Un Chien Andalou (1929)

The descriptive phrase for Luis Bunuel's Un Chien Andalou "French surrealist silent film" seems like a repellent trifecta of adjectives to describe any cinematic experience. At one point or another in everyone's undergraduate experience, this avant-garde sixteen-minute free association movie gets inflicted on the classroom (twice for me), and there are always a couple of asshole students who go on and on about the "beauty" of images of rotting donkeys or ants crawling out of hands.

But of course, the most striking and famous image occurs within the first 45 seconds, making the list of Premiere magazine's "25 Most Shocking Moments in Movie History." The husband draws a razor blade across the left eye of the calmly seated wife, with interspersed images of a thin cloud "slicing" over the moon.

As a special effect in 1929, this eyeball cutting comes across quite convincingly. I read that it was actually a cow eye, with heavy lighting and exposure changes to make the animal fur look like skin. The corneoscleral laceration is seen in close-up, along with the prolapsing vitreous (the "jelly" of the eyeball.)

Here's a teaching point on penetrating ocular trauma from an eMedicine article:

Predicting the visual outcome in patients with corneoscleral lacerations is difficult. The outcome is generally poor in patients who have poor visual acuity at presentation, in patients with delayed presentation, and in patients who sustain agricultural-related injuries.

We never get to see any actual outcome of the wife's unfortunate eye trauma, even in the scenes that are supposed to be eight years later (Huit ans apres.) She appears totally unaffected by the razor injury.

Check out this story of about the premiere of the movie, from the Wikipedia entry:

Given the general distaste for surrealism among the French public, Buñuel and Dalí carried sacks of rocks in their pockets on opening night as self-defense, expecting a negative response from the audience. They were disappointed when the audience enjoyed the film, making the evening "less exciting", according to Dalí.

I don't know if Un Chien Andalou made me quite angry enough to throw rocks. It is a mercifully brief movie, and captured an artistic movement in a way that is probably hard to fully grasp many years down the road. And again, the ocular special effects are quite impressive for the time period. In writing the script, Bunuel wrote "no idea or image that might lend itself to a rational explanation of any kind would be accepted", and commenting on the imagery- "Nothing, in the film, symbolizes anything."

Grading the ungradable? I'll bite- this dog gets a C - .

But don't take my word for it- watch what Roger Ebert calls "the most famous short film ever made" online here!

The Unborn (2009)

Don't be fooled by this promotional poster, people! The Unborn, starring Odette Yustman as Casey Beldon, is kind of boring and unappealing. The movie does contain a few interesting scenes, though, and most of them revolve around ophthalmology.

Surely you remember learning about Josef Mengele, aka The Angel of Death, in high school. This Nazi physician at Auschwitz was apparently obsessed with twins, and used them in terrible experiments in concentration camps. The experiments included intraocular injections of various chemicals in an attempt to change eye color.

This real-life historical horror movie provides the back-story for The Unborn, and one of these injections is shown in a flashback sequence. As you might imagine, chemical injections in the eye can cause some major complications, and corneal clouding is seen in the victim in later scenes.

However, the most interesting eye-related content involves Casey Beldon's changing eye color and her subsequent evaluation by an ophthalmologist, Dr. Lester Caldwell. We covered iris heterochromia in an earlier Ophthalmology in Film entry, but to review:

Iris heterochromia may occur as a congentital condition (usually inherited as an autosomal dominant trait), or it may be acquired as a result of retained intraocular foreign body, topical medications, iris neoplasm, ICE syndrome, Fuchs' heterochromic iridocyclitis, Horner's syndrome, chronic iritis, juvenile xanthogranuloma, leukemia, or lymphoma.

I'll try to avoid a spoiler by letting you pick among the differential diagnosis list for our protagonist! Ophthalmology scenes in this movie include the aforementioned intraocular injection, an exam and consultation by the ophthalmologist, insertion of an eyelid speculum, and slit lamp photography.

The fact that I fell asleep twice during the climactic exorcism scene is telling. This meandering movie has some interesting historical tidbits and some strong eye-related content, but otherwise is a mishmash of disturbing images and horror cliches. I give The Unborn a C - . But don't just take my word for it, here is a quote from Wikipedia to wrap up this entry:

The Unborn received an overwhelmingly negative reaction from critics. Based on 96 reviews collected from notable publications, the film garnered a "Rotten" rating of 13% on review aggregator Rotten Tomatoes.

Ice Age: Dawn of the Dinosaurs (2009)

Ice Age: Dawn of the Dinosaurs represents a modern 3-D homage to Herman Melville's Moby Dick, or a maybe it's just outright plot theft. A one-eyed weasel named Buck obsessively guides the old Ice Age gang through the jungle to find Rudy, an enormous white theropod dinosaur. A flashback scene shows the prior conflict between Buck and Rudy, where the dinosaur's talon strikes Buck's right eye. Fortunately for kids, the violence is only suggested here, rather than graphically depicted. Buck manages to patch his eye with a leaf, and narrowly escapes with his life.

Like Captain Ahab's whale-bone peg-leg, Buck's signature eye patch symbolizes his unending quest to vanquish his foe. Check out Ahab's rage here in Moby Dick:

The white whale tasks me; he heaps me. Yet he is but a mask. 'Tis the thing behind the mask I chiefly hate; the malignant thing that has plagued mankind since time began; the thing that maws and mutilates our race, not killing us outright but letting us live on, with half a heart and half a lung.

While we're quoting material obliquely related to Ice Age 3, how about a quote from the United States Eye Injury Registry?

Data from the National Center for Health Statistics' Health Interview Survey, conducted in 1977, estimated that nearly 2.4 million eye injuries occur in the United States annually. This report calculated that nearly one million Americans have permanent significant visual impairment due to injury, with more than 75% of these individuals being monocularly blind. Eye injury is a leading cause of monocular blindness in the United States, and is second only to cataract as the most common cause of visual impairment. USEIR estimates that 500,000 years of lost eyesight occur annually in the United States. Injury is the leading cause for eye-related hospital admissions.

A wonderful reminder about the importance of eye safety and the use of eye protection.

Ice Age 3 is a hyperkinetic family flick with a reasonable semblance of a plot pilfered from a great American author. There are a handful too many characters and their development subsequently suffers, but ultimately this forgettable movie achieves its modest goals. I'll give it a B - . Herman Melville's Moby Dick? An A - . Go dust off your high school copy, pull that bookmark out from Chapter 6, and give it another honest go.

Valkyrie (2008)

I'm not sure what it is about Tom Cruise and cosmetic contact lenses, but he certainly seems to get a lot of mileage out of them. A subconjunctival hemorrhage in Days of Thunder (1990) and freaky undead eyes in Interview with the Vampire (1994) immediately come to mind. His most recent DVD release, Valkyrie (2008), piles on to his impressive resume of ocular special effects.

In this historical drama, Cruise plays Claus von Stauffenberg, a disenchanted colonel in Adolf Hitler's army who organizes an assassination attempt on the Fuhrer. Early on in the movie, British fighters strafe Stauffenberg's unit in Tunisia, which leads to his left eye enucleation (removal of the eye), along with some extensive hand injuries. The rest of the movie chronicles Stauffenberg's crafty strategy to blow up Hitler and regain political control of Germany (um, spoiler alert, he fails.)

Along the way, though, fans of ophthalmology see some remarkably accurate representations of ocular prosthetics and the use of eye patches, both the cosmetic "pirate"-type patch, and the therapeutic pressure patch. Unlike the enucleation portrayal in Slumdog Millionaire, Valkyrie gets all the details right. Perhaps the most common misconception I come across is that the ocular prosthetic is the whole eyeball, when in reality, an orbital implant is usually inserted deep in the socket immediately after removal of the eyeball. As far as the prosthetic, here's a description from Will's Eye Hospital:

The cosmetic artificial eye (ocular prosthesis) is a plastic device that is molded to fit between the eyelids over the conjunctiva that covers the ball implant. This prosthesis is generally made two to six weeks after enucleation, in order to allow the socket tissues time to heal adequately. Prior to that time, a thin plastic plate (conformer) is usually worn in place of the prosthesis. This conformer helps to prevent shrinkage of the space between the inner surface of the lids and the conjunctival covering of the ball implant. Until the ocular prosthesis is fitted, the upper eyelid may be droopy. The prosthesis supports the eyelid and generally allows the lids to open and close normally.

OK, enough eyeball talk. Valkyrie got generally panned unfairly by the critics, and I'm not just saying that because of the eye-related content. It portrayed an under-recognized part of World War Two history, was beautifully shot, and managed to maintain some element of mystery and suspense despite viewers knowing about the doomed plot from the outset. My crticisms would be about elements of character development and understanding motives, and my own inability to distinguish some of the main characters and their shifting allegiances. Hey, all those Teutonic Nazi officers look the same to me, what can I say?

This one gets a B from me, and worth a look for the eye content alone. Trust me- there's one unforgettable scene with Cruise's prosthetic and a cocktail!

Sex and the City (2008)

"The horrors of presbyopia." I heard this common refrain from one of our attending physicians during training, who warned us over and over about the onslaught of patients who would soon be staring over their glasses at us in the exam lanes, complaining about their increasingly annoying inability to focus clearly to read.

This malady affects everyone over time, and patients become symptomatic between the ages of 40 to 45. The simplest solution is to wear reading glasses and/or bifocals, and I am sure you can guess what sort of looks the 40-something new-onset presbyopic women give me when I present this information.

Sex in the City (2008), the movie version of the popular HBO television series, depicts presbyopia as a metaphorical transition to old age- an adjustment of life expectations and acceptance of circumstance. Carrie, played by Sarah Jessica Parker, steals Mr. Big's reading glasses while trying to read a book on historical love letters. Later in the movie, when one of her gal pals holds up an object for Carrie to read, she pushes it further away to see it clearly.

Although presbyopia is far from glamorous, it is a subject that ophthalmologists and patients must deal with on a regular basis. Sex in the City manages to give the viewer a few well-placed scenes of near vision difficulties. As for the rest of the movie, I thought two key parts were very funny, and the movie was kind of long. The end wrapped too neatly, with the requisite Doogie Howser-like voice over. I am going to give this one a B

Slumdog Millionaire (2008)

As if portrayals of Mumbai slums, massacres, and torture weren't difficult enough to watch, Slumdog Millionaire depicts a bilateral enucleation (removal of the eye). The procedure ostensibly increases the pitiful nature of the street urchin beggar, and therefore increases their profitability. As you can imagine, this procedure is performed quite differently in normal ophthalmology practices. As a rule, informed consent is obtained first, and enucleations are generally performed under general anesthesia in a sterile operating room environment.

In the film though, one similarity was the use of instruments. Although crude, the instrumentation was not totally unlike what is found on an enucleation surgical tray. Here's a picture of the Wells Enucleation Spoon.



I'm not sure if there were budgetary constraints or if the concept of enucleation wasn't totally clear to the director, but when we later see the victim, both eyes are clearly still there, albeit with corneal and periorbital scarring.

It can be tough to judge a movie after hearing about all the hype, but I certainly appreciated the scope and look of Slumdog Millionaire. There are some scenes with top shelf acting, too. I believe Danny Boyle overdirects moments here and there, and the story itself can stretch credulity if you think about it too much. This reviewer's final answer: B + , chai walla!

Twilight (2008)

If you are looking for a Hollywood depiction of how to perform a lousy pupil exam, look no further than the teen Vampire romance Twilight. After nearly being struck by an out-of-control van, we see our heroine Bella Swan being evaluated in the emergency room. The doc working in the ER does a cursory penlight pupil exam, presumably checking for anisocoria (unequal pupil size) in the setting of possible head trauma.

I can't really criticize the depiction of this exam for two reasons. First, the doc is actually protagonist Edward Cullen's father, and he pretty much knows that his son rescued Bella from any harm. His exam is more about appearances and going through the motions. Second, in my experience, this type of quick and poorly performed eye evaluation is, unfortunately, quite typical in the emergency room setting. Note the doctor's improper instruction for Bella to fixate on his hand near her face, which would stimulate her accommodative pupil response. Further, he assesses the direct pupillary response bilaterally, but fails completely to perform the essential Marcus Gunn pupil exam. The viewer is referred here for instructions on how to properly perform and document the pupil exam.

As a movie, though, Twilight is a triumph of casting, and manages to achieve a good balance between teen romance and semi-action flick. I particularly liked the first half and the well-acted awkwardness by Bella. This one gets a B from me. Let's hope for some more ophthalmology content in the sequels!

Blindness (2008)

If At First Sight is the Citizen Kane of ophthalmology movies, Blindness weighs in as The Battleship Potemkin. Mark Ruffalo portrays an ophthalmologist, and his wife, played by Julianne Moore, is the protagonist. The movie is based on Nobel prize-winner Jose Saramago's compelling (but puncutation-challenged) novel about epidemic blindness that suddenly sweeps through a large city.

Early scenes revolving around this mysterious affliction depict the ophthalmologist examining one of the patients with a slit lamp, and performing keratometry. The film treats the viewer with other scenes from the ophthalmologist's office, including refraction of an amblyopic boy, and administration of eyedrops to a young woman with bilateral conjunctivitis. Later in the movie, a Braille typewriter is used by a nefarious member of the tyrannical Ward 3. I'll try to avoid delivering too many spoilers, but obviously there are other numerous depictions of blindness and low vision throughout.

Like the movie At First Sight, an interesting premise and loads of eye-related content do not necessarily guarantee an enjoyable film. Pacing was erratic, and despite an excellent cast, much of the acting came off as overly theatrical. In addition, the intrusive and incongruous soundtrack proved distracting. As a bonus, however, the film did show a whippet on screen for three seconds as a blind person's companion dog. Including a beloved sighthound in your movie is a sure way to score points with this reviewer. Blindness gets a C + from me.

I would be interested in hearing other opinions about this movie, both from those who have read the novel and those who have not!

Master of the Flying Guillotine (1975)

Attempting to work the ophthalmology angle on the Kung Fu classic Master of the Flying Guillotine is a tall order, but I just had to direct some attention to this bizarrely entertaining movie. Some of you might remember my favorite TV show, Kung Fu Theater, where they would run these poorly dubbed martial arts movies after the Saturday morning cartoons finished up. I think I must have seen this movie repeat four times on Kung Fu Theater over the years.

The central character is a blind master whose weapon of choice is the flying guillotine. This thing looks like a small salad bowl with sharp knives lining the edge, attached to a chain. The blind guys throws the bowl over the heads of his victims, yanks on the chain, and the blades close up and decapitate him. He seeks revenge on the one-armed boxer who killed his two students, lopping off several heads along the way.

The movie features an amazingly hip soundtrack (apparently with nonlicensed use of songs), exceptionally poor and erratic dubbing, a weird fighting tournament showcasing various fighting styles, and crazy fake facial hair and eyebrows.

Ophthalmology-related content includes a scene of bilateral eye gouging during the fighting tournament, and of course, the blind title character. Accurately tossing the flying guillotine without being able to see would sharply limit its lethality for most, but the Master skillfully relies on his other heightened senses of hearing and smell. At one point, he tracks the injured one-armed boxer by "smell[ing] blood."

I tried running a quick PubMed search for articles on blindness and extrasensory recruitment, and glazed over at the murky hodgepodge of neuropsychology and developmental biology journals. I think the jury is still out, but it appears to be an area of active interest. Here's part of an abstract from a 2008 article from Beth Israel Deaconess Medical Center and Harvard Medical School:

The loss of vision has been associated with enhanced performance in non-visual tasks such as tactile discrimination and sound localization. Current evidence suggests that these functional gains are linked to the recruitment of the occipital visual cortex for non-visual processing, but the neurophysiological mechanisms underlying these crossmodal changes remain uncertain. One possible explanation is that visual deprivation is associated with an unmasking of non-visual input into visual cortex.

This kind of verbiage never fails to make me sleepy, and I believe you can get pretty much the exact same information by just watching the amazing abilities of the Master of the Flying Guillotine.