Dr. Cheung’s Blog 4/6/2016

Dr. Cheung’s Blog 4/6/2016

April 9, 2016

Some might claim that compassion and empathy cannot be taught

One of my greatest pleasures is reading fiction.  A good novel can be as exhilarating as a roller coaster ride, as beautiful as a rain forest in dawn’s light, and as wretched as a sick puppy.  On a cold rainy day when I am not in the office, there is nothing more I rather do than to curl up with a new book.  For the past seventeen years, I have been a member of a book group with three other physicians and their spouses.  We are a diverse group – different upbringings, religious beliefs and political affiliations – joined only by our love of literature and medicine.  We love books from foreign lands as they transport us to exotic places and times and give us a glimpse of the cultures and histories.  We learned much about India from V.S. Naipual, Virkam Seth, Arundhati Roy and the great Salman Rushdie.  We explored South Africa through the eyes of Nadine Gordimer and J.M. Coetzee.  And we blitzed through Latin America with Gabriel Marquez, Juan Gabriel Vasquez and Isabel Allende.  Out of the nearly one hundred books that we have read, two really resonated with me as an ophthalmologist: Blindness by Jose Saramago and All The Light We Cannot See by Anthony Doerr.

In Blindnessan epidemic of “white” blindness broke out in an unnamed city.  An ophthalmologist who saw the first patient who was blind from this mysterious condition became affected too.  All those afflicted were quarantined and sent to an overcrowded asylum.  Living conditions quickly degenerated and along with it, basic human decency.  Saramago brilliantly used physical blindness as a vehicle to moral blindness.  “Fighting has always been, more or less, a form of blindness.” he noted.  While physical blindness is largely out of our control, moral blindness is entirely voluntary: “blindness is a private matter between a person and the eyes with which he or she was born.”  In the end, the mysterious blindness spontaneously resolved and those who survived the ordeal left the asylum irrevocably changed: “I don’t think we did go blind, I think we are blind, Blind but seeing, Blind people who can see, but do not see.”  Saramago’s style is haunting.  His characters have no names and one paragraph can go on for pages with scant commas and punctuations.  This novel still haunts me even though I read it sixteen years ago.  What is my role as an ophthalmologist to the spirit of a patient who has gone blind physically?  Am I failing my art if I let that human spirit go dim too?  Is it an equal failure to my patients who see perfectly fine but blind to the beauty around him?

I read All The Light We Cannot See last year after a patient, a retired librarian, recommended it to me.  Doerr beautifully interlaced the lives of two young characters during World War II, a French girl (Marie –Laure) who went blind from congenital cataract at the age of six and a German orphan boy (Werner) who had a special talent with radio repair which earned him a place at Hitler’s youth academy.  Just as light can physically alternate between a wave form and a particle form, Doerr alternated between the two characters chapter by chapter until their lives converged in Saint Malo, France in the last days of the Nazis campaign.  To me, this book is about humans trying to do good to one another, even in the worst circumstances and light is the metaphor of this pure goodness.  Doerr possess perhaps the best ability to describe blindness in literature.  He wrote:  “What is blindness? Where there should be a wall, her hands find nothing. Where there should be nothing, a table leg gouges her shin. Cars growl in the streets; leaves whisper in the sky; blood rustles through her inner ears. In the stairwell, in the kitchen, even beside her bed, grown-up voices speak of despair   He also aptly depicted the hyper acute senses experienced by blind persons: “To shut your eyes is to guess nothing of blindness. Beneath your world of skies and faces and buildings exists a rawer and older world, a place where surface planes disintegrate and sounds ribbon in shoals through the air.  Marie-Laure can sit in an attic high above the street and hear lilies rustling in marshes two miles away….”  For an ophthalmologist, his words are pure gems.

Reading eye related journal articles is a whole different matter.  Most scientific journal articles are written in a dry, formulaic, passive voice that is sure to put the readers into deep slumber.  However, when a great article comes along, its brilliance can shine through like a gem beneath a dull luster.  One such article was just published last week in the March 2017 issue of Nature entitled “Lens Regeneration Using Endogenous Stem Cells With Gain Of Visual Function” by a group of investigators from UC San Diego and China.

Stem cells are special cells that retain the capacity to differentiate into various cell types.  These investigators found that the stem cells in the lens are located on the front surface of the lens, just underneath the anterior capsule.  When these stem cells migrate to the equator of the lens, they start to differentiate into clear lens fiber in a highly organized pattern to form the crystalline lens.  Several factors such as PAX6, SOX2 and BMI-1 appeared to play an important role in the proper functioning of these stem cells and to prevent cataract formation.

Traditionally, when we remove cataracts, whether in infants or adults, we first create a round opening of about 5.0mm in the anterior capsule to gain access to the cataract.  This approach would therefore destroy most or all of the stem cells in the lens.  These investigators devised a new method in removing cataracts by creating a small openingg of 1.5mm in the peripheral part of the lens, thereby preserving the stem cells.  With this new method, they observed that the stem cells can regenerate a functioning lens in rabbit by seven weeks and in young monkey by five months.

Encouraged by the animal studies, the same group of investigators also tested this new cataract technique in 12 human infants afflicted with congenital cataracts in both eyes and compared it to 25 infants with congenital cataracts removed in the traditional technique.  Three months after surgery, a functioning lens was regenerated in the experimental group and nearly all the lens remained clear (95.8%) at six months without any other significant complications.  These regenerated lenses have the ability to accommodate – varying focus depending on the image distance which cannot be accomplished with an artificial lens implant even if one were put in an infant.  Additionally, these regenerated lens are expected to grow with the child as opposed to a static implant.

This is a fascinating article and its potential impact on eye care can be huge as over 20 million cataract patients undergo surgery each year.  The same stem cells have been shown to be active in adults suggesting that lens regeneration may be a possibility in the elderly population.  However, age-related adult cataracts tend to be much harder in consistency and will be difficult to remove through a small opening.  Collateral damage to the stem cells may also occur with prolonged surgery times or ultrasound energy.

Lens regeneration may be a subject of science fiction just a decade ago but is now a definite reality.  The power of science to transform our lives is immense and concrete.  I believe, however, that the transformative power of arts is equally potent, albeit more subtle.  Some might claim that compassion and empathy cannot be taught.  They are something that one is born with.  I disagree.  I think that compassion and empathy can be learned through arts and that is one way that arts can save lives.  A gifted writer can develop characters that are so real and palpable that we might as well posse them.  We feel his pain, joy, anxiety, regrets, longings etc – that is real empathy.   I know what blindness is and its many causes.  But it is the genius of Saramago and Doerr that helps me understand what blindness feel like.  It helps me understand the person who is sitting on my exam chair or lying on my operating table.  That’s a pretty powerful tool and that is why I’ll keep reading good fiction.