VISION

2012 VOLUME 28, NUMBER 1

A YEAR OF ADVANCES IN RESEARCH, EDUCATION, AND PATIENT CARE

 VISION
2012 VOLUME 28, NUMBER 1
HEADLINE NEWS
New Duke Eye Center
Clinical Pavilion Takes Shape
IN THIS ISSUE:

HEADLINE NEWS
2 New Duke Eye Center Clinical
Pavilion takes shape

LOW VISION

02
7 Sensory motor training
GLAUCOMA
8 360-degree trabeculotomy
12 New form of
GENETICS RESEARCH glaucoma discovered?
Corneal dystrophy 14 Neurodegeneration
and glaucoma

CORNEA
10 Corneal dystrophy
gene research

10
EDITOR
DRY EYE Justin Hammond
16 Putting the heat on dry eye
WRITERS
MILESTONES
Laura Ingerham
18 Gordon Klintworth celebrates Susan Poulos
GLAUCOMA 50 years of research
Is it the eye or the brain? 20 David Epstein: 20 years ART DIRECTOR
as chairman David Pickel

CONTINUING EDUCATION
PHOTOGRAPHY
22 Advanced Vitreous Surgery Course
Duke Eye Center Photography
Duke Photography
RESEARCH

14
Jared Lazarus
23 Researchers finding ROP earlier Les Todd
Curtis Scott Brown
Jim Wallace
EDUCATION
24 Meet the first-year residents Copyright 2012 Duke Eye Center
Durham, NC 27710
919-668-1345
EYE CENTER UPDATES dukeeye.org
MILESTONES 22 Chancellors Innovation
AD-102

Epstein celebrates 20 years Seminar Series

ON THE COVER
25 Fellows Artist renderings show the
26 Meet the new faculty new entrance to the Eye
Center features a circular drive
28 Awards and honors for ease in dropping off and
30 List of faculty picking up patients, see page 2.

20
32 New Ophthalmic Technician
Program Director
33 Facts and figures
Q&A with David L. Epstein
Can you summarize your feelings
about the past 20 years as chair of
the Duke Eye Center?
When I decided to become chair of the
Duke Eye Center, I sensed I was joining
something very special. Twenty years
later, I feel fortunate to be part of what
has become a world-renowned eye insti-
tute for advances in innovative research,
where patient care is second to none,
there is an internationally recognized
educational program, and there is a truly
unique environment filled with good
people and colleagues.
What are the keys to the future
success of the Duke Eye Center?
In my opinion, the keys to future
success involve the issues of
inquisitiveness and innovation.
Many times I have been asked what
type of physicians I wish to train for the
future of ophthalmology, and to me the
answer is clear: inquisitive clinicians and
clinician-scientists who will be innova-
tive thought leaders and a credit to our
profession of ophthalmology. We pride
ourselves that our clinical care is second
to none and that all of our trainees are
at the very top of their profession in
terms of skill set. But our current thera-
pies are in many cases palliative rather
than curative. Future success will be
determined by changing the very nature
of those therapies.
In my lifetime, the greatest advances
have occurred as a clinician puzzled
over a patients condition, examined the
mechanism for a particular manifesta-
tion of the eye disease, and wondered
whether there might not be a better
way to treat it. The magic words are I
wonder if. As my mentor, W. Mor-
ton Grant, MD, taught me, there is no
greater joy than the joy of a new idea
and a translational discovery that might
improve the outcome for people with
disabling eye diseases.
This all fits into a vision for the Duke Eye
Center as a center for innovation with
collaborations throughout the university,
which is itself committing to a strategic
vision of innovation and entrepreneur-
ship. We have all of the building blocks,
especially with our new Eye Center Clini-
cal Building projected to open in 2015,
to be the nations number one leader in I FEEL FORTUNATE TO
innovation relating to ophthalmology. BE PART OF WHAT HAS
In fact, my strongest desire is that there
be space in the new building on the top BECOME A WORLD-
floor for an Ocular Innovation Center. RENOWNED EYE
At the Duke Eye Center and the Al-
INSTITUTE FOR
bert Eye Research Institute, we have a ADVANCES IN
wonderful group of basic scientists who
conduct translational research into com-
INNOVATIVE RESEARCH,
mon and not so common eye disorders. WHERE PATIENT CARE
They form a conceptual Bell Lab-type
entity, and they collaborate extensively
IS SECOND TO NONE...
with clinician-scientists, clinicians, and
trainees in order to apply the best in
science to ocular disease understanding
and new therapies. This includes not only
new types of pharmacological cures but
also innovative new devices and analyti-
cal and software discoveries, such as in
ocular imaging. In aggregate they con-
stitute a critical mass for a world-class
translational discovery program.
To me the future is very bright because
of our outstanding faculty and trainees,
who have captured the spirit and values
of such inquisitiveness and are contribut-
ing to a truly transformative future of
ocular innovation based at the Duke Eye
Center. I am thrilled to be part of it.
V I S I O N 2012 // 1
David L. Epstein, MD
Chair, Department of Ophthalmology
 HEADLINE NEWS
New Duke
Eye Center
Clinical Pavilion
November 2012, the start
of construction to the right
of the present Eye Center
entrance.
V I S I O N 2012 // 2
Dedicated
TO OUR
Patients
AS THE NEW DUKE EYE CENTER CLINICAL PAVILION takes shape,
there is much more happening here than meets the eye.
While the physical construction of the new facility is hard to miss, its
underlying essence requires a deeper look: Its core is philanthropic in
the true meaning of the wordlove for humankind.
On the drawing board for more than a decade, the building sprang
to life in 2010 when the Eye Center received a $12-million donation,
one of the largest donations in Dukes history, from LC Industries, the
largest employer of visually impaired people in the country.
A catalyst for action, the gift exemplified the commitment of many,
including a confluence of Eye Center benefactors and Advisory Board
members, as well as the Duke Eye Centers world-class eye care
providers. The new, modern facility will be home to Dukes long-
standing, outstanding, and leading clinical care for patients with eye
disease, low vision, and loss of vision.
This is a vision that has come true, says William Hudson,
president of Durham-based LC Industries and chairman of the Duke
Eye Center Advisory Board. We developed a relationship with the
Eye Center early on because it is a perfect partnership. We provide
jobs for the visually impaired, we provide educational opportunities,
but we cant conduct research on eye diseases or offer vision care.
The Eye Center takes over where we leave off. This new facility is a
win-win for everyone.
MULTIDIMENSIONAL VISION CARE
This building is a merging of our central philosophy and goals of trans-
lating research into advanced, novel vision care, matched with a deep
compassion and love for humanity, says R. Rand Allingham, MD,
chief of the Duke Eye Center glaucoma service.
Yes, its a clinical building and will expand the clinical facilities of the
Duke Eye Center, he continues. Yes, it will enable patients to have
V I S I O N 2012 // 3
 HEADLINE NEWS
Leadership from Duke Medicine System
gathered in April 2012 for a ceremonial
groundbreaking for the new clinical
building. (L to R) Kevin Sowers, MSN, RN;
William Fulkerson, MD; Victor J. Dzau, MD;
David Epstein, MD; William Hudson; Kathy
Hudson; Carl Ravin, MD; Ruth Albert.
easier access to the diagnostic evaluations and treatments they
need. And, yes, it will provide a patient-centric venue where
great physicians can continue to create and provide the most
current and cutting-edge care available. The collective activities
in the pavilion will help to reduce the number of people who
experience significant vision loss. I hope this new building will
house the talent that will ultimately put us out of business
that we find cures for diseases like glaucoma, diabetes, and
macular degeneration that destroy sight and are becoming more
common as our society ages, Allingham adds.
Planned with meticulous attention to detail for patient ease,
comfort, and efficiency, the new clinical paviliontogether
with the Albert Eye Research Institute, renovated space in the
Wadsworth Building, and the Duke Eye Center satellite practice
officeswill fulfill the Duke Eye Center credo of providing
outstanding clinical care, second to none, through the trans-
lation of research into innovative, leading patient care to help
cure diseases that cause blindness.
MEETING INCREASING NEED FOR EYE DISEASE TREATMENT
Although academic medical centers and various health-
care entities emphasize prolonging life for those with serious
systemic diseases, there has not been enough emphasis on the
importance of the quality of life. Vision is an underappreciated
and underfundedyet very importantcomponent of this
quality, along with the other senses, says David Epstein, MD,
chairman of the Duke Eye Center.
Duke is among the handful of academic medical centers with
prominent programs in ophthalmology dedicated to the three
missions of excellence in clinical eye care: innovation through
research and technology development to advance the under-
standing and the treatment of potentially blinding eye condi-
tions, excellence in patient care, and education of the next
V I S I O N 2012 // 4
generation of ophthalmology leaders. Unfortunately, most
serious eye diseases, such as glaucoma, macular degeneration,
retinitis pigmentosa, corneal disorders, and many other blinding
conditions, have no true cures todayonly palliative treatments.
David Epstein, chairman of the
Duke Eye Center, celebrates the
groundbreaking with Eye
Center residents.
COMPASSIONATE ARCHITECTURE
FACILITATES WORLD-CLASS CARE
Maintaining the architectural integrity of the Duke campus,
the new pavilion will be easily recognizable by a beacon light
shining from the Erwin Street corner tower. The modest lantern
symbolizes vision, hope, and illumination. From dusk to dawn,
a warm white light will shine, interrupted only by a bright blue
light to alert people to important Duke-related events, including
events related to the Eye Center. Designed with many green
features, the pavilion is on track for Leadership in Energy and
Environmental Design (LEED) Silver certification.
The facility will welcome patients and their families under
a covered, curved canopy for drop-off, with valet parking,
and easy parking garage access. We wanted to create a
comfortable, calming experience for patients and their families,
says Greg Warwick, Duke University Medical Centers architect.
Any academic medical center can seem intimidating, so
we designed every aspect of this pavilionstarting with a
patients arrivalto instill a sense of well-being and ease. Its
difficult enough to be experiencing vision problems, so we are
removing some of the environmental discomforts to enhance the
experience, he says. He worked with the global architectural
firm HOK and consulted with Chris Downey, RA, a low-vision
design specialist, who lost his vision in his 30s, to incorporate
comfort into every phase of a patients visit.
Diane B. Whitaker, OD, chief of the Vision Rehabilitation
Service, was instrumental in involving Downey because of his
unique qualifications. Hes the only blind architect in the U.S.,
and he understands that all senses need to be involved, she
says. He helped us incorporate sound-varying flooring into the
different areas of the center to create different tapping sounds
as cane users move from one area to another. Every color,
texture, contrast of the floors, the walls and furniture, and the
lighting methods are designed so each patient, regardless of
the level of vision impairment, will be comfortable and able to
move with ease.

The Duke Eye Center Clinical
Pavilion will have a positive
impact on the patients and
their families by providing an
environment that is welcoming,
accommodating, and responsive
to the multiple aspects that
influence people with eye-related
diseases and conditions.
// PAUL STROHM
Senior Vice President,
Director of Healthcare
HOK
Duke Eye Center patients were also consulted, and their helpful
insights have been incorporated into all aspects of the design.
For example, Judge Craig Brown, a Duke Eye Center patient
and Advisory Board member, noted that sharp corners and
edges are distressing to people with low vision, so rounded
corners are integrated within the new facility.
From the moment patients step into the clinical facility, they
will have as much or as little support checking in as needed.
Just like air travel, some patients will check in through the
Internet, using interfaces like Dukes HealthView patient portal.
Others will receive the personal touch from patient ambas-
sadors staffing the check-in kiosk.
At the kiosk, pagers will be available to patients indicating
when and where to go next. The multiple waiting areas
resemble comfortable living rooms, as they take into account
the needs of low-vision patients who require varying levels of
brightness and contrast. To aid patient navigation, color-coded
floor tiles and matching wall borders create yellow brick
road pathways that augment the electronic signage.
William Hudson, President of LC Industries, donated
$12 million in order to get the new clinical build-
ing off the ground. (L to R) Victor Dzau, MD; David
Epstein, MD; William Hudson.
Above, temporary entrance to Duke Eye Center
during construction.
The strategic placement of windows overlooking a beautiful
garden creates a connection to the outdoors for patients with
varying tolerances for light. With hopes of further philanthropy,
this area will become a sensory garden where patients can enjoy
various fragrances and textures.
While waiting, patients and their families will enjoy healthful
refreshments at the nutrition station, adjacent to a patient
education center. Here, patients can access the latest infor-
mation about all things eye, including various eye conditions
and diseases, as well as treatments.
SHORTER WAIT TIMES, FEWER STEPS
Challenged with creating the shortest patient waiting times
possible while maintaining patient access, a team of clinicians
(including Scott W. Cousins, MD, retina specialist and vice
chair of research, Department of Ophthalmology, as well as
Allingham), architects, and administrators met for a year to find
the most innovative patient-centric solutions.
Michael Howard, chief operating officer of the Duke Eye
Center, says this team created a patient-friendly flow that
ensures the fewest number of steps will be needed to get
patients from the waiting areas to the various exam and
treatment rooms.
The entire floor plan revolves around patients, including
more patient seating, shorter check-in and checkout times, a
centralized diagnostic suite surrounded by flexible treatment,
exam, and consultation rooms which streamline and enhance
compassionate care for our patients, Howard says. If one
day we have a high number of glaucoma patients, we can use
less-busy adjacent space. This will solve the bottleneck issue we
struggle with today.
V I S I O N 2012 // 5
Whether patients travel from across the state, from a far
corner of the United States or from the other side of the globe,
patient preferences will be easier to accommodate. With the
 HEADLINE NEWS
new building, the Duke Eye Center will be able to get
everything done in one daythe exam, imaging, physician
meeting, and the treatment plan, which may include
injection or laser treatment.
Howard, who has been in health care for 40 years, is
excited to improve the model of care: This new pavilion
will help make the Duke Eye Center among the premier
academic medical eye centers in the world. And, given that
the number of vision-impaired people is expected to nearly
double as the baby boomer generation ages, well be ready
for them now and in 20 years.
LIGHTING THE PATH TO THE FUTURE
The new facility comes at a time when demand for vision
services is growing at an alarming rate. According to the
National Eye Institute, blindness or low vision affects 3.3
million Americans age 40 and up and is projected to reach
5.5 million by the year 2020.
Similar demands for increased services are being felt at the
Duke Eye Center, which consistently ranks among the top
10 eye centers in the country by several organizations.
During the past five years, the Duke Eye Centers volume
has grown in both surgical procedures and clinic visits.
Today, roughly 55 physicians see more than 80,000
patients each year in the Wadsworth Building. Nearly
170,000 patients have been seen this year at all Duke Eye
V I S I O N 2012 // 6
The new entrance to the Eye Center features a circular
drive for ease in dropping off and picking up patients.
Center facilities, including satellite offices. Built 40 years
ago, the current facility was designed to accommodate
eight clinicians and 20,000 patients annually. The new
clinical facility will alleviate increased patient volumes
and support patient growth.
Staff at the Duke Eye Center will continue to see patients
throughout construction of the 127,000-square-foot, four-
story pavilion, which will be located in the current valet
parking lot in front of the Wadsworth Building. The new
clinical pavilion is scheduled for completion in 2015. By
enabling multidisciplinary teamwork, facilitating clinical
research, and making care more effective, efficient, and
patient-friendly, the Duke Eye Center will truly be second to
none. Epstein predicts that the Duke Eye Center will be the
number-one ranked eye center in the nation five years after
the new pavilion is opened.
The Duke Eye Center Clinical Pavilion will be a living
testament to those who stepped forward with a vision, a
passion, and a commitment to improve the quality of life of
patients with eye disease, low vision, and loss of vision. The
beacon of light radiating from the corner tower will be a
reminder that through a love of humankind and a compas-
sionate vision, a breakthrough level of world-class care
focused on the patient has become real.
 LOW VISION

Seeing Is Believing:
Repurposed Rehabilitation
Technology Benefits Athletes
WHAT DO ELITE ATHLETES now have in common with those
who have suffered an acquired brain injury from a stroke,
trauma, or other means?

A machine. But not just any machine.

Brain-injured patients benefit greatly from this machine, known

commercially as the Dynavision D2. Its currently used to
help brain-injured individuals regain their visual processing
speed, a component of visual motor reaction time. This helps
them do things like routine daily activities, and it also improves
their ability to drive.

Now, researchers are using the D2 on members of the mens

basketball team at Duke University to assess how sensory
motor training may enhance visual motor skills and improve
athletic performance.
Diane B. Whitaker, OD, is the primary investigator for the
study. Clinicians and scientists are beginning to realize that
rehabilitative training that allows someone
to regain or improve lost function may also
be able to take the visual motor perfor-
mance of a healthy individual to a higher
level, she says.
The machine provides both a mental and
physical workout by combining visual
targets that require users to make timed
physical motor responses to the targets.
As the individual improves at each task,
the training protocol becomes faster, more
complex, and increasingly difficult.
Diane B. Whitaker
Researchers started using this protocol with
the Duke basketball players in an institutional review board
(IRB) random-control-led trial to see if the men who experi-
enced the special D2 training had better post-training perfor-
mance than the men who didnt, compared to their pre-training
baseline evaluations.
Well look at the individual players and their performance of
the D2 and their post-training assessments, says Whitaker.
The trial data will reveal whether or not actual performance
improved after D2 training in multiple parameters.
The Dynavision D2 assesses how sensory motor training may improve
athletic performance.
are vast, not only for athletes of all kinds but also for the
general public as the boomer population continues to age.
This technology is mainstream, Whitaker says. It is
attractive to all kinds of professional athletes, sports, and the
military. Our clinical trial will give us the definitive data to
know if and how well it actually works.
Whitaker notes that the beauty of being at Duke is the
momentum created by people with a passion for what they do.
We work in a collaborative environment that allows us to
create multidisciplinary programs which foster the cultivation
of new perspectives and processes that advance human health
and performance.
While its rewarding to be on the cutting edge of athletic rehabili-
tation and performance enhancement, Whitaker doesnt forget her
first lovehelping the blind and visually impaired population.
Rehabilitation training for the visually impaired is poorly
funded with little or no insurance reimbursement, she says.
Many sight-impaired people cant work, even though they
want to do so. In comparison, professional athletes can pay
out-of-pocket fees for enhancement training that may give
them a professional edge. My ultimate purpose for getting
involved with sports vision training is the hope that any
V I S I O N 2012 // 7

potential dollars made will come back to serve the blind and
In the demanding world of sports, finding ways to sharpen the
visually impaired.
athletic edge through methods other than biological agents and
sports-enhancing drugswhich offer unfair advantages and are
illegalcontinues to grow. Implications for this kind of training
 GLAUCOMA
360-Degree
Trabeculotomy
SHARON FREEDMAN, MD, a pediatric
glaucoma specialist and chief of the
pediatrics and strabismus service at
the Duke Eye Center, has put new
technology to work to help her patients.
Though her patients are typically
children with glaucoma, Freedman has
successfully performed a procedure
called 360-degree trabeculotomy on
young adult glaucoma patients.
Trabeculotomy was first developed using
a metal probe to open up the canal of
Schlemm to the left and right of the
incision. It only allowed the surgeon
to open the trabecular meshwork and
wall of Schlemm canal for 180 degrees
rather than the full circumference of the
eye. This procedure seems to work well
for children with primary congenital
glaucoma, but has not been appli-
cable for adult glaucoma patients. The
360-degree trabeculotomy is a modifi-
cation of the procedure that involves
the insertion of a flexible suture into
the Schlemm canal and the attempt to
thread the suture through the canal all
the way around its circular length (360
degrees). Feeding the suture through the
entire canal of Schlemm can open it up,
or cheese wire it, as Freedman says.
The problem is that the suture is flexible,
and the canal has tributaries branching
off it. The path of the suture cannot
easily be tracked as it is fed through the
canal, so the suture may go into one of
these tributaries or into other locations
by error that are not useful, and can
even be harmful.
A fairly new technology has alleviated
the problem of the blind pass around
V I S I O N 2012 // 8
the Schlemm canala lighted micro-
catheter called iTrack, developed by
iScience Interventional. The iTrack is
a light, flexible microcatheter with a
channel for a lubricant called visco-
elastic. It was originally developed and
marketed for an adult surgery called
canaloplasty. Freedman and a few others
saw this as a way to facilitate 360-degree
trabeculotomy in children as well. Once
the iTrack catheter is inserted into the
canal of Schlemm, the surgeon can see
where it is going by following the path
of the lighted tip. Since it has a larger
diameter and a rounded tip, the catheter
often can travel all the way around the
canal without veering into one of the
She explained the
procedure and what
to expect afterward.
We decided to go
ahead with the
procedure after
meeting with her
because she made us
feel so comfortable.
// LEENA RAO
tributaries or getting stuck against the
canal wall as a suture often would.
Before this development, patients
with juvenile open-angle glaucoma
and patients who had glaucoma after
removal of infantile cataracts often
did not respond to standard angle
surgery (goniotomy and standard
180-degree trabeculotomy), and were
therefore subjected initially to more
invasive surgery. The use of the
lighted microcatheter has allowed
Freedman and colleagues to success-
fully treat many of these difficult
cases without resorting to more
invasive glaucoma drainage implant
or trabeculectomy surgery.
Freedman performed a study of
the success of the trabeculotomy
procedure facilitated by the catheter.
She and her clinical fellow, Jennifer
Dao, MD, together with collabo-
rator Steven Sarkisian Jr., MD, at
McGee Eye Institute in Oklahoma,
have presented their work at the
2012 Annual Scientific Meeting of the
American Association for Pediatric
Ophthalmology and Strabismus
(AAPOS), and hope that their findings
will encourage other doctors to offer
this procedure to selected young adult
glaucoma patients. One of the patients in
Freedmans study is Leena Rao, DMD.
Rao, a patient of Leon Herndon, MD,
of the Duke Eye Center, was referred to
Freedman for this procedure after her eye
pressures were very high and she had an
unsuccessful laser surgery to address her
elevated ocular pressure.
Rao had successfully undergone laser
surgery once before. The results lasted
for about four years, however, her
second laser surgery was successful
only on the left eye; in her right eye,
the entire meshwork collapsed, and she
was left with high pressure in that eye,
as well as sensitivity to sunlight and
constant throbbing. The procedure may
have also interfered with Raos ability
to exercise regularly and to wear her
contact lenses. Herndon further noted
that most of his trabeculectomy patients

Sharon Freedman examines a patient were older, and he therefore recom-
before surgery.
mended that Rao meet with Freedman
to discuss the possibility of doing the
360-degree trabeculotomy.
Dr. Freedman was amazing, declares
Rao. She explained the procedure and
what to expect afterward. We decided
to go ahead with the procedure after
meeting with her because she made us
feel so comfortable. Going into the
surgery, Rao was not sure what the
recovery would be like or even if the
surgery would be successful. She
happily reports that the healing was
not bad at all! Her vision returned
to normal in about a month and a
half. Freedman concurs: It worked
amazingly well for her.
Rao is pleased with how the procedure
restored her quality of life. Before the
surgery, she used three different kinds
Forcep of drops; now she needs only two. She
advancing also took oral medication that had
microcatheter
side effects like tingling in her lips and
around Schlemm
Microcatheter canal fingers, nausea, weight loss, and extreme
fatigue. I was tired all the time. Even
Cut end of my little one said to me, You used to
Schlemm canal come home from work, eat dinner,
and go to sleep. But now I have much
Sharon F. Freedman, MD
Professor of Ophthalmology
Professor of Pediatrics
Chief, Pediatric Ophthalmology
and Strabismus Service
more energy. The medication didnt
completely relieve the pressure either.
By mid-morning, Rao says, the
pressure would go up and the throbbing
would begin. Every aspect of her life
was affected. I couldnt even open my
eyes in the sun. Now, I dont have any of
those symptoms.
It has now been almost two years since
the procedure. Rao regularly checks her
own eye pressure at home using the Icare
rebound tonometer, which was suggested
to her by Freedman. Her routine
check-ups show that the pre-existing
damage to the optic nerves has stabi-
lized. Her eye pressures decreased from
their highest readings of 45 to 18-19 mm
of mercury, and have remained stable
since the surgery.
Rao is just one of the many patients
Freedman included in her study of this
procedure, and her case is special among
adult patients. It would be premature to
suggest that I believe the trabeculotomy I
performed on Dr. Rao should be widely
used for the typical adults (who are
mostly much older than Dr. Rao) with
open-angle glaucoma of the garden
V I S I O N 2012 // 9
variety, but for those adults whose
glaucoma began in teenage years or
young adult years, I do think it is worth
careful consideration.
 CORNEA
CORNEAL DYSTROPHY
GENE RESEARCH
A COLLABORATION OF EXPERT clinician
scientists has brought about a breakthrough in
the treatment of corneal dystrophy. Duke Eye
Centers Natalie Afshari, MD, and Terri Young,
MD, working with Vincent Soler, MD, a visiting
researcher from France, have discovered the
gene that is believed to be responsible for this
condition. According to Afshari and Young, this
groundbreaking research was made possible by
a combination of international collaboration
and technological advances that came together
in an amazing way.
Afshari and Young are both leaders in their
Vincent Soler
areas of specialty. Afshari, a leading corneal
V I S I O N 2012 // 10
specialist, has done extensive research on
the genetics of Fuchs corneal dystrophy. In
her clinical practice, she also has long-term
experience with a unique group of patients
who became the focus of this collaborative
gene study. These patients, all members of
the Haliwa-Saponi tribe of Halifax County,
North Carolina, suffer from hereditary benign
intraepithelial dyskeratosis (HBID). This gene
sequencing research holds the promise of future
treatment advances for them.
Young, as a researching professor and
specialist in the genetics of myopia, has collab-
orated with gene researchers worldwide. In
2010, she worked with Drs. Patrick Calvas and
Francois Malecaze of Toulouse, France, whom
she met through the Association for Research
in Vision and Ophthalmology (ARVO). These
two doctors mentored Soler and later sent him
to Duke for a year to participate in Youngs
gene research.
Young recalls, I was doing myopia research
with Dr. Solers mentors; I had met them at
ARVO. They sent Vincent over. He
didnt know about Afshari. We were
just doing gene sequencing in the lab for
myopia and other disorders, and Soler
mentioned this family he worked with.
This family included a mother and son
who both presented with corneal scarring
and neovascularization. Soler showed
Young a photo of his patient and asked
if she had ever seen anything like it. She
didnt know what it was, but she knew
Afshari would. Dr. Afshari is one of
the most renowned corneal specialists
in the world, says Young. She showed
the photo to Afshari, who recognized
the patients condition as HBID. This
was startling news in light of the fact
that Afshari had never seen this disorder
outside the Haliwa-Saponi tribe.
HBID patients develop an overgrowth
of abnormal tissue over the cornea that,
over time, becomes invaded by small
blood vessels. It is so readily recognized
among the Haliwa-Saponi tribe that they
have named it red eye disease. Afshari
knew, as Soler did, that the cause was
hereditary, and Youngs work with gene
sequencing would help them pinpoint
the genetic source.
With Soler working alongside, Young
performed readings of the related genes
using exome sequencing. Young explains,
This next-gen sequencing technique has
really accelerated our ability to ID genes.
Instead of traditional sequencing where
we get one read of the genome, we get 50
copies or 100 copies, so theres greater
veracity in the data. Using the new
technology, Young and Soler were able to
do in 10 months what the old technology
would have taken them 10 years to do.
Isolating the gene is just the beginning of
the anticipated advances in treatment of
the disorder. As Young says, When you
understand the genetics, you understand
the biology of the disease. For example,
a change in the amino acid pairings may
cause a protein not to bind to its receptor.
Consequently, the receptor doesnt turn
on, and that complex doesnt occur
as it should. Young describes it as a
cascading effect, in terms of that protein
having an integral function somewhere
along the choreographed dance of what it
does amongst other proteins.
Afshari adds: Over time, it can increase
the overgrowth or fibrosis over the
cornea. Gene therapy is a future hope.
Having the gene identified would increase
our promise of gene therapy down the
line. Since we are getting to learn what
causes it, we could stop the process at
some point. The solution will be compli-
cated, however. Afshari explains, Often
gene therapy is not simple because
stopping the disease at the point where
the protein is altered, causing the scarring
or overgrowth, is not that simple. We
want to be sure we stop just that one
process and not something else.
Halifax County
Members of the Haliwa-Saponi tribe mainly
originate from Halifax County.
When you understand the genetics, you
understand the biology of the disease, says
Terri L. Young.
The treatment could involve the
replacement of a particular protein or
blockage of another protein. It could
be that you augment the function of the
coded protein thats not working so well
with other enzymes, Young says. The
first way you figure that out is by figuring
out what that gene encodes for, what
protein it encodes for, and what other
proteins it dances with.
And when you know what gene encodes
it, Afshari continues, you know who
is at risk, even if they are young, before
they develop it.
The next step after identifying the
encoding gene is to develop an animal
model in which the same DNA mutation
can be produced. Researchers can then
start manipulating the gene in the animal
and observing the results. Young calls
this a gene knockout and rescue
removal of the gene and then its
replacement to see if that is curative.
Young uses zebrafish in her research.
This animal model has some excellent
advantages: The fish grow rapidly, and
they have very large eyes, so changes
in the cornea can be seen easily.
When asked about the most amazing
things about this discovery, the two
doctors list several thingsnext-gen
sequencing, the discovery of the gene,
and the development of the animal
modelall accomplished in a short time.
Yet, both Afshari and Young agree that
the most amazing aspect of this work
has been the human side: the help that
can be offered to this unique group
of patients, the surprising appearance
of patients with the same condition
in another part of the world, and the
collaborative work that was done to
bring about these results.
Both doctors agree that not only
scientifically, but clinically, we put it
V I S I O N 2012 // 11
together, says Young.
 GLAUCOMA
Cerebrospinal Fluid Pressure:
A Key Difference in
Understanding Glaucoma
WHAT IF THE MOST BASIC assump-
tions about glaucoma were suddenly
challenged? Based on data from a
number of studies, doctors like Rand
Allingham, MD, of the Duke Eye Center
are now realizing that some of the
standard wisdom about primary open-
angle glaucoma need to be reconsidered.
Glaucoma has long been thought to
be a problem of intraocular pressure.
Currently, all treatments for the disease
are based on reducing eye pressure,
either surgically or with medication. It
has been thought that high intraocular
pressure damages the optic nerve,
causing loss of vision in scattered areas
of the patients visual field.
Vision loss from glaucoma has almost
no symptoms in its early-to-moderate
stages. Portions of the visual field,
the area of vision in all directions,
are lost slowly. The brain treats these
as missing rather than a blacked-
out area. Consequently, vision loss is
extremely hard to detect until late in the
disease. Unfortunately this vision loss is
largely irreversible, so early diagnosis is
key to prevent vision loss.
The structure affected in glaucoma is
the optic nerve, which carries visual
information from the eye to the brain.
About 1 million fibers, called axons,
are bundled into the optic nerve. Axons
carry the information for sight from
V I S I O N 2012 // 12
the retina, where images are processed, eye pressure and CSF pressure, what we
through the optic nerve to the brain, call translaminar pressure, the greater
where what we see is interpreted. As the risk for glaucoma.
a part of the brain, the optic nerve
Other lines of evidence point to the
is covered by dura mater, the same
same conclusion. A study by a group
material that covers the brain and
spinal cord. Cerebrospinal fluid (CSF)
fills the dura mater and surrounds the
axons within the optic nerve. Data
now strongly suggest that the pressure
exerted by CSF fluid may be a key
player in glaucoma. What may be most
critical is the difference in pressure
between the pressure within the eye and
the pressure around the optic nerve,
explains Allingham.
To reveal how CSF pressure may be
involved in glaucoma, John Berdahl, What may be most
former resident at Duke, and Allingham critical is the difference
looked at tens of thousands of patient
records at the Mayo Clinic, where in pressure between the
there is an enormous collection of pressure within the eye
electronic medical records. This study
looked at the CSF pressure of patients
and the pressure around
with and without glaucoma and found the optic nerve.
CSF pressure to be significantly lower
// RAND ALLINGHAM
in glaucoma patients than in other
patients. This finding supports the
notion that the problem is a pressure
difference between the eye and the in Boston looked at body mass index
brain. Shortly thereafter, a study of (BMI) as it relates to CSF pressure.
glaucoma patients was conducted in People with higher BMI were at reduced
Beijing that confirmed the Duke finding risk for developing glaucoma, particu-
of lower CSF pressure in glaucoma. In larly in women. Allingham recently
glaucoma patients with normal levels led a study that demonstrated a linear
of ocular pressure, even lower CSF relationship between BMI and CSF
pressure. In other words, the thinner
pressure levels were observed. The
you are, the lower your CSF pressure
conclusion derived from this study is
and the higher the risk of glaucoma. In
that the higher the difference between

the Boston study, women who were
heavier actually had a reduced risk
of glaucoma, perhaps one of the few
times being heavier helps reduce risk
of disease.
Glaucoma is a disease of aging; all
studies demonstrate that risk of
glaucoma increases dramatically
after age 50. In a study currently
being conducted, Allingham and
colleagues have found that CSF
pressure drops after age 50, up to
25 percent. We looked at people
with CSF pressure at all ages,
says Allingham. From childhood
through age 50 there was virtually
no change in CSF pressure. After
age 50 CSF pressure begins to drop.
Curiously, this occurs at the same
age that glaucoma rates start to rise.
We feel this drop in CSF pressure
may be a major reason why we see
this rise in glaucoma.
While the discovery of the critical
role of translaminar pressure in
glaucoma is an important one,
questions remain. Allingham
says, A lot is known about CSF
pressure, but the idea of the pressure
differential is new. For example,
in the case of the relationship
between BMI and CSF pressure,
the role of hormones is not clear.
Furthermore, what is the critical
pressure differential between the
eye and cerebrospinal fluid? Is it
the same for patients with a low
or high eye pressure? Allingham
points out that even diagnosing
low-pressure glaucoma is difficult. A
big challenge is how we can measure
and monitor CSF. Currently, the
only way is via spinal tap, which
is not practical on a large scale.
If we could do the CSF pressure
Retinal
vein
measurement more easily, says
Retina
Allingham, we could identify
patients at greater risk of glaucoma.
We need ways of assessing pressure
without this invasive process.
Whatever questions remain, Retinal
Allingham is clear about the signifi- CSF space artery
cance of this new data. To date,
the data all support this theory.
As a matter of fact, he is convinced
that as we learn more about how Normal CSF pressure:
CSF is made and what controls CSF Pressure in the eyeball is similar to
pressure in the optic nerve
pressure, we may find other diseases
related to pressure imbalances
between the CSF space and elsewhere
in the body. Is there anywhere
else in the brain where the pressure
differential makes the difference?
Currently, we dont know, but we
have seen some evidence supporting
a relationship between CSF pressure
and other nerve pain syndromes.
What else will come out of this?
Clearly, much more research
must be done. Right now, what is
known is what happens when CSF
pressure is very high or very low.
What happens in the middle?
asks Allingham, who then answers
Traditional glaucoma:
his own question: It looks like Pressure in the eyeball is higher
glaucoma happens in the middle. than pressure in the optic nerve,
He is encouraged by the growing causing cupping.
body of information. Were
running it down, and were going to
see where it leads us.
V I S I O N 2012 // 13
Another cause of glaucoma:
Pressure in the eyeball is normal but
the pressure in the nerve is low.
 GLAUCOMA

When we examine
the retina, we
are looking into a
window of the brain.

Henry Tsengs research

finds new ways to

t
look at high-pressure
glaucoma patients
reatments for high eye pressure in glaucoma patients have improved consid-
erably in the last 10 years. While this is good news for many glaucoma
patients, doctors have discovered that high pressure is not the whole story.
Approximately one-third of glaucoma patients have normal-to-low eye
pressure; no good treatment exists for this group, because at present every
treatment available addresses high pressure. Henry Tseng, MD, PhD, has been
studying another aspect of the disease in search of an answer: neurodegen-
eration, or nerve cell death.
V I S I O N 2012 // 14

The optic nerve is made up of connections between the retina and the brain. In
both normal- and high-pressure glaucoma patients, these connections are lost.
The nerve cells in the retina lose axons (connecting fibers) and die, and doctors do not
know the cause. This process is called apoptosis, or programmed cell death. Tsengs
research is beginning to uncover a connection between neurodegeneration that occurs
in glaucoma and the same phenomenon in other neuro-
degenerative diseases, such as Parkinsons, Alzheimers,
and amyotrophic lateral sclerosis (ALS or Lou Gehrigs
disease).

Tseng explains apoptosis in this way: The cell makes a

decision to die. For skin cells, you just grow new cells.
In nerve cells called neurons, this is a serious decision
because there is no regrowth. There is some problem
with the circuitry that makes this decision at the cellular
or molecular level. This is hard to study in patients,
so research must be conducted in the laboratory using
animal models.

Tsengs research is focused on studying genetic mutations

of a protein called optineurin. Tseng says this protein is
important for three reasons. First of all, it is relatively
new. No one knew much about this protein before the
year 2002, when it became associated with glaucoma.
Second, it is unlike any other protein in the body. Its
found all over the body, so why is it causing problems
only in the eye? And, third, understanding what the
mutations actually do and how they lead to disease will
be critical to uncovering the control circuits that regulate
neuronal cell death in neurodegenerative diseases.
Tsengs lab work uses a model in which the human If you dont need an MRI or CT, you can just
version of the protein is introduced into transgenic mice. In look into the eye and see that someone has
the last year or so, other doctors from non-ophthalmologic
fields have discovered that this protein with different mutations Alzheimers diseasethats an exciting possibility.
causes other neurodegenerative diseases, such as ALS.
Preliminary data also implicate optineurin in Alzheimers and If these are affected, they could potentially serve as important
Huntingtons diseases. biomarkers for following patients with ALS in clinical trials.

Because of this laboratory research, says Tseng, were
starting to realize that glaucoma is not just an eye problem,
but a brain problem, too. Tseng and other researchers are
now looking for connections between glaucoma and other
neurodegenerative diseases. There may be signaling pathways
or control circuits that could be common to these diseases.
Tseng reports, Were starting to have conversations with
neurologists about neurodegenerative diseases that werent
previously linked with glaucoma.
One of these doctors is Richard Bedlack, MD, PhD, a neurol-
ogist and director of the Duke ALS Clinic. Bedlack confirms
that mutations in optineurin have recently been found in ALS
patients, and thusfor the first timea link has been estab-
lished between ALS and glaucoma. There is little known about
the visual status of ALS patients. Bedlack reports that vision
complaints are certainly not common, but this may be due to
For Tseng, the eyebrain connection is not surprising. The
retina is part of the brain, explains Tseng, who holds a PhD
in neurobiology. When we examine the retina, we are looking
into a window of the brain. Tseng envisions using eye imaging
to diagnose diseases of the brain. If you dont need an MRI
or CT, you can just look into the eye and see that someone
has Alzheimers diseasethats an exciting possibility. For
example, optical coherence tomography (OCT), a fairly new
way to study cross-sections of the retina, could potentially be
used to diagnose brain diseases.
These newly discovered connections point the way to great
possibilities. Focusing on the optineurin protein has provided a
way to study glaucoma and other neurodegenerative diseases,
but Tseng continues to look at the broader picture for patients.
There is the potential for new ways of diagnosing brain diseases
as well as new glaucoma treatments that might be good for
V I S I O N 2012 // 15

the fact that so many other things are happening so fast (loss of neurodegenerative diseases, and vice versa.
speech, swallowing, breathing, and limb functions).

Dr. Tseng and I are currently seeking funding to study vision

[and retinal changes] in the Duke ALS Clinic, says Bedlack.
 CORNEA
Putting the
Heat on
Dry Eye
ALAN N. CARLSON, MD, AND PREEYA GUPTA, MD, cornea
specialists at the Duke Eye Center, are both excited about the
latest treatment for dry-eye patients. LipiFlow, a device intro-
duced late last year, allows physicians to do more than just add
moisture to the surface of the eye; it addresses the problem in
the glands of the eyelids, where it begins.
There are two major types of dry eye: aqueous deficient dry
eye, in which there is decreased tear production from the
lacrimal gland, and evaporative dry eye, in which there is
essentially normal tear production, but excessive evaporation
of the tears that are produced. Evaporative dry eye disease is
by far the more common type. For patients with this type of
dry eye, the problem is a clogging of the meibomian glands,
which secrete the oil that creates a film over the tear layer to
prevent evaporation. There are about 75 of these glands in the
lids of each eye, and in patients with evaporative dry eye, there
may be fewer than five glands working properly. In meibomian
gland dysfunction, the oil trapped in the glands takes on the
consistency of butter in your refrigerator rather than the oil in
your engine. It isnt spreading over the tear layer and doing its
job, thereby increasing tear evaporation. This is the problem
LipiFlow addresses.
So how does it work? The device slides under the eyelids to
deliver precise (but not extreme) heat of 42.5C (108.5F) to
the clogged glands, far more effectively than warm compresses.
Then a series of pulsations act to milk or squeeze the glands.
Carlson emphasizes that it is the synergy of heat and pulsation
that is most important. This is the first device that allows us to
effectively liquefy the abnormal oils and simultaneously precisely
compress the glands, making this much more effective than
anything patients can do at home. With heat alone, the material
V I S I O N 2012 // 16
would not be expressed out of the glands. With pulsation alone,
the material would not be liquefied to ease the flow. LipiFlow
does both, and patients say it does them both comfortably.
To prepare patients for the procedure, a drop of topical
anesthesia is placed in each eye. The device does not lie
Preeya Gupta checks to ensure proper fit of the LipiFlow device during
the procedure.
against the cornea, but rather vaults over it. According to
Carlson, several patients have found pulsating action of the
device to be like a plunger. Afterward, the patients eyes
are irrigated, leaving the eyes feeling refreshed. While some
patients report feeling relief soon after the procedure, it can
take up to three to four months to see the maximal results;
the effects can last up to 24 months.
And who is the typical dry-eye patient? Carlson and Gupta
agree that dry eye is not just a problem of old age; both
doctors see patients in their twenties and thirties. Says Gupta,
Evaporative dry eye is extremely common and likely under-
diagnosed. Carlson adds that it is more common than cataracts,
glaucoma, and macular degeneration combined. He also points
out that while some patients may have a genetic predisposition,
the condition may also be aggravated by lifestyle factors like
long days, insufficient sleep, and long periods of looking at
computer or cell phone screens. Computer gamers, for example,
may go for up to a full minute without blinking. This reduces the
natural pressure on the glands needed for expressing the oils into
the tear film to decrease tear evaporation.
Because it addresses tear evaporation, LipiFlow is very different
from past treatments that focused mainly on increasing tear
production. Gupta knows about the difficulties patients encoun-
tered with these older methods. Treating dry eye can be very
frustrating for patients, as it is often very labor intensive and
relies on patient compliance with frequent use of tears and warm
compresses. Carlson says that these methods treat the problem
downstream, not where the patients need to be. LipiFlow goes
upstream, treating the primary problem. Both doctors are
enthusiastic about LipiFlow. Gupta sees it as a way to really
help patients get that extra boost they are looking for. Carlson
says, The LipiFlow treatment allows them to keep doing what
they do in the normal routine of their lives.
TRAINING
PROVIDES CUTTING-
EDGE, HANDS-ON
SURGICAL SKILL
FOR PARAG D. GANDHI, MD, an oculo-
plastic surgeon at the Duke Eye Center of
Winston-Salem, practice and education
come together expertly. He blends his
passion for oculoplastic surgery and cra-
niofacial trauma management and repair
with his love of educating residents and
fellows with the most current hands-on
surgical skills transfer methods.
One of a handful of AO North America
Craniomaxillofacial (AOCMF) trauma
educators in the United States with a
background in oculoplastic surgery,
Gandhis specialized skills set benefits
the Duke Eye Centers already strong
oculoplastic surgery team, while corre-
spondingly, the AOCMF benefits from
Gandhis experience. He was elected by a
peer-review process to the AOCMF
faculty in September 2010.
I hope I can pass this passion
Its important for ophthalmolo-
gists, Gandhi notes, to have the
most current training in orbital
trauma, soft tissue injury, and
orbitofacial fracture repair and
managementnot only for their
boards and exams but also for their
general knowledge. Its crucial to
be exposed to and deeply under-
stand what goes into these kinds of
repairs and what the complications
can be, he says.
To this end, Gandhi, also a member
of the American Society of
Ophthalmic Plastic & Reconstructive
Surgery (ASOPRS), brings hands-on
skills transfer training to Duke,
facilitates research discussions, and
participates in CMF trauma and
advanced courses.
This fall Gandhi will be teaching
principles and advanced AOCMF
courses for trainees in various facial
surgical subspecialties to learn both
theory and practice.
In these courses, our discussion goes
beyond how to plate and repair facial
traumas. Our small groups work on
model skulls or fresh cadaver skulls in
repairing a variety of fracture injuries,
he explains. We apply the most-current
techniques and theory as we are working
with drills and screws.
Gandhi has already been involved in
multiple training courses for operating
room nurses and personnel about
the science behind these procedures.
When nurses also have the oppor-
tunity to plate skulls, it improves their
facility in understanding how to set up
the operating room.
One of my great passions is to share
with Duke residents and fellows who are
eager to learn about these approaches
and are excited to learn experientially as
a way to augment lectures, he explains.
along through my practice
and my role as an educator.
// PARAG D. GANDHI
A tenet of learning for AOCMF is to work
with other facial surgical subspecialties
in academia (i.e., otolaryngology, oral
surgery, neurosurgery) and also to learn
how each specialty deals with these
kinds of traumas to help everyone be
better at what they do. Cross-training
improves everyones understanding
and skills, ultimately to help patients in
need, says Gandhi.
AO North America has been at the
forefront of trauma and musculo-
skeletal surgery for 50 years, driven by
a commitment to both innovation and
excellence in patient care. This medically
guided nonprofit organization is led
by an international group of surgeons
specializing in the treatment of trauma
and disorders of the musculoskeletal
system. AOCMF offers affiliated
surgeons and operating room personnel
global networking opportunities and
educational services.
Gandhi was inspired to pursue a career
in oculoplastic surgery and craniofacial
trauma management and repair during
his residency at Mount Sinai School of
Medicine in New York, through various
formative experiences. One memorable
incident was an orbital trauma patient
who had sustained significant facial
trauma. Due to other medical and health
issues at the time of the injury, the
patient could not undergo a full recon-
structive procedure for his facial injury.
That left the man with a significant
periocular deformity that stigmatized
him from obtaining a job or presenting
himself in public.
We conducted a modified plating
technique on this gentleman which
was a life-altering procedure for him,
Gandhi says. The experience of
helping change someones life in such a
positive way piqued my interest in this
V I S I O N 2012 // 17
field, and I hope I can pass this passion
along through my practice and my role
as an educator.
 NEWS

Gordon Klintworth, MD, PhD:

50 YEARS IN RESEARCH

SINCE GORDON KLINTWORTHS arrival at Duke in 1962, he

has seen much growth and change in his field: from the creation
of the Department of Ophthalmology at Duke to the estab-
lishment of the National Eye Institute (NEI) to support research
in ophthalmology, to his own 50-year period of continuous
funding for research. Says David Epstein, MD, chair of the
Duke Eye Center, Dr. Klintworth is my hero. Hes one of the
most remarkable individuals Ive ever met. He is an MD-PhD,
but hes an outstanding scientist. Hes been here for 50 years,
and hes still funded. Klintworth himself admits that this is
quite an achievement.
Klintworth started his career in medicine in South Africa.
He describes his departure as part of the brain drain that
resulted from the unrest caused by apartheid. A colleague of
Klintworths, Neville Proctor, MD, had been offered a job by
Stephen Vogel, MD, in the Department of Pathology at Duke.
The department was expanding its research program under
the leadership of Thomas Kinney, MD, who later became dean
of Dukes school of medicine, and Klintworth approached
Proctor to find out if he could
arrange a position for him as
well. I came for training in
neuropathology from 1962-1966
on a fellowship funded by the
National Institutes of Health,
explains Klintworth. As a
neuropathology fellow, I came to
Duke specifically to get formal
training in neuropathology and
anatomic pathology. While being
trained, I saw specimens coming
V I S I O N 2012 // 18
pure accident, but says, it was a fortunate accident. There
was nobody in the pathology department interested in eye
pathology. I got interested in it, and then Duke created a
department, and that generated more and more specimens
that were processed in pathology, and that created a need for
someone to interact with the ophthalmologists.
When Klintworth first arrived, there was a small division
of ophthalmology. It was not established as an independent
department until 1964, under the leadership of Joseph
A. C. Wadsworth, MD. Eventually, the department hired
Robert Machemer, MD, as its second chair, and he recruited
Klintworth as director of research. Soon after the creation of
the NEI, Klintworth obtained its career development award,
equivalent to the K grants that exist now. I was one of the
first people they gave a career development award to, and
Im the only recipient of one of the first career development
awards who still has continuous grant support from the
NEI, says Klintworth.
Klintworth emphasizes the
crucial role the NEI has played
in his research career. Prior
to its establishment, vision
research was supported by the
Institute of Nervous Disease
and Blindness. But shortly after
the creation of the ophthal-
mology department at Duke,
the NEI was established. They
were very much interested in
funding people doing research

from the ophthalmology division, related to visual problems

and I got interested in eye and disorders of the eye,
pathology. I found it fascinating. says Klintworth. Id always
Klintworth calls his intro- L to R: Banks Anderson, Jr. MD; Roy Titus; been interested in research
duction into ophthalmic pathology Gordon Klintworth, MD, PhD. c. 1986 and would not have become

Gordon Klintworth, MD, PhD
involved in research related to ophthalmic diseases if fortu-
itous things hadnt happenedthe creation of the department
and the formation of the NEI. If that hadnt happened, I
would have remained in neuropathology.
The Department of Ophthalmology, and indeed the field itself,
has benefited greatly from this series of events. Since joining the
department, Klintworth has taken part in some groundbreaking
advances in research. For example, a paper Klintworth
coauthored with Vogel on macular corneal dystrophy attracted
a lot of attention, in part because it was the first use of the
transmission electron microscope in the study of any corneal
disease. A few years later, while studying lattice corneal
dystrophy, Klintworth found that the corneal deposits were due
to amyloid, an abnormal protein that had not been identified in
the cornea. His research also identified a unique protein in the
cornea which is encoded by a gene that accounts for several clini-
cally and histopathologically different corneal dystrophies when
mutated. One of the big lessons of this particular discovery was
that one can get diseases that look completely different clinically
and pathologically, and yet they are very similar because they
are due to different mutations in the same gene. Klintworth sees
great possibilities in this remarkable finding. If one can sort
this out by studying rare diseases, imagine if it was in a common
disease. There may be some apparently different common
diseases that are due to the mutations in the same gene.
Certainly, Klintworth has seen amazing growth in the under-
standing of diseases of the eye over the course of his career.
Theres an unbelievable difference in our knowledge about
diseases from 50 years ago to today, he says. For example,
retinitis pigmentosa (RP): We saw these eyes in living patients
and in postmortem specimens, and we thought there was no
way to advance knowledge about this disease. It turned out
that all you had to do was analyze DNA and identify specific
mutations in this disease. This is something I thought was
unthinkable when I first started. Now advances in RP and many
other diseases affecting the eye are fantastic.
Although his contributions in the lab are remarkable,
Klintworth feels that his main contribution has been intro-
ducing ophthalmic pathology to medical students at Duke. He
helped bring ophthalmic pathology into the medical school
curriculum at Duke and into medical student textbooks.
I authored the first chapter on ophthalmic pathology in a
medical student textbook of pathology. When I first started to
teach medical students about diseases of the eye, the standard
textbook had only two sentences dealing with ophthalmic
pathology. One stated that the retina could be affected in
hypertension; the other drew attention to diabetic retinopathy.
In addition to the textbook, Klintworth was involved in Dean
Kinneys goal of creating and delivering a course on ophthalmic
pathology. I gave a 72-hour course, eight hours a week, for
nine weeks, for medical students who wanted to learn. It was a
tremendous amount of work to deliver this course every year.
As the head of the NEI clinician-scientist training program,
Klintworth has been instrumental in bringing many young
doctors into the research lab. For seven years he has been the
program director and principal investigator of a career devel-
opment award for training clinician-scientists. The NEI has had
a major interest in training clinician-scientists through their
K12 Training Grants, says Epstein.
Klintworths contributions to the Duke Eye Center go even
beyond his work as a scientist and a developer of scientists.
Epstein says he has learned much from Klintworth in their
20 years of working together: He would say there is no
compromise with honesty and integrity. Its important to look
V I S I O N 2012 // 19
at life with a long-term perspective and with good humor. Hes
a wise human being as well as ophthalmic scientist and leader
and mentor.
 2
NEWS

David Epstein, MD, MMM:

20 YEARS AS CHAIRMAN

WHEN DAVID EPSTEIN, MD, became chair of the Duke Eye Center
in 1992, it was a very different place. Epstein describes the ophthal-
mology program at that time as very high-quality but small. We
had a truly outstanding faculty, but only one or two individuals in
each specialty except retina. The total faculty was around 12, he
says. There were no women MDs, and the faculty lacked diversity.
Over the next two decades, Epstein oversaw the growth of the
faculty to around 70, and says, We are proud of our recruitment
of women and our overall diversity. The faculty has expanded
to approximately 55 clinicians and 15 basic scientists. Retina,
cornea, pediatric ophthalmology, oculoplastics, glaucoma, compre-
hensive and neuro-ophthalmology, and even eye pathology have
all expanded. Glaucoma, in 1992, had only one clinician. Now we
have 13, as well as a large basic research group, and were one of
the largest glaucoma programs in the country, Epstein says. The
development of the department under Epstein culminated in the
building of the Albert Eye Research Institute a little more than five
years ago. Weve increased in reputation; were the seventh ranked
program in the country. And with the new clinical pavilion, now
under construction, Epstein believes we are going to be the #1
program in the country.

Epsteins influence extends beyond the size and scope of the

department to its very culture. He explains that the departments
emphasis is on translational research, applying science to the
understanding and treatment of eye disease. Theres a sense of
one faculty; whomever we recruit, whatever discipline being hired,
all faculty members are engaged to choose the new faculty. This
sense of unity extends across the community of clinicians and
scientists, with a major goal of increasing their direct interaction.
Epstein is proud that there are no silos at the Duke Eye Center,
but rather a spirit of inquisitiveness and innovation, and a sense
of coherence and cohesion. We offer outstanding clinical care,
outstanding education, a residency program second to none, and
V I S I O N 2012 // 20

truly innovative research.

Epstein recognizes that the location of the Eye Center complex

in the heart of the medical center campus has provided

Opened in 1973, the Duke Eye Center has had three chairmen.
L to R: David Epstein, MD, MMM; Joseph A. C. Wadsworth, MD;
Robert Machemer, MD
David and Susan Epstein with the 200-year-old antique clock
presented to David Epstein by the Eye Center faculty at the
celebration of his 20 years as chairman.
opportunities for great interdisciplinary scholarly programs with
not only other departments in the Duke University School of
Medicine but also other Duke schools, like the Pratt School of
Engineering and the Terry Sanford School of Public Policy. We
have scientific and intellectual collaboration across the whole
university, he reports. This is a fertile environment; something
special is happening here.
Although the department has undergone amazing changes during
his time here, Epstein says that he built on a strong foundation.
My predecessor, Robert Machemer, started the metric of excel-
lence. We have built and expanded on it.
The only real limitation has been the physical space. The current
facility is nearly 40 years old and was designed for only 12 to 15
doctors. The space is also not patient-friendly. It requires a lot of
walking, and it lacks adequate space for education and research.
With completion of the new clinical pavilion in two-and-a-half
years, Epstein envisions that there will be no barriers except our
own abilities to make this the very best ophthalmology department
in the world. My vision for the future, once physical space is not a
problem, is that Duke Ophthalmology will be known for innovation,
My predecessor, Robert Machemer,
started the metric of excellence.
We have built and expanded on it.
// DAVID EPSTEIN
and the department will soar and excel according to the standards
Dr. Machemer established 20 years ago.
In honor of his 20-year anniversary, this years annual Winter
Thaw featured a roast of Epstein. The event was held at the
Washington Duke Inn, and Dr. Pratap Challa served as emcee.
Susan Epstein, Dr. Epsteins wife, was in attendance, as well
as Chancellor Victor J. Dzau and his wife, Ruth, the faculty,
trainees, and spouses. Since Epstein collects clocks, the faculty
presented him with a special 200-year-old antique clock from New
England. Epstein has always been fascinated by antique clocks,
perhaps because they are beautiful yet functional and accurate,
with a legacy of tradition. It is amazing that such clocks are
200-years-old but still accurately keep time and are also beautiful
pieces of furniture. They signify pride in accomplishment and long-
duration quality of intent, and of course clocks come with their
V I S I O N 2012 // 21
own special stories.
 NEWS

ADVANCED presented synopses of their research

work and brought posters for display
multiple-choice questions asked during
transition times between speakers. For
VITREOUS so that participants could view the example, they were asked, Have you

SURGERY
COURSE
THE DUKE EYE CENTER hosted the
17th Advanced Vitreous Surgery Course
on Friday and Saturday, May 4 and 5,
at the Albert Eye Research Institute.
Faculty from Duke as well as nine inter-
national faculty presented lectures, led
panel discussions, and even participated
in lunch table discussions, all focused
on vitreoretinal surgery. Sharon Fekrat,
MD, coordinator of the event, stressed
the importance of the surgical focus
of the meetings in light of a recent
trend away from surgery. The course
attracted more than 150 vitreoretinal
surgeons from all across the United
States, as well as Canada, the United
Kingdom, Belgium, France, Italy,
Spain, Germany, India, Japan, Jamaica,
Colombia, and Australia.
During the day-and-a-half meeting,
participants took part in some new
features. For example, some attendees
work being done by their colleagues.
Stephanie Chiu, a Duke graduate
student in bioengineering, shared her
study, Automated Segmentation of
Retinal Layers in SD-OCT Images with
Age-Related Macular Degeneration
Pathology. Chius co-authors in the
study were Stefanie Schuman, Rachelle
OConnell, Katrina Winter, Cynthia Toth,
Joseph Izatt, and Sina Farsiu.
Between speakers, attendees enjoyed
using electronic responders to
register their answers to yes-or-no or
used viscodissection during vitrectomy
for diabetic TRD? and How often
do you have an IOFB come into your
practice? Participants responded
enthusiastically. They were all over it!
exclaims Fekrat.
During a lunch called Chat & Chew,
participants could sign up for discussion
tables. Topics included Subretinal
hemorrhage in wet AMD: You want
me to do what with the blood? and
You didnt tell me the patient had a
permanent keratoprosthesis!
The meetings menus also reflected
the efforts by Fekrat to create an
outstanding experience. Instead of the
usual junk food snacks, participants used
the blenders provided to make fresh
fruit smoothies, and they enjoyed dark
chocolate and nuts for a treat. Friday
nights Mediterranean dinner included
all attendees, as well as vendors and
exhibitors. Gorgeous, reports Fekrat.
It was a tremendous day.
We tried to make it fun,
explains Fekrat.

INNOVATION SYMPOSIUM
THE DUKE EYE CENTER PROUDLY hosted the first Duke
Chancellors Innovation Seminar Series symposium in January.
The full-day event was kicked off with a keynote address
by Robert Langer, ScD, of the Massachusetts Institute of
Technology, an innovator in biotechnology. Langer was ranked
as one of the 25 most important individuals in biotechnology
in the world by Forbes magazine in 1999. According to David
Epstein, MD, chair of the Eye Center, these seminars are part
of a program to invigorate a culture of innovation at the Duke
University School of Medicine.
The key word of the day is inquisitive, says Epstein, who
was chosen by Chancellor Victor J. Dzau to head the Duke
Medicine Innovation Council (DMIC), the group responsible for
V I S I O N 2012 // 22
here at Duke. Epstein praised Scott Cousins, MD, vice chair of
research at the Eye Center, for helping to foster this atmosphere
in the department, and Chancellor Dzau for forming the
DMIC to nurture innovation broadly across all Duke Medicine
programs. Epstein describes the DMIC as a think tank, a
potential sounding board for generating new ideas for stimu-
lating innovation.
The Innovation Seminar Series was the councils idea for
bringing together the private sector with Duke faculty with the
goal of building programs and partnerships. Although the Eye
Center hosted the symposium, it was a university-wide event.
The second seminar in the series was held in June, and more
are planned through 2012-2013.
For Epstein, the importance of innovation is the difference it
can make in advancing medical care. One of my mentors said,

the symposium. Epstein describes the culture at Duke as one There is no greater joy than the discovery of a new idea,
of innovation, inquisitiveness, and entrepreneurial spirit. It says Epstein. I would add to that, ...especially if it can have a
basically is in the DNA of the entire faculty. Among nationwide practical outcome for patients.
ophthalmology departments, it burns strongest and brightest

FARSIU WORKING
TO IMPROVE EARLY
DETECTION OF ROP
SINA FARSIU, PhD, IS CURRENTLY
applying his biomedical engineering
expertise and his experience with high-
resolution imaging to a study that aims
to set a standard for early detection of
retinal disease in infants, particularly
super-premature babies. The National
Institutes of Health (NIH) has granted
Farsiu the funding to develop and study
a more robust version of the handheld
Spectral Domain Optical Coherence
Tomography (SD-OCT) imaging
developed by Joseph A. Izatt, PhD,
professor of biomedical engineering at
Duke, for the purpose of retinal imaging
of infants. Farsiu, the principal inves-
tigator, will develop the software for
the system, while co-principal investi-
gator Izatt will develop the hardware.
Co-investigator Cynthia Toth, MD, will
actually apply the technology in her
clinical practice.
The problem specific to imaging very
young infants is motion. Babies
wiggle, explains Toth, and we need
to see two particular parts of the retina:
the macula, a tiny spot thats about
500 microns across, and the optic nerve
head, which is about 2 millimeters. Toth
and pediatric ophthalmologists Sharon
Freedman, MD, and David Wallace, MD,
are looking at blood vessels charac-
teristic of retinopathy of prematurity
(ROP). Tortuous (twisted) or dilated
vessels are indicators for treatment of
ROP. These doctors are partnering with
neonatologist Michael Cotten, MD, who
works with premature infants at risk for
the disease. The hope is that through
this study, a protocol of screening and
early treatment will be developed and
applied in places that lack the pediatric
ophthalmic specialists available at Duke.
Farsiu describes ROP as a global public
Sina Farsiu Cynthia Toth
health issue, and he sees a real possi-
bility for far-reaching implications of his
study. Retinopathy of prematurity is
one of the leading causes of blindness
in the developed world. In the devel-
oping world, more and more premature
infants are now surviving, and the cases
of this disease that affect these infants
are expected to grow in number. It is
expected to be an epidemic in coming
years. It is important for the technology
to be robust so that in places where
there are not expert imagers, they will
still be able to do this early-detection
imaging. Farsiu will be working with
Izatt, one of the worlds leading experts
in optical coherence tomography, to
make the technology resistant to the
movements of both imager and subject,
so that it can be used in more children
and produce higher-quality images.
This is not the first collaboration for
Farsiu, Izatt, and Toth. Five years ago,
Farsiu was a postdoc scholar in the
labs of Toth and Izatt, who have been
collaborating for many years.
The team published the first paper on
the use of handheld SD-OCT imaging in
infants in 2009. After its publication, the
system became routinely used at Duke
and other places for evaluating early
signs of potentially blinding diseases.
Building on this work, they now seek to
develop not only higher quality imaging
but also a standard for reading these
images. Were now getting better and
better at picking out whats wrong,
gleaning important critical information
CURRENT EYE CENTER FELLOWS
from images; that data is important
for directing treatment, says Toth.
Treatment must be delivered within a
critical time frame. We go in at the
time Dr. Cotten is going in to screen
for retinopathy of prematurity, usually
at approximately two months before
they should have been born [full term].
Theres a timetable for screening, and
treatment starts commonly two to four
weeks before the 40-week mark.
Better screening and better analysis of
the images will help doctors prevent
catastrophic outcomes. I tend to see
the babies when theyre getting into big
trouble, says Toth. Im called in when a
child is developing a [retinal] detachment
or serious problem requiring surgery.
The goal is to decrease the number of
children in this situation. I want to put
myself out of business as far as operating
on the babies, she says.
Farsiu sees Toths contribution to
the study as critical: Shes a really
important person in handheld OCT
because shes the first to adapt the
system and put it in a working clinic;
shes the engine behind the imple-
mentation of system. Toth, in turn,
emphasizes the importance of Farsius
expertise in super-resolution imaging.
Farsiu looks forward to publishing
the results of his study in two years.
He hopes that the technology can
V I S I O N 2012 // 23
be widely used so that, ultimately,
fewer children will suffer the results of
undetected and untreated ROP.
 RESIDENTS
EDUCATION
MEET OUR
FIRST-YEAR
RESIDENTS
Varsha Manjunath, MD
Canadian native Varsha Manjunath,
MD, comes to Duke after medical
school at Drexel and internship at UT
Houston. Manjunath got her first taste of
ophthalmology as a medical student. She
received a grant that allowed her to do
clinical retina research using OCT for a
year in Boston. I loved it! she says.
Manjunath says that Duke caught my
eye because it had exceptional clinical-
surgical training and unique research
opportunities which would allow me
to grow as a clinician-scientist. She is
keeping an open mind about her area
of specialty.
Manjunath wants to be the kind of
doctor who can connect with her
patients. When people are affected by
blindness, its more than just a medical
condition, she says. When you can
help them function in their everyday
lives, thats very satisfying.
Milica Margeta, MD, PhD
Growing up in Croatia with parents who
were physicians, Milica Margeta, MD,
PhD, always knew that she wanted to
go into medicine. At Stanford, Margeta
earned her MD and a PhD in neuro-
science, focusing on synapse devel-
opment. She liked doing small-scale,
precise imaging and found it applicable
to ophthalmology. The eye is beautiful,
she says.
V I S I O N 2012 // 24
Duke was Margetas first choice for
residency. It had the best combination
of excellent clinical training, great
research, and new technology. She is
interested in retina and glaucoma, but
is open to discovering new interests
during rotations. She sees herself doing
a fellowship in the future as well. I
want to be an academic ophthalmologist
and do a combination of clinical work,
research, and teaching.
Nisha Mukherjee, MD
After completing her internship in
Baltimore, Nisha Mukherjee, MD, is
returning to Duke, where she attended
medical school. She became interested
in ophthalmology when she had a
two-week option of subspecialty during
her surgery rotation. Medical students
usually have to make a choice between
diagnostic work and doing procedures.
In ophthalmology, you can do both.
During her third year of medical school,
she did research on congenital ptosis.
She was pleased to be doing research
work that had a clinical application.
Mukherjees internship was at Harbor
Hospital, an 80-bed facility that she
describes as a family atmosphere. She
appreciates the compassionate patient
care she sees at the Duke Eye Center as
well. The doctors here are amazing,
competent, compassionate physicians.
Its nice to see, and its something I
aspire to.
Veena Rao, MD
After medical school at Yale, Veena
Rao, MD, returned to her North Carolina
roots for her internship at the University
of North Carolina at Chapel Hill and her
residency at Duke. A native of the states
western Carolina region, Rao witnessed
the positive effect her father had upon
their small town as a general surgeon,
and she hopes to follow his example.
Early in medical school, I wouldnt
have anticipated going into ophthal-
mology, she admits. But when we did
anatomy labs, the eye dissection was
my favorite. She gained experience
with a retina study using human fetal
cells to make a model for studying
AMD. Before choosing a specialty, she
wants to gain as much knowledge as
she can. Then I can decide where I can
make the most impact.
Lakshmi Swamy, MD, PhD
A graduate of the University of
Georgia, Lakshmi Swamy, MD, PhD,
completed her MD-PhD at Weill Cornell
Medical College in New York. During
her internship at St. Vincents Medical
Center in Connecticut, she designed an
integrated clinical clerkship curriculum
for the Frank H. Netter School of
Medicine at Quinnipiac University.
She has also worked as an instruc-
tional designer, seeing-eye dog trainer,
volunteer outreach teacher, and even as
a fine jewelry designer.
The tiny procedures that attracted
me to metalsmithing now draw me to
eye surgery, she says. Swamys 2012
research on nerve complex imaging in
glaucoma patients reflects this focus
on minute elements. Ophthalmology
suits my personality like no other area
of medicine, says Swamy. I used to
create visual art. Now I cant wait to
offer vision itself.
 CURRENT EYE CENTER FELLOWS

CORNEAL/EXTERNAL DISEASE
Ladan Espandar, MD
Wei Boon Khor, MD
Jay Meyer, MD, MPH
Noel Rosado-Adames, MD
Varsha Manjunath Milica Margeta Nisha Mukherjee

GLAUCOMA
Wei Huang, MD, PhD
Daniel Moore, MD
Joanne Wen, MD

OCULOPLASTIC &
RECONSTRUCTIVE SURGERY
Sulene Chi, MD, PhD
Andrew Munro, MD
Esfandiar (Jason) Sabet-Peyman, MD
Veena Rao Lakshmi Swamy Bozho Todorich

PEDIATRIC
offers that benefitthe satisfaction of OPHTHALMOLOGY
Bozho Todorich, MD, PhD
knowing that weve truly helped our
As a child growing up in Croatia, Bozho patients, he says. Eniolami Dosunmu, MD
Todorich, MD, PhD, developed an Inna Marcus, MD
aptitude for science early on, around Irene Tung, MD
THIRD YEAR RESIDENTS
the age of five or six. He remembers his
parents often saying that they needed Michael Allingham, MD
a doctor in the family because of the Jacqueline Dzau, MD MEDICAL RETINA
dearth of medical care in their region, Mark Hansen, MD
and Todorich seems to be the fulfillment Manesh Dagli, MD
Sujit Itty, MD
of that vision. Heema Kaul, MD, MBA
Peter Nicholas, MD
Kathryn Pepple, MD, PhD
After earning his MD-PhD from Penn Zachary Zavodni, MD
State, Todorich had a strong desire to
become a clinician-scientist. His search SECOND YEAR RESIDENTS VITREORETINAL
for a place that would allow him to reach
Brian Goldhagen, MD DISEASES & SURGERY
this goal brought him to Duke, which
he describes as the best of both worlds: Kim Jiramongkolchai, MD Joseph Martel, MD
a premier clinical eye center and an Pradeep Mettu, MD Eric Schneider, MD
atmosphere of inquisitiveness that fosters Paula Pecen, MD Lejla Vajzovic, MD
research. At Duke I feel like a bee that Christine Shieh, MD Glenn Yiu, MD, PhD
got dropped into a jar of honey. Laura Vickers, MD
V I S I O N 2012 // 25

Todorich is open to all possibilities

when it comes to his area of specialty.
Theres really no greater satisfaction
than improving someones vision and
watching their reaction. Ophthalmology
 RESIDENTS
NEW FACULTY
PAUL HAHN, MD, PhD
After completing his two-year vitreo-
retinal surgical fellowship, Paul Hahn,
MD, PhD, is looking forward to his
new role in the launching of the vitreo-
retinal surgery practice at Duke Raleigh
Hospital. Hahn will continue to see
patients in Durham as well, and he is
excited to continue his research with
Cynthia Toth, MD, and Joseph Izatt, PhD,
on novel uses of OCT imaging.
A native of New York City, Hahn
attended Harvard before completing
his medical school and residency at the
University of Pennsylvania. He came to
Duke for his surgical fellowship because
of the advances in vitreoretinal surgery
that have been pioneered here. For a
fellowship I wanted the best training,
and I came to Duke for that reason. The
retina faculty is incredible, and its a
privilege to work with them all, he says.
Hahn and his wife have now bought a
home here, and he says, We consider
ourselves North Carolinians. I always
thought Id go back, but its easy living
here, and there are great people.
Prior to coming to Duke, Hahn was
heavily involved in research identi-
fying novel mechanisms in retinal
V I S I O N 2012 // 26
diseases primarily age-related macular
degeneration (AMD). Going forth as
a faculty member, I look forward to
continuing research focusing on areas
that will provide immediate benefit to
clinical care. In his work with Toth and
Izatt, adapting OCT technology for use in
the operating room, Hahn will be helping
to launch what he stresses is a unique
application of OCT. Nowhere else in the
country is able to offer this kind of 3-D
imaging during surgery. Right now its in
the research stage, but the next evolution
in vitreoretinal surgery will certainly
depend on this type of imaging.
Hahn is excited to launch the Duke
Raleigh surgical practice. One of my big
goals will be to provide a Duke presence
that has previously been missing in that
area, and I look forward to providing the
best in clinical care.
ELEONORA LAD, MD, PhD
Eleonora Lad, MD, PhD, moved from her
medical retina fellowship into a faculty
position on July 6. Her research is funded
by a National Institutes of Health Clinical
development of targeted treatment
Scientist Development Award (K12) to
study the role of the amyloid-b protein
in age-related macular degeneration
(AMD). She is very happy to be at Duke.
I have been tremendously impressed
with the collaborative environment and
extent of research resources available
at Duke, Lad says. She appreciates the
supportive philosophy of the department
chair and vice chair, which creates an
atmosphere that encourages academic
endeavors, innovation, and research.
There are not many places like Duke,
says Lad, who studied at the Chicago
Medical School and completed her
residency at Stanford.
With her background in neuroscience
and doctoral work on neural grafting for
Parkinsons disease, Lad became inter-
ested in the retina because of the many
common pathways and mechanisms
between neurodegenerative diseases and
retinal diseases. The project outlined for
her grant, with mentors Scott Cousins,
MD, and Catherine Bowes Rickman, PhD,
ties her training in neuroscience to AMD.
She will investigate the role of amyloid-b
in the pathophysiology of AMD and will
use retinal imaging to identify the retinal
amyloid-b protein that can potentially
become an early diagnostic marker for
both Alzheimers disease and AMD. Its
a wonderful time to be in this kind of
research, says Lad. The goal is to find
out more about the causes and signs of
early disease, especially AMD, because
eventually we would like to prevent and
treat AMD before it becomes advanced.
Lads career goal is to translate her basic
neuroscience research into developing
and applying novel diagnostic and
therapeutic strategies for retinal diseases.
I truly feel that my PhD training in
neurodegenerative diseases will give
me a unique perspective in ophthal-
mology and enable me to assist in the
approaches for retinal degeneration.
PRIYATHAM
PRITHU S. METTU, MD
Although Priyatham Prithu S. Mettu,
MD, is new to the faculty, he is hardly
new to Duke. Mettu earned his under-
graduate and medical degrees at Duke
and completed an ophthalmology
residency at the Duke Eye Center. After
serving as chief resident, he completed
a clinical fellowship in medical retina
as well as a postdoctoral research
fellowship studying age-related macular
degeneration, under the mentorship
of Scott Cousins, MD, vice chair of
research. Mettu joins the department
as a medical retina specialist, and he
will see patients at the Duke Eye Center
main campus as well as at the Duke Eye
Center at Page Road.
Mettu also joins the Duke Center for
Macular Diseases and is a scholar of
the National Institutes of Health Clinical
Scientist Development Award (K12),
which allows promising clinician-scien-
tists the time and resources to establish
a productive disease-focused research
program. Dr. Mettu represents the
best of the new generation of rising
superstars who will be a triple threat:
outstanding physicians, innovative
researchers, and compassionate
educators, says Cousins. We are very and Saban is the right man for the job.
fortunate that Dr. Mettu chose to join
our faculty. Mettu will have an active
translational research program focusing
on diabetic retinopathy and age-related
macular degeneration; in addition to
his laboratory research endeavors, he
is participating in clinical trials of new
therapies for macular diseases.
Duke is going to be a leader in the
innovation of new treatments and
imaging technologies for retinal diseases,
and I am excited to be a part of that
effort, Mettu says. Our goal in medical
retina is to be able to select a treatment
strategy that is personalized for the
individual patient on the basis of his/her
specific disease. We are able to do that
now to an extent, but we look forward
to seeing the full potential of this
approach in the years ahead.
Mettu is originally from the small town
of Pikeville, Kentucky, but Duke has been
a second home. Both of his brothers
attended Duke, and his brother Pradeep
is currently an ophthalmology resident at
the Duke Eye Center. Mettu and his wife,
Neeru, who is currently an oncology
fellow at Duke, have two young children,
and they look forward to planting their
young familys roots here in Durham.
DANIEL SABAN, PhD
The Duke Eye Center is a fantastic place
for Daniel Saban, PhD, to apply his
expertise in immunity, inflammation,
and in uncovering novel targets for
ophthalmic disease therapy. There
is more and more evidence emerging
to suggest that immunity is a central
cause in diseases such as age-related
macular degeneration, glaucoma, and
dry-eye syndrome. He adds, This area
of research is very ripe for exploration,
His doctoral thesis focused on the unique
eye immune responses known as anterior
chamber-associated immune deviation
(ACAID). He received mentorship from
the late world-renowned immunologist
J. Wayne Streilein, MD, and, Saban then
went on to complete his training at
Harvard Medical School, studying the
immune responses in corneal trans-
plant rejection. The esteemed Ruth L.
Kirschstein National Research Service
Award from the National Eye Institute
supported his fellowship. He then set his
sights on building a laboratory team of
his own and became a faculty member at
the Schepens Eye Research Institutea
leader in the field of ocular immunology
research. There, he secured $2.4-million
grant from the National Eye Institute to
study the biologic origins of eye allergies.
Nearly 30 million Americans suffer
from eye allergies, thereby constituting
a major health problem in the United
States. He adds, Unfortunately, current
drug treatments, such as antihistamines,
which target end-stage biological events
that cause allergies, do not cure this
condition. Now at the Duke Eye Center,
Saban will continue to study inflam-
V I S I O N 2012 // 27
mation of the cornea and ocular surface
and looks forward to collaborative
research with Duke Eye Center faculty in
blinding diseases, such as glaucoma and
age-related macular degeneration.
 AWARDS + HONORS

Kim Jiramongkolchai Vadim Arshavsky P. Vasantha Rao Terri Young Lejla Vajzovic

Jiramongkolchai most fascinating properties of vision: Vajzovic receives

selected for Machemer
Research Award
Kim Jiramongkolchai, MD, was
selected for the prestigious Robert A.
Machemer Research Award for her
project Differentiating Glaucomatous
from Non-Glaucomatous Optic
Neuropathy II: Using Automated Macular
Segmentation. Her work was presented
in June at the Eye Centers 2012
Residents and Fellows Day.
The Robert A. Machemer Research
Award, established in 2000, recognizes
a resident, clinical fellow, or research
fellow whose clinical or basic science
research proposal demonstrates high
intellectual curiosity and outstanding
scientific originality, and has a significant
impact on the clinical management of
ophthalmic disease. The award honors
Robert A. Machemer, MD, a past chair of
the Duke Department of Ophthalmology.
Several honored
the ability to rapidly follow the ever-
changing visual environment, so that the
entire visual scene can be refreshed
within a fraction of a second. He
received the Proctor Medal jointly with
Theodore Wensel, PhD, from the Baylor
College of Medicine for demonstrating
how this phenomenon is achieved at the
molecular level.
David Epstein, MD, chair of the Duke
Department of Ophthalmology, was
chosen for the Mildred Weisenfeld
Award for Excellence in Ophthalmology,
presented annually to an individual in
recognition of distinguished scholarly
contributions to the clinical practice of
ophthalmology. Epstein has been widely
considered as one of the most influ-
ential leaders in the field of glaucoma
and glaucoma research for the past 30
years. He has developed novel drugs
for the treatment of glaucoma, leading
to 10 patents that involve all aspects of
ophthalmic patient care and treatment.
P. Vasantha Rao, PhD, was awarded the
Research Award
Lejla Vajzovic, MD, was selected to
receive the 16th Fellowship Research
Award at the Retina Society 45th Annual
Meeting held in October in Washington,
D.C. The award was presented for her
manuscript Maturation of the Human
Fovea: Correlation of Spectral Domain
Optical Coherence Tomography Findings
with Histology.
Heed Award Winners
Nieraj Jain, MD, former Eye Center chief
resident, and fellow Sulene Chi, MD,
PhD, have been awarded the prestigious
Heed Ophthalmic Foundation Fellowship.
The Society of Heed Fellows is a public
charitable and educational foundation
that provides funding for postgraduate
studies in ophthalmology and the
ophthalmic sciences. Beginning with the
appointment of the first fellow in 1989,
the society has provided more than
$430,000 in support of its mission.

at ARVO Cataract Research Award, an international

award from the National Foundation for
Vadim Arshavsky, PhD, the Helena
Eye Research that recognizes promising
Rubinstein Professor of Ophthalmology
lens researchers who have conducted
and scientific director at the Duke Eye
significant scientific work. His research of
Center, was named the recipient of the
crystalline protein function, cytoskeletal
2013 Proctor Medal. It is the top award
biology, and membrane-scaffolding
from the Association for Research in
proteins and their role in lens differ-
Vision and Ophthalmology (ARVO) and
entiation, architecture and function,
recognizes his outstanding research
and cataract formation has been in the
in the areas of experimental ophthal-
forefront of this area.
mology and visual sciences. Arshavsky
V I S I O N 2012 // 28

has been studying signal transduction
in the vertebrate retina for more than
25 years. A large body of his work has
been devoted to addressing one of the
Terri Young, MD, was nominated and
elected as program committee chair of
the Biochemistry and Molecular Biology
Section of ARVO.
Cynthia Toth Edward Buckley

Nieraj Jain Natalie Afshari
Two named to
Top 10 Women
in Medicine
Natalie Afshari, MD, and Cynthia Toth,
MD, were both named to the inaugural
class of the Triangle Medical News Top
10 Women in Medicine and were the
only ophthalmologists to do so. The 2012
class featured glass ceiling breakers, top in
their field for innovative research, ground-
breaking methodology, and consummate
compassion. Patients, peers, family,
and friends raved about the upstanding
character these women represent.
Buckley, Epstein
named Distinguished
Faculty
Every year, the Duke Medical Alumni
Association honors five highly accom-
plished alumni and faculty to receive
Distinguished Awards. In 2012, two
were named from the Duke Eye Center.
Edward Buckley, MD, vice dean of
medical education and professor of
ophthalmology and pediatrics, and
David Epstein, MD, MMM, Joseph A.
C. Wadsworth Clinical Professor of
Ophthalmology, received their award
David Wallace Parag Gandhi Goldis Malek
in October. Buckley is considered one
of the foremost academic pediatric
ophthalmologists in the country and is
recognized internationally for his medical
student training program. Epstein
is celebrating his 20th anniversary
as chair of the Duke Department of
Ophthalmology (see story on page 20).
He is recognized internationally as one
of the leading experts in the under-
standing and treatment of glaucoma.
Wallace named
PEDIG network chair
David Wallace, MD, MPH, has been
appointed the next chair of the Pediatric
Eye Disease Investigator Group (PEDIG)
clinical trials network. Wallace has served
as vice chair for the past several years.
His five-year term as chair begins in
January 2013.
Gandhi wins Reeh
Pathology Award
Parag Gandhi, MD was awarded the
Merrill Reeh Pathology Award, along
with several colleagues, for their paper:
Cutaneous Lupus Erythematosus of the
Eyelid as a Mimic of Squamous Epithelial
Malignancies: A Clinicopathologic Study
of 9 Cases. The Reeh Pathology Award
is a means of honoring an outstanding
contribution to the study of pathology
pertinent to the field of ophthalmic
plastic and reconstructive surgery.
Paloma Liton
Malek awarded
Young Investigator
grant
Goldis Malek, PhD, has been awarded
the 2012 Alcon Research Institute (ARI)
Young Investigator Grant. This grant is
intended to encourage and promote the
early career development of clinicians
and scientists entering research in vision
science and ophthalmology. Malek will
receive $50,000 to support her research.
Bohnsack chosen
for AUPO/RPB Forum
Brenda Bohnsack, MD, a 2011-2012
fellow in pediatric ophthalmology at
Duke Eye Center, was chosen to present
at the 2012 Association of University
Professors of Ophthalmology/Research to
Prevent Blindness (AUPO/RPB) Resident
and Fellow Research Forum in January.
The title of her abstract was Thyroid
Hormone Is Required for Ocular and
Craniofacial Development via Interactions
with Retinoic Acid on the Neural Crest.
Liton awarded
$100,000 AHAF grant
The American Health Assistance
Foundation (AHAF) has announced a
$100,000 grant for Duke Eye Center
researcher Paloma Liton, PhD, for
her work titled Autophagy and
Neurodegeneration in Glaucoma. AHAF
is a nonprofit charitable organization
dedicated to funding research toward
the understanding, treatment, and
prevention of macular degeneration,
Alzheimers disease, and glaucoma.
V I S I O N 2012 // 29
 DUKE EYE CENTER FACULTY AND ADMINISTRATION

FACULTY LEADERSHIP COMPREHENSIVE OPHTHALMOLOGY

David L. Epstein, MD, MMM Chairman Anna Bordelon, MD Assistant Professor of Ophthalmology
Scott W. Cousins, MD Vice Chairman of Research S. Jill Bryant, OD, FAAO Assistant Professor of Ophthalmology
Director, Translational Research Program
Director, Center for Macular Diseases Anupama Horne, MD Assistant Professor of Ophthalmology

Leon W. Herndon, MD Medical Director Thomas Hunter, MD Assistant Professor of Ophthalmology

Vadim Arshavsky, PhD Scientific Director of Research Philip H. McKinley, MD, MPH Assistant Professor of Ophthalmology
Sanjay Asrani, MD Director of Education John T. Petrowski, III, OD, FAAO Assistant Professor of Ophthalmology
Duke Eye Center of Cary Practice Chief
Laurie K. Pollock, MD Assistant Professor of Ophthalmology
S. Jill Bryant, OD, FAAO Director, Contact Lens
Tina Singh, MD Assistant Professor of Ophthalmology
Edward G. Buckley, MD Director, Appointments,
Promotion, and Tenure Robin R. Vann, MD Assistant Professor of Ophthalmology
Vice Dean of Medical Education, Service Chief
Duke University School of Medicine
Alan N. Carlson, MD Faculty Liaison Director, Development
Pratap Challa, MD Director, Residency Program
CORNEA AND REFRACTIVE SURGERY
Sharon Fekrat, MD, FACS Chief, Division of Ophth. at the
Durham VA Medical Center Christopher S. Boehlke, MD Assistant Professor of Ophthalmology

Paulo Ferreira, PhD Assistant Director, Translational
Research Program
Sharon F. Freedman, MD Director, Pediatric Low Vision Program
Preeya Gupta, MD Duke Eye Center at Page Road
Practice Chief
Glenn J. Jaffe, MD Director, Duke Reading Center
Terry Kim, MD Director, Fellowship Program
Duke Sports Vision Center of Excellence
Prithvi Mruthyunjaya, MD Director, Ocular Oncology
Eric A. Postel, MD Director, Perioperative Services
William Rafferty, OD Director, Optometry Education
Catherine Bowes Rickman, PhD Director, Third-Year Medical
Student Program
Jullia A. Rosdahl, MD, PhD Director, Patient Education
Stefanie Schuman, MD Director, Center for Hereditary
Retinal Diseases
Tina Singh, MD Director, Second- and Fourth-Year
Medical Student Program
Cynthia A. Toth, MD Liaison, Duke BioEngineering
Robin R. Vann, MD Faculty Liaison Director,
Information Technology
David K. Wallace, MD, MPH Director, Site-Based Research
(SBR) Program
Julie A. Woodward, MD Director, Public Education Program
Faculty Liaison Director,
Ophthalmic Technician Program
Terri L. Young, MD Director, Pediatric Genetics Program
Faculty Liaison, Singapore
Alan N. Carlson, MD Professor of Ophthalmology
Service Chief
Derek DelMonte, MD Assistant Professor of Ophthalmology
Preeya Gupta, MD Assistant Professor of Ophthalmology
Terry Kim, MD Professor of Ophthalmology
Anthony Kuo, MD Assistant Professor of Ophthalmology
William Rafferty, OD Assistant Professor of Ophthalmology
Terry Semchyshyn, MD Assistant Professor of Ophthalmology
GLAUCOMA
R. Rand Allingham, MD Richard and Kit Barkhouser Professor
of Ophthalmology Service Chief
Sanjay Asrani, MD Associate Professor of Ophthalmology
Pratap Challa, MD Associate Professor of Ophthalmology
David L. Epstein, MD, MMM Joseph A.C. Wadsworth Clinical Professor
of Ophthalmology
Sharon F. Freedman, MD Professor of Ophthalmology
Professor in Pediatrics ++
Leon W. Herndon, MD Associate Professor of Ophthalmology
Jill B. Koury, MD Assistant Professor of Ophthalmology
Stuart J. McKinnon, MD, PhD Associate Professor of Ophthalmology
Associate Professor in Neurobiology ++
Frank J. Moya, MD Assistant Professor of Ophthalmology
Kelly W. Muir, MD Assistant Professor of Ophthalmology

ADMINISTRATION Jullia A. Rosdahl, MD, PhD Assistant Professor of Ophthalmology

Henry Tseng, MD, PhD Assistant Professor of Ophthalmology
Michael Howard, MBA, FAHEC Chief Operational Officer
Christopher Frederick, CPA Chief Financial Officer Molly M. Walsh, MD, MPH Assistant Professor of Ophthalmology

Heidi Campbell, COT Health Center Administrator Carol Ziel, MD Assistant Professor of Ophthalmology
Renee Dawson Coordinator, Continuing Medical Education
Director, Education Program Staff
Justin Hammond, BA, BS Director, Marketing and Communications
Laura Jensen, MBA Research Finance Manager
V I S I O N 2012 // 30

Evelyn Kelly, OCA Health Center Administrator

Erin McKenzie, MBA Director, Development
Suzanne Simmons, COT Health Center Administrator
Martha Wilson, MBA Health Center Administrator
HEREDITARY RETINAL DISEASES
Stefanie Schuman, MD Director, Center for Hereditary
Retinal Diseases
LOW-VISION REHABILITATION SERVICE
Diane Whitaker, OD Assistant Professor of Ophthalmology
Service Chief
NEURO-OPHTHALMOLOGY
M. Tariq Bhatti, MD Associate Professor of Ophthalmology
Associate Professor of Medicine ++
Service Chief
Edward G. Buckley, MD Banks Anderson, Sr. Professor
of Ophthalmology
Professor in Pediatrics ++
Mays El-Dairi, MD Assistant Professor of Ophthalmology
OCULOFACIAL SURGERY
Parag D. Gandhi, MD Assistant Professor of Ophthalmology
Jason Liss, MD Assistant Professor of Ophthalmology
Michael J. Richard, MD Assistant Professor of Ophthalmology
Julie A. Woodward, MD Assistant Professor of Ophthalmology
Assistant Professor in Dermatology ++
Service Chief
PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
Edward G. Buckley, MD Banks Anderson, Sr. Professor
of Ophthalmology
Professor in Pediatrics ++
Mays El-Dairi, MD Assistant Professor of Ophthalmology
Laura B. Enyedi, MD Assistant Professor of Ophthalmology
Assistant Professor in Pediatrics ++
Sharon F. Freedman, MD Professor of Ophthalmology
Professor in Pediatrics ++
Service Chief
S. Grace Prakalapakorn, Assistant Professor of Ophthalmology
MD, MPH
David K. Wallace, MD, MPH Professor of Ophthalmology
Professor in Pediatrics ++
Terri L. Young, MD Professor of Ophthalmology
Professor in Pediatrics ++
Professor of Medicine ++
VITREORETINAL DISEASES AND SURGERY
Scott W. Cousins, MD Robert Machemer, MD, Professor
of Ophthalmology
Professor in Immunology ++
Sharon Fekrat, MD, FACS Associate Professor of Ophthalmology
Paul Hahn, MD, PhD Assistant Professor of Ophthalmology
Glenn J. Jaffe, MD Professor of Ophthalmology
Service Chief
Eleonora Lad, MD, PhD Assistant Professor of Ophthalmology
Tamer Mahmoud, MD, PhD Associate Professor of Ophthalmology
Priyatham Mettu, MD Assistant Professor of Ophthalmology
Prithvi Mruthyunjaya, MD Assistant Professor of Ophthalmology
Eric A. Postel, MD Associate Professor of Ophthalmology
Stefanie G. Schuman, MD Assistant Professor of Ophthalmology
Cynthia A. Toth, MD Professor of Ophthalmology
Professor in Biomedical Engineering ++
RESEARCH OPHTHALMOLOGY
Vadim Arshavsky, PhD Professor in Ophthalmology
Professor in Pharmacology &
Cancer Biology ++
Scientific Director
Catherine Bowes Rickman, PhD Associate Professor of Ophthalmology
Associate Professor in Cell Biology ++
Sina Farsiu, PhD Assistant Professor of Ophthalmology
Assistant Professor of
Biomedical Engineering ++
Paulo Ferreira, PhD Associate Professor of Ophthalmology
Associate Professor in Pathology ++
Pedro Gonzalez, PhD Associate Professor of Ophthalmology
Associate Professor in Pathology ++
Gordon K. Klintworth, MD, PhD Professor of Pathology, Joseph AC
Wadsworth Research Professor
of Ophthalmology ++
Paloma Liton, PhD Assistant Professor of Ophthalmology
Assistant Professor in Pathology ++
Goldis Malek, PhD Assistant Professor of Ophthalmology
Assistant Professor in Pathology ++
P. Vasantha Rao, PhD Associate Professor in Ophthalmology
Associate Professor in Pharmacology
& Cancer Biology ++
Tatiana I. Rebrik, PhD Assistant Professor of Ophthalmology
Nikolai Skiba, PhD Assistant Professor in Ophthalmology
Daniel Saban, PhD Assistant Professor of Ophthalmology
W. Dan Stamer, PhD Professor of Ophthalmology
Sandra Stinnett, DrPH Assistant Professor of Biostatistics
& Bioinformatics
Assistant Professor in Ophthalmology ++
Fulton Wong, PhD Professor of Ophthalmology
Secondary appointment ++
V I S I O N 2012 // 31
 GIFT FROM
CALVIN MITCHELL
Earlier this year, Calvin Mitchell, MD, presented an unusual
gift to Duke Eye Center chair David Epstein, MD. The
Complete Book of World War II Combat Aircraft and a
drawing by Brian Knight of a World War II Spitfire MK1 may
seem a strange gift to give an ophthalmologist, but there is
a fascinating connection between these planes and intra-
ocular lenses, as explained by the Duke Eye Centers Alan
Carlson, MD:

The story of the intraocular lens really begins with Mr.

Harold Ridleys observation of a fighter pilot named
Mouse Cleaver. Mouse was flying a Hurricane fighter in
the 1940 Battle of Britain when he sustained enemy fire.
Shards of his Plexiglas canopy were embedded into his eyes
without causing the anticipated inflammation in his eyes.
Mr. Ridley had the foresight to realize that this material
could be crafted as a lens to be inserted after cataract
removal, leading to the first successful intraocular lens
insertion in 1949. wanted the young doctors to know where the idea came
from, because it all came from the question I wonder if,
Epstein explains that Mitchell, a comprehensive ophthal- and it revolutionized cataract surgery. The book is now
mologist, cataract surgeon, and contact lens specialist, located in the residents resource center.

Duke Eye Center welcomes
new Ophthalmic Technician
Program director
After acquiring years of rich and varied
experience in ophthalmologic services,
Deborah Smith, COMT, BSBA, is
thrilled to be joining the staff at Duke.
Smith comes to Duke from Indiana
University and Midwest Eye Institute
in Indianapolis, although she has had
training and professional experience
at Wayne State University in Detroit as
well. In Indianapolis, she used her clinical
skills as a refractive surgery clinical and
surgical technician. She also marketed
V I S I O N 2012 // 32
the practice and enjoyed
practice building as well
as patient care. It was
a rewarding position,
says Smith, but a narrow
skill set in the clinical
aspect (just refractive),
where I was used to
working in multiple areas.
I missed the variety, and
I missed the educational
environment. When Deborah Smith
she saw the opportunity to
be on staff at Duke, Smith says it was
too big to ignore. Duke appealed to
her because it has a 20-year program,
firmly established, and all the resources
an instructor could want.
Its a fantastic learning
environment. Smith finds
a lot to like about North
Carolina overall: The
people are wonderful,
the state is beautiful, and
I am delighted with all
this area has to offer.
She is most excited
about sharing her broad
experience with students
who will need skills from
all specialties within ophthalmology.
This is a wonderful opportunity to
ignite those brain cells, she says.

Only through the generosity of donors can Duke Eye Center provide its cutting-edge, world-class level of service. Contributions of all
sizes allow the Duke Eye Center to conduct research and find treatments for every eye condition imaginable. To learn how you can
help, please call 919-684-0404 or visit dukeeye.org.
 ABOUT THE EYE CENTER

TOTAL PATIENT VISITS IN FY 2012:

180,000

160,000 168,014
140,000

120,000

156,156 - 11.4%

162,000 - 3.7%
128,999 - 6.5%

145,371 - 2.9%

168,014 - 3.7%
133,813 - 3.7%

141,217 - 5.5%

100,000

80,000

60,000
FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

Duke Eye Center

DUKE EYE CENTER HAS
IN NORTH CAROLINA AND VIRGINIA.
10 LOCATIONS
Ranks in the Top 10
U.S.News & World Report

DUKE EYE CENTER LOCATIONS:

Duke Eye Center of Cary

Duke Eye Center at Duke University Medical Center
FY 2012 AWARD FUNDING:
Duke Eye Center of North Durham
Duke Eye Center at Page Road Federal $8,490,807

Duke Eye Center of Raleigh Non-Federal $5,847,928

Duke Eye Center at Southpoint
Total: $14,338,735
Duke Eye Center for Vision Correction
Duke Eye Center of Winston-Salem

RETINA CLINICS:

Danville, Virginia
Fayetteville, North Carolina

HOW TO CONTACT THE EYE CENTER:

V I S I O N 2012 // 33

// online: dukeeye.org
// patients call: 1-888-ASK-DUKE (275-3853)
// physicians call: 1-800-MED-DUKE (633-3853)
// info@dukeeye.org
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Copyright Duke University Health System, 2012 | AD-102

Macrophoto of human eye showing crystalline lens, suspensory ligament

of zonular fibers and ciliary body.