SOCIAL

  O.D. SCENE

THE PERSONAL SIDE OF OPTOMETRY

Q&A

A few of my colleagues say I have a “man crush”^* on Donald Korb, O.D., F.A.A.O. They may be right. He has been a mentor, teacher and a friend for more than 17 years, and I unabashedly marvel at all he’s accomplished in the areas of contact lenses and dry eye disease.

This month’s O.D. Scene includes a Q&A with Don. Enjoy!

Jack Schaeffer, O.D., F.A.A.O.,
Editor-in-Chief
O.D. Scene

KEY OPTOMETRIC LEADER WEIGHS IN…

Donald R. Korb, O.D.

Q: WHY DID YOU DECIDE TO BECOME AN OPTOMETRIST?

DK: I was a victim of myopia since the first grade and had my eyeglasses shatter directly onto my eyes during sports on two occasions, causing corneal abrasions, though no vision loss. While I considered following in my father’s footsteps and becoming a physician — he was a PCP and a surgeon — in those early years I was not enthusiastic about dissection or the sight of blood. A family friend, who was an optometrist, and my parents encouraged me to study optometry.

Q: CAN YOU DESCRIBE YOUR PRACTICE?

DK: I was fortunate to succeed my professor, who had founded the first contact lens specialty practice in Massachusetts. The contact lens field was exciting to me; within several years I became involved in research. The practice rapidly became a research-based practice. To understand the practice, it is necessary to review how research has and continues to be woven into the fabric of our practice. Working with patients and their unsolved problems has always driven my intellectual curiosity and directed my research. For the past 40 years, I have divided my time equally between practice and research, leading to seminal articles on topics including GPC, ineffective lid seal during sleep despite full lid closure, lid debridement, meibomian gland function and treatment, meibomian gland therapeutic expression, non-obvious obstructive meibomian gland dysfunction (MGD) and, most recently, proposing that the term dry eye is excellent to convey the patient’s subjective experience, but leads to the wrong diagnosis for millions.

The practice evolved into one that specializes in complex contact lens cases and dry eye patients. The research component involves continuing investigation in these fields and includes collaboration with numerous others outside the practice, both nationally and internationally.

As a result of our expertise in the area of dry eye and specialty contact lenses, more than 25% of all patients travel from more than 20 different states, and many are referred by ophthalmologists and optometrists. Dry eye is the most common chief complaint in more than 50% of all patient visits, with keratoconus the second.

Our ability to successfully treat the majority of dry eye changes the very nature of practice and has resulted in a record high level of enthusiasm and personal satisfaction for all of us.

Q: OPTOMETRY OFFERS MANY FACETS. WHY DID YOU CHOOSE TO FOCUS ON DRY EYE DISEASE (DED)?

DK: My original interest was kindled by the observation that corneal staining occurred with rigid and GP lenses and was associated with discomfort. This led to a number of studies on staining and the realization that staining was most frequently a product of lens design and inadequate blinking. The observation that comfortable contact lens wear was compromised or precluded if corneal staining was observed prior to fitting focused my attention on the area of DED. Our discovery that MGD was universally applicable to all of DED resulted in DED becoming my primary research area.

Q: WHEN DID YOU REALIZE THAT THE MEIBOMIAN GLANDS WERE A MAJOR ISSUE IN THE CAUSE OF DED?

DK: The realization that the meibomian glands were a primary factor in DED was the outcome of years of observing contact lens problems that could not be resolved. While meibomian glands were not routinely examined at that time, I had become aware of the role of the meibomian glands in the etiology of meibomian keratoconjunctivitis through a 1977 paper by McCulley and my collaboration with Antonio Henriquez, M.D., Ph.D., of Barcelona, leading to a 1980 paper we wrote that provided physical and cytological data that obstruction of the terminal ducts of the meibomian glands had a profound impact on the tear film and resulted in DED symptoms and other signs. In that paper, we named this condition MGD. This study, some 35 years ago, established the obstructive mechanism of MGD. This mechanism is still accepted as the etiology of most MGD.

1: Dr. Korb speaking with John Kerry.
2: Dr. Korb joined by colleagues, including Irv Borish, O.D.
3: Dr. Korb with Caroline Blackie, O.D.

Q: WHAT WOULD YOU LIKE TO ACCOMPLISH IN YOUR RESEARCH IN TO THE CAUSE AND TREATMENT OF DED?

DK: The prestigious Tear Film and Ocular Surface Society convened the International Workshop on MGD that concluded that “Meibomian gland dysfunction may well be the leading cause of DED throughout the world.” Although there are multiple causes of DED, including immune diseases and mechanical factors, it is now universally accepted that MGD is highly prevalent and a significant factor in the etiology of DED. Our past research has demonstrated that addressing the obstructive condition within the gland must be a first-tier treatment. Our continuing research is focused on improving both the present treatments of MGD and further expanding into effective treatments of other causes and sequelae of DED. We have learned that if obstruction can be ameliorated, other treatments, such as immunomodulators, anti-inflammatory drugs and increasing tear secretion, may provide benefit.

We are now working in the area of pain, frequently a sequelae of long-term evaporative stress. It is now understood that the corneal nerves are physically altered and compromised with DED conditions – this promises to be another important area and further emphasizes the importance of preventing the progression of the sequelae of evaporative stress. It is necessary to acknowledge Perry Rosenthal, M.D., for his pioneering founding of ocular neuropathic pain. It is also important to better understand the cascade of events that start with evaporative stress. We are also initiating both prevalence and longitudinal studies of the development of MGD.

On a personal note, I have recently felt obliged in my teaching to proselytize the slogan that “Dry Eye is the Wrong Diagnosis for Millions.” My reason is that DED has become a generic term including a multitude of anterior segment findings and symptoms, despite the condition of DED almost always being a sequelae and not the etiology requiring treatment. Thus, a diagnosis of DED may channel treatment to tear production, which may not be the etiological factor deserving first-tier treatment and which may focus attention from the importance of dozens of etiological factors for DED, including MGD, inadequate lid seal during sleep despite lid closure, inadequate blinking, immunologic disease and mechanical factors. I am not implying that increasing tear production is not helpful; however, the first-tier treatment must be focused on the primary etiologic factor(s) with supplementary treatment(s) as indicated.

The Korb family sailing.

Q: WHERE DO YOU SEE DED DIAGNOSTIC TESTING AND TREATMENT GOING?

DK: Before answering this question, one must define DED. Defining DED is challenging because it has become a rubric for literally dozens of different conditions varying from the dry eye found with Sjögren’s syndrome to episodic, transient dry eye occurring with computer use and inhibition of blinking to the inadequate seal of closed lids during sleep. Further, the classic definitions of DED no longer reflect the present state of knowledge, as illustrated by the NIH definition of 2013. “Dry eye occurs when the eye does not produce tears properly, or when the tears are not of the correct consistency and evaporate too quickly.” Thus, the first step is to better define the term dry eye. Diagnostic testing has and will be further enhanced by technology providing new instrumentation and metrics to evaluate the function of the complex physiological systems essential to protecting the ocular surfaces. These new metrics also will evaluate the sequelae of dysfunction of these systems; e.g.: metrics for lipid layer measurement, osmolarity, meibomian gland function, lacrimal function, corneal nerve damage and hosts of others. And perhaps most importantly, it is essential that the diagnosis of MGD must evolve to an integral part of examination procedures whenever DED symptoms or DED signs are present or if DED is suspected.

Treatment will be based upon specific etiology, and ideally will be both restorative and palliative, with the emphasis on restorative. This will require early intervention to minimize damage, such as meibomian gland atrophy and dropout, lacrimal gland atrophy, changes to the lid margin and Line of Marx and delivery of sebum, keratinization of many surfaces and a plethora of others. I foresee a new specialty developing to treat these primary etiological factors to prevent their sequelae, which we term DED. It is now obvious that our technological environment from grammar school through our careers compromises blinking and many other factors, increasing evaporative stress with devastating consequences. We now have the tools to intervene and prevent this cascade.

Q: WHY DO YOU THINK DED IS NOT A MAJOR FOCUS FOR PRIVATE PRACTICE OPTOMETRISTS?

DK: The introduction of any new paradigm is always a lengthy process, as described by the luminary Thomas S. Kuhn. Many clinicians have avoided DED because treatment was generally not effective and patients were, therefore, disappointed and would often place culpability on their practitioner. The knowledge of any new paradigm originates with a relatively few and is then embraced by a limited number of early adopters. This knowledge accelerates when manufacturers introduce instrumentation and then teach how to use it. Pragmatically, optometrists adopting the new paradigm will require education, implementation and adequate compensation for these services. I predict that the adoption of the new paradigm will accelerate, and five years from now we will no longer be asking this question.

Q: WHAT PROFESSION OTHER THAN YOUR OWN WOULD YOU LIKE TO TRY, AND WHY?

DK: There are many other professions that would be satisfying. I seriously considered a different direction and the profession of law. However, upon reflection I realized that what was most exciting and satisfying to me was the opportunity to solve problems that impacted health and also to have the opportunity to personally be involved in the research. The profession of law did not offer those options, and there are few professions that could offer what I enjoyed. I made the decision to continue in optometry and remain 50% in research and 50% in practice and to change my primary focus from contact lens designs to the next unsolved area – DED. My second career was initiated with our 1980 publication describing and naming MGD as the primary mechanism of terminal duct obstruction.

Q: WHAT IS YOUR FAVORITE OPTOMETRIC MEETING, AND WHY?

DK: The AAO’s annual meeting because it provides the most contemporary knowledge and insight in both the clinical and the research aspects of optometry. The Academy embraces as its dual mission optimal clinical practice throughout the breadth of optometry and specialties and the support of all research. This knowledge is conveyed at the Annual meeting in courses, lectures, specialty section programs and in remarkable symposia. In addition, the elite of optometry attend and teach and are generally available to the clinician. The opportunity to meet and discuss virtually any area has been a long-standing culture of the Academy.

I should add that the Academy was my most vital mentor, not only because of the excellence of the section on contact lenses and all of the educational programs, but in providing me the opportunity of a platform to present my ideas. The many optometric giants I met and who befriended me were also critical for my career. I also met my wife, Joan Exford, O.D., at an Academy meeting.

Dr. Korb at the helm.

Q: WHO IS YOUR OPTOMETRIC HERO AND WHY?

DK: There are many, but two in particular come to mind because both changed optometry. The first is the unique Bill Feinbloom, who was one of the first in optometry to have an elite Ph.D. He was responsible for the first plastic contact lens and modern low vision practice and even the first bifocal contact lens. The second is the remarkable Irv Borish, whose teachings at the Academy were legendary and whose textbooks taught several generations of optometrists.

Q: WHAT IS THE BEST LECTURE YOU EVER ATTENDED AND WHY?

DK: I was privileged to be invited to a lecture by Richard Ernst at Clarkson University on the development of nuclear magnetic resonance (NMR) for which he was awarded the 1991 Nobel Prize in Chemistry. His clarity allowed anyone to understand how and why he developed NMR and its remarkable value.

However, the best lecture relevant to eye care I ever heard was the Academy’s Prentice Medal Lecture by Judah Folkman, M.D., the father of angiogenesis research, whose work led to treatments for neovascularization. His presentations were legendary for their content, clarity, humor and humility. Although his discoveries were initially scorned by colleagues, he accepted the criticism as a badge of honor while continuing his research, which led to the first commercially available anti-angiogenesis drug.

Q: HOW IMPORTANT IS A RESIDENCY FOR A RECENT OPTOMETRY SCHOOL GRADUATE?

DK: It is a valuable investment in one’s career. It is now a requirement for some positions.

Q: WHAT, IF ANYTHING, DO YOU FEEL IS LACKING IN OPTOMETRIC EDUCATION?

DK: Education can always be improved; however many schools provide truly excellent education. One can never have enough clinical experience and experience under the eyes of expert mentors.

Q: WHO ARE THE MEMBERS OF YOUR FAMILY, AND WHAT DO YOU LIKE TO DO FOR FUN?

DK: My wife, Joan Exford, O.D., is the mother of our two children Cindy and David. We have a number of hobbies, including art, antiques and summer activities, such as boating, sailing and gardening. Our present pastime is spending time with our three grandchildren, all age 5.

Q: IF YOU COULD HAVE DINNER WITH ANYONE LIVING OR DECEASED, WHO WOULD IT BE AND WHY?

DK: Either Bertrand Russell or Thomas S. Kuhn. Both were extraordinary broad spectrum intellectuals with remarkable insights into the human mind. Their impacts will continue for centuries.

Q: WHAT IS YOUR FAVORITE MOVIE, BOOK, BAND AND ADULT BEVERAGE?

DK: Movie: I am not a moviegoer; Book “The Impact of Science on Society” and “The Structure of Scientific Revolutions;” Music: Both Classical and Rock and Roll; Adult beverage: sparkling water with lime.