To be the founding editor in chief of any medical journal is to learn on the job. To juggle tight deadlines and demanding critical reading alongside a busy surgical practice and administrative tasks; to try gently and dispassionately to oversee the nuanced interactions in a large group of talented authors and reviewers; to stare at the bedroom ceiling at night awaiting the Muse’s inspiration for the next issue’s theme, editorial, and cover—these are entries inscribed in the mental diary of every editor in chief.
Surprisingly, the cumulative result of these energetic experiences is not exhaustion or despair but rather gratitude and appreciation. I am so grateful to have been offered a privileged vantage point to learn of new vitreoretinal discoveries, surgical techniques, and insights from innovative colleagues around the world in the stream of manuscripts and correspondence that compose The Journal of VitreoRetinal Diseases. It has been an honor to curate the first steps of this bold ASRS initiative.
Before this column becomes ponderous and heavy (dangers with every farewell), I will step into my dependable, and by now familiar, refuge—the quirky and tangential. The 3 images on the cover are longtime favorites from my personal curio cabinet. Although I am certain they have never been displayed together in a single view, I have found in my own reflections they can offer us a powerful triad of inspiration to better understand the retina and improve care for patients with vitreoretinal diseases.
The top 2 scanning electron microscope (SEM) images of the retina depict a subject certainly familiar to you but in a somewhat startling way. These views of the bovine retina have always entranced me from the moment I placed the sputter-coated tissue in the SEM during my residency so many years ago. There is something eerily beautiful, even unsettling, about the 3-dimensionality of these images. In the right photo, it is almost charming to see the nerve fibers crouching like predatory Moray eels in the recesses between the Müller cell columns.
It would be nothing less than transformational to be able to keep this image, with its sculptural cellular complexity, in mind when I am examining patients in the clinic or treating them in the operating room. I must confess, however, the retina I view with an indirect or other lenses (before checking the OCT) usually looks as flat as a painting to me.
Despite my impression that I am viewing a flat image, the retina is resonant with depth and uniquely important in perception, connecting us to the blazing world of light and movement. It is not merely a passive conduit but rather a sophisticated interface that performs 3 simultaneous miracles.
First, within its highly specialized photoreceptors and retinal pigment epithelium, a complicated visual cycle chemistry converts focused (focused being a nod to my anterior segment colleagues) splashes of light into electrical signals and conveniently sorts these by color, location, and intensity.
Second, it processes these signals, through interactive computing by densely connected inner retinal cells, into the rudiments of shape and motion while these impulses are still within the eye. And third, the retina does all of this adaptively, i.e., its functioning adjusts to the amount of light available, displaying an expansive dynamic range the most advanced digital camera or sonorous grand piano simply cannot match.
We as retina specialists are the prime guardians of this magical tissue. Our actions, whether liberating its cells and vessels from inflammation and exudation, restoring its proper position in contact with the retinal pigment epithelium, freezing/burning tears and lesions, or radiating tumors, etc.—our every move is guided by an understanding of how to restore the retina’s performance of its own inherent miracles. Like coaxing a drunken god away from the wine-laden banquet table and into bed, our role is clearly a supportive one but also vital to restoring otherworldly powers.
We have made astonishing diagnostic progress with OCT, various forms of angiography, electrophysiology, adaptive optics, and other technologies to appreciate the retina as much more than a flat image, but the information remains disjointed in presentation and is cumbersome to assemble and process. It would certainly be most welcome and game changing for our current multimodal imaging to evolve into instruments that assemble these divergent bits of data and place them together in our examination room.
There is hope that additional information can seamlessly be added to a static view, because it has been done before and revolutionized other fields. The lower left figure on the cover is Paolo Uccello’s Battle of San Romano, a major attraction in the Galleria degli Uffizi in Florence; a gilt-framed reproduction is prominently displayed in my home. This masterpiece, created in approximately 1450 to commemorate a daylong conflict between Florentine and Sienese forces on June 1, 1432, is one of the most famous paintings of the Renaissance, not only for its rich and chaotic detail but also for Uccello’s brilliant use of linear perspective.
Artists had been painting for millennia, but the ability to convey a sense of depth in a flat painting was primitive prior to the development of perspective by Brunelleschi and other artists of this period; Uccello was notable for his obsession with its refinement and application. Suddenly, vast amounts of new information could be displayed in the same flat canvas or fresco.
Making the comparison to all of us in our examination rooms, we are still clumsily shifting our view from machine to machine and app to app; so much information is available, and we eagerly await our own Renaissance masters to find new methods to present it with ever increasing clarity, integration, and immediacy.
(Editor’s note: Incidentally, this painting is the center panel of Uccello’s 3 scenes from this battle, with the others on display at the National Gallery in London and the Musée du Louvre in Paris. Certainly, winning this prestigious museum trifecta must be some sort of record for individual sections of a 3-part painting but, alas, my research cannot verify this claim. These 3 panels were separated in the centuries following his death, so Uccello cannot be accused of using a “salami slicing/least-publishable unit” strategy—rampant though discouraged in modern academic publishing—to enhance his reputation.)
The lower right image is probably new to most readers; it is a photograph of a museum reproduction of a pair of bison in clay relief deep in the Tuc d’Audoubert cave in the Ariège region of the Pyrenees in France. These energized and remarkably realistic sculptures were made approximately 14,000 years ago by the Magdalenians, a people who created many famous examples of Paleolithic art. The bison were discovered in 1912 in the farthest recesses of the cave, their beauty resting unappreciated in the dark for millennia. Indeed, it requires a 0.4-mile subterranean trek and crawl to reach them in a low-ceilinged chamber at the final reaches of the cave.
Access to the bison reliefs is restricted and difficult, and we have only speculations regarding their creation, use, and near-ridiculous placement. Nevertheless, we can immediately feel connected to the artistry and extraordinary efforts of their creators. We can be sure they suffered retinal detachments, eye injuries, congenital blindness, and all the rest—and yes, a single drop of our current knowledge would have alleviated so much suffering.
Notwithstanding these outer differences, on viewing the bison there is simply no way to see their creators as primitive in spirit. Indeed, a very clear and human lesson emerges: the individuals crouching in that cave so long ago had something important to do, they did it exceedingly well, and they worked in a manner that intentionally preserved their efforts in perpetuity. The attentive and comprehensive approach embodied in these bison can inspire us to put forth our best in any effort, i.e., in every effort, whether sharing in the creation of a new journal for vitreoretinal diseases or hand fashioning a sculpture from wet clay.
With all due respect to the Beatles, I got by with not a little, but a lot, of help from my friends. Ana Schedler at Schedler Brennan Design took my vague cover ideas and instantly delivered at least 5 mock-ups that perfectly expressed possibilities for my initially clouded vision. Susan Raef at ASRS edited my editorials with a concision that Strunk and White would envy and did it all at my last-minute request—as is my relentless and unfortunate usual—while Jill Blim, Lydia Steck, and others at the ASRS offices shielded me impenetrably from all bureaucracy.
Victoria Ignacio and later Nithya Prabhakaran at Sage Publications meticulously created the finished copy and tolerated my (again) last-minute re-paginations; Jessica Lipowski, Annette Butler, Sameer Grover, and many others at Sage provided incisive help with the myriad issues that arise in a medical publication.
The superb Associate Editors, Drs. Dean Eliott, Marta S. Figueroa, Thomas R. Friberg, Tarek S. Hassan, Heinrich Heimann, and John T. Thompson participated energetically in every article review and decision, lending their impressive expertise to the scientific quality of the journal.
I must single out Dr. Timothy G. Murray for coming forward and literally saving me when JVRD hit full stride and I was struggling to keep up the workflow; Tim stepped in and became my partner and guardian angel, and I am delighted that he will follow me as editor in chief. The full JVRD Editorial Board, comprising acknowledged experts from around the world, offered sophisticated advice and perspective on the important issues of the day.
I am particularly grateful to the 3 Deputy Editors, Drs. Szilárd Kiss, Mario R. Romano, and Yoshihiro Yonekawa; these young superstars already have knowledge that spans our discipline, and they work like Clydesdales (bison?) to expand and share it.
In the end, I offer my highest gratitude to my vitreoretinal colleagues, collaborators, students, and patients; connection with them re-energizes and reaffirms the need for continued vigorous action and inquiry into every aspect of vitreoretinal diseases. I am also thankful that these editorials have provided me the opportunity to study and quietly reflect on many engaging issues and to offer a new perspective. It has been an honor to be placed at the confluence of so many important, strong, and exciting currents, and to discover, like every fly fisherman, that life thrives in the eddies.
Donald J.
D’Amico, MD
Editor-in-Chief
Journal of VitreoRetinal
Diseases