"The Triumph of Science over Death"
replica of sculpture by Jose Rizal
UP College of Medicine
In any medical school, it is easy to spot the students who will choose to train in Internal Medicine after graduation. They are usually the quiet and studious ones, the ones who are always in the top of the class, the ones who ace exams while we mere mortals struggle to pass; they are self-assured and clear-eyed about their future life as doctors.
They are a special breed who choose to train in Internal Medicine - perhaps the most mentally and physically challenging of specialties in medicine: cardiology, pulmonology, nephrology, hepatology, hematology, oncology, gastroenterology, neurology, infectious diseases and more. The rigorous training needed to become an internist, taking up to 10 grueling years AFTER graduating from medical school, is legendary. These are years of 48-hour days, of sleepless nights, of meals forgone, of family life put on hold, battling fatigue and practically living inside the hospital.
Only the most brilliant ones can become internists. They are the ones who know and recognize the most subtle patterns of thousands of diseases, quickly sifting through mountains of data and filtering them in minutes and making decisions that literally could mean the difference between life and death. They are the ones who you hope will be there when your life is on the line. They, more than any other specialty, are the ones who can truly call themselves “Doctors of Medicine.” Only they can rightfully claim the title of “PHYSICIAN.”
Infectious disease specialists are a particularly remarkable breed. During this pandemic they risk their family and their own lives daily and yet they choose to leave the safety of their homes because they know that this is why they have trained so long and so hard. They know they have prepared all their lives for this moment and they feel compelled to help in whatever way they can. Some even made the ultimate sacrifice of losing loved ones. And still, barely taking time to grieve, they chose to jump right back into the frontlines.
Thus it pains me to see how some of them are now shamelessly vilified, their integrity and competence questioned, and accused of doing all this for the money! I am appalled that they can be so recklessly and ruthlessly exposed to the unfair court of public opinion, totally defenseless.
There is no one among us - doctors, lawyers, professors, engineers, politicians - not one of us can, in good faith, even consider these baseless accusations. It is truly immoral to tarnish these heroes’ hard-earned reputations just to assuage the guilt of knowing that perhaps you were largely to blame for the tragedy that has befallen your family.
No, please do not do this to these people. They don’t deserve this…and we certainly don’t deserve them.
TK Gonzales MD
"Should I be using anti-radiation glasses?”
While the world's attention is on the current pandemic, other health issues may seem trivial. But every now and then some fake news or misinformation captures the popular imagination, becomes sensationalized, which then spreads virally; and naturally, savvy entrepreneurs are quick to take advantage of this for profit.
One such “recent finding” is the alleged danger of blue light “radiation” which emanate from the digital screens we all stare at the whole day - from cell phones, to computer monitors, TV, LED and fluorescent lights. If some of these stories are to be believed, everyone living in the modern world is in potential danger.
These claims arose from some recent studies which suggests that exposure to blue light late at night could alter the body’s biological clocks, the so called circadian rhythm, which can lead to sleep-related problems. Since getting adequate sleep is vital, lack of sleep could conceivably lead to all kinds of diseases. It was not long before someone started selling “anti radiation and blue-light protector glasses”. Literally hundreds of different glasses are sold on amazon, shopee and lazada. Optical shops can’t keep up with the demand.
Sadly, the alleged benefits of using these glasses have not been scientifically proven. Just like food supplements and herbal and natural medicines, the evidence of efficacy is mostly anecdotal and probably due to the well-known placebo effect, since the more likely reason for the lack of sleep is the addictive stimulus from the world wide web itself with the endless torrent of information, entertainment, news, etc. from social media and search engines.
A recent post by the The Royal Australian and New Zealand College of Ophthalmologists or RANZCO reviewed all the reported scientific studies both in humans and animals related to health and exposure to blue light and they concluded that:
The Philippine Society of Pediatric Ophthalmology and Strabismus (PSPOS) have also directly addressed this is issue and have repeatedly posted position statements in social media.
But by now, doctors are resigned to the fact that the public can always choose to believe what it wants despite the efforts of experts. Fortunately the greatest danger from this misinformation is loss of money on the part of the buyer, and, if the placebo effect helps them feel better, then the glasses may be worth every peso spent.
The External Eye Disease clinic is one of the more exciting rotations during our residency in the Department of Ophthalmology in PGH. Our mentor there was a brilliant researcher and teacher who was widely respected for his knowledge and experience. We all looked forward to being mentored by him because we get to see and learn about an enormous number of common and even rare cases just from the sheer number of patients that come to PGH everyday.
It was here that I saw the case of a girl, barely 2 years old who was brought in by her mother because the child's eyes were covered in pus. The lashes were stuck together and the child was clearly agitated. With one look, Dr. Valenton, our consultant, sadly shook his head, “it’s gonorrhea”.
“How is this possible?” I thought. Gonorrhea is a sexually transmitted disease. Was the girl a victim of abuse? No, the mother insisted. Then she claimed that her baby probably just had “sore eyes” or “piskat” because many people in the densely populated urban-poor community where they lived also had “sore eyes”. Piskat is a highly contagious viral infection of the eyes that is transmitted by touching contaminated surfaces or body parts. It is easily passed on among persons who live very close together. And a baby is particularly vulnerable because people love to kiss them. It is not unusual for neighbors and friends to ask to hold the baby or playfully kiss it. Someone with mild sore eyes might have kissed this baby and that's why she also got it. Luckily most cases of “sore eyes” will eventually get better after about a week, even with no treatment. Maybe this child simply had piskat?
“Did you drop urine on your baby’s eyes?” Dr. Valenton casually asked the mother. Yes, yes she did, the mother answered. Treating sore eyes with urine is a common practice in many poor communities because it really does seem to be effective. Personal testimonials of people who got well after putting urine were all the proof needed to make the rather gross practice become widely accepted as a cheap form of folk remedy, instead of the expensive eye drops an eye doctor might prescribe.
The use of urine and many other folk remedies result from a wrong conclusion about many self- limited viral diseases because they will eventually get "cured" if given enough time. Very often the treatment claimed to be the reason for the “cure” actually had nothing to do with it. It was just the natural course of the condition. Most of the time, these folk remedies are not dangerous. For example people also believe that mother’s breast milk is effective in "sore eyes", but luckily there’s little harm from using that. And for many people, urine is much easier to obtain than mother’s milk, so they use that instead. Again, other than it being rather gross, this is not necessarily wrong - if the urine is “clean”. The danger is if the person who "donated" the the urine happens to have gonorrhea. Then this simple folk remedy becomes dangerous. This is what happened to this child.
It was very clear that this baby did not just have “sore eyes”. It looked so much worse. Her lids were swollen, red and fresh pus mixed with the tears coming out of her eyes while she cried. We collected a little bit of her tears and stained it on a glass slide. A quick look under the microscope confirmed Dr. Valenton’s suspicion. The baby had gonorrheal conjunctivitis.
Gonorrheal conjunctivitis or GC is a severe bacterial eye infection which, unlike a viral infection, is usually very treatable with antibiotics, although a few strains have developed resistance to the more common ones. This baby was lucky. Her infection responded to the antibiotics and she quickly got well soon after.
Like “sore eyes” COVID-19 is a viral infection that easily spreads in densely populated communities; and just like most viral infections, almost everyone who gets it will eventually get well, often with mild or no symptoms. But the very fact that most patients get well even without treatment is also why it is so easy for some people to jump to the wrong conclusion and easily believe that the folk remedy they tried is very effective. More and more people try it and those who get well then become the strongest evangelists and proponents of the remedy.
This is why many well-meaning and educated people will swear that “tuob cured them.” They are certain that after doing "tuob", their symptoms disappeared and they got well not realizing that they would have gotten well even if they just rested in bed, stayed hydrated and took some pills for the fever.
"Tuob" or the practice of inhaling steam unfortunately may actually make matters worse for the few who will eventually get severely ill; and because they waited too long before getting serious help, they could die. Also, by sharing the communal "tuob", the chances of spreading the infection becomes more likely among the vulnerable members of the family. And even if they don’t actually have the infection, the danger of burns and accidents from using boiling water just can not be ignored.
Testimonials and stories are what doctors call “anecdotal evidence”. Time and again this has been shown to be the weakest form of evidence in proving the efficacy of any remedy. It often unknowingly causes more harm than good.
The very dangerous pronouncements made by people in government who do not seem to accept that they may be very very wrong about something they are encouraging their constituents to do is the reason why doctors are now raising the alarm about such popular practices.
We can not just sit back and let this kind of thinking go unchallenged. I’ve been in practice for 30 years and until now I still don’t understand why people would choose to believe a neighbor, friend, relative or worse, a politician, instead of practically the whole community of doctors.
It’s uncanny how a baseless superstition can spread as quickly as a viral infection. It makes many doctors want to give up, or for some to lose control and say things they maybe should not have said out of sheer frustration at the seeming futility of it all. But this does not mean that what they’re saying is wrong.
Dr. TK Gonzales
by: Ronald Steven Medalle II
An interesting and rare case that I reported during my residency in the DOH-Eye Center of East Avenue Medical Center was published recently in the first quarter 2020 issue of The Asian Journal of Ophthalmology. This case had already been presented at multiple conferences of various Ophthalmologic societies in Manila in the past 2 years.
The patient had a history of blunt trauma to the eye that initially presented with bleeding but which had been treated successfully. Later, it was observed that her eye pressures were persistently lower than normal and yet, uncommonly, she had no symptoms.
We decided to observe her closely for possible complications. Eventually, she developed a cataract which needed surgery. It was only during the procedure that an abnormal cyclodialysis cleft or an abnormal path for eye fluid to flow was noted. This explained why her eye pressure was persistently lower than normal. By performing an uncommon repair procedure along with cataract surgery the cleft was closed off and her condition resolved. Currently, the patient is doing well with very good vision.
Simple blunt trauma to the eye can lead to many complications, some relatively benign as in this case, but not always. Persons who work in hazardous conditions must use protection at all times. I was fortunate to learn about this rare and successfully managed condition during my residency. I'm especially glad the paper was fit for publication in a prestigious international journal.
When we cautiously reopened our clinics 2 weeks ago, we were hopeful that the worst was over and that we could finally get back to serving you for all your eye care needs.
But it quickly became clear that our optimism was unjustified as the number of new cases of COVID-19 in our community surged faster than expected. Just when we thought the worst was over, Cebu finds itself once again facing the threat of an upsurge of COVID-19.
We fully understand the decision of the government to return to ECQ as a necessary sacrifice to prevent what could be even more suffering in the days to come.
Nevertheless, the members of the ACES Eye Team have all agreed that WE WILL KEEP OUR CLINICS OPEN because many of our patients can no longer delay the treatment they need to prevent losing their sight.
We will remain steadfast in our efforts at minimizing the risk of infection for everyone under our care. ACES Eye Clinic will continue to serve you in Perpetual Succor every morning from Monday to Friday and ACES in MAAYO and Dumaguete will continue to be open during regular hours. To check on your doctors schedule, please go to https://www.aceseye.com/clinic-scheduler.html
If you are unable to come to the clinic, we are also offering ONLINE CONSULTATION at https://www.aceseye.com/telemedicine.html
As a necessary precaution we are asking everyone to please set an appointment before your visit.
Yes, we’re scared too but we won’t turn our backs on you. We’re here for good.
Today, June 19 is the 159th birthday of our National Hero Jose Rizal. This famous painting above shows Jose Rizal, who trained as an ophthalmologist in Europe in the 1880’s, examining his mother. He is doing a procedure that is still commonly done by all ophthalmologists to this day, albeit with more sophisticated instruments. He is looking at her retina and optic nerve,
The retina is an important part of at the eye. It is the innermost layer and it contains the cells that are able to detect light and transform it into nerve impulses which in turn is sent to the brain, allowing us to see. Being such an essential part of the eye, it is very important that the retina be examined closely. But, it’s not that easy.
Since the retina is located inside the eye and the only opening, the pupil, is less than half a centimeter, the inside of the eye is normally in near or total darkness. To see the retina, the examiner must provide a source light as illumination otherwise it will be too dark to see anything inside. The tiny pupil limits how much light can enter the eye at any given time to protect the light-sensitive retina from being overwhelmed. This is why you instinctively blink or even turn away to avoid the glare when someone flashes a very bight light in front of you and why it is dangerous to look at the sun directly.
To make things even harder, the examiner has to peer through the same pupil as that of the source of light, so his line of sight will necessarily have to be in the same path. In other words his line of sight as well as the light source have to be on the same axis, or are coaxial. (see fig.1)
In the painting, the source of light is behind his mothers head. Rizal is holding with his right hand a small concave mirror with an opening in the center. This reflects and focuses the light into a narrow beam that is then directed to the inside of the eye through the pupil. The image of the retina is visible on the condensing lens that he holds in his left hand. Since he is looking through the opening in the center of the concave mirror, his line of sight is now co-axial with his examining light.
Nowadays ophthalmologists, and especially retina specialists still use similar instruments that rely on the same principle albeit more sophisticated thus making the procedure much easier to perform and with less discomfort for the patient and the examiner.
Examining the retina is a very important in a lot of diseases because it allows the eye specialist to see in real life the actual condition of the blood vessels and nerves inside our bodies which otherwise would not be visible. Retina specialists are highly skilled in peering deep inside the eye and enables them to see such conditions as retinopathy of prematurity, ARMD, diabetic retinopathy, retinal detachment, vitreous hemorrhage and many more. Glaucoma specialists and neuro-ophthalmologists also rely on this to see status of the optic nerve. In a way, it allows us a peek into the human brain.
The Trail We Blaze by Dr. Stacey Aquino-Cohitmingao
One of my earliest memories was of mini scrub suits. In the late 80’s, little scrubs were not common. My brother and I would wear them and our parents would bring us around to the hospital. Sometimes we would wait in the lounge, while our dad did his surgeries. My child-like brain knew two things: he was good at what he did, and that he was respected among his peers.
We fast forward to the time when I was I had just passed the Philippine Physician’s Licensure Examination. The question was never “what specialty shall we choose for training?” but “which residency training in Ophthalmology are we going into?” There was no other option. It came down to a choice between my father’s alma mater, the Philippine General Hospital, and the Cebu Velez General Hospital, where he was the immediate past Chairman of the Department. In the end, the decision was made to have my education in close proximity to him, so that he may have a hand in teaching me the skills needed for microsurgery.
Residency was a confusing time. Everyone around me thought that I would get special treatment, being the daughter of the Chairman of the Department. The truth, like most children of doctors will tell you, is that I had a worse time than most. Everyone expected a certain level of performance from you. They expected you to be exactly like your father. On more than one occasion, I was treated rather unfairly; because everyone expected me to get special treatment, they would go out of their way to make things difficult for me, so I “wouldn’t get spoiled”. It didn’t matter that none of these people knew who I was, it was easier to make the assumption. This mind space, combined with my initial lack of interest in the specialty, made me resent Ophthalmology as a whole.
But here I was, a first year resident in Ophthalmology. It seemed to me that I had 2 choices: spare myself the grief, and transfer to another specialty; or be master of this one so that all prior accusations would sound ridiculous. Everyone had a different goal in training. Mine was competence and meticulosity. I knew I wasn’t the most brilliant of students, but I was a dry sponge, and I was ready to absorb everything they were willing to teach me. I would make extra efforts in the subjects that were either uninteresting or complicated. The way I saw it, a lazy genius is worth nothing.
The phrase is “Stand on the shoulders of giants”- most people think it’s to give you leverage, so you can see higher than what you’re currently able to. When I think about it, some people are able to stand on the shoulders of giants. Their responsibility is to make sure that they use their time there wisely, to further learning and achievement; but also, to make sure they know how to balance, so they don’t make the giant fall.
My father blazed an amazing trail, it is my responsibility to keep it going.
It started as a blurred area just a little off the center of my vision, enough to be noticed but not that alarming, I thought. I had similar symptoms before and they disappeared on their own after a while. But this time, it did not. Instead it became steadily worse that by the time I was seen by the retina specialist, it was too late. Age-related macular degeneration or ARMD was the diagnosis, the same condition my father had though his came at a much later point in his life. If I had taken my symptoms more seriously and asked for help sooner, it is possible I could have have ended up with less visual loss.
Macular degeneration treatment breakthroughs inspire hope that someday we may see a cure to this disease. Promising treatments depend upon the stage of disease progression.
Learn more about ARMD here
ACES in preparation for the New Normal
In the last two and a half months we have all experienced the effects the COVID19 virus that have impinged on our freedom, safety and emotions. Most occupations are affected in various ways but the Medical Profession probably remains the most exposed to the hazards of getting infected. Thankfully Medical experts all over the world have refined guidelines to adapt in order to make the Eye Center patient encounter as minimal a risk as possible.
At ACES we wish to provide an environment that is safe for the patient and of course our staff and doctors. So we have collated guidelines from DOH, DOLE, DTI, The IATF and our Hospital’s (Perpetual Succour Hospital).
A team was created to adapt these to our center. In addition, a Safety Protocol Officer was appointed to oversee employees’ health monitoring and data collection. Prior to opening, our physical premises were sanitized. Foot mats, Disinfectants, scheduled UV sanitizing schedules were set in place. A rule was set that EYE MDs coming from the same household must have the same work schedule. And that teams working on different half days must not meet - to ensure no cross contamination of the working EYE MDs.
Frequent washing of hands by our professionals and personnel, regular wiping down of our equipment, limitation of patients per hour will complement the ACES personal touch.
For patient appointments, verbal triaging is to be done ideally when he or she calls for an appointment to screen for any COVID 19 risk factor.
Until we find the vaccine, The ACES Team is here to make our visit as safe and as satisfactory as ever…
Taken at the first clinic hour of the first day after the ECQ. June 1, 2020.
Twenty five years after opening the first ambulatory surgical and laser center in Velez Hospital, the ACES EYE Referral Clinics transferred to its new location on the 10th floor of the brand new and ultra modern Velez Medical Arts Building along Ranudo St. beside casino Español. It is just a few meters away from the old clinic but it is a major step forward in the delivery of eye care in the region. Boasting three levels of parking, the new building is serviced by high speed elevators leading to an efficiently designed new clinic with ample waiting areas, wide corridors, large examining rooms, and the latest in high tech diagnostic and tnerapeutic equipment .
There are two state of the art operating theaters equipped with sophisticated machines designed to deliver the highest quality of cataract, retina and other major and complex eye surgeries.