COMMENTARY

Drawn to Innovation? Then Set Your Sights on Ophthalmology

Charles C. Wykoff, MD, PhD

Disclosures

March 06, 2017

The Possibility of Restoring Sight

It is a privilege to care for people's eyes. Vision is incredibly important. Cover your eyes with your hands and imagine living in the dark, permanently. Certainly, many blind people lead happy, healthy, and productive lives, yet ones that are nonetheless very different from those that many of us take for granted on a daily basis.

For me, one of ophthalmology's most exciting aspects is the possibility of restoring sight, both in the future but also very much in the present. For example, excellent medical and surgical interventions are available today that in many circumstances can improve patients' visual function, such as cataract surgery, corneal transplantation, macular hole closure, and retinal detachment repair. There is impressive technology behind these and other interventions.

While all fields of ophthalmology have witnessed advances over the past decade, the evolution of treatments for retinal diseases has been truly extraordinary. At the beginning of 2011, there were no US Food and Drug Administration (FDA)–approved pharmaceuticals for the common retinal vascular diseases of diabetic macular edema and retinal venous occlusive disease. In 2017, we have four FDA-approved medications to treat diabetic macular edema, three to treat retinal venous occlusive disease, and two to treat age-related macular degeneration, the most common cause of blindness in most developed countries.

All of these medications are injected directly into the vitreous cavity through the sclera following local anesthesia in an office-based procedure. They fall into two categories: corticosteroids and antibody-derived medications that target a specific cytokine critical to many retinal diseases, vascular endothelial growth factor (VEGF). These medications have truly revolutionized retinal care delivery and patient prognoses. As evidence, since the introduction of the anti-VEGF class of pharmaceuticals to ophthalmology, the incidence of neovascular age-related macular degeneration–associated blindness in some developed countries has dropped by more than 50%.[1]

Surgical progress has also been remarkable over the past decade. For pathologies of the retina and vitreous that necessitate surgical intervention, the ease of gaining access to the posterior segment of the eye has progressed substantially. What once traditionally required multiple sutures and 20-gauge instrumentation can now often be done with sutureless approaches using 25- or 27-gauge equipment.

Fortunately for patients and the medical community, innovation in the retina space—and in all spaces within ophthalmology—continues to this day. Accordingly, research opportunities within ophthalmology, ranging from basic science to clinical trials and everything in between, are excellent and expanding.

Even in the face of remarkably effective current therapeutic approaches, the promises of the treatments of tomorrow are even more exciting. For example, building upon 20 years of work, gene therapy for retinal diseases appears to be closer than ever to reality. The approach most likely to be first to reach clinical application, gene-based therapy for RPE65-associated Leber congenial amaurosis (also known as LCA2), is under regulatory review in the United States, with an anticipated ruling in 2017. Equally stirring, multiple investigators around the world continue to push the envelope with stem-cell technologies for retinal diseases.

These pursuits offer the plausible reversal of blindness. Now just imagine being able to erase the word "permanent" from someone's blindness.

How I Chose Ophthalmology

Currently, accredited ophthalmology residencies are 3 years in length following a 1-year internship. Ophthalmology may seem like a small field, but there are at least six different potential fellowship tracks, ranging from 6 months to 2 years in length, including oculoplastics, neuro-ophthalmology, strabismus, glaucoma, cornea and refractive surgery, and retina. There are also multiple subspecialties within some of these pathways with their own focused fellowships; for example, in retina, options for further specialization include uveitis, oncology, pediatrics, and inherited retinal diseases.

As an undergraduate at the Massachusetts Institute of Technology, I knew I wanted to pursue a career in science. I enjoyed asking questions to which no one knew the answers. At first, this took the form of basic science. During my PhD years studying how human cells respond to hypoxia, I realized that I enjoyed patient interaction too much to remain solely a basic scientist. In medical school, I found that my scientific pursuits dovetailed well with the field of retina within ophthalmology. The role of the VEGF cytokine in retinal diseases was just being appreciated. The basic science pathways involved in the hypoxic signaling cascade that I had spent years studying now had clinical relevance.

 
Go where your heart is. Go where you want to be, not where your family or friends think you should be.
 

Since then, as a clinician-scientist, I have built a career in which I am a busy medical and surgical retina specialist while creating, designing, coordinating, and interpreting human clinical trials.

There are a multitude of opportunities within medicine. Most of us entered medical school unsure of our ultimate path. But I advise you to bring your past experiences to bear in choosing your field. Go where your heart is. Go where you want to be, not where your family or friends think you should be.

William Shakespeare summarized it well: "The eyes are the window to your soul." I agree, and it is an incredible privilege to help care for those windows.

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