Carol L. Shields, MD, FASRS
Carol L. Shields, MD, FASRS, is director of the Ocular Oncology Service at the Wills Eye Hospital and professor of ophthalmology at the Sidney Kimmel Medical College at the Thomas Jefferson University. She completed her undergraduate studies at the University of Notre Dame where she captained the women’s basketball team for 3 years and was named to the Academic All-American Hall of Fame. She attended the University of Pittsburgh School of Medicine and did her residency at the Thomas Jefferson University within the Wills Eye Hospital.
In 2023, she received the Theodore Roosevelt Award of the National Collegiate Athletic Association (NCAA), the highest award from the NCAA to an individual who participated in Division I collegiate athletics and ultimately became a distinguished citizen of national reputation based on outstanding life accomplishment.
Dr. Shields is half of the power duo that includes her husband, Dr. Jerry Shields. The couple met at Wills and built their remarkable careers working side by side. They are true pioneers who have had a profound impact on the field of ocular oncology as clinicians and educators, impacting the lives of countless patients and families faced with the diagnosis of serious blinding conditions like retinoblastoma and ocular melanoma.
Dr. Shields is a prolific publisher and gifted teacher and lecturer. She has received innumerable national and international awards, including the ASRS Founders Award, the AAO Life Achievement Award and was the first woman to receive the prestigious Donders Award. She is a past president of the International Society of Ocular Oncology and the Macula Society.
We are pleased to share Dr. Shields’ retina reflections here and also encourage you to watch her inspiring History of Retina Leaders & Legends video interview.
Please share an impactful moment that shaped your career. Was there a time in your career when you witnessed history in the making?
I have been lucky to be in the field of retinoblastoma where we have made gigantic strides over the past 20 or 30 years. In 1994, we started with intravenous chemotherapy. Then in 2008, we started using intra-arterial chemotherapy. Then, in 2012, we started using intravitreal chemotherapy. I think all three of these were major game changers in the field of retinoblastoma, allowing children who would have had no choice but enucleation in the early 1990s, to have their eyes saved – and in some cases even retain vision.
Today I saw a boy who first came to see us about 10 years ago with anterior chamber seeds, diffuse vitreous seeds and a large retinoblastoma. Not only were we able to save his eye with intravenous and intra-arterial chemotherapy, we avoided using radiotherapy and his vision is 20/30. It’s crazy when you think of the progress we’ve made and all without prospective trials. Much of this was accomplished through retrospective, observational case series – in other words, ‘this works for me, that doesn't work so well.” We are a small group of ophthalmologists focused in ocular oncology and we watch each other and learn from each other.
Equally exciting has been progress in the field of conjunctival tumors which are now being treated with chemotherapy eyedrops. In the past, squamous neoplasia was a big surgery, and now I tell patients, “Go home, use these eyedrops and come back to see me in a month and we'll make a decision about whether you need to use more eyedrops.” We've witnessed a lot of change in our field.
With regards to Jerry’s experiences, I think the biggest advancements in the field when he was treating was the P32 test. It was a great advance and he worked diligently to popularize the P32 test and plaque radiation. He trained a lot of people to use it.
I also derive a lot of satisfaction from all the work we did stemming back to when Jerry started on the early detection of melanoma. He knew when he entered the field that this was a really important area for him to develop and he kept meticulous records. And then when I came aboard, I did a lot of the scientific statistical analyses on risk factors for growth and risk factors for metastasis of small melanoma and when to intervene.
Jerry is now retired, but he found resection of melanoma and work on retinoblastoma deeply satisfying. In reality, he enjoyed everything. He is an amazing “people person” and all his patients love him, in fact they still ask for him in the clinic. He makes cameo appearances and the patients go crazy, they love seeing him.
What career accomplishment provides you with the greatest sense of satisfaction?
Every case of retinoblastoma gives me a real sense of excitement and satisfaction. Oftentimes, patients who meet me for the first time say, “Thank you for seeing me so quickly.” But the greatest sense of satisfaction and gratitude comes 5 years, 10 years later, when the now teenager walks into the clinic and says, “Thank you for saving my eye. Thank you for taking care of me when life was really challenging and scary.”
It's always an emotional experience to see a child with retinoblastoma and to tell a family in distress, “Don't worry, we have great pediatric oncologists, great interventional neuroradiologists, great chemotherapies and your child will be okay, just give us four months and we can turn this all around.”
I credit Jerry because he taught me to be able to say to a family, “Your son might need enucleation, but there's a bigger consideration here, it’s his life. He might need enucleation to save his life and he's going to look fine and he'll see fine with his other eye.”
Jerry was superb with the retinoblastoma patients and they were his favorite to see. He was also good with the parents. He would go out and sit next to them and spend time explaining everything.
What do you feel is the most significant development or change in the practice of retina?
I would say one of the most impactful changes in the practice of retina has been the use of anti-VEGF. I remember as a resident being trained to see patients with age-related macular degeneration and telling them that there was no treatment available. We could do a laser, which would take out the central vision, but would leave less of a scar than if we let the membrane hemorrhage and do a bigger central scotoma. Boy, was that a hard discussion to have with a 90-year-old patient. In every one of them I saw my parents.
I’ll never forget the ASRS meeting in Montreal, when we heard that the first intravitreal Avastin was given in Miami. That may be one of the most important presentations ever given in the field of retina. Not only did it tell us we could use this medicine and it worked, but it was cheaper and could be used repetitively. We've adapted that into our practice where we prevent radiation maculopathy with anti-VEGF. This is so significant that the DRCR.net is going to do a prospective study comparing long-acting steroid injected into the eye vs faricimab anti-VEGF vs observation and we're going to see whether the steroid or anti-VEGF does better, or whether we really need to do anything.
The other tool that has changed the practice of retina is Optical Coherence Tomography (OCT). You know, ultrasound is great and fluorescein is great, but you can't beat OCT. We use it to look at the tumor surface and the integral findings in tumors and are now able to differentiate tumors just based on OCTs. So, it's been an interesting and a really good time to be in the field of retina. We’re lucky that OCT came out before anti-VEGF so we can use one to help the other.
Jerry was the first to do ultrasonography at Wills. It was all they had back in the early to mid-1960s before we had fluorescein. In addition to ultrasonography, P32 was done in the mid-to-late 60s, early 70s. It was a radioactive isotope you injected intravenously. Jerry put the tamponade on the arm and did the injection. Then he used a Geiger counter up against the globe and took the reading. Forty-eight hours later, he would go into the operating room and take the reading in all four quadrants and in the quadrant of the tumor. If it was a melanoma the reading would be very high. If it was a hemangioma, the reading would be very low, because it would get washed out. If it was a metastasis, it would be high.
We also learned by an error that choroidal osteoma had a very high P32 because that's what caused the first and only enucleation of choroidal osteoma. It was done because the P32 was super high. They called Jerry on the phone and said they had a young lady with a really high P32. Jerry said that it must be a melanoma, and said they could irradiate or consider enucleation. Enucleation was chosen but the tumor was found to be a choroidal osteoma. So finally, we had the pathology of choroidal osteoma. And now we know how to image it. Ultrasound shows calcification. OCT shows Haversion canals, subretinal fluid and if you see CNVM, you inject with anti-VEGF. It’s totally changed.
How do you imagine the practice of retina will change by 2040?
We all say negative things about the COVID-19 pandemic, but it sure was an electric switch for us to quickly advance science, advance communications and advance the electronic impact in our world.
As soon as the pandemic happened, we flipped completely into electronic medical records, because we opened satellite offices for people who didn't want to come downtown Philadelphia and we needed EMR in the cloud. The pandemic made us virtual and I think it’s here to stay.
The days of waiting for the gas station attendant to put gas in your car are gone. These days you don’t even see an attendant or a grocery store clerk. I think it's going to be the same with a doctor's office; you’ll choose one of three ways to have a visit. The first is a pure virtual visit where you go in, you get all your imaging and your doctor contacts you at work to tell you if your CNVM needs treatment or not. The second way will be hybrid-virtual where you go into a virtual office, have photographers and one or two technicians check your vision, your intraocular pressure, your imaging, and then they get the doctor for a Facetime discussion. We probably use this approach for 20% of our follow-up patients now. Third, I think there will still be a role for seeing the doctor face to face. The virtual options will take a lot of stress off doctors’ offices, which are currently bursting at the seams.
I also think a group of smart retina doctors are going to put together imaging centers. Because I think cameras are unaffordable for your average glaucoma doctor or your average cataract doctor. If we have really nice imaging centers, then I think your average small multi-practice group will send patients to the imaging center and they will do the interpretation. It's going to be a way to consolidate the best imaging so multiple practices can use it.
Can you share any advice for future generations of ocular oncologists and retina specialists?
Nothing is going to be handed to you. You have to prove you want to be in that seat at that table. It will require hard work, dedication and enthusiasm.
I encourage young retina specialists to find their niche. You want to love what you do and love your patients, otherwise you can't go to work every day. Follow your heart, find what excites you and makes you happy and go 110% towards your goal.
Do not get caught in following that little carrot – the dollar bill -- because it might lead to a lot of prosperity, but it doesn't always lead to happiness.
I went into ocular oncology because I saw a need. The field was very rudimentary and I saw an opportunity to do some analyses to see, for example, if plaque radiation was worth it -- what were the outcomes, how many patients got metastases, and what was the 10-year risk for metastases. It was a lot of work, but I used the data Jerry had collected for 15 years before I joined as a springboard.
I want the young people in retina to understand that everything you do is important, even if you're just there collecting data on interesting diseases, some smart statistician will use that data. So, keep doing your best exploring, providing good care. It’s all part of building the pyramid of knowledge.
I’m sure the future holds many more exciting things. We are now working on a multi-center prospective study using an injection of a nanoparticle to treat melanoma. It's really exciting. Anything we can do to further the field, we're there!
This has been a really exciting career for both Jerry and me. Exciting to see all of the amazing innovations that have happened and our ability in ocular oncology to save lives and eyes that would have been lost to retinoblastoma and different types of tumors. Thank you all for your support of our interest in ocular tumors.
The ASRS thanks Dr. Shields for sharing her retina reflections.