5 Questions 5 Questions With James C. Tsai, MD, MBA Dr. Tsai reflects on his research interests in neuroprotection, visual function, and glaucoma surgery as well as the benefits of a liberal arts education to exploring these topics.
What led to your glaucoma fellow- Fast Facts ship at Moorfields Eye Hospital in London? • Robert R. Young professor of ophthalmology and visu- During my residency at Doheny al science, chair of the Department of Ophthalmology Eye Institute and my fellowship at and Visual Science at the Yale University School of Bascom Palmer Eye Institute, I came to Medicine, and director of the Yale Eye Center in New recognize the value of learning from Haven, Connecticut, 2006 to present outstanding clinicians, especially with regard to taking • Chief of ophthalmology at Yale-New Haven Hospital, care of patients with a chronic disease that is difficult 2006 to present to manage like glaucoma. I decided what would most • Chair of the Advocacy and Governmental Relations benefit my future patients would be for me to obtain Subcommittee, Patient Care Committee for the the best possible training from exceptional academic American Glaucoma Society, 2011 to present physicians worldwide. To my knowledge, Moorfields is • President of the New York Glaucoma Society, the oldest eye hospital in the world, and some of their 2011 to present; elected member of the American approaches to managing glaucoma were quite differ- Ophthalmological Society, New York Ophthalmological ent from what I had learned at Doheny and Bascom Society, and American Eye Study Club Palmer. I became a better clinician from my exposure • Secretary for English Language Region for the Pan to that diversity of opinion. I had many great mentors American Association of Ophthalmology, 2011 at Moorfields, but Professors Roger Hitchings and Peng to present Khaw particularly stand out. I formed a lot of friend- • Chair of the Glaucoma Subcommittee for the National ships during my time at Moorfields; it was a wonderful Eye Health Education Program of the National opportunity to gain a European perspective and to Institutes of Health, 2010 to present enhance my global passion for ophthalmic education • Chair of the Global Ophthalmic News & Education and training. Network Advisory Board of the American Academy of Ophthalmology, 2008 to present The search for neuroprotection in glaucoma has • Past president (2011-present) and president (2008- been fraught with disappointment. What is need- 2010) of the Chinese American Ophthalmological ed before neuroprotection can become a part of Society clinical practice? • Chairman of the Medical Advisory Board of The This pursuit is going to be a difficult road, but our Glaucoma Foundation, 2006 to present patients are asking us to travel it. Now that we know • Former member of the Medicare Evidence that elevated IOP is not the only cause of glaucoma, Development Coverage Advisory Committee we need to investigate what kinds of therapy would be (MEDCAC) of the Centers for Medicare & Medicaid effective for our patients in whom IOP is not the major Services, 2008 to 2010 causative risk factor. That is why the scientific field is • Past Consultant to Ophthalmic Devices Panel of the interested in neuroprotection, neuroenhancement, and Food and Drug Administration, 2001 to 2008 neuroregeneration. • Associate examiner of the American Board of In 2001, Stephen Strittmatter, MD, PhD, a neurolo- Ophthalmology, 1999 to present gist at Yale School of Medicine, identified a receptor- • Recipient of the American Academy of mediating Nogo inhibition of axonal regeneration in Ophthalmology’s Senior Achievement Award (2009) the central nervous system.1 Since my arrival at Yale in and Visionary Award from Fight for Sight, Inc. (2007) 2006, Dr. Strittmatter and I have been collaborating on
58 glaucoma today may/june 2012 5 Questions
research projects to investigate the effects of inhibition first author of the recent publications from the Ahmed of the Nogo receptor in promoting neuroenhancement Versus Baerveldt (AVB) Study. (Ike Ahmed, MD, at the in glaucoma. Previously, my laboratory confirmed the University of Toronto is the lead principal investiga- neuroprotective effects of cytokines such as erythro- tor.) At Yale, every medical student must complete a poietin. Given the apparent success of erythropoietin thesis to graduate, and Panos approached me about in animal models of glaucoma, we are undertaking new serving as his thesis advisor. I have enjoyed my role as a experiments to study the neuroprotective and neuro- consultant to this international surgical trial as well as regenerative properties of novel anti-Nogo receptor- as a mentor for this talented and exceptional medical blocking compounds. student who was recently matched at the University of The amount of noise and variation with standard Toronto for his residency in ophthalmology. automated perimetry has required clinical trials of The Tube Versus Trabeculectomy (TVT) Study, the neuroprotective drugs to be planned for 3 to 5 years Ahmed Versus Baerveldt Comparison (ABC) Study, and to reach an observable outcome. For neuroprotec- the AVB Study are familiarizing surgeons worldwide tion to become a part of clinical practice, researchers with the indications for, effectiveness of, and unique must find a means by which to shorten the duration complications of glaucoma drainage devices. This of these clinical trials, thereby making it more attrac- research has provided glaucoma surgeons with greater tive for industry to pursue the clinical development of insight into how to individualize their glaucoma surgi- neuroprotective agents. A key to this effort will be for cal procedures to achieve the best outcomes for their the academic glaucoma community to develop new patients. As a result of these studies, I believe that sur- visual function technologies (other than standard auto- geons will have a greater interest in using these aque- mated visual field testing) to characterize and confirm ous drainage devices. disease progression. That is why my collaborators and I have explored the efficacy of the isolated check visual You recently became a member of the Board of evoked potential (VEP) for this purpose. Trustees at Amherst College. What do you hope to achieve? How does the testing of VEP fit into the develop- Amherst has been one of the major influences in ment of neuroprotective drugs? my life, and it provided me with a strong liberal arts Currently, the majority of our clinical studies have background in science. While there, I majored in neuro not looked at whether we are preserving visual func- science, which entailed my taking courses in the social tion in glaucoma. All they have assessed is whether sciences, mathematics, and the humanities in addition to there has been a reduction in IOP in patients with the traditional sciences. glaucoma. These are very different measures. In the As a member of Amherst’s Board of Trustees, I have latter, lowering IOP only decreases a validated risk supported the college’s efforts to build a new, state- factor for the development and progression of glau- of-the-art science center. I hope to help the college in coma. Because a significant number of neuroprotective promoting global academic excellence and the utility agents are unlikely to lower IOP, we cannot rely on of an undergraduate liberal arts education for scientists, this outcome to demonstrate their potential efficacy. engineers, and physicians. In my opinion, for medical care It is my hope that isolated check VEP technology will to be successful, we must treat the whole person and provide information on visual function in addition not just his or her disease. The liberal arts can teach us to data obtained with more conventional visual field a lot about humanity and suffering. Its broad education testing. Although I do not anticipate that testing with will allow us as physicians to connect better with our VEPs will become a standard component of glaucoma patients and individualize their therapy. management in the near future, I do believe that it will Given the challenges inherent in practicing medicine become a valuable research tool in the study of neuro- today, I have to remind myself daily what an incredible protective agents. privilege it is to be a physician. Patients respect and value our clinical judgments, and we clinicians are in a unique How did you become involved in current research position to make a difference in their lives. There are on glaucoma drainage devices, and what impact few professions where, everyday, one can see the direct will these studies have on surgeons’ use of this impact of one’s knowledge, hard work, skill, integrity, and treatment modality? compassion. n
I have been honored to serve as the thesis advisor to 1. Fournier AE, GrandPre T, Strittmatter SM. Identification of a receptor mediating Nogo-66 inhibition of axonal Panos Christakis, a Yale medical student who was the regeneration. Nature. 2001;409(6818):341-346.
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