RETINA REFLECTIONS

Stuart L. Fine, MD

Stuart L. Fine, MD, is emeritus professor of ophthalmology at the University of Pennsylvania and a clinical professor of ophthalmology (part time) at the University of Colorado Medical Center at Denver. 

Dr. Fine, affectionately referred to by some as a pied piper for young trainees, is renowned for his tireless mentoring of young ophthalmologists and investigators. He is also widely recognized for his substantial contributions to the field through his leadership of numerous National Eye Institute-supported multicenter clinical trials to evaluate new and existing treatments for retinal diseases. 

Dr. Fine with Johns Hopkins medical student, Beth Bromberg in 1984.

Among trials Dr. Fine has chaired are the Macula Photocoagulation Study (MPS; 1979-1994), Collaborative Ocular Melanoma Study (COMS; 1985-2005), Choroidal Neovascularization Prevention Trial (1994-1998), Complications of AMD Prevention Trial (1999-2007), and the AMD Radiotherapy Trial. He also served as vice-chair of the National Eye Institute (NEI)-sponsored Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

Stuart Fine was educated at the University of Maryland and its School of Medicine. After completing a residency at the University of Florida, he was a National Institutes of Health (NIH) special fellow in retinal diseases at the Wilmer Eye Institute at Johns Hopkins under the mentorship of Arnall Patz, MD. From 1973 to 1991, he was on the full-time faculty of the Wilmer Eye Institute, where he served as professor of ophthalmology, director of the Retinal Vascular Center, and director of medical student education for ophthalmology. 

In 1991, Dr. Fine relocated to the University of Pennsylvania to become the William F. Norris and George E. de Schweinitz Professor, chair of the Department of Ophthalmology, and director of the Scheie Eye Institute. 

During his 19-year tenure as chair, the Penn Ophthalmology faculty expanded threefold, the annual research budget increased tenfold, and the number of endowed chairs increased, as did the clinical practice and education programs. Dr. Fine’s efforts led to the establishment of Penn’s F.M. Kirby Center for Molecular Ophthalmology, the Center for Preventive Ophthalmology and Biostatistics, the Center for Hereditary Retinal Degenerations, and the Division of Neuro-ophthalmology. 

He has received numerous awards for his leadership in education, research, and patient care. Dr. Fine is most proud of his mentorship of 2 generations of students and house staff, many of whom have become national and international leaders in academic ophthalmology. Here, he shares his Retina Reflections.

Please share an impactful moment that shaped your early, middle, and/or late career.

The Fines and Goldbergs at a 1985 celebration for the dedication of the Lions Eye Research Institute at the Illinois Eye and Ear Infirmary

I became interested in retina while I was serving a 2-year tour of duty in the U.S. Public Health Service (PHS) between 1967 and 1969. This was before residency; and at the time, I had no interest in ophthalmology. It was my association with Mort Goldberg, MD, who had just completed his chief residency at Hopkins and who occupied a PHS office just down the hall from mine, that introduced me to ophthalmology. I’ve never looked back. 

Why retina? I was drawn in by the beautiful image of the retina as seen through an ophthalmoscope or by viewing a fundus photograph, the dynamics of the retinal circulation by the newly popularized technique of fundus fluorescein angiography, and the possibility of treating leaking blood vessels with the argon laser photocoagulator with its slit lamp delivery system. 

Was there a time in your career when you witnessed history in the making? 

1968 Airlie House Symposium on the Treatment of Diabetic Retinopathy, co-hosted by Drs. Goldberg and Fine, set the stage for the diabetic retinopathy study and future clinical trials. A copy of this book was donated to the History of Retina collection by Dr. Goldberg.

I witnessed history in the making early in my career. In September 1968, Mort Goldberg and I co-chaired the Airlie House Symposium on the Treatment of Diabetic Retinopathy. At the time, pituitary ablation was a popular treatment for patients with diabetic retinopathy despite the absence of any evidence of efficacy from a controlled clinical trial. 

Data presented at the Airlie House Symposium made it abundantly clear that pituitary ablation had no place in the treatment armamentarium for patients with diabetic retinopathy. In addition, the Symposium paved the way for a randomized clinical trial of photocoagulation for proliferative diabetic retinopathy, the Diabetic Retinopathy Study. 

What career accomplishments have provided you with the greatest sense of satisfaction?

I’ve had many moments of enormous satisfaction in a career spanning 40-plus years. Among these are all the grateful patients—and even some who may not have been grateful but who were helped by my intervention—and by my leadership of 10 clinical trials, most NEI sponsored, which influenced the practice of retina worldwide. Of particular note were the MPS, the COMS, and CATT, for which I served as vice-chair. 

The MPS documented the benefit of argon laser photocoagulation for patients with age-related macular degeneration (AMD) and extrafoveal choroidal neovascularization. The public health benefit of this intervention was limited by the fact that only a small proportion of patients with neovascular AMD were eligible for treatment and that the benefit of laser treatment was short-lived. 

Dr. Fine presents top line results from the Macula Photocoagulation Study at the NIH in 1982

Nonetheless, from 1982 to 1999, argon laser photocoagulation was the only treatment of proven benefit for patients with neovascular AMD. The emergence of intravitreal injection of VEGF inhibitors has moved laser photocoagulation to the dust bin for patients with neovascular AMD. For patients with extrafoveal neovascularization due to the ocular histoplasmosis syndrome, laser photocoagulation remains a viable option.

The COMS documented no difference in mortality for patients with medium-size choroidal melanoma who were treated by enucleation or with I-125 plaque radiation. The COMS was conducted before the advent of genetic profiling of patients with choroidal melanoma. The COMS outcome data provided reassurance to patients that their life expectancy would not be jeopardized by selecting a treatment that enabled them to retain the tumor-containing eye. 

Among the many collateral benefits of the COMS were the incorporation of standardized echography for measuring the height and defining the acoustic characteristics of choroidal melanoma, and standardizing the techniques of enucleation and plaque irradiation for eye surgeons in over 40 clinical centers that participated in the COMS. 

The CATT demonstrated essential equivalence of visual outcome in patients with neovascular AMD treated with intravitreal injections of bevacizumab or ranibizumab. CATT also documented that injections of these VEGF-inhibitory drugs at follow-up visits only when there was subretinal or intraretinal fluid was about as effective as monthly injections during the first 24 months of follow-up. Surveys of practice patterns among retina specialists continue to show the extent to which the CATT results have influenced practice patterns worldwide. 

At the top of my list for career satisfaction would be the mentoring of medical students and fellows who have gone on to become superstars and major contributors in academic ophthalmology. Among these are Drs. Julia Haller, Bill Smiddy, Mary Lynch, Susan Bressler, Neil Bressler, Peter McDonnell, Dan Martin, Phil Rosenfeld, Tim Murray, Robert D’Amato, and many others.

What do you feel is the most significant development or change in the practice of retina?

The 3 most significant developments, in my opinion, are: the demonstration that panretinal photocoagulation was an effective treatment for proliferative diabetic retinopathy; the use of anti-VEGF intravitreal injections for choroidal neovascularization and for retinal vascular leakage in central retinal vein occlusion, branch retinal vein occlusion, and diabetic retinopathy; and pars plana vitrectomy for non-clearing vitreous hemorrhage, complex retinal detachment, and many other indications. In each case, these treatments preserved or restored vision in what was previously a blinding condition. 

Can you share any advice for future generations of retina specialists? 

My advice for future practitioners is to work diligently, read voraciously, stay abreast of new developments, be open to learning and acquiring new skills, and always put patients’ interests first.

How do you imagine the practice of retina will change by 2040?

The future treatment for choroidal neovascularization will be long-acting anti-VEGF agents, anti-VEGF eye drops, or some form of gene therapy.

Our sincere thanks to Dr. Fine for sharing his retina reflections.


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