Argus II Retinal Prosthesis System

As Ophthalmologists, we do everything we can to prevent vision loss, but sometimes there is nothing more we can do. From the invention of braille to bionic retinas, we are continuously finding new ways to help those with low vision. The goal for assistive technology is to improve their functional independence. Here are five of the most impactful and promising innovations in visual assistive technology today.  

1. Digital Media and Accessibility tools

Eye Pal Optical Character Recognition Software

Our access to information exploded when we entered the digital age, which has revolutionized the way those with low vision learn and stay up to date. Our computers, tablets, kindles, and phones can not only magnify text, but also read out loud (see: iOS voiceover, Android talkback and even brailleback).  

The National Library Service for the Blind and Physically Handicapped produces audio books and also provides a free digital player to those registered with the Library for the Blind and Physically Handicapped.

Other membership or paid services include Bookshare, Learning Ally, or Audible (which also has a large selection of free content). There are also special reading apps with communities of individuals who regularly release audio content such as newspapers or podcasts.  Finally, optical character recognition products (such as Eye-Pal, Kurzweill 1000, or OpenBook) use cameras to "scan" and convert print to a readable digital form.

(Read more about accessible reading technology). 

2. Navigation technology

Smartphones are ubiquitous in our world, and many developers have started making GPS apps that are more "blindness aware." Three popular ones are Nearby Explorer, The Seeing Eye GPS App, and Blindsquare. In addition to giving directions, these apps can regularly announce your location, alert you when you're approaching intersections, and display nearby points of interest.

On a smaller scale, Cheiko Asakawa at Carnegie Mellon has been developing software that can map buildings and campuses using "beacons." They plan to integrate their Navcog app with facial recognition software that can identify acquaintances and recognize facial expressions.

Traveling by car is also no longer an obstacle. With the prevalence of ride sharing services (Uber, Lyft), we can have others drive us. And soon, we can have our cars drive themselves. (See Google's self driving cars)

3. Braille Technology

The search for the "Holy Braille"

Since its invention by Louis Braille in the 19th century, Braille remains an essential form of communication in the low vision community. While originally an entirely analog system, technology has helped maintain Braille's relevance in the modern era.

Both braille writers and readers are now able to connect via bluetooth to smartphones, computers, and tablets. Users can write braille with "braillers" which are essentially braille typewriters.

To read, electronic braille displays analyze text line by line, converting them into braille using lines of movable metal or plastic pins. Unfortunately these displays historically have been very expensive, which has limited their adoption.

A new ambitious project on the way, "Holy Braille" hopes to combat this by creating a low cost, full-page refreshable braille display (a braille kindle.) It's currently being developed at the University of Michigan.

4. The Smartcane

Uploaded by The Better India on 2016-04-09.

The two most common types of canes used by those with low vision are the support cane, which provides physical support, and the probing cane, which probes for obstacles in the path of travel.  The probing cane has a long tip that slides along the ground and can identify curbs, stairs, and large obstacles on the ground. However, it often misses hanging bars, signs, and things not fixated on the ground.

The Smartcane is a electronic travel aid that can be attached to the traditional white cane. It uses ultrasound to detect obstacles and converts them to vibrations that the user can feel. Many canes, gloves, etc.. use similar technology, but the SmartCane is the most widely used due to its simplicity and low cost ($50).

5. Retinal prostheses (BIONIC EYES!!)

The Argus II is an epiretinal implant. The Implant AG is a subretinal implant. 

Science fiction has longed dreamed of cyborgs and "bionic eye." The Argus II and the Retina Implant AG are the two only retinal implants that are currently available to the public outside of clinical trials.

The Argus II system is designed for patients suffering from retinitis pigmentosa. It costs about 150K and involves attaching an implant to the surface of the retina that links to an external digital camera. In one study, 26 of 27 subjects showed a significant improvement on a high contrast visual performance test.

The Retina Implant AG is different than the Argus, as it is implanted below the retina. Developed in Germany over the last 20 years, this implant functions similar to a photoreceptor array and transmits to residual bipolar and horizontal cells in those suffering from AMD or retinitis pigmentosa.  It doesn't use a camera, as the implant itself is a  complementary metal-oxide-semiconductor (CMOS) camera like chip. It does, however, require a cochlear implant that powers it through induction. Awesome.

FINAL THOUGHTS

These are just a few of the many innovations in the field of accessible technology. You can find a comprehensive database of products on the American Foundation for the Blind website. 

I hope this post has been both a practical and informative glance at some of the current and upcoming technologies that exist. I really enjoyed researching this topic, and it has made me very optimistic about the future!

-Louie 

It's Summer - which means outdoor barbeques, beach days, family vacation, and yes, the beginning of the vitreoretinal surgery fellowship match application process. I remember as an applicant feeling overwhelmed with the amount of information (much of it conflicting) thrown my way.

As Albert Einstein wrote, “Out of clutter, find simplicity”.

Here are ten principles to guide prospective applicants through the next 6 months. Significant credit go to the panelists from our Retina Fellowship Match podcast  for their contributions. Another great resource is this article from Retina Today.

1.      Be certain: Before committing yourself (and in many instances, your family) to two more years of post-graduate training at a non-attending level salary make sure this is what you actually want. As much as we all love vitreoretinal surgery we understand that comprehensive practice and other fellowship opportunities available are attractive in their own right. While there is wide variation in vitreoretinal surgery practices, in general it is a busy field with more emergencies than other ophthalmology subspecialties. Every attending guest who has shared their backstory on the podcast had a strong reason for taking the plunge. Make sure yours is a choice of love and rationality and not of ego or perceived prestige.

2.      Be involved: Once you clear the hurdle of principle #1, continue to throw yourself into the field. Do not lose hope if you have not done significant retina research to this point, but understand that the next few months are critical to buff your CV and impress your mentors with your dedication. Don’t have a mentor? Find one! Speak to previous successful matches and use their experiences to find suitable attendings at your institution who have a track record of supporting residents.

3.      Be organized: Start collecting electronic documents you will need to provide your letter of recommendation writers and submit for both SFMatch and individual program supplemental applications. These documents can include but are not limited to: undergraduate and medical school transcripts, medical school Dean’s letter, copy of passport, and OKAPS scores. Get your personal statement and CV done early, and plan that you will also likely need letters of recommendation from your department chair and residency program director (if these are not among your chosen 3 letters of recommendation). If possible try and schedule lighter rotations for the months of October and November which is the height of interview season. Make a spreadsheet of the programs you plan to apply to with columns for application due dates (which vary program to program), supplemental requirements, interview date, and contact information for the program coordinator.

4.      Be timely: Aim to have all applications items including letters of recommendation ready to go by mid-July if possible. Your goal should be to submit your application to SFMatch and all supplemental materials to each individual program well ahead of all deadlines. Remember, each program has a different deadline to receive your full application!

5.      Be honest with yourself: Obtaining a vitreoretinal surgical fellowship can be a competitive process given the high-quality of applicants and the relatively small number of spots nationally; thus, it makes sense to apply as broadly as possible and err on the side of applying to more programs. Still, some introspection can be helpful when choosing programs. If you (and family, if applicable) already know with 100% certainty certain geography will not work then do not waste time, energy, effort, and money. Remember, this only applies if you are 100% certain and more comfortable not matching than matching at a specific program.

6.      Be active: It’s early August, your application is in, and it’s time to relax, right? Not necessarily! The best fellowship applicants stay active in the interim period finishing outstanding projects, submitting manuscripts, and attending fall meetings if possible such as the American Society of Retina Specialists Annual Meeting or The Retina Society Annual Meeting. Not only does staying visible reinforce to your mentors your dedication, it may connect you with future interviewers ahead of the formal interview date. Heck, maybe even take time on your commute and listen to a retina-related podcast or two (shameless plug).

 7.      Be prepared: Interviewing may be easier for some people than others, but just like shooting a basketball or doing cataract surgery the more you practice the better you will be come crunch time. I still have a list on my desktop of my pre-interview notes for myself: stand straight, smile, shake hands firmly, lean slightly forward when talking, maintain eye contact and keep switching eyes to avoid staring, and KNOW YOUR APPLICATION and CV. Practice interviewing with co-residents, family, or faculty mentors. Do your homework and read all information about a program that may be available on their website including the names and training of faculty members, number of fellows per year, clinical sites, and where graduates are practicing. Dress sharply but not memorably, try to fly non-stop whenever possible to minimize delays, and try and pack at least two suits so as to always have a backup.

8.      Be enthusiastic: Again, this comes easier to some people than others. Some applicants are extroverts and thrive on the application process to connect, network, and be the life of the party at interviews. Some have a tendency to retreat inward and come across inaccurately as aloof, uninterested, and standoffish. Know your tendencies and find reasons to be enthusiastic for every program. After all the pain, sweat, tears, and financial investment, it is a shame when lack of energy sinks an interview. Try and be excited, this may be your home base for 2 years!

9.      Be proactive: Make a running rank list of the programs as you complete your interviews to avoid angst later. Keep your mentors updated as to your thoughts as you proceed through the trail. Utilize your mentors to make phone calls and communicate your interest to the programs highest on your list. Feel free to notify your top choice but avoid the fatal and unethical misstep of telling multiple women (or men) you love them the most.

10.  Be thankful: This is true both philosophically and practically. Upon matching celebrate yourself and your accomplishments. You are joining a wonderful field full of amazing people. But do not forget to thank your letter writers, mentors, and friends and family who supported you along the way. They are the unsung heroes behind your achievements.

Thanks for reading!

-Jay

Dr. Sridhar loves to start every interview asking, "Why Retina?" I always look forward to listening to this part of the podcast, because it shows that Ophthalmologists, no matter how long they've been practicing, were once medical students, just like me. Although every journey is unquestionably unique, I've noticed they all a share a common thing:  behind every great story, there are great mentors. 

We probably spend only 5 days learning ophthalmology before our clinical rotations, yet I am 100% certain that I want to be an ophthalmologist. What drew me to ophthalmology wasn't just the field itself, but the people practicing it.  My mentors inspire me every day and are one of the primary reasons why I am choosing this specialty. If you are an ophthalmologist and you're wondering how to inspire those medical students shadowing you, here's a guide on how to be an awesome mentor in ophthalmology

1. Take every student's initial interest seriously, even more seriously then they might be taking it. 

When I started medical school, I found everything interesting. When I first told my advising dean that "I thought ophthalmology might be neat," she immediately scheduled an appointment for me to meet an ophthalmologist, who then in turn, when I mentioned "I might be interested in research," immediately introduced me to the lab where I've been working ever since. Medical students most often don't know what they want, and it can be frustrating to mentor someone who seems change career plans every week. However, my mentors knew I would enjoy the specialty and made sure to create enough opportunities for me to fall in love. 

2. Really listen to your mentees

I really admire my mentors, and they are probably unaware of how much influence they have. I am always so humbled when a busy ophthalmologist makes time to meet with me, answer my questions, and listen to my "revelations" about ophthalmology, which they must heard countless times. However, feeling really listened to is an amazing feeling, especially when the listener is someone who you deeply respect. 

3. Show them the cool stuff (and how to use it!)

Many ophthalmologists take for granted the many cool toys and techniques they use every day and forget how foreign they are for most medical students. I still remember the awe I experienced being introduced to many of the gadgets. I felt like a secret agent trying on the direct ophthalmoscope, I felt like a Nobel physicist learning the theory behind OCT, and I was mesmerized watching an IOL unfold inside the eye.

Most ophthalmology instruments take practice to use - the indirect ophthalmoscope, the slit lamp, etc... so it's important to encourage students to keep trying even if they fail at first - because it's definitely worth it. Nothing beats visualizing the fundus for the first time!

4. Tell them it's ok to be grossed out at first

One of the most common responses I get when I tell people that I'm going in to ophthalmology is ... "eww eyeballs.."  Personally, I have trouble having anything near my own eyes, so I can understand. The first surgery I ever watched was an enucleation of an eye with uveal melanoma. Witnessing the "crunch" of the optic nerve being taken out almost made me pass out. At that moment, I thought I could never do this specialty, but thankfully there was a scrub tech that told me he used to react the same way. He reassured me that it's definitely a phobia that passes with time. Many medical students will have the same visceral experience when witnessing their first surgery. Tell them it's ok to feel queasy and it doesn't mean they can't become great eye surgeons! 

5. Be a great Ophthalmologist

I am always impressed with the humility, knowledge, and kindness of the ophthalmologists I have met. Leading by example is so powerful.. and sometimes your actions have more influence than your words. Just being able to witness excellence inspires me to be better. One of my mentors expects a lot from everyone who works with him, including himself. He is very hard to impress, which always motivates me to set higher standards for myself. 

This is definitely not an all-inconclusive list, but a rather a few of the most impactful things my mentors have done for me. No matter what stage you are at in your medical training, there are people who look up to you. Never betray their respect and always keep striving to be better. Wish you the best of luck in inspiring the next generation of ophthalmologists!

-Louie

Image Sources

http://pediatricophthalmologypa.com/wp-content/uploads/2013/12/eye-exam-for-kids.jpg

https://www.nursingwritingservices.com/images/Pediatric-Ophthalmology.jpg

http://www.advocareschnalleyedocs.com/IntranetPortal/media/advocarephotos/Child-Muscles.jpg

http://www.nyee.edu/files/NYEE/Patient%20Care/Eye%20Services/Pediatric%20Ophthalmology%20and%20Strabismus/pediatric-ophth.jpg

http://www.pflugervillevisioncare.com/wp-content/uploads/2014/11/family-eye-exam.jpg

The Bascom Palmer ophthalmology faculty recently led small group discussions with 1st year medical students at the University of Miami Miller School of Medicine (UMMSM). This annual tradition in the Neuroscience core module dates well beyond my days as a medical student here. As I began my session with five bright and motivated students, I realized with a jolt that it had been officially over a decade since I was in their shoes. I was warned throughout my medical training by seniors and attendings that “the days are long, but the years are short” but only when I was confronted by my more distant than realized past, did I fully understand the truth in these words.

I started the session by briefly outlining how I arrived at my decision to pursue ophthalmology and explaining why they should look into the field. When answering a very specific question about the application process, I paused, realizing that with my dated residency application experience, I might as well have been teaching them how to fix VCR's. Slightly abashed, I was honest and unhelpful, admitting that any advice I could offer would pale in comparison to the experiences of their immediate peers.

That experience really helped me reflect on the mission of the podcast and now this blog. The regular guests and I do not and can not pretend to be experts; on the contrary, we readily admit the limitations defined by our individual experiences. With each episode, we hope to gradually improve the variety and depth of our content, which couldn't be done without our fantastic guests, who generously share their expertise every week. If in each podcast episode, we can deliver one pearl that helps improve the quality of patient care, the research ideas generated, or even the way you manage life responsibilities, then we will have exceeded the goals we set out to achieve.

Given what the podcast offers, why start a blog? Three reasons.

1. We hope the written format may be more readily accessible, say when seeing a complex patient or preparing for a unique surgical situation.
2. Certain ideas are better shared on paper (or screen in this case) than with audio. A photo of a retina is worth a thousand dictations.
3. Third, and most importantly, I want to give a voice to both sides of the story. On one side there’s me, the ostensible teacher - a relatively new but fellowship-trained retinal physician. On the other side there’s Louie Cai, our medical student producer, giving voice to the next generation of physicians still in the throes of training. Louie was skeptical to why those tuning in for ‘the leading experts of vitreoretinal surgery’ would want to hear from a medical student. I explained to him that given how rapidly both medical education and medicine itself is changing, we need both sides of the story, for a medical student’s fresh voice can revitalize an attending’s tired thought patterns.

Louie and I will alternate blog entries each week on topics of our choosing related to the medical field. I have given him free reign and voice to write about what he feels is important.

We hope through this blog, we can show that in our journeys to improve as medical professionals and people, we are all colleagues. Whether pupil or professor, we all have valuable lessons we can share with each other. To our readers and listeners, we love hearing your stories and look forward to sharing them every week with the world at large.

THIS IS

 I hope you will all learn as much from my students as I have.

-Jay