History

History of the New Orleans Academy of Ophthalmology

Arthur Jampolsky

The Smith Kettlewell Eye Research Institute, San Francisco, CA, USA

Once again, I am privileged and pleased to be asked to participate in this meeting of the New Orleans Academy of Ophthalmology. I have been requested to comment on the history of the Academy, and especially to focus on the several strabismus symposia. The Academy has pioneered such symposia, and over several decades, has crafted a unique spirit, content, and form of discussion that has become very well known. I wish to thank Amber W. Howell, who kindly supplied me with the historical material I requested.

It all started when two of the leaders of ophthalmology in New Orleans, William B. Clark and George Haik, invited James H. Allen from Iowa to join them in promoting ophthalmology education goals in this great city. Right after WW II, Jim Allen had organized a symposium on strabismus in Iowa City, which proved to be immensely successful, and which included leading invited guest lecturers. An important aspect of the success was the freewheeling panel discussions. Under Jim Allen’s leadership, a New Orleans symposium was later organized which amplified the uniquely successful round table panel discussions which became more informal, more entertaining, and of immense scientific and practical value (Fig.1).

Fig. 1.

Address for correspondence: Arthur Jampolski, MD, The Smith Kettlewell Eye Research Institute, 2318 Fillmore Street, San Francisco, CA 94115, USA

At the Crossings: Pediatric Ophthalmology and Strabismus, pp. 3–14

Proceedings of the 52nd Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA, February 14-16, 2003

edited by Robert J. Balkan, George S. Ellis Jr. and H. Sprague Eustis © 2004 Kugler Publications, The Hague, The Netherlands

Allen reprinted two of Lancaster’s earlier papers on terminology, which appeared as an appendix in the 1958 Strabismus II publication.*

An early New Orleans Symposium was on the subject of glaucoma and brought together three world experts: Sir Stewart Duke-Elder, Peter C. Kronfeld, and Paul A. Chandler (Fig. 2).

Aside from the practical scientific elegance of the glaucoma presentations, I would like to share with you an unforgettable scene at one of the question-and- answer discussion periods. Someone in the audience asked Dr Chandler a rather long, involved, tripartite question – almost impossible to address. Dr Chandler was a man of relatively short stature and he got up on his tiptoes, his head and shoulders barely visible above the podium, paused for a long moment, looked at the questioner, and said, “Yes!” and sat down. It was a wonderful answer, and a memorable scene and lesson that I carry with me to this day.

Figures 3a and b depict the big, bold, and beautiful emblem, which is symbolic of the New Orleans Academy of Ophthalmology. One of these noble emblems of the Academy appeared on the program cover of the Symposium on Cataract, the other on the Symposium on Glaucoma. In stark contrast to this noble academy emblem introducing those symposia, was the Picasso-like drawing from outer space on the cover of the first Strabismus Symposium (Fig. 4). The message appeared to be clear: replacing the noble emblem with a far-out, somewhat undecipherable strabismic drawing seemed to infer that one should simply let the crazy strabismus cults gyrate and wave their hands in mortal combat. Now, some forty years later, I believe that this deserves some comments. According to the Peter Principle, cataract surgeons rise to their highest level of competency – that is, carpentry, when they sort of rearrange the furniture at the front of the eye. There is not much to strategize about, nor much to think about – just exercise a skill. And glaucoma surgeons reach their highest level of competency as plumbers. Simply put, there are two strategies – turn down the spigot, or flush fluids out better. A lot of thinking is not really required. But the strabismus people have to deal with twelve eye muscles. They have to know neurophysiology, as well as anatomy, and have to devise strategies for the wide panorama of different types of strabismus cases. And – they have to think. Most ophthalmologists know that thinking is painful, and cataract and glaucoma surgeons have learned to avoid that pain. Oh, I forgot the retina people. The retina surgeons are essentially hole closers – a different type of carpentry altogether. Until relatively recently, retina surgeons paid little attention to the function of the retina, as long as it was surgically back in place. The degree of residual functional vision was not really of much concern to the retina specialist, since the patient would return to the referring doctor to do the monitoring and refraction. In recent years, there has been an interesting retinal function test developed that retinal surgeons did in fact begin to use. It was called the “switch test”. The patient sits in the examining chair after surgery. The retinal surgeon explains that the retina is now nicely back in place. He then goes to the wall where the light switch is and asks the patient to, “Tell me if the light is on or off” as he switches the lights. The switch test was an early retinal assessment test devised by retinal surgeons, and admittedly, things have come a long way since then.

Well, I guess I may have lost a few friends today by the above descriptions. Figure 5 depicts the 1962 Strabismus Round Table participants – and, as you can

Fig. 4.

Fig. 5.

see, the moderators are the three originators of the New Orleans Strabismus Symposia.

Figure 6 depicts a third New Orleans Academy Strabismus Symposium, and particular note should be taken of the program chairman, Dr Oliver H. Dabezies, who played such a significant second-generation role for many years in organizing these symposia.

Harold W. Brown (of Brown’s syndrome fame) (Fig. 7) was a magnificent stra-

Fig. 6.

Fig. 7. Harold W. Brown, MD.

bismus diagnostician, who published sparingly in journals so that many of his prime contributions appear in the New Orleans symposia, either in his lectures, or in the delightfully informative discussions. For instance, Figure 8 depicts a method of clinically recording, in a simple way, strabismus deviations and eye rotations in different fields of gaze, as measured by cover test, as if you were observing the patient with the patient’s right eye on the reader’s left, and the left eye on the reader’s right. This recording method has been modified in many useful ways, and was a significant departure from European methods that were primarily subjective, such as the Hess screen. I would invite those interested in strabismus to read Harold Brown’s lectures and round table discussions in order to capture the flavor and spirit of this magnificent observer and person.

In preparing for my assigned topic of an historical review, I rummaged through some of my own slides from that era, presented at one of these round tables (Fig. 9). At that time, esodeviations and exodeviations were lumped together in management discussions and in recorded results. This figure was meant to emphasize that esos and exos were completely different animals, and that we should separate the management concepts, especially the reported results of surgery. It seems almost unbelievable that, today, some strabismus authors still lump results together and report “plus or minus ten prism diopters of deviation” as a good or fair – or whatever – result. For example, in reporting the surgical results of childhood esotropia, the above-lumped term would indicate that five prism diopters of esophoria as a result, would eventually end up the same as five prism diopters of exotropia, which is patently wrong. Strabismus management may have come a long way since that era, but alas, not everyone has closed that circle.

As noted previously, the rather informal discussions, with active moderators participating in the discussion of controversial topics, were and still are one of the highlights of a New Orleans symposium. They have become extremely popular, and have developed into an art form. I have selected some examples from some of these early discussions, which I thought would be of interest as well as of amusement to current participants. Figures 10 and 11 describe some typical round table exchanges. In one such exchange (Fig. 11), von Noorden posed the question of very early surgery for infantile esodeviations. Dr Knapp’s often pithy remarks might be directed at anyone. Von Noorden, as a polite moderator, evidently wanted to drop this hot potato, a controversial issue at the time (as it still is today), by deferring the question to me, but the answer (see Fig. 11) did not cool it down one bit.

Figure 12 depicts Philip Knapp, one of the all-time greats in strabismology. He was an uncanny observer of events, an innovative thinker, and a straight shooter. His slides were few, at best typewritten and homemade, but his lectures were superb. Phil was one of my closest friends, and one of my most severe critics. When Philip and I first met in the early 1950s, there were no fellowship programs in strabismus at the time. Unbeknownst to each of us, Phil devised his own fellowship itinerary from New York, and I did the same from San Francisco. Our paths crossed repeatedly and we kept track of which expert was good to visit, and who should be passed by. My wife Peggy and I developed a close relationship with Phil and his family, enjoying many meetings together throughout the world, and exchanging sharp opinions. One time after I gave a lecture, Phil told me that I lacked a crucial synapse between brain and tongue.

Marshall Parks’ retorts at the New Orleans symposia were a bit more restrained,

Fig. 10.

Fig. 11.

Fig. 12. Philip Knapp, MD.

Fig. 13. Phil Knapp and Marshall Parks, two-thirds of the ‘working’ group.

such as, “There is certainly a difference of opinion.” That was one of the harshest remarks of Marshall that I could find, he being a thoroughly Southern gentleman. Marshall and I have developed an interesting relationship, which I like to term as a respectful disrespect professionally, and the warm personal friendship between our families has been most enjoyable during these many decades.

After one of the round table discussions, Phil Knapp, Marshall Parks and I

found ourselves unable to agree on such a simple and fundamental thing as what constituted a reasonable statement of surgical cure. Not long after this, the three of us found ourselves in Minaos, Brazil, since some of our small group wanted to visit the famous little opera house built in this small town by descendants from the USA. Marshall, Phil and I discussed the subject of the criteria for a strabismus cure during lapses in good fishing on a boat on the Amazon, where we caught the oddest-looking, prehistoric-like fish any of us had ever seen. We were serious about trying to resolve the question of surgical cure criteria, which we decided to call The Amazon Accord. Well, I can tell you that no accord was ever reached, though we did meet several times for this purpose. There was a little table in a cabin on the small boat, and we had a sort of small working group, taking turns to lead the informal discussion among the three of us. On the third day, it was my turn to lecture. I took a photograph of the audience (composed of Marshall and Phil) during my presentation (Fig. 13). And I learned a completely different lesson, namely that a working group consisting of three people works best if two of them are asleep. And so, we never did present our attempted Amazon Accord at any of the subsequent strabismus symposia.

I would like to share with you two short vignettes that occurred during these symposia. During one round table discussion, Marshall Parks asked me, after I had answered a question rather curtly, “Well Art, how do you really know that?” I hesitated and replied, “I’m sorry, I thought you knew. I didn’t recognize that it wasn’t well known, but the good Lord speaks to me on the first and third Sunday of every month, early in the morning, and tells me these things quite directly. I feel a bit guilty that you are all at somewhat of a disadvantage.” And Marshall very quickly answered, “Art, I don’t remember speaking to you on the first and third Sundays.” It’s tough to beat a man like that.

When I received this nice invitation to present some historical remarks at this symposium, I was also asked if I could possibly find the sound motion picture clip that I presented at the subsequent strabismus symposium after the above-described Amazon Accord had occurred. After rummaging through several decades of old motion picture film, my secretary finally found it. So I re-run it here. (The film depicted a space machine soaring through celestial clouds, and a satellite view of Earth, with my audio-modified deep voice coming through the clouds admonishing Marshall to listen more closely to my statements. These words being pronounced with this author sitting on a throne in a cloud, with a halo-decorated head.)

The question-and-answer discussion periods of the New Orleans Academy symposia were published verbatim, you could not change what you had said, which produced some interesting documentations. In concluding, I would like to share a short episode that reflects the attitudes and friendly atmosphere that prevailed. It involves some correspondence that was conducted with the editors/publishers of one symposium, and my lecture entitled, Some Uses and Abuses of Orthoptics. A prominent part of this lecture was directed at the uses, which included some uses that I felt perhaps some had not thought of. This was the body of the lecture. The uses were confined to discussing my feelings that the sensory and motor examination of strabismus should be performed by the ophthalmologist, and these could and should be done efficiently on repeated patient visits by the same observer, allowing comparison of the initial diagnostic evaluation and the subsequent evaluative examinations. I presented slides (Figs. 14a and b) that labeled the formal

Chapter 19

Fig. 14a.

Fig. 14b.

orthoptic diagnostic aides with three numbered blank paragraphs. It then went on to discuss some good orthoptic training in some detail. The editors returned this part of the manuscript to me with the comment that there must have been a typing error, the three sentences regarding diagnostic uses having been left blank. It was a very polite letter. I responded with an equally polite letter, thanking them, and stating that it was not an error at all, but that I felt the three blank ‘uses’ would speak louder than words about the diagnostic part of the problem, since I felt that each ophthalmologist should carry out his own diagnosis. After all, the cataract surgeon does his own anterior segment examination, and the retina specialist performs the retinal diagnostic examination.

The editors sent back a stronger letter stating that they had a real problem publishing my three blank sentences – and quite emphatically asking me to change them. I responded in kind with the tone of my letter equaling that of theirs, but pointing out that there was an agreement between the editors and authors that the proceedings would be printed as spoken. Moreover that I understood their strong feelings, and if they still felt that way, it would be perfectly all right with me if they simply deleted the chapter, did not publish it, and sent it back. Well, I never heard from them again. They published it – just as you can see in Figure 14. The editors of the New Orleans Academy symposia lived up to their promises. Though

their letter was strong, I have received stronger letters. A friend of mine once sent me a telegram that stated, “Art, go to hell… strong letter follows.”

However, this was hardly the end of the episode just described with that boldly stated title. I received a good deal of correspondence concerning that particular chapter. I used to think that the truth will set you free. And actually, throughout the years, I have learned that the truth will indeed set you free – free of some colleagues and free of some friends.

Once again, I want to thank the past and present New Orleans Academy hosts of these wonderful symposia, for allowing me to participate in this, my sixth symposium, over many decades.