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Korb: Pioneer of clinical optometry research
Donald R. Korb, OD, FAAO, is credited with research in ocular surface disease and contact lenses that has spanned decades.
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As part of Primary Care Optometry News’ 20th anniversary celebration, in each issue throughout 2015 we are profiling a “Pioneer in Optometry” as chosen by the PCON Editorial Board.
In this issue we feature clinician and innovator Donald R. Korb, OD, FAAO.
“Dr. Donald Korb is an extremely deserving individual for this award and perfectly exemplifies the pioneering spirit in optometry,” PCON Editorial Board member Scott G. Hauswirth, OD, FAAO, shared. “His dedication to research and astute observations regarding the intricacies of the tear film and components of the ocular surface unit have contributed immensely to our overall knowledge of dry eye and have fundamentally shifted our clinical approach in caring for our patients. The wake of his work has influenced my own practice, as well as optometry, ophthalmology and industry, and I am personally very happy to see my colleague receive this honor.”
PCON Editorial Board member Jerome A. Legerton, OD, MS, MBA, FAAO, told PCON: “Don Korb is relatively slight in stature and yet he is a giant in achievement in the ophthalmic industry. His contributions span 6 decades. I fit my PMMA lenses using the Korb Technique in the late 1960s and gave every patient a brochure on “Proper Blinking” with a picture of an owl with one eye closed that was authored by Don. He next invested time in the gas-permeable lens development space, followed by a great contribution with the CSI family of lenses with the wonderful polymer crofilcon and his attention to the importance of lens-eye relationship and edge geometry.
Donald R. Korb
“Don continued his interest in lids and the ocular surface and is best known to the current generation with his work in ocular surface disease and meibomian gland dysfunction (MGD). While these are intellectual, technical and commercial achievements, Don is also loved by everyone he touches. Don and his wife and professional partner, Joan Exford Korb, demonstrate their exemplary leadership and generosity to the profession in so many ways. While clearly a pioneer, he is even more a leader and a wonderful human being.”
“Dr. Korb is the quintessential clinician/researcher,” PCON Editorial Board member Randall Thomas, OD, MPH, FAAO, said. “From his standard-setting development of the CSI soft contact lens, to his development of a lipid-based artificial tear, to the development of his LipiView/LipiFlow (TearScience) technology, he has made massive contributions to both the profession of optometry and the science of ophthalmology. Donald intuitively embraces the concept of a team approach involving many researchers in his unrelenting pursuit of advancements for the betterment of humankind. Dr. Korb’s pioneering work has influenced other clinician/scientists throughout the world, and he (and his team of researchers) has radically redefined and redirected our perspective on dry eye disease from aqueous deficiency to meibomian gland dysfunction – a monumental paradigm change.
“Dr. Korb is truly legendary in his contributions to eye care, and I am honored to share these few words on his behalf.”
PCON Editorial Board member Ron Melton, OD, FAAO, commented: “Donald Korb is a ‘giant’ in the field of optometry, and his contributions in the area of contact lenses and ocular surface disease have been enormous. His work in the development of the CSI membrane lens and in MGD have helped shape the face of optometry over the past several decades. He is truly unique in having practiced clinical optometry in Boston for more than 50 years and yet he is better known as a researcher, inventor, lecturer and author.
“His dedication and allegiance to the profession of optometry has been extraordinary, and his many honors and awards much too numerous to list,” Melton continued. “Yet with all of the accomplishments, he remains one of the most kind and humble individuals I know. He has gone out of his way many times over the years to share his new ideas and research with me and Randall Thomas. For this I consider him a personal friend as well as a professional colleague and mentor. And you cannot talk about Donald Korb without giving his lovely wife Joan credit for being there by his side in this special journey. There is no one in our profession that deserves to be known as a ‘Pioneer in Optometry’ more than Donald Korb.”
In an interview with PCON, Korb shared his beginnings in optometry and what he considers to be his most significant contributions to the profession.
PCON: Why did you choose optometry as a career path?
Korb: I was myopic from the first grade, and my own myopic condition always interested me. Initially, I considered becoming a physician. During my premedical studies I discovered that I simply didn’t like the sight of blood, and the next thing I knew I was studying optometry, having been encouraged by a family friend who was an optometrist.
PCON: How has your career unfolded?
Korb: After graduation, I became excited about contact lenses, having been fortunate to have had a course in contact lenses the fourth year. This led me to seek clinical opportunities with pioneers in the field. With this knowledge I was able to understand the primary research questions at that time, such as, how one could accurately measure the topography of the cornea to better fit contact lenses. I was fortunate to obtain a position with the Polaroid Corp. here in Boston and was the principal for two projects: one on profile photography with “instant” 60-second infrared film, and the other on corneal topography. While technically successful, the computing power was lacking to bring the work to commercial fruition. But it did lay the foundation for my later research in that it was tremendously inspiring, and I learned how to invent, to patent and, most importantly, to collaborate.
Irvin Borish, OD, DOS; Leonard Seidner, OD; Korb; and Korb fellow Jack V. Greiner, PhD, OD, DO (from left to right).
Images: Korb DR
All of this time I was simultaneously practicing — seeing primarily contact lens and low vision patients 4 or 5 days a week — and conducting clinical research with the patient base while spending evenings in the laboratory. This established the pattern for my career: practice and research. My research career is built on the appreciation that, when I go into the examining room, I have a unique opportunity to observe what I do not know and what I do not yet understand. For that reason I have always maintained an active practice 3 days per week, with all of my remaining time in research. My stimulation and ideas have always been the product of contact with patients, particularly those with complex problems.
PCON: What are you doing now?
Korb: I am in the same mode that I have been for the past 40 years; very little has changed. In 2006 I cofounded my fourth startup company, TearScience, with the mission of bringing a new paradigm to the treatment of dry eye. In 1980 I, along with Antonio Henriquez, MD, PhD, of Barcelona, published the first paper establishing that obstruction of the terminal ducts of the meibomian glands had a profound impact on the tear film and resulted in dry eye symptoms and other signs. In that paper we named this condition MGD. This study, more than 30 years ago, established the mechanism of the obstruction that, remarkably, is still valid and provided the concept for TearScience to take the next steps.
The French philosopher Nicole reported there are very few original ideas, and it’s wise on occasion to revisit the work of the past. This is because prior work often fails to achieve success because the technology for one or more aspects of the work had not yet been developed. With the explosion of new tools and techniques in the realms of science, ophthalmology and optometry, we are now in a position to bring these areas to a successful end point.
The past 9 years have been very productive where, working with Caroline Blackie, OD, PhD; Steve Grenon, the head of research and development for TearScience; and many other colleagues, a resulting series of inventions and developments are changing the practice of ocular surface and dry eye.
Examples are: the first metric for meibomian gland function, the Korb meibomian gland evaluator; the first computerized interferometer, the LipiView; the first method cleared by the FDA for the treatment of evaporative dry eye, the LipiFlow; the first test for evaluating the efficacy of the lids sealing air from the ocular surface during sleep, the Korb-Blackie light test; and the introduction of débridement of the lid margins and Line of Marx to offer an improved surface for the storage and transfer of meibomian sebum from the skin to the tear film. I should further emphasize that over these past 9 years I have truly enjoyed a remarkable and highly productive research relationship with Dr. Caroline Blackie, a multifaceted and unique intellectual, researcher, statistician, innovator, collaborator and colleague. Without her collaboration, our work would not have reached its present level and broad spectrum status.
I have also recently embraced an additional personal mission: to proselytize that “dry eye is the wrong diagnosis for millions,” since we now know from the International Workshop on Meibomian Gland Dysfunction and other data that MGD may well be the leading cause of dry eye disease throughout the world. Our group is not attempting to change the name dry eye, because it is a very effective term to convey the symptoms and signs of the ocular surface disease. Our concern is that its use diverts our attention from the root cause of the majority of dry eye, MGD, and impedes specific treatment for MGD, directing treatment to dry eye’s tear production.
The 1981 launch of first membrane contact lens – the CSI.
We have submitted and look forward to the publication of the first study supporting the concept that dry eye is the wrong diagnosis for millions. It is our belief that this slogan will lead the field of ocular surface and dry eye forward to a new perspective and more effective treatment, just as anti-angiogenic therapies have revolutionized the treatment of wet macular degeneration.
PCON: What have you learned?
Korb: This is a difficult question, because I still learn virtually every day. I can offer that I was very fortunate to learn by observing Edwin Land, the founder of Polaroid and instant photography, that persistence and dedication to a passion is the prime ingredient for the success of any project. I have averaged 80 hours a week between clinical practice and research for the past 40 years. My only regret is that I did not have more time and energy for my passion to answer so many important questions. Frequently these questions were never addressed or, if addressed, were not published. I learned to focus on a single or limited number of projects at any one time to avoid diversion and failing to answer any question.
Perhaps one of the most helpful learning lessons for me was simple: to look seriously at the two ends of the clinical spectrum, those with and those without problems. One needs to understand the norm to understand the abnormal, but I have found that by welcoming all problems there is a wealth of opportunity. This philosophy led to me discovering corneal edema with contact lenses, MGD, lid wiper epitheliopathy, giant papillary conjunctivitis (GPC), nonobvious MGD and other conditions and tests including the Dry Eye Test for tear film stability and the Korb-Blackie light test.
I have also learned how to collaborate and to subjugate one’s ego. Subjugating one’s ego is easily learned here in Boston, as there are many individuals I see in practice or research who provide a clear example of extraordinary intellectual ability combined with the ability to communicate with clarity. Several are rated as number one worldwide in their field. A realistic comparative appraisal of one’s abilities compared to this community leaves one in awe, with the benefit that there is no justification for egotism.
And I have learned to treat others as you would wish to be treated if you were in their position and possessed their abilities. What I have not learned is to discipline myself to publish our work – most of my research is unfortunately unpublished, although I have been improving over the past 5 years, primarily the result of my full-time collaboration with Dr. Caroline Blackie, who is simply extraordinary in so many areas and my teacher in many.
PCON: What is your most significant accomplishment?
Korb: I have been fortunate to have had a number of satisfying accomplishments.
I hope that my work in MGD will be number one for significance. I recognize that it will be difficult to change the imbedded culture of the eye care professions from their position that dry eye is of tear production etiology rather than understanding that dry eye with its symptoms and signs are usually the sequelae of MGD. MGD results in evaporative stress and a host of sequelae, many of which are interpreted as primary or secondary etiologies of dry eye rather than as sequelae of MGD and resultant evaporative stress and evaporative dry eye (with the exception of severe immune disease, neuropathic involvement and mechanical factors). For that reason I hope to see the slogan that dry eye is the wrong diagnosis for millions replace the inadequate tear production model, which has dominated our thinking and led us for the past 100 years to ignore the critical role of meibomian secretion in maintaining the tear film.
In 1965, Korb developed the first infrared profile topographer at Polaroid Corp.
Korb’s current office staff.
I look forward to the adoption of targeted therapies for MGD, particularly those methods that address obstruction to the terminal ducts of the gland. LipiFlow is the first FDA-cleared treatment for MGD and evaporative dry eye. Because MGD is the root cause of 85% or more of all dry eye, these targeted treatments will be vital not only for those patients with dry eye and a diagnosis of MGD, but to prevent the condition from progressing and hopefully prevent MGD from starting. This is analogous to dental treatment and home therapy preventing gum disease and loss of teeth.
I have had many research passions. One of them was the creation of the first membrane contact lens, the CSI lens, in the 1970s. This was the first lens to mimic a membrane, with thicknesses of 20 microns to 50 microns. Marketed by Syntex Corp., it was very successful commercially. With its thin membrane design, this lens is the grandfather of most modern disposable and 1-day lenses. The evolution of materials and manufacture has relegated this concept to an occasional historical reference by those who fitted the lens early in their career.
However, others might judge my work in identifying and naming GPC to be of permanent value. With contact lens rigid designs, my development of designs that were known as lid attachment was very important at that time but has become less important with time and new designs. Similarly, the discovery of how to observe corneal edema resulting from rigid lenses was very important in demonstrating the problem and led to the development of GP lenses. Oxygen permeable materials then reduced these techniques to irrelevance.
Our study and publication indicating that pressure on the apex of the keratoconic cornea from lens bearing leads to corneal scarring (still the only study of this unfortunate result) has proven of long-term importance for all contact lens designs for keratoconus. But most of my early work has become irrelevant, since science and technology have moved forward and eliminated the problem the development addressed. An example is the fenestration of corneal lenses, obsoleted by GP materials.
However, I believe MGD and much of our current basic work will be important for generations. MGD, the result of terminal duct obstruction, will only increase with the demands of the electronic information age and will require both treatments for those with MGD and prophylaxis for all those who we now know are at risk. However, even as it has taken the dental profession more than 50 years to change culture and implement flossing with approximately 50% of the population, I would predict that implementing prophylactic treatment for MGD will unfortunately require a generation, but the time to start has passed.
Our work with lids, including diagnostic tests such as the Korb-Blackie light test and lid margin débridement, will remain in clinical practice as important diagnostic and treatment tools for generations because lid and ocular anatomy will not change. All of this is very exciting in that it changes our perspective and leads to still more questions for us and others to pursue. And this may be the greatest pleasure of all: to make and present observations and outline the questions for the future, see others embrace the areas and then have the pleasure of observing their contributions.
PCON: What have you contributed to optometry?
Korb: I hope that my and my colleagues’ research has contributed not only to clinical optometry but has demonstrated that the clinician can also be a clinical scientist and make worthwhile contributions. In addition, I have also been active in education and in expanding the scope of optometry. I have served as the educational chair of many organizations, including the American Academy of Optometry’s contact lens program and then as the chair of the general program of the academy. I used these positions to bring key areas to the profession’s attention, including holding the first interdisciplinary colloquium on drugs at the academy in 1969, which proved critical in supporting the first diagnostic drug bill in Rhode Island. I have been a passionate advocate of research by optometry, having been taught that research is necessary for the vitality of any profession.
PCON: What do you enjoy most about optometry?
Korb: I enjoy the challenges and the broad-spectrum nature of all that can be achieved in optometry. It is truly remarkable, and despite all of the advances that I have been privileged to be a part of – from dry eye to contact lens designs to low vision – the field is virtually unlimited, particularly with the expanded scope of the profession. Being able to work face-to-face with patients is another true privilege. Lastly, the relatively small size of the profession compared to medicine has allowed the development of friendships and collegiality that is far more difficult as the group enlarges.
PCON: What do you wish for the future of optometry?
Korb: I foresee optometry evolving to being the dominant primary care eye profession, with ophthalmology focusing on tertiary medical care and surgery. The challenge will be to provide adequate residencies and fellowships to achieve a high level of competence across the broad spectrum of primary eye care. I am very optimistic that this will continue to progress, and optometry will be universally recognized as the entry point for eye care, with unmatched expertise in many areas, from contact lenses to dry eye to functional vision. – by Chelsea Frajerman Pardes
- Reference:
- Nichols KK, et al. IOVS. 2011;52(4):1917-2085.
Disclosure: Korb developed the CSI family of lenses and cofounded TearScience.