FAST FACTS
• Chief of the Glaucoma Service and Surgeon Director at the New York Eye & Ear Infirmary in New York
• Professor of Clinical Ophthalmology at the New York Medical College in Valhalla, New York
• Founder, Vice President, Medical Director, and Chairman of the Scientific Advisory Board of The Glaucoma Foundation
• President of the New York Glaucoma Research Institute
• Named Ophthalmologist of the Year by the Heed Ophthalmic Foundation, 1998
What prompted your involvement in founding the Ophthalmic Laser Surgical Society?
I began performing laser iridotomies in 1978, and, after completing four successful procedures in a row, I initiated the first course on the topic at the AAO. By 1982, there were 500 people in the audience, and it was standing room only. By this time, we had added argon laser trabeculoplasty to the course material, and new uses for the laser were rapidly being developed. I thought the time was right for a society based on laser surgery.
Raymond Harrison, MD, Francis L'Esperance, MD, and I founded the Ophthalmic Laser Surgical Society in 1981. We envisioned the organization as a forum for disseminating new information and as a model for other societies. Charter members included Drs. Ronald Carr, Max Forbes, Paul Henkind, Lawrence Yannuzzi, Keith Zinn, David Krohn, and Maurice Luntz. We formatted the meetings to begin with 5-minute lectures by members on their experience with a new aspect of laser treatment. The feature event was a guest speaker from out of town. More recently, we incorporated the topics of imaging and regenerative ophthalmology. We now have more than 50 members.
What are the goals of the Lindberg Society?
Ahti Tarkkanen, MD, of Helsinki, Finland, Gottfried Naumann, MD, of Erlangen, Germany, and I founded the Lindberg Society in 1998. The organization's purpose is to disseminate knowledge, advance understanding, stimulate research, and eventually effect a cure for exfoliation syndrome, the single most common identifiable cause of open-angle glaucoma in the world. John Lindberg, MD, first described the disease for his medical school thesis in 1917. We estimate that approximately 60 million people worldwide have exfoliation syndrome, and nearly 6 million have exfoliative glaucoma. The syndrome also predisposes individuals to angle closure and central retinal vein occlusion, and it is etiologically involved in the development of cataracts. The potential ramifications and importance of exfoliation extend well beyond glaucoma. Exfoliation material has been found in a number of systemic organs, and the syndrome has been associated with Alzheimer's disease, transient ischemic attacks, stroke, myocardial infarction, and vascular disease. Nonetheless, American ophthalmologists have been virtually uninterested in exfoliation syndrome. Because it was originally described in Finland, there is a longstanding misconception that it affects only Scandinavians.
We must learn the biochemical nature of exfoliation syndrome, the method of its production, what turns it on and off, and either how to prevent its formation or how to dissolve exfoliation material within the eye. Only a handful of people worldwide are researching this disease—the impetus behind the Lindberg Society's formation. In 1999, we held a conceptual Think Tank on exfoliation syndrome in order to share current thinking on the disease, develop new ideas, and generate interest from researchers within and outside of ophthalmology. Jorge Ghiso, PhD, at New York University is one of the world's foremost amyloid researchers, and he is now supervising one of our postdoctoral fellows in the biochemical analysis, production, and tissue culture of exfoliation material. We hope to make our symposia annual events in the future.
What effect do you feel the Optic Nerve Rescue and Regeneration Think Tank has had on the field of glaucoma?
During a 1990 dinner with Joseph LaMotta, who was then President of Oppenheimer Capital and Chairman of the Board of The Glaucoma Foundation, he asked for my thoughts on how we could apply the foundation's limited funds to deliver the greatest impact on the field of glaucoma. I suggested focusing on the fantastical possibility of restoring vision and reversing blindness through optic nerve regeneration and on molecular genetics. I further suggested organizing a think tank that would allow interaction between researchers in and outside of glaucoma.
In 1994, 12 participants attended the first Think Tank in New York City. The glaucoma clinicians included Paul Kaufman, MD, Robert Weinreb, MD, and me. Among the other attendees were Albert Aguayo, PhD, the director of the Center for Research in Neuroscience in Montreal, and Richard Bunge, MD, the Director of the Basic Sciences for the Miami Project for Spinal Cord Paralysis. The meeting began with the clinicians' giving an overview of the then current concepts of glaucoma, glaucomatous development, and glaucomatous damage. Sansar Sharma, PhD, spoke on the biological mechanisms underlying nerve regeneration, Dr. Bunge described the promotion and inhibition of axon elongation, and Dr. Aguayo spoke on the regeneration of visual systems in mammals. Other topics included neuroprotectants, ganglion cell rescue, neurotrophic and growth factors, and the principles of fetal tissue grafting and its potential applicability to glaucoma. The talks served primarily as a stimulus for discussion and synthesis.
The following year, Michal Schwartz, PhD, from Israel spoke on her optic nerve crush model, the relevance of cross-talk between the immune system and nervous system in neuroprotection and neuroregeneration after optic nerve injury, and its relevance to glaucomatous optic neuropathy. Dr. Schwartz had been unfamiliar with glaucoma research, and most of the glaucoma investigators had been unaware of her optic nerve crush model. It was at this meeting that the concept of neuroprotection for glaucoma was born.
Topics of discussion at the 1996 Think Tank included the pharmacology and molecular biology of NMDA receptors, stimulating the regrowth of cut retinal ganglion cell axons, the role of astrocytes in glaucoma and optic neuropathy, the implications of inflammation for optic nerve regeneration, and the potential for future work in gene therapy in glaucoma. Robert David, who was then Research Director of Allergan, Inc. (Irvine, CA), was present. After an intense discussion on the possibility of bringing about neuroprotection for glaucoma, participants ultimately decided that the best available compound for neuroprotection was memantine. One week later, Allergan, Inc., bought out Cambridge Neurosciences and began the current global trial assessing the efficacy of memantine in patients with glaucoma.
After continuing to focus on neuroprotection for 2 more years, we switched the focus of the 1999 Think Tank to the molecular genetics of glaucoma and the genetics of ocular development. Julia Richards, PhD, was Senior Research Scientist for the Department of Ophthalmology at the University of Michigan. She was instrumental in our efforts to begin establishing research collaborations and developing specific research goals. In 2000, the Think Tank participants discussed a set of concepts that could eventually pull together genetics, immunology, and neuroprotection for glaucoma. By 2001, we were able to focus the Think Tank on the potential of gene therapy for glaucoma, and the Ninth Annual Think Tank in 2002 centered on the topic of stem cells and glaucoma.
How has working internationally broadened your view of the glaucoma subspecialty?
Working internationally has been one of the most satisfying portions of my career. I made my first trip abroad in 1981 to attend the Asia Pacific Academy of Ophthalmology in Bangkok, Thailand. I fell in love with the country and decided that I must have been Thai in my last life. At that meeting, Hung Por Tying, MD, from Taipei, Taiwan, and I gave the first presentations in Asia on laser iridotomy for angle closure. During a return trip in 1982, I learned that I was the only foreign ophthalmologist to visit Thailand that year. As a result, six other ophthalmologists and I organized the First Annual Bangkok Ophthalmological Symposium in 1985. At that time, there were only 80 ophthalmologists for 55 million people in Thailand, and most of those ophthalmologists, as well as nurses and residents, flew in for the meeting. We had an audience of approximately 200 people—one of the most appreciative audiences I have ever had, in fact. By the mid-1990s, the number of ophthalmologists in Thailand had grown to nearly 800, and new residency programs had been established all over the country.
I began my trips to Malaysia in 1987 when I was ophthalmologist to his Highness Tunku Abdul Rahman, the founder and first Prime Minister of the Malaysian Federation. I scheduled a day of ophthalmology lectures for August 30th without realizing that it was the 30th anniversary of Malaysian National Day, which was to be celebrated countrywide with events, parades, and celebrations. Nevertheless, two-thirds of the Malaysian ophthalmologists attended the conference. Plans to build a glaucoma center at the Tun Hussein Onn National Eye Hospital in Kuala Lumpur were derailed a few years ago by the country's economic crisis, but I hope the project will proceed soon.
In 1990, I became, to my knowledge, the first American legally to enter Laos alone since the end of the Vietnam War. There was only one formally trained ophthalmologist in the country. Vithoune Visonavong, MD, who had trained in the Soviet Union with Svyatoslav Fyodorov, MD, was performing two full-time jobs: running the Eye Hospital and single-handedly establishing a National Prevention of Blindness Program. I used my connections in Thailand to enable medical students from Laos to obtain residency training in the former country.
I commenced my trips to Myanmar in the mid-1990s. There are approximately 60 ophthalmologists for more than 50 million people, and some provinces such as Kachin State have a population greater than 2 million but only a single ophthalmologist. In addition to other ophthalmologists, a psychiatrist and neuroradiologist have accompanied me on my travels to Myanmar, and they are now busily establishing their own programs there. This is the last unspoiled country in Asia.
I must give credit to the many ambassadors of Southeast Asian nations to the United Nations. Their friendship and assistance over the years has facilitated the organization and the logistics of the programs I have outlined herein.
What do you believe are the greatest challenges that the field must face in the next 2 decades?
Within the next 10 to 20 years, gene therapy will become a reality, and our increased knowledge of that field, as well as of stem cell replacement therapy and tissue bioengineering, will ultimately enable us to reverse blindness and regenerate the optic nerve. Progress will occur more rapidly on therapy for diseases of the photoreceptors such as retinitis pigmentosa. In glaucoma, we will need not only to regenerate retinal ganglion cells, but also to cause them to enter the optic nerve, proceed to the lateral geniculate body (which is also pathologically affected in glaucoma), make connections there, and find a way to transmit visual impulses to the visual cortex in a functional manner. I think that achieving these goals will take a long time.
We will also come to understand the genetic and molecular causes of common diseases leading to glaucoma, including exfoliation syndrome. A great challenge will be transmitting across the globe what we learn and develop. As the populations of many countries grow and the proportion of elderly individuals increases within those populations, the incidence of glaucoma will rise steadily. I hope to be able to use my positions on the International Committees of both ARVO and the AAO and on the Advisory Committee of the International Council to help improve ophthalmologists' abilities to diagnose and treat glaucoma in the many countries that presently have a high rate of blindness due to this widespread and debilitating disease.
