Erin Burnett needs #ophthalmology consultation for #ViralConjunctivitis #PinkEye #CNN

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.

Advertisements

Ravi’s Quick Guide to Credit Report Protection post Equifax data breach

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!

Ravi’s Quick Guide to Ophthalmology MIPS Reporting 2017

Dear Ophthalmology Colleagues,

I’ve started to read the MIPS Manual: A Primer and Reference from the EyeNet Supplement (August 2017).

My practice plans to use the IRIS Registry web portal for MIPS reporting. The IRIS Registry dashboard eases confusion. The EyeNet Supplement (August 2017), Page 10, states that EHR vendors may also submit for all three performance categories. IRIS Registry (also free for AAO members) is a better fit for my practice this year.

There are 3 MIPS performance category baskets:
1. Quality – IRIS Registry does the calculation and suggests which measures to submit (with green flags!).
2. ACI  (Advancing Care Information) – Practices need to select measures to submit.
3. IA – (Improvement Activities) – Practices need to select measures to submit.

Here’s my plan to achieve maximum benefit from the 2017 MIPS cycle:

  1. Watch the Academy’s 2-minute video “How to Avoid a 2019 MIPS Penalty”by George Williams, MD, Academy Secretary for Federal Affairs.  The page includes instructions to report a single quality measure before December 31, 2017 to avoid 2019 penalties.  My practice uses IRIS Registry AND I still plan to submit some claims-based quality measures.
  2. Review the AMA’s “MIPS Action Plan – 10 Keys Steps for 2017” (Opens as PDF)  The AMA web portal for MIPS Action Plan is here.  (It pays to be an AMA Member!)
  3. Review the Academy’s EyeNet Supplement (August 2017).  Have a highlighter ready and circle measures you can meet easily.  The supplement is initially overwhelming so plan ahead.
  4. If you participate in IRIS Registry, login into IRIS Registry portal and click MIPS in the left hand column (easier from desktop vs. tablet). This is where the rubber hits the road.  I had my greatest ANXIETY RELIEF when I logged into IRIS Registry and reviewed the MIPS information.  The 3 performance category baskets are outlined and I could more easily understand (with EyeNet graphics) which measures to submit. (See below)
  5. Develop a September action plan so that you can meet the measures needed to report successfully.  If you plan on going for more than the minimum (#1 above) then you’ll need to develop a plan in September and start no later than October 2.
  6. I will continue to add and edit pearls in the weeks ahead. If you send me a pearl (in the comment section below or via @RaviDGoel), I will add with credit in this blog.

—–

My IRIS Registry Dashboard currently looks like this:

1. Quality – We need to submit 6 of 15 measures which the IRIS Registry is extracting from our EMR. Some measures have green flags, some red flags and some gray flags. I plan to monitor this so that we can submit for the full year if we have at least 6 measures with green flags.

2. ACI -Advancing Care Information – Here are the measures which IRIS Registry has for ACI. I will plan to master the mandatory measures and then use the EyeNet Supplement to see which other measures we need to submit to maximize our score.

3. IA – (Improvement Activities) – Here also, I will work with my team to identify the best measures to meet the IA component. IRIS Registry is a big help.

The IRIS Registry Dashboard will allow you to keep score along the journey.

Happy Labor Day weekend!

Please revisit this page for additional pearls and suggestions for measures which are more easily achievable with EMR.

Ravi

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.

Ravi D Goel collection on Henry Roe Cloud (Yale BA 1910, MA 1914): Yale’s First Native American graduate

Henry Roe Cloud was the first known Native American to graduate from Yale College (BA 1910, MA 1914), a campus celebrity and member of the Elihu Club. Roe Cloud, a Ho-Chunk Native American, has a remarkable history as described in Joel Pfister’s The Yale Indian: Henry Roe Cloud (2009). 

Item 02 YaleBA1910

1910 Yale Degree. Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

There is an extensive collection of “Roe Family Papers” at the Yale Library which includes letters between Henry Roe Cloud and his adoptive mother, Mary Roe.  Joel Pfister states, “Again, it must not be forgotten that Roe Cloud wrote many of his letters to a white woman whom he admired and whom he wanted to admire him, and thus may have excised or modified some of what he could have told her about his daily life.”  

Item 04A YaleComposite

Yale Class of 1910 (Henry Roe Cloud seated in first row). Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

Item 04B YaleComposite

Henry Roe Cloud, Yale Class of 1910. Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

Pfister also writes, “It is important to keep three things in mind when taking stock of the Roe family archive and its focus.  First, there is no Roe Cloud archive per se at Yale … he did not give Yale reams of his private letters.  Many of these, no doubt, would have been sent to and received from family members and Indian friends (Roe Cloud was often on the road, especially in the 1920s and 1930s).” 

I first learned about Henry Roe Cloud after stumbling across an Elihu Club silver tray from a leading auction house.  Elihu is one of Yale’s senior societies (aka secret societies).  Some of the senior societies used to send a group gift when one of their graduates (before the early 1970s, all men) were married.

ElihuClub

Elihu Club Silver Tray (Delegation of 1910 Wedding Gift to Kent Sarver Clow).

The silver-plated Gorham presentation tray was from the Elihu Club Delegation of 1910. The auction house’s archivist graciously included the names and significant research about the members of the delegation.  In addition to Yale’s 1st Native American student (engraved “HR Cloud“), the delegation also includes the co-author of the Whiffenpoof Song (Meade Minnigerode).  Frank Thayer Nelson won a silver medal for pole vaulting at the 1912 summer Olympics.  Hildreth Benner was reported an usher at Teddy Roosevelt Jr.’s wedding.  (TR lore: the ushers walked in their khaki uniforms and the 26th President of the United States (Teddy Sr) stood up and bowed).  Charles Carroll Glover Jr. is credited with the layout of the main boulevards in Washington DC. A jovial lot for sure.

(Regarding the archivist’s notations: the New York Times (May 29, 1910) reported on Theodore Roosevelt Jr. wedding. Alas, Hildreth Benner was a groomsman in the Bowen-Stevens wedding (Column 3) and not TR Jr.’s nuptials (Column 1-2, in which TR Jr.’s groomsmen are reported to be mostly Harvard classmates). Both appeared under the three column headline “Society Home and Abroad” which may explain auction house error. In addition, the Washington boulevard credit belongs to Glover Sr. and not Elihu man Glover Jr.).

Item 08 AuburnTheological

Henry Roe Cloud at Auburn Theological Seminary. Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

Yale’s second oldest senior society, Scroll & Key, gives beautiful silver bowls to a member of its “College Street crowd”, etched with members names, bridal couple, date and the society’s symbol with “CSP/CCJ.” Secret society “neutral” Lyman Bagg (Yale grad but not a secret society member) reports in Four Years at Yale of the Keys’ motto as, “Collegium Sanctum Pontificum / Collegium Conservat Jupiter.”

img_0895

CSP/CCJ. Scroll & Key wedding bowl (1912 Delegation) Yale University Art Gallery

A former Keys member told me that “CCJ” is the more venerated motto.  Delegation  leaders, known as Z’s (Zanoni (1842 novel) or Zeus?) take members along a journey well described in Gurney’s 1992 Keys’ history True Fellowship in All Its Glory.  (The phrase “true fellowship in all its glory” also appears in an 1889 Yale class decennial report in which one of the three authors (WL Armstrong) is a Keys member.  Love Google Books.)

The Yale Art Gallery owns a Scroll & Key wedding bowl — donated by Philip Skinner Platt, B.A. 1912 and gorgeous in its own right.

ag-obj-10023-001-pub-med

Scroll & Key wedding bowl (1912 Delegation) Yale University Art Gallery

I was also interested in Roe Cloud because I once owned another item with a Yale – Native American connection.  My Yale collection includes a 1719 letter by Joseph Willard (1714).  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 was skinned by Indians in 1723 and this is the only letter I’ve been able to locate by him anywhere. (And thus more rare than Declaration of Independence Signer Button Gwinnett 50+ known signatures in existence, though my appraiser would likely not see the relevance of my argument).

1719JosephWillard1714FrontPage

Josiah Willard (Yale 1714). Ravi D Goel collection on Yale, Yale Manuscripts & Archives.

A year after purchasing the Elihu Club tray, I purchased the Henry Roe Cloud papers from one of his direct descendants.  In November 2014, the items were donated to the Yale University Library, Manuscripts and Archives and are part of the Ravi D Goel Collection on Henry Roe Cloud.  I timed the gift to mark the 2014 centennial of Henry Roe Cloud’s graduation from the 1914 Yale Masters program.

Item 11 YaleMasters1914

Yale Master Degree (1914) Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives. (*** Note, the degree corrects erroneous dates elsewhere)

The finding aid summarizes the collection’s provenance: “The Ravi D. Goel Collection on Henry Roe Cloud was originally the possession of Cloud’s daughter, Marion Roe Cloud Hughes. After the death of Marion Roe Cloud Hughes and her husband, Edward Hughes, their grandson Shahn Hughes inherited the materials. They were then sold to Dr. Ravi D. Goel with the understanding that they would be donated to Manuscripts and Archives at Yale University.”

Item 01 MountHermon1906

Mount Hermon School diploma (1906). Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

The collection includes Roe Cloud diplomas from 1906 Mount Hermon School, Yale 1910 BA, 1912 Auburn Theological Seminary, and 1914 Yale MA.  Almost all of the letters were addressed to his fourth and youngest daughter, Marion Roe Cloud Hughes. The candor is extraordinary and defines Henry Roe Cloud’s view on Native American issues through the 1930s.

Item 10 AuburnDiploma

Auburn Theological Seminary Degree (1912). Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

Item 07 AuburnTheological

Henry Roe Cloud at Auburn Theological Seminary. Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

Item 07 AuburnTheological.JPG

Collection highlights include Roe Cloud’s candid thoughts on many Indian tribes, leading figures and the state of US-Indian affairs.  A detailed April 1937 letter addresses Cloud’s views on the Crees, Joseph Dussome, Baptiste Samatt, and Rocky Boy Superintendent Earl Wooldridge.

Item 13A IndianDress

Henry Roe Cloud in Indian Dress (marked “Silver Bay – June 1916”). Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

In a February 14, 1938 letter, Cloud writes about a reunion with his Yale 1910 classmate and then Chinese Ambassador to the United States Wang Zhengting.  He states in a most breathtaking letter, “In the next room stood the Ambassador and a long line of Chinese – the receiving line.  I stepped up with my heart in my throat, when the Ambassador said, ‘Henry Cloud, how stout you are!  What have you been eating?’  I replied ‘Wild Turkey and Buffalo meat.’  The dainty sweet pretty daughter standing next to him on the receiving line said sweetly ‘And butter, perhaps.'”  Roe Cloud goes through receiving line “feeling fatter than ever.” (See also Yale Manuscripts and Archives April 2015 blog, “Party Diplomacy: The Ravi D. Goel Collection on Henry Roe Cloud.”)

In a January 12, 1939 letter, he writes of the opportunity to see his Yale classmate and US Senator Robert Taft on his upcoming visit to Washington, DC.  U.S. Senator Taft was Skull & Bones 1910 and was at Yale while his father William Howard Taft (Skull & Bones 1878) served as 27th US President (and Yale Corporation trustee!).  The younger Taft was instrumental in the young Roe Cloud meeting President Taft.  Roe Cloud represented as head of a Winnebago delegation at the White House meeting. (See Pfister, The Yale Indian, page 44).  (Both Robert A. Taft (philosophical oration stand) and Henry Roe Cloud (first dispute) are mentioned in the 1910 NY Times article on Yale Commencement honorees.)

My collection also includes the original manuscript of his most famous 1915 essay, “From Wigwam to Pulpit: A Red Man’s Own Story of His Progress from Dark to Light.

Page 01

“From Wigwam to Pulpit” (1915 Manuscript). Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

The original From Wigwam to Pulpit manuscript is a more genuine read in Cloud’s own words versus the edited version that appears in The Missionary Review of the World (1915). This is one of the cornerstone gems of this collection, and mesmerizing in every word as he describes his childhood, Indian life, and conversion to Christianity. This 11-page manuscript autobiography is 97-98% complete with only 2-3 sentences and the post-script missing.  The NY Times honors Roe Cloud’s essay as his 1950 obituary begins, “Dr. Henry Roe Cloud, a Yale graduate of 1910, who was born in a wigwam on the banks of the Missouri River, died on Thursday of a heart attack in Siletz, Ore.”

Yale is in the process of digitizing many of these documents for access globally.  The Native American Cultural Center at Yale hosts a Henry Roe Cloud conference.  The Yale Group for the Study of Native America (YGSNA) also supports the Henry Roe Cloud Dissertation Writing Fellowship in American Indian and Indigenous Studies.

The Henry Roe Cloud collection is referenced in Kipling collector, Yale Library Development Council vice-chair, and Skull & Bones Trustee David Richards ’67 upcoming book, “Skulls & Keys: The Hidden History of Yale’s Secret Societies.” Richards is reported in a June 19, 2000 NY Times article as the outgoing senior who tapped 43rd U.S. President George W. Bush ’68 for Skull & Bones (no Bones wedding trays that I’ve been able to find, though Scroll & Key alum Alexandra Robbins reveals intriguing wedding rituals in her book Secrets of the Tomb).

IMG_2178.JPG

David Richards’ extraordinarily well written and researched 800 page book will soon become the starting point for future generations interested in Yale history.  I was delighted to review early drafts.  He mentions Henry Roe Cloud’s 1910 Elihu Club photo.

FullSizeRender (1)

David Richards, Skulls & Keys. HR Cloud details.

Here’s what I believe is the Elihu Club Delegation of 1910 photo:

Item 06 ElihuClub

Elihu Club Delegation of 1910. Ravi D Goel collection on Henry Roe Cloud, Yale Manuscripts & Archives.

I include a 2014 YouTube video of an excited overview I created during the process of documenting the collection for my appraiser (he’s “Bob” in the narrative):

 

I hope that these items will help spark more research and understanding of Yale and Native American history.

The documents may have increased interest with the August 9, 2017 Yale Alumni Magazine Daily Snap entitled “Disarmament.”

dailysnap0809_861x1299_0_0_460 (1)

Yale Alumni Magazine “Daily Snap” August 9, 2017.

See also :

1. Yale Daily News (August 22, 2017), “Yale to remove offensive stonework from library entrance.”

2. Artnet (August 21, 2017): Yale University Altered a Campus Sculpture Depicting Violence Against a Native American

Today is the Solar Eclipse! 7 Eye Safety Tips for #ProtectingSight during #SolarEclipse2017

Today is the Day! #SolarEclipse2017! This is a same day updated blog on protecting sight during the solar eclipse. My initial blog is here. A second blog is here.

As an ophthalmologist, I am increasingly interested in AND concerned with today’s (August 21, 2017) solar eclipse. Ophthalmologists are well aware of the risks of prolonged sunlight exposure to the health of the central vision (macula).  As early as 400 BC, Socrates warned, “People may injure their eyes by observing or gazing on the sun during an eclipse.” Some 2400 years later, we still have an increased risk of vision loss if we do not use proper eye protection when watching the solar eclipse.

img_2725

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

In my previous blog posts, I offered detailed explanations and links which explain the potential causes and effects of solar eclipse sun gazing and vision loss. Highlights include Retinal Physician (2013) (ophthalmology-speak) and a consumer friendly NASA’s FAQ’s on retinal rod and cone damage here. The oldest article I could find via PubMed search is from a British soldier who experienced a blind spot after the July 1945 solar eclipse in Europe. The full article is in my previous blog post.

Here are my Seven Eye Safety Tips (I call them Pearls) for #ProtectingSight during today’s solar eclipse:

1. The eyes are delicate organs & must be protected! The American Academy of Ophthalmology has an excellent starting point for Solar Eclipse Eye Safety.

2. If you plan to view the sun during the solar eclipse, please use certified solar eclipse glasses manufactured by reputable dealers. The American Astronomical Society (AAS) has a list of reputable vendors for solar glasses and viewers. Please check the glasses for any imperfections before the start of the eclipse. Suggested technique: Look AWAY from the sun (i.e. Turn around with your back to the sun) when you put the glasses on AND when you take them off. You should not remove the solar glasses at any point while you are looking in the sun’s pathway.

3. *** Your regular sunglasses are NOT good enough! *** Your regular sunglasses will NOT be sufficient to counterbalance the intensity of enhanced light ray effect during the solar eclipse. They may actually make the situation worse as non-certified solar eclipse glasses may cause the pupil to become bigger (dilate) and not give proper eye protection.

34a3d470-445f-4c27-ab37-b7093df4d75c

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

4. As an ophthalmologist, I recommend that children must be under extra precaution during the solar eclipse. You don’t want a child to “take a peek” outside of the protective eyewear. The “take a peek” can possibly cause irreversible retina damage.  NASA has an excellent article on “How to safely observe the Sun with young children” (Opens as PDF).  Note the authors explicit recommendation, “Solar glasses should be modified with elastic or tape around the back so they stay on young children’s small faces.” (Safe Viewing Options, page 55)  Great care must be taken for anyone and especially children.

This is one of the best & safest ideas I’ve seen from friends’ kids.  Solar glasses & colorful paper plates, easy to secure and able to protect against peeking:


5. Ophthalmology is about #ProtectingSight. Even this once in a generation event is not worth the risk without proper eye protection. Solar media … ummm I mean social media has numerous stories of patients who lost sight and are advocates for protecting sight. Here is one story from the 1962 solar eclipse.  Instead, watch the livestream eclipse Through the Eyes of NASA!

6. Make notations of the solar eclipse trajectory in your hometown via Time Magazine interactive map. I recommend solar eclipse glasses for all sun viewing during the moon’s entire trajectory across the path of the sun (including in areas of complete darkness!).  NASA eclipse maps are here.

7. A wonderful 4-minute YouTube video by ophthalmology colleague and social media guru Steve Christiansen MD is available on his website (with written narrative) and below.

8. (BONUS PEARL!) We live in a social media world! Don’t forget that your iPhone / Android and other smartphone devices need special filters to block out the intense light AND take useful images. Here is an image with an iPhone taken through a solar eclipse glasses filter:

Here is the same image cropped for social media:

Here is another image with the iPhone closer to the solar eclipse glasses filter to show the intensity of light (also with an Instagram enhancement!):

See the American Academy of Ophthalmology detailed post: Learn How to Photograph an Eclipse Without Damaging Your Eyes or Your Camera.  I have a short YouTube video also:

9. (BONUS PEARL #2) I enjoyed an engaging interview with Fox 29 Philadelphia’s Joyce Evans. All of the video pearls are included in the narrative above. (I’ll post video once available online).

Please stay eye safe on #SolarEclipse2017!

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.

An Ophthalmologist’s Seven Pearls for #ProtectingSight during #SolarEclipse2017

We are one day away from #SolarEclipse2017! This is a shortened & updated blog on protecting sight during the solar eclipse. Initial blog here.

As an ophthalmologist, I am increasingly interested in (and concerned with) the upcoming August 21, 2017 solar eclipse. Ophthalmologists are well aware of the risks of prolonged sunlight exposure to the health of the central vision (macula).  According to Plato, Socrates warned, “People may injure their eyes by observing or gazing on the sun during an eclipse.” (400 BC!)

img_2725

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

Sunlight exposure due to a solar eclipse can cause damage quickly! An excellent explanation of solar retinopathy is available from Retinal Physician (2013).  In addition, Rozanowska et. al state, “Exposures lasting for several minutes to tens of minutes are sufficient to cause an ophthalmoscopically visible damage.”  (Light-Induced Damage to the Retina)  NASA’s FAQ’s include a patient friendly explanation of rod and cone damage here.  During an eclipse, your pupils may dilate allowing more sunlight to come in.  As NASA authors state, “The problem is that the sun’s surface is so bright that if you stare at any portion of it, no matter how small, it produces enough light to damage individual retinal cells.”

I wondered about the first reported case of solar eclipse retinal damage. Thanks to the Yale Library’s Scan & Deliver service, I found a 1946 article in the British Journal of Ophthalmology of an ophthalmologist’s report for a soldier who experienced solar eclipse macular damage following the July 9, 1945 event. This is the oldest article I could find via PubMed search.

I was fascinated by Dr. EC Zorab’s description & Dr. NA Jevon’s additional report. I take for granted the many diagnostic machines (including Optical Coherence Tomography (OCT) & fundus photography) which allow today’s ophthalmologists to evaluate the retina at the level of 1/1000th of a millimeter. The post-World War II drawings and narrative details are refreshing elements of comprehensive ophthalmic consultations. The full article is in my previous blog post.

Here are my Seven Pearls for #ProtectingSight during the upcoming August 21, 2017 solar eclipse:

1. The eyes are delicate organs and must be respected! The American Academy of Ophthalmology has an excellent starting point for Solar Eclipse Eye Safety.

2. If you plan to view the sun during the solar eclipse, please use certified solar eclipse glasses manufactured by reputable dealers. The American Astronomical Society (AAS) has a list of reputable vendors for solar glasses and viewers. Look AWAY from the sun when you put the glasses on AND take them off. You should not remove the solar glasses at any point while you are looking in the sun’s pathway.

3. *** Your regular sunglasses are NOT “good enough!” *** Your regular sunglasses will NOT be sufficient to counterbalance the intensity of enhanced light ray effect during the solar eclipse.

34a3d470-445f-4c27-ab37-b7093df4d75c

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

4. As an ophthalmologist, I recommend that children be under extra precaution during the solar eclipse. You don’t want a child to “take a peek” outside of the protective eyewear. The “take a peek” can possibly cause irreversible retina damage.  NASA has an excellent article on “How to safely observe the Sun with young children” (Opens as PDF).  Note the authors explicit recommendation, “Solar glasses should be modified with elastic or tape around the back so they stay on young children’s small faces.” (Safe Viewing Options, page 55)  Great care must be taken for anyone and especially children.

This is one of the best & safest ideas I’ve seen from friends’ kids. Solar glasses & colorful paper plates, easy to secure and able to protect against peeking:


5. Ophthalmology is about #ProtectingSight. Even this once in a generation event is not worth the risk without proper eye protection. Solar media … ummm I mean social media has numerous stories of patients who lost sight and are advocates for protecting sight. Here is one story from the 1962 solar eclipse.  Instead, watch the livestream eclipse Through the Eyes of NASA!

6. You can also see how the solar eclipse will look from anywhere in the US via Time Magazine. I recommend solar eclipse glasses for all sun viewing during the moon’s entire trajectory across the path of the sun (including in areas of complete darkness!).  NASA eclipse maps are here.

7. A wonderful 4-minute YouTube video by ophthalmology colleague and social media guru Steve Christiansen MD is available on his website (with written narrative) and below.

8. (BONUS PEARL!) We live in a social media world! Don’t forget that your iPhone / Android and other smartphone devices need special filters to block out the intense light AND take useful images. Here is an image with an iPhone taken through a solar eclipse glasses filter:

Here is the same image cropped for social media:

Here is another image with the iPhone closer to the solar eclipse glasses filter to show the intensity of light (also with an Instagram enhancement!):

See the American Academy of Ophthalmology detailed post: Learn How to Photograph an Eclipse Without Damaging Your Eyes or Your Camera.  I have a short YouTube video also:

Please like and share this blog! Comments most appreciated.

Stay eye safe on #SolarEclipse2017!

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.

Richard Warren Pershing (Yale 1966, Skull & Bones, Vietnam War Hero & Grandson of General John Pershing)

I purchased a copy of the Yale secret society Skull & Bones Class of 1966 photo album in December 2011.  This is one of those iconic Bones’ classes whose members include US Secretary of State John Kerry ’66, Fedex founder Fred Smith ’66, and many prominent Yale graduates.

IMG_6342

Richard Warren Pershing (Yale 1966 Skull & Bones album, Ravi D Goel collection on Yale, Yale Manuscripts & Archives Library)

My album came from the estate of Richard Warren Pershing ’66, who died in February 1968 during the Vietnam War.  Pershing was then a 25 year old grandson of World War I General John Pershing.  Richard Warren Pershing, along with his brother John Warren Pershing III, are buried in Section 34 of Arlington National Cemetery near their grandfather along Pershing Drive.  Upon Richard Warren Pershing’s death, the album became the property of John Warren Pershing III (died 1999).

I shared this find with a Skull & Bones member and friend.  He responded, “Unbelievable!  This one is iconic.  Good for you for saving it.  I didn’t know Dick, but his portrait was up in our building by the time my senior year started.”

IMG_6352

A New York Times 2004 article explored in detail then US Presidential candidate John Kerry’s reaction and struggles with his best friend Pershing’s death which influenced Kerry’s rise in politics.

FullSizeRender

I timed my gift to coincide with the Class of 1966 50th reunion and the conclusion of Secretary Kerry’s tenure at Department of State.  When I emailed the Yale Library in April 2016, I asked that the item have restricted access until five years after Kerry was out of office.  The Yale Library was hesitant to honor this request, and the timing at the conclusion of the Obama administration allowed the item to be donated and made available soon after the next presidential administration had begun.  

IMG_6357

I mentioned the book and provenance in a chance encounter with Secretary Kerry at President Salovey’s reception before the 2015 Harvard-Yale Game.  He was most intrigued (startled really, “You’re kidding!”) by this information and we spoke briefly about Pershing and Pershing’s brother.  Clearly, his security detail was not as excited about our conversation as I was!

IMG_0607

 

Original seller’s description: “Up for auction is an extremely rare Yale 1966 Skull & Bones yearbook in very good condition. One small smudge on the “1966” on the cover (see first photo), might be able to clean?  Only 16 photographs of members mounted on thick cardboard pages.  20 pages in all, no text. This edition belonged to the late Richard Pershing, I salvaged it from his late brothers estate. I purposely did not post the photo’s of the individuals.” (With the exception of Pershing’s photo, I also have refrained from posting other members’ photos online)

1966Bones1

Provenance (from seller to me in email dated December 16, 2011): “This 1966 Yale Skull and Bones book was salvaged by me from the estate of the late John Pershing, brother of Richard Pershing.  I had the pleasure of knowing John Pershing before his death in 1999 and was recently charged with disposing some of his stored books at my discretion.  There is not much more I can tell you about this item, neither John or Richard Pershing had any children and without my intervention this copy was destined for destruction.”

The Yale Skull & Bones Class of 1966 includes successful politicians, businessmen, physicians, educators and collectors which can be found through other links.

1966Bones2

The album will be added to three sets of documents at Yale’s Manuscripts and Archives and become part of the “Ravi D. Goel Collection on Yale” (2008, 2011, 2012). (As of August 2017, with Yale Manuscripts & Archives undergoing renovation, the 1966 Skull & Bones album has still not been accessioned in the database online)  In November 2016, the 2008, 2011 and 2012 documents were added to the Yale Digital Collections. They include a scrapbook of 100+ letters among members of the Skull & Bones Delegation of 1874. Also included is letter written by then US Appeals Court judge & future 27th President of the United States William H. Taft (1878) signed “Yours in the Bones.”  There is also a “Ravi Goel collection of Reuven Kosakoff” at Yale’s Irving S. Gilmore Music Library (2013).  In addition, “The Ravi D. Goel collection on Henry Roe Cloud” of Yale’s 1st known Native American was donated to Yale’s Manuscripts and Archives in 2014.

IMG_6321.JPG

Some of these items are referenced in Kipling collector, Yale Library Development Council vice-chair, and Skull & Bones Trustee David Richards ’67 upcoming book, “Skulls & Keys: The Hidden History of Yale’s Secret Societies.Richards is reported in a June 19, 2000 NY Times article as the outgoing senior who tapped 43rd U.S. President George W. Bush ’68 for Skull & Bones.  His extraordinarily well written and researched 800 page book will soon become the starting point for future generations interested in Yale history.

1966Bones3

An Ophthalmic Report of the July 1945 Solar Eclipse (Burn of Macula) Remains Relevant!

As an ophthalmologist, I am increasingly interested in the upcoming August 21, 2017 solar eclipse. Ophthalmologists are well aware of the risks of prolonged sunlight exposure to the health of the central vision (macula).  According to Plato, Socrates warned, “People may injure their eyes by observing or gazing on the sun during an eclipse.” (Socrates lived from 470/469 BC – 399 BC)

img_2725

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

Sunlight exposure due to a solar eclipse can cause damage quickly! I have the number “55 minutes” burned into my memory from ophthalmology board certification examinations.  This is the number of minutes a patient undergoing ophthalmic surgery which can cause permanent macular damage due to the operating microscope’s light intensity and saturation. As residents in training, senior residents and attending ophthalmic surgeons would tell us, “make sure the case is done in less than 55 minutes.” But a solar eclipse intensifies the light rays and can literally burn the most critical layer of the retina 100x faster.

There maybe some dramatic license with “100x faster” of a microscope light vs. sunlight as pointed out by a Yale classmate & optics friend.  An excellent explanation of solar retinopathy is available from Retinal Physician (2013).  In addition, Rozanowska et. al state, “Exposures lasting for several minutes to tens of minutes are sufficient to cause an ophthalmoscopically visible damage.”  (Light-Induced Damage to the Retina)  NASA’s FAQ’s include a patient friendly explanation of rod and cone damage here.  During an eclipse, your pupils may dilate allowing more sunlight to come in.  As NASA authors state, “The problem is that the sun’s surface is so bright that if you stare at any portion of it, no matter how small, it produces enough light to damage individual retinal cells.”

I wondered about the first reported case of solar eclipse retinal damage. Thanks to the Yale Library’s Scan & Deliver service, I found a 1946 article in the British Journal of Ophthalmology of an ophthalmologist’s report for a soldier who experienced solar eclipse macular damage following the July 9, 1945 event. This is the oldest article I could find via PubMed search.

I was fascinated by Dr. EC Zorab’s description & Dr. NA Jevon’s additional report. I take for granted the many diagnostic machines (including Optical Coherence Tomography (OCT) & fundus photography) which allow today’s ophthalmologists to evaluate the retina at the level of 1/1000th of a millimeter. The post-World War II drawings and narrative details are refreshing elements of comprehensive ophthalmic consultations.

I include the articles in full as a courtesy to colleagues & patients worldwide:

Patient pearls for the upcoming August 21, 2017 solar eclipse:

1. The eyes are delicate organs and must be respected! The American Academy of Ophthalmology has an excellent starting point for Solar Eclipse Eye Safety.

2. If you plan to view the sun during the solar eclipse, please use certified solar eclipse glasses manufactured by reputable dealers. The American Astronomical Society (AAS) has a list of reputable vendors for solar glasses and viewers.

3. *** Your regular sunglasses are NOT “good enough!” ***

34a3d470-445f-4c27-ab37-b7093df4d75c

iPhone 7 image of the sun taken through American Astronomical Society vendor-recommended solar eclipse glasses.

4. As an ophthalmologist, I recommend that children be under extra precaution during the solar eclipse. You don’t want a child to “take a peek” outside of the protective eyewear. The “take a peek” can possibly cause irreversible retina damage.  NASA has an excellent article on “How to safely observe the Sun with young children” (Opens as PDF).  Note the authors explicit recommendation, “Solar glasses should be modified with elastic or tape around the back so they stay on young children’s small faces.” (Safe Viewing Options, page 55)  Great care must be taken for anyone and especially children.

This is one of the best & safest ideas I’ve seen from friends’ kids. Solar glasses & colorful paper plates, easy to secure and able to protect against peeking:


5. Ophthalmology is about #ProtectingSight. Even this once in a generation event is not worth the risk without proper eye protection.

6. You can also see how the solar eclipse will look from anywhere in the US via Time Magazine. I recommend solar eclipse glasses for all sun viewing during the moon’s entire trajectory across the path of the sun (including in areas of complete darkness!).

7. A wonderful 4-minute YouTube video by ophthalmology colleague and social media guru Steve Christiansen MD is available on his website (with written narrative) and below.

8. (BONUS PEARL added 8/21/2017!) We live in a social media world! Don’t forget that your iPhone / Android and other smartphone devices need special filters to block out the intense light AND take useful images. Here is an image with an iPhone taken through a solar eclipse glasses filter:

Here is the same image cropped for social media:

Here is another image with the iPhone closer to the solar eclipse glasses filter to show the intensity of light (also with an Instagram enhancement!):

See the American Academy of Ophthalmology detailed post: Learn How to Photograph an Eclipse Without Damaging Your Eyes or Your Camera.  I have a short YouTube video also:

9. (BONUS PEARL #2) I enjoyed an engaging interview with Fox 29 Philadelphia’s Joyce Evans. All of the video pearls are included in the narrative above. (I’ll post video once available online).

Please stay eye safe on #SolarEclipse2017!

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.

27 Contact Lenses in the Eye Meet 10 Year Old Braces in the Stomach

Ophthalmology & social media were abuzz last month as a patient in the U.K. was found to have 27 contact lenses “in the eye,” or under the upper eyelid.  The lenses were found as the asymptomatic patient was about to undergo cataract surgery.  See my previous blog here.

Retained contact lenses (Morjaria R, BMJ 2017; 358)

A new case from the BMJ Case Reports tells of a 30-year old patient who had braces removed 10 years previously and was found to have brace wire in the stomach.  The case is titled, “Orthodontic braces come back to bite: a novel presentation of a small bowel volvulus” (BMJ Case Reports 2017; doi:10.1136/bcr-2017-221152)  

CT image (coronal) of orthodontic wire at the root of the small bowel volvulus.

At first, I thought there might be a foreign body crisis in the U.K. National Health Service (NHS) but the dental patient is in Australia.

The authors give an excellent & scholarly description of a patient who presents with abdominal pain for a second time to an emergency department.  On the second trip, the CT scan finds the foreign body.  (And without seeking to offend any colleagues worldwide — and given the cost of care in the US — I’d wager a standard protocol in the US would be to get a diagnostic study before the patient was even evaluated by an emergency department physician in the US.)

The authors conclude, “Most inert ingested objects, if they pass the cricopharyngeal sphincter, will pass spontaneously.1The most common site for perforation or obstruction is the ileocaecal valve.1 The case we describe here is therefore novel in the decade delay in presentation and the clinical sequelae.”  (Layman’s translation: “If you swallow an object it’s most likely to pass naturally through the bowel.  The most common site of perforation or obstruction (ie. a bad thing) is at the junction between the small intestine and colon (ileocaecal valve).  This case was a 10-year delayed diagnosis in a patient who was otherwise asymptomatic.”  They forgot to mention “Do not try at home!”)

BracesinBowelResection2017.gif

The clinical pearl is that contact lenses and braces are among numerous “medical devices” which can be retained in parts of the human body for many years and without incident.

It’ll be interesting to see if this causes mass hysteria among parents who will now worry if their child has retained braces wire. Or whether they really should have just invested in the Invisalign (which likely has a plastic foreign body risk).

Cases which hit the mainstream media are usually the zebras and not the horses.  As stated in the 1940s by Dr. Theodore Woodward, professor at the University of Maryland School of Medicine, who instructed his medical interns: “When you hear hoofbeats, think of horses not zebras”.[2] (The medical slang explanation for “Zebras in medicine” has a Wikipedia page here).

In any event, good luck to orthodontic & GI colleagues in the days (or Warhol’s 15 minutes) ahead.

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.

27 Contact Lenses Magically Discovered & Debunked!

I saw the report of 27 contact lenses found in a 65 year old female patient about to undergo cataract surgery in the UK via my Twitter Newsfeed this past Sunday.  I use Twitter as an excellent source of ophthalmology case reports and cutting edge studies. Ophthalmology is a visual specialty, and journal highlights offer numerous pearls which help me in my clinical practice everyday.

By Monday morning, a Yale classmate (and Harvard Law grad) posted an NPR article and tagged me in a Facebook post with the question, “Ravi Goel is this even possible? How could she get that close to surgery without anyone noticing it sooner?”  

I wondered the same thing!

I responded that after 2 (or at most 3) contact lenses in the visual axis the patient would be legally blind in that eye, unless the lenses settled outside the visual axis. As described, the lenses must have been in the superior or inferior fornix (** As a cataract surgeon in between patients, I originally stated “sulcus” but it’s fornix).  I was not sure when or why my UK colleagues were, as reported by NPR, “injecting anesthesia into the woman’s eye.” (ie. pre-op area or in the OR Theater).

“I’ll review original article,” I promised.

I emailed the author, Dr. Rupal Morjaria (Sandwell and West Birmingham Hospitals NHS Trust) who graciously sent me the one page case report from the British Medical Journal.  The original article is behind a firewall, and the quickest way to read the article is to email the author directly.  Her email response with PDF arrived in 10 minutes. (I also use Yale University Library’s Scan & Deliver Service ($150 annually for alumni) which will send a PDF copy of any article they have in print form.  The best kept secret for Yale alums.  Received the Yale PDF in 2 hours, a superb bargain which has saved many hours in my research for ophthalmology and historical documents).

British Medical Journal

British Medical Journal

As I speculated, the article mentioned that the contact lenses were found in the “superior fornix” and the patient was noted to have “deep set eyes.” I remembered a Johns Hopkins / Wilmer Eye Institute grand rounds case circa 1999 in which a patient with unexplained chronic infections had a contact lens, long forgotten, embedded in a similar location.  I remember the roar of disbelief among the Wilmer ophthalmology elite nearly 2 decades later to a superb resident presentation (shout out to Seth Biser MD and his smug look when the origin of the unexplained infection was revealed!).

PubMed, the biomedical literature database, includes a 1966 article in the Japanese ophthalmology literature of “A case of a foreign body granuloma due to a contact lens retained long in the upper fornix.” (Nihon Ganka Kiyo. 1966 Aug;17(8):103-6).  In addition, numerous citations for “retained contact lens” have appeared since that first known article (I count 15 of the 100 search results as being scholarly articles which describe a lost or forgotten contact lens retained “in the eye” or “under the eyelid”).

Highlights include a 2013 case in India of a contact lens masquerading as a chalazion and a 2011 British case of an 81 year old male with an embedded rigid contact lens believed to be from a long forgotten fitting 40 years previously. (Yes, 2 score years ago, and which the authors state “appears to be the longest delay in diagnosis reported in the ophthalmic literature”!!).

Congratulations to the 2017 British colleagues and authors on their discovery.  I wonder what the pre-operative cataract measurements showed and how the measurements will change in the months ahead without the retained contact lens and changes to ocular surface architecture.

I include a superb 3 minute video from ophthalmology superstar & retina fellow Steve Christiansen MD which explains how contact lenses can be retained in the ocular surface corners (fornix) but not in the eye:

 

Clinical pearls:

  1. Never sleep in your contacts!
  2. If you lose your contact lens, look on the table, in the contact lens case, on the floor etc. until found.  On many occasions as an ophthalmology resident, the 3 am Saturday night patient returned home from the Emergency Department to tell me, “You were right, doc, the lens is right here on the sink’s edge!”
  3. If you cannot find your contact lens and feel any discomfort, see an ophthalmologist and ask them to “flip my lid” (eyelid eversion and assessment of ocular tissues) to evaluate for possible retained contact lens.

——

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.