Robert Stegmann, MD: taking on the challenges of ocular trauma and disease

In addition to his seminal work with viscoelastics, Dr. Stegmann has repaired hundreds of eyes injured in the African bush.

Elephants roam the game preserve not far from the office of Robert Stegmann, MD, outside Pretoria, South Africa. A self-proclaimed “bush surgeon,” he was raised in South African bush country, where life depends on self-reliance. Confidence and the ingenuity to survive are traits he has brought with him into the practice of ophthalmology.

“I grew up in the bush during my formative years. In the bush, you have to learn to survive,” Dr. Stegmann said.

Accustomed to challenges, Dr. Stegmann was drawn to ophthalmology, which he felt had plenty for him to tackle. Born to a family with a tradition in the practice of law, Dr. Stegmann was the first in his line to choose medicine as a career. He initially chose dentistry as his specialty but decided to change to ophthalmology in his third year of medical school.

Robert Stegmann, MD, was the first in his family to choose medicine as a career.

“I found it difficult to find something in medicine that was stimulating and exciting. What appealed to me about ophthalmology was that you didn’t have to guess for a diagnosis. Everything you saw was through high magnification at the slit lamp,” he said.

At the time when Dr. Stegmann was studying, ocular surgery under a microscope was still new, but when he saw such surgery performed – “It really blew my mind,” Dr Stegmann said. “It just seemed to be such absolute control.”

Other factors drew Dr. Stegmann to ophthalmic surgery, along with its precision.

“Ophthalmology seemed to combine a lot of stimulating challenges. There are very few diseases in the human body that do not manifest themselves one way or another in the visual system. It had a little bit of everything: mechanics, surgery, it had stimulation, medicine, decision-making, and it had great results,” he said.

Since Dr. Stegmann chose ophthalmology as his specialty he has made “bush surgery” something of a subspecialty, honing his skills to match the diseases and the types ocular trauma that most commonly affect his patient base in South Africa.

Dr. Stegmann was first widely recognized for his early work with viscoelastics, substances that have made cataract surgery safer and more controlled. Today he is working to perfect his now widely known viscocanalostomy procedure for glaucoma. He continues to focus on ocular trauma in his daily practice.

Stepping up to challenges

Working in the South African bush, Dr. Stegmann encounters many cases of ocular trauma, an area with which most ophthalmologists have little experience. Dr. Stegmann and his wife have arranged research funding in order to pay travel expenses for their patients’ follow-up visits after viscocanalostomy surgery. Dr. Stegmann said that he and his wife pay the equivalent of $8,000 to $9,000 a month in bus and train fares to bring these patients back because many are poor patients for whom it is a hardship to come back twice a year. Dr. Stegmann enjoys many outdoor hobbies such as golf, trout fishing and wildlife painting.

Working in the South African bush, Dr. Stegmann encounters many cases of ocular trauma, an area with which most ophthalmologists have little experience.

“I operate mainly on the problematical: pediatric cataract, pediatric glaucoma, serious trauma and congenital defects in adults. I don’t do routine cataracts anymore. I used to, but I find these types of cases much more challenging,” he said.

Dr. Stegmann said he chose these difficult procedures to concentrate on not only because they are challenging but because they are necessary in his patient population.

Ocular trauma is common in South Africa, he said, where children’s eyes are often punctured by thorns while they are running through the bush country. Some branches in the bush hold long, curved, hooked thorns, and trauma sustained from them can be severe, he said.

Frequent occurrence of this type of trauma spurred Dr. Stegmann to develop innovative surgical approaches.

“I have an interest in making anything better. Most ophthalmologists don’t like ocular trauma because it looks terribly time-consuming, and the results have been uniformly bad over the past decades. It’s the domain of the emergency-room staff late at night. But to me, to be able to take these badly injured eyes and put them together again and restore almost normal vision in a far higher percentage of cases than were ever dreamt, is one of the most exciting and challenging areas I’ve ever been involved in,” he said.

Pediatric cataracts have also held his interest.” Pediatric cataracts is a field that I believe has been terribly neglected, and I do believe that today we have literally the same results in a pediatric case as in an adult case. This is something, again, that was never dreamed of until recently,” he said.

Intractable glaucoma is another common problem in Dr. Stegmann’s patients. Because the standard glaucoma treatments did not seem to benefit his patients, out of frustration he looked for a better way to treat them. He developed viscocanalostomy, the procedure for which he is probably best known currently. The procedure reopens Schlemm’s canal to allow circulation and dispersion of aqueous to resume. In 1989, he began using it as his first-line treatment of glaucoma.

Although the concept is simple, according to Dr. Stegmann, the procedure is delicate, involving pumping viscoelastic into Schlemm’s canal to dilate it and allow aqueous fluid to circulate through it once again. The technique lowers intraocular pressure and has been successful in stabilizing field loss in many of his patients. He said his current reoperation rate is about 20%, although he thinks a newly adopted method of statistical analysis of his data may bring his success rate up closer to 90%.

Dr. Stegmann credits himself as the originator of the viscocanalostomy procedure but not of the idea.

“There were people long before me who thought of this. The sad part is they didn’t have the operating microscopes and instruments for it in the 1960’s to return aqueous to the canal. I may have come up with an operation that was original, but I was only standing on their shoulders,” he said.

Complications of the procedure are few, but intraocular pressure may increase again postoperatively, requiring treatment with beta-blockers or a second surgery, Dr. Stegmann said.

“You’re opening a canal the size of a human hair, so for it to close off is not too difficult,” he said.

The technique has drawn the interest of ophthalmologists all over the world, but Dr. Stegmann continues to closely monitor his results. He and his wife, also an ophthalmologist, meticulously document patient results with twice-a-year follow-ups after surgery.

“What’s exciting is that I started performing this in 1989, and I still learn something new every 2 weeks. I think this is the first time the profession has looked at glaucoma in a more objective manner,” he said.

His viscocanalostomy patients stay in the hospital for 2 weeks (for which they pay the equivalent of about $1.50), then are seen 2 weeks after they are discharged, again at 3 months, and then every 6 months thereafter. The Stegmanns have been following some cases for 11 years, he said.

Husband-and-wife team

Dr. Stegmann and his wife, Anëna Stegmann, MD, work together. He said he admires her bedside manner as an ophthalmologist.

“She has a rapport with patients that I may never in my life have. I may have the respect of patients, but she has their love. People said working together would be the end of the marriage, but if anything, it’s strengthened it. Without her, I could never have done what I’ve done,” he said.

Dr. Anëna Stegmann arranges the follow-up care and has orchestrated research funds so that the Stegmanns can pay their patients’ expenses to come back for examinations.

“We pay the equivalent of $8,000 to $9,000 a month in bus and train fares to bring these patients back because they’re poor patients and it’s a real hardship for some of them to come back twice a year. It’s a lot of money to pay out of pocket. Some of them come as far as 400 miles,” he said.

After Dr. Robert Stegmann’s viscocanalostomy surgeries, Dr. Anëna Stegmann examines each patient at the slit lamp. Then her husband examines them again when he comes out of the operating room. Together, they have reviewed more than 7,000 cases.

Busy but blessed

Dr. Stegmann is often visited by surgeons who want to see him perform viscocanalostomy. He also travels extensively to ophthalmic meetings and has taught the procedure in hospitals all over the world

This leaves little time for pastimes, but in past years he enjoyed wildlife painting and was also a passionate trout fisherman.

“I used to play a lot of golf, tennis, squash and cricket, which have all fallen by the wayside. Basically, I have many interests which sooner or later I will revive,” he said.

Though he would like to have time to improve his golf game, he stays committed to solving the challenges of ocular disease.

“I’d like to play more golf, but I’ve been so busy. But I’ve also been very blessed. I never thought that in the time that I’ve been in ophthalmology, I would have been exposed to so much exciting and gratifying work and have met so many exciting, intuitive minds,” Dr. Stegmann said.

007

Dr. Stegmann first received attention in ophthalmology for his work in viscoelastics as a fellow of David Miller, MD, at Harvard Medical School. In 1977, Dr. Miller was interested in applying Pharmacia’s recently developed hyaluronic acid product, Healon, in IOL surgery. Dr. Stegmann did some of the animal work on Healon in Boston and then performed clinical trials of the substance in surgical patients in South Africa during 1978.

Through their work together, Healon was approved by the Food and Drug Administration in a remarkably short time. From animal studies to human clinical trials to FDA approval took only about 2 years.

“It was a bit of a fairy tale how quickly everything fell into place,” Dr. Stegmann said.

Dr. Miller said he greatly admires Dr. Stegmann for devoting his career to poor patients in South Africa. As a South African government employee, Dr. Stegmann is salaried, Dr. Miller pointed out.

He said Dr. Stegmann has operated on more than 8,000 injured eyes, whereas most ophthalmologists have done only perhaps a few hundred.

“They don’t cut them like Rob Stegmann. There’s nobody in the business like him. He’s incredibly honest, has the best surgical hands I’ve ever seen, and has given his talent to the poorest people,” Dr. Miller said. “I don’t know a better surgeon in the world than him.”

Dr. Stegmann’s ability to succeed in his efforts through perseverance and hard work earned him the nickname “007” from Dr. Miller’s children, after a certain suave, tuxedoed secret agent.

“He’s a gifted surgeon, golfer, a ranked tennis player, an expert photographer and a marvelous teller of stories. He can do anything,” Dr. Miller said.

Challenges for the future

Asides from his ongoing work in glaucoma and ocular trauma, Dr. Stegmann has been working on what he sees as the next step in refractive surgery. Since 1984, he has been intermittently working on refractive surgery from the intraocular side, where he believes more refractive problems can be corrected. His idea is to refill the capsular bag with an accommodating lens material. The goal is to restore older eyes to the state of a young eye with perfect vision. Although the final necessary ingredient has not been developed, Dr. Stegmann said he has successfully performed all the preliminary steps of the procedure in baboons.

“The obvious next step in refractive surgery is to replace the natural lens with a lens that would give the patient full accommodation. … That’s the challenge of the future,” Dr. Stegmann said.

“We’ve gone through every step except finding the right polymer, which I hope is right around the corner.”

The challenges ahead for him are still plenty, despite his full career, he said.

“I’d like to sew up surgical glaucoma. I’d also like to take certain aspects of surgery such as penetrating keratoplasty to a level it would be tailor-made, so that 20/20 or 20/15 would be the rule and not the exception,” Dr. Stegmann said. “Whether I will have the time to do it is questionable. At the same time I don’t want to be greedy because I’ve certainly had a wonderful inning.”

For Your Information:

• Robert Stegmann, MD, can be reached at the Medical University of South Africa, P.O. Box Medunsa 0204, Pretoria, South Africa; +(27) 12-521-4111; fax: +(27) 12-560-0086.
• David Miller, MD, can be reached at 100 Charles Plaza, Boston, MA 02114; (617) 523-2010; fax: (617) 523-4242; e-mail: millermd@massmed.org.