Edward Gelber, M.D., F 75
Ed Gelber’s Reflections on a BPEI year.
For those fellows currently attempting to become fluent with the exponential expansion of the knowledge base in their sub-specialty, know that this has been the case for many years. As Doug Anderson’s second fellow in glaucoma, circa 1974, the changes to the field were exciting even in those Dark Ages. However, none of the advancements in medicine were more remarkable than the changes to the physical structure of the Institute itself. Imagine arriving for an interview and being shown through a double-wide house trailer which was the clinic! Of course my dismay and concern were instantly put to rest by meeting that day with Doctors Norton, Machemer, Glaser and Anderson.
Coming from a high surgical volume residency, when I arrived at the Institute I had probably done about the same number of cataract surgeries as had Doug. In contrast to my novice abilities, however, his meticulous attention to detail was immediately evident and personally transforming. I recall an early instance where upon concluding a case, removing the drape from above the head and pulling it forward across the surgical field, Doug advised me as to the proper manner of doing this. To this day, I think about that moment when I sit down and review the quality of the draping prior to beginning every case. During that year Doug and I would alternate at the head of the table (with the other assisting) no matter what the case. This was a wonderful vote of confidence for me but at the same time an indication of Doug’s ability to fix any of my misadventures.
The trabeculectomy procedure had only been developed several years earlier and we were involved with “tweaking” the technique with every case. In the absence of mitomycin C, all the fine tuning was met with failure far more often than in today’s surgical arena. As a result we became adept at every means of salvaging a failing bleb and we fought the fight down to the last cicatricial scar. As my practice grew in later years and I worked with new techniques such as Holmium laser sclerostomies (it came and went so don’t be upset if you never heard of it) along with more traditional surgery, I never failed to exhaust every means to maintain that bleb.
In those days we were performing much of the cataract surgery being done at the Institute at the time. As many of the glaucoma patients had cataracts and as the staff was small, we dealt with almost everything that came our way. Of course all the cataract surgeries were intracapsular extractions. One day Doug suggested that we visit the O.R. of Norman Jaffe at Miami Heart Institute to watch some intraocular lenses being implanted . Henry Clayman, David Light and Jaffe were among a handful of surgeons in the United States implanting IOL’s. Picture an intracapsular procedure during which one removes the entire cataract lens but not the vitreous, and, with the hyaloid face staring back at you, a Copeland lens is inserted under the iris and secured in place with Miochol. As there was no viscoelastic we gave a bolus of Osmoglyn to reduce the vitreous volume. Those were the days when good sphincters were essential . I don’t recall Doug or me placing any IOL’s but the experience of that day gave me the confidence to begin implanting IOL’s shortly after entering private practice. Having performed some 15,000 lens extractions and evolving my technique from intracapsular to planned extracapsular then to modern phaco techniques (first phaco in 1979) I have been on an exciting and stimulating adventure these past 35 years.
Speaking of lens extractions, you must remember that we were creating aphakes not pseudophakes. We were doing a visual field examination on these aphakes using a tangent screen or a manual Goldmann perimeter with the patient wearing a +14.00 diopter lens in the trial frame. The depression of the field made results often difficult to interpret. Doug and I worked on doing field testing with patients wearing RGP lenses which helped to reduce this artifact. It was during this year that automated perimetry became available which eliminated some of the misery associated with generating a meaningful field in an aphakic glaucoma patient and returned some sanity to the techs and at least one glaucoma fellow.
One of my research interests was the management of patients with chronic angle closure glaucoma. These were also the days prior to the advent of the Argon laser and an iridotomy was done as an intraocular procedure. We determined that various visual field criteria should be the deciding factor in selecting the surgical approach (iridotomy or trabeculectomy). The work we did developed into the article Surgical Decisions in Chronic Angle Closure Glaucoma. I was asked to discuss this paper at the ANGLE Meeting (Annual North American Glaucomologists Learning Ensemble), thirty or so international glaucoma enthusiasts who later formed the American Glaucoma Society. When the Argon laser entered the arena it was a welcome addition to the armamentarium and made this study a moot subject, but nevertheless a worthy intellectual pursuit.
In the area of therapeutics there were few options; pilocarpine, Diamox and Phospholine Iodide were the only drugs of choice. Red eyes and heartburn were the rule. I recall sitting at a BPEI (non-sanctioned) poker game on Key Biscayne one evening when the topic was brought up regarding whether the new beta blocker coming to market would have any impact on quality of care and whether an investment in Pfizer would be prudent.
The overarching impact on my practice of medicine has been that I learned to see detail when examining patients because I knew that Doug was next to look at them and on occasion, Dr. Norton would take a look.
While I planned to return to Virginia following my year at the Institute, my wife, Laura, who had transferred from law school there to U.M., asked me to remain in Miami since she had one more year to complete her studies. I enjoyed that time working locum tenens and resolving glaucoma problems in several offices around Miami. About mid-year Laura was invited into a postgraduate program and by then I had my tennis racquet and my Hobicat and I had come to enjoy living here. Now 35 years later two truths still abide: I will never get the sand of South Florida out of my shoes, and, Doctors Norton and Anderson walk into the exam rooms and the O.R. with me on every case.