Karen Jeng-Miller, MD, MPH
Mass Eye and Ear, Harvard Medical School
Day 2 of The Retina Society annual meeting was filled with excellent discussions regarding pediatric retinal disease, age-related macular degeneration, ocular inflammation, and imaging. The Historical Symposium marked a highlight of the day, and provided an insightful set of presentations that reflected on where the field has been and its bright future ahead.
The session began with Dr. Mark Johnson’s introduction to the significance of the year 1967 – birthdate of the The Beatles’ “Sgt. Pepper’s Lonely Hearts Club Band,” the 25th amendment to the U.S. Constitution, the first human heart transplant, and the The Retina Society, which was founded on October 29 of that year. Since its inaugural meeting in Swampscott, MA, the Retina Society has served as a fruitful place for discussion, collaboration, and mentorship for retina specialists around the world.
Dr. Bradley Straatsma spoke next and brought the audience back in time to July 21, 1943 when Jacques Perot, a lumber mill operator situated near the Pyrenees mountains, narrowly escaped arrest by Gestapo officers for aiding the Belgian resistance. This dramatic story took a surprising turn with the revelation of Jacques Perot’s true identity: Charles Schepens, then a medical officer in the Belgian Air Force. Dr. Straatsma continued to tell Dr. Schepens’ incredibly impactful life story, from his invention of the binocular indirect ophthalmoscope allowing a stereoscopic view of the retina, to establishing the first retina service in the world at Mass Eye and Ear in 1947.
Dr. Schepens was a champion in fostering community collaboration through organizing meetings among retina specialists and fellows. Others followed suit in organizing meetings throughout the years; it was the successful 1965 meeting in Houston, chaired by Dr. Alice McPherson, which was spotlighted as the impetus for the establishment of The Retina Society. Since its creation, The Retina Society has perpetually promoted and celebrated collaboration and innovation in retina practice and research, demonstrated through awards such as The Award of Merit in Retina Research, which started in 1978, and the J. Donald M. Gass Lectureship, which began in 2006.
Following Dr. Straatsma, Dr. Johnson took the stage again and honored the charter members of 1968, poignantly acknowledged those now passed, and recognized the former presidents of the Retina Society.
Dr. Lee Jampol next highlighted progress of medical retina in the last 50 years. Medical retina as we know it today did not exist 50 years ago; the specialty was largely surgical. Surprisingly, the main proponents for the advancement of medical retina were in fact neuro-ophthalmologists, the most prominent of which being Dr. David Cogan, who were interested in the systemic findings of retinal disease.
Dr. Jampol also touched upon advances including the binocular indirect ophthalmoscope, laser photocoagulation, photodynamic therapy, intravitreal injections, fluorescein angiography, and ophthalmic clinical trials. Optical coherence tomography was spotlighted as arguably the most impactful invention for clinical practice. Through these discussions, we learned the origins of many of these innovations. Dr. William Richard Green was integral in elucidating the anatomy and physiology of the retina. Dr. Arnall Patz, described as quiet and unassuming, discovered that high concentrations of oxygen for preterm infants contributed to a life-long blinding disease. When he could not obtain NIH funding, Dr. Patz incredibly used his own personal funds to test and validate his theory.
Dr. Gerd Meyer-Schwickerath’s story regarding the principle of laser photocoagulation was quite dramatic: after a sleepless night in 1949, he realized he could create a retino-choroidal adhesion with concentrated sun rays, and subsequently tested this theory on a rooftop with his assistant. Through Dr. Patz’s work at Wilmer Eye Institute, this principle was refined through development of the argon laser for treatment of retinal disorders.
The history of VEGF was also discussed, beginning with Dr. Isaac Michaelson, who recognized that a certain “Factor X” was released in response to retinal ischemia, thus causing proliferative retinopathy. Dr. Judah Folkman, a pediatric surgeon, proposed a novel idea to treat cancer by truncating the tumor blood supply. And lastly, it was Dr. Napoleone Ferrara who discovered at Genentech that Dr. Michaelson’s Factor X was in fact VEGF. Collectively, this seminal work contributed to the development of bevacizumab and ranibizumab. And thus, the age of anti-VEGF treatment for retinal vascular disorders was born.
Finally, Dr. Jampol concluded with the story of Dr. James Fujimoto, an MIT scientist, who pioneered OCT, an imaging technique that has revolutionized the practice of ophthalmology.
Dr. Kirk Packo next laid out the history of surgical retina through a Retina Society JeoParody game show format, with hosting skills rivaling those of Alex Trebek. Dr. Packo drew attention to both unexpected and known giants in surgical retina innovation. Marc Giraud Teulon was acknowledged for developing the first version of the binocular indirect ophthalmoscope using a lighted candle in 1861, and it wasn’t until 1947 that Dr. Schepens created his functional version, which is used today.
Prior to Dr. Jules Gonin, primitive retinal detachment surgery involved intense sweating, intravenous thyroid hormone injection, and pressure induced by sandbags, all of which produced an abysmal success rate of 0.1%. Dr. Gonin pioneered the Ignipuncture technique, the first successful surgery for the treatment of retinal detachments.
Dr. Packo next turned towards the evolution of scleral buckling techniques, starting with the red rubber catheters of Dr. Ernst Custodis, and leading to Dr. Harvey Lincoff’s development of a soft silicone sponge. Dr. Paul A. Cibis was credited as first using silicon oil for retinal detachments, an approach modernized by Dr. Relja Zivojnovic. The roots of vitrectomy began with Dr. Tsugio Dodo in 1955 through “open sky” vitrectomy, evolving into the first successful closed vitrectomy performed by Dr. C. Haruta in 1959. Dr. Robert Machemer, a pioneer of modern retinal surgery, performed the first closed vitrectomy case through the pars plana on a diabetic retinopathy patient.
Dr. Conor O’Malley was credited with first using the 20G vitrectomy system with a separated infusion and illumination cutter; subsequent evolutions resulted in transconjunctival sutureless 25G vitrectomy, first performed by Dr. Packo through the “Micro-Tap” instrument and then pioneered by Dr. Eugene de Juan.
Dr. Mark Blumenkranz concluded the symposium with a focus on the future of retina. He began by spotlighting broad areas most likely to change: drug therapy, genomics and gene therapy, cell and tissue transplantation, neural prosthetics, diagnostic and therapeutic imaging, laser therapy and microsurgical instrumentation, proteomics, along with digital medicine and information sharing.
Some predicted advances received special focus, including i) drug development of neuroprotective agents, ii) tackling technical hurdles of the short and long term drug delivery systems, iii) gene replacement therapy and gene editing for rare and difficult mutations, iv) use of CRISPR for versatile genome editing systems in situ, v) decreasing the size and increasing the performance of retinal prostheses, to implant them sub-retinally, and to enable increased permeability for choroidal nutrition, vi) retinal and even whole eye replacement with progress in regenerative therapy, and vii) increased clinical use of proteomics and sequencing on intraocular tissue and fluid.
Dr. Blumenkranz discussed the possible miniaturization, image guidance, and robotic automation of surgical instruments and lasers, and the use of possible virtual or augmented reality goggles to replace screens and play a key role in surgical training. In terms of medical systems, he predicted low-cost, high-resolution specialized cell phone adaptors and software to aid in decentralizing the sites of retinal care, and advances in digital medicine and electronic health records to provide access to big datasets. Importantly, the economic sustainability of future healthcare systems was acknowledged as a key impediment for future progress, likely requiring substantial overhauls.
The Retina Society’s historical symposium underscored the old adage, “you don’t know where you’re going until you know where you’ve been,” and aimed to inspire the next 50 years worth of innovations in the field.