UPFRONT

The Big Picture

PETER K. KAISER, MD

Here’s the big picture. I am writing this column with my seat leaned back, a nice cup of green tea by my side, and in an almost silent cabin traveling at 250 kilometers an hour between Kyoto and Tokyo on the Nozomi Shinkansen, better known as The Bullet Train.

My computer is plugged in, and I am surfing the internet with WiFi. I was dropped off at the station 10 minutes before departure, and I did not have to pass through any security checks (this may not be a good thing, but in a society like Japan, it works).

We will arrive precisely on time, as the average delay all of last year on the Shinkansen was 30 seconds. The trip will take two hours with three stops, considerably faster than flying. I can walk around, have a nice bento box in the lounge, and admire the incredible scenery, including Mount Fuji. This is the way to travel. If you are ever in Japan, you must take this train.

In the United States, we have been trying for years to build a similar highspeed train system. However, we were missing the big picture. The closest equivalent is the Acela between Boston and Washington, DC, which shaves minimal time over the non-express trains.

The recent stimulus package gave the states money to build a true high-speed rail line. Almost all of the state governors only saw the small picture of having to maintain the line after it was built and not the big picture of what it would do for travel in the United States. One of the few states to keep the money was California, but it remains to be seen if a San Francisco to San Diego line will ever be built.

What does this have to do with retina? In the past, we have looked mainly at the central macula in vascular diseases, such as diabetic retinopathy. Certainly, looking at the periphery with sweep views was possible, but such views were rarely obtained.

With the advent of widefield angiography, it is now possible to image both the central macula and periphery in the same view, offering new insight into vascular diseases. Physicians who look only at the macula are missing the big picture. In many instances, recalcitrant diabetic macular edema responds remarkably well to peripheral scatter laser photocoagulation. Without the big picture, these patients would be getting serial anti-VEGF injections or focal laser treatments with little effect.

We are only beginning to see the potential of this larger view in retina. It’s too bad that the governors didn’t with our US bullet train.