Influential Surgeons

We Stand on the Shoulders of Giants

By Allon Barsam, MD, MA, FRCOphth

When I first met with Hank Perry, MD, and Eric D. Donnenfeld, MD (Figure 1), to discuss joining the Ophthalmic Consultants of Long Island’s cornea, cataract, and refractive surgery fellowship program, they said to me, “We are already successful; the aim of this fellowship is for us to make you successful.”

They certainly lived up to that promise, and both men, in different ways, have influenced my career tremendously since that time.

I have been privileged to benefit from Drs. Perry and Donnenfeld’s collective experience of more than 60,000 laser eye surgery procedures, 5,000 corneal transplants, and more than 25,000 cataract operations, including many of the most challenging cases on the East Coast of the United States. Drs. Perry and Donnenfeld devoted a lot of time and effort to ensuring that I was able to function at the same high level as they do, and this has put me in a unique position back in the United Kingdom, as there are few UK-based surgeons who have benefited from that kind of intensive training and support.

Dr. Perry has an encyclopedic knowledge of corneal function and disease. I learned from him how an interest and involvement in research and publishing can have a direct and positive influence on what we can offer our patients. Having contributed to so much of the relevant literature on corneal disease, Dr. Perry still has the humility to constantly adopt and explore new ways of treating corneal problems. He showed me that, at all times, it is essential to question the rationale behind diagnostic and treatment options. An essential ethical tenet of being a doctor is embodied in the Latin saying, “Primum non nocere”—First, do no harm. Dr. Perry’s approach to patient care embodies this, and, whenever I find myself dealing with difficult and challenging cases, I still feel his concern to make certain that we are giving these patients the safest care possible.

Dr. Donnenfeld is something of a phenomenon. I know of no other doctor who can see 160 patients in a single day and interact with a large team of dedicated staff without ever making anyone feel that he is too busy for them. He effortlessly combines a razor-sharp mind with charm, a sense of fun, and an uncompromising desire to ensure that he is the best at what he does. I learned from Dr. Donnenfeld how to translate a passion for ophthalmic surgery into excellence in providing it. Many ophthalmologists enjoy and are good at what they do, but few love and excel in it as much and manage to maintain such a status on the national and international stage while remaining so nice to everyone.

I recently ran into Dr. Donnenfeld at the European Society of Cataract and Refractive Surgeons (ESCRS) meeting in Amsterdam. Despite being in the middle of his term as president of the American Society of Cataract and Refractive Surgery (ASCRS) and being a partner in one of the East Coast’s most thriving ophthalmic practices with a large and complex practice of his own, the first thing that he said to me was, “Allon, is there anything that I can do to help you?”

Industry relies on surgeons like Dr. Donnenfeld to refine existing technologies and develop new technologies for the future, and he showed me how to work with industry to develop new tools and devices for the benefit of our patients.

Constantly striving to raise the bar in what we can do for patients demands an enormous amount of time and dedication. Drs. Perry and Donnenfeld still inspire me to do this on a daily basis. Such is the unidirectional nature of training that I will never be able to repay the gratitude that I owe these two giants of our field. What I can do, though, is resolve to pass on my skills and experience and perhaps a little inspiration—to the next generation of ophthalmic surgeons.

Allon Barsam, MD, MA, FRCOphth, is a Consultant Ophthalmic Surgeon at Luton & Dunstable University, The Western Eye Hospital, Imperial College Healthcare NHS Trust, and Focus Clinics in London. Dr. Barsam is a member of the CRST Europe Editorial Board. He may be reached at e-mail: eyes@allonbarsam.com.

Influential Figures in My Medical Career

By Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin)

During the period prior to my training while I waited for a training post; my actual 7 years of training in Pretoria, South Africa; my early days as a specialist in South Africa; and my 15 years as an ophthalmologist in Ireland, there have been many influences on my professional life—far too many to mention by name. My professors in South Africa, my senior fellow trainees from whom I learned so much, and visiting consultants have all played a role in providing the foundation on which my career is built.

In this article, however, I will cite a few specific encounters that changed the way that I think about ophthalmology— through ideas or thoughts that are not necessarily found in textbooks.

The first such encounter was with Guy M. Kezirian, MD (Figure 2), who, at the time, was conducting the US Food and Drug Administration (FDA) clinical trial for the WaveLight laser (now Alcon). Dr. Kezirian came to visit me in Dublin, where I had already been using the WaveLight for a few years, to gain insight into the laser’s performance in preparation for the trial. This was the first time that we had met, and Dr. Kezirian was asking questions, getting to know me.

In South Africa, besides doing cataract and refractive surgery, I was also the retinal consultant to our group practice, doing, on average, five to eight retinal detachments or posterior vitrectomies per week. In Dublin, at the time that I met Dr. Kezirian, I was doing only LASIK as I had not received admitting privileges to the local hospitals yet for cataract and other surgery.

During our conversation, I trivialized LASIK in my attempt to impress Dr. Kezirian with my wider ophthalmic experience. “LASIK is easy, and doing so many cases can become boring,” I said. Dr. Kezirian’s response threw me, as, deep down, it was exactly how I felt. He said something like, “If you find doing LASIK boring, stop doing it now. Your patients deserve better. If you find it easy, it is because you are not trying hard enough to make each and every case 100% perfect and trying to make each outcome meet or exceed the patient’s expectations.”

That response cemented what I had always thought, namely that LASIK surgery should be more demanding of the surgeon than retinal surgery. With retinal surgery, the patient has a problem and is seeking sight-saving surgery. With LASIK, the patient is seeking sight-preserving or sight-enhancing surgery in an otherwise completely healthy eye. Having Dr. Kezirian reiterate my thoughts, which, at the time, I thought were quite unique, has encouraged me to always speak truthfully about how I feel.

Another strong influence on my ophthalmic career has come from a physicist well-known in the field of ophthalmology, Michael Mrochen, PhD (Figure 3). Dr. Mrochen is the scientist who runs IROC Science to Innovation and IROC InnoCross. His companies develop crosslinking products and help with translational research, taking ideas to market through research and development. Dr. Mrochen’s influence on me has been through his absolutely rigorous approach to research. His inquiring mind has helped me look at new developments and technologies through differently tinted glasses and to continually ask questions and delve deeper. Scientific rigor and attention to detail are what the future of ophthalmology is built on, in my opinion.

Another influence came from a group of colleagues and friends known collectively as the WaveLight Beta Site, a group that used to meet before big international conferences (Figure 4). Under the leadership of Theo Seiler, MD, PhD, these 10 ophthalmologists from around the world met once or twice per annum with WaveLight’s management and engineers, trying to align the wishes of ophthalmologists, scientists, engineers, and management. The group no longer formally exists, but it led to a collaborative way of thinking and was, for all of us, the highlight of any conference that we attended. I will forever be grateful to all of the members of the Beta Site, as each one of them had a positive influence on my career.

Finally, I owe a debt of gratitude to Matthias Maus, MD, who did an amazing job of exceeding my expectations when he performed my LASIK procedure some years ago.

I unreservedly apologize to those who know they have influenced me positively but whose names I have omitted. Interestingly, I get as big a kick from talking to colleagues who are continually seeking ways to improve their own patient outcomes. Last but by no means least, we all owe collective gratitude to the engineers, PhDs, and scientists who deliver amazing technologies to us, allowing us to provide our patients with better and safer outcomes. We truly are blessed to be working as ophthalmologists at this exciting point in time.

Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin), is a Consultant Ophthalmologist at the Wellington Eye Clinic and UPMC Beacon Hospital in Dublin, Ireland, and Associate Chief Medical Editor of CRST Europe. Dr. Cummings may be reached at e-mail: abc@wellingtoneyeclinic.com.

A Longtime Mentor and Friend

Damien Gatinel, MD

I attribute much of my career success to my friend and mentor Dimitri Azar, MD (Figure 5). I first met Dr. Azar in 2000, after he was offered the position of visiting professor at the Rothschild Foundation in Paris, in the department to which I had just been recruited as an assistant professor. On the day of his arrival, I was asked to pick him up at the Charles de Gaulle Airport. I was anxious, as I realized that I might not be able to hold the interest of a renowned Harvard University professor who had authored many books and papers, or at least find enough interesting topics to maintain conversation during the 30- to 45-minute drive back to our hospital. In fact, I was secretly hoping that jet lag would cause him to remain quiet. I was in for a big surprise!

On our drive, the conversation with Dr. Azar was casual, friendly, and open, and I was intrigued by his ability to ask good questions and his genuine interest in me. When we arrived at our destination, he invested well over another hour in this first meeting, which was memorable in many ways. We both became excited by new ideas regarding how he could mentor me to explore strategies to correct astigmatism with the excimer laser or to investigate subtle effects of laser-ablation profiles on the cornea. That day was the beginning of a long-term friendship and collaborative relationship that has now lasted 12 years.

Since that initial meeting, Dr. Azar has repeatedly given generously of his time, his contacts, his wisdom, and his concern for me. When I visited him at the Massachusetts Eye and Ear Infirmary in Boston, he introduced me to all of his family, his business associates, and many of his friends from both near and far. He opened his home to me, made introductions that led to research opportunities for me, and repeatedly gave me high recommendations. What really struck me while in Boston was the realization that the workday does not necessarily stop when you shut the office door, turn off your laptop, or go out to dinner.

Dr. Azar’s positive, lighthearted humor—always embellished by his trademark bow tie—makes him endearing. He is one of the brightest people I have ever met, and, at the same time, he remains down-to-earth and approachable. One remarkable trait of his ability as a mentor is that he can take any idea or project to a higher level. Further, instead of imposing his views, he would rather plant a seed and have you reach the appropriate conclusion on your own.

I honor my longtime mentor and friend Dr. Azar with this tribute to his influence and support in my life, and I thank him for his contributions to the success I have enjoyed. I sincerely hope that we remain connected for many years to come.

Damien Gatinel, MD, is an Assistant Professor and Head of the Anterior Segment and Refractive Surgery Department at the Rothschild Ophthalmology Foundation, Paris. Dr. Gatinel is a member of the CRST Europe Editorial Board. He may be reached at tel: +33 1 48 03 64 82; e-mail: gatinel@gmail.com.

The Father of Excimer Laser Surgery

Ronald R. Krueger, MD

I started my education at Rutgers University College of Engineering. Because of my love for science and my fascination with lasers, I chose electrical engineering as a career. As a college senior, however, I took an elective in bioengineering, which inspired me to make a career change. After completing a report on the use of lasers in eye surgery, I decided to pursue medicine—ophthalmology specifically— so that I could use lasers and technology to help people. I spent 1 year at the University of Washington, where I earned my Master of Science in Engineering while conducting research in laser surgery. With the idea of pursuing CO2 laser radial keratotomy, I began medical school in New Jersey in 1983.

In 1982, Stephen L. Trokel, MD, a Professor of Ophthalmology at Columbia University in New York with a background in engineering and physics, was impressed by the recent finding that the Nd:YAG laser could be used to precisely cut through the posterior capsule after cataract surgery. This motivated him to experiment with different lasers to reshape the cornea with the hope of correcting refractive errors. Previously, in 1981, John Taboada, MS, described the effects of the 193-nm argon fluoride (ArF) excimer laser on ocular tissue. He noted that the laser could imprint an indentation in corneal epithelium, but this would fill in 1 hour later.¹ This observation suggested to Dr.Trokel that tissue was being removed without collateral damage, prompting him to undertake further study.

In 1983, Dr. Trokel was introduced to Rangaswamy Srinivasan, PhD, a photochemist using the 193-nm ArF excimer laser to etch microprocessors at IBM. Dr. Srinivasan demonstrated to Dr. Trokel how the excimer laser could precisely remove organic tissue without producing collateral thermal damage in a human hair (Figure 6), and Dr. Trokel proceeded to experiment with animal corneas in Dr. Srinivasan’s laboratory. This work led to a seminal 1983 paper describing experiments on enucleated calf corneas and suggesting the use of the excimer laser for refractive corneal surgery.² Dr. Trokel then leased an excimer laser from Lambda Physik and commenced the first animal experiments at Columbia University in the fall of 1983.

It was in this year that I first heard of the new so-called cold excimer laser being used in New York. My interest piqued, I contacted Dr. Trokel, and together we conducted bovine eye experiments to refine the excimer laser technology. From 1983 to 1985, we worked to determine the ablation threshold³ and optimal ablation rate⁴ for the excimer and to demonstrate the presence or lack of thermal tissue damage at certain wavelengths and fluences (Figure 7).

Dr. Trokel and I also treated rabbit corneas with large-area circular ablations at the suggestion of optical engineer Charles Munnerlyn, PhD. At the time, removing tissue from the optical center of the cornea was controversial because of concerns about scarring. However, the sculpting potential of the excimer laser was quickly realized. The laser was capable of removing large areas or graded circular disks of tissue in both rabbit and primate eyes, where healing took place without leaving a central scar (Figure 8).^5,6 This was practically applied in the first excimer laser phototherapeutic keratectomy procedure at Columbia University, in which fungal keratitis was successfully removed from rabbit eyes using the laser.⁷

Over the past quarter-century, the development of the subspecialty of refractive surgery has followed a fast-paced and exciting course thanks to Dr. Trokel’s pioneering work and the subsequent contributions of numerous other researchers.⁸ Millions of patients have benefitted from his recognition of the excimer laser’s potential for use in corneal refractive surgery.

Dr. Trokel brought engineering and ophthalmology together for me and was truly a foundational mentor. In 1998, when I had the opportunity to become a mentor to others at the Cole Eye Institute, I kept in mind what I had learned from Dr. Trokel: Become a mentor and father figure in the life of a young student, and he or she will follow in your footsteps.

In 2008, at the ASCRS meeting, I had the honor of inducting Dr. Trokel into the ASCRS Ophthalmology Hall of Fame for his contribution of bringing excimer laser refractive surgery to the field of ophthalmology (Figure 9). Being a mentor can lead to the development of a rich and lifelong relationship that can be an inspiration to all those around you.

Ronald R. Krueger, MD, is Medical Director of the Department of Refractive Surgery, Cole Eye Institute, Cleveland Clinic Foundation. Dr. Krueger is a member of the CRST Europe Global Advisory Board. He may be reached at tel: +1 216 444 8158; e-mail: krueger@ccf.org.

1. Taboada J, Archibald CJ. An extreme sensitivity in the corneal epithelium to far UV ArF excimer laser pulses. Proceedings of the Scientific Program of the Aerospace Medical Association; May 4, 1981; San Antonio, Texas.
2. Trokel SL, Srinivasan R, Braren B. Excimer laser surgery of the cornea. Am J Ophthalmol. 1983;96(6):710-715.
3. Krueger RR, Trokel SL, Schubert HD: Interaction of ultraviolet laser light with the cornea. Invest Ophthalmol Vis Sci. 1985;26:1455-1464.
4. Krueger RR, Trokel SL. Quantitation of corneal ablation by ultraviolet laser light. Arch Ophthalmol. 1985;103:1741-1742.
5. Marshall J, Trokel S, Rothery S, Krueger R. Photoablative reprofiling of the cornea using an excimer laser: photorefractive keratectomy. Lasers Ophthalmol.1986;1:21-48.
6. Marshall J, Trokel SL, Rothery S, Krueger R. Long-term healing of the central cornea after photorefractive keratectomy for myopia. Ophthalmology. 1988;95:1411-1421.
7. Serdarevic O, Darrell RW, Krueger RR, Trokel SL. Excimer laser therapy for experimental candida keratitis. Am J Ophthalmol. 1985;99:534-538.
8. Krueger RR, Rabinowitz Y, Binder PS. The 25th anniversary of excimer lasers in refractive surgery: historical review. J Refract Surg. 2010;26(10):749-759.

An Instrumental Surgeon— In Italy and Beyond

Matteo Piovella, MD

Lucio Buratto, MD (Figure 10), is one of a small circle of ophthalmologists and scholars who were friends of Charles D. Kelman, MD, the father of modern cataract surgery. However, Dr. Buratto himself has also made a fundamental contribution to the evolution of cataract surgery.

As a young doctor, Dr. Buratto left the hospital where he was employed to dedicate his entire life to and inject all of his energy and enthusiasm into this challenging area of medicine. The enterprise—the development of phacoemulsification and IOLs—was extremely demanding, and he and others encountered considerable opposition from the ophthalmic establishment. These were difficult years of heated debate and controversial discussions regarding the advantages and disadvantages of the new methods and techniques, and Dr. Buratto was labeled a heretic by some members of the academic ophthalmic world; however, he eventually became Italy’s most important reference point for modern cataract surgery.

The surgical techniques Dr. Buratto developed were rapidly appreciated and in great demand, and he operated on many members of the Italian parliament. However, he always remained true to his ethical and surgical principles, as he refused to comply with the then-prime minister’s request to be operated on bilaterally in the same session.

Over the years, Dr. Buratto spent long periods in the operating room every day, Sundays included. His passion for surgery also drove him to innovate in the field of refractive surgery. He was an early adopter of the keratomileusis technique developed by Joaquin Barraquer, MD, and, at a later stage, together with Ioannis Pallikaris, MD, he came to hold the joint honor of inventing the LASIK technique.

Dr. Buratto is undoubtedly a man of great genius, and this is coupled with an intrinsically complex personality that is sometimes difficult to understand for those who cannot fully appreciate his best qualities. I met this influential surgeon at Videocataratta, the international live surgery meeting that he conceived and directed for 30 years. Over the years, he has made significant contributions to the diffusion of modern cataract surgery in Italy and abroad, with the remarkable result that today’s advanced cataract surgery techniques are practiced successfully across Italy.

Observing him at work and appreciating his skills in live surgery inspired my confidence to attempt to emulate his approach, which, at that time, was misunderstood by many ophthalmologists. For several years, only Dr. Buratto, I, and two other surgeons were successfully implanting IOLs in Milan. Together, we founded the Associazione Italiana Facoemulsificazione (Italian Association of Phacoemulsification; AIF); for 10 years, Dr. Buratto was the president and I was the secretary. This association was a turning point in the diffusion and ongoing evolution of cataract surgery in Italy.

In 1998, Dr. Buratto supported my candidacy for secretariat of the Società Oftalmologica Italiana (Italian Society of Ophthalmology; SOI), for which I am currently serving as president. Our paths separated at a certain point—although our respect for each other remained unchanged—but we met professionally some time later, thanks to the pursuit of our common objectives.

Dr. Buratto has written or contributed to dozens of books, atlases, and monographs; he embraced the role of publishing editor and works tirelessly on Italian and English publications. In his spare time, he has also written cookbooks to promote proper nutrition to protect sight.

It would be almost impossible to comprehensively describe Dr. Buratto’s many merits and achievements, his extraordinary professional skills, his inventive contributions,and his international recognition and prestigious awards— more than most practicing ophthalmologists could ever hope to receive.

Finally, I wish to highlight how Dr. Buratto has been able to exemplify the qualities for which Italians are appreciated all over the world: intelligence, skill, cleverness, and imagination, to mention a few. He is a prince of the ophthalmic world and an ambassador for our beautiful country, reflecting all of the qualities described by the Italian diplomat, historian, and politician Niccolò Machiavelli in his book Il Principe (The Prince).

Thanks, Lucio.

Matteo Piovella, MD, is President of the Italian Ophthalmological Society and Medical Director of the Centro di Microchirurgia Ambulatoriale, Monza, Italy. Dr. Piovella is a member of the CRST Europe Editorial Board. He may be reached at tel: +39 039 389 498; e-mail: piovella@piovella. com.

A Lesson in Precision

Magda Rau, MD

One of my most important mentors in ophthalmology is Dieter G. Dausch, MD, PhD (Figure 11). I worked with him in his practice and eye clinic in Amberg, Germany, and later at a laser eye clinic in Nuremberg, Germany. Dr. Dausch taught me to be precise with my diagnosis: Any visual acuity less than 20/20 must be explained and documented.

Dr. Dausch knew many ophthalmic syndromes by heart, and, whenever he was stumped, we would search his comprehensive ophthalmology library after work, often until 10 pm. Dr. Dausch was enthusiastic when searching through the textbooks. Office hours would start at 7 am, and I was living in another town 20 km away. During these evening sessions, whenever I announced that I had to drive home to rest, he always answered reproachfully, “Just when it’s really good, you have to leave.”

Along with Thomas Neuhann, MD, Dr. Dausch was the first ophthalmologist in the Bavaria region of Germany to perform phacoemulsification. He was a gifted, exact, and precise surgeon. He always treated tissue gently, and he preferred elegant methods and shunned more invasive ones. I learned much from him and have adopted his attitudes of precision and elegance.

Dr. Dausch was a pioneer in refractive surgery, specifically PRK. He developed and was the first surgeon in the world to perform hyperopic excimer laser ablation. I was involved in the circle of surgeons who first performed hyperopic PRK and topography-guided excimer laser treatment.

Dr. Dausch was never in favor of LASIK. When Massimo Camellin, MD, gave the first presentation about LASEK at the ASCRS meeting in New Orleans in 1999, Dr. Dausch and I were both sitting in the first row; immediately after arriving home, we bought the appropriate instruments and began to do LASEK in Nuremberg. Dr. Dausch’s preference for LASEK continues to influence my surgical choices, as today I seldom perform LASIK, preferring instead the advantages of LASEK’s superficial ablation or my own modification, LASEK viscodissection.

Dr. Dausch introduced me to scientific work and taught me how to write presentations and how to publish. He helped me with my first international presentation, and we have also been coauthors. For example, we published our results with implantation of intrastromal corneal rings in cataract and refractive surgery.¹

Through this professional relationship, our friendship developed, and to this day, when I am ill, Dr. Dausch and his wife are supportive.

My other mentor, who taught me outpatient cataract and glaucoma surgery, is Oded Ben Chain, MD. He came to Germany from Tel Aviv and trained my team and me in outpatient cataract surgery in 1992. Dr. Chain was a great teacher, and with his help, we were one of the first centers in Germany to perform outpatient cataract surgery.

Magda Rau, MD, is the Head of the Augenklinik Cham and Refractive Privatklinik- Dr. Rau, Cham, Germany, and Eye Centre Prag, Czech Republic and a Visiting Professor at the Bulgarian-American Eye Institute ProLight. Dr. Rau is a member of the CRST Europe Editorial Board. She may be reached at tel: +49 9971 861076; e-mail: info@augenklinik-cham.de.

1. Rau M, Dausch D. Intrastromal corneal ring implantation for the correction of myopia: 12-month follow-up. J Cataract Refract Surg. 2003;29(2):322-328.