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  • Remembering Paul A. Chandler, MD

    The legacy of Paul Austin Chandler, MD (1896-1987) deserves to be remembered for many reasons.

    A Harvard professorship bears his name as does one of the most respected glaucoma organizations, the Chandler-Grant Glaucoma Society. In addition, the recently released sixth edition of “Chandler and Grant's Glaucoma” is one of the preeminent textbooks in the field.

    It’s impossible to convey the full range and depth of Dr. Chandler's contributions in the space of this article. But hopefully I can provide some basic insight into how Dr. Chandler earned such profound respect in the field of glaucoma by reviewing some of his significant contributions, contributions in the context of a tireless teacher, a skilled clinician and master surgeon and as a pioneer of new insights into glaucoma diagnosis and treatment.

    Dr. Chandler was educated at Harvard Medical School and completed his residency training in ophthalmology at the Massachusetts Eye and Ear Infirmary. After residency, he briefly practiced in Nebraska, but soon returned to Boston, where he joined the clinical staff at Mass Eye and Ear and developed a referral practice with special emphasis on glaucoma. He was an avid teacher, and once back in Boston, he started giving well-regarded lectures on clinical glaucoma management.

    Around 1940, he was joined in this teaching effort by his friend and colleague, W. Morton Grant, MD. In 1964, Drs. Chandler and Grant were invited to give a series of talks at the New England Ophthalmological Society. A year later, their talks coalesced into a book. Chandler and Grant published “Lectures on Glaucoma.” Their initial book remains remarkably readable and informative, providing thoughtful and practical guidance aimed at the ophthalmic practitioner caring for patients with glaucoma.

    Dr. Chandler created a prominent reputation as a glaucoma consultant. Colleagues appreciated his exceptional knowledge of glaucoma, which he conveyed in a clear and straightforward manner. His surgical skills were exceptional, and he was always eager to share surgical advice and compare methods. Once convinced of the value of peripheral iridectomy for treating a narrow angle, Dr. Chandler became an ardent proponent and practitioner of the procedure, but he was always quick to point out that credit for the theory behind the operation — relative pupillary block — belonged to  others. Although not the originator of peripheral iridectomy, he did introduce important new modes of therapy — both medical and surgical — for malignant (ciliary block) glaucoma, one of the most devastating post-operative complications of surgery for narrow angle glaucoma.

    Paul A. Chandler, MD. Image reprinted with permission from the Abraham Pollen Archives at Massachusetts Eye and Ear.

    Malignant glaucoma is a particularly troublesome condition characterized by elevated intraocular pressure along with marked, unrelenting shallowing of the anterior chamber, typically developing after filtration surgery for uncontrolled angle closure glaucoma. Reasoning that relaxation of the ciliary body, by increasing tension in the lens zonules, might deepen a flattened anterior chamber, Drs. Chandler and Grant initiated a trial of mydriatic-cycloplegic treatment in malignant glaucoma. This new therapy was successful in all eight of their initial cases, and it remains a useful therapy for this condition. By odd chance, the treatment was unsuccessful in their next six cases, which resulted in instructive discussions, particularly with their trainees, because a potentially useful treatment could have easily been rejected if the order of cases had been reversed.

    When medical therapy fails, malignant glaucoma requires surgery, and Dr. Chandler was a thoughtful contributor to the development of effective surgical management for this condition. In these extreme cases, some surgeons had resorted to lens removal, sometimes with good effect. But lens removal was an awkward choice, since, in some cases the lens was still clear, and intracapsular extraction — the standard at the time — required major (large incision) surgery on what was usually a highly inflamed eye. San Francisco ophthalmologist Robert N. Shaffer, MD, had developed the hypothesis that the cause of the shallow chamber was a misdirection of aqueous humor into the vitreous where it was trapped. Dr. Shaffer had advocated releasing this trapped aqueous using deep incisions into the vitreous face after lens removal. Dr. Shaffer's success with this approach agreed with Dr. Chandler's observation that lens removal was most beneficial when accompanied by vitreous loss.

    To relieve trapped aqueous while avoiding potentially hazardous lens removal, Dr. Chandler developed a new method to remove aqueous humor that was being trapped posteriorly. He introduced a large bore needle directly into the vitreous space — passing the tip posteriorly, through a peripheral iridectomy and underlying zonules and between the edge of the lens and the tips of the ciliary processes — a "peri-lenticular incision." He had good success with this bold and innovative technique in a small number of cases, though he later abandoned it due to complications — mainly cataract. It was later refined and revived and incorporated into an elegant stepwise approach by his associates, Dr. Richard J. Simmons and Dr. Grant. Of interest, in pseudophakic eyes, successful surgical results are now being reported by anterior segment surgeons using Dr. Chandler's peri-lenticular pathway to treat malignant glaucoma.

    Another of Dr. Chandler's notable contributions was his description of a unique form of essential iris atrophy now known as Chandler's syndrome. This paper, like many of his clinical reports, was based on his meticulous and well-documented study of a small number of cases. The unique character of these cases, in contrast to essential iris atrophy, was a distinctive abnormality of the corneal endothelium (creating a "hammered silver" appearance), very mild iris alteration (no full thickness “holes”) and mild glaucoma that was more likely to cause corneal edema than to damage the optic nerve.

    Before concluding, I would like to make some comment on Dr. Chandler's character and values. Many important attributes are revealed by his lifelong commitment to all forms of teaching, his steadfast support of his colleagues, his responsive and effective care of patients and his remarkable energy and interest in all facets of glaucoma. His fame built up slowly, year by year, on a foundation formed by patience and persistence coupled with his excellent powers of observation and an ever-present desire to improve patient care.

    Consider, as an example that the first edition of “Lectures on Glaucoma” was distilled from 30 years of public lectures — material honed, refined and improved before a live audience. Dr. Chandler was fond of Newton's quote regarding the way scientific knowledge expands: "We stand on the shoulders of giants." For Dr. Chandler this was a sincere expression of his humility and gratitude for his education and the opportunities it had provided him. He was naturally pleased that he had been able to contribute personally in his chosen field, but he maintained a healthy and balanced perspective, and readily acknowledged the influence of others on his thinking.

    Furthermore, he was friendly and easy to talk with, honest and down-to-earth, and he knew how to laugh at himself, as this story shows. Although he was often sought out for consultation, he was also often ready to seek consultation for himself when he found a situation puzzling. This often meant sending a case over to the Howe Lab for Dr. Morton Grant’s input. On this occasion he sent a young man with unexplained mild and intermittent glaucoma symptoms in one eye. Dr. Chandler called Dr. Grant and asked if he had solved the mystery. Dr. Grant responded: “Yes, I have. I think this man has Chandler’s syndrome.” The master clinician had missed diagnosing his own syndrome! Both men laughed heartily at this ironic twist, and afterword this “teaching moment” was freely and frequently shared with others.

    In closing, I’d like to give a final tribute to Dr. Chandler’s role in shaping the learning environment at the Mass Eye and Ear Infirmary — namely, his participation in the weekly glaucoma meeting in Dr. Grant’s laboratory. These were small meetings characterized by their informality and welcoming atmosphere. There was no written agenda — anything glaucoma related was appropriate, and exchange of ideas was free and open. It’s hard to explain fully, but almost always the conversation was vital and exciting. Dr. Chandler came to meetings eager and full of interest, happy to listen to others, and, when asked, happy to share from his own rich experience — freely discussing not just moments of triumph, but also occasions with troubling clinical outcomes as well. He participated and contributed, but didn’t dominate, and in this way he helped establish the unique atmosphere of these valuable gatherings.

    Dr. Chandler has earned an enviable reputation in glaucoma — he has become one of those giants on whose shoulders those who follow now stand.