Peter J. McDonnell, MD

He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.

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 without doubt one of the most important and colorful figures of Classical Athens.

Born in 524 BCE, he became a leading statesman and general and his emphasis on making Athens into a naval power ensured Greece’s survival against the greatest threat it had ever faced: mighty Persia.

The value of a reputation: Mixing medicine, politics a bitter tool

, Thucydides states that “Themistocles was a man who exhibited the most indubitable signs of genius; indeed, in this particular he has a claim on our admiration quite extraordinary and unparalleled.”

He came from a middle class family and (like many geniuses) was apparently not considered to be a gifted student. 

As an adult politician, he is credited with building the city of Piraeus into the largest naval base in the Greek world, and argued that a strong navy would one day be needed for defense.

In 490 BC, the Persian army, under Darius, invaded Greece. In the land battle of Marathon, the Greeks prevailed and Persians retreated to lick their wounds.

During the next ten years, Themistocles grew the Athenian fleet from 70 to 200 triremes.

With a triple bank of rowers, the trireme could ram opposing ships and the soldiers (hoplites) aboard would leap onto the enemy vessel and slay their opponents.

A decade after his father failed to prevail at Marathon, Xerxes returned in 480 BC with his enormous army and navy, dwarfing the defensive forces of the Greeks.

The Greek fleet, composed of the independent fighting forces of the various city-states, needed an overall commander.

 A naval historian friend tells me that an election was held to select the leader of the Greek armada, with each captain being given a vote for who should be the leader.

The vote was not helpful, as some 300 candidates each received a single vote when each and every captain voted for himself.

A second election was then held, and this time the question being voted upon was: “If it must be someone other than you, who would you want to lead the fleet?” This time there was a clear answer, with virtually every vote cast for Themistocles.

Luring the large Persian vessels into a narrow strait, the smaller and more maneuverable Greek vessels picked off the invading ships one at a time, negating the Persian numerical advantage. The naval Battle of Salamis, still studied some 2500 years later, was a crushing defeat for the Persians. 

Shortly thereafter the Greek land army prevailed against the invading ground forces, and Persia ceased to be a threat. Themistocles had bought Greece some 500 years of power, by which time the Romans would ascent to preeminence.

Themistocles was the man of the hour. Even the Spartans, traditional hated rivals of Athens, foisted honors upon him.

But Themistocles’ glory was short-lived.Only four years after his landmark victory, Themistocles was accused of being thirsty for power and riches and was exiled by his fellow Greeks. In a testament to what must have been his incredible political skills, Themistocles fled by merchant ship to—of all places—Persia, where he was welcomed by Ataxerxes I.

He spent the last decade of his life as governor of Magnesia, honored by the Persians whose navy he had destroyed, while simultaneously being declared a traitor and condemned to death in absentia by the Greeks whose country he had saved from the Persians!

Personally, I love the idea of an election in which all the candidates are forced to choose the person who—if it cannot be them—would be best qualified to lead.

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When an ophthalmology resident or fellow is learning to perform surgery, or when an ophthalmologist who has been practicing for years decides to learn a new surgical procedure (such as LASIK or corneal cross-linking), the ethical physician must consider it their duty to inform the patient.

For example, when I was in clinic with a 

 fellow and saw a patient who needed a corneal transplantation, I would explain to the patient that when I was training to be a cornea specialist my professor would have me operate while he watched, assisting and critiquing what I did. 



Saving memories: Do anti-VEGF agents contribute to cognitive loss?



With the fellow standing next to me, I would tell the patient that, with their permission, I would have my fellow do the same, with me present to ensure that things were done as well as (if not better than) if I were the primary surgeon rather than the assistant.

The vast majority of my patients would give their permission, often after confirming that I would be present during the entire procedure. 

Probably 5% or fewer patients would say that because the result of 

 in their fellow eye had been disappointing, they had been referred to me for surgery in the second eye, and the referring doctor had cautioned them to insist that no one other than me would perform the operation. The patient’s wishes would be respected.

Recently, another ophthalmologist who is the residency program director in his department told me that his approach is similar when he asks his patient to allow a resident to perform some or all of their procedure. 


Improving surgical safety, efficiency, and outcomes for patients​ 

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​The twist that I heard from his experience was that although many patients were agreeable, if they were a physician or the family member of a physician it was much more likely that they would refuse to allow the trainee to operate.

I found it surprising that someone who had mastered their profession by learning to operate on patients under the supervision of the professor would refuse the same opportunity for current trainees. 

Is it not hypocritical for physicians who learned, and who perhaps teach their own residents and fellows today, in this manner, to refuse themselves to participate in this same system? Should we not, as they say, “eat our own cooking”?

A perfect example of this is the experience of Alan C. Woods, MD, who from 1934 to 1955 served as the second director of the Wilmer Eye Institute.

 

Toward the end of his term as director, Woods developed cataracts that required 

. From among his roster of senior, famous surgeons, whom did Woods choose to operate upon him? 

The answer was none of them. 



Performing follow-up perfects surgical technique



He arranged to have his cataracts removed by the chief resident. Woods was very cognizant of the fact that his choice would be widely commented upon and also that if his residency really was the tremendous teaching program he claimed it to be, the most tangible way to demonstrate that to the world was to let himself be one of its patients.

We know that Woods’ surgery went perfectly. We also know that he was a terrible patient. 

He refused to stay in bed for 2 weeks like the other patients (these were the days before operating microscopes and fine sutures) and instead walked around inspecting the inpatient floors of the institute, giving orders to the nurses, quizzing the residents, and otherwise being officious.

He may not have been an obedient patient, but Woods was exemplary when it came to eating his own cooking. 

If the care provided by the Wilmer residents was of high enough quality for the many thousands of patients who came to his institute, then it was good enough for the chairman. 


1. Knox DL. Alan C. Woods, Sr, MD: a giant in his time. 

. 1999;98(1):51-81. doi:10.1023/a:1002149124172

Eating our own cooking: Ophthalmologists standing behind their products

potentially very interesting observation:

According to Subhransu K. Ray, MD, PhD, and colleagues in his retina practice, patients who receive more intravitreal injections with anti-VEGF agents are more likely to experience cognitive decline.

In a cross-sectional study, they compared the results of cognitive testing in 300 patients with neovascular 

Unproductive worry: Conquering fear during a pandemic



An interim analysis of the first 116 patients studied revealed a higher prevalence of cognitive impairment in patients who received more than 20 intravitreal injections and the difference was statistically significant.

Patients who received no intravitreal injections had a 27.6% risk of cognitive impairment, those who received 1 to 20 injections had a 31.8% risk and those who received more than 20 injections had a 41.9% risk.

The authors, appropriately in my view, point out that their data do not establish a causal link and need to be confirmed by others. But they do suggest that the optic nerve plays a role.

I think it is premature, based on preliminary findings, to alert our patients to a danger of their AMD treatment contributing to their development of dementia. It is an interesting exercise to consider alternative explanations of the data, including:

 The apparent association is not real, and additional studies by other groups will not confirm the association.

 Injecting anti-VEGF agents into the vitreous cavity results in some fraction of these molecules accessing the optic nerve and/or CSF, reaching the cerebral cortex, impairing the vasculature and causing cognitive dysfunction on the basis of ischemic injury.

 Anti-VEGF agents are toxic to cortical neurons and cause cognitive loss on the basis of neuronal loss.

 and dementia are similar. Thus, people with more advanced 

, requiring more intravitreal injections, are also the people who are losing cortical neurons at a more rapid rate and therefore more likely to show evidence of cognitive decline during the two years of this study.


 People who are developing cognitive decline are more likely to have family members step in to take care of them and make sure they show up to their doctors’ appointments. Thus, the patients with dementia are missing fewer follow up appointments and therefore are getting more injections.

, requiring more injections of an anti-VEGF agent, are more likely to experience substantial vision loss than are patients with less severe forms of the disease. The vision loss causes these more severely affected patients to read less, become less socially interactive, and overall to become less involved with their surroundings and others. This leads to an acceleration of their cognitive decline.

 Having a needle inserted into one’s eye is stressful and anxiety-provoking. This stress and anxiety heightens cognitive decline.

 People who are well-insured or wealthy are more able to afford to pay for their doctor visits and retina drugs than are the poor, who therefore elect to have fewer injections. Thus the two groups (few injections and many injections) may not be equivalent with regard to other variables, such as socioeconomic status and diet.


Contrast sensitivity shows potential for measuring visual function loss in early AMD

Perhaps you have some alternative hypotheses of your own. Whatever the truth is, I think it is worth examining in greater detail whether anti-VEGF agents might play a role in cognitive loss.

Ray presented “Cognitive Testing in patients receiving intravitreal anti-vascular endothelial growth factor therapy for wet age-related macular degeneration” at the American Society of Retina Specialists 2020 virtual annual meeting.

Read more editorials by here Dr. McDonnell

 yourself engaging in unproductive worry? Heaven knows that ophthalmologists these days have a lot to ponder. 

From time to time, perhaps you ruminate about things over which you may not have control—pandemics, economic recession and stock market volatility, wars, the current state of American politics, making payroll in your clinical practice when many ophthalmology practices have had to lay off many of their employees, declining physician reimbursement, maintenance of certification, or your children’s happiness.

Dale Carnegie, an American writer and public speaker, noticed 80 years ago that many of the students in his self-improvement courses spent much of their time in unproductive, sometimes disabling, worry. 

Carnegie developed courses in self-improvement, salesmanship, corporate training and public speaking. 

He studied the problem and, using his students as test subjects, proposed and validated strategies to allow a person to overcome the tendency to waste time worrying. 

His research formed the basis of a book, published in 1948, titled 

Carnegie offers a number of concrete suggestions for how to overcome worry:


Write down in great detail exactly what you are worried about

. 

Then write down a minimum of 3 options available to you to respond to that worry. Consider the pros and cons of each option and decide upon the most attractive way to proceed. 

If you cannot decide between 2 options, arbitrarily choose one and begin implementing it. If after a few days or weeks that strategy seems to be working, continue. 

But if not, move on to the second-best option. According to Carnegie’s research, deciding upon a course of action and acting goes a long way toward converting the seemingly impotent worrier into an empowered person of action.



The value of a reputation: Mixing medicine, politics a bitter pill

Write down the answer to “What is the worst thing that could happen?

” 

This might be sobering to contemplate, but it certainly forces one to squarely confront the worst-case scenario. Then list a bunch of items that, if you accomplished them, would make the nightmare scenario less bad. 

Let’s imagine, for example, that you worry about contracting coronavirus disease 2019 from a patient and, after a long stay in an ICU, becoming disabled and no longer capable of financially providing for yourself and your family. 

On your list of to-do items, you might therefore include obtaining or confirming that you have good disability insurance, a power of attorney for health care allowing a person you trust to make decisions about your health if you are unable to do so, a good investment portfolio, etc. 

Carnegie found that as his students checked off items on the list, they were transformed from unproductive worriers into persons who believed that they were having a positive impact on their futures. Even if the person checks only 1 item off, they have improved upon the worst-case scenario.


On the bright side .... looking for the positive amid pandemic's many negatives

Do the best you can today, and let tomorrow take care of itself.

Generals in wars that may last for years are able to sleep at night if they know that today they did everything within their power to give their best people the best equipment and best action plans. That was all that a good general could do. And tomorrow would be another day, in which the general would do the same.


If we ophthalmologists end each day knowing that we did the best we could that day for our patients, our colleagues, our families, and others, and that tomorrow we will do the same, unproductive and disabling worry will be kept at bay. Pandemic or not.

Author | Peter J. McDonnell, MD

Articles

Eating our own cooking: Ophthalmologists standing behind their products

Saving memories: Do anti-VEGF agents contribute to cognitive loss?

Unproductive worry: Conquering fear during a pandemic

Themistocles: Everyone's second chance