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Marianas Eye

A Saipan blog about life on a tropical island through the eyes of “not your average" eye surgeon. Here find island adventure, food, culture, humor, travel, medicine, and random thoughts about living a fulfilling life (along with an occasional gory eye

Updated: 2018-04-19T21:50:26.162+10:00


Eulogy for My Father


Dr. Houshang KhorramIt is a very difficult honor to have, to share with you some thoughts about my father, and his life. He led a life so full, and so full of service and dedication to this community, that it is simply moving. My father had a tender heart. He would be moved to tears, and his voice would quiver by anything that brought love. When he was preparing to retire a year ago, as he was wrapping up the last months of his life as a pediatrician, he told me he would shed tears every day – families would come into his exam room and cry at his coming retirement, and he would cry with them. For several months, he put off accepting the invitation to the retirement party the hospital wanted to hold for him, because he knew it would be an emotional evening. Now, unfortunately, I inherited my father’s heart. My children tease me about the emotion that wells up within me about the simplest things. I’ll say, “This is great popcorn,” and they’ll say, “Are you going to cry?” So today, of all days, these emotions are sure to well up. If I have difficulty speaking, bear with me, and know that this is a bit of my father coming through. Mine are not tears of sadness but of love, and fullness, and celebration of a wonderful life.Middlesboro knew my father first and foremost as a beloved pediatrician. He grew up in Iran, in Yazd, during the 1930’s and 40’s. Yazd was probably not that different from Appalachia at that time – poverty, disease, needless suffering. And my father chose to tackle these issues by studying medicine. He was accepted to university in Shiraz, where during his medical studies he met my mother, who was a nurse. They married, they had a son, and they moved to the United States where this promising young doctor continued his studies at Johns Hopkins University. And a daughter was born. To stay in the United States, my father had to go where doctors were needed, and he came to Eastern Kentucky. He practiced medicine for 50 years, and forty six of those years were spent here in Middlesboro. Over the past few days, the tributes have poured in from this community – words like: “He was one of a kind. Touched so many lives and the little ones he took care of so tenderly for so many years.” “I loved him… He saved my baby girls life.” “Our grandson was a baby and had just started talking when we'd taken him to see Dr. Khorram. As he was leaving the room our grandson said, ‘I love you, Dr. Khorram.’ Dr. Khorram stopped, turned around and came over and hugged him. Our grandson really loved Dr. Khorram! He's 19 and would drive himself to go see Dr. Khorram when he was sick!”This was my father. A kind, gentle man, who spent his life caring for children. There is no possible way I can capture all of the feelings that have been expressed about his passing, and I don’t think I need to, because, after all, he was a part of your lives and a part of your hearts. What can I say, that you do not already feel deeply yourselves?Although he must have known the impact he had on this community, he never talked about it, never acknowledged that he was even aware of it. You see, he was just thankful to you, for entrusting him with the privilege of caring for your families. He was thankful for such meaningful work. He loved his life serving the children of the area. His work filled him with joy and with purpose. On weekends, he was waiting for Monday, so he could get back to doing what he loved.When I was here five years ago, he took me to his office one weekend. And I stood in the silent office, looking at the hundreds of pictures on the walls. The pictures of his patients, who over the years, would bring in school photos for their beloved doctor. Many of the pictures were faded, some were more than 40 years old, the faces of children, with gap-toothed smiles, and lopsided haircuts, and innocent eyes, all captured in time, all a witness to his work.From the time my dad hit sixty – that more than 20 years ago! -- we would ask him about retirement. To retire was simply not something he wanted to d[...]

My Experience with Manual Small Incision Cataract Surgery (MSICS or SICS) Training at Arasan Eye Hospital, Erode India


Two surgeons being trained simultaneously at Arasan Eye Hospital -- one in SICS, the other in phaco.  The instructor monitors the cases in progress.I'm currently finishing two weeks of training in manual small incision cataract surgery (MSICS or SICS) at Arasan Eye Hospital, in Erode, Tamil Nadu, India, and thought it would be useful to share my experience.  It was a very positive experience.  Before I came I had difficulty finding out much detailed information about the training or the experience, so I hope this is helpful to you.Surgical BackgroundMany of the ophthalmologists who come to Arasan to learn MSICS or phaco, often with limited experience with the procedure.  I think that the experience you bring with you to the training affects your experience and the speed at which you gain mastery. In my case, during my residency at Northwestern in Chicago in the early 1990's we were trained in ECCE and phako with a superior tunnel incision.  There were no foldable lenses widely available yet.  After my residency I headed out to the Pacific because of my interest to serve in an underserved area.  I was for a year at the LBJ Tropical Medical Center in Pago Pago, where because of limited technology, I did ECCE with manual Simcoe I/A.During the ensuing 5 years, I was at the Commonwealth Health Center on the island of Saipan, in the Mariana Islands.  There I continued with ECCE with manual Simcoe I/A.  At that time, the Blumenthal mini-nuc emerged, and I tried this technique a few times, but wasn't able to master it.Eventually, I opened my own practice, acquired a phaco machine, and went back to phaco with a superior tunnel, but quickly transitioned to temporal clear cornea with a foldable lens through a 2.75 mm incision and topical anesthesia.So, that's my background and skill level I brought with me.  I had experience with every step of the procedure except for prolapse of the nucleus into the anterior chamber.  But, it had been years since I have done the other important steps of the procedure.  I hadn't made a scleral tunnel or put in anything other than a foldable IOL for at least 10 years.Why SICS?My goal in getting training in SICS was to be able to take several trips a year to underserved areas for volunteer work.  I have done surgical expeditions in the past with SEE International, however, they now require all their surgeons to have SICS training, as that is the primary procedure being used in most eye camps.  So, that's what motivated me to spend two weeks here learning SICS.Why Arasan?For some time I tried to set up "in the field" training with SEE International, but it just didn't work out.  Although I am American, I am living in Europe now, and while SEE offers wet-lab training in MSICS in the US once or twice a year, it was too far to travel simply for a weekend of wet-labs.  I did a bit of research, and there are quite a few hands on training programs in India, but most of them are a month or longer in duration.  Arasan, however, provided a 2 week training program in MSICS.  That was doable for me.  I emailed Arasan, and got initial information from Anitha, who manages the doctors who visit.  I wanted to talk to some of the other people who had done the training, and Anitha sent me the emails of all the doctors who had been here over the past year.  Everyone I heard from was generally positive, so I decided it would be a good way to get training.CostAt Arasan, the cost of all their training programs are on a "per case" basis, and they guarantee you that number of cases during your time here.  If you want additional cases than the minimum amount, there are additional charges.  The prices fluctuate from year to year, and I think are adjusted somewhat according to country of origin, or level of training.  Information is available through contacting Arasan.  In my situation, a US trained experienced ophthalmologist, seeking MSICS training in 2016, the price for 30 [...]

Diabetic Eye Disease - My New Book, Website and Blog


It's finally happening.  I'm two days away from the launch of my new book, Diabetic Eye Disease - Don't Go Blind From Diabetes. 

I have set up a new blog and website, Diabetic Eye Expertdedicated to the topic, and will be offering online courses and webinars through the site.

Take a look, and make sure to sign up for a list of courses!(image)

Guamology Interview for World Peace, a Blind Wife, and Gecko Tails


I was interviewed about my book back in 2009 by Kel Muna, a film-maker, and host of the website. Since then, Guamaology has gone off-line, as Kel has become busy planning the Guam International Film Festival. I enjoyed the interview, and thought I'd post it here since Guamology is no longer around.World Peace, A Blind Wife and Gecko Tails. It's such a great title. How did you come up with it? Did you have any alternate titles before settling on your final choice? As I was having friends review the book, I'd ask them, "What is this book about?" and the typical answer was that because the pieces covered a potpourri of subjects, the title would have to be reflective of that. I also wanted the title to be a bit intriguing and memorable. Someone suggested that many of the pieces were about world peace, so that became the opening of the title. The blind wife and gecko tails are references to specific pieces in the book. I also wanted to give reference to our tropical location, and that's why I chose "Gecko Tails" as part of the title. My first thought for a title was simply, "Thoughts from an Island". How does it feel to know that Blind Wife is required reading for sociology students at the University of Guam, where before Blind Wife it had been Mitch Albom's "Tuesdays With Morrie"? Honestly, I'm a bit stunned. I'm always surprised when someone tells me that something I've written is meaningful to them. I receive the reflection papers that the students write after reading the book, and it's both rewarding and humbling to know that something I've written has in some way touched someone's life. "Tuesdays with Morrie" is such a powerful book. I can't really get my head around the fact that Blind Wife has displaced it from the reading list. I understand that Blind Wife is a compilation of all of your most popular columns from the Saipan Tribune. When and how did you come to write for the paper? I started writing for the Tribune as a columnist in 2004. I had wanted to be more disciplined in my writing, and I felt like having a weekly deadline would help. I also am a curious person by nature, and like to pull ideas from various places, so the column provided me a place to share the things I was learning or thinking about. When did you get the idea and interest of turning your columns into a book? How long did the process take to put the book together? The book came about as a result of panic. About a year before it was published, I decided to take more time off from work and write a book I had been thinking about for some time. I had given a series of talks on the subject of establishing unity in communities. People told me that I should turn that into a book -- "7 Habits of Unity" or something like that. So I took time off to write this book, but really didn't have a clear idea of where I was going with it -- the tone, the audience, the purpose. And because of this uncertainty I began to have all kinds of personal doubts and misgivings while trying to write it. I spent a lot of time just staring into past my computer screen into space. After nine months, I realized that the year was coming to a close, and I had nothing to show for it, and that I'd feel like a total loser if the year ended and I hadn't published a book. So, I realized I could pull together my columns, which were already written and which had been well-received in the community, and publish them. So this book came about because I wimped out at writing the other one. Your writing style is very easy to relate to as well as reflective. Did you have a formal education in writing? I got the same training that we all get by virtue of going to school. I didn't take any special writing courses or workshops. But I did have some terrific teachers who taught me the value of re-writing, and the need to read your own writing out load to make sure it makes sense and that it flows. One of my comparative religion professors had a journalism degree, and he emp[...]

The Retina Blog


I've got a new blog, over at The Retina Blog. It contains "clinical pearls for retina specialists, fellows, residents and others interested in advances in the field of retina." At least 50% of my practice is dedicated to retinal disease. The field is evolving very rapidly, mostly due to the use of various biological modulators that we inject into the eye. As I read articles and studies that are important to the clinical practice of retinal disease, I summarize them and place them on the blog, mostly as a source of future reference for myself.(image)

Risk of stroke with Lucentis vs. Avastin


In the February 2009 issue of Ophthalmology, a meta-analysis was reported in a letter to the editor pointing out some risks associated with intravitreal injection of ranibizumab (Lucentis). The letter looked at pooled data from the MARINA, ANCHOR and FOCUS studies which were done to determine effectiveness and adverse effects of Lucentis. The authors of the letter point out that when pooling all the data, the ranibizumab group had a 2.2% incidence of stroke, whereas the control group had a 0.7% incidence of stroke. They conclude that the risk of stroke rises as a result of ranibizumab treatment. When they look at the incidence of myocaridal infarction (MI), the ranibizumab group had a 1.9% incidence whereas the control group had a 3.0% incidence. They did not "conclude" that intravitreal injection was protective for MI, but the incidence is lower in the group receiving the drug vs. the control group.

Since the letter was published, there has been some discussion regarding the implications of this meta-analysis for those of us using Avastin. At the current time the feeling is that this data cannot be extrapolated to Avastin, in part because Avastin is a larger molecule (the entire globulin, vs. the immune arms as with ranibizumab). This molecular characteristic is felt to result in less egress of Avastin into the systemic circulation, and it is to this characteristic that the longer-acting effect of Avastin has been attributed. There is currently an NIH sponsored head-to-head clinical trial comparing Lucentis and Avastin underway. The results are due in 2012. The study is ongoing, and the fact that it has not been stopped is some solace to those of us who prefer Avastin that the study has not to date shown that Avastin is either hugely inferior or has significantly higher side-effects that Lucentis.

What is the Baha'i Faith?


Here is my Saipan Tribune column from this past week.*** A close friend of mine recently said to me, "You know David, most people really don't know what the Baha'i Faith is all about." I was a bit surprised to hear this, but I knew it was true. After all, when I mention to people that I am a Baha'i, there is often a puzzled look on their faces. Most people seem to have the impression that the Baha'is are a good bunch of people, working in some way toward peace. But beyond that, most people don't have an understanding of the basic principles of the Baha'i Faith. This realization was a bit surprising to me because the Encyclopedia Britannica lists the Baha'i Faith as the second most widespread religion after Christianity. And The LA Times noted that the Baha'i Faith is among the top two fastest growing religions in the world. So I thought it would be useful to explain the fundamentals of the Baha'i Faith. It is likely something that you will encounter more and more in the coming years. Baha’u’llah – The Promised One When someone asks me, "What is the Baha'i Faith?" The brief explanation that I give goes to something like this: The Baha'i Faith is a world religion whose purpose is to unite all peoples and races. Baha'is are the followers of Baha'u'llah, whom they believe is the Promised One of all ages. The traditions of almost every people include the promise of a future time when peace and harmony will be established and humankind will live in prosperity. Baha'is believe that the promised hour has come and that Baha'u'llah is the great personage whose teachings will enable humanity to build a new world. This brief explanation raises a few key points. First, the Baha'i Faith is an independent world religion. It is not an offshoot, sect or denomination of another Faith. Second, its purpose is to establish unity among the peoples and races of the world. Third, the Baha'i Faith accepts Baha'u'llah as the one whose teachings will establish the long-awaited peace on earth. It's a large claim for sure, and most people are rightfully skeptical at first. But millions of people find it a claim worth looking into. God is Unknowable Baha'u'llah teaches that there is a source of creation that we call "God." Yet God is unknowable in his essence. Our finite minds cannot fully grasp God and we should not make images of God in our mind, thinking of him, for example, as a man. God created all things out of love: "O Son of Man! I loved thy creation, hence I created thee. Wherefore, do thou love me, that I may name thy name and fill thy soul with the spirit of life." The Manifestations of God Baha’u’llah teaches that throughout the course of history, God has given humanity guidance. This guidance comes to humanity through the Manifestations of God -- those special beings who revealed (or “manifest”) to humanity the word and the will of God. History knows them as the founders of the world's great religions: Krishna, Buddha, Moses, Christ, Muhammad, and Baha'u'llah. This idea that a single God has sent these various Manifestations of himself to humanity is a fundamental teaching of the Baha'i Faith. Baha'is accept the divinity of all of these individuals, that they all speak with the same authority, and that they have progressively revealed the will of God to humanity. Referring to these Manifestations of God, Baha’u’llah has written, “If thou wilt observe with discriminating eyes, thou wilt behold them all abiding in the same tabernacle, soaring in the same heaven, seated upon the same throne, uttering the same speech, and proclaiming the same Faith.” Teachings for a Global Age According to Baha’u’llah, the Manifestation of God returns from the same source from age to age, as people stray away from the teachings of the previous Manifestation of God, and as society changes.[...]

Patients Gone Wild and Healthcare Reform


(I'm blogging from the operating room.  Here's my Saipan Tribune column for this week.) I recently had the opportunity to read President Barak Obama’s letter on Health Care Reform, dated June 3, 2009.  There is one paragraph in particular that jumped out at me, because it seeks to identify the “root cause” of rising health care costs.  Here it is: “At this historic juncture, we share the goal of quality, affordable health care for all Americans.  But I want to stress that reform cannot mean focusing on expanded coverage alone.  Indeed, without a serious, sustained effort to reduce the growth rate of health care costs, affordable health care coverage will remain out of reach.  So we must attack the root causes of the inflation in health care.  That means promoting the best practices, not simply the most expensive.… That's how we can achieve reform that preserves and strengthens what's best about our health care system, while fixing what is broken.” First, let me say, that I agree with the gist of the statement.  Rising health care costs are killing our economy (well, that and a few other things), and medical care can definitely be improved so that it is more cost effective. But here’s the truth.  The single best way to reduce the cost of healthcare is to reduce the need for healthcare.  We are a sick bunch of people, and for the most part, it’s because of our own behavior – we’re all “patients gone wild.”  The majority of us are sick, not because we’re out doing healthy things and suddenly get struck down by some horrific disease.  No, we’re sick because we eat too much, sit around too much, eat the wrong foods, smoke, consume alcohol, and generally ignore the things that lead to good health.  We’re sick because of the wild and crazy choices we make.  The vast majority of healthcare costs in America and the CNMI are tied to chronic “lifestyle” diseases.  The top ten causes of death in the US include heart disease, stroke, diabetes, and cancer.  And every single one of these has been incontrovertibly linked to how we live our lives – whether it’s what we eat, what we do, what we drink or what we inhale.  To a large extent, we’re digging our graves with our spoons and forks.  Last year, we spent over $20 billion dollars on cholesterol lowering drugs.  That’s billion, with a “B”.  If you had $20 billion dollars, and decided to burn a million dollars a day, every single day, it would take you 55 years to spend $20 billion!  Why is our cholesterol high and why does it need to be lowered at a tune of $20 billion a year?  High cholesterol is a major risk factor for heart disease and stroke.  Our bodies produce some cholesterol, but most of the problem comes from what we eat.  Only animals have cholesterol in them.  Vegetables have no cholesterol at all.  We’ve known for decades that the most effective way (and the cheapest way) to lower cholesterol is to lower our consumption of animal products – animal flesh, animal milk, animal cheese, animal crackers, etc.  But you know what? We’d rather not make that kind of change.  We’d rather pop a pill and keep eating whatever we want to eat.  And that’s $20 billion dollars we spend so we can do what we want to do, which is to eat lots of animals.  The same is true for diabetes, which is devastating our community, and growing at an alarming rate.  We know that for most of us, the adult onset variety can be controlled, or at least hugely improved, with diet and exercise.  Yet we choose not to make these difficult changes.  We choose to eat what we want, and take pills and go on dialysis and lose our vision and our feet and our erections.  And we spend untold billions on the cost of care for diabetes and its related problems.  A diet high in animal fat is also linked to a slew of cancers.  Pass the proce[...]

Risk Factor for Swine Flu


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What they're not telling you about Swine Flu


Here's a portion of an email I got from one of our public health officials, just to put things in perspective:

I am getting more than 8 Swine Flu "Updates" per hour.  Good grief.  This is a true epidemic, likely soon to be a global pandemic.  My guess is that we'll be in Phase 6 next week.  But the relatively minor human toll (low morbidity and low mortality) does not yet justify the resource allocation, nor the media attention that we have all seen.

We need to insure that we have a "measured response" that is commensurate with the real, not the perceived, threat.  And responding appropriately, in the face of media hype and patient worry and governmental involvement, is a real art.  I am hoping to hear your opinions on this.

In the past six weeks, Swine Flu has killed between 20 and 80 people.  More than 2000 have had clinically significant infections.  In the same time period, more than 40,000 people have died from routine influenza.  Millions were infected.  More than 40,000 died from TB just last week.  40,000 more died from malaria last week.


Jerks Die Younger


The next time some jerk is yelling at you for no good reason, you can smile, knowing that they'll be off the planet sooner than you.

A new study published in the Journal of the American College of Cardiology finds that people who are angry and exhibit hostility have a 19% higher risk of dying from coronary artery disease -- i.e. a heart attack.

The average person hopes that future studies will show an increased risk.


Sexualization of Young Girls


I was at the Thursday night street market, where every week on Saipan you'll find food vendors and live entertainment.  Tonight, a dance schools performed.  I'll tell you, it was a sad scene.  There were kids, girls, six, seven, eight years old, dressed like teenagers, with short skirts, makeup, and shin-high boots, and dancing suggestively to lyrics like "Let's make love, ooh, baby, let's make love."

When did this happen?  When did parents start looking the other way, and give their assent to the sexualization of their young girls?  It's like they all went out for a walk, let some stranger called  a dance instructor come into their house, and in the name of "developing talent" twist their kids into these vacant performers.  It disgusts me.  What happened to protecting innocence?  What are these parents thinking?  Do they think this is okay?  To have their young daughters thrusting their pelvises while lip-synching these overtly sexual lyrics?  I don't get it.

Nagoya City University Hospital


A few years ago, I needed some surgery that wasn't available on Saipan, so I was faced with finding a surgeon to undertake my care.  Part of the issue for me was that I wanted to get the care close-by, and being self-insured, I needed it to be cost effective.

My main four choices came down to Australia, Hawaii, Manila and Japan.  I visited one of the top surgeons in Sydney during a trip there, and I wasn't impressed.  I scratched Manila off the list pretty quickly.  I've had a fair bit of experience with patients going to Manila for care, and although one of the surgeons I've worked with there is good, I've found that in general, the delivery was not up to the standards I expect when sending a patient to a major medical referral center.  Sorry guys, but that's the truth.  I wouldn't go to Manila unless it was a last resort.  I'm sure many have had good experiences there, but seeing many of my patients return, I haven't been too happy with the quality of care they received.

Hawaii was an obvious choice because, well, it's US quality medical care.  The problems with US care is that it's expensive.  If I'd had the procedure in Hawaii, it would have cost me $10K.  If I had had insurance, my 20% co-payment would have been $2K, for an outpatient procedure.  So, I just held this option in reserve.

I started to look seriously at Japan.  In the world of medicine, Japan is one of the areas, along with the US and parts of Europe, that lead medical research and publish in medical journals.  I know the quality of care there is top-notch, and that the cost is reasonable.  I ended up finding one of the best surgeons in the world for my condition, and headed there for my surgery.  I was very happy with the quality of the care I received, and the cost was only $2K.  That included the surgery, and five days in the hospital, getting fed and watered.  The system of care in Japan is a little antiquated, and many expatriates in Japan complain about it for this reason, but as someone in the medical field and as someone who has experienced the care first-hand, I think that the care is on par with anyplace in the US, and even better than the US, it's cost effective.

After I returned, I tried to convince the powers that be to start looking at Japan as a place to send our medical referral patients from the CNMI.  It close, it's cheap, and the quality of care is outstanding.  It's taken a while, but finally the CNMI has a relationship with the Nagoya City University Hospital (NCUH), and we have liaison people on the ground to help patients navigate a foreign country.

Nagoya City University Hospital is an 800 bed medical center (CHC has 72 beds).   The first patient from the CNMI that went there was an infant, a few days old, who was on the way to Hawaii for cardiac surgery, decompensated while on the tarmac in Nagoya, and was taken to the NCUH where the pediatric cardiac surgeons did an outstanding job on a very complex surgical procedure.  Since that time, the relationship has deepened, and in the next few weeks, I hope to send the first ophthalmology patients there.  This should provide closer and less expensive care than is available in Hawaii, and  as high a quality of care.   I'm looking forward to using NCUH as a referral center.

Truth, Death, Unity and Classroom Cataract Surgery


Because of my book, I was invited to give the keynote address to the University of Guam during their faculty development day on Friday.  I just shared some thoughts that were on my mind.  I think in some way, the points I raised had to do with some of the anchoring principles of my life.  It was also an opportunity for me to try out some of the stand-up comedy material I had been working on, and most of the jokes got laughs.  Here were my key points.

1.  "Truthfulness is the foundation of all human virtues.  Without truthfulness, progress and success in all the worlds of God are impossible for any soul."  Before I really started to think about this principle in my own life, I used to "fib" so much to avoid embarrassment or to stay out of trouble.  Being committed to total truthfulness required me to change the way I did a lot of things, but it was a liberating process.  It's a pain, and I feel I sell out pretty easily at times.  But it's still one of the key principles that I think everyone can benefit from.

2.  We're all gonna die.  Really.  Remaining conscious of this truth on a daily basis helps lend clarity to life.  This can be done by bringing oneself to account each day.  "Bring thyself to account each day, ere though art summoned to a reckoning, for death unheralded shall come upon thee and thou shalt be called to give account for thy deeds."

3.  The motto of UOG is "Unity in Diversity."  Unity requires that as individuals we refrain from faultfinding.  The process of higher education gears us toward "critical analysis" which makes faultfinding a natural way of life.  Faultfinding is an intellectual activity that is quarantined to one's mind.  But the real problems arise when we mention the faults of others -- when faultfinding moves to backbiting.  It's endemic in our culture, and there is a need to establish "no backbiting zones" around our mouths, and even our ears, so we don't participate in this corrosive force.

4.  Cataract surgery brings vision.  Teaching brings vision.

The faculty were appreciative of having a speaker who wasn't there with charts and numbers, and as someone said, "we're all human, and it's nice to remember that at times."

Gory Eye Picture - Dermoid from Hell


This is a weird growth that some people are born with.  It's called a dermoid.  It can enlarge over time, as this one has.  (This guy walked in this week is in his 20's.  Time to remove it, don't ya think?)  You can see it has hair growing on it.  Sometimes there's bone and teeth and cartilage and other Frankensteinian components in them.   Growths like this that consist of tissue not normally found at the site are called "choristomas".   One choristoma made it to the big screen in the movie, "My Big Fat Greek Wedding," where the Aunt is telling the fiance of the lump that was removed from her back that had teeth and hair in it, and that it was the remnants of her twin that was never born.  It was a great scene, and a proud day for choristomas everywhere.

Often, ocular dermoids go deep into the substance of the eye wall, so despite it's "stuck-on" appearance, you can't just slice it off, (or lacking instruments, pluck it off), because you could end up with a hole in the eye.  So you have to have donor tissue available to patch up the hole at the time of surgery.  They occur in about one per 10,000 people.  




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"The fact is that without inner peace and wisdom, we have nothing we need to be happy. Living on a pendulum between hope and doubt, excitement and boredom, desire and weariness, it's easier to fritter away our lives, bit by bit, without even noticing, running all over the place and getting nowhere. Happiness is a state of inner fulfillment, not the gratification of inexhaustible desire for outward things."

~Matthieu Ricard(image)

Gory Eye Picture


I'm amazed by how many people complain to me that I don't warn them that these pictures might give them nightmares and why don't I warn them of the graphic nature. What do you think it means when the title of the post is "gory eye picture," kittens?

Without further warning, here it is:


I'm Back


Sort of... maybe... in a different way.

I've been in blogging rehab. Everything is okay. It's just that blogging was becoming a toxic force in my life. It was taking up way too much of my mental space. I was checking my hit counter every few hours, planning posts days in advance, writing things when I had nothing to write. And all for no clear purpose other than some narcissistic drive to climb higher in the blog rankings. It was pitiful.

I woke up and realized this, and one day, just quit. With the help of my family, I have been able to successfully withstand the pains of withdrawal, and I thank them for their loving support during this difficult time. I know that even writing this post is dangerous for me, since just a little sip has the power to strangle me in its clutches.

So, I'm not sure what the future holds. For now, I'm chilling out. I may post occasionally, when I'm compelled to share something I think is meaningful or profound, or to stay connected with family and friends in far-off lands. If you're from Saipan and you miss what you've been reading here, heck, call me up and let's go to lunch. You know how to get in touch with me.(image)

The Bottom of the Economic Development Ladder


Here is my Saipan Tribune column from Friday.


How do we, who are having such bad economic times here, stack up compared to the rest of the world? Where are we on the world's economic development ladder? I don’t know much about economics, but these questions were recently asked of me, so I thought I’d find out. Economic development, as it turns out has a fascinating history. Economist, Jeffrey Sachs, describes a four step ladder, as a way of viewing the world in terms of economic development. The first step, which I’ll describe today, is not really a “step” because it’s not even on the ladder. It is “extreme poverty.”

Today one billion people – one sixth of the earth’s population – live in extreme poverty. This "bottom billion" is so economically destitute, that their very survival is at risk on a daily basis. Their lives are fragile. They live with drought, famine, starvation. Any small change can make the difference between life and death – a storm that wipes out meager crops, being struck with a simple disease, but having no access to medicine to treat it, late delivery of food – all of theses sorts of threats are very real, and can mean death to entire populations living in extreme poverty. If there is any income that comes into the hands of those in extreme poverty, it is counted in pennies per day.

For much of human history, the vast majority of the world’s population has lived in extreme poverty. Our ancestors struggled for their very survival, in a harsh world, with a fragile existence. Wealth, above extreme poverty, did not become accessible to common people until the mid 1700’s. It is only since about 1750 that humanity has climbed onto the first rungs of the economic development ladder.

Extreme poverty does not exist in developed countries. It is a condition that afflicts swaths of the developing world. Seventy percent of the extreme poor live in Africa. Ten to fifteen thousand of them die of preventable causes, like hunger, malaria, and dysentery every single day, day after day, year after year.

The tragedy of our times is that such dire circumstances affect one billion of our fellow men, women and children, in a world with such vast resources.

One of the goals of the United Nations is to wipe out extreme poverty by the year 2025, and to cut it in half by 2015. It requires commitment from wealthy nations, but I think it also requires awareness by the rest of humanity that such conditions exist and that solutions are available. The bottom billion require assistance to get on the economic ladder, to move from extreme poverty to just regular poverty. It is a small step, but the most important one in terms of the survival.


Marine Sting Photos Wanted


(image) I got an email from Dr. Paul Auerbach from Stanford University Medical Center. He hosts the blog, Medicine for the Outdoors. He's looking for photos of stings from marine animals.

Thanks for your kind comments about Medicine for the Outdoors at Grand Rounds this week. You have a great blog. If you ever encounter a marine animal sting for which you need assistance, please let me know - I serve as a consultant to the Divers Alert Network for that sort of thing.

Also, if you get any good photos of stings, eye or otherwise, it would be wonderful to see them, as I am always on the lookout for images for the textbook Wilderness Medicine and other teaching purposes. If you allow a photo to be used in a book, it would be credited as you indicate.

Divers, if you get any good photos, let me know and I'll put you in touch with Dr. Paul.(image)

Victoria's Secret to Include Free Safety Goggles with Thong Purchases


(image) This is all over the news in the past few days. A 52 year-old woman in Los Angeles (where else?) is suing Victoria's Secret because while she was putting on her newly purchased thong, a piece of decorative metal flew from it and struck her eye. Her attorney states that it caused "excruciating pain" and that the injury was so severe it required "steroid drops" and that she'll be living with the effects of it her whole life.

Gimme a break. I treat corneal abrasions all day long, and I'll use steroids in about 25% of them, just to get rid of any residual inflammation after the abrasion has healed. It's no big deal.

Every abrasion has a theoretical risk of becoming a "recurrent erosion." The attachments of the corneal epithelium can sort of get weak after the abrasion heals, and there is a chance that during rapid eye movement of sleep (REM sleep), the epithelium will split open again, causing a few hours of pain. Of all the thousands of abrasions I've treated I've had one patient with recurrent erosions. It's most common with abrasions caused by paper and by fingernails.

I know what it's like. I developed corneal erosions after my son poked me in the eye when he was a year old. The abrasion healed over a few days (and yes, it was very painful), but then a few months later, I'd wake up most nights with pain from recurrent erosions. But guess what? You can get the recurrent erosions fixed. I had some laser treatment done on my eye, and I never had a problem again.

So, boo-hoo is what I say. I just can't understand the mentality that sues over a thong induced corneal abrasion. The woman and her attorney are giving interviews on the morning talk shows, including the Today Show. I'm sure she'll get a book deal, which will spill over into a screenplay, a night at the Oscars, and an action hero figure whose secret weapon is a lethal metal-firing thong that gets activated when placed on a wrinkled butt.(image)

My Blog Knows Me So Well


Blogging really is a weird kind of sickness -- sort of like love. Bloggers will recognize themselves in this post by The Blog that Ate Manhattan, titled, I Love My Blog.(image)

Gory Finger Picture


It's been a long time since I've posted a gory eye picture. Having had nothing gory to present, I'm resorting to gory finger pictures.

Remember that story about the guy who was wearing his class ring, and went up to dunk the basketball, but got his ring stuck on the rim? Not urban legend. Photos courtesy of this site. Dr. Ramona Bates, over at Suture for a Living, tipped me off to this story (pun intended).


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Hiccups during surgery


Yesterday was my surgical day. My last case of the day, a cataract patient, got the hiccups during the surgery. Under the operating microscope, it was like a series of earthquakes. It made for an interesting few minutes until the anesthesiologist could give him enough sedation to put the hiccups to sleep. The patient looked great this morning, except that the hiccups woke up after the surgery and are still there.(image)