The Future Awaits

By seeing oneself as an actor in a retina-based narrative, one moves toward a holistic understanding of the continuum of scientific development.

By Murtaza Adam, MD
 

As I approach the final months of my vitreo-retinal fellowship training, I look ahead at what is to come after graduation with a mix of excitement and trepidation. Newfound independence can be thrilling, akin to the feeling one experiences just before the first drop on a roller coaster. The naïve prospect of independence after 10 consecutive years of formal medical training ultimately gives way to the realization that true freedom as a physician is a mere illusion. I will always be beholden to something or someone—be it the medical system in which I function, the employees in my clinic, my partners, referring physicians, or, most importantly my patients.

I will also be beholden to keeping up with the rapid evolution of our subspecialty. The ability to adapt is mandated, lest we provide suboptimal care. Reading the latest journals, attending conferences, and watching surgical videos can all be great ways to keep up with the latest and greatest. Still, the sheer volume of scientific and clinical minutiae can be too overwhelming to digest. And it is only going to get harder as the rate of the doubling of medical knowledge continues to accelerate. Estimates are that the doubling of medical knowledge in the 1950s would take 50 years; in 2010, it was 3.5 years; in 2020 it is estimated to be 0.2 years (73 days!).1 Astoundingly, the knowledge base of a medical student who began medical school in 2010 will represent only 6% of what will be known 10 years later in 2020.

It is not just new information that we may struggle with, but also old information, which is often just as elusive. In working with residents and medical students, I am humbled by the questions they ask me. Why does a retinal detachment occur in some people and not others? Why does the vitreous liquefy with age? Where does subretinal fluid come from? I am able to answer questions like these on a basic level, but the more involved the questions become, the deeper the rabbit hole goes. At the end of it lies the limit of my understanding, and this is where I have realized how much knowledge—both historical and novel—I take for granted.

THE PATH TO KNOWLEDGE

Despite the inevitable knowledge gap facing the physicians of today and tomorrow, not all hope is lost. As Sir Isaac Newton once remarked, “If I have seen further, it is by standing on the shoulders of giants.” Indeed, without the pioneering work of Galileo and Kepler, Newton might not have had as profound an impact on physics and mathematics. Progress in all fields, especially medicine, rarely occurs in a vacuum. The giants need each other, we mere mortals need them, and, believe it or not, they need us to propagate the impact of their discoveries. The narrative of our scientific endeavors, amalgamated with the collaborative spirit of humanity, has created a foundation of intellectual bedrock for all of us to build upon and find shelter in.

Take retinal detachments, for example. The modern principles of rhegmatogenous retinal detachment repair sound deceptively intuitive: find the retinal breaks, relieve traction on the breaks, and treat the breaks. Taking these principles at face value, it was shocking for me to discover that, prior to 1920, it was thought that retinal breaks were a consequence of, rather than the cause of, retinal detachments. In their chapter on the history of retinal detachment repair, Rezaei and Abrams discuss the many ways in which retinal detachments have been “repaired”: with compression ocular bandages, a salt-free diet, subconjunctival injection of hypertonic saline, and even intravitreal injection of vitreous fluid extracted from rabbits.2

Although cautery had been used in a variety of unsuccessful manners to attempt to repair retinal detachments, it was not until Jules Gonin recognized that retinal reattachment was dependent upon the successful treatment of retinal breaks that a breakthrough was made.3 His procedure involved use of sharp cautery to penetrate the sclera in the meridian of the causative retinal breaks. Upon removal of the cautery element, subretinal fluid was partially drained, and the retinal break was then incarcerated into the drainage site, permitting resolution of subretinal fluid in more than 50% of cases treated. Upon reporting his technique and theory, in 1920, that vitreous traction on retinal tears was the cause of retinal detachments, Gonin was met with significant resistance. He persevered and was ultimately proven correct. Although nobody in their right mind today would repair a retinal detachment in the way Gonin described, his work allowed many other giants in the field of vitreoretinal surgery—including Schepens, Lincoff, and Machemer—to bring our nascent field to where it is today.

With this perspective, I look forward to my post fellowship future with renewed confidence. I no longer hear the names of the giants in our field and think of them as mere characters in the history books. I feel akin to them. Having trained in fellowship under the supervision of my own personal giants—physicians with a passion for teaching, a wealth of knowledge, and wisdom gained through the collective experience of generations of vitreoretinal surgeons—I feel I am a part of a legacy, and I am comforted by that.

 

1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.

 

2. Rezaei K, Abrams GW. A history of retinal detachment surgery. In: Kreissig I, ed. Primary Retinal Detachment. Springer-Verlag; 2005:1-24.

3. Brown AL. Gonin’s cautery puncture for detached retina. Report of three cases. Trans AMA Sect Ophthalmol. 1930;81:236.

 

Section Editor Murtaza Adam, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.
madam@midatlanticretina.com

 

Section Editor David Ehmann, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.
dehmann@midatlanticretina.com

Section Editor Sundeep K. Kasi, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.
skasi@midatlanticretina.com


Tags: fellowship
 

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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.