Article Date: 1/1/2007

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THE EVOLVING RETINA SPECIALIST: A PERSONAL PERSPECTIVE

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