v i s i o nFall 2008

FOCUS: VEI’s 2020 VisionRegional and International Outreach • Patents Pending • Pediatric Eye Care

PROFILE: Brad Kehler, O.D. • NEWS: “Gass Atlas” Updated

V a n d e r b i l t

Dear Friends,

Over the past decade, Vanderbilt University Medical Center has experienced unprecedented

growth: new hospital and research facilities, dramatic increases in research funding, hundreds of

new faculty members, and greater clinical volumes both for outpatient and hospital care. We

have been dramatically successful at becoming bigger. However, as we move towards the seconddecade of the 21st century, our mission is shifting towards becoming better. In fact, the newstrategic plan for the Medical Center focuses on creating a measurable impact on health by

working in new ways, producing results that matter and transferring those successes to society.

Here at the Vanderbilt Eye Institute, our mission is clearly in step with our Medical Center. While we also have

experienced unprecedented growth in facilities, faculty, clinical volume, and research grants, we are committed to

making a difference in addressing the challenges of vision loss. This goes well beyond contemporary sutureless

surgery for cataracts, bladeless refractive lasik for myopia, or intraocular injections of antiangiogenic agents for

wet macular degeneration. Greater impacts can be achieved through our novel preventive care programs, such as

screening for diabetic eye disease and amblyopia.

The Vanderbilt Ophthalmic Imaging Center (VOIC) has instituted diabetic retinopathy mobile screening in several

underserved areas, including urban Nashville, the upper Cumberland region of Tennessee and Peru. The VOIC facilitates

capturing retinal images from diabetic patients, which are sent electronically to the VOIC reading center, where “at

risk” eyes are identified and referred to specialists in the care of diabetic eye disease. Similarly, our pediatric

ophthalmologists have worked in collaboration with the Lions Clubs of Tennessee to screen pre-kindergarten children

for lazy eyes, or amblyopia. Volunteers originally used a sophisticated camera to take pictures of the eyes; when

interpreted at Vanderbilt, children with abnormalities would be referred for evaluation and treatment. Now the

cameras have been replaced by a digital system, which is less expensive because there is no longer the cost for film,

and is equivalent in accuracy. Each year, we screen over 30,000 children in Tennessee. More significantly, the program

has spread to other states and other countries, so that approximately one million children have been screened using

the Vanderbilt-Lions model.

The Medical Center has named their new strategic plan Vision 2020. For those of us at the Vanderbilt Eye Institute, we live Vision 2020 every day!

Sincerely yours,

Paul Sternberg, Jr., M.D.

G. W. Hale Professor and Chair

Vanderbilt Eye Institute

EDITOR’SNOTESVanderbilt Vision is a publication ofVanderbilt Eye Institute, a department ofVanderbilt University Medical Center.Vanderbilt Vision provides ophthalmologistswith information on current research andstate-of-the-art clinical applications.

CHAIR, VANDERBILT EYE INSTITUTE

Paul Sternberg, Jr., M.D.

EDITORIAL BOARD

Paul Sternberg, Jr.John PennDavid CalkinsLouise MawnSarah ReynoldsAnne Enright ShepherdJoel LeeMeredith Carr

Vanderbilt University Medical Center is acomprehensive research center committedto excellence in patient care and physicianeducation.

Vanderbilt Vision is written for physiciansand friends of the VEI and does not providea complete overview of the topics covered.It should not replace the independent judgment of a physician about the appropriateness or risk of a procedure for a given patient.

PLEASE DIRECT ANY CORRESPONDENCE TO:

John S. Penn, Ph.D.Vice ChairmanVanderbilt Eye Institute1215 21st Avenue South8000 Medical Center EastNashville, TN 37232-8808

Release date: November 5, 2008Vanderbilt University Medical Center

contents2 FOCUS

VEI’s 20/20 Vision

6 Vanderbilt Ophthalmic Imaging Center

8 PROFILE

Brad Kehler, O.D.

10 Patents Pending

14 Pediatric Eye Care

15 NEWS

“Gass Atlas” Updated

16 ELECTIONS, AWARDS & GRANTS, EVENTS

Vanderbilt Eye Institute2311 Pierce AvenueNashville, TN 37232

P. 615.936.20201.866.565.EYES (3937)

F. 615.936.1483

www.vanderbilteyeinstitute.com

Fall 2008

Cover: The Future is Now, Vanderbilt Eye Institute’s 20/20Vision. Artwork: Getty Images and Tony Richardson.

TABLE OF

2

FOCUSVEI’S 2020 VISION

3

Impacting the Future One Patient at a TimeThe goal of Vanderbilt Medical Center over the past decade has

been to become one of the best medical centers in the country

– by solidifying its financial base, improving and document-

ing its quality, building its infrastructure and physical plant,

and attracting the best clinicians, students, researchers and

faculty. In its recently published strategic plan for the next

decade – Vision 2020 – the Medical Center outlines its

objectives for the decade leading up to the year 2020.

The plan’s focus is outward: harnessing Vanderbilt’s assets

to create measurable and obvious impact on the health of

our society. This impact will be accomplished by:

• working in new ways

• producing results that matter, and

• transferring its successes to society.

The Vanderbilt Eye Institute is ahead of the curve in

planning for 2020. For the last five years, our efforts have

focused on addressing the most critical health issue facing

ophthalmologists today – preventing blindness in light of an

aging population and an increase in diabetes and other chronic

diseases that affect vision. We are doing this by focusing on

three leading causes of vision loss – diabetic retinopathy,

age-related macular degeneration, and glaucoma – and three

key areas of study: oxidative damage and aging, vascular

biology and hemodynamics, and neuroprotection.

That’s the “what” . . . but what about the “how”? The

following examples clearly demonstrate how the Vanderbilt

Eye Institute is supporting the Vision 2020 philosophy in

everything we do. (continued)

Opposite Page: Patient Sullivan Pardee is being treated for congenital glaucoma at the Vanderbilt Eye Institute (photo by Joe Howell); Female diabetes patient in Peruwith her husband (photo by Larry Merin); Recent cataract surgery at VEI helped Marjorie Orth, 102, remain active (photo by Susan Urmy)

4

Working in NewWaysCurrently, several VEI faculty members have patents pending thatwill revolutionize the way eye care isdelivered in the next decade (see article, page 10). Most of these inventions could never have beenpossible without collaboration withVanderbilt’s brilliant biomedicalengineers or the recently establishedTechnology Transfer group. It isthese collaborations that turn our ideasinto working models that can be usedin delivering care to real patients.

“Breakthrough learning most

often occurs at the intersections

of disciplines rather than

within the orthodoxy of a

single discipline. Can we find

new ways to coalesce research

and clinical teams to solve

real-life problems in medicine,

as well as transforming our

understanding of biology?“

In previous issues of the Vision, wehave highlighted VEI clinicians andresearchers who are partnering withother Vanderbilt departments in discovery efforts. In our Spring2007 issue, we shared an excitingcollaboration – including theCollege of Arts & Science, PeabodyCollege, the School of Engineeringand the VEI – to study vision andthe brain through the VanderbiltVision Research Center. The discov-eries coming out of this partnershipare making international headlines.

Producing Resultsthat Matter

"To generate a meaningful

impact on society, begin by

thinking of patient care."

Significant vision impairment affectsmore than 2 million Americans andranks behind only arthritis and heartdisease as the reason for impaireddaily functioning in Americans overthe age of 70. At the VEI, we havebeen working toward discoveries thatwill prevent blindness and keeppatients functioning at a high capacity:

Diabetic retinopathyResearch conducted by John Penn,Ph.D., and his colleagues suggeststhat penetrating ocular wounds, likethose resulting from intraocularinjections, effectively slow abnormalretinal and preretinal neovasculariza-tion, and that the wounds likely doso using the retina’s own naturalcomplement of proteins. This workhas led his group to explore howthey can harness this naturalresponse into a new mode of treat-ment for the blinding aspects of dia-betic eye disease.

GlaucomaDavid Calkins, Ph.D., and his labare working with scientists to discovermedical interventions that can slowthe progression of neuro-degenerationof the eye – including promisingpossibilities for preserving ganglioncells and slowing the progression ofglaucoma. And Louise Mawn, M.D.,has developed an endoscopic surgicalmethod that will allow us to accuratelyreach the optic nerve for directadministration of neuroprotectiveagents to the structure at risk.

“We possess at this university a wealth of intellect – extraordinary bandwidth that when fully engaged can have great power and potential.”

(from Vision 2020)

FOCUSVEI’S 2020 VISION

5

Macular degenerationA collaborative study by VEIresearchers and Duke UniversityMedical Center has found a singlegene variation traceable to 43% ofcases of macular degeneration, suggesting that a combination oftreatments and lifestyle modificationscould prevent this disorder. And anew collaborative study between theVEI macular degeneration groupand the Vanderbilt Center forHuman Genetics reported theimportance of mitochondrial DNAabnormalities in the risk for development of AMD.

The Vanderbilt Eye Institute is notjust sitting back and waiting for discoveries to translate into treatments– we’re also addressing the practicalrealities of living with eye disease.Jeffrey Sonsino, O.D., has a patentpending on a pair of glasses that willhelp patients with macular degenera-tion read and thereby stay engagedwith the world.

Transferring OurSuccesses to Society

“We need to lead in the

aggressive evidence-based

application of prevention and

screening to the citizens in our

region. Earlier diagnosis and

effective prevention reduce

the human and financial cost

of disease.”

Larry Merin, RPB, of the VanderbiltOphthalmic Imaging Center hasdeveloped a mobile screening devicefor diabetic retinopathy, and is takingthe screening out to underservedpopulations that wouldn’t ordinarilyreceive it. Brad Kehler, O.D., as avolunteer for Prevent BlindnessTennessee, screens patients inNashville and ensures they get thefollow-up care they need.

Sean Donahue, M.D., Ph.D., andhis staff – in collaboration with theTennessee Lions Eye Program – havescreened almost a million childrenworldwide for amblyopia and othervision-threatening diseases.

“Much of our impact on

society can be created

through our mission to teach

the next generation of

practitioners.”

The VEI faculty is consistently inthe forefront of developing new waysof teaching. Denis O’Day, M.D.,chairs the medical school-wideEmphasis Program. DavidMorrison, M.D., John Penn andother faculty lead case study groupsfor the capstone course taught tograduating senior medical students.Laura Wayman, M.D., and the VEIeducation committee have transformedthe VEI residency by redesigningthe curriculum to include innovativetransfer of surgical skills from thewet lab to the OR and to providemore hands-on experience withpatients.

At the Vanderbilt Eye Institute, we are doing remarkable things and poised to make even greater contributions to vision care. Ouroutreach efforts are a benchmark of our success.

6

FOCUSVANDERBILT OPHTHALMIC IMAGING CENTER

Larry Merin grins from ear to ear ashe emerges from his office. “I’m sohappy to get to talk about this,” heexclaims. He’s speaking of his pro-gram to take diabetic retinopathyscreening to underserved popula-tions in Tennessee and in Lima,Peru. Mr. Merin is assistant profes-sor of ophthalmology at VEI and head ofthe Vanderbilt Ophthalmic ImagingCenter, or VOIC.

Through support from Vanderbiltand community organizations, VOICoperates a program serving a varietyof clinics where medically vulnerablepeople with diabetes obtain generalmedical care. “Diabetic retinopathyis a wicked foe that cuts across allboundaries,” explains Merin. “Bybringing specialist eye care to a gener-al clinic, we are able to overcomemany significant barriers associatedwith disparities such as race, ethnici-ty, geography and socioeconomic sta-tus.”

The obesity epidemic in the U.S.has dramatically increased the inci-dence of diabetes. An estimated 23.6million Americans have the disease

and up to 54 million have pre-diabetic conditions (impaired glucoseintolerance). By 2020, it is estimatedthat there will be 38 million peoplewith diabetes.

Over 5.3 million of those with diabetesare affected by diabetic retinopathy.It is the leading cause of blindnessfor people aged 20-74: 12,000 -24,000 people become blind annuallyfrom the disease. African-Americansand Latino-Americans have anincreased likelihood of developingdiabetic retinopathy.

But it is often the most vulnerablediabetes patients that don’t get thescreening. Many disenfranchisedwould-be patients are elderly, poor,cannot speak English, or cannot getto the clinic because they live inrural areas. Those without adequatehealth insurance receive their diabetesdiagnoses at primary care clinics, andare often unable to see an eye specialist.

“It is these populations that theVOIC outreach programs seek toreach,” says Merin. “We want tochange the paradigm of diabetic ophthalmic care.”

Diabetic retinopathy establishes itselfearly in the disease. It can be con-trolled if detected early, preventingeventual blindness. A simple eyescreening can detect retinopathy, andshould be conducted when a personis first diagnosed with diabetes andannually thereafter. The disease’sprogression can then be slowedthrough laser photocoagulation therapy.

While retinal imaging has beenaround since the 1880s, digital imaginghas taken it to a completely newlevel. The mobile camera systemused by Merin and the VanderbiltOphthalmic Imaging Center is whatmakes this outreach possible.

The VOIC diabetic retinopathyscreening program screens patientswhere they customarily receive medical care - in internal medicine or primary care clinics. Screening cameras may be permanentlyinstalled in these offices, or VOICtakes a mobile unit to the office andscreens patients by appointment.

VOIC began the program with at-riskpatients in Nashville. In an unprece-dented collaboration with Tennesseecommunity health centers and safetynet clinics, the program currently hasfixed camera locations at several clin-ics in Nashville as well as at theNashville and Murfreesboro VA

Taking Screening to Hard-to-Reach Patients

VOIC – Urban, Upper Cumberland and Peruvian Outreach Programs

7

Hospitals. The program expandedby collaborating with CommunityHealth Network. Three mobile cameras service community healthclinics in the west, middle and easternregions of the state. Images are sentback to the VOIC for reading.

Last May, the VOIC began screeningpatients in county health departmentsthroughout the region as part of“Project TennesSEEwell,” a state-funded program. Local ophthalmolo-gists and optometrists work with thecounties to see patients once sight-threatening diabetic retinopathy hasbeen detected. Though the ongoingtreatment is not free, it is subsidized.

Because of the quality of digitalimaging, Merin and his deputy,Sandra Anderson, CRA, FOPS,can often detect other problems bylooking into the eye. For instance, ifthey see plaque breakup – whichtypically has a 50% mortality rate in5 years – they can recommend that thepatient get treatment. Screening fordiabetic retinopathy thus begins tosave lives as well as prevent blindness.

VOIC in PeruIn order to better understand thecultural, sociological and economiccontexts of diabetes care, the VOIChas initiated a retinopathy screeningprogram in Lima, Peru under theaegis of Vanderbilt’s Center for the

Americas. Begun two years ago, thisinnovative project – with start-upfunding provided by the university –brings together a multidisciplinarygroup of experts from a variety ofinstitutions and disciplines, includingnursing, psychology, health policy,sociology, endocrinology and ophthalmology.

Vanderbilt operates this program in collaboration with UniversidadPeruana Cayetano Heredia in Lima.The project has attracted the attentionand support of the Peruvian Ministryof Health and of the Pan AmericanHealth Organization. .

The indigenous people of the Andesprovide a perfect case study. Tired ofsubsistence farming and herding,they are moving to the city in recordnumbers. Away from daily physicallabor and eating an unhealthy diet,they are being diagnosed with diabeteswith an incidence similar to that ofNorth Americans.

Research objectives for the programare to study diabetics’ self-carebehavior, socioeconomic and culturalbarriers to health care delivery, andclinical designs for chronic diseasemanagement, in addition to traininglocal healthcare workers and aiding inthe creation of other outreach projects.But the core foundation of the initia-tive is diabetic retinopathy screening.

98% of Peru’s ophthalmologistspractice in Lima, but the cost of careand lack of education remain barriersto preventive ophthalmology. “There’sa stigma attached to diabetes,” saysMerin. “Many still consult shamans,so getting the patient to the clinic canbe difficult.” Merck has donated avan to help move the camera to remoteclinics. Similar to the Tennessee program, the patients are screened andthe images are sent back to a newreading center the VOIC helpedestablish in Peru, with the VOICproviding guidance and qualityassurance.

Merin: “I can’t sit here and let peoplego blind when we have tools to preventthis catastrophe,” he says. “We wantto give them hope.”

Diabetes patient at home with pet bird in Lima, Peru (Photo by Larry Merin)

8

PROFILEBRAD KEHLER, O.D., F.A.A.O.

Volunteer State of Mind

Brad Kehler, O.D., F.A.A.O., sees beyondthe walls of the Vanderbilt EyeInstitute. He is one of 60 optometristsand ophthalmologists across the statewho volunteers with Prevent BlindnessTennessee (PBT) to screen needypatients for vision problems. In 2007,as part of its Senior Sight program,PBT volunteers provided 1,328 patientswith vision screenings, 189 with complete eye exams, and 341 witheyeglasses.

Dr. Kehler has also been instrumentalin coordinating PBT’s role in ProjectTennesSEEwell (see article, page 6). PBT volunteers organize incoming datafrom screenings sites and from VOIC,input the data into a master database,send letters with patient educationalmaterials to patients and, when possi-ble, match destitute patients found tohave sight-threatening disease withtheir own volunteer eye care providers.

In addition, PBT volunteers provided 47 eye exams and provided surgery or treatment for diabetic retinopathy to 5 patients in 2007. Kehler's work with Prevent BlindnessTennessee has earned him the organization's Support ofVision Volunteer Award. Today, he serves on the group'sBoard of Directors.

When he isn’t donating his time and expertise to preventingblindness, Dr. Kehler is a full-time faculty optometrist at theVanderbilt Eye Institute. In fact, he has been part of theVanderbilt community since his undergraduate years (he’sstill a big Commodore sports fan!). A Dallas, Texas native, hehas been interested in a career in vision since high school.

Brad Kehler in a patient examing room at VEI (photo by Anne Rayner)

9

“I have always been fascinated with how the human visualsystem processes information into what we perceive assight,” he says. “And I was attracted to health care for theopportunity to serve society. Optometry seemed like theperfect profession since I could be involved in both visionscience and patient care.”

After receiving his bachelor’s degree at Vanderbilt, Bradeventually returned to Nashville after earning a doctorateat the Illinois College of Optometry. His wife, Lori Ann,whom he met in optometry school in Chicago, is also aVanderbilt optometrist specializing in pediatric optometry.

“We were both attracted to the university setting due tothe ability to teach, see patients, and conduct visionresearch,” explains Kehler. “We plan on making a career inacademia.” And they are making a family. The two have anew baby – their first.

With low vision and specialty contact lens fittings his sub-specialties, Brad sees many patients in the VEI clinic withissues like glaucoma and diabetic retinopathy. But it's thepeople he meets out in the field who really inspire him.

“Out in the clinics we screen at-risk patients,” says Kehler,“people who can’t make it to an eye clinic for health oreconomic reasons. Getting to these patients really puts aface on Vanderbilt’s work and research.”

Prevent Blindness screening sites are typically set up at aprimary care office or walk-in clinic. The volunteeroptometrists and ophthalmologists can screen up to 20patients a day. During the screening process, Dr. Kehlersometimes uncovers problems that go beyond the eyes andrequire urgent attention.

One patient in her sixties complained that her vision hadworsened. Dr. Kehler discovered a massive central retinal

vein occlusion, or hemorrhagic stroke of the eye. He checkedher blood pressure – and found it to be dangerously high.

“We contacted her primary care doctor on the spot,” herecalls. After organizing a follow-up appointment with thewoman’s physician and a time and place for her to pick upblood pressure medication, Dr. Kehler placed her with a retinaspecialist to treat her vein occlusion. “We may have savedthe patient’s life, in addition to saving her vision,” he saysnow. “While highly stressful, that was a feel-good momentbecause I know I made a difference for someone who desperately needed appropriate care.”

In his volunteer work and his practice at Vanderbilt, Bradfinds it very rewarding to see an improvement in a patient’squality of life. “I think it’s an obligation,” he says. “As physicians, we have a privileged position in society, and wedefinitely have the tools help others.”

But Kehler doesn’t just stop with vision. In addition to hispractice and his volunteer work, he is an avid cyclist andrepresents the VEI in the annual “Jack and Back” ride formultiple sclerosis.

10

FOCUSPATENTS THAT COULD IMPACT PATIENTS NOW

Vanderbilt Eye Institute researchersdon’t sit back and wait for the latesttreatments for vision problems –they’re inventing them. CurrentlyVEI optometrists and ophthalmolo-gists, in collaboration with otherVanderbilt faculty, have severalimportant patents pending that couldimpact patients now.

Illuminated LowVision Glasses

Jeff Sonsino

Dr. JeffreySonsino hasbeen interestedin low visionever since hisyears at theNew EnglandCollege ofOptometry.

Today he sees patients in the Centerfor Sight Enhancement at Vanderbilt,where he has invented an innovativeset of eyeglasses after carefully study-ing hundreds of patients with lowvision.

Illuminated low vision glasses provideillumination, magnification, andprism correction that improve con-trast and letter recognition. They area godsend for patients who cannotproperly read with ordinary reading

glasses or contact lenses, and whosecondition cannot be corrected withsurgery. This often includes peopleafflicted with macular degeneration,diabetic retinopathy, glaucoma, cataract,and other vision-impairing eye diseases.

Dr. Sonsino’s glasses are portable,far less bulky, and easier to use thanother low vision reading aids. High-powered LED lighting is built intothe spectacle frame, illuminating thepage through magnifying, high-pow-ered lenses. Built-in prism correctionallows sustained reading at the focaldistance of the lenses. And unlikecurrent low vision devices on themarket, which run at thousands ofdollars, illuminated low vision glassescan be inexpensively produced anddo not require a medical prescription.

To take his idea to the next level,Dr. Sonsino approached Vanderbilt’sOffice of Technology Transfer andEnterprise Development (OTTED).The OTTED licenses technologydeveloped by Vanderbilt inventorsand innovators, and assists in thestart-up of companies which com-mercialize Vanderbilt technology.

They helped him get the model built,and included them in a portfolio ofpatents they were showing to a consulting group. The consultantsranked the glasses the number onemost fundable idea.

The OTTED registers copyrights,markets and licenses patents, andnegotiates agreements related tolicensing and material transfer, andsponsored research. It distributesroyalties and other income to theinventors.

“Tech Transfer offers a lot of supportfor doctors,” says Sonsino. “Theytake all the initial risk.”

This new technology has the poten-tial to help millions of people afflictedwith low vision. Dr. Sonsino feelsthat if it is low-cost and availableover the counter, the sales potentialis considerable. He may be right:after a story on the glasses appearedon a Vanderbilt News and PublicAffairs Web video, calls came infrom patients all over the world.

“We want to have this in as manyhands as we possibly can,” he explains.

Illuminated low vision glasses with built-in prismcorrection for reading at focal distance of lenses(photo by Anne Rayner)

Sonsino with illuminatedlow vision glasses (photoby Anne Rayner)

11

Dr. Louise Mawn’s research focuseson surgical advances in treating orbitaldisorders. She was the principalinvestigator for a research studyfunded by the National Eye Instituteto examine endoscopic approaches toorbital disease. Now, with the helpof biomedical engineer Bob Galloway,Ph.D., Dr. Mawn has developed anorbital endoscopic surgical apparatusand method.

“Bob’s decades of research anddevelopment in image guidance arereally what have made this technologya reality,” Dr. Mawn explains.Galloway holds several patents inimage-guided therapy.

The eye’s extreme delicacy makes itvery difficult to reach the regionbehind it. Until now, directly accessingthe optic nerve has required anorbitotomy – a difficult, invasiveprocedure in which either the lateralbony wall of the orbit (eye socket) isremoved (causing permanent facialscarring or disfigurement) or a rectusmuscle is dissected from the side ofthe eyeball (and then later re-attached)allowing the eye to be carefully‘rotated’ to expose the optic nerve.

Moving the eye in the socket canpotentially damage the eye.

Even very small flexible endoscopesare problematic for orbital surgeriesand biopsies. Orbital structures areof similar color, and traditionalorbital landmarks are lost as theendoscope is moved through theorbit, and the orbital fat obscures the optic nerve.

Image guidance may help the transorbital endoscopic procedure – perhaps even eliminate the need forinvasive surgery. The system devel-oped by Mawn and Galloway – theAurora system (Northern DigitalInc, Waterloo, Ontario) – is analternating current magnetic localizerwhich emits alternate-current magneticfields. It consists of a field generatorand a small coil sensor that can beembedded in catheters, needles andother instruments.

With the Aurora system’s imageguidance, coupled with an endoscopetracked precisely and in real-time,neuroprotective drugs could traveldirectly to the target site, providing a highly effective treatment fordegenerative or traumatic damage tothe optic nerve. With proper cutting

tools, the endoscope can perform anoptic nerve sheath fenestration.

“Being part of the process of takinga science fiction-like concept into areal working instrument has beenvery satisfying,” Dr. Mawn says ofher collaborative work.

“The unique advantage of being aVanderbilt faculty member is theworld-class scientists who are oncampus and willing to work withbusy surgeons to make the conceptof better treatments and safer surgeries possible.”

Bob Galloway and Louise Mawn (photo by Anne Rayner)

Transorbital Endoscopic Image GuidanceLouise Mawn

12

FOCUSPATENTS THAT COULD IMPACT PATIENTS NOW

Targeting PressureSensitivity in theOptic NerveDavid Calkins

Glaucoma is generally considered adisease of front of the eye because akey risk factor is elevated intraocularpressure (IOP). But glaucoma blindsthrough the death of the optic nerve,which is in the back of the eye.

David Calkins, Ph.D., and hisresearch team focus on understandingthe mechanisms through which theoptic nerve is sensitive to ocularpressure. “We don’t understandwhy,” says Dr. Calkins. “We knowthat the eye is very sensitive to itsown pressure . . . but we still don’tknow how IOP translates to

degeneration.”

Intraocular pressure is controlled bythe secretion of fluid from the ciliarybody adjacent to the crystalline lensand the drainage of fluid throughtiny channels located at the intersec-tion of the iris and the cornea.Elevated intraocular pressure is theonly modifiable risk factor for glaucoma and is currently treated inone of two ways: lowering IOP witheye drops or opening the drainagechannels surgically.

Dr. Calkins and his colleagues haveidentified novel therapeutic targets –transient receptor channels – withinretinal ganglion cells. Blocking thesechannels decreases the sensitivity topressure and prevents the pressure-induced death of retinal ganglioncells in the laboratory. The teamfound that when they relieved neuralsensitivity to IOP, they could preventthe degeneration of the optic nervedue to pressure at the back of theeye. Simply put, the therapeuticintervention would blunt the effectof the pressure.

“It’s like giving you a shot of novo-caine before you go to the dentist,”explains Calkins. “You’re not removing the procedure. You’re justblunting the response to it.”

Dr. Calkins has filed a patent basedon the idea that blocking mechanicallysensitive pressure sensors in the retinaand optic nerve is a means to reducethe risk of blindness associated withglaucoma.

“When you apply for a patent, thereare such things as pure idea patents,but this is an application patent inthe sense that we have garnered a significant amount of sensible data to support a claim,” explains Calkins.“Targeting these channels is a poten-tially therapeutic intervention,” hecontinues. “We back up that claimwith a great deal of experimentalresults.”

Practically speaking, pharmaceuticalintervention is the goal. The Officeof Technology Transfer is workingwith Dr. Calkins and with a localpatent law firm to develop industrialinterest and licensing to get it outinto the public domain.

Portable Erbium:YAG LaserJin-Hui Shen & Karen Joos

Laser physicist Jin-Hui Shen, Ph.D.,shares a research suite with KarenJoos, M.D., Ph.D. As a clinician,Dr. Joos is exposed to specificpatient cases and brings the needs of

David Calkins examines a slide in his lab (photo by Neil Brake)

13

the patient to their research.Together the two have developed apatented prototype of a portableerbium:YAG laser that can be outfit-ted for eye surgery.

This new laser system is a perfectexample of both interdisciplinarycollaboration and translationalresearch. As an active ophthalmicsurgeon and free electron laserresearcher, Dr. Joos knew that the2.94 micron wavelength of this laserwould be very useful for certain delicate microsurgical procedures.

Unfortunately, this wavelength isvery difficult to deliver to the surgicalsite, because few optical fibers cantransmit it in a reliable and efficientmanner. With the problem of beamdelivery in mind, Dr. Shen decidedto remove the need for flexible fiberdelivery all together, by creating anew Er:YAG laser that fits in thesurgeon’s hand.

Shen’s idea was complex, requiringprecision machining, optics, andelectronics expertise and instrumen-tation. Despite considerable technicalhurdles, he was able to construct acomplete prototype system, which isnow available for further experimentaluse by Vanderbilt researchers.

Dr. Shen: “At Vanderbilt, there are

so many people with so much expertiseworking together. This collaborationaccelerates the research process andgets the technology to market faster,helping physicians and patients.”

Jesse Shaver, Dr. Shen’s student collaborator, agrees. Mr. Shaver – astudent in Vanderbilt’s M.D./Ph.D.Program – came to Vanderbilt withhis own invention, and Dr. Shen hasworked with him to perfect it. Theaffordable hand-held device usesrapid-scanning confocal microscopyto measure the thickness of thecornea. Because of its convenienceand accuracy, it could ultimatelyreplace the current eye drops/ultra-sound method that is uncomfortablefor patients and often unreliable.

Recent research indicates a strongstatistical relationship betweencorneal thickness and glaucoma, soan easier way to measure the corneacould mean faster diagnosis and bettertreatment.

Shen’s lab is also working on anaccommodative intraocular lens.This multifocal lens will replace therigid lenses currently implanted following cataract surgery.

“Most basic science labs focus onbiology,” explained Dr. Shen.“We’re inventing – understandingwhat the problem is or the diseaseprocess involved and finding thesolution.”

Karen Joos discusses a new project with Jin-Hui Shen (photo by Anne Rayner)

14

FOCUSPEDIATRIC EYE CARE

Ophthalmologists agree that it isimportant to discover serious eyeproblems in children before age sixbecause they are easier to correct.But at this young age, children can-not verbally express a problem orread an eye chart.

That’s where the Tennessee LionsOutreach Program comes in. Forover ten years, the Tennessee chapterof Lions International has operated a statewide Outreach Program todetect the most common vision dis-orders that can lead to blindness inyoung children. A network of over900 trained Lions Club volunteersprovide free vision screening for pre-literate children at day care centers,preschools, Sunday schools andother organized sites upon request.The program provides the infrastruc-ture and follow-up to ensure thatevery Tennessee child who needs itreceives quality vision care.

Today, the Tennessee Lions EyeCenter (TLEC) screens 30,000 children annually and refers 4.5% of these to local eye professionals. Agrant from the International Lionsenables Vanderbilt staff to follow up

on these referrals, increasing the percentage from 35% to 75%.

“Vanderbilt couldn’t have done thiswithout the tremendous volunteerismand generous financial support of theof the Lions Club members acrossthe state of Tennessee,” explains SeanDonahue, M.D., Ph.D., OutreachDirector of the Lions Eye Center.

Most young patients seen by theoutreach program are between sixmonths and four years of age.Photographs are taken of the chil-dren’s eyes and examined for a vari-ety of vision problems.

Results go to the VanderbiltOphthalmic Imaging Center, orVOIC, where they are interpreted,entered into Vanderbilt’s “FirstGlimpse” access database, andreturned to the screening site. Dr.Donahue and other TLEC physiciansreview photos and make recommen-dations for follow-up treatment.Parents of children with imperfectvision receive a list of area eye careprofessionals who have agreed to seereferrals from the screening program.

“Talk about an impact,” says Donahue.“We’re coming up on our one millionth child worldwide screenedthrough Lions Club International!”

Project PAVE

VanderbiltEye InstituteoptometristJeffreySonsino isinvolved with alandmarkVanderbilt program calledProject PAVE

(Providing Access to the VisualEnvironment). The program servesTennessee children and youth ages 3through 21 who have visual impair-ments, providing them with compre-hensive low vision services andpreparing them for independent visual functioning to the greatestextent possible.

Project PAVE was started in 1994,when Ann Corn, Ph.D., wrote asmall grant to include about 10 chil-dren in the Nashville Metro schoolsystem. Dr. Sonsino took over theproject, funded by the TennesseeDepartment of Education, aftermany years of seeing pediatric lowvision patients.

All services are without cost to families and schools. Supervisors ofspecial education across the statereceive written notice of ProjectPAVE services each August and are

One Million Kidsand CountingTennessee Lions OutreachProgram

A young patient beingexamined for low vision(photo by Dana Johnson)

15

asked to disseminate the informationto all teachers who have eligible students. Referrals are taken fromlocal optometrists, ophthalmologistsand directly from school systems.

Following the evaluation, parentsand local education agencies receivewritten reports listing any recommen-dations the optometrists determinemay be beneficial to the student. Thereport may include prescriptions foroptical devices like monoculars, handmagnifiers and therapeutic contactlenses.

Prescriptions for optical devices arefilled by Project PAVE withoutcharge to families or schools. Oncethe devices are received, a ProjectPAVE staff member meets with the student, their parents, other familymembers and appropriate school personnel to train and discuss useand care of the devices.

“These are bright kids…they justdon’t see well,” explains Sonsino. “Itdoes them a disservice to put them inthe classroom with children whohave severe learning disabilities.”

“Project PAVE is a wonderful exam-ple of collaboration across many disciplines to provide a life-alteringservice for our patients.”

The Stereoscopic Atlas of RetinalDisease, known by retina specialistsaround the world as the “GassAtlas”, is currently being updated byVanderbilt Eye Institute facultymember Anita Agarwal, M.D. Thiswill be the 5th edition of the referencework, which was originally publishedin 1963. The last update was in 1996.

J. Donald M. Gass graduated fromVanderbilt in 1950 and in 1957,received a medical degree and theFounder’s Medal from the VanderbiltUniversity School of Medicine.After medical school, he served aninternship at the Wilmer Institute atJohns Hopkins and a fellowship atthe Armed Forces Institute ofPathology.

Dr. Gass then joined the faculty ofthe newly established Bascom PalmerEye Institute at the University ofMiami, where he stayed for 32 years.He returned to Vanderbilt in 1995and spent the remaining years of hiscareer with the VEI. In 1999, whenhe was 70, he was named one of theten most influential ophthalmologistsof the 20th century.

The Stereoscopic Atlas of RetinalDisease is a big part of his legacy.“This is a unique book,” says Dr.Agarwal. “There is no other text inophthalmology quite like it.”

The book uses simple language todescribe the pathogenesis of retinaldisease. “It is almost written in thefirst person,” Dr. Agarwal explains.The text is illustrated with highlydetailed diagrams and photographsof actual cases. In the current edition,90% of the patients included in thebook were seen by Dr. Gass himself.

Dr. Agarwal: “We will supplementthe data on the work that has alreadybeen described and add new cases.Most of the updates will involvetechnological advances in retinaltreatment.”

She hopes to have samples of thenew edition at the AAO conferencein fall 2010. The book will be pub-lished by Elsevier in spring 2011.

VANDERBILT EYE INSTITUTEGASS ATLAS UPDATED

Anita Agarwal in the Gass Slide Room at VEI working onthe updated “Gass Atlas” (photo by Anne Rayner)

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VANDERBILT EYE INSTITUTENEWS AND AWARDS

The Vanderbilt Eye Institute is pleasedto announce the following:

Paul Sternberg, Jr, M.D.Named Chairman of the Board atCheekwood Botanical Garden andMuseum of Art, Nashville.

Association for Research in Visionand Ophthalmology (ARVO)Paul Sternberg, Jr, M.D.Named Vice President-Elect.

Franco Recchia, M.D.Elected to the Program Committeeof the Retina Section.

John S. Penn, Ph.D.One of two candidates for Trustee ofthe Retinal Cell Biology Section.The election will take place onlinethis spring.

International Society for EyeResearch (ISER)John S. Penn, Ph.D., NorthAmerican Councilor of ISER,played a leadership role in the plan-ning, organization and managementof the ISER Congress in Beijing,China in September. VEI facultyJiyang Cai, Rachel Kuchtey andPenn presented their latest work.

Grants and AwardsDavid Calkins, Ph.D.R01 grant from the National EyeInstitute entitled “TransientReceptor Potential Channels andRetinal Ganglion Cell Death inGlaucoma.”American Health AssistanceFoundation National GlaucomaResearch Grant: “A Novel Neuro-protective Target in Glaucoma”.

John S. Penn, Ph.D.New research contracts with AlconLaboratories, Inc., MerckPharmaceuticals and Celgene Corp.

Jiyang Cai, Ph.D.R21 grant from the National EyeInstitute entitled “MitochondrialDNA variation and susceptibility tooxidative injury in the RPE”.

Rachel Kuchtey, M.D., Ph.D.Received an American GlaucomaSociety Clinician Scientist Award.

From the recent Vanderbilt Eye Institute 2008 Symposium: Neurodegeneration & Glaucoma

Clockwise from upper left: Jason Porter, University of Houston; Melissa Gottron, Duke University, StephenBartells, Bausch and Lomb, Inc. and Tom Brunner, CEO, Glaucoma Research Foundation; Bruce Berkowitz(in front of poster), Wayne State University; Helen Huang, University of Utah. Left: David Calkins andJohn Penn, Vanderbilt Eye Institute (photos by Anne Rayner)

Paul Sternberg, Jr., M.D.Chair, Vanderbilt Eye Institute RETINA/VITREOUSSpecial interests: age-related maculardegeneration and complex retinal detachments.

Anita Agarwal, M.D. RETINA/VITREOUSSpecial interests: inflammatory diseases ofthe retina and diabetic retinopathy.

Jiyang Cai, M.D., Ph.D.VISION RESEARCHSpecial interests: mitochondrial oxidativedamage and protection in aging and age-related degenerative diseases.

David J. Calkins, Ph.D. VISION RESEARCHSpecial interests: degenerative disorders ofthe visual system and the genetic mechanismsof retinal disease.

Min S. Chang, M.D.VISION RESEARCHSpecial interests: growth and maintenanceof corneal epithelial cells.

Amy S. Chomsky, M.D. COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Veterans AdministrationHospital Chief Attending.

Sean P. Donahue, M.D. Ph.D.NEURO-OPHTHALMOLOGY/PEDIATRIC OPHTHALMOLOGYSpecial interests: amblyopia, surgical management of complicated strabismus,pediatric neuro-ophthalmology, and visualfield testing.

Robert Estes, M.D.PEDIATRIC OPHTHALMOLOGY/ADULT STRABISMUSSpecial interests: Childhood and adult strabismus, ophthalmic genetics.

James W. Felch, M.D., Ph.D., F.A.C.S.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Cataract surgery

Jin Hui-Shen, Ph.D.VISION RESEARCHSpecial interests: laser surgery and theinvention of surgical devices.

Karen M. Joos, M.D., Ph.D.GLAUCOMASpecial interests: low-pressure glaucomaand pediatric glaucomas.

Jeffrey A. Kammer, M.D.GLAUCOMASpecial interests: neovascular glaucoma andcomplicated glaucoma cases.

Brad Kehler, O.D., F.A.A.O.OPTOMETRYSpecial interests: low vision rehabilitation,specialty optics, contact lenses.

Lori Ann F. Kehler, O.D., F.A.A.O.OPTOMETRYSpecial interests: amblyopia, pediatric eyecare.

Steve J. Kim, M.D.RETINA/VITREOUSSpecial interests: uveitis.

Mark A. Kroll, M.D., J.D.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Cataracts, refractive surgery,secondary IOL implantation, corneal trans-plantation.

John Kuchtey, Ph.D.VISION RESEARCHSpecial interests: immunological aspects ofanterior chamber pathology in glaucoma.

Rachel W. Kuchtey, M.D., Ph.D.GLAUCOMASpecial interests: cellular and molecularmechanisms of aqueous outflow in glaucoma.

Patrick Lavin, M.D.NEURO-OPHTHALMOLOGYSpecial interests: eye movement disorders,nystagmus, neuro-otology, headache andmetabolic disorders affecting the visual system.

Jennifer Lindsey, M.D.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Cataracts, eyelid disorders,ocular trauma, diabetic eye disease, andglaucoma.

Louise A. Mawn, M.D.NEURO-OPHTHALMOLOGY/OCULOPLASTICSSpecial interests: ophthalmic plastic surgerywith a particular interest in orbital disease.

Mark R. Melson, M.D.OCULOPLASTICSSpecial interests: ophthalmic plastic surgery.

Lawrence M. Merin, RBP, FIMIOPHTHALMIC IMAGING CENTERSpecial interests: retinal imaging, epidemiologyand diabetic eye disease.

David Morrison, M.D.PEDIATRIC OPHTHALMOLOGYSpecial interests: strabismus, pediatriccataracts, and retinopathy of prematurity.

Denis, M. O'Day, M.D., F.A.C.S.CORNEA and EXTERNAL DISEASESpecial interests: ocular fungal infections.

John S. Penn, Ph.D.VISION RESEARCHSpecial interests: molecular basis of ocularangiogenesis.

Franco Recchia, M.D.RETINA/VITREOUSSpecial interests: pediatric retinal disordersand retinal vascular disorders.

Chasidy D. Singleton, M.D.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: refractive errors, corneadisorders, cataracts, glaucoma, diabetic eyedisease, ocular trauma, and strabismus.

Jeffrey Sonsino, O.D., F.A.A.O.OPTOMETRYSpecial interests: complicated and difficult-to-fit contact lenses, and low vision rehabilitation of adults and children.

Uyen L. Tran, M.D.CORNEA and EXTERNAL DISEASE/LASER SIGHTSpecial interests: corneal transplantation,cataract surgery, and refractive surgery.

Laura L. Wayman, M.D.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Director of ResidentTraining and cataracts.

Daniel S. Weikert, M.D.COMPREHENSIVE OPHTHALMOLOGYSpecial interests: Cataracts, refractive sur-gery, secondary IOL implantation, sportsophthalmology - team physician forTennessee Titans and Nashville Predators.

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VANDERBILT EYE INSTITUTECELEBRATING OUR HISTORY

Vanderbilt's resident training program in ophthalmology was begun in 1957.It was granted full approval in 1962 under the guidance of George W.Bounds, M.D., who served as acting chair of the department from 1958 until1966. On Friday evening, October 10, 2008 VEI faculty, friends and Dr.Bounds’ family members gathered to celebrate Dr. Bounds' contribution at the unveiling of his portrait. Joining the festivities were three ophthalmologyheads: James Elliott, M.D., who joined Vanderbilt Ophthalmology in 1966 andwas appointed chair in 1970, Denis O'Day, M.D., who was appointed to theposition at Dr. Elliott's retirement in 1992 and Paul Sternberg, M.D., currentchair who came to VEI in 2003.

Dr. Bounds was a community-based ophthalmologist who continued his practice during the time he was affiliated with Vanderbilt. Honoring Dr.Bounds at the unveiling were his son, George, also a physician, Dr. HarryJacobson, M.D., Vice Chancellor for Health Affairs, Dr. Sternberg and Dr. JeffBalser, M.D., Ph.D., who was that day named the 11th dean of VanderbiltUniversity School of Medicine.

Bounds’ Portrait to Join Others at VEI