Méndez Caratini is a professional ophthalmic photographer. These series consists of color retinal photographs and black and white fluorescein angiographies documenting different pathologies and diseases of the eye.

Ricardo Viera
Lehigh University Art Galleries
Director / Curator
Bethlehem, PA
October 2003

White people see with their eyes.
While shamans (medicine men)
see with their minds.

THE EYES OF THE MIND

Héctor Méndez Caratini in Conversation with Ricardo Viera
(The following interview took place over the internet from February to May 2015.)

Without the eye and the mind, there is no art—there is no photography. The reciprocal and collaborative phenomena that a visual image is able to inspire and challenge us to interpret and describe images as words and words as images, is a creative humanistic journey. Photography is at the same time an ever-growing scientific discovery and bonafide universal art medium within the living theater of the mind and the eye. In the 80’s I established a photography exhibition series at Lehigh University Art Galleries from our Teaching Collection, called “Intentions and Techniques” as an advanced exercise of looking versus seeing and photography as contemporary art: techniques could be appropriate to direct intention, as well intentions may inform techniques or a function of technique may inform what the photographer’s intention is not about. Endless possibilities are attached to the sense of unity in a medium constantly and rapidly changing since its invention in 1839.

Opposite:
The Eye as Art.

Ricardo Viera: In the 1930s, when the visionary engineer and inventor of the stroboscope, MIT professor Harold “Doc” Edgerton (1903–1990) [Fig. 1], was involved in experiments that led to what is known today as electronic flash photography, the term “art” was not part of the scientific vocabulary. However, in 1934 Edgerton was awarded a medal by the Royal Photographic Society. Do you think the ophthalmic community today considers what you are doing, in addition to its important scientific underpinning, an art form? Explain to us, if so, how, keeping in mind that fine art expressions, particularly abstract images, continue to be not well received and only accepted and collected by a minority.

Héctor Méndez Caratini: In his day, Doc Edgerton was a well-known scientific revolutionary who used new technology to create artistic images. Today, in the Ophthalmic Photographers Society, artistic scientific images are considered to be part of the vocabulary. This organization has created several categories in their annual Scientific Exhibit Best of Show Awards, held in conjunction with the American Academy of Ophthalmology Convention. Excellent—or we might say “beautiful”—eye photographs are publicly recognized.

On the other hand, I have tried without much success to introduce my deliberately artistic—that is, non-ophthalmic—work into the educational programs of the OPS, at its annual conventions. I’ve been told that my artistic work—the work not related to ophthalmology per se—is of no educational value to the participants in the convention, because their members will not receive OPS or JCAHPO credits if they come and listen to my talk. Even so, through perseverance, during my last PowerPoint presentation to the OPS members I managed to let them know the influence that ophthalmic collages have had on my artistic work. I showed them how images from my Fiebre series (2004–2008) [Fig. 2] use retinal collages as their source of inspiration.

I, and another artistically inclined friend, have managed to organize get-togethers after the official meetings are over, at which we show our artistic work to the public. The editor of the Journal of Ophthalmic Photography has been very receptive to this, and has invited me to publish two different photo-essays [Fig. 3] of my artistic photographs in that journal.

RV:      Looking at the images of the retinopathy series you are currently creating, I have to admit that the fear of a decorative result may or may not affect the aesthetic integrity of such science-specific and health-related subject matter. But that turns out not to be a problem at all. The images transcend the ordinary. There is not really a concern in your technological analysis about including D-Stretch software. Interestingly enough, the technological balance of the work speaks for itself.

HMC:   In 2014 I began experimenting, on my own, with a computer software program called D-Stretch. It is one of the technologies used by NASA on the Mars Exploration Rover Mission [Fig. 4] to analyze images sent by the orbiter and robot back to Earth. This scientific technology has never been applied to ophthalmology. I believe, though, that it’s a useful tool that can be incorporated into the study of retinal images—specifically the program’s filters that highlight the red channel, which can be used for viewing the choroidal and retinal vasculature, as well as pigmented lesions.

The variations that can be obtained from a single image when several D-Stretch filters are applied to it are endless. Chance plays an important role in the result. When seen together, these images, from an artistic point of view, are reminiscent of Pop Art and Andy Warhol’s avant-garde photographs [Fig. 5]. I have played with the element of chance in previous bodies of work, such as Xibalba (1987) [Fig. 6] and The Buddha Series (2010) [Fig. 7]. In the former series, the color was added via an electronic signal to the original black-and-white images.

Also, one of the private medical practices I work with has acquired a brand new ultra-wide-field camera that uses a laser as its main light source. With this equipment I have been able to create new scientific images with considerable, I think, artistic value. This revolutionary instrument takes images at varying wavelengths that can help in diagnosing many illnesses and conditions. They are used in such tests as indocyanine green angiography, fluorescein angiography, autofluorescence, infrared, blue, and green peak filters, etc.

Furthermore, the use of optical coherence tomography enables you to view cross-sections of the retina, in situ and in real-time, allowing the ophthalmologist to map and measure the thickness of the various layers of tissue. These measurements can help in the early detection, diagnosis, and treatment of many retinal diseases.

So you see, there is an intimate relationship between art and science, whether people perceive the image as decorative or not. Some photographs are a feast for the eyes, as well as for the mind. Ophthalmic imaging is a very advanced field. The future of diagnostic imaging depends on emerging scientific medical technologies, such as three-dimensional OCT and fluorescein angiography OCT. The techniques related to this profession have unquestionably influenced my personal artistic work.

RV:      Creatively documenting the struggle for identity and loss of culture, assimilation, and nationality, syncretism and popular religious beliefs in Latin America, the rest of the Caribbean, and particularly on your own native island has earned you a well-deserved place in the history of Puerto Rican photography. Interestingly enough, in the last few years, you have also been creatively documenting other faraway cultures very different from your own. What motivates you to do that and what are you looking for photographically?

HMC:   My visual research projects take several years to complete. For example, I worked on Loiza (1975–1996) [Fig. 8] and the Petroglyphs series (1975–1995) [Fig. 9], in parallel, at the same time, for over two decades! I also finish some series while working on others simultaneously.

My photography, as you noted, has several common threads. Even today, there are topics that recur in my current Asian Period (2010-2014), which I’ve been documenting for the past four years.

But change is also an integral part of the scenario. My profession as an ophthalmic photographer has taught me to have patience while studying the pathological changes that occur in a patient’s eye. In the several major medical clinical trials, I have participated in (principally the Diabetic Retinopathy Study [1973–1979] and the Early Treatment Diabetic Retinopathy Study [1979–1989]), I have photographed the same patients’ eyes over a period of ten years! The subject of death is also present in my work—the death of a culture, as in Dreams of the Patriot (1977–1979) and Vieques: Chronicles from Hell (2000) [Fig. 10], and death itself, as in my current photo-essay on cockfights, titled Invictus (2014–2015) [Fig. 11].

Since early in my career, I have traveled all over the world trying to figure out why people think the way they do. It’s fantastic! The quest has taken me to many countries (Haiti, Venezuela, Brazil, Peru [Fig. 12], the Amazon [Fig. 13], Borneo, Tibet [Fig. 14], Nepal [Fig. 15], Bhutan [Fig. 16], Cambodia [Fig. 17], Thailand, Japan, China, and others), where I document the many manifestations of religious beliefs.

White people see with their eyes. While shamans (medicine men) see with their minds (thus the reference to the title of this conversation). I record the ancient wisdom of the world’s indigenous peoples from an anthropologist’s ethnologist’s perspective. It is my own eternal search for the universal within the particular. So it really doesn’t matter where, in what country, I am documenting. It is mankind’s spiritual search, and the conservation of nature as a whole, that interests me.

RV:      Within photography, there is a long-running debate over whether photography tells the truth or lies. In other words, is photography another way to perceive reality or just a change in the manner we are conceiving its reality—as well as conceiving ourselves? From that perspective, we tend to push the artistic discourse in diverse platforms that do not totally satisfy the sensibility of a contemporary artist when the subject is being introduced as a “weak thought” (pensiero debole). In the semiotic terms of postmodernist philosopher Gianni Vattimo, is the duality of your photographic indicators and the iconographic effect of your retinopathy imagery the essence of your artistic discourse?

HMC:   Gianni Vattimo’s model of the pensiero debole (weak thought) is found above all in the arts, where a model of verità (truth) is presented that is adaptable and susceptible to an infinite number of interpretations. In his book La fine della modernità (The End of Modernity, 1985), Vattimo says that “the postmodern experience of the truth is an esthetic experience.” According to him, the claim that “there are no facts, only interpretations, and this too is an interpretation” amounts to saying that hermeneutics cannot be seen as the most accurate description of the permanent structures of the reality of human existence.

Therefore, we can conclude that what constitutes the truth is debatable. It all depends on the creator of that particular truth. Truth, like beauty, has many manifestations, and many meanings, depending on who interprets those manifestations. Also, this esoteric philosophical concept is very similar to the layman’s proverb “Beauty is in the eye of the beholder” and to English poet John Keats’ oft-quoted lines from “Ode on a Grecian Urn”: “Beauty is truth, truth beauty. That is all/ Ye know on earth, and all ye need to know.” This implies that the perception of beauty, and of truth, is subjective. Different people, according to their cultural values, have different ideas as to what is beautiful or what is the truth.

In this particular case, I am documenting images of eye diseases. Whether the spectator finds beauty in them or not, truth or lies is not really important. What matters most is that I have selected them because they are images that say a lot about the interpretation of specific eye diseases. My other artistic images, such as the ones manipulated with D-Stretch filters to accentuate colors, do not imply truth or lie either. The beauty of the retinal images in this series is just a means to an end, which is to produce images with artificially saturated colors that might be of help in accentuating choroidal lesions and by doing so, help in the diagnosis of certain eye diseases. That is the essence of my artistic discourse here. As you can see, I am a compulsive image gatherer. I create atlases of different bodies of work and I leave to others the interpretation of my legacy. 

THE UNIVERSE WITHIN

Héctor Méndez Caratini

The retina [Fig. 1] is a layer inside the eyeball containing neurosensory cells that are sensitive to light and trigger nerve impulses that pass down the optic nerve to the brain, where a visual image is formed. The eye is composed of several layers: the sclera, vitreous, choroid, retina, optic nerve head, macula, etc. The optical instrument used to photograph the retina is called a fundus camera, as “fundus” is the technical name for the rounded part of the eye opposite the pupil.

The German optical-lens and camera manufacturer Carl Zeiss introduced the first commercial fundus camera in 1926. Four years later, filters were developed to observe dyes flowing through retinal blood vessels. In 1953, electronic flash technology was applied to fundus photography.

Angiography is the study of blood circulation. Angiograms are helpful in determining the caliber of vessels, detecting circulation blockage, ischemia, neovascularization, macular diseases, site-specific diseases, and so on. Retinal angiography allows the ophthalmologist to study the entire retinal vasculature.

In 1961, two medical students, Harold R. Novotny and David L. Alvis, successfully performed the first retinal angiogram. They used a fundus camera equipped with an exciter filter, barrier filter, and electronic flash to document the blood flow in the retina after a sodium fluorescein injection. The men co-authored a groundbreaking scientific paper titled “A Method of Photographing Fluorescence in Circulating Blood in the Human Retina”.

Sodium fluorescein [Fig. 2], as its name might suggest, is highly fluorescent. In a fluorescein angiogram, the fundus camera’s exciter filter does just that: it excites the molecules of the fluorescein dye, which then absorbs blue light between 485 and 500 nm [Fig. 3]. The energy imparted to the molecules by the absorption causes the molecules to emit a green light of a longer wavelength, between 520 and 530 nm, and the barrier filter allows only that green light to continue into the image-recording device. The fluorescent green light tells us where in the retina the sodium fluorescein has traveled.

There are several phases in an angiogram. The Early Phase photographs are critical in certain clinical diagnoses, such as for macular degeneration. These are the rapid sequence of images of the initial blood-flow dynamics of the fluorescein dye in the choroid and arterial filling of the retina. Mid Phase photographs correspond to the venous filling phase and the recirculation (arterio-venous) phase. The Late Phase occurs at five to seven minutes post-injection and will reveal the extent to which the sodium fluorescein did or did not leak.

Color fundus photographs of the retina are taken at the beginning of the study. Monochromatic Red Free black-and-white fundus photographs, which accentuate red lesions, are also taken with a green filter. There are many more photographic techniques available to highlight other types of retinal pathology. Among these are autofluorescence filters and indocyanine green angiography. The newer camera models utilize a laser as the main light source, and this technique produces images in other wavelengths, such as blue, green, infrared, etc.

Another useful technique is stereo fundus photography. This three-dimensional procedure requires that two slightly different images of the same area of interest be taken, either sequentially or simultaneously. When viewed together, with a stereopticon, the viewer’s brain fuses them together into one single image. Tissue depth relationships can be observed in this special close-up macro photography of the human eye.

Fundus cameras are manufactured with different angles of view (the optical angle of acceptance of the lens). In the 1970s, 30 degrees was considered the normal angle of view. Today, wider angles, with views of 45 degrees through 140 degrees, are preferred.

I began working as an ophthalmic photographer in 1973 in the University of Puerto Rico School of Medicine’s Ophthalmology Department. A year later, I attended one of the first annual meetings of the recently founded Ophthalmic Photographers Society. It was held at the American Academy of Ophthalmology Convention in Dallas-Forth Worth, Texas.

While at the University of Puerto Rico School of Medicine I worked on the Diabetic Retinopathy Study (DRS). It was the first, and largest-ever, randomized multicenter clinical trial sponsored by the National Eye Institute in Bethesda, Maryland. Over 1,700 patients were enrolled and 16 U.S. medical centers participated in the ten-year investigation. The trial documented the value of laser photocoagulation in reducing the risk of visual loss from diabetic retinopathy, then the leading cause of blindness in the world, thus saving the eyesight of millions of diabetics.

Ophthalmologist Matthew D. Davis, of the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, was the founding director of the DRS. He helped to develop the standards in photographing the fundus for diagnostic study. He also established the Fundus Photograph Reading Center where retina photographs would be graded and studied. Stereoscopic photographs of the seven standard fields [Fig. 4], were taken, at a 30-degree angle of magnification, every three months, so that changes in the pathology could be detected over time.

Later on, from 1985 to 1987, I worked at the Joslin Diabetes Center, academically affiliated with Harvard Medical School, based in Boston, Massachusetts. Joslin is the world’s largest diabetes research center, diabetes clinic, and provider of diabetes education. Under the leadership of world-renowned ophthalmologist Lloyd M. Aiello, I participated in several other clinical trials that were being carried out at that time, such as the Early Treatment for Diabetic Retinopathy Study, Diabetes Control and Complications Trial, Sorbinil Retinopathy Trial, Pregnancy Study, and many others. In 1986, while at Joslin, I became accredited as a Certified Retinal Angiographer by the Ophthalmic Photographers Society.

Since 1989, I have been an independent freelance photographer working in several private retinal practices, including the Veterans Administration Medical Center in San Juan, Puerto Rico. Working in the medical field has helped me to keep abreast of technological breakthroughs. I was one of the first photographers in Puerto Rico to use digital photography before the technology became widely adopted.

Today, I use several different software programs to compose collages or montages. I digitally stitch together several photographs, next to each other, to attain a wider-angle view of the retina. Last century, photographs were printed on paper and then glued together on a larger piece of paper. Since adopting digital processing, I have used this collage technique to produce my artistic photographs, such as the Ser o no ser diptych (1998) [Fig. 5] and the Fiebre series (2006–2008).

With imagination, one can “see” the cosmos, stars, and distant galaxies inside the human eye. This is what I call the macrocosm in the microcosm. In my mind, images of the universe resemble images of the world within our bodies. Circular red images of the retina [Fig. 6] resemble NASA photographs of Mars [Fig. 7]. Some diseases, such as asteroid hyalinosis, resemble distant yellowish bright stars. One can envisage star clusters, or the Milky Way [Fig 8], in a Mid Phase angiogram of diabetic macula edema. Floating hemorrhages in the vitreous cavity might be perceived as faraway nebulas [Fig. 9].

At this moment in time, with the evolution of technology, almost all manufacturers of the newer models of fundus cameras integrate optical coherence tomography into their equipment. This diagnostic imaging tool, which has been around for over a quarter-century, allows for high-resolution images of cross-sections of the retina, providing a straightforward method of assessing macular degeneration.

Recently, I have been experimenting, on my own, with the use of Decorrelation Stretch technology to enhance retinal images. As the name implies, decorrelation stretch is a process that is used to enhance (stretch) the color differences found in a color image. It has been used in remote sensing devices to enhance multispectral images. NASA used it successfully to enhance the Mars Curiosity Rover Robot images. I have experimented with this technology in some of the photographs seen in this book, giving it a pioneering scientific application, to help accentuate lesions not often so clearly viewed, and for artistic purposes, to attain Pop Art like images.

In conclusion, the camera and the eye join together in my medical work, as the epitome of the universe. The camera is, for me, an indispensable instrument serving mankind, utilized for the identification and documentation of eye diseases. The ophthalmic photographs I take serve as a diagnosis and treatment tool helping doctors care for their patients and thus helping to preserve the vision of thousands of people at risk. The photographs seen here are a commemoration of my life’s work—a four-decades-plus career of uninterrupted work in the profession. The same basic principles can be applied to my personal artistic work, which serves, anthropologically, as a visual catalog of the races and countries of the world.