Retina Is for the Birds

Hawks have more than one fovea and a cornea that changes shape to sharpen focus on prey. Who knew? Well, one retina doctor did. James C. Major Jr, MD, PhD, joins us for an episode to review his early contributions to animal imaging. But the story is bigger than that. Dr. Major's journey illustrates that a marriage between two passions-in his case, the blossoming world of optical coherence tomography in the early 2000s and an ornithological hobby-can send a retina doctor down uncharted paths of scientific discovery.

Ranna Jaraha: Let's do this.

Scott Krzywonos: I'm Scott.

Ranna Jaraha: I'm Ranna.

Scott Krzywonos: This is New Retina Radio. We're keeping things short with this episode.

Ranna Jaraha: Yeah, it's, after all, it's not easy to pin down everyone at the start of summer.

Scott Krzywonos: But we think you'll like what we have to offer. It's our first singles interview.

Ranna Jaraha: Now, not a dating interview. We already did that spinoff, but this is an interview of a single doctor, something short and sweet.

Scott Krzywonos: This actually goes back to New Retina Radio's very first interview and we've been wondering what to do with it ever since.

Ranna Jaraha: Yeah. The recording is so old that the mics and equipment are different.

Scott Krzywonos: If this episode sounds unusual, do not adjust your radio dial.

Ranna Jaraha: Right. So, it's the same show quality, but maybe some different sound quality.

Scott Krzywonos: Or maybe not. We won't know until we release it.

Ranna Jaraha: Yep.

Scott Krzywonos: Anyway, this episode will likely scratch an itch that all retina surgeons have, that of scientific curiosity.

Ranna Jaraha: Mm. Let's start with the guest.

James Major: My name is James Major. I'm with Retina Consultants of Houston in Houston, Texas. I also work at the Blanton Eye Institute, which Houston Methodist Hospital.

Scott Krzywonos: James has a unique passion.

James Major: My father, um, who was also an ophthalmologist, is an avid birder, so when I was little, ever since I can remember, he would take me out birding, on these, and you know, trips out in the field, really. From the Everglades to Texas to Alaska, we went everywhere. And so, I sort of developed an early love for nature and birding and hiking, uh, in that regard, so my interest has always been in sort of field biology in general bef- even pre-ophthalmology, pre-retina.

Ranna Jaraha: Cool. There's something calming about bird watching, right?

Scott Krzywonos: Birding.

Ranna Jaraha: Huh?

Scott Krzywonos: Uh, I called it bird watching also, but it turns out that it's called birding.

Ranna Jaraha: Oh, okay.

James Major: Yes. Bird watching is sort of the older term. Birding refers to a young, vibrant person going out looking at birds.

Scott Krzywonos: People like James.

James Major: People think of bird watching as watching birds. You're really identifying species. So you're saying, I've seen 550 birds from this geographic area and you're really trying to list and see as many bird species as possible.

Ranna Jaraha: Ah, so it's more than just posting up in a tree with a pair of binoculars, huh?

Scott Krzywonos: James pursued this as a scientific interest in his undergrad career as a biology major. He went to school in the South.

James Major: Emory University in Atlanta, Georgia.

Scott Krzywonos: And loved it. It was birding paradise.

James Major: Particularly, and my favorite class was of course field biology. I loved the classes where we'd basically go out, catch snakes, amphibians, birds, everything.

Scott Krzywonos: He continued his academic career in the field.

James Major: I took that Emory University degree to the next logical step and I went to the University of Texas in Austin where I was a graduate student in, at the time, zoology.

Scott Krzywonos: He stays on, gets a PhD, is an assistant professor for a while.

James Major: Two years.

Scott Krzywonos: Eventually medical school beckons him.

James Major: But the call of medicine, sort of like the call of the wild, um, I knew inside after about four or five years of being in graduate school that I wanted to go to medical school.

Ranna Jaraha: Did he know he wanted to be an ophthalmologist?

Scott Krzywonos: He did. His dad was an ophthalmologist, so it was in his blood.

Ranna Jaraha: In his vitreous.

Scott Krzywonos: Right, right. It was in his vitreous. Anyway, he knows he wants to be an ophthalmologist. He's not sure if he wants to be a retina specialist.

James Major: When I arrived at Bascom Palmer as a first-year resident, I said, "Oculoplastics is for me. I want to do oculoplastics."

Scott Krzywonos: His mentors at Bascom Palmer Eye Institute are all retina people.

James Major: Carmen Puliafito, Dr. Flynn, Dr. Bill Smiddy.

Scott Krzywonos: It was an exciting time in retina.

James Major: Dr. Rosenfeld was just ushering in the Avastin age and the anti-VEGF era was starting, and I said, "This is the stuff I really like."

Scott Krzywonos: And a friend stepped in.

James Major: John Kitchens said to me, "Look, do you love the lids?" And I said, "Well, I like the lids." And he said, "No, do you love the lids? If you love the lids, you go into oculoplastics."

Scott Krzywonos: It was a one or the other question in the mind of John Kitchens. In his words:

James Major: "Do you like operating outside the eye? Do oculoplastics. Or if you like operating inside the eye, do retina."

Ranna Jaraha: Okay. This is all interesting. A doctor with a passion for birding and PhD in zoology and a love for lids surpassed by a love for the posterior segment. But what's all this have to do with retina?

Scott Krzywonos: Well, it turns out that James's birding skills translated to retina surgery.

James Major: Birding has a term that you can adopt in- into retina in ophthalmology and it's called GISS, G-I-S-S.

Scott Krzywonos: It's an acronym.

James Major: General impression of shape and size.

Scott Krzywonos: James described it this way.

James Major: Once you get good enough at birding, you can see a bird fly past you. You don't really know exactly what color it is or exactly, um, the lighting might be poor, but you know, hey, that's a species A, that's a mourning dove, because you're learning the way it flies, the way it moves and the size of it, the shape of it and how it flies. Uh, or how it sits on a branch.

Scott Krzywonos: Turns out, at least according to James, such a skill is useful in the posterior segment.

James Major: The same exact thing occurs in retina. The more you've seen something, um, you know, the first time you see a retinal detachment you see how that retina is wavy and has a hole in it, you know you quickly learn what it's like and, and learn the nuances or something like early proliferative vitreoretinopathy retinopathy, or PVR, you begin to recognize that early.

Scott Krzywonos: General recognition of size and shape.

James Major: It's really pattern recognition, seeing something one or two times and then being able to repeat that and seeing ag- seeing it again and knowing exactly what it is.

Ranna Jaraha: Fair enough. Seems like an odd connection between birding and retina, but I get it.

Scott Krzywonos: Oh, it gets better, too. Birds start getting involved.

James Major: The first hawk that we looked at was blind in one eye. The eye looked totally normal.

Scott Krzywonos: Back after this.

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Greg Nothstein: New Retina Radio is an independent podcast supported with advertising by Alcon.

Mike Lee: This is Mike Lee at Horton Plaza Park in San Diego, here for the Retina Society 2016 meeting. New Retina Radio is brought to you by Alcon Surgical. Stop by our booth at an upcoming meeting to see how Alcon is advancing vitreoretinal surgery.

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Scott Krzywonos: Hi listeners. It's Scott, here at the replica rainforest at the California Academy of Sciences in San Francisco, where this whole bird story started. New Retina Radio is brought to you by the New Retina MD app, available for smartphone and tablet. Search New Retina MD in the app store, download the app, select the issue you want to read, and then you'll have NRMD on the go. Inside each issue, you'll find exclusive content including videos, news items, and social media opportunities. All right. Back to the birds.

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Scott Krzywonos: Welcome back. I'm Scott.

Ranna Jaraha: I'm Ranna.

Scott Krzywonos: Back to our interview with James Major, birder and retina doctor. Even as a child, he had an interest in birds of prey, also called raptors.

James Major: I've always known that raptors have fantastic retinae. They have two fovea, they have a muscle that actually moves into their cornea and changes the shape of their cornea. In other words, the equivalent would be like having instant LASIK as you walk around.

Scott Krzywonos: They have superior visual acuity.

James Major: Their vision is probably 5/20, meaning what we can see at five feet, small print and really small print at five feet, they can probably see at 20 or 25 feet, if not better.

Scott Krzywonos: Superior cone density.

James Major: They have five times the number of cones, especially in their fovea.

Scott Krzywonos: Which means a superior color palette.

James Major: When you look at a, um, a tree, you see light green, medium green, dark green. They see, light green, medium-light green, darker-light green, light-medium green, et cetera.

Ranna Jaraha: In other words ...

James Major: It's a super eye.

Scott Krzywonos: Remember that James grew up near the Everglades, giving him access to all sorts of birds.

James Major: Growing up in Miami, my scuba diving instructor for when I was a child, his wife was in charge of the bird of prey center at the Miami Science Museum.

Ranna Jaraha: Pretty nice connection for a birder.

Scott Krzywonos: An even nicer connection for a birder ophthalmologist such as James.

James Major: I let my worlds collide by using the spectral-domain OCT, which was an experimental machine at the time, wasn't commercially available, but they were working on that at Bascom Palmer, and I brought these birds of prey through my connections.

Ranna Jaraha: James's connection was just giving Bascom Palmer birds to scan?

Scott Krzywonos: Uh, not quite. These birds had some sort of vision issue.

James Major: The first hawk that we looked at was blind in one eye. The eye looked totally normal.

Ranna Jaraha: How do you know if a bird is blind? Does he move his head strangely?

Scott Krzywonos: You know, I had the same question and James had a pretty interesting answer.

James Major: Well, you could take your hand and as you moved your hand around where their right eye was, they saw nothing and then right as you moved to the left, they would jump, and so they knew he was blind in one eye, even though it looked normal.

Scott Krzywonos: So something was up.

James Major: We imaged that eye and we could see the retinal detachment that he had back there.

Ranna Jaraha: Wait, wait. Slow down. They imaged the eye of a hawk?

Scott Krzywonos: Mm-hmm (affirmative). James described the challenges.

James Major: The hardest part of the study was not the actual imaging. It was concern that their muscle of their iris is skeletal muscle, unlike our muscle, which is smooth, so dilating drops don't work on them.

Scott Krzywonos: They even called in a vet to see if they could use inhalational gasses to dilate the bird. No dice. So they resorted to an old-fashioned method for dilation.

James Major: We turned off the lights and bam, their eyes dilated. Just with the lights off, we could hold their bill gently at the OCT machine and scan their retina.

Ranna Jaraha: What did they find exactly in the blind hawk?

James Major: You get a retinal detachment with subretinal fluid and a strange posterior hyaloid face. We had images of the fovea, which is incredible. They have a different fovea than we do, densely, densely packed. We were even able to look at the choroid a little bit.

Scott Krzywonos: And what did they do for this bird? Nothing to be done, sadly.

James Major: It looked like a chronic retinal detachment, anyway, that probably wouldn't have done well even in a good surgeon's hands.

Ranna Jaraha: They were tame birds, I guess, since they were in captivity.

Scott Krzywonos: Too tame, sometimes.

James Major: The owl, if you scratched the back of its neck, would sit there and would sort of be very, very relaxed. The only problem, if you scratched the back of their neck too much, he would fall asleep. (chuckles) He would start to close his eyes, which is not good for getting the OCT scan.

Scott Krzywonos: All in all, it was a success.

James Major: But anyway, but we got the first images on raptor retina with an OCT available. This has since been published, um, in a book called Evolution's Witness, and in, in another journal, IOVS, on, on these wonderful, wonderful images.

Ranna Jaraha: All interesting, but are there any human implications. I mean, it's not like James is an avian ophthalmologist or could even do anything for the birds after they were imaged.

Scott Krzywonos: Yeah, I know what you mean, but James pointed out something that surprised me: that scanning raptor eyes at Bascom Palmer—which, for a young trainee, married his passions of retina and ornithology—helped build a foundation for animal-model research.

Ranna Jaraha: Mm-mm. (affirmative)

James Major: I ushered in, um, s- using the OCT to, to image small animals', uh, retina. So that was the first time that a small animal, whe- u- in other words, used for experiments, so in the age now of gene therapy, where you need to get an OCT of a mouse or a rat, some of those early findings, um, and the way it was done, have helped to image small animals, which hopefully in the future, will bring gene therapy and other benefits to humans in these clinical trials, which are really coming down the pike.

Scott Krzywonos: James is humble about it.

James Major: I'm sure someone else would have come along with it, had ... you know, hadn't I didn't and I don't know how much I contributed, but it was nice to be one of the first people to do it and to at least help usher in that age.

Ranna Jaraha: Yeah, and he and his Bascom colleagues were still part of that conversation.

Scott Krzywonos: Agreed.

Ranna Jaraha: What did he learn beyond the immediate here?

Scott Krzywonos: What do you mean?

Ranna Jaraha: Like, did he learn something other than the fact that a few birds had some, unfortunately, inoperable eye conditions?

Scott Krzywonos: Oh. Yes he did. Let's let him tell it.

James Major: What it shows me is whatever you do in life, if you have a passion for what you do, be it a hobby or a career, um, you're always going to be happy and good things are always going to come of it. If you work hard and follow your passion, even, you know, a lot of people work at a the certain job or they have a passion in another field. Um, it makes you happy and, and good things come of it down the road, whatever it may be, and you're contributing to that field in a positive manner.

Scott Krzywonos: All right. Well, that's it for this episode.

Ranna Jaraha: I hope you liked our first singles installment.

Scott Krzywonos: Special thanks to James Major for sitting down with us.

Ranna Jaraha: And for being so patient while we produced an episode for an interview he did over a year ago.

Scott Krzywonos: I'm Scott.

Ranna Jaraha: I'm Ranna.

Scott Krzywonos: See you next time.

Ranna Jaraha: Bye bye.

Voicemail: Press two to play new messages.

James Major: Hi, this is James Major and I just got back from a week-long trip to the Galapagos Islands, where I cruised, of course, looking at birds. Um, this is New Retina Radio. It's a production of Bryn Mawr Communications and New Retina MD. The show is produced by Scott Krzywonos with help from Ranna Jaraha and Rachel Kagan. This show was recorded by Andy Leos. It was mixed and edited by Greg Nothstein. Our staff includes David Levine, Megan Beisser, Alicia D’Amato, Laura Geiss, Julie Kassab, Kira Mazurek, Meredith Pollack, and MJ Stewart. Our publisher is Janet Burk. For advertising questions, contact us at NewRetinaRadio@bmctoday.com. It was a pleasure to do this. Thank you so much and I really appreciate the opportunity.

Voicemail: (beep) End of messages.

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Scott Krzywonos: Hey there, listeners. This is Scott outside of the Liberty Bell in Philadelphia, PA. New Retina Radio was brought to you by the New Retina MD app available for smartphone and tablet. Search New Retina MD in the app store, download the app, select the issue you want to read, and voila, you've got retina on the go. Inside you'll find exclusive content, including video meeting coverage from Eyetube.net, news updates and social media opportunities.

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