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Cover Focus: Family Tree | Feb 2017

The Mackools

The Greatest Understatement of My Life

By Richard J. Mackool Sr, MD

Having my son RJ follow in my footsteps and choose my profession is, of course, a great source of pride to me. Of much greater importance, however, is that his choice has enabled us to spend so much time together. Even when we are apart, we spend a considerable amount of time conversing by phone about our patients, therapeutic options, new concepts, methods, instrumentation, and so on. It is really a father’s dream.

Before his ophthalmology residency, RJ had training in general, plastic, and craniofacial surgery, so he was well positioned to assess our specialty. I have not asked him, but I would be surprised if he has not concluded that we have an incredibly gratifying occupation. I have felt that way since my first exposure to ophthalmology as a third-year medical student, a mere 49 years ago.


About 10 years ago, RJ was a plastic surgeon operating at our ambulatory surgery center. I would often call him in to watch interesting procedures such as artificial iris implantations and dislocated IOL repairs. He was thus exposed not only to the incredible beauty and elegance of these procedures but also to the miraculous results in the eyes (pun intended) of these and many other patients. It was at about that time that he was offered a position as director of the craniofacial service at a prestigious medical center. When he returned from his interview, I asked him what he was going to do. To my surprise, he replied, “I want to be an ophthalmologist.” To say that this was welcome news would be the greatest understatement of my life. I had absolutely no clue that he was even considering this career change.

Figure 1. A young Richard Jr (age 12) with Richard Sr.

How wonderful it is to be able to transfer decades of often painfully gained experience to your child, to watch him absorb it at lightning speed, then to add to it in ways that have improved the outcomes in many of our patients. A few examples of this: it was at RJ’s suggestion that we began to routinely perform viscodissection of the lens before phacoemulsification, when I had been doing it only for congenital cataracts. This immediately reduced our incidence of posterior capsular tears from 0.8% to 0.1%. Additionally, we have together developed improved suturing techniques to fixate dislocated IOLs, and he discovered a method to more accurately determine the amount of corneal astigmatism to be corrected at the time of cataract/IOL surgery. I have learned a lot from him, and his relentless effort to get things right inspires everyone around him.


As far as things I have taught him, I think that I have been able to reinforce such things as the value of patience, objective self-assessment, careful surgical planning, and what I refer to as a “Spock-like evaluation” of problems and issues. This was not a terribly difficult task; RJ already had considerable skills in these areas that made my job immeasurably easier.

On a number of occasions, he has helped me relearn the value of patience. Many ophthalmic procedures are challenging to master, and there can be a tendency on the part of those who have a lot of experience to place unrealistic expectations on those who are at earlier stages of the learning curve. (This tendency can be magnified when it comes to your offspring.) That said, RJ acquired skills so rapidly that only a modicum of patience has been required on my part.

Our greatest challenge initially was the unavoidable and expected desire of patients to have me perform all their surgeries. This issue has gradually faded as RJ’s skills and superb results have become obvious to all.


I have described a few of RJ’s contributions to both our practice and our specialty, and I am proud of them all. So, I will take the liberty of describing an enormously bittersweet moment that we shared. As the massive tragedy of September 11, 2001, unfolded in New York City, no one understood the dangers that existed for everyone in the vicinity of the disaster.

At that time, RJ was a general surgery resident at a nearby New York City hospital, and I was in another state, helplessly watching on television as both World Trade Center buildings collapsed. Fearing for RJ’s safety, I called and implored him to leave the city as soon as possible. Without a moment’s hesitation, he replied that the hospital was expecting many victims who would need burn care, and he was not going to leave. I managed to say something to the effect that I understood; we said our goodbyes and hung up. If the reader is a parent, there really is not anything more for me to say.

Accidental Oversight

By Richard J. Mackool Jr, MD

When I was a child (Figure 1), my father would bring me to the hospital, and I would sit at the nursing station while he did his rounds. When I was about 6 or 7 years of age, he brought me into the OR to watch a corneal transplant. I had access to cataracts in formalin for school projects, and medical journals were always around the house.

This all led to my interest in medicine as a profession. While I was in medical school, I became interested in the medical applications of computers, and I started working in the radiology department on imaging systems. I later worked in a craniofacial surgery department on 3-D modeling systems, and eventually I decided to go into plastic surgery.

After training in general, plastic, and craniofacial surgeries, I entered private practice, and over my first few years in practice, I became more interested in oculoplastic surgery. I started working in my father’s office and developed a renewed interest in intraocular surgery. I suppose being too familiar with ophthalmology from childhood had made me overlook it as a profession in the first place. I realized that restoring sight seemed like a better fit for me, over the long term, than plastic surgery.

Figure 2. The Drs. Mackool in the OR.

I liked the idea of working with my father, so I returned to the hospital, completed an ophthalmology residency, and started working with him full time. The transition was fairly easy, perhaps because I had already been in practice but now had a full-time, trustworthy partner.


When I first entered my father’s practice, patients naturally wanted to see my father, and I had people asking me the same questions I was asked as prompts for this article (“What made you want to go into ophthalmology?”). Those things never bothered me. I was more concerned with catching up to his level of expertise and mastering the skills that would make a difference for our patients.

I was lucky in that I did not have to make the mistakes most others have to as they progress in practice, and I had immediate access to an expert when needed. When one of my trabeculectomy patients developed serous choroidals with a shallow anterior chamber, I asked my father when to drain them. He immediately said, “I wrote a paper on that,” and he explained that, if there are more than two corneal thicknesses of aqueous between the cornea and lens, “you don’t need to drain them, and they will resolve.” Problem solved in two sentences.

We continue to work on cases together whenever we can (Figure 2), and those are usually our favorite cases in general. It is truly a family practice: My aunt is our practice manager, and to this day, she makes the practice run smoothly, allowing us to focus on the medicine. I have no qualms about saying I have been lucky in my choice of career.

Richard J. Mackool Jr, MD
Richard J. Mackool Jr, MD
  • assistant director, Mackool Eye Institute and Laser Center, Astoria, New York
  • mackooleye@aol.com
Richard J. Mackool Sr, MD
Richard J. Mackool Sr, MD
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