the results of a fluorescein angiogram to a patient and her family. He went on to explain that her retina represented the “film” in the camera and that it was swollen with fluid and wrinkled, which was the cause of her blurred vision. Everyone present easily understood the analogy, as 35mm cameras were commonplace at the time. The idea of warped or wrinkled film resonated as an analogy.    

Although it was my first time hearing this comparison, it was not a new or unique concept. The compelling connection between the eye and camera dates as far back as the 16th century when Leonardo DaVinci drew a comparison between the camera obscura and the human eye. In the next century, Della Porta, Cigoli, and Descartes also made a similar connection in their writings on optics and vision.

With the introduction of practical photographic methods in 1839, the analogy soon extended beyond the optical comparison between eye and camera obscura to include the comparison between vision and imaging. As photography and cameras quickly grew in popularity, scientists, physicians and ophthalmologists such as Helmholtz and LeConte advanced the analogy between photographic camera and the eye.​

“The further explanation of the wonderful mechanism of the eye is best brought out by a comparison with some optical instrument. We select for this purpose the photographic camera. The eye and the camera: the one a masterpiece of Nature’s, the other of man’s work.”

            Joseph LeConte

​From the earliest days of photography, several investigators sought to use the camera to document the condition of the eye. Due to the technical limitations of available photosensitive materials and the difficulty in illuminating the interior of the eye, fundus photography became the “holy grail” of medical imaging. Over the next several decades there were incremental advances in optical instrumentation and photographic processes, all moving steadily towards practical examination and photography of the eye. The most notable of these milestones was the 1851 introduction of the ophthalmoscope by Helmholtz.

Lucien Howe, one of the early pioneers in fundus photography echoed the idea of eye as camera in his 1887 article in which he described having captured the first recognizable fundus photograph:

“We know that the eye itself is a camera, and when placed behind an ophthalmoscope it has pictured upon the retina an image of an eye observed.”

Lucien Howe

The analogy was taken yet a step further by Mann who presented a paper utilizing animal eyes as an actual camera by placing photographic film against an aperture cut in the posterior pole of the globe.

“The main object has been to demonstrate that the eye can actually be used as a camera, a fact which is of interest chiefly because of the frequent comparison between the two.”

William Mann


From that point on there were several milestones in the evolution of both photography and ophthalmic photography that culminated in reflex-free fundus cameras equipped with electronic flash by the 1950’s. The modern fundus camera revolutionized ophthalmic photography and provided the platform for the important development of fluorescein angiography techniques by Novotny and Alvis in 1959. Optical coherence tomography has further revolutionized ophthalmic imaging, but fundus photography and angiography remain vital tools in the diagnosis and treatment of ocular disease.

In today’s wireless and digital age, the analogy of eye as camera may not be as universally accepted as it was a generation ago. Most 35mm cameras had a spring-loaded pressure plate on the film door to ensure the film was held flat and firmly in place. It was easy to envision the concept of a piece of film (or a retina) being wrinkled, torn, or warped.

Today’s digital cameras do not open to reveal the fixed sensor inside so the analogy doesn’t resonate as well. Yet the optical comparison between the eye and camera lens still rings true today, even with sophisticated scanning instruments such as SLO and OCT.

“The eye is like a camera.”…. Since the days of DaVinci, this idea has been echoed countless times by philosophers, artists, ophthalmologists and photographers. As an ophthalmic photographer, I consider myself fortunate to have spent a career photographing the human eye: one camera being used to preserve the capabilities of the other.

“The camera exists because men were intrigued by the function of the eye and wished to be able to reproduce on a permanent record that which the eye enabled the brain to record. How appropriate then that ophthalmology has turned the camera into a valuable tool for recording the structures of the eye.”

R. Hurtes

“The eye is like a camera.”

References

Wade NJ, Finger S. The eye as optical instrument: from camera obscura to Helmholtz’s perspective. Perception 2001; 30:1157-1177

LeConte J. The Eye as an Optical Instrument. from Sight: An Exposition of the Principles of Monocular and Binocular Vision. 1897

Howe L. Photography of the interior of the eye. Trans Amer Ophth Soc. 23:568-71 July 1887

Mann WA. Direct utilization of the eye as a camera. Trans Am Ophthalmol Soc 42:495-508, 1944

Novotny HR, Alvis DL. A method of photographing fluorescence in circulating blood of the human retina. Circulation. 24:82, 1961

Meyer-Schwickerath, G. Ophthalmology and photography. AJO 66:1011, 1968

Bennett TJ. Ophthalmic imaging – an overview and current state of the art. Journal of Biocommunication, 32(2):16-26, 2007.

Bennett TJ. Ophthalmic imaging – an overview and current state of the art, part II. Journal of Biocommunication, 33(1):3-10, 2007.

Hurtes R. Evolution of Ophthalmic Photography. International Ophthalmology Clinics. 1976; 16(2):1-22

 

 

Me, Myself, and Eye

Although it may seem like a recent phenomenon, the photographic self-portrait has been with us since the dawn of photography. Perhaps the earliest known “selfie” was taken by Hippolyte Bayard (Portrait of a Drowned Man), a Frenchman who claimed to have invented a photographic process prior to the Daguerrotype. The same can be said of William Henry Fox-Talbot (The Reading Establishment).

In recent years, the photographic self-portrait has exploded in popularity into a global phenomenon, fueled by social media sites such as Facebook, Instagram, Twitter, Snapchat, and others. It is estimated that over one million “selfies” are taken every day. A recent search of Instagram returned over 211 million photos with the hashtag “#selfie”. The term “selfie” is believed to have originated in Australia and has been elevated from internet slang to our common vernacular and even inclusion in several formal English dictionaries. In fact, selfie was Oxford Dictionary’s word of the year for 2013!

Everybody seems to be getting into the act including celebrities, politicians, and even the Pope! Selfies are even popular in space.  Astronauts have shared several spacewalk selfies online, and last year, NASA promoted a global selfie project to celebrate Earth Day. They solicited over 36,000 selfies from around the world and created an interactive composite image that can be viewed on their website.

The selfie is so ubiquitous in today’s pop culture that cell phones and digital cameras often include built-in selfie-friendly apps and features such as extra wide angle lenses, articulating screens or front facing screens that facilitate the selfie pose.  You can also purchase selfie sticks to extend the camera to a better vantage point.  These popular items go well beyond the simple self-timer found on many cameras of yesteryear. Selfies are often purposely self-deprecating, campy, cheesy, or irreverent. They are meant to be spontaneous and fun and are not usually taken very seriously. The selfie craze has even spawned the infamous “duck face” pose.

Despite the fun and seemingly harmless spirit behind them, there is a belief that taking selfies can be a sign of narcissism rather than simple self-expression. There is also some concern it can be addicting and unhealthy. But there is a growing trend in telemedicine where patients can take and forward selfies to their doctors to help diagnose or triage the urgency of their condition.  So maybe there are some legitimate uses for selfies.

As a life-long photographer, I’ve taken my share of selfies over the years. I’ve even attempted a few with the equipment I use for diagnostic ophthalmic photography. Some are goofy, and in the spirit of social media selfies. Some are more practical.

Most ophthalmic imaging devices are not what you’d normally consider selfie friendly, at least not in terms of taking a photo of one’s own eyes. Because the optics of these devices are designed for photographing curved surfaces found in the interior of the eye, they usually create distortion when backed up an appropriate distance to take a facial portrait. The effect of this distortion eliminates the need for a goofy facial expression if your goal is just to post a unique selfie on the internet!

But what about useful diagnostic or artistic photos of your own eyes, photos that go beyond distorted face selfies? It’s not only possible, but surprisingly good images can be obtained with some devices.  Non-mydriatic instruments with a monitor that can be pivoted toward the patient/photographer lend themselves to self-imaging, while those with an optical viewfinder (fundus camera) or fixed monitor position (Cirrus) do not. I’ve been able to obtain eye selfies with the Zeiss Stratus, Heidelberg HRT, Heidelberg HRA/OCT, Clarity RetCam, Tomey specular microscope and various handheld external cameras. But, you might ask, “So what?” or “Why?”

Well, there have been times when I needed to check a device during maintenance or a software upgrade and it was convenient to use myself as the patient. Sometimes while training staff to use a device, I’ll demonstrate the procedure on myself. Other times, I’ve needed a quick example of a “normal” eye for a lecture like those above.

Surprisingly, the ability to take eye “selfies” has helped me identify and track pathology in my own eyes. Two years ago I suffered an idiopathic retinal tear with avulsed bridging vessel and persistent vitreous hemorrhage. This was successfully treated with vitrectomy. Like many patients, I developed a cataract after the vitrectomy. I also began to notice some distortion that corresponded to progression of an epiretinal membrane (ERM) in the same eye.

Any time I noticed a change in vision I would repeat an OCT on myself. Over the course of six months I tracked an increase in thickness of about 100 microns. The cataract also progressed and I was scheduled for cataract surgery. Two weeks prior to surgery I noticed a very subtle change in vision and sat down at the OCT like I’d done several times in the past. The OCT detected some cystoid macular edema (CME) from the ERM. Picking up the CME prior to cataract surgery was very beneficial. Preexisting CME can be exacerbated by cataract surgery, so my surgeon began a course of treatment that reduced the edema. My OCT selfies likely helped us avoid more severe or persistent edema by catching it in advance.

Cataract surgery went as planned, but within a few hours of my procedure I began to notice a new visual abnormality: a paracentral gray scotoma. Upon arriving at the clinic the next day for my post-operative check, I immediately did an SLO/OCT selfie and identified an unusual finding that corresponded directly to the scotoma.

SD-OCT demonstrated an area of hyper-reflectivity in the middle retinal layers just temporal to the fovea (green arrows) and the IR reflectance image showed a distinct dark gray lesion. Fortunately, the scotoma began to fade within a few days and so did the lesion. The jury is still out on the exact cause of the lesion but the selfies have enabled us to track improvement of my condition and possibly publish a case report. We believe it may be a case of paracentral acute middle maculopathy (PAMM), a recently described variant of acute macular neuroretinopathy (AMN). It’s rare enough, that I was able to present it at the OPS Rare Case Symposium in Ann Arbor.

As you can see, image quality can be quite good with a little practice. So good in fact that I’ve received a bill from my institution for OCT images that I’ve performed on myself! Here is a double selfie video of a Spectralis IR fundus image showing how easy it is to capture my own epiretinal membrane.

I’m beginning to think maybe I should stop taking selfies of my own eyes. After all I keep finding abnormalities! But there is a growing trend in telemedicine where patients can take and forward selfies to their doctors to help diagnose or triage the urgency of their condition.

Ophthalmic Photographers taking diagnostic selfies: obsessive, silly, or beneficial?