What interests you about congenital glaucoma?
Fixing congenital glaucoma is unquestionably the
most positive experience I have had as a glaucoma doctor.
To see people on whom I operated 25 years ago
drive their cars to my clinic is incredibly rewarding.
The year after I finished my fellowship, my then-partner John Lynn, MD, and I had a case involving a 6-month-old with congenital glaucoma. The affected eye was so large as to render standard instrumentation useless. I looked at Dr. Lynn and said, we have to think of something better. He mentioned having heard Redmond Smith, MD, say that one could put a suture in the canal to open it. During the case, I suggested using a blue suture so that it would be visible on gonioscopy. We placed the suture and were able to open the canal for 360° with two incisions. It was an incredibly exciting moment, and the baby did really well. We began using the technique with increasing frequency before reporting on it.1 Suture trabeculotomy is now used by surgeons all over the world. The funny thing is, after Dr. Lynn and I completed our first suture trabeculotomy, I looked up the article by Dr. Smith and saw that his work was on cadaveric eyes.2 I now realize how much Dr. Lynn taught me. The technique is described in detail with improvements by Beck and Lynch.3
Congenital glaucoma interests me so much, because the suture trabeculotomy has improved with new instrumentation such as microcatheters to help find the canal. It is fascinating to me to see gonioscopically how the blood-aqueous barrier repairs itself in babies and allows the drainage system to function. These patients have pressures of 10 mm Hg 20 years later.
How can physicians maximize the utility
of visual field testing?
What drives me nuts is seeing clinicians
test—sometimes for 10 to 20 years—the
entire central 30° of the field of a patient
who only has a 10° field. That testing
yields little information and makes the
patient feel hopeless, because he or she
does not see the light for a long time, if
ever. Unfortunately, this approach to testing is what doctors
are taught.
Visual field testing should be tailored to the patient's stage of disease. For example, for someone with tunnel vision, the field should only cover the central 10°. This strategy will produce far more accurate data, and the patient will feel better about the test and be less fatigued. It is a win-win situation. Another pearl is to use a larger test object (stimulus size V vs III) if the patient's visual field is very damaged but in a generalized way. Suddenly, the physician may uncover a large portion of the visual field that he or she thought was blind but is not. The clinician can then help to preserve that vision.
In terms of the future, I anticipate continued improvement in the algorithms to achieve threshold and the statistical packages to determine progression.
Where do you see glaucoma surgical interventions
heading in the next 10 years?
The key is channelography, which will be the corollary
to the arteriogram for cardiologists. The latter
shows where the blood flow is poor in the heart. In
glaucoma, we will be able to inject a dye and analyze
the distal collector system. If this test shows that the
system is viable, then we can find a way to get fluid
there with newer procedures such as canaloplasty, ab
interno trabeculotomy, and various other canal procedures.
If the test shows that the collector system is not
functional, then we will know that filtering surgery or a
procedure that shunts fluid for uveoscleral outflow is a
better choice. Channelography will permit intelligently
directed therapy.
What led you to assume roles on various professional
committees, and how has that service affected you as
a physician?
The AGS was a young organization when I joined in 1989. Shortly after I became a member, George Spaeth, MD, and Dick Simmons, MD, asked me to represent the society at a meeting in Dallas regarding glaucoma accreditation fellowships. The experience introduced me to a more political world. A lot of highprofile people attended the meeting. I felt kind of like a breadcrumb. I realized, however, that the AGS needed to be represented at the national level. Everybody else was at the negotiating table except for glaucoma. Glaucoma subspecialists needed to take their skills from the anterior chamber to the legislative chamber. The founding fathers of the AGS inspired me to represent glaucoma care at a national level, and I did my best.
In 1995, Dr. Spaeth and Allan Kolker, MD, asked me to serve as the AGS councilor, who acts as the society's ambassador to the rest of ophthalmology. They had been the first and second councilors, respectively. I asked them, what do I do? Their response was, you do what is fair and stand up for glaucoma care! I held this position for 6 years, and the experience led to my election to the post of chairman of the AGS Patient Care Committee in 2003. Originally a one-man committee, it evolved over my 5 years of service to a 30-member group with five subcommittees addressing issues such as coding, health care policy, and quality quotients. The committee quickly became the glaucoma community's militia. When insurance companies stated that they would not pay for imaging, our members convened a technology-assessment subcommittee to write a letter outlining the evidence-based medicine supporting the use of imaging and its reimbursement. In addition, we worked on the Medicare Glaucoma Detection Benefit, which allows glaucoma screenings, and it was signed into law by President Bill Clinton while I was chairman. It was fascinating to see how a bill is created and enacted.
At present, I work with the current chairman of the Health Care Policy Committee, Cynthia Mattox, MD. Our chief focus is physician profiling, and our group is working on a new classification system for coding that will include the severity of glaucoma. That way, it will be clear when frequent testing is necessary because a patient has advanced glaucoma and when a clinician is abusing the system by ordering four visual fields per year for a glaucoma suspect.
How much time do you devote to music, and to what
are you currently listening?
I love music and strive to compose. I helped set up
the first AGS band, which was the brainchild of Richard
Wilson, MD, who is always trying to bring out the artistic
talents of the membership. At the end of a tough
day, I love to go home and play the piano. Every night, I
will play my own songs, jazz, pop—whatever I feel
like—for 30 minutes to an hour. It helps me to deal with
the trials and tribulations of a busy glaucoma doctor. I
will improvise and may never play the same thing again.
My compositions are typically a hybrid of jazz and pop.
I have tried to write classical music, but I just do not
have the necessary training in theory and composition.
My daughter is a composer and a senior in the Thornton School of Music at the University of Southern California. Her dream is to write music for films. I feel inspired every time I listen to her compositions on my MP3 player. She is the real composer!
