Illustrating Damaged Eyesight, Online and in the Courtroom

I have an unusual niche in the legal services world: I illustrate damaged eyesight, like eye injuries or surgical issues. Eye injuries include accident, product liability, adverse drug reactions, and brain trauma. Medical malpractice includes cataract surgery, refractive surgery (LASIK, PRK), missed retinal detachments, missed glaucoma, and other various botched surgeries. Where necessary, I testify about these illustrations.

I stumbled into this niche in 1998, after my own LASIK surgery from a highly regarded surgeon who had written a major textbook on LASIK complications, and performed over 4,000 surgeries. After the surgery, I was 20/15 in both eyes. That sounds wonderful, but this was my vision in the right eye:


Unfortunately, since reading and computer work were my life, you can see that despite being 20/15, the right eye was worse than useless. In fact, it was potentially career-ending. That was my first lesson with LASIK: There’s a difference between visual acuity and visual quality.

Late in 1999, a friend called about ABC’s 20/20 exposé on LASIK. Watching the episode, I heard about a nonprofit called the “Surgical Eyes Foundation.” Surgical Eyes had been created by patients who’d experienced complications from Radial Keratotomy (RK), the refractive surgery that was marketed as safe and effective before LASIK. They formed a nonprofit that would provide a safety net to catch these patients and help them. A former firefighter named Ron Link was the Executive Director. The organization needed a Research Director. I had a PhD, training in research methodology, lots of publications, and had seen depression, suicidal ideation, and post-traumatic stress as part of my clinical training. I volunteered.

Since I had always been good with computer technologies, it fell to me to webmaster the Surgical Eyes website. There were already two good simulators there written in Adobe Flash, and a number of illustrations of other post-refractive surgery vision problems, but these did not capture the range and severity of what could happen. I decided to create more illustrations. I wasn’t too good with Flash yet, but I found a program called Paint Shop Pro (essentially a basic Adobe Photoshop-like program, now owned by Corel) and began educating myself about computer graphics.

I learned that a variety of “filters” could be applied to simulate damaged Lasik eyesight. Foremost among these was blurry vision. By pulling a single slider control, different levels of blur could be applied to any picture. Some patients said their vision was streaked or smeared. Sometimes it was just a single smear, but it could also be a V-shaped smear, with the V being more or less narrow or open. By applying a motion blur in different directions, then stacking the layers on top of each other and applying some transparency, I could come close to illustrating these V-shaped smears. Other patients saw two images, one on top of another, what they called “ghosting.” This was easier. I just needed to stack the layers, and give the ghost image some transparency.

Eventually, I learned how to create other Lasik aberrations, as well. Although the industry still denies that pupil size has anything to do with outcome, a substantial number of victims saw halos and starbursting. Halos are huge globes that appeared around lights at night. Starbursts are huge rays coming off lights. Sometimes the rays were very long filaments of light packed closely together. Sometimes the rays were huge spikes of light shooting out at various directions. To illustrate halos, I learned about “feathering.” Feathering gives objects a soft edge, an edge that appears to fade into the background, rather than a hard edge, which ends suddenly. By creating a white circle and feathering the edge, I could illustrate halos around stoplights and car lights. That was important, because almost all the patients I knew saw halos of some size and density. In fact, many claimed to see halos nested two, three, or more layers deep. Illustrating these was just a matter of stacking the halos and giving each layer some transparency.

Along the way, I realized that these vision simulations had an important psychological purpose: they allowed patients to communicate their experience to others. When our community first formed, we were alone. You’ve heard the old saying, “Seeing is believing.” The converse is also true—not seeing is not believing. The visual problems of patients could be described with words, but as long as these problems were not actually seen, compassion was limited. I also knew of many cases where a refractive surgeon had told the patient’s family that the patient was exaggerating their problems. With the simulations, the subjective is transformed into objective; the internal world of the patient is opened up and made available for inspection by others, leading to understanding.

Over time, patients began asking me to construct vision simulations for their lawsuits. At first, I did not want to get involved. I’d already fought a long hard fight, and I was tired. I was going to expose myself to depositions from mean attorneys, too? Unfortunately, these patients did not have a way to adequately demonstrate their damage. Some were like me, their visual acuity was good, and yet their vision was a mess. What could I do? Was I going to back out on them? All of us face important choices in life.

So in 2003, I launched VisionSimulations. The site has more illustrations of damaged vision than any other website, including blurry vision, smeared vision, ghosting, loss of contrast sensitivity, halos, and starbursting. These problems are not limited to refractive surgery, but overlap many diseases and conditions, including keratoconus and visual snow. As such, the website has become a resource for people all over the world who need to show others their vision problems.

Through the years, I’ve revised the site numerous times. The first versions of VisionSimulations were based only on HTML and CSS. To construct a simulator for ghosting, I applied some drag-and-drop javascript to an image, and then set its transparency using a CSS alpha filter proprietary to internet explorer. Microsoft had largely defeated Netscape in the browser wars, so I was comfortable using its CSS filters during this period of Microsoft’s unrivalled dominance. There was also a CSS blur filter, which made illustrations of blurry vision straightforward.

As new browsers began to appear, it was clear that I needed to move away from Microsoft’s CSS filters. The simulators I’d constructed early on wouldn’t work in Opera or Firefox. Moreover, I personally disliked the inherently insecure Internet Explorer. The fact that Windows seemed to crash multiple times per day didn’t help my love of Microsoft any, either.

I found the answer in Adobe Flash. Most people know Flash as an animation tool used to construct advertisements at the top and sides of webpages. To my surprise, I discovered it to be so much more than this. Almost everything I needed to construct illustrations of damaged eyesight was already in Flash, including blur and the capacity to create images consisting of various layers, composited together and given transparency. Creating animations was as simple as creating a sprite, assigning it some graphics, and then changing its X and Y coordinates over time. I could even create my own controls in Flash. I spent several days building an attractive slider control, which has been in use in all my Flash programs at VisionSimulations for at least seven years.

Today, there are eleven main simulators on the site, namely blurry vision, ghosting, glare, daytime glare, glare-starbursting, halos, loss of contrast, starbursting, starbursting with fine rays, visual snow, and dry eye tear break up. The latter two require comment. Visual snow is not a LASIK issue, but like LASIK , it creates a seriously depressing visual scenario. Some people see “snow” in their visual field. This “snow” is like noise or signal interference on the old CRT televisions: it looks like a bunch of white or colored dots flashing on and off randomly in one’s visual field. Some people see more of the dots, others see less. Some people see the dots flashing quickly, others see them flashing more slowly. Two slider controls—density and speed—allow visual snow suffers to tune the simulator to their vision. What I thought would help only a few people with a rare condition has turned out to be one of the most popular simulators on the website.

The dry eye simulator was inspired by a LASIK patient who told me he’d seen fifty ophthalmologists in the past year. After LASIK , most people go through a period of dry eye. The human cornea contains more nerve endings than any other tissue in the human body, 60 times denser than dental pulp. That’s evolution’s way of making sure you know something is in your eye. When the LASIK flap is created, these nerves are severed. Feedback from the cornea to the lacrimal gland (which make tears) is stopped. The gland no longer receives information about the state of the cornea. The post-LASIK cornea can be as dry as a bone, but as far as the lacrimal gland is concerned, it’s a paradise. Once the nerves are severed, the cornea can’t tell the gland anything else. With fewer tears to spread around, they break up more quickly, which the patient sees as blurry vision. The simulator allows the dry eye patient to set the number of seconds until tears break up, and the level of blurry vision that results. Once the patient blinks, the tears are spread out again, and the simulation repeats.

In 2014, I will launch a national directory of “eye attorneys,” which will include attorneys who serve both plaintiff and defense.

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