I’ve enjoyed participating in the Wills Eye Hospital resident teaching courses on cataract surgery pearls & techniques. With the 2-day course coming up this week — one on suturing and the second on basic phacoemulsification techniques — I wanted to share pearls and online resources. This post is ideal for ophthalmology residents in training and colleagues engaged in lifelong learning.
I offer the following pearls for ophthalmology residents as they start the journey of cataract surgery:
Watch videos. When I was a resident, I’d watch VHS tapes & DVDs of top ophthalmologists performing cataract surgery. I enjoyed the calmness of watching world-renowned surgeons share their pearls on difficult cases (Howard Gimbel MD chief among them). I visit CataractCoach.com daily and friend Uday Devgan, MD has created a cutting edge channel for cataract surgery pearls.
Watch surgeons in the operating room through the microscope AND from 5-10 feet away. Learn to appreciate hand movements from a distance. Focus on patient head positioning, surgeon posture and where senior colleagues rest their hands.
Make a list of every item you need for surgery. Glove size, Microscope PD, routine and complicated cataract cases all use various instruments, etc. Take photos of the cataract surgery phaco settings for sculpting, quadrant removal, etc. You may operate in different facilities and will want to give the OR team your preferred items. Make a list of special items you want on-hand for difficult cases.
Also issues to make you as comfortable as possible. Do you like lights on or off during surgery? Music in background? Is the surgeon chair comfortable and appropriate? Ergonomics is critical and especially during the early days of microscopic surgery.
Record all of your cases and watch back in real-time. No fast forwarding allowed! During my 3rd year of residency and early years in practice, I watched every case in real-time and often with my brother, Sonny Goel MD, a cataract & refractive surgeon. I still remember the pearls of an independent observer as he reviewed my cases with me. Be able to explain and minimize all time delays between steps and during the procedure.
Every second counts in the operating room. If an OR team member needs to leave the room to get a special instrument, have the instrument on-hand for future cases. I will not enter a room unless a Malyugin Ring, Vision Blue, and other special devices are in the room before I operate.
Start performing functions with your non-dominant hand. Cataract surgery is a bi-manual technique and you’ll want to be able to use both hands easily during surgery. I would try writing, shaving, etc. with my non-dominant hand as a resident.
Make copies of dictations from various cataract surgeons. Surgeons have numerous techniques, and you’ll find surgery note dictations helpful as your style evolves. Develop special templates for complicated cases.
Calculate your own intraocular lens powers. I use 7 formulas to optimize & select the intraocular lens power. This includes older generation formulas (SRK/T, Holladay 1, Holladay 2, Hoffer Q) and newer generation formulas (Barrett Universal II, Ladas, and Kane, currently free online). I also calculate lens powers for in-the-bag, sulcus, and ACIOL before surgeries. I use special colored sheets (red for right eye (OD) and light blue for left eye (OS)) as an added patient safety measure.
Here are some blog posts and videos on suturing and cataract surgery techniques. I may add more links in the weeks ahead. I hope this is a helpful start.
1. Howard Gimbel MD – When I was a resident, an ophthalmology device company sent all residents a VHS tape of Dr. Gimbel performing 5-6 cataract surgeries, telecast live to an ophthalmology conference. I watched Dr. Gimbel’s videos hundreds of times (for many years, every week and on the night before I operated!). Here’s a recent video from on Effective Fracturing in Cataract Surgery.
2. Richard J. Mackool, MD – I visited Dr. Mackool at his Astoria, NY practice & surgery center twice early in my career. The first time was in 2002 and the second in 2006. Dr. Mackool is a brilliant ophthalmologist and cutting edge cataract surgeon. His columns and surgical pearls have guided me for two decades. His 2019 Mackool Online Fundamentals: Episode 1, Phaco Fundamentals is an ideal starting point for the busy resident and lifelong learner. And in 3-D online!
3. Uday Devgan, MD – I love cataractcoach.com! Here’s a link to his complete list of videos. Start with his routine cataract surgery case here.
4. My guest submission on CataractCoach.com “Bleeding from a Pupil Expander! Now What?” is here.
5. Lisa Brothers Arbisser, MD Routine Cataract Surgery (2012) here.
6. Dr. Takayuki Akahoshi performs 10,000 cataract surgeries a year. Here is a case he performed on a grade V cataract using ICG (indocyanine green) and a pre-chopping technique. This case had a Cumulative Dissipated Energy (CDE) = 9.86. (Keep a personal log of your aspiration time, CDE, and fluid exchange throughout residency!)
7. This is an example of my cataract surgery technique video in which I describe each step of surgery in a patient-friendly manner (you’ll never look at an M&M candy the same again).
8. I also include a white cataract in which I used Vision blue here.
PS. A most successful suturing & phaco course! The Wills Eye Hospital Measey Ophthalmic Surgery Training (MOST) Lab is a game changer in ophthalmology microsurgery training. Congrats to colleagues and leaders for helping the next generation in the journey of #ProtectingSight & #EmpoweringLives. #BelievingIsSeeing
I will continue to add pearls & links to this blog post. Please send me helpful links & comments below or via social media: YouTube | Twitter | Instagram | LinkedIn
Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also an instructor at Wills Eye Hospital. #ProtectingSight #EmpoweringLives #BelievingIsSeeing
A year ago, I experienced the collector’s thrill of a lifetime. I started collecting documents related to Yale history in 2003 (around my tenth year reunion). I’ve been fascinated with the Yale campus, architecture, traditions, societies, and college life since my first day of freshman year. My original intention was to collect Yale-related historical documents — the interest grew to include Colonial, Civil War and US Presidential history — between my 10th and 25th reunions. I planned to gather documents “in secret” and make a single donation in honor of the 25th reunion.
As I soon discovered, the research time needed to curate each item in preparation for donation increased exponentially in the passing years. As Google increased its offerings on Google Books, the opportunity to research and learn about the many authors and subjects in my collection became an obsession in itself. I also realized that historical documents are best enjoyed when available to other researchers and scholars. By 2008, I decided to donate my entire collection to Yale in honor of my 15th reunion. After suffering a month of donor’s remorse, I enjoyed seeing documents available for research. I continued to assemble documents and made additional donations during numerous reunions and events (in honor of the 15th, 20th, and 25th reunions, the 2011 conclusion of the Yale Tomorrow Campaign, and the 100th anniversary of Henry Roe Cloud’s (BA 1910, MA 1914) masters degree in 2014).
📷: Monisha Sopori Crisell ’93
As part of my 25th reunion weekend, I shared my love of collecting with classmates during a Friday afternoon exhibit at the Gates Classroom, a newly renovated Manuscripts & Archives teaching space once devoted to the Gutenberg Bible. The Gates Classroom is adjacent to the L&B rooms in Yale’s Sterling Library. The first YouTube video includes a 12 minute impromptu overview with collection highlights from the May 2018 exhibit. (My college roommate & class treasurer recorded the speech with my iPhone and eventually gave me the hook!)
In the second video, I mention a 25th reunion gift to the Beinecke Library. During the appraisal process, my appraiser discovered a rare manuscript leaf in the hand of famed author Frank Norris. The Frank Norris and Conrad Richter letters from the Frederic Taber Cooper collection were displayed at the Beinecke Library throughout the 2018 reunion weekend.
(Corrections from 2nd YouTube video: Conrad Richter was awarded a Pulitzer Prize in 1951. Frank Norris died October 25, 1902 of peritonitis from a ruptured appendix. Regarding the number of Frank Norris’ The Octopus manuscript leaves known to survive, the University of California – Berkeley Bancroft Library finding aid states, “The Octopus: notes; character sketches; two leaves of the original manuscript; photocopies of four additional leaves.”)
After the Gates Classroom exhibit, many classmates approached me in appreciation of the opportunity to see the documents. One classmate told me about his brother who collects Harvard memorabilia. We’ve probably been rival bidders at many an auction!
Classmates also spoke about their own collecting interests, which led to many positive interactions. And the Yale Library, Development Office, and University friends were most gracious to attend late on a Friday holiday afternoon.
For me, the Gates Classroom exhibit was the highlight of many years of the “wonderful illness” of collecting. Very much appreciate the class, reunion leaders, and University’s graciousness.
TD 1993 (Ring the Bell!)
Below is an inventory of items which were on display. With thanks to former Head of Collections Bill Massa who prepared this inventory. I also funded the digitization of my collection which is available on the Yale Library Digital Collections.
Selection of manuscript materials donated to Yale University Library by
Ravi D. Goel, Yale College Class of 1993, between 2008 and 2014.
Gates Classroom, Manuscripts and Archives, Sterling Memorial Library
May 25, 2018
#1 Josiah Willard (BA 1714) letter, 1719 Apr 20, to an unnamed recipient. RU 1081. (** Willard was named one of Yale’s 30 most prominent graduates at Yale’s 300th Anniversary by the Yale Alumni Magazine in 2001 (one per decade which includes Princeton founder Jonathan Dickinson, Noah Webster of Webster Dictionary, US Presidents George HW Bush, WH Taft, and Bill Clinton among many). Willard, then a 27 year old preacher, was captured during a turkey-expedition and skinned by Indians in 1723. This is the only Willard letter I’ve been able to locate.)
#2 Timothy Cutler letter, 1736 Oct 8, to Sir Geflow Cambridge. Cutler served as Rector (now President) of Yale College from 1719 to 1722. RU 1081 (** The son-in-law of Yale’s 2nd Rector, 3rd Rector Timothy Cutler (Harvard 1701) was dismissed by a vote of Yale’s Trustees in 1722 after giving an Anglican blessing. The details of this 1736 letter are extraordinary. Mentions Maderia wine, the comments of Sir Isaac Newton, and procurement of books from a fellow at Eton College. Also mentions Harvard, Cambridge, Oxford, London, many Cambridge professors and religious struggles in New England.)
#3 Jacob Heminway (BA 1704) quit claim, 1746 Apr 15. First student to receive instruction at Yale, then the Collegiate School in the Colony of Connecticut, in Rev. Abraham Pierson’s parsonage in Killingworth (now Clinton). RU 1081 (** This is only the 2nd known signature of Yale’s First Student that I’ve been able to find. The other is at the Beinecke Library. See also Judith Ann Schiff’s superb profile of “Yale’s First Student” in the Yale Alumni Magazine (2004).)
#4 Eleazer Wheelock (BA 1733) agreement (early copy), 1777 November 9, with Mr. John Smith as Dartmouth College’s first professor. Wheelock was the founder and first president of Dartmouth. RU 1081. (** As I mention in the video, Dartmouth curators are unable to locate the original copy of the contract between Dartmouth and their First Professor. My “Copy from the Original” may well be the only one which survives.)
#5 Horace Holley (BA 1803) letter, 1802 Feb 14, to his father Luther Holley. RU 1081 (** Holley was an educational pioneer. As a Yale student, he writes passionately about the Judiciary Act, Constitution, and future of the young United States. My Holley letters have been quoted in James P Cousin’s Horace Holley (2016) biography. And a Yale senior essay!)
#6 Edward Anthony Bradford (BA 1833) letter, 1833 Jun 17, to his mother Lois Bradford. RU 1081. (** I love this letter. Members of this Yale class, which include William Russell and Alphonso Taft, founded Skull & Bones. Salutatorian EA Bradford writes to his mother about 7th US President Andrew Jackson’s Yale visit. He states, “Jackson left town this morning for Hartford. He arrived here Saturday afternoon from New York + remained over Sunday, thusgiving me a full opportunity to inspect him. He was attended by Mr. Van Buren (VP) … (NY Governor) + other distinguished characters.” )
Taking a moment to sign indenture papers for the Ravi D Goel Scholarship Fund
#7 Wyllys Warner (BA 1826) letter, 1843 Mar 17, to Aaron Kellogg about an indigent student fund. RU 1081. Warner served as Yale’s treasurer (1833-1852) and Secretary (1858-1869). (*** I am proud to be a “financial aid kid” from Yale. I have a lifelong appreciation of alumni & philanthropists who have supported financial aid across generations.)
Yung Wing (1954) statue, L&B Rooms
#8 Yung Wing (BA 1854) letter, 1851 Jun 25, to Albert Booth (BA 1850). Yung Wing was the first Chinese citizen to receive a degree from an American College. RU 1081. (*** This document is mesmerizing in every detail. Yung Wing writes about “the many disadvantages in which I labor.”)
#9 Yung Wing’s senior class autograph album. Yb71 854y. Donated by Mrs. Violet Chan, 1955. Henry L. Hubbell’s album with engravings and autographs. Yb71 854hu. Donated by Charles H. Small (B. Div. 1885).
#10 Heman Potter Babcock letter, 1860 Jan 22, to Tracy Peck, Jr. (BA 1861) with a hand-drawn Skull and Bones symbol. RU 1081. (** Babcock had left Yale and was writing to Peck, then a junior, a few months before Peck was tapped for Skull & Bones).
#11 John Jacob Edic (BA1864) letter, 1861 Feb 2, to his brother. Makes a brief mention of secession by Georgia. RU 1081. (** Thomas Carolin Clay (1841-1897) is the student who left Yale. He enlisted as a Private in the Liberty Independent Troop in 1862, which became part of Company G, 5th GA Regt. of Cavalry. This letter is also quoted in a Yale senior essay which includes many more details of Clay’s life. I forgot to mention that we were standing in Yale’s Sterling Library, named for Yale’s greatest philanthropist John W. Sterling & Clay’s classmate in the Yale Class of 1864.).
#12 Bound volume with a series of letters about Skull and Bones, Delegation of 1874. RU 1081. (** My biggest regret from donating historical documents to Yale! I wish I had kept for many more years and researched each item more thoroughly. The letters include “Yours in 322 … Temple Fund … Bones,” and many key details of Skull & Bones history).
#13 William Howard Taft (BA 1878) letter, 1898 Dec 18, to Frederick B. Percy (BA 1877). RU 1081. (The future 27th US President, then writing on US Court of Appeals stationery, laments being unable to attend a Yale alumni gathering in Boston. Taft writes, “I do not doubt that night under the eaves of her ancient evening, Yale’s spirit burns brightly in the breasts of her sons …” This handwritten letter is signed, “Yours in the Bones,” a detail missed by the auction house).
#14 Edward A. Bouchet (BA 1874) postcard, 1911 Aug 8, to James F. Alston. RU 1081. For years Bouchet was recognized as the first African American to graduate from Yale College. In 2014 evidence was found that Richard Henry Green was likely the first African American to graduate from Yale in 1857. Bouchet remains the first African American to receive a Doctor of Philosophy degree from an American university—Yale—in 1876; he studied physics. An online finding aid for Green’s papers is here. (** I remember this as one of the first Yale-related historical documents I ever purchased).
Rob says, “So then Ravi promises to give me his latest acquisition —- Queen Victoria’s copy of Shakespeare’s First Folio —- as a Christmas gift.” ( 📷: Monisha Sopori Crisell ’93)
#15 Class of 1911 Scroll and Key photograph album. RU 1081. (** From 1860 to 2020, there are about 160 delegations with photo albums. With an estimated inventory of 2000 – 2400 volumes per society (160 x 15 = 2400 for Bones & Keys, and 130 x 15 = 1950 for Wolf’s Head), the Yale Library owns less than 30 for Bones, less than 20 for Keys, and 2-3 for Wolf’s Head (the rest are in Egypt). Stay tuned.)
#19 Henry Roe Cloud letter, 1938 Feb 14, to “My dear Marion”, likely his daughter Elizabeth Marion. MS 2008. (** See also a Yale Manuscripts & Archives blog post on this remarkable letter: Party Diplomacy: The Ravi D. Goel Collection on Henry Roe Cloud. Cloud writes in detail about his travels in the snow to a lavish embassy party hosted by his Yale 1910 classmate Wang Zhengting, Chinese Ambassador to the US. Of note is that the Yale 1910 class includes Robert A. Taft, who may have been instrumental in Cloud’s leading a Winnebago delegation meeting with 27th President Taft in 1912. “Taft was a Yale alumnus and his son had been Roe Cloud’s classmate. Roe Cloud’s Yale connections provided him with access to political power and politicians which were not available to reservation Indians.” (Native American Netroots)).
#21 Class of 1966 Skull and Bones photograph album. Personal copy of Richard Warren Pershing (BA 1966), grandson of General John Joseph “Black Jack” Pershing. Yeg2 R9x 1966 Oversize. (** See also my blog post on this item: Richard Warren Pershing. A New York Times 2004 article explored in detail fellow Bonesman & then US Presidential candidate John Kerry’s reaction and struggles with his best friend’s (“Persh”) death. History will judge this to be among the rarest Skull & Bones albums ever to come to private hands. The only one I’m aware of to include a US Presidential candidate’s Bones photo in the public domain. Through a FOIA request, a curator was unable to locate 27th President Taft’s album at the Library of Congress or in US Government holdings … the search continues.).
I finished ophthalmology residency in 2001. Since 2002, I’ve attended every American Academy of Ophthalmology Mid-Year Forum (left early circa 2007 for a friend’s premiere at the NY Metropolitan Opera. I also missed two days in 2015 when my practice partner served as president-elect of our state society). I’ve attended as a member of the Young Ophthalmology (YO) committee, Leadership Development Program (LDP), American Academy of Ophthalmic Executives (AAOE) and as a representative to outside organizations (AMA Ophthalmology Section Council). I’ve also enjoyed the privilege of speaking at numerous Mid-Year Forum educational sessions.
The Academy’s Mid-Year Forum (#AAOMYF) originally included state and speciality society leaders, Academy volunteers & committee members, representatives to outside organizations, international leaders and the Academy’s board of trustees. Since 2004, the Academy has welcomed residents and fellows to serve as Academy Advocacy Ambassadors. The program was started by members of my Leadership Development Program (LDP) VI class (Jen & Beth!) and has evolved into one of the Academy’s growth areas of leadership development & YO engagement (“YO” = Young Ophthalmologist, coined circa 2000).
To make the most of the Mid-Year Forum, I offer the following suggestions to Advocacy Ambassadors:
Wednesday night – Meet mentors, colleagues and residents from your state. During the dinner briefing, you’ll learn about the key issues which ophthalmology faces at the federal level. Try to identify three talking points which will help when you meet Members of Congress and their staff.
Thursday – Capitol Hill Visits – You’ll travel to Capitol Hill and meet Congressional offices on both the House and Senate side. Have your running shoes on! You will want to speak with your mentors and fellow residents who will be attending. Do not be disappointed if you do not meet directly with your Member of Congress. Legislative Assistants (LAs) and Congressional staff are well versed in health care issues and in fact are wonderful liaisons with Congressional offices on key issues. Your perspective as a young ophthalmologist is critical to the ophthalmology efforts to protect sight. If you offer to follow-up on an issue, write down names, emails and follow-up! If the Congressional office requests more information beyond the “leave behind” packets which the Academy has prepared, alert Academy staff on the post-meeting forms.
Thursday-Saturday Mid-Year Forum – attend as many events as you can and meet colleagues from your state and subspecialty. The Surgical Scope Fund (SSF) and OPHTHPAC host receptions with modest contribution levels ($50 for Advocacy Ambassadors, $500 for other attendees). These are optimal opportunities to meet colleagues who volunteer hundreds of hours outside of their clinical practices to move medicine forward. If you have a specific interest (“Hey, I want to write an article for EyeWiki & EyeNet” or “I’d love to learn more about international ophthalmology”), feel free to reach out to connect with key leaders.
The Academy’s Mid-Year Forum is the premiere meeting to learn about health care policy, challenges and solutions for ophthalmology. The pearls you learn now will serve you well once you finish residency & fellowship. I’ve formed lifelong friendships and interacted with colleagues worldwide in a shared mission of #ProtectingSight & #EmpoweringLives.
See you soon!
Ravi
PS. 1. Bring your business cards!
2. Please engage in social media early & often! Every post helps your patients, legislators and colleagues keep up-to-date with your travels on behalf of the #ProtectingSight journey. #AAO2019 #MYF2019 #WhyIAdvocate. You can find me on Twitter (@RaviDGoel) and Instagram (@rdgoel).
3. Bonus pearl: If you curate the perfect post (photo and caption), you may well be rewarded with a retweet/repost by the Academy or legislator.
I recently donated a collection of documents related to American editor, literary critic and author Frederic Taber Cooper (1864-1937) to Yale’s Beinecke Library. Cooper (Harvard AB and Columbia LLB, AM, PhD), was an associate professor of Latin and Sanskrit at New York University (1895-1902). He was also an editor of The New York Commercial Advertiser (1898-1904), The New York Globe, and The Forum (1907-1909). His NY Times obituary states, “It was while Dr. Cooper was editor of The Forum that it began to take a leading position in literature and changed from a quarterly to a monthly publication.”
Cooper profiles Frank Norris among fourteen distinguished writers in Some American Story Tellers (1911). In the preface, Cooper writes, “The late Frank Norris once wrote that in every child a story teller was born, but that the vast majority died soon after birth.” Cooper features Norris as a novelist among a group who possess “the gift that makes them next of kin to the minstrel and troubadour, to the ancient fabulist, and to the forgotten spinner of the world’s first nursery tales, – the gift of holding the attention by the spell of the spoken word.”
During the collection’s appraisal process, the appraiser discovered an unsigned document which he described as “Believed Frank Norris” manuscript related to his work, The Octopus. He writes, “A highly important literary discovery: fascinating manuscript working draft from Norris’ epic The Octopus: A California Story, from Cooper’s files. Oversize sheet 10-1/4 x 15-3/4, with corrections also in Norris’ hand. Norris died the year after publication, at just 32, from a ruptured appendix. A major work in the annals of Western Americana and turn-of-century literature, here dealing with American free trade, and iron and steel tariffs!”
The Beinecke Library displayed three Frederic Taber Cooper items during my 25th reunion weekend. The label states, “an uncredited manuscript that may be a draft fragment of Frank Norris’s acclaimed 1901 novel The Octopus.”
The display also included “surly” letters between Frederic Taber Cooper and then-future Pulitzer prize winner Conrad Richter.
I am most excited to share the images below. The Frank Norris manuscript leaf at the Beinecke Library appears authentic when compared to the known manuscript leaves at the Bancroft Library.
Infact, based on the Bancroft descriptions (leaf numbers 190, 213, 7), the document I donated to the Beinecke Library may well be leaf number 117. (See the number notations in red ink in the upper right hand corner.)
Below is an image of a known manuscript fragment, which has a representative Bancroft Library stamp and leaf number “190” in upper right corner (Gift of Dr. Frank Norris, 1969).
The Bancroft Library collection includes negatives of The Octopus manuscript fragments from the Bohemian Club (San Francisco) and New York Public Library (leaf numbers not identified).
I hope to get color images of the Bohemian Club and New York Public Library manuscript fragments for comparison in this most extraordinary inventory. (Also, Frank Norris was a member of the Bohemian!)
In addition, I exchanged emails with leaders of the Frank Norris Society. Frank Norris Society President Eric Link replied, “This is potentially a very exciting discovery, indeed.”
I hope that Frank Norris scholars will study & share insights into this fragment leaf.
Patients are increasingly presenting to my office with difficulty with night vision, including glare and halos with nighttime driving. I was delighted to post an article on the American Academy of Ophthalmology EyeSmart patient education site, which can be found here.
Night vision is the ability to see in low light conditions. There are a few main differences between daytime vision and night vision:
The pupils become larger and the eye lets in more light when it’s dark outside.
A different, more sensitive kind of cell in the eye — rod cells — collects the light for night vision.
Night vision is mostly or completely in black and white. Color vision is poor in very low light conditions.
What to Do About Night Vision Problems
If you notice that your night vision is getting worse, you should see an ophthalmologist for a full exam. Decreasing night vision can be a sign of serious eye conditions, a temporary side-effect of other conditions or a natural part of aging.
There are no home treatments or exercises that can improve night vision. Prompt medical treatment of any underlying conditions will preserve as much vision as possible. Your doctor can help figure out what’s best for you.
How Do We See In the Dark?
In darkness, the iris opens wider, making the pupil larger. This dilation lets more light into the eye, so more light reaches the retina.
In dark conditions, most of the rods in the retina are turned on, but only a few cones are working. That’s why, when it’s dark, vision is all or mostly in black and white. Cones begin to turn on and contribute some color vision when the amount of light approximates what you’d see on a starry night.
Trouble seeing at night can increase the risk of falling and can make it hard to drive safely.
As the pupil gets bigger in the dark, some people become more nearsighted than they are in bright light. This night myopia can make distant objects appear fuzzy. This condition may be a sign of a need for glasses or a change to your glasses’ or contacts’ lens power.
Some of the diseases and conditions that can affect night vision are:
Cataracts. Trouble seeing or driving at night can be one of the first symptoms of a cataract. Cataracts can make vision blurry or dim and can increase glare, halos or streaks from headlights and streetlights.
Glaucoma. Glaucoma first attacks peripheral vision before harming central vision. Both daytime and nighttime vision are affected as parts of the retina stop working.
Macular degeneration. As the retina changes from macular degeneration, distortion and blind spots can appear in both daytime and nighttime vision.
Retinal diseases including retinitis pigmentosa. Diseases that directly affect the retina often harm low-light vision first because there are far more rod cells in the retina. Rod cells also cluster more around the edge of the retina, where damage may start.
Vitamin A deficiency. Night blindness (nyctalopia) is one of the first signs of vitamin A deficiency. Vitamin A deficiency reduces the production of rhodopsin, the pigment that your rods need to see in low light.
Congenital night blindness. Several genetic conditions can reduce or block night vision.
Refractive error. If you need glasses or contacts, or need a new prescription, your night vision will be blurry just like your daytime vision.
Refractive surgery (Lasik, PRK, etc.). Changes in the shape of the cornea can affect how light is bent and cause more glare or halos around lights at night.
How is Night Vision Tested?
To assess night vision, your ophthalmologist may ask you questions, look at your eyes and test your vision. One common test is the Pelli-Robson Contrast Sensitivity Chart. It is like the Snellen eye test letter chart, but with letters in different shades of grey. This test measures how well you can see the contrast between white paper and light grey shapes.
—
Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also a clinical instructor at Wills Eye Hospital. His patient-friendly YouTube cataract surgery educational videos are here.
I remember the days you were both born and less than three months apart. You brought great joy to my brothers, sisters-in-law and our extended families. Now you are both entering college and I wanted to give you some advice. Having no children of my own, and hoping to one day have children, I thought it best to record some of my feelings.
I’ve had the joy of being a doting chacha (uncle). For many years I could watch you grow, attend birthday parties, participate in activities and then pass you back to your parents. Uncles enjoy the best parts of parenting without the responsibilities. You have both grown up to become wonderful young adults.
Still in your teenage years and ready to take on the world. Having spent my own childhood obsessed with college admissions and watching your journeys I offer you the following advice:
The college experience is a privilege not a right. With online resources, college-level courses, podcasts andblogs, you could achieve a world-class education for free online. Appreciate that a university community enhances the learning experience.
Learn as much as you can in the next four years. Both from your professors and classmates. You will be surrounded by mentors.
Universities have vast resources available to you. Take advantage of them.Libraries are places to study and explore. The book you find in the stacks will have resources adjoining ready to be discovered. Google Books & Wikipedia are nice starts but originality comes from researching primary sources.
Remember that borrowed & purchased books should not simply collect dust. Books are meant to be opened, read, and enjoyed. You may not read every book in the curriculum and you will be fascinated that your classmates “read that book in high school.” Learn at your own pace and seek help when you don’t understand concepts.
More than 25 years after graduating college, one of my biggest regrets is that I did not go to professor office hours often enough. You’ll be surrounded by world-class faculty and graduate students who have the skills to teach you outside the lecture hall. Honor and respect them. Seek out your teachers for help. They are not there to complete your coursework. Rather, come prepared with questions and ask them to guide you in the journey of learning.
Learn gratitude. Write to teachers, counselors and mentors to thank them for helping you along your journey. A text message doesn’t count. Put pen to paper.
Be careful not to judge yourself against your peers. You are now surrounded by many more classmates who have natural abilities which you do not have.
Remember that success depends on those who have grit. Success and failure are both part of success. You cannot be successful in life unless you fail on occasion. The mark of success is being able to give your best effort, be knocked down, and still stand up and fight again. (Read Teddy Roosevelt’s In The Arena and watch my high school classmate Angela Lee Duckworth’s TED Talk before the first day of class.)
Love Naomi Osaka’s leadership, humility & grit!
9. Surround yourself with classmates that inspire you. Find ways to avoid those who do not inspire you or take away from your learning & growth experiences.
10. Limit social media. Every post you make will be reviewed by graduate school admissions officers and human resource departments. Turn your phone into airplane mode, set an alarm for 30-60 minutes and then study uninterrupted. (I learned this from Shane Parrish’s wonderful Farnam Street blog & The Knowledge Project podcast.)
In four years I hope to be at your graduation. I hope that you will look upon these next few years as a learning experience. I hope that you will utilize the unlimited resources that are available to you.
If you need help, assistance, or an ear to listen to, I’m here for you. Your parents, siblings and extended families are here for you. You are surrounded by those who want you to succeed in life. Do not waste these next four years on stress, the loss of learning opportunities, nor regret.
I graduated from college in May 1993 and went straight to my state medical school. My student loan debt was $100k+ after 4 years (I missed out on the NYU College of Medicine’s remarkable tuition free initiative earlier this week). When I saw Troy Aikman’s tweet earlier today asking for a Twitter ophthalmology consult, I Googled the former Dallas Cowboys QB’s name and learned he signed an 8-year, $50 million deal the same week I had taken my anatomy final! (link)
I love Twitter and have embraced the American Academy of Ophthalmology’s hashtags #ProtectingSight & #EmpoweringLives. I also follow many ophthalmology colleagues, eye hospitals and ophthalmology related organizations.
I have the privilege of being an on-call phone consultant when colleagues have difficulty finding an ophthalmologist in their local communities (including the Great State of Texas!). One friend who was then-president of the American Medical Association called me with a curbside question while managing patients in his ER. (Emergency Medicine colleagues know how to get the information they need to help patients with efficiency!) Ophthalmology is a visual specialty, and the patient history and clinical findings dictate management.
The American Academy of Ophthalmology has a detailed Preferred Practice Pattern for conjunctivitis management (link). A patient friendly guide is here. (“Pink eye,” or “red eye” are among the many descriptions for this acute or chronic condition.)
Acute conjunctivitis is a common ailment which affects upto 6 million people in the US yearly. Viral conjunctivitis is the most common cause, followed by bacterial conjunctivitis. The cost of antibiotics therapy for bacterial conjunctivitis alone is estimated to be $377 million to $857 million per year (Azari AA in JAMA 2013; 310(16): 1721-1730. doi:10.1001/jama.2013.280318 ). In addition, allergic conjunctivitis affects 15-40% of the population.
For Mr. Aikman (whom I have not examined) and patients with similar symptoms, I recommend ophthalmology consultation. Specialists consider the zebras of rare conditions when they hear the horse hoofbeats of common infections. In the absence of immediate ophthalmology availability I recommend:
1. Maintain contagious precautions – Wash your hands and your workplace frequently. Do not shake hands and avoid door knobs. Literally walk with your hands in your pockets. Take time off work and keep kids out of school as you may cause others to become infected.
2. Discontinue contact lenses (if you wear them) – With any pink eye or conjunctivitis, stop wearing contact lenses and throw away the current case and contact lens solutions.
3. Seek medical (preferably ophthalmology) consultation immediately – As the American Academy of Ophthalmology Preferred Practice Pattern alludes, there are numerous vision threatening conditions which need to be assessed in a timely fashion and treated immediately. Azari offers a helpful algorithm for clinicians and patients to approach suspected acute conjunctivitis:
The AAO Preferred Practice Pattern has a helpful high yield summary paragraph:
“The ophthalmologist plays a critical role in breaking the chain of transmission of epidemic adenoviral conjunctivitis, primarily by educating the patient and family about proper hygiene. Infected individuals should be counseled to wash hands frequently with soap and water (as opposed to sanitizer only) and use separate towels, and to avoid close contact with others during the period of contagion. Avoiding contact with others is especially important for individuals in professions with high potential for transmission, such as health care workers and child care providers. While the exact length of the period of infectivity is variable, many consider 7 days from the onset of symptoms as the contagious period, because the recovery of virus from infected cases drops off after 7 days of infection.43 However, other studies have suggested that patients should be considered potentially contagious for at least 10 to 14 days.44,45″
Good luck to Mr. Aikman. With his public stature, I hope this potentially contagious conjunctivitis can be limited from spreading to colleagues and fans.
And #FlyEaglesFly!
—-
Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also a clinical instructor at Wills Eye Hospital. His patient-friendly YouTube cataract surgery educational videos are here.
I finished ophthalmology residency in 2001. Since 2002, I’ve attended every American Academy of Ophthalmology Mid-Year Forum (left early circa 2007 for a friend’s premiere at the NY Metropolitan Opera. I also missed two days in 2015 when my practice partner served as president-elect of our state society). I’ve attended as a member of the Young Ophthalmology (YO) committee, Leadership Development Program (LDP), American Academy of Ophthalmic Executives (AAOE) and as a representative to outside organizations (AMA Ophthalmology Section Council). I’ve also enjoyed the privilege of speaking at numerous Mid-Year Forum educational sessions.
The Academy’s Mid-Year Forum (#AAOMYF) originally included state and speciality society leaders, Academy volunteers & committee members, representatives to outside organizations, international leaders and the Academy’s board of trustees. Since 2004, the Academy has welcomed residents and fellows to serve as Academy Advocacy Ambassadors. The program was started by members of my Leadership Development Program (LDP) VI class (Jen & Beth!) and has evolved into one of the Academy’s growth areas of leadership development & YO engagement (“YO” = Young Ophthalmologist, coined circa 2000).
To make the most of the Mid-Year Forum, I offer the following suggestions to Advocacy Ambassadors:
Wednesday night – Meet mentors, colleagues and residents from your state. During the dinner briefing, you’ll learn about the key issues which ophthalmology faces at the federal level. Try to identify three talking points which will help when you meet Members of Congress and their staff.
Thursday – Capitol Hill Visits – You’ll travel to Capitol Hill and meet Congressional offices on both the House and Senate side. Have your running shoes on! You will want to speak with your mentors and fellow residents who will be attending. Do not be disappointed if you do not meet directly with your Member of Congress. Legislative Assistants (LAs) and Congressional staff are well versed in health care issues and in fact are wonderful liaisons with Congressional offices on key issues. Your perspective as a young ophthalmologist is critical to the ophthalmology efforts to protect sight. If you offer to follow-up on an issue, write down names, emails and follow-up! If the Congressional office requests more information beyond the “leave behind” packets which the Academy has prepared, alert Academy staff on the post-meeting forms.
Thursday-Saturday Mid-Year Forum – attend as many events as you can and meet colleagues from your state and subspecialty. The Surgical Scope Fund (SSF) and OPHTHPAC host receptions with modest contribution levels ($50 for Advocacy Ambassadors, $500 for other attendees). These are optimal opportunities to meet colleagues who volunteer hundreds of hours outside of their clinical practices to move medicine forward. If you have a specific interest (“Hey, I want to write an article for EyeWiki & EyeNet” or “I’d love to learn more about international ophthalmology”), feel free to reach out to connect with key leaders.
The Academy’s Mid-Year Forum is the premiere meeting to learn about health care policy, challenges and solutions for ophthalmology. The pearls you learn now will serve you well once you finish residency & fellowship. I’ve formed lifelong friendships and interacted with colleagues worldwide in a shared mission of #ProtectingSight & #EmpoweringLives.
See you soon!
Ravi
PS. 1. Bring your business cards!
2. Tweet early & often: #AAO2018 #MYF2018 @RaviDGoel
The text came from a college classmate who is also an Emergency Medicine physician. She and I caught up over the weekend when I asked her to donate to our college class’ upcoming 25th reunion gift. She declined and cited a wonderful endowed scholarship she had recently created in her mother’s memory for under-represented medical students who are “first in their family” to pursue advanced degrees.
I also have the privilege of being one of my classmate’s on-call phone consultants when she has difficulty finding an ophthalmologist in her local community. (Another friend who was then-president of the American Medical Association once called me with a curbside question while managing patients in his ER. Emergency Medicine colleagues know how to get the information they need to help patients with efficiency!) Ophthalmology is a visual specialty, and the patient history and clinical findings dictate management.
My classmate texted, “Do you watch CNN? Poor Erin Burnett trying to hide a terrible r conjunctivitis or something…. please tweet her to take a day off!!! Poor girl is sick w adenovirus or rhinovirus ! Give her second a chance!!! She looks crazy!!!”
I immediately tuned to CNN, “The Most Trusted Name in News,” which I turn to daily along with NPR, ABC World News Tonight, the NY Times, and the Oldest College Daily.
The CNN segment included Ms. Burnett interviewing the expert on the recent UFO project. The numerous cameras kept going in and out with minimal time allotted to the anchor asking questions. A most unusual and adaptive technique. I turned to my iPad and took a quick screenshot of Ms. Burnett at the end of the segment.At low resolution, a viewer can appreciate the anchor’s “pink eye” with upper eyelid ptosis (secondary drooping of the right upper eyelid from inflammation) and conjunctival redness. On higher resolution, the findings are confirmed.
She likely also had light sensitivity, though it was difficult to assess with CNN strategic video angles.
The American Academy of Ophthalmology has a detailed Preferred Practice Pattern for conjunctivitis management (link). A patient friendly guide is here.
Acute conjunctivitis is a common ailment which affects upto 6 million people in the US yearly. Viral conjunctivitis is the most common cause, followed by bacterial conjunctivitis. The cost of antibiotics therapy for bacterial conjunctivitis alone is estimated to be $377 million to $857 million per year (Azari AA in JAMA 2013; 310(16): 1721-1730. doi:10.1001/jama.2013.280318 ). In addition, allergic conjunctivitis affects 15-40% of the population.
For Ms. Burnett (whom I have not examined) and patients with similar symptoms I recommend ophthalmology consultation (a bias and specialists consider the zebras of rare conditions when they hear the horse hoofbeats of common infections). In the absence of immediate ophthalmology availability I recommend:
1. Maintain contagious precautions – Wash your hands and your workplace frequently. Do not shake hands and avoid door knobs. Literally walk with your hands in your pockets. Take time off work and keep kids out of school as you may cause others to become infected.
2. Discontinue contact lens (if you wear them) – With any pink eye or conjunctivitis, stop wearing contact lens and throw away the current case and contact lens solutions.
3. Seek medical (preferably ophthalmology) consultation immediately – As the American Academy of Ophthalmology Preferred Practice Pattern alludes, there are numerous vision threatening conditions which need to be assessed in a timely fashion and treated immediately. Azari offers a helpful algorithm for clinicians and patients to approach suspected acute conjunctivitis:
The AAO Preferred Practice Pattern has a helpful high yield summary paragraph:
“The ophthalmologist plays a critical role in breaking the chain of transmission of epidemic adenoviral conjunctivitis, primarily by educating the patient and family about proper hygiene. Infected individuals should be counseled to wash hands frequently with soap and water (as opposed to sanitizer only) and use separate towels, and to avoid close contact with others during the period of contagion. Avoiding contact with others is especially important for individuals in professions with high potential for transmission, such as health care workers and child care providers. While the exact length of the period of infectivity is variable, many consider 7 days from the onset of symptoms as the contagious period, because the recovery of virus from infected cases drops off after 7 days of infection.43 However, other studies have suggested that patients should be considered potentially contagious for at least 10 to 14 days.44,45″
Good luck to Ms. Burnett and the CNN team! (I hope this potentially contagious conjunctivitis can be limited from spreading to colleagues).
—-
Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also a clinical instructor at Wills Eye Hospital. His patient-friendly YouTube cataract surgery educational videos are here.
I returned from vacation to learn that my personal information may have been hacked via Equifax, one of the three biggest credit reporting agencies. I’ve infrequently reviewed the “free credit reports” available via the three companies, which a prudent consumer would rotate and obtain every four months (once learned I had a 20 year old Macy’s account still active). I’d usually get a report from all three companies at the same time and every couple of years.
The Equifax data hack, which could have affected 140 million+ consumers, is a wake up call to us all.
Here’s my quick pearl list to protect your credit report and personal identity post-Equifax:
1. Read Ron Lieber’s “Equifax’s Instructions Are Confusing. Here’s What to Do Now.” (NY Times). This is the most straight-forward summary I’ve seen. Based on this, I will NOT sign up for the free Equifax service post-hack, which strips away legal rights for arbitration.
2. I created a security freeze on on my credit reports with the three big credit report agencies (and a 4th one below). Each state has various costs to freeze, temporarily unfreeze, or permanently unfreeze your credit. I live in a state which is FREE to freeze and costs $5 to “lift” (temporarily unfreeze). I’ve seen the costs vary even for my state via the agencies online links. (Transunion is most web friendly) If you are a consumer advocate, now is the time to lobby your state legislators to address these fees and especially if they are higher than other states.
Here’s a quick run-down of how I initiated credit report security freezes this morning:
A. Equifax – relatively easy to do. You need your current information. Created immediate 10 digit PIN you need to unfreeze (I took a screenshot and wrote down).
B. Experian – relatively easy to do. They will ask you about old account details (5 multiple choice questions, “What is the last 4 digits of a phone number (or a primary checking account) … Which is a street number of an old address?” ) Creates 10 digit PIN.
C. Transunion – straightforward. Need to create an account and then select freeze (You may need to create an account, log out, then log back in). You then get to pick your own 6 digit PIN.
D. Innovis – straightforward but they will send you a letter once you sign up.
3. Obtain a free credit report every four months at annualcreditreport.com. Here, you simply set up a mobile phone / desktop calendar alert every 4 months to obtain a credit report from Equifax (September 1), Experian (January 1 ), TransUnion (May 1). Do this on the same day you change the air filter in your heating system (Air filters should actually be changed every 3 months!). In any event, a calendar alert should be a good reminder to review your credit report for FREE (federal law) every few months.
My NEW calendar Alerts:
I will add more links as this story evolves. Please like, share and comment below!
At low resolution, a viewer can appreciate the anchor’s “pink eye” with upper eyelid ptosis (secondary drooping of the right upper eyelid from inflammation) and conjunctival redness. On higher resolution, the findings are confirmed.
