click! Photography Changes Everything

Michael Kelly, ophthalmic photographer, explains how detailed photographs of the eye transformed the field and practice of ophthalmology.

“The eye is like a camera, and the retina is the film.” As I listened to the doctor explain to my father that he had suffered a retinal detachment, I—even as an eight-year-old—began to grasp the severity of the situation. The analogy was perfect. The photographs the doctor showed us, comparing a normal retina to that of a detached retina, helped us to understand; I giggled inside, thinking of a camera taking a picture of a camera. A split-second later, the bad news: “Mr. Kelly, you will probably lose most of the vision in that eye.” And, indeed, he did.

Fast forward. Retinal surgery and treatments have evolved and changed, as has photography. The retinal photographs that simultaneously helped both a 53-year-old and an 8-year-old understand what had happened—I found out a decade later—were only one small application of the art and the craft of ophthalmic photography. There I sat fresh out of photography school on day-one of my first real job in my chosen field and the doctor/employer was saying “the eye is like a camera, and the retina is the film;” I smiled, because I already knew this. What I didn’t know, and was about to learn, was extraordinary. He continued. “We, you, can take retinal photographs in a rapid sequence as a fluorescent dye is injected into the patient’s arm. Within seconds, the dye travels to the eye, where the abnormal blood vessels are, and the photographs taken then are used to determine the treatment, which can save that person’s vision.” I was blown away.

The human retina has been documented photographically since 1886. But in 1960, Harold Novotny, a medical student, and David Alvis, M.D., an intern, introduced a way of photographing the circulation of blood in the human retina using sodium fluorescien dye and a ZEISS retinal fundus camera, a low-powered microscope with a camera attached. Their ground-breaking work shed new light on the pathophysiology of retinal disease and forever changed the way ophthalmologists and scientists viewed, studied, and treated the innermost layer of the eye.

For almost 100 years retinal photography had been limited to magnified fields of view that only showed 11% of the retina in each picture. Then, in another advance in 1992, Douglas Anderson and his company Optos developed an ultra-wide angle imaging device that was able to capture 82% of the retina in one image. Anderson’s motivation was simple: his five year-old son had gone blind in one eye when a retinal detachment was detected too late; he did not want this to happen to another child. Although his son had been having routine eye exams, they were uncomfortable, especially for a child, which made it impossible for the doctor to view his entire retina. To date, over 10 million patients have been imaged using these patient-friendly photographic devices, which have often allowed doctors to detect peripheral retinal disease that may not have been seen using standard retinal cameras.

In ophthalmology, you can’t treat what you can’t see. When ophthalmic photography went from being documentary to diagnostic it changed the practice of ophthalmology and subsequently saved the vision of millions of people worldwide. Abnormal retinal blood vessels that were always suspected could now be delineated photographically using fluorescein dye. Once found, laser photocoagulation (the application of a laser beam to purposely burn intraocular tissues) was used to seal-off the abnormal blood vessels, preserving vision. As photography moved from film to digital, the more sensitive digital imaging technology allowed use of another type of dye to ‘see’ through the retina and photograph the hidden vessels beneath. This made laser photocoagulation possible for another segment of patients previously considered untreatable.

Ophthalmic photographers document all tissues of the eye using a variety of lighting techniques, high-magnification cameras, filters, dyes, and creativity to make eerily beautiful images that add to the understanding of each patient’s ocular disorder. Photographs of the eye help educate not only patients and their families, but also the next generation of ophthalmologists who will no doubt use photography in expanded ways to provide even better, more effective treatments for those who suffer from blinding eye disease. Photography not only changes the way we look at the world, for some it allows them to continue to see the world.