The Crash Reel (2013)

 

What E.T. the Extra-Terrestrial (1982) lacked in ophthalmology content, it made up for in emotional punch, choking up this then eleven year old viewer with empathy.  The Crash Reel, a new HBO documentary, hits home with incredible portrayals of tragedy and heroism, and prominently features ophthalmology to deliver the total package.

 

Kevin Pearce, world-class snowboarder, suffers a horrifying crash during a half-pipe training run in Park City, UT in 2009. The documentary chronicles Pearce's rise to fame, his recovery, and the subsequent challenges faced by him and his impressive family.

 

 

 Unfortunately, the type of injuries suffered by Pearce are not unfamiliar territory for practicing ophthalmologists. He sustains left orbital fractures (facial CT scans shown in the movie), intracranial hemorrhage and traumatic brain injury, a described but not shown traumatic mydriasis, acquired nystagmus, and a cranial nerve palsy which leaves him with persistent diplopia (double vision). The diplopia treatments shown run the whole gamut, and include occlusion filters, Fresnel prisms, prism glasses, vision therapy, and eventual strabismus (eye muscle) surgery. Pearce's ophthalmologist is shown reviewing some aspects of the informed consent process, and footage from inside the operating room and later in the post-op recovery area (see below) documents the first major film to feature strabismus surgery that this reviewer has ever seen.

 

 

Since The Crash Reel was released two weeks ago on HBO, I do not want to get into too many of the specific non-ophthalmic details of Lucy Walker's riveting and multi-faceted documentary. Ophthalmologists and non-ophthalmologists alike will be thrilled and challenged by what may very well be the best movie I have seen so far this year. A .

I Love You, Beth Cooper

With the one-two punch of the Thanksgiving-Christmas holiday combo rapidly approaching, the high school comedy I Love You, Beth Cooper serves up a timely eye safety message.

The movie opens up with the class valedictorian, Denis, delivering a graduation speech professing his secret love for the popular cheerleader, Beth Cooper.  Wouldn't you know that wacky antics ensue, and that, against all odds, these two crazy kids manage to get together?  I'd put a spoiler alert warning before this brief recap, but I think you'd be justifiably insulted by it!

The above-mentioned antics kick off with a cork flying out of a champagne bottle and toward Denis' right eye.  Incidentally, the bottle is provided with parental approval, and the father of Denis is acted by that guy who played Cameron, the friend in Ferris Bueller's Day Off.  Champagne cork injuries to the eye are actually somewhat common, and can be devastating.  From the British Journal of Ophthalmology 2004:

Among [eye injuries from] bottle tops, the champagne bottle cork remains the main culprit. A 750 ml champagne bottle contains 4.125 litres of carbon dioxide with a pressure of 6.2 bar—almost three times higher than a typical car tyre’s (Champagne France Information Bureau, 2002); this can shoot the 30 g cork up to 13 metres. The blinking reflex offers no help: from the typical opening distance of 60 cm, the cork needs less than 0.05 seconds to reach the eye.

Fortunately for Denis, the cork impacts his right orbital rim, rather than the globe, and he escapes serious ocular injury.  Unfortunately for the viewer, this means that the movie continues its absurd storyline, rather than perhaps a more interesting plot involving a trip to the emergency room, and an engaging consult with a friendly ophthalmologist.

Most champagne bottles in the US apparently "carry conspicuous warning labels explaining the dangers to the eye and showing the correct way of bottle opening."  I can't verify this at the moment, but I'll check on it the next time we open a bottle.  From a press release by the American Academy of Ophthalmology, here are some tips on opening a bottle of champagne properly:

• Make sure sparkling wine is chilled to at least 45 degrees Fahrenheit before opening. The cork of a warm bottle is more likely to pop unexpectedly.


• Don’t shake the bottle. Shaking increases your chances of eye injury.


• To open the bottle safely, hold down the cork with the palm of your hand while removing the wire hood. Point the bottle at a 45-degree angle away from yourself and from any bystanders.


• Place a towel over the entire top of the bottle and grasp the cork. 


• Keep the bottle at a 45-degree angle as you slowly and firmly twist the bottle while holding the cork to break the seal. Continue to hold the cork while twisting the bottle. Continue until the cork is almost out of the neck. Counter the force of the cork using slight downward pressure just as the cork breaks free from the bottle.


• Never use a corkscrew to open a bottle of champagne or sparkling wine.

Other than its vivid demonstration of the potential ocular hazards associated with champagne corks, I cannot find a lot to recommend about I Love You, Beth Cooper.  I sort of liked the first scene when Denis gave his speech, and I think the two buddy actors share a few funny moments, but almost everything else about the movie seems forced and awkward.  Further, what might pass as harmless merriment in another high school comedy setting comes off as lurid and irresponsible here.  Maybe I'm just getting older or something.  For a much better movie about the tired theme of "seize the day", check out Jim Carrey's Yes Man.  For a better high school comedy, just cover your eyes and pick any DVD out of the 80s bargain bin.  I Love You, Beth Cooper gets a D .

The Expendables (2010)

You don't stroll into Applebee's seeking out a culinary epiphany, right? Similarly, The Expendables will almost certainly deliver the expected goods to its target audience, satiating ones appetite for automatic weapons, knife-throwing, beheadings, and flimsy plots of government corruption by ex-military personnel. But can the eye-content hungry movie-goer find a morsel of ophthalmology in The Expendables? Read on!

Early in this mercenary flick, Jet Li delivers a ferocious kick with a steel-toed boot to Dolph Lundgren's left upper eyelid, causing a superficial laceration. Dolph's character even comments on the injury, stating that it will probably require sutures, and he expresses his dislike for sutures.

Later in the movie, the viewer notes that his laceration has been repaired with simple Steri-Strips, thin adhesive strips produced by 3M. They are applied across the laceration in a manner which pulls the skin on either side of the wound together. Their purported benefits compared to sutures include less scarring, easier care and application, and enhanced patient comfort. A major drawback is the loss of integrity when wet, something that a badass New Orleans-based soldier of fortune might want to take into consideration.

I won't go into a long treatise on the relative benefits of wound closure by suture versus Steri-Strips versus Dermabond, but suffice it to say that like with many areas of medicine, this issue is surrounded by heavy dogmatic declarations. ER doctors (read "I'm never going to see this patient again in follow up") will have a greater preference for quick and easy wound closure, whereas plastic surgeons (read "I'm not the one knee-deep in an ER swamped with drunkards and screaming kids at 3 AM") will pride themselves on meticulous suture closure with a grateful, well-insured, and sober clientele.

It's hard to judge The Expendables, because you get exactly what you signed up for. It's still pretty tough to overlook the banal plot and shabby dialogue. There should also be a law against movies where people run, out in the open, away from an army of people firing machine guns from less than 20 feet, escaping any serious injury. The whole theme of Jet Li repeatedly getting his ass kicked by a shady white person and then getting rescued by a noble white person got a bit old for this Asian-American male reviewer, too. Where is the Chuck Norris-spanking Bruce Lee from Enter the Dragon when we need him?

I'm going to give The Expendables a C - , which pains me, because I went to high school with one of the executive producers (see if you can guess which guy in the picture!) Sorry, Jason. Let's see if we can get just a little more ophthalmology content in the sequel, OK?

Unfaithful (2002)

Other than a brief scene of chemical keratoconjunctivitis in Kickass (hairspray in the eyes), there has been a dearth of eye-related movie content on DVD and in theaters lately.  Since we've covered the tired theme of chemical irritation several times (Bolt, Made of Honor, Did You Hear About the Morgans?), I had to resort to HBO to come through with Unfaithful from 2002, starring Diane Lane, and directed by Adrian Lyne.  Lyne also directed Flashdance, Fatal Attraction, and Indecent Proposal.

I guess marital infidelity flicks are Mr. Lyne's specialty, and Unfaithful depicts a tragic family implosion sparked by adultery.  What appears to be an ideal and secure home life proves stifling for suburban housewife Connie Sumner, and her New England manor and even-keel husband can't compete with the exciting, care-free city life offered by French book dealer, Paul Martel.  You can almost connect the dots here with a standard story about the bored housewife, intriguing foreigner, suspicious husband, private investigator, etc, etc.  There's a shift at the end of the second act that steers the plot in a different direction than I was expecting, and for as standard as the rest of the movie is, the power of the directing and acting ultimately produces something more intriguing than it should be.

The downtown loft-dwelling home wrecker, Paul Martel, has more in his bored-housewife seducing toolbox than just a French accent, toned abs (see photo), and inappropriate public displays of affection.  Among the piles of books in his apartment, there is a copy of a book in Braille in the kitchen, and one of his pick-up techniques involves taking Connie's hands in his and drawing them over the pages as he "reads" the words.  From Wikipedia:

The Braille system is a method that is widely used by blind people to read and write. Braille was devised in 1821 by Louis Braille, a blind Frenchman. Each Braille character or cell is made up of six dot positions, arranged in a rectangle containing two columns of three dots each. A dot may be raised at any of the six positions to form sixty-four (2⁶) possible subsets, including the arrangement in which no dots are raised.

The Braille system was based on a method of communication originally developed by Charles Barbier in response to Napoleon's demand for a code that soldiers could use to communicate silently and without light at night called night writing. Barbier's system was too complex for soldiers to learn, and was rejected by the military. In 1821 he visited the National Institute for the Blind in Paris, France, where he met Louis Braille. Braille identified the major failing of the code, which was that the human finger could not encompass the whole symbol without moving, and so could not move rapidly from one symbol to another. His modification was to use a 6 dot cell — the Braille system — which revolutionized written communication for the blind.

Interestingly, Braille literacy statistics show that 50% of legally blind people were able to read Braille in 1960, and this has dropped to around 10% today.  Technological advances and budgetary constraints have been cited as some possible reasons.  I have never met a visually impaired person who could actually read Braille.  This lack of Braille fluency is kind of reflected in the movie, since Paul Martel (who is not visually impaired, by the way) just makes up what he is "reading" with Connie.

Unfaithful is a well-acted and produced movie, with occasionally nuanced moments that rescue it from a movie-of-the-week descent.  A few scenes of peculiar pacing and heavy-handed directing are balanced by a restrained exploration of motive.  It will remind you of "The Stranger" in a movie form.  Let's give Unfaithful a big Braille B .

Blindsided (2006)

Unlike the similarly titled The Blind Side starring Sandra Bullock, Blindsided is a documentary film full of ophthalmology content.  This 65 minute documentary chronicles 12 year-old Jared Hara's experience with a particularly cruel disease known as Leber's hereditary optic neuropathy, a rare form of vision loss which typically develops in a person's teens or twenties.  From the National Institutes of Health:

These vision problems may begin in one eye or simultaneously in both eyes; if vision loss starts in one eye, the other eye is usually affected within several weeks or months. Over time, vision in both eyes worsens with a severe loss of sharpness (visual acuity) and color vision. This condition mainly affects central vision, which is needed for detailed tasks such as reading, driving, and recognizing faces. Vision loss results from the death of cells in the nerve that relays visual information from the eyes to the brain (the optic nerve). Although central vision gradually improves in a small percentage of cases, in most cases the vision loss is profound and permanent.

In the movie, we see Jared's ophthalmologists,  re-enactments of his exams, and witness his personal struggles with his progressive disorder.  The movie's strength lies in its rendering of how disease affects not only the individual, but also their family and friends.  Leber's hereditary optic neuropathy's basis on mutations in maternally inherited mitochondrial DNA also elicits complex feelings of guilt, blame, and unpredictability within the family.

In many ways, Blindsided (and movies like it) should be required viewing for  medical students.  Not every doctor (or even ophthalmologist) will encounter Leber's hereditary optic neuropathy in their career.  These personalized accounts of illness bring textbook descriptions alive, making obscure and intangible diseases very real.  And of course, feelings of helplessness and desperation in the patient and their family when dealing with medical conditions are something important for every practitioner to remember, even when rushing from one exam room to the next.


Blindsided won Best Documentary at the Idaho International Film Festival in 2006.  It has been showing lately on HBO, and is available on DVD.  As a movie, it relies heavily on Ken Burns-style pan and zooming, with an occasionally distracting soundtrack and some awkward sequence editing.  None of this takes too much away from the power of the story, and its illuminating portrayal of a tenacious victim of optic neuropathy.  Compared to that cloying Sandra Bullock football movie, Blindsided has a hell of a lot more ophthalmology content, and a far more nuanced representation of family dynamics and heroism.  B  .

Hachi: A Dog's Story (2009)

The famous true story of Hachiko, the loyal Japanese dog who awaited his master's return every day at the Shibuya train station, gets a modern makeover starring Richard Gere and Joan Allen.  Sony Pictures Entertainment booted this movie straight to a DVD release (just like the last movie re-make I reviewed, Ice Castles), so you'd expect that it would be pretty bad.  But after watching this one, I was surprised it never got a proper theatrical release.

Is there some rule that dog-centric movies must culminate in ultimate sadness?  Entertainment Weekly's review cites Marley and Me and I Am Legend  as recent examples of this man-dog bond motif.  Gere plays a music professor who stumbles upon the lost puppy, Hachi.  The movie bounces between scenes at the university, the professor's home, and the community of merchants around the commuter train station.  I'll try not to give away anything from this story based on events from the 1920s. but you can bet every effort to squeeze tears from the viewer is exhausted here.

The ophthalmology content involves scenes from Hachi's point of view, and show obvious color perception derangement.  This begs the question: Are dogs really color-blind?  My research took me to Paul Miller's (from University of Wisconsin-Madison's School of Veterinary Medicine) excellent review article Vision in Dogs.  Some selected excerpts:

Color vision in domestic mammals has been the subject of numerous studies with conflicting results.  More recent, well-controlled studies suggest that most domestic mammals possess, and use, color vision... cones constitute less than 10% of the visual streak in the dog, whereas they occupy almost 100% of the human fovea.  Additionally, instead of the three types of cones found in humans with normal color vision, dogs have only two functional cone types.

The article goes on to state that dogs lack or do not use "green" cones, and confuse red and green colors.  The canine visible spectrum is divided in the violet and greenish-yellow ranges.  Additionally, dog discrimination of closely related shades of grey is thought to be superior to that of a human.

Despite its manipulative tear-jerking stunts, Hachi tells a compelling story with likable characters and strong actors.  The train station scenes and season changes are very appealing and capture a strong sense of place.  The dog point-of-view scenes accurately reflect current thinking in canine veterinary ophthalmology, depicting a desaturated and altered color spectrum, but not a total lack of color perception.  I think this movie could have enjoyed modest success at the box office, and I reward this dog DVD with a solid B .

Ice Castles (2010)

Following occipital lobe trauma from an ice-skating mishap, figure skater Lexi Winston suffers cortical visual impairment.  You might think this sort of devastating injury would be career-ending, but Lexi and her plucky hockey-star boyfriend Nick set out to prove us wrong.

Normally I might include a bunch of "Spoiler Alert" tags on the plot summary, but this Ice Castles is actually a re-make of the Ice Castles from 1978.  C'mon, you remember tearing up hearing that Academy Award winning song "Theme from Ice Castles (Through the Eyes of Love)", don't you?  The 2010 movie serves up the modern, requisite syncopated re-make of the song, with hyper-stylized vocals.

Transient post-concussive visual disturbance is commonly encountered, but Lexi's type of prolonged/permanent vision loss from head trauma is not as common as you might think.  After the accident, we see her imaging evaluation in an older model General Electric MRI scanner (I think).  While standing in the radiology control room, the matter-of-fact physician counsels Lexi's father about the poor prognosis, advising him to take her home and prepare her for the difficult transition to a life of low vision.

These types of consultations are not normally done while standing in a control room, and in fact, the radiologists and technicians usually don't like it when non-radiologists hang out in there, let alone the family member of a patient.  Also, the doctor's assessment of Lexi's vision as "light perception" is clearly inaccurate, since Lexi's point-of-view shots suggest her ability to discriminate some shapes and movement.

Ice Castles didn't get a theatrical release, instead going straight to DVD with its release timed for the winter Olympics.  Despite some likable personalities and good skating cinematography, there is some seriously wobbly acting and an overall dingy look to the movie.  This one gets a C - , but worth a look if you have a special interest in figure skating, traumatic brain injury, or if you are a 13 year old girl.

Tidbits from 2010

There hasn't been enough eye-related content in a single film to warrant its own entry, but I think we have enough piecemeal content from a few current movies to make a mash-up post.

Sherolock Holmes - Did you know that the author, Sir Arthur Conan Doyle, received a medical degree from the University of Edinburgh in 1885, and later studied ophthalmology in Vienna?  His failure to develop a successful ophthalmology practice in London allowed him to use his spare time to write "A Study in Scarlet", which introduced the character Sherlock Holmes.

The Princess and the Frog - In this Jazz Age fairy tale, Mama Odie is a 200 year old voodoo queen afflicted with bilateral blindness.  The etiology of her ocular condition remains unspecified in the movie.  Given her age and ethnicity, I would list glaucoma, cataracts, and age-related macular degeneration as contenders.  I actually saw this movie with Sydney and her cousin, and I would give it a B+ .  The character Mama Odie has generated a bit of controversy- check out this quote and link from Movie Line:

Meet Mama Odie, the blind, 200-year-old “magical fairy godmother” with a “seeing-eye snake” who might have easily been the mascot for popular turn-of-the-century pantry product, Mama Odie’s Sambocakes and Waffle Batter.

Did You Hear About the Morgans? - Chances are nil that I will watch this abortion of a movie (at least in the theater), but the previews show scenes of Hugh Grant spraying himself in the face with bear repellent.  We've covered ocular pepper spray injuries here a few times already, but I was interested to read the claim that "bear repellent is the only proven way to prevent a grizzly bear attack. In fact, bear spray has a 90% success rate in preventing injury, making it more effective than guns in deterring an aggressive grizzly bear."

... and finally,

The Blind Side -  Despite the title, let me give you fans of ophthalmology in film a heads-up- this movie probably contains little to no eye-related content.  The term "blind side" in football refers to the side opposite the direction a player is facing.  For example, when a right-handed quarterback sets up for a pass, the left tackle is responsible for protecting his blind side.  I haven't seen the movie, but I have heard good things from people.  Wussy people.

OK peeps, that's your round-up for this month.  Happy viewing!

Ninja Assassin (2009)

Attempting to catalog the ocular and periorbital trauma in the ultra-violent Ninja Assassin would be as tedious as estimating the total blood loss in the movie. One particular injury, though, bears mentioning for its graphic depiction and very realistic post-traumatic appearance.

I don't think I'll be ruining anyone's movie-going experience by describing the plot, which involves the standard outline of an orphan, Raizo, being inducted into a grueling martial arts training regimen. The story gets told in a flashback style, reminding me a lot of David Carradine's TV show Kung Fu. Throw in the requisite rivalry with a fellow pupil, and the student-versus-master storylines, add several hundred gallons of stage blood, and you have a pretty good idea of what Ninja Assassin is all about.

OK, on to what you have all been waiting for: the eye injury. Sho Kosugi, the godfather of all ninja movies, plays Ozuno, the leader of the ruthless clan. He sustains a facial trauma and penetrating eye injury delivered by a Kusarigama, a traditional Japanese weapon with a sickle on a metal chain, with a weight on the end. Many years later, convincingly rendered evidence of Ozuno's injuries are seen, including eyelid and corneal scarring. Interestingly, Ozuno's magic regenerative ninja healing powers don't seem to work on his right eye. Also, it seems the vision loss in his right eye does not hamper his incredible ninja skills in the least.

Here is a resource for living well with vision in one eye.

And here's an eye fact from a 2005 article on eye injury from the Archives of Ophthalmology:

In the United States in 2001, an estimated 1,990,872 (6.98 per 1000 population) individuals experienced an eye injury requiring treatment in an emergency room, inpatient or outpatient facility, or private physician’s office.

I can't really objectively assess a movie like Ninja Assassin, since I spent a big part of my childhood watching ninjas in movies and on TV, reading about ninjas, and pretending to be a ninja. For me, this was a hugely enjoyable movie-going experience, full of stylized martial arts and weaponry. The final cinematic fight scene alone is worth the price of admission. For those concerned with nuances like coherent plot, continuity, or believable dialogue, Ninja Assassin will surely disappoint. For everyone else, this movie gets an A - .

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.

Get Smart (2008)

Although I can't say that Get Smart left me more fulfilled from a comedic or artistic standpoint, the ophthalmology content definitely taught me something new! In one scene, Maxwell Smart (Steve Carell) escapes a locked interrogation room by using his captor's ocular biometrics, holding up the beat-up bad guy's face to the eye scanner and lifting his eyelid.

You've probably seen this kind of scene before- remember Demolition Man (1993) with Wesley Snipes and Sylvester Stallone, or how about Tom Cruise getting an eye transplant in Minority Report (2002) to mask his identity?

What you might not realize, as I didn't, is that ocular biometrics actually does exist in many forms right now. There are two main technologies: iris recognition, which images the detailed surface of the irides of an individual's eyes; and retinal scanning, which utilizes infrared light to map the unique vascular pattern of a person's retina.

Apparently these scanners no longer exist just in science fiction movies. Retinal scanners have been used by the FBI, CIA, and NASA. Iris recognition seems to enjoy more widespread applications, notably in the UK Iris Recognition Immigration System, several US and Canadian airports, and in Pakistan for a refugee repatriation project. An interesting iris registration fact from Wikipedia:

The iris has a fine texture that – like fingerprints – is determined randomly during embryonic gestation. Even genetically identical individuals have completely independent iris textures, whereas DNA (genetic "fingerprinting") is not unique for the about 1.5% of the human population who have a genetically identical monozygotic twin.

Hey, I must have missed the ultra-cool ocular biometrics lecture somewhere along the way! I don't really recommend Get Smart ( C - ) based on the eye-related content alone, but maybe if you were totally into the old TV show, the cameos and references to it might make it a worthwhile pursuit. A plane, train, and SUV make for an impressive stunt-filled finale, too.

Here are some parting images of an iris and a retina. Enjoy!

Bolt (2008)

We all know and love the standard Disney formula: independent hero(ine) strays far from home and family, struggles to journey back with assistance from scrappy sidekicks, and along the way learns a little something about their true self. Bolt sticks to the tried-and-true, borrowing more than a few plot points from Toy Story, but ultimately delivers an enjoyable and technically astonishing experience.

As an added bonus, there are a few ophthalmology related features to address.

First, an animal control worker gets maced in the second half of the movie, resulting in toxic conjunctivitis. Nothing new here- these scenes seem to be a dime a dozen! Interesting mace tidbit from Wikipedia:

Due to the current brand-name use of the term "Mace" to refer to pepper sprays and the fact that mace is illegal in most Western countries, it is very difficult to find information on traditional mace. "Mace" and "Pepper Spray" are frequently used interchangeably.

Also, we saw the version of Bolt in 3-D, which I highly recommend. As you may have read in the reviews, Disney Digital 3-D is a huge technological leap from the old red-and-blue 3-D glasses. The animators really skillfully avoided 3-D cliches here, and used the added technology to complement the story-telling. How does it work? We got circular polarized 3-D glasses, and the movie frame rate is jacked up to 144 frames per second. The digital projector has a polarizing screen that matches the right and left filters in the glasses. The alternating left-right projected perspectives are then perceived by the viewer as a three dimensional image!

Finally, the villain in the movie, Dr. Calico (voiced by Malcolm McDowell of A Clockwork Orange) exhibits two ophthalmic features of note. He is occasionally referred to as "The Green-Eyed Man" by Bolt.

This blurry screen capture of Dr. Calico demonstrates iris heterochromia (different colored irides), and also corectopia (displacement of the pupil from its normal central position).

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.

The differential diagnosis for corectopia includes trauma, prior anterior segment surgery, ICE syndrome, iris coloboma, iris tumor, prior inflammatory change, iris stromal hypoplasia, posterior embryotoxon, Peter's anomaly, and ectopia lentis et pupillae.

Wonderful ophthalmology teaching points, Bolt! This movie gets a B + from me, and if you are considering watching it, I highly recommend seeking out one of the 3-D theaters to enhance the experience.