ABSTRACT
We came together in March 2021 for a joyous celebration of Dr Gordon Plant’s incredible career. This is a report of the meeting tidings.
KEYWORDS: Festschrift, meeting tidings, neuro-ophthalmology
We came together in March 2021 for a joyous celebration of Dr Gordon Plant’s incredible career. It was hard for us to imagine Dr Plant ever retiring! It was only with some persuasion that he agreed to having a Festschrift. It was an honour for this to be a United Kingdom Neuro-ophthalmology Society (UKNOS) event, and very fitting too, as UKNOS developed from its earlier roots as the UK Neuro-ophthalmology Special Interest Group (UKNOSIG) founded by Dr Plant.
The initial plans for the in-person celebrations in March 2020 were scuppered by the COVID-19 pandemic. A year on with ongoing pandemic uncertainties, we decided to transition to a virtual event over two half-days, not without some trepidation as we were keen to foster a warm, intimate, friendly feel to the event despite the online format. We were most grateful to the Royal Society of Medicine (RSM), London, UK for co-hosting the online event with us.
Speakers were selected with the help of Dr Plant to reflect aspects of his career and interests. Those in the original programme for March 2020 generously agreed to the webinar format of six sessions of three to four short talks followed by a longer informal panel discussion between Dr Plant and the respective speakers. We enjoyed the anecdotes about each speaker as Dr Plant personally introduced them before their talks; and in turn we also enjoyed the speakers’ anecdotes and jokes about Dr Plant.
On Day 1, it was a delight for the first session to be kickstarted by Professor Neil Miller. Dr Plant shared that their 30-year friendship started in London at a Trends in Ophthalmology meeting and that he has ‘hung on [his] every word every word since!’. Professor Miller spoke about the molecular genetics of optic nerve sheath meningiomas (ONSM) and shared interesting preliminary results of next generation sequencing on ONSM specimens. ONSMs showed similar types of genetic mutations as to skull base meningiomas, i.e. the majority being due to neurofibromatosis type 2 (NF2), and the non-NF2 mutations including TRAF7, AKT1, KLF4 and SMO. This raises the possibility of targeted chemotherapy in patients who cannot be treated with radiotherapy. The second speaker for this session was Professor Robert Sergott, who gave an fascinating talk, about the potential uses of multicolour optical coherence tomography (OCT). Specifically, he highlighted how this technique could be used in a number of ways including as a potential biomarker for ischaemia within the retinal circulation; as a sensitive way to detect emboli, including in patients with non-arteritic anterior ischaemic optic neuropathy; as a way of differentiating neuromyelitis optica from multiple sclerosis; and as a possible index of mitochondrial metabolism within vascular endothelium. The third speaker was Professor Dan Milea, who spoke about the future of artificial intelligence (AI) in Neuro-ophthalmology. He shared thought-provoking work that AI can be a transformative tool to improve our practice, e.g. results of the Brain and Optic Nerve Study with Artificial Intelligence (BONSAI) study where machines were taught to detect papilloedema compared to normal; and hinted that preliminary results of a study on the potential for AI to differentiate idiopathic intracranial hypertension (IIH) from non-IIH papilloedema. Cautious optimism was encouraged as we take the future steps to move this “from code to clinic”.
Professor Randy Kardon opened the second session on Day 1 with “a blink of an eye” detailing a novel accessory to the pupil response. This was the recording of the eyelid movement in response to light. He further convinced the audience that the lid response could localise an optic neuropathy, just as would be seen in a relative afferent pupillary defect. But there was more! When comparing the eyelid responses in a healthy person versus a person with Horner’s syndrome, the eyelid movement was different, thereby demonstrating an efferent response. In the second half of his tribute to Dr Plant he detailed the translational work his team has done in understanding the blink reflexes in animal models.
Professor John Barbur highlighted the 40 year collaboration between himself and Dr Plant. He paid tribute to Dr Plant’s passion for training Neuro-ophthalmologists from around the world, but also for his training of Physicists and engaging them in clinical research. With colour being a main theme for their discussions, the UK Colour Vision Group has evolved into a thriving meeting. Professor Barbur outlined the rationale for increasing the sensitivity of colour vision assessments in the clinical settling by specifically using the colour vision screener and colour assessment & diagnosis (CAD) test.
In the introduction of Professor Chris Kennard, Dr Plant reminisced about travelling from Cambridge to the stimulating Neuro-ophthalmology club that Prof Kennard had begun at the Royal London Hospital. This, in time, was the spark that spurred Dr Plant to set up UKNOSIG, which has now developed into UKNOS. Professor Kennard’s talk framed the typical challenging person with severe oscillopsia unresponsive to medical therapy that we have all seen in our clinics. He outlined the roadmap of designing and developing biologically compatible magnets that could be placed within the orbit to minimise oscillopsia. In the last part of his lecture he outlined the development of smart glasses for the visually impaired. The discussions following these lectures were lively with Dr Plant reaffirming to the audience that his belief that “the patient is always right” was true. This was evidenced by Professor Barbur’s assessment of a young person sent to his lab by Dr Axel Petzold who had declared an issue with her yellow colour vision spectrum!
In the last session of Day 1 Professor Tony Arnold discussed the topic “Optic neuritis: What precisely does atypical mean”. Professor Arnold gave a history of how the approach to optic neuritis has changed with the recognition that it is not a single homogenous disease with Dr Plant to thank for his role in the description of chronic relapsing inflammatory optic neuropathy (CRION). He stated that “the management of a significant neuro-ophthalmic disorder has been modified by the careful observation of an astute clinician. We have Dr Plant to thank for that”. Dr Petzold discussed how “Time is Vision”, recounting how Dr Plant has been instrumental in proposing, particularly in patients with recurrent steroid responsive optic neuritis such as CRION, that hyperacute corticosteroid treatment at the onset of pain may prevent vision loss. Dr Plant first proposed this in a series of eight patients. Dr Petzold recounted how this study was reported in the accompanying editorial as a David compared with the Goliath of the Optic Neuritis Treatment Trial and that Dr Plant outdid James Lind, who needed 12 sailors to find a treatment for scurvy. Professor Tamas Revesz discussed the history of his and Dr Plant’s journey that started with a pathological study at Maida Vale hospital, London, where they both worked, and led through collaborations with colleagues in Aarhus, Denmark and New York, United States of America (USA), to the discovery of a novel mutation of the BRI2 gene on chromosome 13. This mutation causes the disease now termed familial British dementia, a type of cerebral amyloid angiopathy. Dr Pinar Aydin O’Dwyer finished the season with a wonderful review of how blindness is used a metaphor in opera with many examples of unilaterally and bilaterally blind characters. She played an exert from Iolante by Tchaikovsky – the scene where Iolante’s sight has been restored. This was initially very frightening to her as she felt everything was crowding in on her, but the doctor reassured her, asking her to look above her as she would not be frightened by the sky. Iolante: “Oh, how wonderful. So much light, what is it? God?” Doctor: “Light and heaven”.
Professor Andy Lee launched the first session of day 2 with a characteristically high octane and highly informative presentation. He opened using the example of Augenblick (German for ‘Eye glance’) to illustrate how in much of Ophthalmology the diagnosis can be made on the first inspection of the eye but how the Augenblick approach contrasts with the challenges of Neuro-ophthalmic diagnosis with which the Ophthalmologist is dependent in equal measure on both their Ophthalmic and Medical training. Structured around quotes from both Gordon Plant and Gordon Ramsay, Professor Lee proceeded to illustrate the importance of locating lesions using physical findings such as the homonymous sectoranopia secondary to a lateral geniculate lesion, using an example published by Dr Plant. He discussed the importance of adapting to change by referring to the introduction of checkpoint inhibitors and the accompanying Neuro-ophthalmic side effects and emphasised Dr Plant’s contribution to the understanding of neuromyelitis optica, another current rapidly evolving field. Professor Lee concluded with the importance of avoiding physician burnout by including in the working day particular tasks that we enjoy, explaining that his own choice in the mentorship and education of the future generation of clinicians is inspired by Dr Plant’s own enthusiasm for Neuro-ophthalmology and for imparting his knowledge to others.
The second half of the session was structured around three excellent presentations. Professor Jette Frederiksen discussed the flicker test for specifically diagnosing demyelinating optic neuropathy. The flicker test involves a patient matching the subjective brightness of a flickering field with a steady state illuminated field. Interestingly, the brightness of a flickering field is overestimated if a patient performs the test with an eye previously affected by demyelinating optic neuritis. Professor Vivek Lal presented ‘Neuro-Ophthalmic Challenges in India’. He discussed the ongoing issue with tuberculous meningitis (manifesting as basal exudates on magnetic resonance imaging [MRI]) and other encephalitides now more unusual in the West, such as subacute sclerosing panencephalitis in the context of previous measles infection. Professor Lal presented his case series of patients with ophthalmic migraine, which are specifically different from the group reclassified as third nerve neuritis. He also discussed methanol induced toxic optic neuropathy and the associated basal ganglia destruction. The session concluded with Dr Roberto Ebner presenting his experiences with corneal neurotisation and using confocal microscopy to visualise corneal reinnervation.
Professor Lee presented Dr Plant with a commemorative figurine likeness, which was warmly received.
The second session on Day 2 focussed on visual fields, pathways, blind sight, fantastic knees and 20th century liaisons in San Francisco. The first and third talks were from Professors Klara Landau and Jonathan Horton, fellow fellows of Dr Plant in the close orbit of Professor Bill Hoyt in San Francisco, USA, in 1990. The second and final talk (courtesy of technical difficulties) was from the incredibly energetic Professor Holly Bridge whom Dr Plant anointed the UK functional visual MRI expert of choice.
Professor Klara Landau displayed the exotic shirt and enigmatic expression that Dr Plant had worn to her own Festschrift in 2018. She revealed that her enduring talk ‘Personal Perimetric Pearls’ was founded on a long love of perimetry. Due to time constraints, she presented a single dazzling Pearl formed at the dawn of MRI of a 47-year-old woman with periurethral adenocarcinoma, reading difficulties and a normal examination apart from Goldmann perimetry displaying a right central homonymous field defect suggestive of a lateral geniculate nucleus (LGN) injury. MRI revealed a left LGN metastasis. Her talk highlighted advances in LGN imaging, functional MRI and insights into visual snow. She recounted her own 2 hour research MRI scan, which culminated in her being awarded the prestigious Bill Hoyt award for the ‘girl with the most beautiful LGNs’.
Professor Holly Bridge talked about ‘Investigating residual pathways in homonymous hemianopia’. She explained research work into the phenomenon of blindsight with functional MRI had revealed activation in the visual motion cortex (MT) in the absence of any V1 activity. Professor Bridge’s further elegant clinical and radiological studies suggest that the phenomenon of blindsight is dependent upon preservation of a direct pathway between the LGN and MT. In the discussion section Professor Bridge explained the potential reasons for the LGN MT pathway in health – before Dr Plant revealed that MT allows us to play cricket.
Professor Jonathan Horton tackled the issue of whether Wilbrand’s knee exists. Wilbrand had described a contingent of fibres emanating from axons from the inferonasal retina that deviated into the contralateral optic nerve before proceeding into the optic tract that appeared to elegantly explain the phenomenon of junctional scotoma. In the 1990s, Professor Horton, aided by a troop of macaques, diligently went in search of the knee but found none. When he presented his findings to Professor Hoyt, he too revealed his own search some 30 years previously had also concluded that there was no knee. Professor Horton attributed the knee to an artefact of enucleation in Wilbrand’s original experiments and artistic licence in textbooks. He proposed that junctional scotomas can be fully explained by common pathology, which asymmetrically injures optic nerves and chiasm, such as a compressive pituitary tumour. At the group discussion, Dr Plant clarified that Wilbrand’s knee does exist – just not in the way that Wilbrand had described – it is purely an anatomical phenomenon of enucleation that is clinically irrelevant. Professor Horton drew the lesson from Wilbrand that one should not mould the facts to fit even a very clever idea.
The final session of the meeting focussed on some of the far-flung international collaborations that Dr Plant has enjoyed over the years.
In his introduction to Professor Thorkild Tylleskär’s talk, Dr Plant recalled the sunny day in London when he first heard of the work on konzo, a neurotoxic disorder found in parts of Africa. Professor Tylleskär, alongside Hans Rosling and other collaborators, determined that inadequately processed cassava (leading to cyanide toxicity) was the cause of konzo. Konzo causes abrupt and permanent neurodisability of an upper motor neuron type. This disorder remains particularly important as approximately 600 million individuals rely on cassava as a staple of their diet. It became clear to Professor Tylleskär that some of those affected by konzo developed visual symptoms and signs and Dr Plant was enlisted to examine these cases further. This problem was shown to be an independent optic neuropathy, similar to that observed in epidemic proportions in Cuba and amongst British prisoners of war in the Second World War. Many questions followed in the discussion after the session.
Dr Xiaojun Zhang’s talk on Neuro-ophthalmology in China followed. A warm greeting from Dr Plant, and a reminder that she had been responsible for all his enjoyable trips to mainland China, preceded this. Dr Zhang informed us that the field of Neuro-ophthalmology in China is an expanding one with many up and coming trainees benefitting from Fellowship opportunities overseas. She introduced us to the past Neuro-ophthalmology pioneers in China and explained that, now with 20 regular Neuro-ophthalmology clinics plus an annual Chinese Neuro-ophthalmology conference, the subject is progressing apace. Dr Zhang explained that her time with Dr Plant in London taught her about “work structure” and she reminded us of his impressive three hospital Consultant posts. In conclusion, she showed a picture of some contributors at a Chinese Neuro-ophthalmology conference, which prompted Dr Plant to tell of his unsuccessful attempt to make up for forgetting to take along his clarinet to the conference. Opting to tell a joke instead in English to a Chinese audience (despite a proficient translator) is clearly not to be recommended as an alternative form of light entertainment.
Dr Panitha Jindahra spoke next from Bangkok, Thailand. In his introduction, Dr Plant explained how Dr Jindahra had come to London on a Neurology Diploma course with a plan to stay for a further two weeks observing the Neuro-ophthalmology service. Four years and one PhD later she returned to Thailand! It was fascinating to hear her account about optic neuritis in Thailand, particularly to understand how different the aetiological case mix is there compared to the United Kingdom. A much higher prevalence of idiopathic or neuromyelitis optica spectrum disorder cases was observed in the Thai cohort. She also provided some interesting observations on Jo-1 associated cases and their clinical features.
Finally, Dr Abdi Dalmar, from Somalia, a collaborator with Dr Plant and another former PhD student talked about his 25 years of “mentorship, friendship and partnership” with Dr Plant. In particular, he spoke of his work in Dar Es Salaam, Tanzania investigating the nutritional optic neuropathy noted by Dr Tylleskär. Dr Dalmar explained that he had always appreciated the “advice and encouragement” he continued to receive from Dr Plant when he established his Neuro-ophthalmology service in Mogadishu, Somalia.
We are most grateful to the generosity of the speakers for their contributions to the day, and the participation from the audience with the panel discussions. Photos of the day are shown in Figures 1 and 2.
Figure 1.
Screenshots of the panels from each session on Day 1.
Figure 2.
Screenshots of the panels from each session on Day 2.
The online format enabled several opportunities that further enriched the event. We enjoyed musical interludes between the above sessions. Dr Plant’s daughter Emma and her musical and technical wizardry enabled livestreaming of Jazz music with Dr Plant and friends, including Professors Neil Miller and Dan Milea, and Emma’s “Jolly Good Jazz Band”.
The online format enabled a larger and wider reach of participants. At approximately 330 participants per day, it was a four-fold increase compared with the postponed in-person event; and a truly global reach, from the Americas to Australasia, from the Caribbean to Asia, from Europe to beyond. Such a global reach reflects Dr Plant’s tremendous legacy of enriching and supporting far-reaching Neuro-ophthalmology communities.
This two half-day online format also enabled participants to send messages and photos. One of us (SHW) had the privilege of collecting these messages on the day. We had also prepared a surprise for Dr Plant’s March 2020 in-person Festschrift, a book of handwritten messages from past trainees, which was posted to him instead (Figure 3). It was awe-inspiring to feel the depth of love, loyalty and lives touched by Dr Plant, and he has our collective heartfelt gratitude.
Figure 3.
Dr Plant opening his Surprise – a bound collection of handwritten messages from past trainees – intended for March 2020 in-person event postponed due to COVID-19 pandemic, which was posted to him instead.
The best was saved for last, and most appropriately, for Dr Plant’s family. Dr Plant was surprised with a family video, followed by the live appearance of his daughters on screen, joining Dr Plant and his wife, raising a glass congratulating him.
Funding Statement
The authors reported that there is no funding associated with the work featured in this article.
Declaration of interest statement
No potential conflict of interest was reported by the authors.
Post-script
Catch-up recording of this event is accessible to UKNOS members on the UKNOS website’s members-only section: https://uknos.com.