In February 2002, the Bascom Palmer Eye Institute (BPEI) of the University of Miami celebrated its 40th anniversary. This milestone provides an opportunity to review the role of its neuro-ophthalmology service, replete with a cast of remarkable and memorable clinicians and dedicated teachers. A single institution, a single department of ophthalmology, at one time sustained a stable of six “card-carrying” neuro-ophthalmologists. It is a story of natural selection, small-world coincidences, and fortuitous inbreeding.
This writer has fortunately been involved with the BPEI since 1962, precisely this 40-year interval, and has had the distinct privilege of close associations with the principals as student, colleague, and friend. The circular nature of these recurrent connections will be apparent; indeed, they constitute the leading theme. The reader will, I trust, forgive any personal intrusions in the interest of authenticity, and excuse unwitting omissions.
The neuro-ophthalmology program at the BPEI has been the successful outcome of one of the consuming interests of Edward Norton, MD, who assumed the initial chairmanship of the ophthalmology department in 1958. Already an avid student of neurology while at Cornell Medical College, and indeed himself a survivor of self-diagnosed bulbar polio in the 1948 epidemic, Norton completed a 15-month residency in neurology under the direction of Harold Wolfe, MD, at New York Hospital–Cornell Medical Center and at the Bronx Veteran's Administration Hospital. There, Norton also enjoyed a close collaboration with the Cushing-trained neurosurgeon Bronson Ray, MD. In an era before the advent of computed tomography or magnetic resonance imaging, it is said that Ray frequently planned surgical procedures based principally on Norton's clinical assessments. Under the subsequent tutelage of David Cogan, MD, at Harvard University and Frank Walsh, MD, at Johns Hopkins University, Norton was enthusiastically primed for a lifetime's fascination with neuro-ophthalmology. Walsh, Cogan, and Norton sustained a deep lifelong mutual admiration (1). Norton told me early during my own residency training that he was also especially influenced by a book of Alfred Kestenbaum, MD, a refugee from Vienna at the time of the 1938 Nazi anschluss:Clinical Methods of Neuro-Ophthalmologic Examination (1946).
Serendipitously while in Boston, Norton learned to effectively use the indirect ophthalmoscope that Charles Schepens, MD, had brought from Belgium. Thus, the origins of Norton's exceptional second (!) career as a retinal detachment surgeon. Among his earliest surgical successes was Harry Belafonte.
Housing the clinical facilities, faculty offices, library, and research laboratories of the department of ophthalmology, the BPEI opened formally in 1962. The original full-time faculty in 1958 consisted only of Norton and Victor Curtin, MD, Norton's lifelong friend, colleague, and confidante. Interestingly, the next faculty member recruited was a neuro-ophthalmologist, J. Lawton Smith, MD, from Duke (see accompanying interview). Donald Gass, MD, and John Flynn, MD, came next, to make up the “Founding Five Forefathers.”
Smith was the product of Duke Medical School, an Emory-Grady Hospital internship, and the Wilmer ophthalmology residency at Johns Hopkins, but he marched to his own inimitable percussion section. Smith must be considered the principal popularizer of neuro-ophthalmology in the second half of the 20th century. No one who has heard his down-in-the-country style, spiked with clinical “pearls and gems,” can soon forget the encounter. To the various rhythms of nystagmus patterns, Lawton provided synchronous tongue-clucking soundtracks. His re-enactment of an expanding pituitary adenoma was described by Dr. Noble David, a medical school classmate, colleague at Duke, and lifelong interpreter, as follows: “Anyone who has seen Dr. Smith in conference at half crouch in his far-from-silent pantomime of the inflamed intrasellar growth, arms and legs aggressively flailing out at imaginary regional anatomy, will not easily forget the lesson” (2). It was Smith's extraordinary talent and forte to clarify clinical conditions by vigorous and dramatic body language and unique distillation of medical terms (see “The Language of Lawton” in the accompanying interview of Smith in this issue). For these reasons, he was an incomparably popular lecturer and teacher.
An important lifelong association was sealed between Smith and William F. Hoyt, MD, while both were at the Wilmer Institute in 1957. Hoyt recalls Smith as “a phenomenon and a fascinating, entertaining, redheaded southerner. Unbelievable...Lawton was the fastest typist. No secretary could keep up with him. Lawton used to carry a typewriter around with him on ward consultations” (3). Their fond friendship blossomed: “If I wasn't going to get famous doing what I was doing, Lawton was going to make me famous because he constantly kept referring to me as `Toughy Hoyt”' (2). Hoyt's loyal support helped establish the University of Miami Neuro-Ophthalmology Symposia. Moreover, Hoyt has also been instrumental in the careers of three other BPEI faculty members: Robert Daroff, MD, Todd Troost, MD, and Joel Glaser, MD (that would be me).
Accompanying Smith south to the University of Miami in 1962 was Noble (“Nobbie”) David, MD, a Duke neurologist first excited by Walsh's textbook and later drawn naturally into the circle of the active neuro-ophthalmology mafia (see accompanying interview of Dr. David in this issue). Specializing in pituitary apoplexy and progressive supranuclear palsy (he enjoyed pronouncing “Olszewski”), David was the Shakespeare- and limerick-reciting intellectual foil and complement to Smith's southern-fried jargon. It was David who brought to the BPEI the nascent Duke experience with fluorescein angiography of the fundus, which blossomed under master ophthalmic photographer Johnny Justice. The development of angiographic techniques provided the substrate for the remarkable career of Donald Gass, MD.
Stunned by the rumor that Hoyt had, in 1965, accepted a neurologist as a postgraduate fellow, and aware that no less a figure than Walsh had cautioned that “neurologists cannot be trained in neuro-ophthalmology,” Smith, irresistibly challenged, took a gamble and told Hoyt that “my neurologist is gonna be better than yours. ” The constellations were in the right alignment. Within hours, Smith signed up his neurologist-fellow, Norman Schatz, MD!
It was clear, however, that Smith and Schatz were not cut precisely from the same cloth, their shared enthusiasm for neuro-ophthalmology notwithstanding. By his actions and words, Smith had been called to represent the forces of Good, leaving Schatz no choice but to align himself with “the forces of Evil.” (This is, of course, an in-joke not to be taken too seriously.) Schatz, proud of his historic Philadelphia medical upbringing, and claiming direct descent from Polish royalty-of-a-sort, resolutely refused to be called “Dockey” (see “The Language of Lawton” in accompanying interview of Smith). And I, a restrained second-year resident at the BPEI in 1965, watched in wonder as Schatz regularly passed himself off as “Dr. Smith,” entertaining and startling patients by employing an optokinetic tape studded with photos of semiattired Playmates. (Here was a man whose examination techniques were worth watching, and I still do). Schatz later returned to Philadelphia to direct the neuro-ophthalmology service at Wills Eye Hospital and to train a generation of admiring residents, fellows, and nurses.
Another of Smith's earliest (1966–67) and brightest postgraduate fellows was John “Tex” McCrary, MD, who stayed on as a BPEI faculty member in 1967–69 before returning westward to Baylor to spread the word as an outstanding teacher.
My own involvement at the BPEI began in 1962, when an extramural senior medical student elective was arranged. The dean at Duke was Barnes Woodhall, MD, a renowned neurosurgeon, who was well acquainted with Smith's salad days at Duke and was entirely supportive of my plans for a fall vacation with “Red Smith” in Miami. It was, for me, the opportunity of a lifetime. Smith, who had just arrived at the BPEI, was often joined for lunch by Norton—“The Chief”—and David. I tagged along, often stunned at the breadth of luncheon topics. As a familiar presence I was not only tolerated by my heroes but expected to participate in clinical presentations at the Saturday morning neuro-ophthalmology conference, organized in the mold of the famous Walsh Saturday conference at Hopkins. These 10:30 to noon meetings were clearly the educational highlight of the week, attended enthusiastically by the housestaffs of ophthalmology, neurology, and neurosurgery.
Before my arrival to study with Smith in Miami, I had interviewed for internship at the University of California, San Francisco, and had rather casually dropped by to investigate the ophthalmology program there. Absolutely by chance, while I was speaking to his secretary, Michael Hogan, MD, the chairperson of ophthalmology, walked by. Informed of my interest in ophthalmology, and that I was to do a student elective with Smith in Miami, Hogan suggested that I “go around and see Bill Hoyt,” of whom I had never heard! After a short and unexpectedly warm conversation, Hoyt offered to have me spend a 4-month Fight-forSight student fellowship under his supervision. So, after 3 months of rigorous basic training with Smith, off I went to San Francisco in January 1963: the first student ever to do an elective with Hoyt, and surely the first to train for 7 months in neuro-ophthalmology before even beginning an internship!
I returned to San Francisco after finishing my ophthalmology residency in 1969 for a postgraduate neuro-ophthalmology fellowship under Hoyt. Together with Todd Troost, MD, and James Corbett, MD, we provided mutual support and encouragement while learning with a not-yet-mellow Hoyt. It was, of course, a marvelous year, during which the neuro-ophthalmology unit was visited by Alan Bird, MD (just finishing his fellowship with Smith in Miami and about to head back to London's famous Moorfield's Eye Hospital and The National Hospital for Nervous Diseases), Ronald Burde, MD (just beginning his faculty position as neuro-ophthalmologist at Washington University in St. Louis), and Tadashi Fujino, MD (on his way back to Tokyo after 2 years at the BPEI).
Also along for a 3-month elective during that time was a young medical student from Nebraska, who was so enthusiastic that on his second day he accepted the responsibility of presenting a patient to “The Master” on ward rounds. The freshman presentation did not go especially well. Afterward, Hoyt pulled me aside to say, “See if you can teach that guy how to present a patient!” Indeed, “that guy” learned—well enough to later co-edit the 5th edition of the incomparable Walsh & Hoyt textbook (Clinical Neuro-Ophthalmology). He was, of course, Neil Miller, MD.
Wait, the plot thickens. Corbett joined Schatz at Wills, Troost joined Daroff in Miami, and Glaser, before returning to the BPEI, wrangled 4 months at The National Hospital for Nervous Diseases, working with Alan Bird, Michael Sanders, MD (a 1968 Hoyt fellowship graduate, along with Daroff), Ralph Ross Russell, MD, Ian McDonald, MD, and a keen Moorfields Eye Hospital registrar named Ivor Levy, MD (later to become a BPEI neuro-ophthalmology fellow in 1973).
Thus, in 1970, gathered on the faculty at the University of Miami were Smith, David, Glaser, and the world-class Ocular Motor Laboratory consisting of Daroff, Troost, Louis Dell' Osso, PhD, and Larry Abel, PhD. Norton also continued an active interest in neuro-ophthalmology. Also on the Miami scene was the extraordinary series of almost-annual neuro-ophthalmology symposia that regularly featured such guest speakers as Frank Walsh, MD, David Cogan, MD, Richard Lindenberg, MD, Hoyt, Hans Newton, MD (neuroradiologist at the University of California, San Francisco), Ronald Burde, MD, Robert Hollenhorst, MD, Swithin Meadows, MD, A. Earl Walker, MD, Blaine Nashold, MD, Maurice Victor, MD, Henry van Dyk, MD, Dwight Parkinson, MD, Simmons Lessell, MD, Michael Sanders, MD, Stanley Thompson, MD, Alan Bird, MD, Lars Frisen, MD, Elizabeth Gould, MD, Ian MacDonald, MD, Albert Rhoton, MD, and many others.
The lectures from the programs of the Miami symposia series provided the principal substrate for the series of ten neuro-ophthalmology books, published from 1963 to 1979 under the shared editorship of Smith and Glaser.
The bibliography of other publications of the BPEI neuro-ophthalmology faculty in texts and refereed journals is substantial, including major contributions to the Duane-edited Clinical Ophthalmology volumes. But one other contribution is especially noteworthy. While others formed committees and argued the pros and cons of a dedicated neuro-ophthalmology journal, Smith just forged ahead. With the cooperation of the Masson Publishing Company, the Journal of Clinical Neuro-Ophthalmology was born in 1978, dedicated to “the treating doctor,” with “no abbreviations,” and with the bonus of a “new pearls checklist” if the reader is “just too tired and too busy to read anything” (4). Of course, gentle reader, you hold in your hands at this moment the fruits of that forward-looking decision: the present Journal of Neuro-Ophthalmology, the Chief Editor of which, Jonathan Trobe, MD, was a BPEI neuro-ophthalmology fellow in 1976.
In 1980, Daroff, Troost, and Dell' Osso left Miami with the Ocular Motor Laboratory for Case Western Reserve University in Cleveland, where Daroff became chairperson of the neurology department. Schatz replenished the BPEI neuro-ophthalmology faculty in 1982, when he began a bigamous existence: 6 months in Philadelphia, 6 months at the BPEI. At Norton's invitation, Schatz became a full-time faculty member in 1986, joining Smith, Glaser, and David.
After an exceptional career, Smith retired from practice in 1994. Ronald Tusa, MD, reconstituted the eye movement facility from 1989 to 1997. Matthew Kay, MD, joined the faculty from 1993 to 1994. BPEI neuro-ophthalmology fellowship graduate Michael Siatkowski, MD, was a faculty member from 1994 to1997 (now at the University of Oklahoma), and BPEI neuro-ophthalmology fellowship graduate Byron Lam, MD, came in 1996. Presently, Lam, Schatz, and Glaser hold the fort. The bona fide mark of a successful clinical service surely must also include its impact on post-graduate education. The members of the BPEI neuro-ophthalmology faculty have had the responsibility and privilege of playing a part in the training of almost 90 bright young physicians, most of whom have assumed academic positions (see Table). BPEI-trained neuro-ophthalmology fellows now play important roles at training institutions in North Carolina, Virginia, Texas, Florida, Boston, New York, Philadelphia, Cleveland, Chicago, Detroit, and Ann Arbor in the United States; in Edmonton, Toronto, Kingston, and Montreal in Canada; and in London, Tokyo, Switzerland, Israel, and Mexico. They include department chairpersons, deans, editors of journals, and founders of the North American Neuro-Ophthalmology Society (NANOS). At the end of the day, these men and women who carry on the tradition of excellence in patient service, clinical research, and enthusiastic teaching are the most important contribution of BPEI to worldwide neuro-ophthalmology.
It is unlikely that a single institution will ever again mount the sustained interest sufficient to match the multitude of neuro-ophthalmic clinicians once gathered under the BPEI roof. How much less likely still to encounter the variety and depth of its cast of characters. This is history worth recalling, one still paying rich dividends. How we yearn to be able to repeat it!