Volume 12, Number 2
August 2003
Preview Reception Highlights Celebration of
40 Years of Glaucoma Fellowship at Wills
Edna and Stanley Tuttleman hosted a reception
at their home in Lower Merion on June 5th to thank patrons, partners,
and sponsors for their support of the Foundation’s October 3–5
Scientific Symposium and Celebration of 40 Years of Glaucoma Fellowship
at Wills Eye Hospital. The event also served to introduce the
Glaucoma Service, the Glaucoma Service Foundation, and the International
Society of Spaeth Fellows to other community leaders in the Delaware
Valley.
Stan Tuttleman, long-time patient and friend of
Dr. Spaeth, is also a member of the Foundation’s Board of Directors
and of the Steering Committee planning the October 4th Celebration.
“The extremely important work being done by this Foundation and
the physicians on the Glaucoma Service at Wills is having a significant
impact around the world. But I am not sure enough people locally
really understand what they are accomplishing through their various
research and education programs. My wife Edna and I hosted this
Preview Reception because it seemed like a good way to highlight
those accomplishments. We also hoped it would be an opportunity
to tell people about the October 4th Celebration and generate
some excitement about that event.”
As the lovely summer evening began, over 50 guests
chatted, enjoying hor d’oeuvres on the stone patio overlooking
the exquisite boxwood gardens.
Mr. Tuttleman began the program, welcoming the
guests, and introducing Dr. William Tasman, Ophthalmologist-in-Chief
at Wills Eye Hospital. Dr. Tasman thanked Mr. and Mrs. Tuttleman
for hosting the reception, the distinguished guests for coming,
and Dr. George Spaeth for his years of dedicated service in building
what is perhaps the finest facility in the world for the diagnosis
and management of glaucoma.
Mr. Tuttleman then introduced Dr. Spaeth. After
thanking Mr. and Mrs. Tuttleman and the Celebration Steering Committee
— along with Mr. Tuttleman, Committee Chair Bonnie Long, Ann Spaeth,
and Foundation Managing Director Nancy Petrongolo — he spoke about
the importance of doctors’ being sensitive to each unique individual
seeking their help.
This principle, he explained, has been the centerpiece
of the Glaucoma Service Fellowship program for the past 40 years.
It is also the theme of the Scientific Symposium to take place
at the time of the Celebration, “Enhancing the Quality of Life
of Patients with Glaucoma: A World of Individuals,” as well as
the founding principle of the group of 194 physicians trained
on the Glaucoma Service, the International Society of Spaeth Fellows.
“The goal of the Celebration,” he continued, “is
not only to bring our Fellows and leading glaucoma experts together
for a landmark conference and to strengthen the International
Society of Spaeth Fellows. It is also intended to publicize the
accomplishments of the Glaucoma Service of Wills Eye Hospital,
locally, nationally, and internationally, with the hope of gaining
support for our important research and educational programs.”
“We hope,” he concluded, “that all will leave
the Celebration in some way transfigured, more aware of the tragedy
of unnecessary blindness, more aware of what we can do to decrease
the misery caused by glaucoma and other illness, and more committed
to caring knowledgeably for every person, every unique person
everywhere.” (Dr. Spaeth’s comments are presented
in detail, click here to read “Hallmark of the Glaucoma Service.”)
Foundation Chair Dr. Andrew Medcalf, after sharing
his personal story of living with glaucoma, reiterated the importance
of the Foundation’s research and education programs and the need
for funds to ensure that they continue and expand. Adding his
personal testimony about the essential role the Glaucoma Service
has played and continues to play in his own life, he concluded,
“A commitment to the Glaucoma Service Foundation is a commitment
to glaucoma patients everywhere.”
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Foundation Board member and Preview
Reception host Mr. Stan Tuttleman (left), Glaucoma Service
Director and Foundation President Dr. George Spaeth (center),
and Foundation Chair Dr. Andrew Medcalf sport their “Celebration
ties” at the Preview Reception. The ties (and scarves for
the ladies) were donated in part by Philadelphia University
and Lord West Accessories specifically for the occasion.
|
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At the Celebration Preview Reception at the home of Edna
and Stan Tuttleman (left to right): Glaucoma Service Foundation
Board member and President of the Board of Directors of City
Trusts Mr. Louis Esposito, Mrs. Alice Lea Tasman, Wills Ophthalmologist-in-Chief
Dr. William Tasman, and Mrs. Anne Esposito. |
 |
In addition to the Tasmans, Tuttlemans, and Espositos,
Preview Reception guests including Dr. and Mrs. James Gallagher,
Mr. and Mrs. Mark Baiada, Mr. and Mrs. John M. Kellogg, Jr.,
Mr. and Mrs. James Keating, Dr. David Adamany, and Executive
Director and CEO of Wills Eye Hospital Mr. James Mulvihill
listen as Dr. Spaeth speaks about the Hospital, the Glaucoma
Service Foundation, and the upcoming Celebration. |
 |
Celebration Honorary Committee Co-Chair Mrs. Dorrance
(Dodo) Hamilton (left) and Philadelphia University President
Dr. James Gallagher listen as Foundation Board Chair Dr. Andrew
Medcalf shares his vision of the future of the Foundation
and Wills Eye Hospital. Photos by Roger
Barone |
Celebration Volunteer: Portrait of a Remarkable
Lady
By Ken Parker, PhD
 Elizabeth
Kennedy is one of several volunteers who are helping to do all
those pesky little, but absolutely essential tasks needed to ensure
the success of the October 4th Celebration of 40 Years of Glaucoma
Fellowship. I spoke with her one day when she and three other
volunteers, Gloria Fischer, Ann Spaeth, and Marie Torchon Sixto,
were busy putting labels on “Save the Date” postcards being mailed
to 1000 former fellows and friends of the Glaucoma Service.
She explained that volunteering is not something
she usually does. For her, she says, it meant “stepping outside
my comfort zone.” Understanding why she took such a step in this
case involves understanding a bit about this remarkable 74-year-old
woman and her experiences with the Glaucoma Service of Wills Eye
Hospital. In a nutshell she says she’s
volunteering because it is a “great cause” and
“because I have been helped by Wills Eye Hospital and the Glaucoma
Service.” And, indeed, not just herself. In the early ‘70’s her
father was a glaucoma patient at the Hospital, treated by Dr.
Spaeth. She herself was diagnosed with glaucoma in 1985. She came
to see Dr. Wilson for emergency treatment in 1993 to fix a failed
trabeculectomy. “He saved my sight,” she said.
Though the vision in her left eye is gone and
she has only one-half center vision in the right, she continues
to follow her credo to “not let what you can’t do get in the way
of what you can do.” This means, among other things, a remarkably
active involvement with computers. It is an involvement that goes
back to 1969 when she programmed IBM’s first commercial computer
at John Wanamaker. Then, she went on to become the administrator
for SmithKline Beecham’s electronic mail system. All the while
she was actively involved in home decorating and landscaping.
Following a 1996 trip to China she matriculated
at Chestnut Hill College, where she majored in “Culture, Science,
and Technology.” Now she is on the Dean’s List at Community College,
where she is studying website design and is in charge of the College’s
website. It seems only natural that she regularly reads the “Chat
Highlights” on the Glaucoma Service website.
When she, a regular contributor to the Glaucoma
Service Foundation’s Annual Fund, heard about the celebration
of training on the Glaucoma Service and the need for volunteers,
something about it seems to have captured her imagination. Being
who she is, she knew she had to do it. We can all count ourselves
fortunate for that. Indeed, her remarkable spirit is, I believe,
what the Celebration is all about.
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Celebration volunteers (left to right) Marie Torchon
Sixto, Gloria Fischer, Ann Spaeth, and Elizabeth Kennedy
help with the mailing of 1000 “Save the Date” postcards
for the October event.
Photos by Ken Parker |
Dr. Wilson Chats About Doctor-Patient Communication
Wednesday evening, July 16th, Dr. Richard Wilson
“chatted” with visitors to the Glaucoma Service and Foundation’s
website about communication between doctors, patients, and their
families. Here are some excerpts.
Moderator: I guess most new glaucoma
patients are frightened. Do you have a way to gauge a patient’s
fear and if help is needed to overcome it?
Dr. Rick Wilson: I am not sure I have
a way, other than trying to be sensitive to the patient’s emotional
state. Since glaucoma for most people is a lifetime disease, the
doctor has to be honest or he or she will be found out. Finding
the balance between honesty and sensitivity is the key.
P: I understand patients’ fear. I
fainted a few times during laser surgery and I shake during appointments.
The patient gets scared if the doctor is candid. Then the doctor
reassures the patient. It seems like an endless cycle for the
patient. If the news can always turn bad, how can the endless
cycle of fear and relief from it be broken?
Dr. Rick Wilson: For most glaucoma
patients, the doctor can be relatively reassuring. Most of the
damage caused by glaucoma, occurs before the patient sees the
doctor. We have good medicines and good surgery. It still is scary
for the patient, but not anything like it was when I first started
doing this in 1978.
P: Visits with my glaucoma specialist
are rushed, with little time for more than a few quick questions.
With his waiting room full, and an additional workload as a professor
and a researcher, that’s not surprising. I understand his time
is valuable, but I leave frustrated. Do you have any tips on how
we can both gain maximum benefit from the visit? By the way, the
opportunity to ask questions and have them answered in this chat
room has enabled me to keep my sanity.
Dr. Rick Wilson: Thanks. One way would
be to come to the office with a list of questions each time. If
you hand the list over and let him run through the questions,
you might get the most information with the least demand upon
his time. You could also suggest that he dictate a letter to you
later, when he is less rushed.
P: I think a lot of patients are intimidated
by doctors and are afraid that getting a second opinion might
insult them. My primary care doctor is very supportive, but I
haven’t discussed getting a second opinion with my eye doctor.
Do you have any suggestions about that?
Dr. Rick Wilson: I think the softest
approach is to say, “I have full confidence in you, doctor, but
my wife (husband, daughter, etc., someone the doctor does not
run into) is worried about me and would like me to get a second
opinion. To keep her happy, can you suggest another glaucoma specialist
I can see for a second opinion?”
P: That’s a good way of putting it,
Dr. Wilson. You can tell you had a residency in psychiatry.
Dr. Rick Wilson: Thanks. It has come
in handy. If your doctor is secure, he or she should not mind
your seeking a second opinion. It is always best, from my point
of view, to have the patient totally assured that the course chosen
is the most rational one. If the doctor gets too upset, it might
be better to move on.
P: Do you think well-informed patients
who require treatment that may be uncomfortable or difficult are
more or less compliant than poorly informed patients?
Dr. Rick Wilson: I try to have all
my patients well aware of their circumstances — the risks of the
treatment plan, as well as the benefits and alternatives. It is
not only better for them, but also for me if they know the challenges
we both are facing and the possibilities of how things will play
out. If an untoward event happens, then the patient is much more
understanding.
P: There are psychologists who are
good at devising coping strategies and activating support from
family, etc. They think of things we patients wouldn’t think of,
things that make a big difference in coping with the uncertainty.
Dr. Rick Wilson: I agree, and occasionally
I suggest people avail themselves of that help if our support
group and the chat room aren’t enough.
P: I want to know more, but my doctor
just keeps telling me it’s all right. (I have not noticed any
severe vision change). I think he is too reassuring. He does not
give me details — simply that he can see changes. What suggestions
do you have so I can get more details?
Dr. Rick Wilson: Tell him you participate
in this chat group, and you would like to see your visual fields.
Read the information we have on visual fields on the website.
That information will give you a tool to see for yourself how
much damage you have and follow it along with the doctor.
P: The baby boomers, who are reaching
their 60’s, are more computer- literate than their parents. Do
you think glaucoma specialists will be using e-mail more often
with the baby-boomer generation?
Dr. Rick Wilson: Yes. The problems
at the moment are that e-mail is usually written at the end of
a 10- to 14-hour day, is not reimbursed, and means more liability
in both HIPAA (Health Insurance Portability and Accountability
Act), medical aspects, keeping records, etc.
P: Are there many women glaucoma specialists?
Some women seem to prefer women doctors and seem to relate better
to them.
Dr. Rick Wilson: About 1 in 8 is a
woman, as I remember, but that ratio may be changing. All three
of our fellows (fellowettes?) this year are female.
P: What kind of training do glaucoma
specialists receive in learning to relate to the patient, not
just to the glaucoma?
Dr. Rick Wilson: Unfortunately, that
depends entirely upon who is doing the training and how they relate
to patients. I think one of the strongest aspects of the Wills
glaucoma fellowships is that our fellows get to see eight specialists
and how they interact with their patients.
P: In the last three months since
my diagnosis, this chat room has been a source of security. I
have learned to open up with my doctor and to talk to him like
he is a person. He now talks to me the same way. I was on the
verge of a breakdown when I found this chat room. I have to say
thanks to everyone and to you.
Dr. Rick Wilson: Hearing that it
helps makes the time I invest worthwhile. Good night, everyone.
Moderator: Good night, and thanks
again.
Dr. George Shafranov Speaks to Fellows
Dr. Jay Katz (left) with Dr. George Shafranov, Assistant Professor
of Ophthalmology and Director of the Glaucoma Service, Department
of Ophthalmology and Visual Science, Yale University. Dr. Shafranov
spoke in May to fellows and residents about corneal thickness
and glaucoma. His talk was co-sponsored by Alcon and Pfizer.
Photo by Ken Parker
The Disc Damage Likelihood Scale and Patient
Care
By Ken Parker, PhD
Sometimes when we don’t feel well we take our
temperature. Perhaps it’s 99°F. We decide that’s not so bad and
take an aspirin and then measure it again a little later to see
if the aspirin’s worked. We may then measure it again a few hours
later to see if the fever has returned after the aspirin has worn
off. Or, in another scenario, let’s say we feel really sick, take
our temperature, and find a high fever, 104°F. We will want to
do more than take an aspirin! We may call the doctor or go directly
to the emergency room. The doctor, then will, just as we did,
provide a treatment appropriate to the severity of the condition
and then continue to measure the temperature at regular intervals
to see if the treatment has had the intended effect.
In the same way, in order to be able to provide
the most appropriate treatment, a glaucoma doctor needs to know
the severity of the patient’s glaucoma and whether it is getting
worse, staying the same, or improving.
It is with this fundamental need in mind that
Dr. George Spaeth developed what he calls the Disc Damage Likelihood
Scale (DDLS).
In May of this year it was adopted by the National
Eye Institute for use in their glaucoma studies. In a recent interview
I asked Dr. Spaeth to explain the development and importance of
the DDLS in patient care.
What was behind the development of the DDLS?
A clock measures the passage of time. How is the passage of glaucoma
measured? If the passage of glaucoma cannot be measured reproducibly
and validly, then it is not possible to determine whether a person
is getting worse, staying the same, or getting better. By “reproducibly”
I mean simply in such a way that different examiners taking measurements
in the same way will come up with pretty much the same measurements.
If the measurements they took were different we would think that
either those examiners or the method they were using were not very
reliable. But even if the measurements are reproducible, they still
may be wrong. Treatment cannot be appropriate unless it is known,
reproducibly and validly, whether the person’s condition is getting
worse, staying the same, or getting better.
Three Ways to Determine the Passage of Glaucoma
1. Ask the Person
There are three major ways to determine the passage of glaucoma:
The first is to ask the person. In some situations, especially
when a person has far-advanced glaucoma, the person’s symptoms
may be the most important measure of how the person is doing.
Many patients, however, are unable to provide accurate histories.
They may be deniers, worriers, or poor observers. Furthermore,
in the early stage of the disease damage can occur and progress
without causing any symptoms, even in the most realistic and sensitive
person. For these reasons, the history is an appropriate way to
monitor the course of glaucoma only in certain individuals and
at certain times.
2. Administer a Visual Field Test
The second way is to measure the nature of the visual field. The
visual field has been used for years as a way to chart the course
of glaucoma, but there are disadvantages to that method also.
Specifically, between one third and one half of all the nerve
fibers must die before enough damage has occurred that a visual
field defect is detectable using standard testing. Additionally,
many things affect the visual field other than glaucoma, including
the patient’s ability to understand and cooperate, and a variety
of other illnesses, such as brain tumors and cataracts. Thus,
while visual fields are an important part of the evaluation of
patients, like taking a patient’s history, they have limited value
because they cannot monitor the passage from start to finish and
are neither highly reproducible nor universally valid.
3. Measure the Nature of the Optic Disc
The third way is to measure the nature of the optic disc. In most
people with glaucoma the optic nerve becomes damaged prior to
the development of visual field loss. Furthermore, the changes
that occur in the optic nerve are sufficiently characteristic
that they are of great value in determining whether or not a person
actually has glaucoma. When glaucoma damage becomes far advanced,
it is difficult to see further damage occurring in the optic nerve.
However, the difficult decisions regarding if and how vigorously
to treat usually involve the early and moderate stages of the
disease. By the time damage is far advanced it is obvious that
treatment needs to be vigorous. Furthermore, in patients with
very severe damage, patients themselves notice any further deterioration.
Therefore, the progress of the disease at that point is best determined
by careful questioning of the patient. Finally, the examination
of the optic disc does not depend on the patient’s subjective
feelings. It is an objective measure of whether or not glaucoma
damage is present and how much damage has occurred.
Thus, evaluation of the optic nerve is at the
heart of the diagnosis and management of patients with glaucoma.
Being able to measure quantitatively the amount of damage that
is present allows a highly valuable and practical assessment of
whether the patient has glaucoma and whether the patient is getting
worse, remaining stable, or improving.
Behind the development of the DDLS, then, was
the desire to find a method of monitoring the course of glaucoma
that was more reproducible, more valid, more practical, and more
valuable than any system we presently have.
How would you describe the DDLS?
The Disc Damage Likelihood Scale is a method of estimating the amount
of damage that has occurred to the optic nerve based on one consideration,
specifically, the width of the tissue that is made up of the living
nerve fibers that pass from the retina, through the optic nerve,
back into the brain. Or, if that tissue is absent, the extent of
its absence.
Optic Nerve and Optic Disc
One can look into the eye and see the end of the optic nerve,
the optic disc. The disc is part of the back side of the
eye ball. Nerve fibers extend from the retina, converge in a bundle
of fibers that pass out through the wall of the eyeball, and reach
back to the middle of the brain. This bundle of nerve fibers is
called the optic nerve, and the inside surface of it that
one can see when one looks into the eye is called the optic disc.
The Cup and the Neuroretinal Rim
Where the fibers all come together they make a funnel, which is
tiny in some people and large in others. That funnel is called the
cup, and the rim of the funnel surrounding the cup is called
the neuroretinal rim. It is the width, or the extent of absence,
of the neuroretinal rim that is the basis for the DDLS. Viewed
from the front, the optic disc looks rather like a donut, the hole
being the optic cup, and the actual donut being the rim. The DDLS
is based on looking at the rim, and estimating how wide the rim
is in comparison to how wide the entire disc is. If one had a donut
with a tiny, tiny hole in the middle, then the percentage of the
rim width to the width of the disc would be great. Whereas if one
had a donut that was very narrow with a huge hole, then the relative
rim width would be small. In glaucoma the rim gets increasingly
narrow as the nerve worsens. In some people the rim actually
disappears in a localized area (see c. in the illustration), and
in others who have especially severe glaucoma, the rim disappears
almost completely. Thus, a wide rim is a good sign, and the absence
of rim a bad sign.
The Stages of the DDLS: Measuring the Level of Damage
by Measuring the Width of the Neuroretinal Rim
The DDLS is divided into stages in the same
way that a thermometer is divided into degrees. The DDLS has 10
stages, from 0 to 7, the first and the last stage being subdivided
into 0a and 0b and 7a and 7b, respectively. Stage 0 signifies
the absence of any damage at all. A DDLS score of 0 indicates
an optic disc that has absolutely no glaucoma damage (see a. in
the illustration). In contrast, a DDLS score of 7 would mean that
the glaucoma had almost killed the optic nerve, and that there
were virtually no nerve fibers left.
The first five stages of the DDLS are determined
by measuring the point of the optic disc where the rim is narrowest.
0a means that there is no narrowing of the rim at all. Stage 3
means that the rim in at least one area is extremely narrow; so
narrow that one can just barely see it. The final five stages
of the DDLS describe discs in which at least one portion of the
neuroretinal rim has been lost totally. In stage 4, this occupies
less than one eighth of the circumference of the entire rim, whereas
in stage 7b more than three quarters of the entire neuroretinal
rim has been lost.
It becomes possible to stage the amount of glaucoma
damage, then, merely by looking into the eye with a standard ophthalmoscope
and noting the width of the rim or the extent of loss of the rim.
Because the width of the rim varies with the absolute size of
the optic nerve, it is also important to determine the size of
the optic nerve before attributing the DDLS score to a particular
patient. This can be done quite easily with standard equipment.
I believe that some doctors use the cup/disc ratio method
to characterize the amount of optic disc damage. What is that?
Why do you believe the DDLS is better?
The cup/disc ratio method is still the standard
method of staging optic discs in glaucoma. The idea is that the
larger the width of the cup is in comparison with the width of
the whole optic disc, the more damage there is. There are two
problems with this method. Most importantly, it assumes that rims
become narrower concentrically. This is not usually the
case, at least not in the commonest type of glaucoma. Also, neither
is an optic disc with a large cup/disc ratio necessarily damaged,
nor one with a small cup/disc ratio necessarily healthy. Thus,
the validity of the cup/disc ratio method is not high.
In our studies of the DDLS we found that measurements
obtained using it correlated better with amount of visual field
loss than did cup/disc ratios. Additionally, the DDLS is more
reproducible than cup/disc ratios. It is presumably because the
validity is high, the reproducibility is good, and the method
is simple to use that the National Eye Institute has decided to
use the DDLS as a way to characterize the optic discs of patients
with glaucoma.
In glaucoma the neuroretinal rim gets increasingly narrow as
the nerve worsens. It is the width, or the extent of absence,
of the neuroretinal rim that is the basis for the DDLS.
In the illustrations, the cup is the area inside
the inner “circle” and the rim is the area between the two “circles.”
“a” is a healthy optic disc, DDLS Stage 0a,
in which the ratio of the rim to the whole disc (rim/disc ratio)
is 0.4.
“b” is an optic disc which may possibly be
damaged, DDLS Stage 2, with a rim/disc ratio of .25.
“c” is a severely damaged optic disc, DDLS
Stage 7a, with no rim at all from the 9:30 o’clock to the 5:30
o’clock position.
Glaucoma Research Center Actively Recruiting
Patients for Studies
The Wills Eye Hospital Glaucoma Service is actively
involved in clinical trials that are attempting to improve treatment
strategies for people with glaucoma. If you are interested in
participating in one of the following studies, please call the
Research Center at (215) 928-3123.
- A study comparing medication therapy to laser therapy with
the new selective laser as an early treatment for patients with
glaucoma. Needed are patients diagnosed with primary open-angle
glaucoma who have not been previously treated with glaucoma
medications for more than 14 days.
Sponsor: Lumenis
Principle Investigator: Dr. Katz
- A study to test how well the medication Cosopt lowers eye
pressure in glaucoma or ocular hypertension patients. Patients
who have an eye pressure of 30 mm Hg or higher and who have
not been treated in the last 4 weeks are needed.
Sponsor: Merck
Principal Investigator: Dr. Wilson
- A study to evaluate which of the two medication combinations,
Cosopt (Trusopt + Timoptic) or Xalatan/Timoptic increases blood
flow in the eye more.
Sponsor: Merck
Principal Investigator: Dr. Katz
- A study investigating if the substance Healon 5, when used
during glaucoma surgery, affects a patient’s long- and short-term
eye pressure.
Sponsor: Pfizer
Principal Investigator: Dr. Moster
- Patient-Generated Index — Determining by means of a questionnaire
to patients the areas of their life that are most affected by
their glaucoma and what tasks of daily living, if any, they
feel having the disease affects the most. Needed: another 40
or so glaucoma patients to complete the questionnaire
Unfunded
Principal Investigator: Dr. Spaeth
- A study comparing the IOP-lowering of either Xalatan or Lumigan
alone with a combination of the two medications.
Sponsor: Allergan
Principal Investigator: Dr. Katz
- Measuring the thickness of corneas of children with glaucoma
to see how it compares with that of children without glaucoma.
Unfunded
Principal Investigator: Dr. Wilson
- Determining if taking a photograph of the back of the eye
provides doctors as much information as an in-person examination.
If so, in the future patients could have a complete eye examination
at a location close to their home, without having to see a doctor
that specializes in glaucoma.
Unfunded
Principal Investigator: Dr. Henderer
- Comparing CAT-152, an anti-scarring drug, not yet FDA approved,
with another such drug, 5-fluorouracil, the standard drug used
during glaucoma surgery to reduce the risk of failure.
Sponsor: Cambridge Antibody Technology
Principal Investigator: Dr. Katz
- Evaluation of the safety and effectiveness of a new, investigational
surgically implanted device for glaucoma: the GMP Bi-Directional
Glaucoma Implant (the “GMP Shunt”) for use in advanced glaucoma
cases.
Sponsor: GMP
Principal Investigator: Dr. Wilson
- 100 patients with glaucoma who have never had glaucoma surgery
are needed to complete a questionnaire that will enable them
to be compared with patients who have undergone a primary patent
laser peripheral iridotomy that resulted in a ghost image or
blurring. The goal is to determine the risk factors for these
complications following this kind of laser procedure.
Unfunded
Principal Investigators: Dr. Moster and Dr. Spaeth
Hallmark of the Glaucoma Service: Focusing on
Each Unique Glaucoma Patient
Speaking at the Preview Reception
for the Celebration of 40 Years of Glaucoma Fellowship at Wills,
Dr. Spaeth emphasized the importance of focusing on each unique
glaucoma patient.
A Glaucoma Patient Who Became Dizzy When she Put in her Drops
He began with a story about a patient of his,
Ms. M. When she put drops of pilocarpine in her right eye, she
told him, there was no problem. But, she complained, as soon as
she tried to put a drop in her left eye she immediately got dizzy.
The fact that she used the word “immediately” struck Dr. Spaeth
as peculiar. Even though it is not unusual for pilocarpine to
cause dizziness, he knew that it takes time for the drop to be
absorbed, enter the bloodstream, and to affect the nervous system.
He concluded that something else must be causing her dizziness.
So, as a little experiment he asked her to make
believe she was using her drops. When she held her head back,
mimicking the way she put the drop in the right eye, everything
was fine. However, as soon as she turned to the right to “put
a drop” in the left eye she got dizzy. Probably, he conjectured,
there is something about her anatomy that is compressing the large
blood vessel that runs up the back of the neck when she turns
her head to the right, causing a sudden lack of blood flow to
her brain, making her dizzy. If that proved to be the case, and
it did, the solution to Ms. M’s problem was clear. Change the
way she uses her drops, not the drops.
Tension Between the Average and Unique
The moral of the story is the theme of the entire Symposium and
Celebration of 40 Years of Training on the Glaucoma Service of
Wills Eye Hospital — what Dr. Spaeth called the “tension between
the average and the unique, the standard and the idiosyncratic,
the likely and the unlikely.”
He went on to explain. On the one
hand, it is crucial that aspiring glaucoma specialists and, indeed,
all medical students, master a complex body of knowledge — for
example, that it is not unusual for pilocarpine eye drops to cause
dizziness, that compressing a large blood vessel to the brain
can impede blood flow to the brain and cause dizziness, that the
average person does not get dizzy when he or she turns his or
her head one way but not the other.
The Myth of the “Average Person”
But these doctors-to-be also must be fully aware
that the person before them is not some mythical “average person.”
He or she is an individual with a unique anatomy, a unique genetic
makeup. The “average person” does not get dizzy when he or she
turns his or her head one way but not the other. But Ms. M did.
A doctor who relied only on his knowledge about “average” individuals
might be tempted to find a quick fix, jumping to the conclusion
that the pilocarpine was causing her immediate dizziness. “It
is,” said Dr. Spaeth, “easy and quick to base diagnosis and treatment
on ‘the likely,’ ‘the average.’ Indeed that is what physicians
have been taught to do ever since the statistical model of disease
became dominant in the 19th Century.” But fixation on “the average”
can easily result in inappropriate diagnosis and treatment.
On the other hand, a doctor who understood that
Ms. M was in fact Ms. M and not an “average person” would have
stopped to consider possible ways in which she was not average.
He might have considered that perhaps her unique anatomy could
be causing her to get dizzy when she turned her head to the right.
As in this case, being open to such a possibility, can facilitate
correct diagnosis and treatment.
Caring for Individuals
“I mention Mrs. M and the matter of the average versus the unique
because this reception is about Wills Eye Hospital and the Glaucoma
Service at Wills Eye Hospital. What the physicians and surgeons
at Wills have done well since 1832 is take care of patients as individuals.
That is what we continue to do well. Our coming Celebration focuses
on the accomplishments of the Glaucoma Service in that regard, especially
the training of glaucoma specialists who are today diagnosing and
treating patients on every continent except Antarctica with a superb
combination of medical knowledge and sensitivity to the individual.”
Goals of the Celebration
Scientific Symposium The goals of the Celebration
are threefold, he explained. The first is to bring together many
of these ex-Fellows and other international glaucoma experts in
a scientific symposium entitled “Enhancing the Quality of Life
of Patients with Glaucoma: A World of Individuals.” The focus
will be on how to apply the knowledge about the “averages” researchers
have discovered about glaucoma to each unique individual in a
way that will work best for each individual.
This, he explained, represents a powerful new way
to meet the challenge of glaucoma, the leading cause of irreversible
blindness in every country in the world, an approach shared by
the 194 Glaucoma Service-trained fellows, over 100 in foreign
countries, who are now caring for glaucoma patients, doing research
on glaucoma, teaching about glaucoma, and acting as academic and
administrative leaders.
How can we find those many, many individuals,
over half of those who have glaucoma, who will go blind from glaucoma
because they were never diagnosed? How can we assure that those
who do make it into the health-care system do not go blind because
there is no way to determine what is the best treatment for each
of these unique individuals? The Glaucoma Service at Wills Eye
Hospital is approaching these problems in many ways. One important
way is by developing an inexpensive, user-friendly way of quantitating
the actual amount of optic nerve damage present in an individual
(see interview with Dr. Spaeth). Another is, under the leadership
of Dr. Douglas Rhee, by working toward the goal of being able
to describe each unique person in terms of his or her genetic
makeup and his or her biologic and socioeconomic nature so accurately
that the best, the most appropriate care, including gene therapy,
can be given to each individual with glaucoma.
The International Society of Spaeth Fellows
The second goal of the Celebration is to strengthen
the International Society of Spaeth Fellows, who hold leadership
positions in nearly every major glaucoma society around the world.
As an organized group, they have tremendous potential to bring
the knowledge and skills they have acquired on the Glaucoma Service
of Wills Eye Hospital to bear, in a powerful and focused way,
on meeting the challenge of glaucoma world-wide.
Publicizing the Accomplishments of the Glaucoma Service
of Wills Eye Hospital
The third goal, he explained, “Is to publicize
the accomplishments of the Glaucoma Service of the Wills Eye Hospital,
so that we might gather the support of community leaders such
as yourselves in our bold new quest. This we hope to do in a way
that is informative, inspirational, dignified, beautiful, and
fun. Thus, the centerpiece of the Celebration will be the world
premier of a ballet commissioned for the occasion, a ballet which
will serve as a metaphor for what we are trying to accomplish,
the healing of the unique individual.”
Caring Knowledgeably for Every Unique Glaucoma Patient
“We hope,” he concluded, “that all will leave the Celebration in
some way transfigured, more aware of the tragedy of unnecessary
blindness, more aware of what we can do to decrease the misery caused
by glaucoma and other illness, and more committed to caring knowledgeably
for every person, every unique person everywhere.”
Glaucoma Service Symposium and Celebration October
3–4, 2003
Friday, October 3: Scientific Symposium Opens
Former fellows and leaders in the field of glaucoma
are featured speakers. Their topics are expected to challenge
traditional thinking about diagnosis and management of glaucoma
and to propose new conceptions, terminologies, methodologies and
goals. It is hoped that these presentations will also influence
thought leaders and policymakers in business, finance, education,
politics, industry, health care and the arts and that they will
find the comments sufficiently stimulating to initiate or expand
various scientific projects.
International Society of Spaeth Fellows Reception sponsored
by Allergan
Friday evening there will be a reception for all
of those attending the Symposium, leaders and organizers of the
Celebration and Symposium, and major sponsors of the weekend’s
events. The reception will be held in the auditorium of the new
Wills Eye Hospital, with tours of this state-of-the-art facility,
including the 11th floor where the Glaucoma Service Foundation,
the fellowship training program, the Glaucoma Research Center,
and physicians’ private practices are located, and the 14th floor,
site of the Wills Eye Hospital Laboratory for Molecular Ophthalmology.
Saturday, October 4: Celebration of 40 Years of Fellowship
Training
The Scientific Symposium concludes after lunch.
Saturday evening, the Celebration of 40 Years
of Fellowship Training will be held at the Kimmel Center for the
Performing Arts. The black tie event will begin with a cocktail
reception and dinner for approximately 500 guests in the Center’s
Commonwealth Plaza. The program in the Center’s Perelman Theatre
following dinner will be the most exciting part of the entire
weekend, including the premier of a new ballet developed specifically
for the occasion.
Dr. and Mrs. George Spaeth, are working with Meredith
Rainey, a choreographer and principal dancer with the Pennsylvania
Ballet, in the development of this ballet which will deal with
sickness and healing, areas almost totally absent from the ballet
repertory. The performance will explore the idea that the practice
of medicine is an art involving the same types of knowledge, technical
excellence, dedication and attention to individuality that are
essential in the other arts, including ballet. It is intended
to be thrilling, with the hope that it will become a standard
part of the ballet repertory, a magnificent but not unrealistic
goal.
Following the program, guests will enjoy an International
Dessert Reception and dancing in Commonwealth Plaza. It is hoped
that all those in attendance will leave the event with a heightened
awareness of the nobility, the excitement, and the beauty of celebrating
life and healing.
Congratulations!
 Research
Fellows Drs. Sushma Rai (left) and Tara Uhler received Glaucoma
Fellow Awards from Pfizer for their research at the Annual Meeting
of the Association for Research in Vision and Ophthalmology (ARVO)
in Fort Lauderdale, Florida, in May. Dr. Uhler was honored for
her research in community glaucoma screenings, Dr. Rai for her
study of Bausch & Lomb’s new Proview™ home tonometer. Pfizer presents
the awards to those they judge, on the advice of Dr. Marty Wax,
glaucoma specialist at Washington University in St. Louis, to
have had the best presentations at the ARVO or American Academy
of Ophthalmology annual meetings.
Photo by Nancy Petrongolo
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