• Frances and Ray Stark Professor of Ophthalmology, Department of Ophthalmology, and Professor, Department of Epidemiology, School of Public Health, University of California, Los Angeles, 2004 to present and 2003 to present, respectively
• Associate Professor, Department of Ophthalmology, Charles Drew University School of Medicine, Los Angeles, 1998 to present
• President of Women in Ophthalmology, 2003 to 2006
• One of the best doctors in America, 2005 to 2006
• Awarded the AAO's Secretariat and Senior Achievement Awards, 2004
• Principal Investigator for the Ocular Hypertension Treatment Trial (NEI 5 U10 EY010428-01, 1994 to 2008) and the Ocular Hypertension Treatment Trial—Ancillary Study (NEI 5 U10 EY1115, 1995 to 1997)
1. How did your glaucoma fellowship training at the Wilmer Eye Institute in Baltimore affect you professionally?
I was fortunate to have as my mentors Irving Pollack, MD; Harry Quigley, MD; Alfred Sommer, MD; Alan Robin, MD; and Henry Jampel, MD. Besides the depth and breadth of their knowledge of the field, they each imparted to me their passion for glaucoma care. Dr. Quigley was my primary research mentor, and he taught to me the skills and knowledge requisite for success in a basic science laboratory. Using primate models, we did some of the initial work on the correlation of structural optic nerve damage and imaging devices.1,2 This work was funded by a training grant from the NEI.
Although my first exposure to ophthalmic epidemiology was through Marilyn Farber, DrPH, when I was a resident at the University of Illinois in Chicago, Dr. Sommer nourished my budding interest through guest lectures sponsored by the DANA Center and through collaborations on a study to evaluate the benefit of disc images versus photographs in the monitoring of glaucoma patients.3 As one of the examiners in the nursing home study that was part of the Baltimore Eye Survey,4 I learned about the collection and analysis of data in a population-based study. My clinician scientist training at Wilmer also consisted of the design, execution, analysis, and publication of five investigator-initiated pharmaceutical clinical trials with Drs. Quigley and Robin.
I worked with ophthalmology residents and glaucoma fellows who have become leaders in the field. When you consider the list of individuals (including John Morrison, MD; Don Zack, MD, PhD; D. L. Chris Diehl, MD; Jonathan Javitt, MD, MPH; Rohit Varma, MD, MPH; Paul Lee, MD, JD; Robert Derick, MD; and Louis Pasquale, MD), you can appreciate what a rich academic environment Wilmer provided.
2. Why did you decide to obtain a doctoral degree, and how did you manage the associated demands while a full-time faculty member at UCLA?
One of the attractions of a faculty position at UCLA was its strong School of Public Health. Bradley Straatsma, MD, then Chair of the Department of Ophthalmology and Director of the Jules Stein Eye Institute, had supported my longtime UCLA faculty colleague M. Roy Wilson, MD, MS, in his pursuit of a master's degree in epidemiology. While I was still a fellow at Wilmer, I had decided to pursue graduate study in this area. At first, I was only going to get my master's degree, but I realized that I could contribute more to ophthalmology and glaucoma care if I developed the independent research skills associated with doctoral study in ocular epidemiology.
Obtaining a career development award (also known as a “K” award) from the NEI was a key factor in my success, because the grant covered a substantial portion of my salary during my doctoral training. Without it, I would have needed to maintain a larger clinical practice. Still, I did have to juggle my doctoral training and the demands of a full-time faculty member, especially given the need to mentor residents and fellows and the fact that I was also a member of the UCLA institutional board of review at the same time.
I remembered Dr. Quigley's advice to take on challenges step by step with an aim of making progress every day. I remained extremely focused on the tasks at hand and sought to multitask whenever possible. Reaching difficult goals in the face of intense demands does require a certain amount of determination, but being able to draw on a passion for developing the scientific foundation for glaucoma care helped me through.
3. Do you think that evidence-based medicine will have a clinical impact on the management of glaucoma?
I think it already does. Evidence-based medicine is a way of thinking and approaching patient care. It requires the use of the published clinical studies to help make decisions about the management of glaucoma. Ophthalmologists order corneal pachymetry on their glaucoma suspects because of the evidence provided in the Ocular Hypertension Treatment Study (OHTS) that it is a risk factor.5 There is also evidence that lowering the IOP prevents the development of glaucoma in ocular hypertensive patients6,7 and slows down further visual field progression in open-angle glaucoma.8-10 There are many aspects of glaucoma care for which we do not have airtight evidence of clinical efficacy, and there will always be areas where we practice medicine without evidence, because not all of the patients we see are comparable to those who have been enrolled in clinical trials. The clinician's art is being able to navigate these gray areas to develop sound treatment strategies for individual patients. I believe, however, that the concept of evidence-based medicine helps point to areas where the data need to be strengthened and will lead to additional research to help improve the care of patients.
4. What motivated you to investigate the glaucoma-related issues of socioeconomics and quality of life?
Health services research is focused on the delivery of care, quality of care, and societal benefits of care. Medical training tends to concentrate on individual patients, but it is natural to think about how to optimize health outcomes in a world where human behavior and budgetary limitations constrain our choices. I consider ophthalmologists to be public health ambassadors. When we treat an individual, we are also acting as a line of defense for the patient's family and community and, ultimately, for society. By being aware that our individual decisions set standards and can have a global reach, we can be more effective as clinicians.
5. What are the most challenging aspects of being involved in a large, NIH-sponsored trial?
Being involved in the OHTS under the direction of Michael Kass, MD, and Mae Gordon, PhD, has been a tremendous career opportunity. Their contribution has helped move the field from indecision regarding how to treat ocular hypertensives to insight about the factors that predict the development of glaucoma in patients similar to those enrolled in the OHTS. One of the biggest challenges in the study has been keeping the coordinators and subjects motivated to remain in the clinical trial. With determination, data collection, and strategic communication, the OHTS Coordinating Center has done a fabulous job of helping individual investigators retain subjects.
Another challenge in a large sponsored trial is that treatment options must be considered in the context of an overall study protocol, the integrity of which is essential. Although the OHTS protocol includes the flexibility for individual clinical decisions, such as when the participating physician thinks that a patient needs more aggressive management, the Coordinating Center encourages communication with the study's investigators so that changes in treatment can be recorded and captured in the study's analyses.
The need to include large numbers of subjects inevitably requires a large investigative team, which by extension requires an administrative structure to make the project feasible. Physicians might feel it would be difficult to make an individual contribution to the study and therefore might be less motivated to get involved. Drs. Kass and Gordon have a yearly investigators meeting where we can learn from each other and offer our input about changes and new directions for the study. Part of the administrative structure is a Data, Safety, and Monitoring Committee, which must approve all decisions that affect the study. Because the ultimate goal of research is the advance of knowledge, we have to work cooperatively, on a national or international level, if we are to understand glaucoma.
1. Coleman AL, Quigley HA, Vitale S, Dunkelberger G. Displacement of the optic nerve head by acute changes in intraocular pressure in monkey eyes. Ophthalmology. 1991;98:35-40.
2. Quigley HA, Coleman AL, Dorman-Pease ME. Larger optic nerve heads may have more nerve fibers in normal monkey eyes. Arch Ophthalmol. 1991;109:1441-1443.
3. Coleman AL, Sommer A, Enger C, et al. Interobserver and intraobserver variability in the detection of glaucomatous progression of the optic disc. J Glaucoma. 1996;5:384-389.
4. Tielsch JM, Javitt JC, Coleman A, et al. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. The Baltimore Nursing Home Eye Survey. N Engl J Med. 1995;332:1205-1209.
5. Brandt JD, Beiser JA, Gordon MO, Kass, MA, and the Ocular Hypertension Treatment Study (OHTS) Group. Central corneal thickness and measured IOP response to topical ocular hypotensive medication. Am J Ophthalmol. 2004;138:717-722.
6. Kass MA, Heuer DK, Higginbotham EJ, et al, for the Ocular Hypertension Treatment Study Group. The Ocular Hypertension Treatment Study: a randomized trial determines that ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120:701-713.
7. Higginbotham EJ, Gordon MO, Beiser JA, et al, for the Ocular Hypertension Treatment Study Group. The Ocular Hypertension Treatment Study: topical medication delays or prevents primary open-angle glaucoma in African American individuals. Arch Ophthalmol. 2004;122:813-820.
8. The effectiveness of intraocular pressure reduction in the treatment of normal-tension glaucoma. Collaborative Normal-Tension Glaucoma Study Group. Am J Ophthalmol. 1998;126:498-505.
9. Lichter PR, Musch DC, Gillespie BW, et al; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108:1943-1953.
10. Heijl A, Leske MC, Bengtsson B, et al; Early Manifest Glaucoma Trial Group. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120:1268-1279.
