Bartly J. Mondino, MDDirector, UCLA Stein Eye Institute | Chair, UCLA Department of Ophthalmology | Bradley R. Straatsma, M.D., Endowed Chair in Ophthalmology
Photography: Ann Johansson
On the occasion of the 50th anniversary of UCLA Stein Eye Institute, director Bartly J. Mondino, MD, reflects on the advances that have taken place in his specialty over the past half-century.
UCLA Stein Eye Institute, which recently celebrated its 50th anniversary, consistently is ranked among the top centers in the nation for the preservation of sight and prevention of blindness, as well as for its groundbreaking research, training program and outreach to the community locally and globally. The Stein Eye Institute’s surgical- and outpatient-treatment volume has grown more than tenfold since its opening. Bartly J. Mondino, MD, director of UCLA Stein Eye Institute, chairman of the UCLA Department of Ophthalmology and the Bradley R. Straatsma, M.D., Endowed Chair in Ophthalmology, spoke with U Magazine contributing writer Dan Gordon about the advances that have occurred in his field over the last 50 years and the impact UCLA Stein Eye Institute continues to have.
How different is the practice of ophthalmology today from when Stein Eye Institute opened its doors 50 years ago?
Dr. Bartly J. Mondino: Over the course of five decades, every aspect of our work here has been refined and redefined. We see developments almost every day: greater precision, smaller incisions, more detailed imagery, better ways to identify problems, new treatments for the previously untreatable. All of these elements are changing patient care for the better.
What are some of the best examples of these advances?
Dr. Mondino: Cataract surgery is a good example. It is the most common eye surgery. When I started in ophthalmology in the 1970s, large incisions were necessary, and techniques were in use that didn’t completely correct vision. Patients stayed for several days in the hospital, after which they still required very thick glasses or contact lenses. Fast forward to the present day, when cataract surgery is an outpatient procedure with a small incision, and the patient goes home with a lens inserted in the eye to correct vision. Instead of the inpatient operating rooms of the Jules Stein building, patients now go to an outpatient surgical center in the new Edie & Lew Wasserman Building, where we have six state-of-the-art operating rooms designed so that every procedure, from the simplest to the most complex, can be done as comfortably and conveniently as possible for patients. So, we’ve seen an evolution of cataract surgery from a long, intense process to a short, efficient, comfortable process.
We’ve also seen important advances in corneal surgery. What often leads to the need for surgery is that the cells in the back of the cornea aren’t functioning properly — they aren’t pumping fluid out. As a result, the whole cornea becomes thick and swollen, which affects vision. Today, in many cases, rather than replacing the entire central cornea, we have the option of replacing only the back layers, which means less chance of rejection, along with a smaller-size wound and less suturing. Another dramatic example is in macular degeneration, a leading cause of vision loss among older adults and previously untreatable. Now, with anti-VEGF therapy, we inject medications into the vitreous of the eye to prevent the growth of blood vessels that have the potential to rupture and cause vision loss. If there are blood vessels growing in the macula, you can use these intravitreal agents to suppress them and prevent the bleeding. At the Stein Eye Institute, we were part of the early clinical trials of these agents, some of which also are being used for diabetic retinopathy, which is a growing concern, given the epidemic of diabetes in our society.
What other conditions do you see more today than in the past?
Dr. Mondino: Age is the major risk factor for most of the conditions we see. So when you think about how much longer we’re living today than people lived 50 years ago, it’s not surprising that we’re seeing more cataracts, more macular degeneration and more glaucoma, which have been the three biggest causes of visual disability in the United States. We don’t think much about cataracts because they’re so easily treated now, but that would be a leading cause of blindness if left untreated. The conditions that are causing the most blindness now are glaucoma and macular degeneration. You spoke of the advances in treating macular degeneration. Where is the field with glaucoma? Dr. Mondino: Glaucoma continues to be treated using topical drops and drugs, and if that’s not successful, surgery is performed. Today, there are less extensive surgical treatments for glaucoma using smaller devices, which makes for a faster recovery, but, unfortunately, the vision outcomes are not significantly improved. So glaucoma still is a big challenge and a major research focus. In addition to controlling the intraocular pressure, there is an ongoing focus on finding agents that will protect cells in the retina so they don’t degenerate.
What advances will we be talking about in the near future? What are some of the areas of research that you are most excited about?
Dr. Mondino: One is the potential for using stem cells to replace the retinal pigment epithelium in the back of the eye, which is lost in macular degeneration. Just a couple of years ago, the first human embryonic stem cells were injected beneath the retina in our operating rooms. Another exciting area involves the use of gene therapy for patients with certain genetic conditions that are affecting the eye. There are studies looking at that now. And, finally, big data will enable researchers to look for patterns in databases with millions of patients as a way to get clues that can be used to try to solve some of the mysteries associated with certain conditions. There also is interest in the use of bioelectronic chips to restore retinal vision. So far, it’s only rudimentary vision, not any kind of detail, but with advances in the technology, this could be beneficial in the future. There also is an interest in robotic surgery. Our scientists here are looking at that, but so far, it doesn’t have a place in ophthalmology, given the delicacy of eye surgery.
How is the study and treatment of ophthalmic diseases different from research and treatment involving other parts of the body?
Dr. Mondino: The eye is one of the most sophisticated structures in nature. It captures and absorbs light, it pumps chemicals, it protects from infection. And when the protective parts of the eye — the lids, the tear film, the surface lining — break down, it can cause devastating infections. On the other hand, when it comes to treatment, there actually are a lot of advantages. You can see what you’re working on, unlike internal organs in the body. I can see the cornea, break all the layers down with the slit lamp, look into the eye with the ophthalmoscope and see the retina, the blood vessels, the nerves and the vitreous. Of course, the eye is very delicate and sensitive, so you don’t have room for error. And patients tend to be more nervous when it’s their eyes being treated as opposed to other parts of the body.
In December 2013, The UC Regents signed an affiliation agreement with Doheny Eye Institute that has led to the opening of three Doheny Eye Center UCLA locations — in Arcadia, Fountain Valley and Pasadena — along with UCLA Stein Eye Institute facilities in Westwood and Santa Monica. What is the significance of this agreement?
Dr. Mondino: This is an unprecedented affiliation in ophthalmology, combining the tremendous resources of both institutes with synergies in vision research and education. It expands UCLA’s footprint tremendously by providing patients with greater access to the top doctors from both institutes. We are the hub here in Westwood, but we also have integrated programs at Harbor-UCLA Medical Center, Olive View-UCLA Medical Center, the Greater Los Angeles VA Healthcare System at Sepulveda and West Los Angeles and our Stein Eye Center in Santa Monica. With these sites, plus the Mobile Eye Clinic and the Doheny Eye Center UCLA locations, we are reaching more people than ever before. It means we’re doing a lot more eye care for Los Angeles, whether it’s for those who can afford it or those who can’t. We’ve gone from performing approximately 1,800 surgical procedures in 1967 to 19,000 a year today. We did about 20,000 outpatient visits when Stein first opened; now it’s a quarter-million a year. Then there’s the research and the training for all the ophthalmologists of the future — the residents, as well as fellows, who come from all over the world to train here.
You alluded to doing eye care for those who are not able to afford it. Expand on that.
Dr. Mondino: Community outreach is one of our missions, along with research, education and patient care. The Mobile Eye Clinic, which the UCLA Stein Eye Institute has operated for more than 40 of its 50 years, travels to schools, senior centers, health fairs, homeless shelters and low-income community clinics to provide screening and care. To date, more than 300,000 children and adults have been reached. These efforts have been intensified; in just the last few years, we have screened nearly 100,000 children. It’s wonderful to say Stein Eye Institute is helping patients who come to us from all over the world, but if people in our own backyard are struggling with vision problems, we have work to do, and often that means we need to go to them.
Obviously everyone wants to see well, but what’s the larger impact Stein Institute makes by addressing vision problems?
Dr. Mondino: Just as an example, a member of our faculty conducted a study showing that cataract surgery reduced the risk of fall-related hip fractures among the elderly. So these advances have a public-health impact beyond the quality of life that comes with better vision. When older adults fall, it can lead to fractures and serious health declines.
On the other side of the age spectrum, we know that vision problems can affect school performance, and, too often, children in underserved communities are just living with those problems. If they can’t see, they won’t do well in school. Through our Mobile Eye Clinic, we are doing outreach in these communities to provide eye care and glasses, as well as to screen children so they are ready when they go to school. Many people can’t afford eye examinations for their children. Even when the child gets an exam, the family might not be able to afford glasses, and even when the child gets glasses, stigma may prevent the child from wearing them. To address that, we have a comprehensive program to examine, treat, provide glasses and make sure parents and teachers understand that if these glasses sit in a drawer, they aren’t providing any benefit. Not only that, but for every 100 kids who are screened, we also will find some with a pathology that the family hadn’t known about, and it’s important to be able to diagnose and treat those children as well.