Health, medicine, and ophthalmology: facing the facts and paying the piper LVI Edward Jackson Memorial Lecture

PURPOSE: To describe the sources of tension within the health care system and methods for pursuing their solution. METHODS: Presentation of observations pertinent to patient, provider, and payer perspectives relevant to the cost, delivery, and quality of care and their impact on health. RESULTS: Societal forces, not just wealth, are major determinants of both health and the costs of health care. CONCLUSIONS: Tensions created by rising health care costs in the face of finite societal resources will increase in the years ahead. These can be resolved only by realizing new efficiencies in care, and prioritizing, through an explicit process, the care that is to be provided.     

Survival with excellence: education and the future of ophthalmology. XLII Edward Jackson memorial lecture

Health care and medicine are in tremendous flux. Survival of the specialty of ophthalmology in a traditional sense is in question. Positive adaptation to our new environment must occur. A central focus of ophthalmology has always been its commitment to excellence in education. Residency education in ophthalmology is at a high level. Far more random and non-individualized education characterizes continuing education in ophthalmology and all of medicine. The fundamental approach is to base our future on personal accountability and excellence in providing consummate care. I have proposed a more systematic, individually oriented approach to continuing education in ophthalmology. A combined effort by the American Academy of Ophthalmology with other ophthalmic organizations and the individual ophthalmologist would provide individual assessment and educational programs based on practice setting and clinical emphasis.     

Factors related to the initiation and recurrence of uveitis. XL Edward Jackson memorial lecture

Uveitis comprises a complex group of diseases in which morbidity may depend on the nature of the initial inflammation as well as on the genetic, hormonal, and emotional background of the patient. Uveitis is initiated in every instance by some form of tissue injury. This may occur as an attack on individual cells by organisms such as Toxoplasma gondii or Herpesvirus hominis. Autoimmune disease may be produced as a late result of microbe-induced injury. The development of specific forms of autoimmunity seems to be dependent upon genetic as well as hormonal factors, particularly estrogens. Tissue injury of immunologic origin takes several forms, such as cytotoxic damage from sensitized lymphocytes, immune complex-mediated injury, and injury from the oxidative products of inflammatory cells. In some cases, permanent alteration of uveal vascular permeability results. Recurrent uveitis may be attributed in some instances to the reappearance of infectious organisms in the target tissue. In other cases, recurrence of inflammation may be attributed to the localization of immune complexes in the uveal tract. Changes in immunoregulation can be attributed to pregnancy, aging, and emotional factors. Neurohumoral pathways related to stress-mediated changes in immunoregulation have recently been described in laboratory animals. These pathways may be linked with stress-related recurrences of uveitis in humans.