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July, 2009

Visionary

NEI's One-Stop Shop for Ophthalmology

By Genevive Bjorn, M.S.
NEI Freelance Science Writer

Rachel Bishop.
Rachel Bishop, M.D.
Chief, Consult Services Section
National Eye Institute

Rachel Bishop, M.D., spends her days examining people who come to the National Eye Institute (NEI) outpatient clinic. She's a general ophthalmologist, so she sees patients who have a wide variety of eye disorders. As head of the NEI Consult Service, she's the go-to eye doctor when patients from anywhere within the National Institutes of Health (NIH) need their eyes examined while they are participating in a medical study.

In a recent interview, Bishop talks about her three years at the NEI and her latest research project involving a condition called graft-versus-host disease.

What types of patients do you see at the NEI?

Patients are here at the NIH for a wide range of research purposes, and my patients see me as part of their care while they participate in clinical trials. The patients I see have a protocol number that tells me the study in which they are enrolled and the Institute sponsoring it. So nobody comes in off the street to see me. I'm really a consultant, and that's why my area of the NEI clinic is called the Consult Service.

What's your specialty?

I'm pretty much the only clinician at the NEI who doesn't practice a subspecialty within ophthalmology. I evaluate any patient who has an eye problem, regardless of which part of the eye is involved. What allows me to do this is my terrific colleagues. I can knock on any of their doors when I need help assessing a patient, and without that, I certainly couldn't be a one-stop shop for ophthalmology. We see some complicated patients, and a team effort is necessary to manage these cases successfully.

How do you handle all the paperwork involved in being a one-stop shop?

You might be surprised, but I don't face the bureaucratic challenges that most doctors do. One reason for this is that my service is small. Two of us, my ophthalmology partner and I, see most of the patients. We typically see fewer than 12 patients each per day. The other reason is that there's no private insurance to deal with because all of the costs are covered under the research protocols. The only exception is if patients need medications for conditions unrelated to a research study. They have to fill those prescriptions on their own.

You came to the NEI about three years ago. How has your experience been?

It has been terrific. I'm very well supported by a great boss, a wonderful technician, and an excellent support staff in the clinic. I have zero complaints. Can you believe it?

You're planning to start your own research study. What eye problem are you addressing?

Some of my most challenging patients are those with a condition called graft-versus-host disease. This occurs when a person with one of a variety of diseases, including types of leukemia and lymphoma, receives a stem cell transplant from a donor. Immune cells in the transplanted tissue can attack cells in the recipient's body. If these immune cells destroy the lacrimal gland--the gland that produces tears in the eye--the patient can experience severe dry eye. We call this condition ocular graft-versus-host disease.

How are you planning to approach this disease?

Currently, cyclosporine eye drops are routinely used as an anti-inflammatory medicine to treat dry eyes. They are also used to treat ocular graft-versus-host-disease, but only after someone has already developed the condition. By that time, it's often too late for the treatment to be effective. So in this study, we want to see whether using cyclosporine as a preventive treatment in a sustained form, before a patient notices any eye problems, will reduce the development of ocular graft-versus-host disease. We're still working on the details of the study, but the cyclosporine will likely be delivered through a device implanted under the conjunctiva--the thin, clear tissue that lines the white surface of the eye.

Wouldn't that feel uncomfortable? Even the tiniest speck of dust in the eye can be really irritating.

Not necessarily. When you get something like dust in your eye, what you're feeling is most likely irritation from the cornea, where there are a lot of nerves. People can't tolerate surface irritation, but this device would be implanted under the eye's surface, where it should be well tolerated. Ultimately, we hope to make patients more comfortable. And at the end of the day, it's helping patients feel better that brings me the greatest reward.

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