The Lost Art of Retinal Drawing
by Stephen R Russell and LuAnn Dvorak
Review by Mark Cohen, MD
Most physicians are familiar with direct ophthalmoscopy, which produces an upright, unreversed, and virtual image of approximately 15 times magnification. Binocular indirect ophthalmoscopy produces a stereoscopic inverted, reversed, and aerial image of 2 to 5 times magnification (depending on the power of the field lens) between the patient and examiner. The advantages of the direct ophthalmoscope are its relative portability and the ease of learning its use. Its disadvantages are a flat image and an inability to view the anterior fundus. The main advantages of the binocular indirect ophthalmoscope relate to its ability to view "the big picture" stereoscopically and, with manual depression, the ability to see out to the ora serrata and sometimes further. The biggest disadvantage is learning to master the techniques that require use of both hands simultaneously, a steady hand, and good hand-eye coordination.
To this end Charles Schepens, who is most responsible for popularizing the indirect exam, taught and required by example the meticulous drawing of all the structures and abnormalities viewed. His method was adopted by most, if not all, ophthalmic training programs. Considering that in using this technique the examiner is seeing the image upside down and backwards, accommodation is made by having the patient lie down on a Gurney with the clipboard holding the drawing paper placed upside down on the patient's chest. An array of colored pencils is used to draw the structures and pathology. Such examination, especially when indenting the globe through the eyelids to view the periphery, may take an hour or more, especially when learning the technique. In recent years, with the advent of vitrectomy and other modern tools and techniques, there is no longer a need for detailed drawings in the operating room. Because of this and economic necessities, retinal drawing has become "The Lost Art."
As the authors point out, these drawings were considered so precious that at the University of Iowa they were kept separate from the patients' records. When Stephen R Russell, MD, returned to become the Director of the Vitreoretinal Diseases and Surgery Service in 1997 (where he had completed his retinal fellowship in 1988), he wondered what happened to those old drawings. By serendipity they were rediscovered when an employee from a storage facility asked if they could be destroyed. The Lost Art of Retinal Drawing is the product of a loving endeavor, previously documented in The Permanente Journal.1 The authors tell the story well and have accompanied the drawings with the personal anecdotes of their creators who all cherished memories of this golden era. As I read this book and hovered over the drawings, my mind wandered back to my own time of learning. What I remembered was a shared intimate experience with the patient. Because of the time needed and the necessary discomfort caused by the exam, I needed to reassure my patient that this effort would insure the best possible outcome. We also were able to explore and discuss expectations and fears; in short getting to know the person, not only the pathology. In the end I was also proud to put my signature on my drawing, which was an outcome of practicing the art of medicine. To paraphrase the authors' summary, in the efficiency of modern medicine are we in danger of trading our role as healers to that of technicians? This book should be a welcome addition to any medical library and to anyone with an interest in medical history.
1. Dvorak LA, Russell SR. Retinal drawing: a lost art of medicine. Perm J 2011 Summer;15(3):74-5. DOI: https://doi.org/10.7812/TPP/11-101.