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THE
EVOLVING RETINA SPECIALIST: A PERSONAL PERSPECTIVE
LAWRENCE A. YANNUZZI,
MD
In
the past few decades, the retinal specialty has changed rather dramatically. The
comprehensive specialist has become a specialist-specialist. This professional metamorphosis
has been characterized mostly by the emergence of the medical-retinal specialist.
The medical-retinal subdivision finds its origins in the classic 1967 description
of "The pathogenesis of disciform detachment of the neuro-epithelium" by J. Donald
M. Gass, MD, which was published initially as a supplemental issue of the American
Journal of Ophthalmology.
Prior to this milestone in the
field, which is still worthy of reading by all retinal physicians today, a "retina"
specialist was essentially a "buckler" — an ophthalmologist trained to excel
in indirect ophthalmoscopy in order to find a "break" to reattach the retina. Inspired
by Dr. Gass' brilliant work and spurred by technological advances, a new breed of
retinal specialist began to surface in the early 1970s.
PIONEERS IN MEDICAL RETINA
With the introduction of a novel
diagnostic adjunct, fluorescein angiography, retina specialists began to develop
a deeper understanding of chorioretinal diseases and the pathologic mechanisms leading
to exudative and vasogenic manifestations. This new insight led to the proliferation
of superb medical-retinal texts and atlases.
Although many important publications
on the retina preceded this period, a few notable contributions from distinguished
international figures set the trend for future developments in the medical-retinal
arena. These individuals included Koichi Shimizu, MD (Japan), who wrote Atlas
of Fluorescein Fundus Angiography in 1968; Achim Wessing, MD (Germany), who
wrote Fluorescein Angiography of the Retina in 1969; Emanuel Rosen, MD (United
Kingdom), who wrote Fluorescence Photography of the Eye in 1969; and Dr.
Gass (United States), who wrote Stereoscopic Atlas of Macular Diseases in
1969. This last text proved to be the medical-retina "bible" — actually the
"Old Testament," as his later atlas, the fourth edition, is still the "New Testament"
in this area.
At the same time, an unexpected
development, the advent of medical-ophthalmic lasers, was to have a major impact
on the specialty. This monumental advance resulted originally from the work of a
number of early pioneers, but was then legitimized by the work of Gerd Meyer-Schwickerath,
MD (Germany), on Light Coagulation with the Xenon Photography in 1969. This
work led to the introduction of the Argon Laser Delivery System to a Slit-Lamp
Biomicroscope for Applications in Ophthalmology by Lloyd M. Aiello, MD, Francis
L'Esperance, MD, Arnall Patz, MD, and H. Christian Zweng, MD, here in the United
States.
This innovative technology justified
medical-retinal pursuits by offering a potential for treatment of previously unmanageable
chorioretinal diseases, most particularly diabetic retinopathy. Actually, the argon
retinal laser was developed more specifically for direct treatment of preretinal
neovascularization at the disk in the diabetic eye and focal treatment of retinal
pigment epithelium leak in central serous chorioretinopathy with a short, intense
burn. Curiously, both of these applications proved to be potentially harmful rather
than therapeutic in nature.
ADVANCES IN DIAGNOSTICS
An elite corps of academic clinicians
became the second generation of retinal specialists, combining surgical and medical
capabilities, as they were obliged to become exquisitely trained in the diagnostic
and therapeutic methodologies of the discipline. Skilled in critical and factual
analysis of their clinical and angiographic observations, these physicians furthered
the work of their predecessors. A list of these figures and their texts and atlases
can be found in the foreword of The Retina Atlas by Lawrence A. Yannuzzi,
MD, David Guyer, MD, and W. Richard Green, MD, published by Mosby in 1995.
Collectively, these publications
formed a literary chronicle of the early history of the medical-retina specialty.
These scholarly texts with beautiful illustrations coincided with technological
advances in imaging of the fundus, including enhanced methods for high-speed stereoscopic
retinal angiography. Clinical research retinal specialists identified new disorders
and better defined existing chorioretinal entities. Moreover, they published treatment
strategies that were ultimately indisputably confirmed through well-designed clinical
trials, beginning with diabetic retinopathy and retinal branch vein occlusion.
Matthew D. Davis, MD, John G. Clarkson,
MD, and Daniel Finkelstein, MD, set standards for retinal vascular disease. Shortly
thereafter, Stuart L. Fine, MD, at the Wilmer Retinal Vascular Center coordinated
a series of clinical trials on age-related macular degeneration (AMD). International
figures such as Alan C. Bird, MD, August F. Deutman, MD, Jean-Jacques DeLaey, MD,
Rosario Brancato, MD, Gabriel Coscas, MD, and Gisèle Soubrane, MD, provided
meaningful medical-retinal contributions.
Complementing fluorescein angiography,
the gold standard diagnostic adjunct, was an array of other diagnostic advances
that assist and augment the capabilities of retinal specialists. These include,
in chronological order, b-scan ultrasonography (D. Jackson Coleman, MD), indocyanine
green angiography (Dr. Yannuzzi), ophthalmic coherence tomography (Carmen A. Puliafito,
MD, MBA), multifocal electroretinogram (ERG) and microperimetary (Edoardo Midena,
MD), and most recently, fundus autofluorescence (Dr. Bird).
The addition of these tools to
the armamentarium of retinal specialists broadened their understanding of retinal
pathology and, more importantly, led to enhanced patient care. On the clinical-pathological
front, the legendary Dr. Green and the experimental clinical pathologist, John
Marshall, MD, made sense of the imaging observations and clinical correlations.
These early medical-retinal specialists and their contributions elucidated the multiple,
tortuous ways in which the medical-retinal specialty evolved. Their textbooks and
clinical scientific publications provided a practical, current, comprehensive, and
authoritative account of the field, reflecting unique concepts in diagnosis and
treatment.
Thanks to Lawrence J. Singerman,
MD, David H. Orth, MD, and Alexander J. (Sandy) Brucker, MD, the Macula Society,
a new professional organization designed initially to enhance the medical aspects
of retinal disease (macular disorders and retinal vascular diseases), was formed.
Paul Henkind, MD, PhD, Ronald E. Carr, MD, and I formed the original Fluorescein
Club in New York. This was followed by a pre-American Academy of Ophthalmology group
headed by Howard Schatz, MD, European counterpart groups, and even more recently,
a Midwest group led by William F. Mieler, MD.
SURGEONS IN TRANSITION
In the meantime, what happened
to the "buckler" and its organization, the Retina Society? Actually, the medical-retinal
specialist was initially derived from the ranks of these detachment surgeons, many
of whom had to relearn their trade. Except for a very few, the bucklers did not
have formal training or experience in the use and interpretation of fluorescein
angiography. They were basically familiar with xenon photocoagulation. So the transition
to laser photocoagulation was relatively simple. They learned the fundamentals of
fluorescein angiography as they switched from diathermy to cryosurgery to laser
photocoagulation.
The end result was a hybrid of
surgery and medical-retina, or the comprehensive retinal specialist and its society.
These specialists formed a professional organization, the American Society of Retinal
Specialists, originally called the Vitreous Society. The international retinal group
had, and still has, its society, the Club Jules Gonin.
In this period of transition, the
retinal surgeon had become the vitreoretinal surgeon, thanks to the pioneering work
of Gholam A. Peyman, MD, Harvey Lincoff, MD, Robert Machemer, MD, Steven T. Charles,
MD, Ronald G. Michels, MD, Mark S. Blumenkranz, MD, Stanley Chang, MD, and others.
Physicians like Michael T. Trese, MD, applied these principles, even to the pediatric
setting, which incorporated sophisticated vitreoretinal reattachment procedures
together with cryosurgery and laser therapy.
Gradually, some comprehensive retinal
specialists focused on one or the other — medical or vitreoretinal surgery.
Very few were able to master both ends of the surgical-medical retinal spectrum.
Morton F. Goldberg, MD, Stephen J. Ryan, MD, Jay L. Federman, MD, Gary W Abrams,
MD, Paul Sternberg Jr., MD, Kurt A. Gitter, MD, William Tasman, MD, Robert P. Murphy,
MD, William E. Benson, MD, Travis A. Meredith, MD, Gary C. Brown, MD, James C. Folk,
MD, Henry J. Kaplan, MD, Dr. Mieler, and perhaps above all, Thomas M. Aaberg Sr.,
MD, were some of these exceptional individuals who were able to excel in both areas.
MEDICAL THERAPIES IN FOREFRONT
The medical economics of the specialty
was also experiencing changes. Surgical retinal once constituted two-thirds of the
specialist's time and income. Now, medical retina assumes that role for most, but
not all, retinal specialists.
There is also now an increasing
prevalence of pure medical-retinal specialists with fellowships available for their
training, led by Dr. Schatz in macular disease, Lee M. Jampol, MD, in inflammatory
disease, Jerry A. Shields, MD, in oncology, Edward M. Stone, MD, PhD, in genetics,
and Neil M. Bressler, MD, in clinical trials. Gradually, stereo film-based imaging
evolved into exclusively digital systems for all of the diagnostic devices, clinical
trials, and patient management.
THE INTRAVITREAL ANSWER
This transition has been facilitated
by a new therapeutic concept, the intravitreal administration of pharmacological
agents. At last, there is a way to inhibit retinal vascular exudative or abnormalities,
and above all, vasogenic disorders, such as diabetic retinopathy and neovascular
AMD.
For the retinal specialist, the
first line of treatment is not necessarily laser photocoagulation therapy for some
cases of venous occlusive disease or diabetic retinopathy, and for sure neovascular
AMD. Rather, beginning with administration of steroids, first introduced by Dr.
Peyman, followed by Eyetech and pegaptanib sodium (Macugen), Genentech and ranibizumab
(Lucentis), and reformulation of bevacizumab (Genentech, Avastin) by Philip J. Rosenfeld,
MD, PhD, retinal specialists now have an array of alternative forms of treatment
to introduce into the vitreous for the treatment of chorioretinal diseases. Along
the way, medical-retinal specialists switched from thermal laser to "cold" laser
and photodynamic therapy (PDT) through the use of verteporfin for injection (Visudyne
QLT/Novartis) pioneered by Evan S. Gragoudas, MD,
and Joan Miller, MD.
Even without the legitimacy of
validating clinical trials, intravitreal administration of drugs, with its intrinsic
risks, limitations, and uncertainties, has become a worldwide standard of care,
sometimes in conjunction with PDT or so-called combined therapy, originally proposed
by Richard F. Spaide, MD, for neovascular AMD.
The intravitreal route of administration
will hopefully be supplemented by use of these medications with novel forms of drug
delivery that will avoid the necessity for repeated injections into the vitreous.
However, such alternative approaches are still futuristic. Similarly, retinal specialists
on the surgical end of the spectrum are still awaiting definitive developments for
removing scar tissue in the macula and replacing it with cellular transplantations
in neovascular as well as apoptotic disease.
Thus, in the past half-century,
retina has evolved in the most dramatic and gratifying fashion. With the advent
of new technological diagnostic adjuncts, surgical devices and instrumentation,
and novel therapeutic modalities, the specialty has segregated into surgical and
medical divisions, each rewarding in its ability to provide better ways to preserve
and restore vision. However, the comprehensive retinal specialist still persists,
particularly in suburban areas and outside of large teaching centers. There is great
promise and expectation in the future, thanks to imaging specialists, bioengineers,
molecular biologists, immunologists, and geneticists, who will pave the way to safer
and more effective treatment for the chorioretinal diseases that constitute the
main causes of vision loss.
| Lawrence
A. Yannuzzi, MD, is vice chairman and director of retinal services, Manhattan Eye
and Ear Hospital (New York) and professor of clinical ophthalmology, Columbia University
School of Medicine. |
Retinal Physician, Issue: January 2007