Issue 1: My Explorations

Some might think of me as an an explorer or an innovator of new technology. While it’s true that I have a strong desire to research and understand the unknown, let me say that the titles of explorer and inventor don’t really sit with me that well. My explorations have been pretty modest and personal, and the invention of Optos technology was very much a team game. Having said that, if I had not persevered and constantly pushed myself and my team – whether it be my family ‘team’ or colleagues – new discoveries, especially those that would significantly benefit eye care clinicians and their patients, would not have occurred.

But back in the day, I was a somewhat obsessive winter mountaineer always seeking to pioneer new, to me at least, more interesting and exciting ways upward and onward in the ice and snow. And I always looked to remote places to seek adventure.

Although not very talented either as a climber or as a design engineer, I perhaps made up these deficiencies by being persistent and certainly curious to explore the limits of what was possible for me. One advantage I have always had is a certain ability to observe things in the round unconstrained by accepted wisdom, so that when others were perhaps convinced by some detail to believe that the endgame had arrived, I was often thinking things were just kicking off.

So when our first child arrived convention, and some might say sanity, dictated that the days of climbing and wilderness exploration were in the past, instead we embarked upon what was to become a sustained 30 yr exploration of the fjords, glaciers and mountains of the East Greenland coast (Fig. 1).

Fig1) Close pack ice off the East Greenland coast near Nordre Aputiteq

I have always been captivated by the beautiful forms in nature whether it be the slowly evolving sculptures that wind and water carve in rock and ice (Fig. 2) or the layered micro-structures that sustain the life and purpose of our eyes (Fig. 3).

Fig 3) Large Retinal Break and Detachment

The process of discovery is to my mind the finest of activities and it is the more rewarding because it is so difficult, time consuming and unpredictable. I always suspect that some new understanding lies beyond and if I am lucky enough to have this thing revealed then it will be a matter of great excitement and wonder. Whether its the discovery of sickle cell disease (Fig 4.) or new ice forming in a tide crack (Fig 5.) furthering our understanding of new frontiers is an exhilarating experience which can benefit us all.

In taking my children every year exploring in the arctic (Fig. 6), first as infants barely 8 months old, and then again with each year as they grew up, many hidden things were slowly revealed about these places and about ourselves. Our travels were not just random visits. I wanted us to develop understanding, appreciation and contentment in the act of traveling the wilderness. Mostly we traveled just by ourselves without support, without a radio or hope of rescue. We did not tell others of our leaving, or of our route, nor of our coming back. We just went off and had many weeks of small unadulterated adventures. Our primary transport, apart from our feet, was a small inflatable boat well overloaded with expedition impedimenta, mountains of diapers and childish things, and of course food and fuel enough for up to 1000 miles.

Fig 6) Kids at Breakfast

By this process I think we discovered self sufficiency and an intimacy that is otherwise hard to achieve. We felt the weather in our face and on our hands and the tremendous, at times terrifying, power of arctic pack ice moving around us. We experienced the exhilaration of exposure to a great wilderness that only such remoteness and the total absence of other human beings can bring.

When the bodies’ systems were purged of life’s pollutions, primeval senses awoke enabling us to smell the air and even to see the way when blinding fog shrouded our hoped for landmarks. In the cold impenetrable grayness of arctic fog, shapes are deceptive and sometimes scary; like having just become convinced of the outline of a distant snowy shore suddenly it solidifies into an iceberg of Titanic proportions with impact only seconds away. But eventually the grayness releases you and you burst out into dazzling light with a magnificent explosion of understanding and relief.

In our family journeys, some landscapes have proved amazingly difficult to reach (e.g. Fig. 7 and Fig. 8). One remote ice pressed cape took 15 yrs of persistent attempts before we manage to round it. Many rebuttals were forced upon us by bad weather, too hard a press of ice, or more frequently too small a supply of “skipper’s nerve”. Eventually however in 1997 good luck aligned itself with a peak in my confidence and the passing of that frightful cape was finally achieved.

And so you might ask what’s so important around these corners that we would go to all this trouble to see?

Well there are quite a few answers to this question but one answer is definitely to appease a passionate curiosity to investigate and understand the unknown.

And some of these unknowns can turn out to be amazingly significant.

For instance the discovery that the piece of open water upon which you are floating is shown on the map as a mighty glacier. And the realization that this is not an error of cartography or navigation but evidence that the landscape is changing big time. And that parallel applies just as well to the landscape of eye care today.

Fig 9) 360 degree Retinal Detachment

Never before has there been such change not least that driven by the array of new imaging tools that are daily opening up understanding for the curious and will surely make for discovery of better treatments in due course.

Another answer is a certain willfulness to disprove people who say it can’t be done; it’s too risky, or there will be no value in it.

It so happens that, in parallel with our family endeavors to confront the icy cape and many another impasse, at Optos we were building our technical teams. They were challenged to find a better way to see the wider structures of the retina (e.g. Fig. 9); discovering on the way the unique technology that lies at the heart of Optos imaging devices.

I had many reasons for challenging the wisdom of the day… “That diseases that occur in the periphery are rare or insignificant.”….” That all major eye diseases manifest themselves in the posterior pole”…. not least because as with all dogmas presented with such confidence and certainty they invite the suspicion that that certainty is likely misplaced.

Discovery in our development of the first widefield scanning laser ophthalmoscope may have had fewer life threatening moments than our arctic endevours, but it had its parallels with exploration in terms of moments of revelation and high drama; Of routinely overcoming seemingly insurmountable obstacles to expose the unexpected confirmation of some long held suspicion. As our technology has developed, it has shown itself increasingly capable; penetrating cataracts that blind other techniques, at times embracing the whole retinal landscape even when a very small pupil is trying desperately to constrain the view.

In overseeing our developing technology, I have observed many fascinating structures (e.g. Fig. 10) from the photoreceptors of the cone matrix, to the nerve fibers reaching outwards to the Ora Serrata.

Fig 10) Post operative scleral buckle with droplets of sillicon oil

In many diabetic eyes, widefield fluorescene angiography has exposed vast unsuspected peripheral ischemia (Fig. 11) that with manual examination looked tolerably healthy. Other work in vascular disease demonstrates that there is often far more extensive ischemia in the periphery than might be otherwise supposed by looking only at the narrow view. These discoveries invite the consideration of exciting new possibilities for treatment and potentially earlier, less dramatic interventions. I can tell you that being among the first to see these surprising findings has been just as rewarding as finally breaking through to view some long sought after wilderness.

Fig11) Widefield Angiogram schemic peripheral retina

More recently, our widefield autofluorescence imaging has uncovered equatorial and far peripheral retinal pigment epithelial (RPE) damage in some patients that may yet prove to be a precursor to age-related macular degeneration (AMD). In the widefield autofluorescence image can be seen mid peripheral RPE cell damage in a patient without any macular manifestations. This image is part of a series from a study conducted in Reykjavik in 2008 and reported by Moorefield’s at the Association for Research in Vision and Ophthalmology (ARVO) congress of 2009 first coining the phrase “Peripheral AMD.”

Fig12) Widefield Auto Fluorescence image of PAMD?

At one level, PAMD might seem a contradiction in terms but to me as a mountaineer it seems eminently sensible that in some patients (as with hypothermia where extremities die first) the eye might sacrifice the periphery first (Fig. 12). Further research with the new tools may demonstrate this to be valid or not but in the meantime, as an engineer/explorer who has spent a long time out in the cold both literally and metaphorically, it seems a very reasonable hypothesis to me!

Reflecting on my personal and professional explorations, I am reminded of the words of Capt. James T. Kirk in the original Star Trek science fiction television series “…to explore strange new worlds, to seek out new life and new civilizations, to boldly go where no man has gone before.”  It is my hope that we will continue to overcome obstacles and change the landscape of eye care together with our technology.

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