Dear Cyndy,

Thank you for your two letters.

As for your question: Concussion of the head would not cause
"dry" macular degenerationa to turn "wet". Theoretically 
concussion might precipitate detachment of a retina whose 
support has been compromised by collapse of the vitreous jelly. 
I have never observed such a sequence of events. Otherwise the 
globe of the eye is deemed to be so well cushioned in its orbit 
(the bony enclosure), that aside from a blow directly to the
globe, head injuries sufficiently severe to damage the eye are 
deemed incompatible with survival.

Extrapolating from those of your previous medical decisions 
of which I am aware, I believe your decision to consent to
intravitreal injection of Avastin is the correct decision for
you. I do not know what decision I would make if I were in
your position. What I can say now would reflect nothing more 
than an hypothetical decision, and I believe an hypothetical 
decision can be nothing more than an exercise in logic and 
mathematics. Existentially a decision in an hypothetical 
context is a sham. If you don't understand what I mean, 
and want to know, just ask.

Telephone conversations seem to me a very efficient way to
communicate. In ten minutes I can explain ideas that would take
two hours to set out in an essay. Whether I could make myself
understood is another matter. You also might be able to express
yourself more readily and more freely in a conversation than in
a letter. As for the time, from my perspective no telephone
appointment is necessary, and you should not constrain an impulse
to call at any time. Except for consultations with patients
which are becoming less and less frequent, I am pleased to 
interrupt whatever I happen to be doing. As you know, our timetables
do not coincide. I am usually up until 11:30 p.m. or later, and I
try to get nine hours sleep. I don't mind being woken up, but I'm
blind until I get my contact lens in place, and even then it takes
me several minutes to shake off the muddleheadedness of sleep. So
the stretch of time from late morning until you head for bed would
probably be best. Alternatively it would be reasonable to plan
telephone calls by the calendar, and to make a tentative agreement
to telephone at biweekly or weekly intervals or even more often
at an agreed upon time. I'm very flexible and open to all
suggestions.

As for the treatment of your macular degeneration, I think you should
keep a very open mind as to how you will proceed. The injection on
Tuesday will not commit you to any specific course of action.
You may have fewer than three injections or you may have several
times that number. Wait and see how you feel about it.

So far as "terminal" care and the end of life are concerned, I
believe not only the medical profession, but our culture as a whole,
has it all wrong. I believe that death is a natural event, in 
some ways the most wonderful of all that befall us; that the
prolongation of life that cannot be productive or useful
is an obscene absurdity. My notions are so deviant from the
mainstream that I hardly dare express them. I wonder, if on
my deathbed, I'll change my mind and sing a different song.
Only time will tell.

I hope that as the days and weeks pass, you'll feel less
anxious and more confident, not about the outcome of the
macular degeneration treatment, but of you abiliky to be
happy and content in the face of whatever is ahead.

Please give my best to Ned.

Jochen