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Vision Quest

In 1966, Lyndon Johnson was president, it cost 5 cents to mail a letter, Star Trek hit the airwaves and the Jules Stein Eye Institute opened its doors for the first time. Like the nation, the Jules Stein Eye Institute (JSEI) has undergone countless changes in the four decades since its birth on the campus of UCLA. Yet, under the steady leadership of just two directors in all that time—Dr. Bradley R. Straatsma and Dr. Bartly J. Mondino—the Institute’s core research, teaching and patient-care mission has remained remarkably stable: to preserve sight and prevent blindness. “We know that it’s much better to prevent a problem than to try to treat it,” says Dr. Straatsma. “That certainly is true with something as marvelously constructed as the eye.” Dr. Straatsma was the founding director of JSEI. He headed the Institute for 28 years, and remains on the faculty as professor emeritus of ophthalmology. Dr. Mondino is the current director. He joined the Institute in 1982, and became its director in 1994. UCLA Medicine spoke with Drs. Straatsma and Mondino about JSEI’s challenges, accomplishments and future.

What was the origin of the Jules Stein Eye Institute?

Dr. STRAATSMA: In the 1960s, UCLA was a growing institution with quality leadership and a receptiveness to new ideas that was extraordinary and represented a great opportunity. And we had the good fortune of attracting the interest of the philanthropist Dr. Jules Stein and his wife, Doris, and through them, many of their friends and associates. Dr. Stein was a musician who was also professionally trained in ophthalmology. He founded a company that became one of the giants of the entertainment industry: MCA. He remained committed to the preservation of vision, and in 1960 started a non-profit called Research to Prevent Blindness, which continues to provide research grants to ophthalmology departments and research institutes across the United States. After launching that endeavor, he was receptive to spearheading a specific program to be located here at UCLA.
The faculty developed a plan [for a research, teaching and patient-care institute], the university endorsed it and provided its full support, and it was made possible by enlightened philanthropy.

What challenges did you face when you took on the role of director?

DR. STRAATSMA: The challenge 40 years ago was to anticipate what the needs would be for ophthalmology and vision science in the years ahead. It was important to look ahead and to recognize that the advances in eye care were going to come from basic science, from translational science, from technology and from carefully conducted clinical studies.

DR. MONDINO: For me, the challenge when I became director was to maintain the Institute’s high levels of excellence in terms of its three missions of research, education and patient care. And, of course, I hoped to enhance those levels.

What were the most common eye problems when you assumed leadership of Jules Stein? How has treatment changed since?

DR. STRAATSMA: Cataract probably was the most common problem then, as it is now. When the Institute opened in 1966, cataract patients underwent a surgical procedure, which was followed by several days in the hospital. Thereafter, they were required to wear either very thick glasses that distorted the visual field or contact lenses that required constant insertion, removal and care. Today, cataract surgery is generally an outpatient procedure, and often it is combined with insertion of an intraocular lens that is multi-focal, so that individuals recover not only distance vision but also the ability to see objects that are close without the need to wear glasses or with minimal dependence on glasses. It’s a tremendous difference.

DR. MONDINO: Many of the common conditions we see now are similar to those of the past, though some issues have risen in prominence over the decades. The first report of eye complications of AIDS, for example, came from JSEI in the 1980s.
Also, shortly after I arrived here, Dr. Barry Weissman and I published our studies showing that extended-wear soft contact lenses were associated with a dramatic increase in corneal ulcers and infections. We then participated in a very large national study, published in the New England Journal of Medicine, which confirmed our results and ended this epidemic.
Glaucoma also is a condition that remains common today. Our Glaucoma Division has been working with methods of imaging the optic nerve and the retinal nerve fiber layer that lead to earlier detection of glaucoma and enable the specialist to follow it better.

DR. STRAATSMA: Another area that’s changed greatly has been the management of diabetic retinopathy. Forty years ago, diabetic retinopathy often led to blindness. Studies in which UCLA participated have made it possible to now preserve vision in more than 95 percent of the patients with proliferative diabetic retinopathy, and to offer additional assistance to people who have diabetic macular edema or macular disease.

What have been some significant research milestones accomplished at Jules Stein?

DR. STRAATSMA: The scientific discovery that really brought national and international recognition to the Jules Stein Eye Institute was the work of Drs. Richard Young and Dean Bok in the 1960s. Their discovery of photoreceptor renewal led to a flurry of scientific work at literally hundreds of laboratories around the world.
Dr. Joseph Demer’s translational work with children showed how muscles and pulleys within the orbit determine how we move our eyes left, right, and up and down. If a child has esotropia (crossed eyes), for example, we can now use computer modeling to determine which muscles to move, and how much to move them. Being able to simulate the surgical procedure before we perform it is a huge advance.
Also noteworthy in translational research is the work of Dr. Gabriel Travis, which determined that a formof childhood blindness is caused by a defect in one of the critical enzymes that permits a chemical transformation. Clinical trials are beginning this year.

DR. MONDINO: Dr. Robert Goldberg, chief of Ocular Plastics, and others in his division, have developed new ways to access the orbit. Thanks to their work, we no longer require a massively invasive approach that involves sawing bones in order to reach tumors, vascular malformations and other lesions located behind the eye.

DR. STRAATSMA: In clinical research, I would also mention the collaborative ocular melanoma study, which demonstrated the efficacy of radiation treatment for intraocular melanoma. I was co-chairman of this study, which was conducted at 43 centers in this country and Canada. We showed statistically that for most patients, it was just as effective to treat with radiation as it was to remove the eye. This changed the treatment of this disease around the world.
Additional basic research at JSEI includes that of Dr. Wayne Hubbell, whose work in proteomics — the critical study of the way proteins change shape to initiate chemical reactions and control chemical reactions — is an important addition to our scientific armamentaria.

DR. MONDINO: I don’t think proteomics has progressed anywhere in ophthalmology to the degree that it has here at UCLA. Dr. Hubbell was just inducted into the National Academy of Sciences last year. So he really leads this effort. dr. straatsma: Altogether, dozens of basic-science studies and more than 50 ongoing clinical trials are taking place within the Institute, so it is really a very exciting place, and it is positioned well for the future.

What other areas show promise?

DR. STRAATSMA: There has been a cascade of new clinical applications, and two things seem to be driving this. One is molecular intervention. For example, we are now injecting a number of materials into the eye that are specifically designed to control molecular processes. Secondly, technology is driving advances. An example would be the changes in cataract surgery we talked about earlier. Now we can remove the opaque lens, which is what a cataract is, through a small incision, and place an intraocular lens implant through the same small incision. While 40 years ago, we might have made an incision 11 or 12 millimeters in length, we now make an incision that may be only about 2 millimeters in length.

DR.MONDINO: The cataract center is certainly an exciting area. Dr. Kevin Miller heads the clinical aspect. We also have a research arm, where Dr. Joseph Horwitz works on the biochemistry of cataract. He’s a leader in that field in the United States.
Ocular inflammation has always done very well here, and we’re expanding that area. Dr. Gary Holland is the director of the Ocular Inflammatory Disease Center and will continue efforts there in corneal inflammation and uveitis.
Our clinical trials for macular degeneration are ongoing in the Retina Division, directed by Dr. Steven Schwartz. That’s very exciting work, and our retina specialists are in the forefront. In addition, we just recruited Dr. Michael Gorin from the University of Pittsburgh. He has done some very important work on the genetics of macular degeneration and will continue that work here at UCLA. The Institute has been very involved in the treatment and patho-physiology of macular degeneration, but now we’ve got someone who’s doing landmark genetic work in that area, and I think this kind of a program will synergize with many of our other activities.

We have talked about research and treatment. Let’s discuss Jules Stein’s educational mission.

DR. STRAATSMA: All of the UCLA medical students during the past 40 years have experienced training in ophthalmology with the Department of Ophthalmology and the Eye Institute working as a unit. We’ve had several hundred of the best and brightest come here as ophthalmology residents for their specialty training. A special part of the residency is the Eye-STAR program, which is for those residents who anticipate entering an academic career and want special training in advanced research.

DR. MONDINO: In addition to our own UCLA medical students and ophthalmology residents, we’re involved in the education of ophthalmology fellows who come to us for training from throughout the United States and abroad. Our international fellows then return to their home regions to become leaders in the field. We also teach community ophthalmologists who attend our grand rounds and our courses, and who depend on us for their continuing education. And our faculty teach everywhere, from senior centers to local hospitals to national and international meetings. Education is one of our primary missions, and we take it very seriously.

How does Jules Stein connect with the community?

DR. MONDINO: Our outreach is very extensive. Our Mobile Eye Clinic, for example, travels into the community to examine and screen underserved children, adults and elderly for conditions that require a referral. Physicians and Mobile Eye Clinic evaluate about 5,000 patients each year, free of charge.
Our volunteers provide vision screenings at local preschools and give educational presentations about the eye at community elementary schools. Our residents, fellows and physicians staff Olive ViewMedicalCenter,Harbor- UCLA Medical Center and the Wadsworth and Sepulveda Veteran’s Administration hospitals.
In addition, we have a philanthropic program, funded by the Annenberg Foundation and other donors, to help indigent adults and children obtain eye-care services here at the Jules Stein Eye Institute. These are people with difficult problems that can best be treated with the technology and expertise available at the Institute.

What’s ahead for Jules Stein?

DR. STRAATSMA: Next year we hope to begin construction of the Edie and Lew Wasserman Eye Research Center at UCLA, a 100,000-square-foot addition to our visionscience campus. The center will enable us to create new facilities for ophthalmic surgery and molecular-genetic intervention. It will permit an expansion of our basicresearch areas into new fields. Some of the fields that we’re investigating today in neurobiology and molecular sciences weren’t even conceived of 10 years ago. So we need to provide programs for those areas.

DR. MONDINO: The Wasserman Center will enable us to expand our existing faculty and programs, and to create revolutionary new programs that will dramatically change the way we diagnose, treat and even cure eye diseases.

What do you think your successors will be talking about 40 years from now?

DR. MONDINO: I think they’re going to have the joy and excitement of seeing a lot of this research come to fruition in terms of specific therapies. They’re going to have the pleasure and excitement of seeing the first gene-therapy surgeries done here at UCLA.
Just as I’ve had the excitement of seeing things develop that weren’t around 30, 20 or 10 years ago, they’re going to have the pleasure and excitement of seeing the fruition of many of the areas we’re working on now.

_{Written by Nancy Sokoler Steiner, freelance writer in Los Angeles. She writes frequently on healthcare issues.
Photocomposite by John Lichtwardt}

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