Volume 1, Number 1
Fall, 1992
What is the Glaucoma Service
Foundation to Prevent Blindness?
The Glaucoma Service of Wills
Eye Hospital has been known for many years as one of the premier
glaucoma treatment centers in the world. This reputation for the
finest patient care continues to draw glaucoma sufferers from
all corners of the globe.
The number and variety of
patients who have crossed our threshold offer a gold mine for
clinical research into the causes, evolution, and treatment of
the devastating but still mysterious complex set of eye diseases
known as glaucoma. So much is to be learned from current patients,
including the many who participate in the numerous ongoing studies
being conducted here. Just as valuable are the records of literally
thousands of patient visits.
Over 10 years ago, when Wills
Eye Hospital was still located on Spring Garden Street, some farsighted
Glaucoma Service physicians began discussing among themselves
how these riches could be turned into effective weapons in the
fight to prevent the blindness that inevitably comes if glaucoma
remains untreated. They decided that what was required was an
organization that could bring together physicians, patients, and
researchers in the quest for sight-saving knowledge. The result
was the Eye Disease Foundation, supported in these early years
by the physicians themselves.
Some of the important research
contributions in these earlier years included the development
of computerized perimetry and analysis of the optic disc, laser
treatment, releasable sutures in surgery, and a system of glaucoma
management based on improvement as well as deterioration criteria.
Birth of the Glaucoma
Service Foundation
About three years ago, it
became increasingly clear that, despite notable successes, the
full potential for glaucoma research at Wills could not be realized
without the broader support of glaucoma patients, their families
and friends, and others appreciating the need to intensify research
and educate the general public about glaucoma.
At that point, the name of
the Foundation, in order to reflect more accurately the specific
focus of its activities, was changed to "Glaucoma Service Foundation
to Prevent Blindness." The new name reflects the fact that the
Foundation is still sponsored by the individual glaucoma specialists
on the Glaucoma Service of Wills Eye Hospital, currently Ann Chan,
L. Jay Katz, Marlene Moster, Ralph Sando, Courtland Schmidt, Louis
Schwartz, E. Sivalingam, and Richard Wilson, with George Spaeth
as President. These Board members, however, have been joined by
interested nonphysicians, whose skills and commitment will help
the Foundation grow to fulfill its true potential.
One measure of recent Glaucoma
Service research success was the presentation by the clinical
and research Fellows, of six studies at the 1991 meeting of the
Association for Research in Vision and Ophthalmology, the nation's
premier gathering of ophthalmology researchers. No other glaucoma
research center in the country had so many presentations.
Current Research
The Glaucoma Service Foundation
is pursuing research on many fronts, reflecting the multifaceted
character of the disease:
- What are the basic causes of glaucoma?
- What are the earliest signs of glaucoma?
- Why do some people who have glaucoma get worse while
others remain stable.
- How does glaucoma affect quality of life?
- Why does surgery fail in some people?
- How can medical and surgical treatment of glaucoma be
made safer and more effective?
- What types of surgery are the most effective in treating
advanced glaucoma?
- How can the laser be used more effectively to treat
glaucoma?
|
Clinical/Research
Fellows (left to right) Martha Leen, Annette Terebuh, and
Fritz Paul confer in the Glaucoma Service Diagnostic Laboratory.
(Photograph by Jamie Nicholl) |
- What are the basic causes of glaucoma?
- What are the earliest signs of glaucoma?
- Why do some people who have glaucoma get worse while
others remain stable.
- How does glaucoma affect quality of life?
- Why does surgery fail in some people?
- How can medical and surgical treatment of glaucoma be
made safer and more effective?
- What types of surgery are the most effective in treating
advanced glaucoma?
- How can the laser be used more effectively to treat
glaucoma?
|
Clinical/Research
Fellows (left to right) Martha Leen, Annette Terebuh, and
Fritz Paul confer in the Glaucoma Service Diagnostic Laboratory.
(Photograph by Jamie Nicholl) |
Maura Smith, Research Director
Supervising this research is Dr. Maura Smith, who holds a B.S.
in biology from the University of Scranton, and an M.D. from Temple
University. Having completed a Preventive Medicine Residency at
the University of Maryland at Baltimore, she brings to the Glaucoma
Service Foundation a wealth of research methodology skills, an
impressive level of microcomputer facility, and, increasingly,
a familiarity with the ophthalmologic medical literature.
The Research Fellows
Individuals committed to full-time research are selected on a
continuing basis from among dozens of talented young applicants
from all over the world. In addition to these full-time researchers,
each year, the Glaucoma Service selects three individuals from
over 80 top-notch applicants to serve as clinical/research Fellows.
These Fellows devote a substantial part of their time to learning
and applying research techniques.
Under the overall coordination of Dr. Smith,
the physicians on the Glaucoma Service work with these Fellows
on projects suggested by these seasoned practitioners' broad range
of clinical experience, matched with the background and interests
of the Fellows.
Vital Costa
Dr. Costa, our most recent full-time research Fellow, has his
M.D. from the University of Sao Paulo, Brazil, where he was Chief
Resident in Ophthalmology in 1991. His contributions over a few
short months have been impressive. Three studies are set for publication
in major ophthalmological journals: one on the loss of visual
acuity after trabeculectomy, another on the results of primary
trabeculectomy in young adults, and another focusing on the successful
treatment of a hitherto difficult-to-treat type of glaucoma. His
several other projects include a comparison of the effectiveness
of three methods of assessing the progression of optic disc damage
(direct observation with an ophthalmoscope, photographs, and computerized
analysis); an assessment of the relationship between blood flow
and optic nerve damage; and finally, microscopic patterns of the
skin eruptions that sometimes occur in glaucoma patients taking
oral methazolamide to control the pressure in their eyes.
Martha Leen
One of the three clinical/research Fellows, Dr. Leen has a B.A.
and M.D. from Brown, and completed her residency in ophthalmology
at Hahnemann University Hospital. She is pursuing a project comparing
the effectiveness and complications associated with two types
of anesthesia in glaucoma filtering surgery as well as studying
the use of a drug, 5-FU, that may be useful in preventing the
closing up of the surgical opening created to facilitate drainage
of excessive eye fluid that can cause glaucoma after cataract
surgery. Further studies include work with the new Holmium laser.
Fritz Paul
Another clinical/research Fellow, Dr. Paul has a B.S. and M.D.
from the University of Michigan, and completed a residency in
ophthalmology at the University of Pittsburgh. His research projects
include an evaluation of the use of the relatively new diode laser
for glaucoma procedures and the use of fibrin glue, a material
commonly used in vascular and neurosurgical procedures, to repair
conjunctival leaks after glaucoma surgery.
Annette Terebuh
Also a clinical/research Fellow, Dr. Terebuh has a B.S. in biology
from the University of Cincinnati and an M.D. from the Medical
College of Ohio in Toledo. She completed her residency in ophthalmology
at the Nassau County Medical Center in East Meadow, New York.
She is currently working on measuring the eye's ability to detect
differences between lighter and darker parts of images (contrast
sensitivity) as a means of detecting early glaucomatous visual
loss that may go undetected by current conventional testing methods.
Research Fellow Vital Costa (left)
and Research Director Maura Smith (right) contemplate the
latest data.
(Photograph by Jamie Nicholl) |
Vision for the Future
Achieving the Foundation's
mission -- doing all within our power to minimize the blindness
caused by glaucoma -- requires the help of many, many people.
Those listed below already have joined us in our mission, helping
us to take those first few momentous steps.
To sustain our present level
activities and grow, however, more resources are desperately needed.
We need to invest in new technology (image analysis equipment,
psychological testing instruments, high-resolution video) and
hire more staff (statisticians and, most importantly, a full time,
PhD, trained investigator). Looking beyond these immediate needs,
to ensure that our research program can continue uninterrupted
for many years to come we need to establish an endowed professorship
and an endowment fund to support research Fellows. And inevitably
we will need more space; our present quarters are already cramped.
Please consider helping us grow, click
here to use our on-line contribution form.
What Treatment is Best?
by George L. Spaeth, M.D.
[In this article, Dr.
George Spaeth, President of the Glaucoma Service Foundation
to Prevent Blindness and Director of the Glaucoma Service at
Wills Eye Hospital, begins a three-part discussion of an issue
of the utmost importance for all glaucoma patients and physicians:
How to decide what treatment is best?]
Each individual is unique.
This means that the decisions regarding what is best for each
individual are also unique. How can the doctor and the patient
determine what treatment is best? Here, I will consider two basic
difficulties the fact of each patient's uniqueness poses in bringing
the results of clinical studies to bear on treatment decisions:
- Studies provide information about groups,
not individuals.
- "Success" as defined by a study may not
be the same as "success" as defined by a particular patient.
A properly designed study
can allow us to draw valid conclusions based on what we find.
For example, half of 100 patients with similar cases of primary
open-angle glaucoma can be treated with eye drops and the other
half with surgery. The study might demonstrate that 10 years later
the group of patients who had surgery did "better" than the patients
who took eye drops. However, we can be quite sure that not every
patient who had surgery did better than every patient who took
eye drops. That is, while many more patients (more so than would
have occurred "by chance") did better with surgery than with eye
drops, some did better with eye drops than with surgery.
It is virtually never possible
to learn from a study which particular patient will do better
with one treatment as opposed to another. Still, clinical studies
can provide useful information. For example, our hypothetical
study may have shown that 90% of patients who had surgery did
better than those taking the eye drops. This is important information.
It is important, but far
from decisive. The study does not prove that an individual having
surgery will do better than one taking the drops. It tells us
only that one type of surgery performed in a particular way works
better in most patients than a certain kind of eye drop.
Another important consideration
is that a patient may do "better" according to the definition
of the study, but may not do better as defined by the patient
himself.
For example, in our hypothetical
study, let us say that after 10 years we find that patient A has
a lower intraocular pressure and has lost less visual field than
patient B. However, let us also say that the filtration bleb the
surgeon created in patient A to allow drainage of excessive eye
fluid, is too large and interferes with his vision and appearance.
In contrast, let's say that patient B has a higher intraocular
pressure and has lost visual field; however, he has no side effects
from the eye drops he is using, and he barely notices the loss
of field.
Patient A thus may have done
"better" according to the definition of the study, but patient
B may be happier and more comfortable. Patient A, on the other
hand, may be pleading with his doctor to reoperate in order to
improve his vision and appearance. Patient A did "better" according
to one set of criteria, and patient B "did better" by a different
set.
The point is, "best" treatment
can only be defined in terms of the patient's definition, not
that of the investigator of the physician.
Being aware of these two
limitations of studies is one important factor involved in deciding
what treatment is best for a particular patient. In the next Searchlight
I will discuss a second major factor: realizing that all treatment
decisions involve risk.
Acknowledgement
Ken Parker, PhD, has served
as editor of this first issue of "Searchlight on Glaucoma." He
acknowledges the kind cooperation of photographer Jamie Nicholl,
designer Ron Butler, and Anne-Marie Wagner, Professional Duplicating,
Bryn Mawr, Pa. This issue is being distributed free to current
and former patients of the Glaucoma Service, Wills Eye Hospital.
Others wishing to be placed on our mailing list should contact
Ken Parker at the Glaucoma Service. Individuals or companies interested
in subsidizing this newsletter also may contact
him.
|
