Marianas Eye

The Retina Blog

2009-11-08T07:53:00.006+10:00

I've got a new blog, over at The Retina Blog. It contains "clinical pearls for retina specialists, fellows, residents and others interested in advances in the field of retina." At least 50% of my practice is dedicated to retinal disease. The field is evolving very rapidly, mostly due to the use of various biological modulators that we inject into the eye. As I read articles and studies that are important to the clinical practice of retinal disease, I summarize them and place them on the blog, mostly as a source of future reference for myself.

Risk of stroke with Lucentis vs. Avastin

2009-10-25T11:10:00.003+10:00

In the February 2009 issue of Ophthalmology, a meta-analysis was reported in a letter to the editor pointing out some risks associated with intravitreal injection of ranibizumab (Lucentis). The letter looked at pooled data from the MARINA, ANCHOR and FOCUS studies which were done to determine effectiveness and adverse effects of Lucentis. The authors of the letter point out that when pooling all the data, the ranibizumab group had a 2.2% incidence of stroke, whereas the control group had a 0.7% incidence of stroke. They conclude that the risk of stroke rises as a result of ranibizumab treatment. When they look at the incidence of myocaridal infarction (MI), the ranibizumab group had a 1.9% incidence whereas the control group had a 3.0% incidence. They did not "conclude" that intravitreal injection was protective for MI, but the incidence is lower in the group receiving the drug vs. the control group.

Since the letter was published, there has been some discussion regarding the implications of this meta-analysis for those of us using Avastin. At the current time the feeling is that this data cannot be extrapolated to Avastin, in part because Avastin is a larger molecule (the entire globulin, vs. the immune arms as with ranibizumab). This molecular characteristic is felt to result in less egress of Avastin into the systemic circulation, and it is to this characteristic that the longer-acting effect of Avastin has been attributed. There is currently an NIH sponsored head-to-head clinical trial comparing Lucentis and Avastin underway. The results are due in 2012. The study is ongoing, and the fact that it has not been stopped is some solace to those of us who prefer Avastin that the study has not to date shown that Avastin is either hugely inferior or has significantly higher side-effects that Lucentis.

What is the Baha'i Faith?

2009-09-14T04:44:00.005+10:00

Here is my Saipan Tribune column from this past week.

***

A close friend of mine recently said to me, "You know David, most people really don't know what the Baha'i Faith is all about." I was a bit surprised to hear this, but I knew it was true. After all, when I mention to people that I am a Baha'i, there is often a puzzled look on their faces. Most people seem to have the impression that the Baha'is are a good bunch of people, working in some way toward peace. But beyond that, most people don't have an understanding of the basic principles of the Baha'i Faith. This realization was a bit surprising to me because the Encyclopedia Britannica lists the Baha'i Faith as the second most widespread religion after Christianity. And The LA Times noted that the Baha'i Faith is among the top two fastest growing religions in the world. So I thought it would be useful to explain the fundamentals of the Baha'i Faith. It is likely something that you will encounter more and more in the coming years.

Baha’u’llah – The Promised One

When someone asks me, "What is the Baha'i Faith?" The brief explanation that I give goes to something like this: The Baha'i Faith is a world religion whose purpose is to unite all peoples and races. Baha'is are the followers of Baha'u'llah, whom they believe is the Promised One of all ages. The traditions of almost every people include the promise of a future time when peace and harmony will be established and humankind will live in prosperity. Baha'is believe that the promised hour has come and that Baha'u'llah is the great personage whose teachings will enable humanity to build a new world.

This brief explanation raises a few key points. First, the Baha'i Faith is an independent world religion. It is not an offshoot, sect or denomination of another Faith. Second, its purpose is to establish unity among the peoples and races of the world. Third, the Baha'i Faith accepts Baha'u'llah as the one whose teachings will establish the long-awaited peace on earth. It's a large claim for sure, and most people are rightfully skeptical at first. But millions of people find it a claim worth looking into.

God is Unknowable

Baha'u'llah teaches that there is a source of creation that we call "God." Yet God is unknowable in his essence. Our finite minds cannot fully grasp God and we should not make images of God in our mind, thinking of him, for example, as a man. God created all things out of love: "O Son of Man! I loved thy creation, hence I created thee. Wherefore, do thou love me, that I may name thy name and fill thy soul with the spirit of life."

The Manifestations of God

Baha’u’llah teaches that throughout the course of history, God has given humanity guidance. This guidance comes to humanity through the Manifestations of God -- those special beings who revealed (or “manifest”) to humanity the word and the will of God. History knows them as the founders of the world's great religions: Krishna, Buddha, Moses, Christ, Muhammad, and Baha'u'llah. This idea that a single God has sent these various Manifestations of himself to humanity is a fundamental teaching of the Baha'i Faith. Baha'is accept the divinity of all of these individuals, that they all speak with the same authority, and that they have progressively revealed the will of God to humanity. Referring to these Manifestations of God, Baha’u’llah has written, “If thou wilt observe with discriminating eyes, thou wilt behold them all abiding in the same tabernacle, soaring in the same heaven, seated upon the same throne, uttering the same speech, and proclaiming the same Faith.”

Teachings for a Global Age

According to Baha’u’llah, the Manifestation of God return from the same source from age to age, as people stray away from the teachings of the previous Manifestation of God, and as society changes. “This is the changeless faith of God, eternal in the past, eternal in the future.” The Manifestations of God all have the same purpose -- to bring God’s guidance to humanity. Their spiritual teachings remain the same: develop your virtues -- love, kindness, justice, compassion. However, their social teachings – those that guide the complexities of society -- are not the same. The social teachings change in accordance to the circumstances of the times: one says you can divorce, another says you can’t. Eat pork; eat what you want. Have four wives; don’t have four wives. These differences exist not because of intrinsic differences between the Manifestations or of their source. The differences in the social teachings exist only because of the changing circumstances of humanity at a particular time and place in history. Math in one grade is different from math in another grade, not because the teachers are in conflict, but because the students are different. The religions are not really different religions. They are stages of one common faith, like the chapters in the same book.

The spiritual teachings of long ago are still valid today. This is the reason millions of people continue to find sustenance in faiths that are thousands of years old. However, people are increasingly disillusioned by their religions (or any religion) because they do not appear to address the needs of the age, they do not appear to be relevant to life in the 21^st century.

When Baha’u’llah appeared in the mid 1800’s, he claimed to bring God’s message that humanity would soon be moving into a global age, and that new teachings were required to govern a global society. Of course, at the time, these teachings were considered insane. How could anyone speak of “global” society, when the fastest way to travel was by horse? When communication required a message be carried by hand from place to place? But he spoke of the need to recognize the oneness of humanity, the oneness of God, and the oneness of religion. Those who accept his claims do not think of him as an enlightened or prescient man, but regard him as the most recent of the Manifestations of God, who has come to usher in the universal age of peace and unity.

I hope that these basic teachings of the Bahá’í Faith help make it less of a mystery to you. If you want to learn more, information is available at www.bahai.org.

MacSpeech Dicatate: Way Thumbs Up

2009-08-04T22:07:00.004+10:00

I'm dictating this blog entry with new speech recognition software that I've picked up over the last week. One of the worst things that I do for my posture is spend a lot of time at a computer, or rather at a keyboard. I hunched forward, my shoulders droop, my chin moves forward. I developed some serious neck pain over a period of several months which was fairly debilitating. I ended up seeing a neurosurgeon who did an MRI and told me that all my problems had to do with poor posture. So in my quest to stand up straight, I did some research on voice recognition software.

Because I have an Apple computer, I got the only speech recognition software that is compatible with it: MacSpeech Dictate. It is based upon the best voice recognition software out there, Dragon Naturally Speaking, which is designed exclusively for PCs. I've had it a few hours, and it's working great. I've had to make a few corrections as I dictated this entry, but I've made them all with voice navigation and commands. My arms are folded across my chest and I'm sitting up straight.

Of course it's not perfect, but it's pretty accurate. I will read a sentence from an article that is sitting in front of me: "Combining genetic risk markers with clinical risk factors makes for very complex translational challenges with diagnostic, clinical and therapeutic implications for treatment."

Wow! It got it 100% correct, and those are not typical words you'd usually dictate. I'm impressed. MacSpeech Dictate gets five stars from me.

Patients Gone Wild and Healthcare Reform

2009-06-11T08:56:00.002+10:00

(I'm blogging from the operating room. Here's my Saipan Tribune column for this week.)

I recently had the opportunity to read President Barak Obama’s letter on Health Care Reform, dated June 3, 2009. There is one paragraph in particular that jumped out at me, because it seeks to identify the “root cause” of rising health care costs. Here it is:

“At this historic juncture, we share the goal of quality, affordable health care for all Americans. But I want to stress that reform cannot mean focusing on expanded coverage alone. Indeed, without a serious, sustained effort to reduce the growth rate of health care costs, affordable health care coverage will remain out of reach. So we must attack the root causes of the inflation in health care. That means promoting the best practices, not simply the most expensive.… That's how we can achieve reform that preserves and strengthens what's best about our health care system, while fixing what is broken.”

First, let me say, that I agree with the gist of the statement. Rising health care costs are killing our economy (well, that and a few other things), and medical care can definitely be improved so that it is more cost effective.

But here’s the truth. The single best way to reduce the cost of healthcare is to reduce the need for healthcare. We are a sick bunch of people, and for the most part, it’s because of our own behavior – we’re all “patients gone wild.” The majority of us are sick, not because we’re out doing healthy things and suddenly get struck down by some horrific disease. No, we’re sick because we eat too much, sit around too much, eat the wrong foods, smoke, consume alcohol, and generally ignore the things that lead to good health. We’re sick because of the wild and crazy choices we make. The vast majority of healthcare costs in America and the CNMI are tied to chronic “lifestyle” diseases. The top ten causes of death in the US include heart disease, stroke, diabetes, and cancer. And every single one of these has been incontrovertibly linked to how we live our lives – whether it’s what we eat, what we do, what we drink or what we inhale.

To a large extent, we’re digging our graves with our spoons and forks. Last year, we spent over $20 billion dollars on cholesterol lowering drugs. That’s billion, with a “B”. If you had $20 billion dollars, and decided to burn a million dollars a day, every single day, it would take you 55 years to spend $20 billion! Why is our cholesterol high and why does it need to be lowered at a tune of $20 billion a year? High cholesterol is a major risk factor for heart disease and stroke. Our bodies produce some cholesterol, but most of the problem comes from what we eat. Only animals have cholesterol in them. Vegetables have no cholesterol at all. We’ve known for decades that the most effective way (and the cheapest way) to lower cholesterol is to lower our consumption of animal products – animal flesh, animal milk, animal cheese, animal crackers, etc. But you know what? We’d rather not make that kind of change. We’d rather pop a pill and keep eating whatever we want to eat. And that’s $20 billion dollars we spend so we can do what we want to do, which is to eat lots of animals.

The same is true for diabetes, which is devastating our community, and growing at an alarming rate. We know that for most of us, the adult onset variety can be controlled, or at least hugely improved, with diet and exercise. Yet we choose not to make these difficult changes. We choose to eat what we want, and take pills and go on dialysis and lose our vision and our feet and our erections. And we spend untold billions on the cost of care for diabetes and its related problems.

A diet high in animal fat is also linked to a slew of cancers. Pass the processed meat that starts with “S” and ends in “M” and rhymes with “PAM”. Or just pass a burger or wiener or any other chunk of meat. Alcohol consumption is linked to many cancers. Pass a Bud (better make that a Bud Lite). Tobacco is irrefutably linked to cancer. But we can’t seem to manage to pass legislation to ban smoking in public spaces. Pass the votes.

I admire efforts to improve the cost-effectiveness of the healthcare we deliver, but I know that the “root cause” of the mess includes our culture of indiscretion, of consumption, of sitting around. Any serious effort to fix the healthcare mess must include a change in our culture – what we eat, what we do, what we drink and what we inhale. These changes won’t solve all the problems, but they’ll make a huge dent in the demand for and the cost of healthcare. A major portion of the responsibility to “reform” belongs on our shoulders -- those who end up needing healthcare. Reduce the need, and you reduce the cost. It’s simple. But it’s not easy. We humans typically don’t like change. Yet failure to change our behavior will result in more and more people needing healthcare every year, rising costs, and eventually, not enough doctors, hospitals or other resources to take care of so many sick people. We’re experiencing the fallout right now, right here in the CNMI.

Addressing our behavior needs move to the front and center in the public policy discussion on healthcare reform. It’s a nut we must crack.

_______________________________________________________________________

David Khorram, MD is the co-founder and medical director of Marianas Eye Institute. He is the author of the book, World Peace, a Blind Wife, and Gecko Tails, which is available on Amazon.com and at Marianas Eye Institute. Dr. Khorram can be emailed by visiting www.MarianasEye.com, or by phone at 670-235-9090. © David Khorram, 2009.

Risk Factor for Swine Flu

2009-05-02T16:51:00.003+10:00

What they're not telling you about Swine Flu

2009-05-01T17:03:00.002+10:00

Here's a portion of an email I got from one of our public health officials, just to put things in perspective:

I am getting more than 8 Swine Flu "Updates" per hour. Good grief. This is a true epidemic, likely soon to be a global pandemic. My guess is that we'll be in Phase 6 next week. But the relatively minor human toll (low morbidity and low mortality) does not yet justify the resource allocation, nor the media attention that we have all seen.

We need to insure that we have a "measured response" that is commensurate with the real, not the perceived, threat. And responding appropriately, in the face of media hype and patient worry and governmental involvement, is a real art. I am hoping to hear your opinions on this.

In the past six weeks, Swine Flu has killed between 20 and 80 people. More than 2000 have had clinically significant infections. In the same time period, more than 40,000 people have died from routine influenza. Millions were infected. More than 40,000 died from TB just last week. 40,000 more died from malaria last week.

Jerks Die Younger

2009-03-13T10:45:00.006+10:00

The next time some jerk is yelling at you for no good reason, you can smile, knowing that they'll be off the planet sooner than you.

A new study published in the Journal of the American College of Cardiology finds that people who are angry and exhibit hostility have a 19% higher risk of dying from coronary artery disease -- i.e. a heart attack.

The average person hopes that future studies will show an increased risk.

Sexualization of Young Girls

2009-03-12T21:31:00.003+10:00

I was at the Thursday night street market, where every week on Saipan you'll find food vendors and live entertainment. Tonight, a dance schools performed. I'll tell you, it was a sad scene. There were kids, girls, six, seven, eight years old, dressed like teenagers, with short skirts, makeup, and shin-high boots, and dancing suggestively to lyrics like "Let's make love, ooh, baby, let's make love."

When did this happen? When did parents start looking the other way, and give their assent to the sexualization of their young girls? It's like they all went out for a walk, let some stranger called a dance instructor come into their house, and in the name of "developing talent" twist their kids into these vacant performers. It disgusts me. What happened to protecting innocence? What are these parents thinking? Do they think this is okay? To have their young daughters thrusting their pelvises while lip-synching these overtly sexual lyrics? I don't get it.

Nagoya City University Hospital

2009-02-28T12:59:00.006+10:00

A few years ago, I needed some surgery that wasn't available on Saipan, so I was faced with finding a surgeon to undertake my care. Part of the issue for me was that I wanted to get the care close-by, and being self-insured, I needed it to be cost effective.

My main four choices came down to Australia, Hawaii, Manila and Japan. I visited one of the top surgeons in Sydney during a trip there, and I wasn't impressed. I scratched Manila off the list pretty quickly. I've had a fair bit of experience with patients going to Manila for care, and although one of the surgeons I've worked with there is good, I've found that in general, the delivery was not up to the standards I expect when sending a patient to a major medical referral center. Sorry guys, but that's the truth. I wouldn't go to Manila unless it was a last resort. I'm sure many have had good experiences there, but seeing many of my patients return, I haven't been too happy with the quality of care they received.

Hawaii was an obvious choice because, well, it's US quality medical care. The problems with US care is that it's expensive. If I'd had the procedure in Hawaii, it would have cost me $10K. If I had had insurance, my 20% co-payment would have been $2K, for an outpatient procedure. So, I just held this option in reserve.

I started to look seriously at Japan. In the world of medicine, Japan is one of the areas, along with the US and parts of Europe, that lead medical research and publish in medical journals. I know the quality of care there is top-notch, and that the cost is reasonable. I ended up finding one of the best surgeons in the world for my condition, and headed there for my surgery. I was very happy with the quality of the care I received, and the cost was only $2K. That included the surgery, and five days in the hospital, getting fed and watered. The system of care in Japan is a little antiquated, and many expatriates in Japan complain about it for this reason, but as someone in the medical field and as someone who has experienced the care first-hand, I think that the care is on par with anyplace in the US, and even better than the US, it's cost effective.

After I returned, I tried to convince the powers that be to start looking at Japan as a place to send our medical referral patients from the CNMI. It close, it's cheap, and the quality of care is outstanding. It's taken a while, but finally the CNMI has a relationship with the Nagoya City University Hospital (NCUH), and we have liaison people on the ground to help patients navigate a foreign country.

Nagoya City University Hospital is an 800 bed medical center (CHC has 72 beds). The first patient from the CNMI that went there was an infant, a few days old, who was on the way to Hawaii for cardiac surgery, decompensated while on the tarmac in Nagoya, and was taken to the NCUH where the pediatric cardiac surgeons did an outstanding job on a very complex surgical procedure. Since that time, the relationship has deepened, and in the next few weeks, I hope to send the first ophthalmology patients there. This should provide closer and less expensive care than is available in Hawaii, and as high a quality of care. I'm looking forward to using NCUH as a referral center.

Truth, Death, Unity and Classroom Cataract Surgery

2009-02-22T10:12:00.004+10:00

Because of my book, I was invited to give the keynote address to the University of Guam during their faculty development day on Friday. I just shared some thoughts that were on my mind. I think in some way, the points I raised had to do with some of the anchoring principles of my life. It was also an opportunity for me to try out some of the stand-up comedy material I had been working on, and most of the jokes got laughs. Here were my key points.

1. "Truthfulness is the foundation of all human virtues. Without truthfulness, progress and success in all the worlds of God are impossible for any soul." Before I really started to think about this principle in my own life, I used to "fib" so much to avoid embarrassment or to stay out of trouble. Being committed to total truthfulness required me to change the way I did a lot of things, but it was a liberating process. It's a pain, and I feel I sell out pretty easily at times. But it's still one of the key principles that I think everyone can benefit from.

2. We're all gonna die. Really. Remaining conscious of this truth on a daily basis helps lend clarity to life. This can be done by bringing oneself to account each day. "Bring thyself to account each day, ere though art summoned to a reckoning, for death unheralded shall come upon thee and thou shalt be called to give account for thy deeds."

3. The motto of UOG is "Unity in Diversity." Unity requires that as individuals we refrain from faultfinding. The process of higher education gears us toward "critical analysis" which makes faultfinding a natural way of life. Faultfinding is an intellectual activity that is quarantined to one's mind. But the real problems arise when we mention the faults of others -- when faultfinding moves to backbiting. It's endemic in our culture, and there is a need to establish "no backbiting zones" around our mouths, and even our ears, so we don't participate in this corrosive force.

4. Cataract surgery brings vision. Teaching brings vision.

The faculty were appreciative of having a speaker who wasn't there with charts and numbers, and as someone said, "we're all human, and it's nice to remember that at times."

Gory Eye Picture - Dermoid from Hell

2009-01-31T07:00:00.004+10:00

This is a weird growth that some people are born with. It's called a dermoid. It can enlarge over time, as this one has. (This guy walked in this week is in his 20's. Time to remove it, don't ya think?) You can see it has hair growing on it. Sometimes there's bone and teeth and cartilage and other Frankensteinian components in them. Growths like this that consist of tissue not normally found at the site are called "choristomas". One choristoma made it to the big screen in the movie, "My Big Fat Greek Wedding," where the Aunt is telling the fiance of the lump that was removed from her back that had teeth and hair in it, and that it was the remnants of her twin that was never born. It was a great scene, and a proud day for choristomas everywhere.

Often, ocular dermoids go deep into the substance of the eye wall, so despite it's "stuck-on" appearance, you can't just slice it off, (or lacking instruments, pluck it off), because you could end up with a hole in the eye. So you have to have donor tissue available to patch up the hole at the time of surgery. They occur in about one per 10,000 people.

Bullet Behind the Eye

2007-03-12T10:33:00.000+10:00

This is why, as an eye surgeon (and as a human being) I hate pellet guns, BB guns, and all the rest. This 11 year-old boy and I spent several hours together at the hospital on a recent Friday evening because a friend accidentally shot him with a "toy" gun while he was eating a bowl of cereal at his own kitchen table. The X-ray, is a profile view of him facing to the right. You can make out his teeth towards the bottom. The big dense white blob in the middle is the fragmented pellet that entered through his lower eye lid, completely missed the eye (lucky!), didn't go into his brain (lucky again!) but lodged itself deep in his eye socket behind his eye.

Kids and guns aren't a good mix. Well, people and guns aren't a good mix either. The skin is just too dang soft to keep the bullets out.

Time Slowed Down

2007-03-15T14:40:00.000+10:00

First he saw a flash of light. Then he felt clear fluid on his cheek. Next the smell of blood. Then darkness and searing pain. Finally, he heard the explosion.

In the Emergency Room, that’s how my friend Jeffrey described to me the slow motion of instantaneous events he experienced when the bottle-rocket blew apart his eye. It made sense. The flash of the retina being compressed, before the anterior chamber ruptured and spilled its clear contents on his cheek. Then the blood from the explosion of vessels and tissues deeper in the eye. Next the shearing of the optic nerve leading to darkness. And finally the activation of pain impulses. Then… then the sound wave, slower than both light and electricity, arrived at his eardrums, and he heard the explosion. Like the delay of thunder arriving after the lightning. His body buckled forward. All within a split second.

He wasn’t using the fireworks. And they weren’t being used by kids. He was just one of the adults standing around at a party while everyone “enjoyed” the fireworks. Light. Noise. The smell of gunpowder. Laughter suddenly gone still.

On an island where you’re the only ophthalmologist, you don’t have the hope of calling in a detached colleague to do the surgery on your friend. I told Jeffery it was serious. That I would do everything possible to put the pieces of his exploded eyeball back together. That he would need more surgery later. And that his chances for recovering any vision were slim. He was 21, right out of college, a volunteer teacher at one of the schools. He thought of the life ahead of him without the sight of one eye, and sobbed. He was my friend. I put my hand on his shoulder. It was the first year of my career. I wasn’t yet 30.

He spent the next seven hours under general anesthesia while I pieced together his mangled eye. Microsurgery. Sutures smaller than human hair. I used package after package of 10-0 nylon suture, 9-0 nylon suture, 8-0 nylon suture. “How many stitches,” everyone wants to know. Probably a thousand. You just stop counting. Within the first hour, I knew his vision was lost, but I didn’t have the heart to remove his eye. Better it be done at a tertiary care center where there would be no doubt that everything humanly possible had been done to save that eye.

As the sun rose, I walked out of surgery into the tropical half-light, drained and exhausted. Before we went into the operating room he had given me his parents’ phone number. “Call them for me,” he had asked. Now it was up to me to break the news to them. I had to pull them out of President Clinton’s Inaugural Ball to take the call. They were thankful.

Within a day, they had flown Jeffrey to Manhattan Eye and Ear Hospital, one of the finest eye care facilities in the world. The surgeons called me. They just wanted to talk to the guy who had done more to rebuild an eye than they had thought possible. Then they did what they had to do. They removed Jeffrey’s eye and plunked it into a jar.

Jeffery has a glass eye in his empty socket. He looks normal. But he wears glasses every waking second of his life. They're there to protect his remaining eye from the harrowing possibility of a stray rock, or finger, or shattered windshield, or elbow or gunpowder propelled projectile, snuffing out his sight. No spare left. A lifetime in darkness.

I’m happy -- no, eager -- to give up one small aspect of all of my celebrations: fireworks. Their joyful sounds will never be enough to drown out the sobs of a person losing an eye. It’s not a common occurrence, but it’s not a rare one either. I hear those sobs every single year.

Ban the fireworks.

Saipan Dining Adventures

2007-03-20T10:34:00.000+10:00

My friend and colleague, Mark, and his wife, Bev have probably eaten in every restaurant on Saipan. They have an adventurous streak, which you have to have to explore the full range of dining experiences here.

Take for example the time they went back to the new Mexican restaurant. The burritos had been fantastic the first time, so they returned for a “known known.” Again, the burritos came smothered in sour cream. But the first bite betrayed the true identify of tonight’s sour cream. Not sour cream. What is that taste? It's familiar. Could it be...??? Yep. Sure enough. Thick rich creamy white mayonnaise glopped on top of that hapless burrito. Yummy. The kitchen was out of sour cream, so the cook used the next best thing – the next white thing. Mayonnaise. Makes perfect sense. That’s why you just keep eating.

The following week they ventured out to a Korean restaurant. They are warmly welcomed at the door with halting English and a sense of excitement that real live Americans are visiting the establishment. This could be a new beginning, a whole new market! Mark and Bev are seated with grace and a flourish at a table for two, a red plastic rose on the white plastic tablecloth. They are given menus.

One of the nicest things about many Asian restaurants is that the menus include photos of the food, which is necessary in this case, because the rest of the menu is in Korean. But the photos are still not completely helpful to Mark and Bev, because they are only slightly larger than a flattened clove of garlic.

Mark strains to make out the details of the pictures. Bev can do no better. The logical thing to do is to ask the waitress for help -- try to get enough of a description from her to make an informed choice. So they begin, and ever so slowly, work their way, item by item, down the menu. The waitress struggles to find words – any words – but particularly words for foods that have no English equivalent. “Is this spinach?,” asks Mark, pointing to the picture. “No,” says the waitress. “Is it kelp?,” asks Bev. “What ‘kelp?,’” inquires the waitress. “Oh, kelp is like seaweed,” offers Mark “What seaweed?,” asks the waitress. “Seaweed is nori,” explains Bev, drawing on her knowledge of a Japanese word that might be familiar to the waitress. “Ahhhh,” says the waitress as her face lights up, “No, not nori.” “What is it then?” asks Mark. “Like spinach,” reports the waitress. Ahhhh, full circle. Not spinach. Like spinach.

Mark and Bev are enjoying their detective work and are quite content to explore the menu in this way. But the waitress, who has never experienced happy inquisitive Americans before, must believe that Mark and Bev are struggling and suffering as much as she is through this ordeal to place a simple order.

Eager to bring some relief to everyone, she offers a great solution. “Maybe you go eat someplace else. Maybe someplace that have spaghetti.”

In that instant, her suggestion doesn’t quite register with Mark and Bev. But after a few seconds pass, their comprehension catches up with their hearing. Did she really just ask us to leave?? To go eat spaghetti??? They glance at each other over their menus and try to hold back their laughter.

Undeterred and ever adventurous, Mark and Bev plow forward, asking a few more questions, making a decision, ordering their meals, and enjoying it all. And tonight they have an opportunity to use their recently gained knowledge -- to taste everything white to make sure it’s not mayonnaise in disguise.

Tropical Naw-Ruz

2007-03-22T12:36:00.000+10:00

Yesterday was Naw-Ruz, the Bahá’í New Year. We took the kids out of school, and to celebrate, took a boat ride over to Managaha, a tiny picturesque island about 20 minutes off of Saipan’s western shore. The island is reserved for recreational use, and no one lives there.

Naw-Ruz also marks the end of the 19 day period of fasting for Bahá’ís. Below is a brief talk that I gave a few years ago explaining Naw Ruz, the Fast, and an overview of the Bahá’í Faith at our community's celebration. That's followed by some photos of our day at Managaha.

***

We would like to welcome you all here to this celebration of the Bahá’í New Year, Naw-Ruz. Naw Ruz is a time of hospitality and rejoicing, and we thank you all for being here to celebrate this festive occasion with us.

The Bahá’í year begins each year at sunset on March 20, the day of the vernal equinox. The equinox is the day on which the sun equally illuminates the whole earth. In many cultures, the equinox is a symbol of life and of divine illumination.

The Fast

Sunset today, also marks the end of the 19 day period of fasting for Bahá’ís. For the past 19 days, Bahá’ís around the world have arisen before dawn to pray and meditate, and have abstained from food and drink from sunrise to sunset. The fast is symbolic – a reminder. Its significance and purpose are fundamentally spiritual in character. It is a time of self restraint, a time to focus more actively on our spiritual side, a period of spiritual recuperation.

So we are honored to have you with us this evening, as we end our fast, and move into a new year.

The Bahá’í Faith

This evening marks the 160^th (2007 is the 164th) year of the Bahá’í calendar. The Bahá’í Faith is the most recent of the world’s major religions. It began in 1844 in what was known as Persia, amidst tales of heroism and great sacrifice.

Bahá’u’lláh taught that there is a creative force, a creative energy in the universe, which is unknowable to us, and which humanity has called God. Throughout human history, this creative force, this unknowable essence, God, intervenes in human affairs, giving guidance to humanity through individuals that have come to be known as the founders of the world’s great religions – through Buddha, Krishna, Zoroaster, Abraham, Moses, Christ, Mohammad and, Bahá’u’lláh.

The teachings brought by these manifestations of God bring two sets of teachings – spiritual teachings and social teachings. The spiritual teachings address the spiritual life and growth of humankind, and remain essentially the same – that we be loving, kind, merciful, just and peace-loving. The social teachings change from age to age because humanity changes, and the needs of society change. The social teachings become the basis of the laws of society, and upon them, great civilizations are built.

The teachings of the Bahá’í Faith address the needs of an emerging global civilization. They include the recognition of the essential oneness of humankind, the elimination of all forms of prejudice, the equality of men and women, the need for universal education, and the essential harmony between science and religion. So the fundamental teachings of the Baha’i Faith – that there is only one God, that all the world’s religions have come from the same source, and that humanity is one – are captivating the hearts and unifying people around the world. The Bahá’í s here tonight come from Buddhist, Zoroastrian, Jewish, Christian and Muslim backgrounds. We live and work believing that humanity is now on the threshold of that long awaited day when peace will envelop the earth, when we will regard ourselves as all one people, and the earth as a common homeland.

Again, we welcome you and thank you for joining us, on this celebration of the Bahá’í New Year, the festival of Naw-Ruz. We hope you will all enjoy yourselves. In the words of Bahá’u’lláh, “Rejoice with exceeding gladness”.

***
(Click on any of the photos to enlarge)

Preparing to Leave Saipan

Approaching Managaha. Look at that blue water!

At the Managaha dock.

Clear water, white sand, palm trees, blue skies. Just another average day in the South Pacific! Click on this photo to really appreciate the beauty (then click "back" to get back here).

Staying in the shade.

Managaha's eastern shore has been eroding. The soil is now gone, but the trees are still there. The whole island can be circumambulated in about 15 minutes (even with a two-year-old). That's Saipan in the background.

Managaha is the burial place of Chief Aghurubw. This is his statue and the plaque on the monument.

Ready to head home, after a great day. (This photo taken by a pair of Japanese tourists. Very nicely done! Domo arigato gozaimasu!).

CNMI Men's National Football Team Enters the World Stage!

2007-03-25T19:24:00.000+10:00

The CNMI Men's National Football Team won the admiration and respect of their nation and of the East Asian Football Federation (EAFF) this afternoon by playing competitively against Guam in the CNMI's first ever international match. Although Guam prevailed 3-2, the CNMI kept the match close, tying twice at 1-1 and then 2-2. Most remarkable is that the CNMI National Team has existed for only about six weeks, and the average age of the team is around 35, with the oldest player at 46. The oldest player on the Guam team is 25.

This was the first match in the East Asia Football Championships 2008. The team travels to Guam next week for the second qualifying match.

Congratulations to the CNMI Men's National Football Team, and to Coach Jeff "Ziggy" Korytoski! A national soccer team is born through Coach Ziggy's "Circle of Death". FIFA here we come.

(I took this photo from The Saipan Blogger . Visit his site to get a more personal view of the game. He's a starting member of the team.).

Forbidden Island

2007-03-28T22:22:00.000+10:00

“Don’t ever tell anyone I brought you here. And speak softly when we’re by the water’s edge.” With those words, our indigenous friend began to lead us down the steep trail to Forbidden Island, an outcropping off Saipan's eastern shore. It’s called “Forbidden” for a reason. A place of raw beauty, with a butte rising out of the sea, rock formations, tidal pools, and secret cold water caves, the ocean there swallows life. Any local will tell you, talk too loudly and the voracious sea wave will roar up from of the calmest day, like a screaming beast, foaming teeth bared, and snatch bewildered talkers from the shore, pull them deep, wring soul from bone, and maybe burp a broken body back, a floating consolation for family to bury.

And so again this week, the community mourns the death of four. College students out for a hike, a celebration of youth and life, turned tragic as friends watched helpless and stunned.

An island is defined by the sea. Without the sea, it does not exist. Its beauty comes from the sea. Its life comes from the sea. And death, too, comes from the sea. The sea is a life-giver and a life-taker, and when you grow up by the sea, you respect it as such. You fear it as such. You know the names, woven through the tapestry of generations, of those gone into it, never to return.

Learn to swim, and you may have a savior. But learn to swim and you may also have confidence, and cockiness and hubris that will draw you away from the safety of land and air, and into the seductive liquid arms that will grip you and teach you who is master. Learning not to swim is a greater savior, many a local family will tell you.

Duck, Saipan!

2007-04-02T05:20:00.000+10:00

Not the sort of "eye" I was expecting to write about this week, but here she is. Our first typhoon of 2007 is expected to hit in about 24 hours.

Unlike the coastal US, our buildings are constructed for these things, which come hard about every two years. Almost all our buildings on Saipan (and all the Marianas) are made of concrete, so we just board up the windows and wait it out. Hopefully no one gets hurt, and we get power back within a week or so.

And now a tsunami??!

2007-04-02T09:34:00.000+10:00

This just in. An earthquake in the Solomon islands has set off sensors indicating that a tsunami has been generated. The wave is due here in about an hour. If we survive this, we'll have a typhoon tomorrow (see below), and the following day, locusts, pestilence (more than usual) and the plague.

From the Pacific Tsunami Warning Center:

TSUNAMI BULLETIN NUMBER 003
PACIFIC TSUNAMI WARNING CENTER/NOAA/NWS
ISSUED AT 2239Z 01 APR 2007

THIS BULLETIN IS FOR ALL AREAS OF THE PACIFIC BASIN EXCEPT
ALASKA - BRITISH COLUMBIA - WASHINGTON - OREGON - CALIFORNIA.

NOTE: AREAS TO THE NORTH OF THE SOLOMON ISLANDS SHOULD NOT BE SIGNIFICANTLY
AFFECTED

... A TSUNAMI WARNING AND WATCH REMAIN IN EFFECT ...

A TSUNAMI WARNING IS IN EFFECT FOR

SOLOMON IS. / PAPUA NEW GUINEA / VANUATU / NEW CALEDONIA / NORTHEASTERN
AUSTRALIA / TUVALU / KIRIBATI / FIJI /

A TSUNAMI WATCH IS IN EFFECT FOR

KERMADEC IS / NEW ZEALAND /

FOR ALL OTHER PACIFIC AREAS, THIS MESSAGE IS AN ADVISORY ONLY.

AN EARTHQUAKE HAS OCCURRED WITH THESE PRELIMINARY PARAMETERS

ORIGIN TIME -  2040Z 01 APR 2007
COORDINATES -   8.6 SOUTH  157.2 EAST
LOCATION    -  SOLOMON ISLANDS
MAGNITUDE   -  8.1

MEASUREMENTS OR REPORTS OF TSUNAMI WAVE ACTIVITY
HONIARA  15CM ZERO-TO-PEAK OBSERVED AT 21:37 GMT

EVALUATION

SEA LEVEL READINGS INDICATE A TSUNAMI WAS GENERATED. IT MAY HAVE  
BEEN DESTRUCTIVE ALONG COASTS NEAR THE EARTHQUAKE EPICENTER AND   
COULD ALSO BE A THREAT TO MORE DISTANT COASTS. AUTHORITIES SHOULD 
TAKE APPROPRIATE ACTION IN RESPONSE TO THIS POSSIBILITY. THIS     
CENTER WILL CONTINUE TO MONITOR SEA LEVEL DATA TO DETERMINE THE   
EXTENT AND SEVERITY OF THE THREAT.                                
                                                                 
FOR ALL AREAS - WHEN NO MAJOR WAVES ARE OBSERVED FOR TWO HOURS    
AFTER THE ESTIMATED TIME OF ARRIVAL OR DAMAGING WAVES HAVE NOT    
OCCURRED FOR AT LEAST TWO HOURS THEN LOCAL AUTHORITIES CAN ASSUME 
THE THREAT IS PASSED. DANGER TO BOATS AND COASTAL STRUCTURES CAN  
CONTINUE FOR SEVERAL HOURS DUE TO RAPID CURRENTS. AS LOCAL        
CONDITIONS CAN CAUSE A WIDE VARIATION IN TSUNAMI WAVE ACTION THE  
ALL CLEAR DETERMINATION MUST BE MADE BY LOCAL AUTHORITIES.        

ESTIMATED INITIAL TSUNAMI WAVE ARRIVAL TIMES. ACTUAL ARRIVAL TIMES
MAY DIFFER AND THE INITIAL WAVE MAY NOT BE THE LARGEST. THE TIME
BETWEEN SUCCESSIVE TSUNAMI WAVES CAN BE FIVE MINUTES TO ONE HOUR.

Wax Museum of Saipan

2007-04-05T21:20:00.000+10:00

Every couple of months, our staff at Marianas Eye Institute gets together for a staff outing. Recently, we’ve gone to race go-carts, played beach volleyball, gone to PIC happy hour, and now last week, visited the Wax Museum of Saipan.

I’ll have to tell you, I was impressed. I don’t remember ever being to a wax museum before. After all, there never seemed to be much appeal in seeing statues of a bunch of famous people. You’re there to look at the wax, and ooh and ahh at how lifelike/waxlike everything appears.

Well, the Wax Museum of Saipan is different. In fact, it’s really not about the wax nor the statues. It’s an interactive lively museum of the history of Saipan. I learned a few things about our history that I had wondered about and hadn’t understood from visiting other museums on Saipan. Saipan history is depicted in scenes using life-size statues and figures. It is amazingly well done. It starts with the pre-history of the Marianas, and moves, room by room and scene by scene to the present day. The grand finale is a replica of the Governor’s Office, where you can sit at the desk, flags behind you, and have your photograph taken.

Each scene has a written description of the scene in English, Korean, Chinese and Japanese. The reading is brief enough that you get a good idea of the history without having to spend more than a minute reading – great for those like me who get a bit restless in museums.

The photographs throughout the museum are beautiful depictions of past and present scenes of Saipan life. There are sound effects and lighting effects, which bring many of the scenes to life.

The museum has also produced a documentary interviewing some of the local survivors of World War II. It’s playing in the reception area, and is worth seeing.

For local residents, the admission price is about the cost of a movie. If you are looking for a family outing, a place to take the kids on the weekend, an educational trip for your classroom, or a place to take a date, the Wax Museum of Saipan is a worthy option. I plan on going back.

The Wax Museum of Saipan is located in the heart of Garapan near GIG Discotheque. You may reach them at 233-7447. Support this great addition to Saipan.

How I Spent My Saturday Afternoon

2007-04-10T03:34:00.000+10:00

This gentleman had a corneal transplant done years ago in San Diego. The graft failed, which means it did not remain clear -- it turned white. A cornea is supposed to be clear, so that the light can shine through it. When it is opaque, the vision is poor. In his case, he could see light, and nothing more.

He came in because he was playing with his four-year-old son, who jumped up and banged his father's eye with his head. The eye ruptured, right along the interface where the graft had been sutured to the "host" cornea. Of course the sutures had been taken out years ago, but this area remained the weakest of the eye, and any significant stress would cause it to rupture right here at the interface.

It wasn't just a simple rupture though, since a bunch of the "guts" of the eye had also squirted out (Ewwww!) -- iris, intraocular lens, vitreous and more blood than anyone likes to see seeping out of an eyeball.

I spent about 3 hours getting everything sewn back together. This kind of eye surgery (actually almost all eye surgery) is done through a microscope (that's why it's called "microsurgery"). You can see that the sutures are thinner than the diameter of his eyelashes. Click on the picture or the diagram to enlarge them.

He's doing well now, and this photo is from yesterday. The goal was to simply put Humpty Dumpty back together again. There was no expectation that the vision would improve because of his previously failed graft. Luckily, I didn't need to remove the eye. He still has light perception vision, same as before the surgery. He's very happy to still have his eye. His other eye is normal.

What to you guys think? Want to see more of this kind of stuff? Click on "comments" below.

Advanced Cataract Surgery at Marianas Eye Institute

2007-04-13T08:22:00.000+10:00

We made the business section of today's Saipan Tribune. (That's the Commonwealth Health Center's two cataract surgery technicians, Lea Estinopo and Chris Batenga, in green). Here's the full story:

MEI Acquires New Device for its Cataract Patients

Marianas Eye Institute has purchased new equipment that improves the recovery time and enhances the safety of cataract surgery. The new device, called the Sovereign Compact cataract removal system, enables the surgeon to efficiently remove a patient's cloudy cataract using digitally modulated ultrasound.

Marianas Eye Institute CEO Russ Quinn and medical director Dr. David Khorram met with representatives of Advanced Medical Optics in Hawaii to arrange purchase of this newest technology.

“Advanced Medical Optics had announced the release of its latest Sovereign Whitestar technology, and we were eager to provide the latest and best for our cataract patients here in the CNMI,” explained Quinn.

A cataract is the clouding of the eye's lens and is part of the aging process that affects more than half the adults over 60. It is also very common in diabetics in whom it occurs at younger ages.

With over 2 million cases performed each year, cataract surgery is the most common surgical procedure in the United States.

The two Marianas Eye Institute official said they felt it was imperative to purchase this new equipment in order to continue providing the most advanced techniques and the highest quality care.

“With this brand new technology, there is nowhere in the world that is more up to date with cataract surgery technology than Marianas Eye Institute,” said Quinn. “We pride ourselves in providing world-class eye care. We have a multi-year agreement with Advanced Medical Optics to provide ongoing technology updates, ensuring that our cataract surgery system remains state-of-the art as new advances are made into the future.”

Prior to this new technology, the Marianas Eye Institute has been using the phacoemulsification technique (or “phaco”) since 1999. This type of cataract removal technique allows the cataract to be dissolved using ultrasound, and removed through a tiny incision, just over 2 millimeters in size. In most cases, stitches are not even needed. The procedure takes about 20 minutes and patients are home and back to their regular activities the same day. Khorram said it is virtually painless.

“This new Sovereign Whitestar technology is a major upgrade to the “phaco” technique. It is even gentler on the eye, and promises faster, easier recovery,” said Khorram. “We have used the Sovereign Whitestar cataract removal system for 14 patients so far, and it is an amazing piece of technology. For example, during the cataract surgery, the Sovereign Whitestar measures the pressure inside the eye 50 times per seconds and makes adjustments which make the surgery very smooth.”

To install the new “phaco” technology, AMO regional technician, John Garland, visited the CNMI from California for the first time and was impressed with Khorram's surgical skill. “He uses the latest cataract extraction techniques that are being used at U.S. mainland facilities. He has a brand new phaco machine which is the latest on the market and his microscope was recently upgraded to have the best view possible. Your patients in the CNMI are truly getting a world-class cataract operation,” said Garland.

Garland also praised the facilities, noting that it is more advanced than most in the US mainland. “I was very impressed with Marianas Eye Institute's office, overall organization, and cataract surgery facility. The office set up is a higher quality than most ophthalmologist offices here in the U.S. Very few facilities here have the advanced electronic medical records that Marianas Eye Institute has and very few have the ability to custom-make their own lenses for glasses. I was very impressive with the friendly extremely helpful staff.”

For more information visit Marianas Eye Institute or call 235-9090.

I'm about to do a very scary thing...

2007-04-16T21:07:00.000+10:00

For the past few weeks I've been working through a book many of you may have heard about: The Artist's Way, by Julia Cameron. It's honestly one of the most powerful books I've interacted with. I don't say "read" because it's not really a "reading" book. It's a "doing" book, with weekly assignments focused on various facets of developing creativity.

Well, here is this week's assignment: reading deprivation. Nothing reading. That's right. One week with no reading. No newspaper, no email, no websites, no books, no blogs, no magazines, no brochures, nada.

It's just a way to turn off the distractions and to turn inward; to find some inner quite space. Kinda scary for some of us. After all, what will I do if I'm not checking my email six times an hour, jumping from blog to blog, and paper to paper?!

I'm looking forward to the week. I've got my email autoresponder set, and I'm ready to see what chaos breaks loose. It's always fun to shake yourself up a bit. Care to join me?

Thank-you, Angie

2007-05-03T16:47:00.000+10:00

I've never met Angie Jordan. I stumbled upon her blog one day by clicking on "Next Blog" up there at the top of this page. She's a very talented cartoonist and artist in Philadelphia, and we linked our blogs. I visited her site today and saw this, which touched my family deeply.

For you, Arman

"I worked on a rendering of Arman last night to hopefully brighten his spirits, along with his family, in hopes he can recover, very soon, from a serious health concern.

"Best wishes Arman!"

It's people like Angie that make this a great world to live in.

There is nothing new to report. We're still awaiting mono test results, but he's really looking and acting healthy. He was invited to be in a segment for a "healthy cooking" TV show, and apparently was a real chatterbox in the studio today, telling everyone about how we don't have TV (so he won't be able to watch the show), and about how important it is to eat healthy food, and how his mom really likes vegetables.

If the mono test results are not back by tomorrow, I'll probably take him in for an ultrasound to see if his spleen is getting smaller. If it is, I think we're out of the woods.