Dr. Gass at his view box reviewing clinical and histologic 35 mm slides. Photo courtesy Gass family
Contributed by Anita Agarwal, MD
J. Donald M. Gass, MD, is widely recognized as the father of macular diseases. He made significant contributions to the diagnosis and treatment of macular diseases and in the interpretation of fluorescein angiography of the macula and retina. As Harry W. Flynn, Jr., MD, FASRS, stated, "He described It first and described It best."
At Bascom Palmer Eye Institute, Dr. Gass was known for his weekly fluorescein conferences in which his peers, fellows, and students attempted to stump him—to no avail. Many images from those conferences are featured in Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment (aka Gass’ Atlas).
Dr. Gass wrote many of the seminal articles describing clinical features and natural history of chorioretinal diseases. He is known, in particular, for establishing the subtyping of choroidal neovascularization in exudative macular degeneration based on anatomic location. Type 1 was below the retinal pigment epithelium (RPE) and above Brüch’s membrane, and type 2 was above the RPE and below the neurosensory retina. Type 3 was subsequently named that includes an intraretinal component of the neovascularization.
In the late 1980s, when there were many theories on macular hole pathogenesis, Dr. Gass presented the tangential theory of vitreomacular traction. He described his observations of macular hole progression stages in detail—observations later confirmed by optical coherence tomography. He helped inspire surgeons to consider macular hole surgery to repair a previously untreatable disease state.
highlights
1960s
Pioneered the use of fundus and fluorescein angiography cameras for the study of retinal diseases
Published the first edition of Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment—widely known as Gass’ Atlas. The Atlas describes several hundred congenital, infectious, age-related, and inflammatory eye diseases with accompanying photographs and drawings. He published 3 additional editions in 1977, 1987, and 1997.
Highlighted the significance of the Müller cell cone, an overlooked part of the anatomy of the fovea centralis and its role in Macular holes and idiopathic type 2 juxtafoveolar telangiectasia.
Donald Gass thought of everything in 3 dimensions and stereoscopically; his pathology training helped him immensely with this. I believe that this ability singlehandedly enhanced his skills in understanding pathogenesis of diseases and patterns seen on angiograms. He made meticulous drawings of features beneath the surface based on clinical appearance, fluorescein angiography features, and his knowledge of anatomy. These drawings are now famously corroborated with modern day OCT and OCT angiography images.
For many years, Dr. Gass carried 4" x 6" index cards in his pocket and quickly jotted down information on interesting new findings when he saw patients with novel or unusual features; he kept these in his box of "unknowns." When he saw more patients with similar features, he gathered all his cards, began studying them in detail, and came up with descriptions of many new disorders. More often than not, he cataloged his notes and patient information himself rather than delegating to anyone else. I believe this helped him know exactly where he could find the information later and amplified his recall.
Dr. Gass was an idol to many of us, from both near and afar. In training with him, we not only imbibed the art of meticulous history taking and examining skills, but also watched the mannerisms of a thorough gentleman and a considerate physician who always put patients first. This quality has made each of us just a little more tolerant, slightly more patient, and generous with our time. I often remind myself of this on a long, trying day.
Simplicity and acknowledgment of everyone’s efforts came naturally to Dr. Gass. One never heard a harsh word come out of his mouth. When anyone who has had the privilege of meeting or learning from him speaks about Dr. Gass, the reverence with which the words are spoken is a true reflection of the greatness and impact of this special human being.
Don Gass, Media Gass (daughter), Lawrence Yannuzzi and Emily Chew at the National Institutes of Health attending the Lowy's Foundation Macular Telangiectasia Type II Symposium. Photo courtesy of Lawrence A. Yannuzzi, MD.
Lawrence A. Yannuzzi, MD
J. Donald Gass was an intellectual giant, the most famous person in clinical ophthalmic science in the past century—and for medical retinal disease, the most famous of all time. He was admired and respected by all in the field, and he singularly inspired us all.
Donald Gass’ influence started in 1967 with a supplement to the American Journal of Ophthalmology entitled "Pathogenesis of Detachment of the Neurosensory Retina,” which became the origin of the field of medical retina. (I have a signed hardcover copy in my library.) This publication was the beginning of a series of newly identified diseases and a description of newly recognized manifestations of known diseases, based only on the new diagnostic adjunct, fluorescein angiography. The subsequent surge of imaging technology has only confirmed his experiences.
This and other Gass papers, and their corresponding presentations at specialty meetings, educated and inspired a legion of followers. Although he found a climate of freedom at the Wilmer and Bascom Palmer Eye Institutes to further his quest for knowledge and truth, Donald Gass would affect students and peers globally. The diligent would become more diligent, the indifferent would find time to contribute, and the slothful would be energized to activity. He did this always in a state of cheerfulness, alert and bright, with never a disagreeable word.
On a personal note, I recall 3 aspects of Donald Gass’ professional conduct worthy of emphasis. First, he had incredible powers of observation—in spite of an inhibiting pathway through the Hruby Lens, a challenge to many of us. Second, he was devoted to honesty, always searching for convincing evidence to support his conclusions; and third, he was dedicated to compassionate clinical care.
I remember during an interview process, he once said to me, “These young people are all brilliant, but I want each to say that he or she is interested only in what is in the best interest of the patient.” I have always remembered these words and principles in my code of conduct, as Donald Gass did until the end of his days. His friendship made me a better physician, and a better person.
J. Donald Gass, MD and fellows (L to R) David A. Quillen, MD, Justin L. Gottlieb, MD, FASRS, and Timothy D. Polk, MD. Photo Courtesy of Justin L. Gottlieb, MD, FASRS.
Barbara A. Blodi, MD, and Justin L. Gottlieb, MD, FASRS
Being in clinic with Dr. Gass was a treat. Although he did not give the fellows instructions on what he expected us to do, we simply learned to see the patients first, write our notes, and then, if possible, follow the patients as they went to photography and then to see Dr. Gass. We learned to step into Dr. Gass’ room when he was seeing one of his patients with a rare, complex, or unknown retinal diagnosis.
We learned so much just listening to Dr. Gass discuss the patient’s diagnosis and dictate a letter of his examination findings and conclusions (“Sign it ‘Don’ and send it along”). It was amazing to be in “the room where it happens” (as they say in Hamilton) and to finally learn from Dr. Gass what the patient really had!
Because of Dr. Gass’ modest personality, he would at times tell patients he didn’t yet have a definitive diagnosis, but would ask the fellow to share their images at the weekly Bascom Palmer Fluorescein Conference. It was a bit puzzling to us to hear Dr. Gass say he would look to residents and fellows for other diagnostic opinions—did he really think we would have anything useful to contribute? The respect he showed to the fellows, residents, and staff was the same as that he paid to every patient who was referred to him.
Several times in clinic, a patient would be accompanied by one or more staff from Bascom’s philanthropic arm. Right away, we knew that patient was a VIP. However, to Dr. Gass, the patient’s VIP status made absolutely no difference; he was oblivious to everything but the patient’s retinal condition.
Working with Dr. Gass was a life-changing experience, and one we will never forget.
J. Donald Gass, MD and Robert Braunstein, MD, MBA. Photo courtesy of Robert Braunstein, MD, MBA.
Robert A. Braunstein, MD, MBA
I was a fellow of Don Gass from 1977 to 1979; he was an extraordinary individual and a man of great character. Don had the rare skill of making the most difficult seem simple. Before the advent of OCT, he was able to visualize structural changes that few could see.
He was a gifted teacher who treated everyone with respect, never allowing anyone to feel stupid. The most ridiculous comment at a fluorescein conference would elicit a nod from Don while remarking with seriousness, “I see.”
Don would often laugh at himself. During my second year of fellowship, at the annual resident-fellow softball game, Harry Flynn’s wife, Donna (a great athlete, having run the Miami Marathon while 6 months’ pregnant) was on the mound. Don tried to stretch a single into a double. Conversation stopped; everyone watched in horror as a 50-year-old slid head-first into second base. Don got up, dusted himself off, and with a big grin, started to chuckle.
We both lived on Key Biscayne and often drove together to Bascom Palmer. In my second year of fellowship, my father died. When I returned to Miami weeks after the funeral, I told Don that on some days, it might be better for me to drive by myself, as I planned to stop at a local synagogue on the way home to say a memorial prayer for my dad. Don insisted we continue to drive together; on many evenings, he would park outside the synagogue and wait for me.
Stature or wealth did not impress Don. Ten years after leaving Miami, I received a call from my friend, Stan Chang, trying to locate Don to see a VIP patient Don had seen years before. Bascom Palmer was unaware of Don’s whereabouts. I knew that Don and Margie Ann were visiting their son in California, and I put Don in touch with Stan.
Don agreed to see the patient on his return to Miami the following Monday. The patient offered to send his private jet to California to pick up Don and Margie Ann, fly them to Manhattan so he could be examined in New York, and then fly them back to Miami on his private jet. Don said he already had a plane ticket (coach) and would see him in Miami.
On Saturday morning, February 26, 2005, the final day of the Macula Society Meeting on Key Biscayne, I received a call from Margie Ann telling me that Don had passed during the night; 28 years earlier, Don had opened and concluded the first meeting of the Macula Society, also on Key Biscayne; as Don’s fellow, it had been my responsibility to run the slide projector. We lost one of the best.
Lee M. Jampol, MD
Dr. Gass poses a question at the 1987 Macula Society Meeting in Cannes, France. Photo courtesy Lee Jampol, MD.
If I ask our residents and fellows whether they know who Charles Kelman or Edward Maumenee was, the answer is almost always, “No.” On the other hand, they know Donald Gass, who left us a legacy of creativity and discovery that impacts our practice to this date.
Gass was a softspoken Canadian who trained at Vanderbilt and the Wilmer Eye Institute. He was a key part of the development of the Bascom Palmer Eye Institute and later was professor at Vanderbilt University Medical School. Donald Gass was honest, ethical, and a prodigious worker. In my 50 years in ophthalmology, no one has made a greater contribution to the field of medical retina.
Don described a multitude of new diseases and physical findings. He was an incredible observer and could see things in the retina that were not apparent to others. Because he had a memory that retained images of previous patients, he could link similar cases and write descriptions of his new findings.
He fastidiously created Gass’ Atlas of Macular Diseases, which has so many new observations and images. If one thinks he or she has discovered a new retinal disease, it most likely is already in Gass’ Atlas. Don Gass was a great teacher and trained a series of exceptional fellows and residents who have become leaders of our field. If one goes to an imaging conference, even today, it is very likely that Gass’ name will be recognized. This rarely occurs with other members of his generation.
I had the honor to write a paper with Don Gass, and it was a great experience. In conjunction with his colleague, Larry Yannuzzi, he attended our major teaching conferences at the American Academy of Ophthalmology, the East Coast Retina Club, and many others. Everyone turned to Don when there was difficulty in diagnosis or management. His presence is still greatly missed.
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