DATE PREPARED: December, 2020
PART I: General Information
Licensure and Certification:
2007 AcrySof IQ TORIC LENS® Certified Surgeon
Hospital or Affiliated Institution Appointments:
Hospital and Health Care Organization Clinical Service Responsibilities:
Major Administrative Responsibilities:
Major Committee Assignments:
Community Service Related to Professional Work:
Awards and Honors:
Part II: Research, Teaching, and Clinical Contributions
A. Narrative report of Research, Teaching, and Clinical Contributions
As a clinical scientist, my entire academic career has focused on caring for patients, teaching
Medical students, Ophthalmology residents, and graduate students, as well conducting research based on my clinical observations. My passion is helping patients find treatments and relief from eye disease.
Since my work at Harvard Medical School, I have been in private practice and part of Johns Hopkins University Medicine with Suburban Hospital. Our busy clinical practice allows us to see thousands of patients each year to help those with their vision loss from cataract, glaucoma, pterygium, and retinal disease as well as help relieve discomfort and pain from conditions, such as ocular surface disease (from various causes including dry eye disease, post Lasik/PRK, previous isotretinoin use, Sjögren’s syndrome and other autoimmune disease, Stevens-Johnson syndrome, Graft Versus Host Disease).
Since my time at Harvard researching the angiogenesis-basis of facial and ocular rosacea, I have been focusing on diagnosing and treating patients with Dry Eye Disease, particularly children. We see many patients with dry eyes from meibomian gland dysfunction (MGD) primarily due to chronic, excessive-electronic-screen-viewing and chronic pain from ocular surface disease and MGD. We are looking for better treatment options for severe dry eye disease and hoping to find a cure for dry eyes using multiple tools, such as autologous serum, Platelet Rich Plasma (PRP), cord blood serum, and autologous-adipose derived stem cell implantation into atrophied meibomian glands according to an IRB approved protocol.
Prior to the use of stem cells, I noted that a patient’s platelet rich plasma also contained many growth factors and some concentration of a patient’s own stem cells. Two of my patients with severe Sjögrens syndrome were treated by inserting their own PRP into each of their meibomian glands. Surprisingly the atrophied meibomian glands noted prior to the procedure on meibography, appeared to “grow back” clearly on the post-procedure meibography.
Given the nature of autoimmune diseases, it is not clear how long this positive effect will last and whether stem cell injections into the meibomian glands present a possible cure for dry eyes or a better treatment option than what is currently available to patients.
Thus I have embarked on the study of autologous stem cell insertion and injections into the meibomian glands, lacrimal glands, and limbal stem cells of patients with or without added autologous platelet rich plasma. Our hypothesis is that stem cell injections will regenerate the patient’s cells involved in producing a stable, complete tear, which have been damaged by medications, autoimmune disease, aging, chemotherapy/radiation, chronic inflammation, and/or excessive screen time.
Additionally, I have performed hundreds of pterygium surgeries and have a very low recurrence rate and excellent cosmetic outcomes. I have published in this area and continue to do research to improve our cosmetic results with pterygium surgery. My research in meibomian gland disease has revealed that patients with a pterygium show greater meibomian gland loss in the corresponding meibomian glands. We plan to publish in this area to encourage patients to have the pterygium removed sooner to prevent chronic dry eye as any new growth on the eye is a source of inflammation for the crucial meibomian glands.
The narrative below represents the activities during my time at Harvard Medical School’s Department of Ophthalmology at the Massachusetts Eye and Ear Infirmary.
My research interests stem from a desire to improve the lives of my patients. One area of my research involves the use of surgical outcome tools to improve surgical results, improve residents’ ability to learn and perform surgery, and to improve our understanding, as well as our patients’ understanding, of preoperative surgical risk and how this relates to outcomes. The second area involves evaluating the role of angiogenesis in ocular rosacea, a chronic, often debilitating condition I see in many of my patients.
A. Harvard Medical School Residents in Ophthalmology Cataract-Surgery-Outcomes Study (HMS ROCS):
The first area of research I have been interested in since my arrival to the Massachusetts Eye and Ear Infirmary is in the area of epidemiological research of surgical teaching. When I was a resident, it was clear that there was no uniform method of assessing or improving surgical skills for residents. Upon my arrival to Harvard Medical School, I wanted to create a more objective tool to evaluate surgical skill and surgical bedside manners, and then use the data obtained to improve surgical teaching. In order to address this issue, I developed a protocol entitled the Harvard Medical School Residents in Ophthalmology Cataract Surgery outcomes study (HMS ROCS).
This protocol has three key goals. The first goal is to develop new surgical assessment tools to evaluate residents’ surgical competency. The second goal is to use these tools to assess the surgical outcomes of the residents on the service. The third goal is to improve the way we teach surgical skills to our residents and to improve our patients’ surgical outcomes.
Thus far we have achieved these goals in the following ways. First, my team developed two new surgical assessment tools called OASIS (Objective Assessment of Skills in Intraocular Surgery) and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) (published, Journal of Ophthalmology 2005). They have been nationally hailed as models for assessing residents’ surgical competency. Additionally, we developed a similar assessment tool for oculoplastic surgery presented at the American Academy of Ophthalmology meeting in October 2005 with Dr. Peter Rubin. We have also developed a specific tool for penetrating keratoplasty (OASIS-PK), for LASIK surgery, and for strabismus surgery (GRASS: Global Rating Assessment of Strabismus Surgery) presented at the 2006 annual AAO meeting.
Second, we have now created the largest surgical outcomes database of ophthalmology residents in the world. With over 3000 cases thus far, we have been able to evaluate patients’ short term and long term surgical outcomes. Third, we have been able to show the positive effect of this outcomes research on our overall surgical complication rates.
In 2004 at the national meeting of the Association of Cataract and Refractive Surgeons (ASCRS), we reported a statistically significant lower vitreous loss rate in resident-cases staffed by full time surgical attendings. This finding supported a decision in our own department to utilize only full time attending staff as surgical preceptors. Since this change, we found that our overall vitreous loss rate decreased by 31%. For our program, this represented a direct application of data analysis from this objective database. This presentation is also the first report demonstrating the use of an outcomes tool to improve residents’ surgical outcomes. This project will likely be a strong model for other surgical training programs around the world for improving residency training and patients’ surgical outcomes.
OASIS is now capturing attending surgeons’ surgical cases as well. As a consequence, we then began comparing surgical outcomes between residents and attendings. In order to do compare results fairly, we developed a surgical risk profile called RACS-Risk Assessment in Cataract Surgery which represents the first valid risk profile in cataract surgery (AAO meeting, Chicago, Il, Nov 2006). Now we are in the process of combining OASIS data with preoperative RACS scores to be able to compare surgical skill and outcomes equitably. RACS will be used to identify which cases a beginning resident can perform versus an experienced resident or can only be performed by an attending surgeon. Additionally, RACS can be used to provide pre-operative surgical counseling to cataract patients. A new project we have started attempts to prove the following hypothesis: surgical patients who are given their RACS score report higher patient satisfaction scores on a tool called PAST (Patient Assessment of Surgical Treatment- developed by our team), than those who are not instructed about their RACS score. If our hypothesis is true, it could mean a major change in how we consent surgical patients as well as identifying surgical risks and decreasing malpractice risks for entire surgical practices and residency programs.
In 2009, OASIS became a web-based system in effort to centralize reporting among various hospitals within the Harvard system. The long term goal of OASIS is to centralize reporting of all cataract surgery by ophthalmologists in the US and throughout the world.
There are numerous abstracts that have come from the OASIS database. Some of the highlights of OASIS projects are listed below:
1. Evaluating the incidence of Intraoperative Floppy Iris Syndrome (IFIS) in patients taking commonly prescribed alpha-1-receptor blockers for benign prostatic hypertrophy or urinary retention. These medications have been proven to increase surgical complication rates in cataract surgery if IFIS is not recognized early. We continue to evaluate our data in OASIS to see the effect of these medications on surgical outcomes. Initial findings presented at ARVO 2005.
2. Risk of Cystoid Macular Edema (CME) after cataract surgery. We recently submitted our paper entitled, “Clinical Pseudophakic Cystoid Macular Edema: Risk factors for Development and Duration after treatment,” to the Journal of Ophthalmology (September 2006). This is the first paper to our knowledge to show a statistically significant increase in CME risk in patients with a history of retinal vein occlusion, independent of other surgical factors. We also demonstrated the following: that treatment with NSAIDs alone or NSAIDs plus steroids was associated with a faster resolution of CME compared to steroids alone or no treatment; patients with known risk factors for CME (i.e., DM, intraoperative complications), when treated with postoperative prophylactic NSAIDs for at least 1-3 months, had no higher incidence of developing CME than non-high risk group.
3. Increased Intraocular Pressure on the First Postoperative Day Following Resident-Performed Cataract Surgery. Abstract presented ARVO Annual Meeting 2005. Paper submitted to Acta Ophthalmologica, June 2010 with co-authors Jae Yong Kim MD, PhD, Stacey C. Brauner, MD, Zandra Ferrufino-Ponce MD, Rasha Ali, MD, and Bonnie An Henderson, MD.
B. The Role of Angiogenesis in Rosacea and Ocular Rosacea
The area of research that has captivated my mind and heart is investigating the role of angiogenesis in rosacea and ocular rosacea. Currently no one has fully described this connection pathologically or clinically. Prior to his death, I had the honor of working with Dr. Judah Folkman in an effort to prove the central role of angiogenesis in the pathophysiology of ocular rosacea. Our hypothesis presents the possible connection between severe ocular rosacea and a patient’s internal angiogenic risk. I hypothesized that patients with severe ocular rosacea have a higher circulating angiogenic factor and risk profile that increases the risk of other conditions that rely on angiogenesis, such as wet macular degeneration, proliferative diabetic retinopathy (if they have diabetes), and certain internal cancers. Additionally I postulated that severe ocular rosacea is an external sign of high internal risk for many angiogenic-based diseases. Dr. Folkman presented a possible flip side to this hypothesis: namely the possibility that severe ocular rosacea is a sign of protection from other conditions that rely on angiogenesis, such as many cancers, since angiogenic factors are being “used up” in the facial area. We proposed a long term study to evaluate which hypothesis was correct.
This study has three phases. In the first phase, we developed a valid severity score criteria for ocular rosacea. Currently there are no published valid tools or systems for diagnosing ocular rosacea. Through the collaboration among 3 academic institutions (MEEI, NYEE, and Bascom Palmer), our tool called SCOR (Severity Criteria for Ocular Rosacea) is a new, innovative system for rating ocular rosacea severity. We initially presented SCOR at the American Academy of Ophthalmology Meeting in Nov. 2006. It is currently in review for publication.
In the second phase of the study, we evaluated eyelid margin and conjunctival biopsies of patients with severe ocular rosacea for levels of angiogenesis markers compared to controls with the help of Dr. Folkman and Dr. Martin Mihm of MGH. Additionally, we are evaluated for Vascular Endothelial Growth Factor (VEGF) levels in tear samples of our severe ocular rosacea patients. Our initial results demonstrated an increased level of VEGF and CD31 in patients with severe ocular rosacea. We hope to replicate these results and proceed to measure plasma endostatin, circulating endothelial cells, and circulating progenitor cells in patients with severe ocular rosacea for comparison to controls. Such research will be the first pathologic studies to fully investigate the role of angiogenesis in ocular rosacea.
The third phase of the study involves the prospective evaluation of patients with severe ocular rosacea. This phase involves collaboration with departments of dermatology, oncology, epidemiology, and biostatistics. We will report the incidence of cancer, wet macular degeneration, and proliferative diabetic retinopathy in this cohort of patients compared with controls. This is novel research for a condition which affects over 20 million Americans at a cost of over 2 billion per year. In the end, I hope to develop a better understanding of the pathophysiology of ocular rosacea and thus develop a cure.
In the teaching sphere, I taught residents and fellows the clinical and surgical aspects of ophthalmology in the office and in the operative room from 2000-2009 at Harvard Medical School. Most of our teaching sessions involve direct patient care and after hours chart reviews. The creation of the surgical evaluation tools OASIS (Objective Assessment of Skills in Intraocular Surgery) and GRASIS (Global Rating Assessment of Skills in Intraocular Surgery) helped my ability to teach residents key surgical skills and attributes they need to have for their patients. Before and after each surgical case, I review the OASIS form with the resident and provide formative feedback and constructive criticism. At the end of the surgical day, I review GRASIS with the resident to provide summative feedback. At the end of the rotation, we can provide more objective feedback to the resident in terms of surgical outcomes and GRASIS scores or trends.
I also lecture to the residents yearly on surgical techniques for cataract surgery at the Massachusetts Eye and Ear Infirmary and was a participant in the 1st Annual Harvard Medical School Intensive Cataract Course in 2005. Additionally, I participated in the intensive Lancaster Course Series in Colby College, Colby, Maine for ophthalmology residents from around the country. Finally, I have also been actively involved in teaching the Harvard Medical School students ophthalmology as part of an organized series of classes as well as during their rotation with me on our service. I have also hosted numerous international medical students and foreign ophthalmologists since 2000. Most recently, I helped establish a yearly fellowship at the Comprehensive Ophthalmology Service, and helped launch the careers of three physicians planning to go into ophthalmology (two) and oncology (one).
A final educational effort I continue to pursue is as a teacher to my patients. I have made a great effort to improve the explanation of their disease process and treatments for their diseases by creating informative literature and brochures. Additionally I have developed a more uniform method in the service of helping patients explain their symptoms, medical history, and concerns and thus help them communicate more effectively with their surgeon. I also give talks to patient groups about the function of the eye and its disease and have been involved in outside activities aimed at educating patients about preventable eye disease, such as the Governor’s Annual Conference on Aging. By empowering patients with information, I hope to help them decrease their risk for future eye diseases.
In the clinical realm, I am an eye surgeon who specializes in cataract and anterior segment surgery as well as refractive and glaucoma laser surgery with a particular research interest in Dry Eye Disease. I perform many laser, extraocular, and intraocular surgeries weekly, including state-of-the art cataract surgery, amniotic membrane transplantation, pterygium excisions, secondary sutured intraocular lens implantations, refractive intraocular lens implantations, refractive laser surgery and laser surgeries for glaucoma.
As a surgeon, I stay on the cutting edge of new state-of-the-art techniques and instruments, by continuously incorporating new skills into my clinical practice. I have incorporated the latest technology in my care of patients with cataracts and glaucoma. I am certified to use the femtosecond laser for cataract surgery and LASIK surgeries, as well as the iStent and Cypass for glaucoma surgery. By keeping on top of the latest innovations in ophthalmic surgery, I strive to provide all my patients the best care possible.
As patient education represents a large part of my daily activities in my clinical practice, I am a patient advocate and strongly believe patients should understand as much as possible about their eye condition. In addition to creating patient educational material as discussed above at Harvard, I believe my work in identifying surgical risks via the tool RACS, can help patients better understand their eye condition and surgical prognosis.
As of 2013, I have been working in private practice and continuing my research in outcomes and interest in dry eye treatments, particularly looking for a cure for dry eyes with autologous stem cell injections into meibomian glands, lacrimal glands, and limbal stem cells regions.
Specifically, in my dry eye research initiative, I have developed a protocol to begin injection of autologous stem cells for patients with severe dry eye.
In the area of cataract surgery, we are looking at the effects of femtosecond laser cataract surgery on visual recovery and long term endothelial cell damage. I have initiated an outcomes database of all the cataract surgeries and pterygium surgeries in our practice.
In the area of pterygium excisions, we are looking at key factors involved in recurrence and other complications, such as ptosis, dellen, and infection.
B. Narrative report of Research, Teaching, and Clinical Contributions at Visionary Eye Doctors
This narrative represents the activities during my time at Visionary Eye Doctors in Washington DC.
Research: My at Visionary Eye Doctors has focused on outcomes research in dry eye treatments, pterygium surgery and cataract surgery. We have published two papers in the area of pterygium surgery and have presented multiple papers at international conferences. I have a paper in review by the New England Journal of Medicine on our finding of Dry Eyes in Children with excessive electronic screen use.
With regards to my pterygium research: my key goal is to decrease recurrence rates in pterygium surgery and provide the best cosmetic outcomes for our patients.
In the area of cataract surgery, our outcomes research has been centered on how to best decrease total phaco energy used during cataract surgery to help protect inner cell structures of the eye (the endothelial cells).
Teaching: I have mentored our research fellow Jenny Ha and Carlos Pigotti since we started a research fellowship at Visionary Eye Doctors. Together we have enlisted the help of multiple residents and medical students at Georgetown Medical School and Hospital.
Clinical: hundreds of patients a month with a special interest in patients needing cataract surgery, pterygium surgery, and dry eye patients.
B. Funding Information
C. Report of Other (Non-Funded) Activities
D. Report of Teaching
1. Local contributions
Medical School Courses
Resident in Ophthalmology, Ivey Eye Institute, Department of Ophthalmology, University of Western Ontario
2. Regional, national, or international contributions
E. Report of Clinical Activities
Part III: Bibliography
Books, Monographs, and Textbooks