A Great Conversation With Lanning Kline

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD A Great Conversation With Lanning Kline Meagan D. Seay, DO, Rachel Calix, MD, Kathleen B. Digre, MD M eagan Seay (MS): Today, we’re speaking with Dr. Lanning Kline, a neuro-ophthalmologist at the University of Alabama in Birmingham (UAB) and the University of California San Diego, as well as the former editor of the Journal of Neuro-Ophthalmology (Fig. 1). We’re happy to have you with us today. I’d like to start by asking you about where you grew up and your life before medical school. Lanning Kline (LK): I grew up in Edmonton, AB, Canada. I’m a Canadian by birth. I don’t think that I can tell you exactly why I became a doctor. My father was in the jewelry business and ran a very successful jewelry business in Edmonton. My mother seemed to think that “you can do better than going into the jewelry business.” So I guess that influenced me not to become a businessman! LK: Upon graduating from high school, I went to the University of Alberta to get a bachelor’s degree. I applied to both law school and medical school. I took the Medical College Admission Test (MCAT) and as the day got closer for the Law School Admission Test (LSAT), for a variety of reasons, I decided I did not want to be a lawyer. I applied to some medical schools in Canada and the United States. One of my father’s best friends was a cardiologist who had colleagues that did some of their training at Duke and encouraged me to apply there. I was fortunate to be accepted at Duke medical school. MS: Do you regret not going to law school? LK: No, I don’t really regret it at all, and certainly I love being a neuro-ophthalmologist, so it worked out. MS: What interested you in ophthalmology while you were a med student? LK: My uncle, my father’s brother, was an optometrist. He told me that if I went to medical school, I might want to think about ophthalmology. Maybe that had some influence. I was always interested in the eye. I remember doing some projects in high school that had to do with vision and color vision. In medical school, I did an ophthalmology rotation at Duke and really enjoyed it. MS: Tell us about where you did residency. LK: Well, I’ll just finish by saying that Dr. Stanley Appel was the Chair of Neurology at Duke when I was in medical school. One of my electives was neurology, which I really enjoyed. I got into this bind about whether I should do ophthalmology or neurology, and that led me to neuroophthalmology. I enjoyed surgery, so I pursued a residency in ophthalmology. LK: When I applied for an ophthalmology residency, I thought I was going to move back permanently to Canada. That was my plan. So I went to McGill University in Montreal. At the time, Brian Younge was the neuroophthalmologist at McGill and the Montreal Neurological Institute. I thought if I’m going to go back to Canada, that would be a place to get exposed to neuro-ophthalmology. MS: So, then you went back to Canada for residency? LK: Right. I did my residency at McGill and then I wanted to do a fellowship in neuro-ophthalmology. There were a number of programs that I looked at. I narrowed it down to the Bascom Palmer Eye Institute, the University of Iowa, and the University of California in San Francisco. I was reluctant to apply to UCSF as my mentor would be Departments of Ophthalmology and Neurology (MDS, KBD), University of Utah Moran Eye Center, , Salt Lake City, Utah; and Departments of Ophthalmology and Neurology (RC), Ochsner Medical Center, , New Orleans, Louisiana The authors report no conflicts of interest. Address correspondence to Meagan Seay, DO, 65 Mario Capecchi Dr., Salt Lake City, UT 84132; E-mail: [e-mail] 282 FIG. 1. Lanning B. Kline, MD. Seay et al: J Neuro-Ophthalmol 2022; 42: 282-286 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations William Hoyt. He was known as a demanding teacher and I was somewhat intimidated by his reputation. LK: I ended up doing a fellowship in Miami, and my mentor was Joel Glaser. Some people would call that the “golden age” of neuro-ophthalmology in Miami, because not only was Dr. Glaser there, Lawton Smith was there as well as Robert Daroff, Lou Dell’Osso, and Noble David. There were 5 “heavyweights” in neuro-ophthalmology at the time, and it really made for an incredible experience. LK: The other attraction was that the Bascom Palmer was the premier eye institute in the country. There were other people there like Dr. Don Gass in retina, and when attending his conferences, you’d learn so much more ophthalmology. It was an incredible experience in terms of just continuing to learn more ophthalmology, as well as doing neuro-ophthalmology. MS: Are there any particular pearls you remember from fellowship that stuck with you throughout your career? LK: Joel Glaser was my mentor, and he was a tremendous teacher, extremely smart, and a very caring man. At times, his personality could be “prickly,” but when you got to know him, he was tremendous, and we became great friends. LK: My time with Lawton was also memorable. He was probably the best clinical teacher I’ve ever been around. He had a spell-binding way to lecture, and he had a great way of organizing and thinking about things in a way that really stuck with you. He made complicated subjects understandable and did so with medical students, residents, fellows, and practicing clinicians. LK: I would say, although Dr. Glaser and Dr. Daroff were terrific mentors, as was Dr. David, Lawton Smith had a tremendous influence on me in terms of how to teach neuro-ophthalmology. MS: Do you think you’ve been able to translate that to the trainees that you’ve been working with? LK: One of the things I’m really proud of is a book, which I edited for over 30 years, called NeuroOphthalmology Review Manual. It was initially written by a previous Bascom Palmer fellow named Frank Bajandas. Frank was at the University of Texas in San Antonio. He created this book, incorporating much of what he was taught as a fellow. LK: And I remember there was an Academy meeting in Atlanta in the 1980s, and I had lunch with Frank and I told him how much I admired his book. I told him when he revised the book, I’d be honored to do it with him. He said, "Lanning, that would be great. I’m going to do it within a year or two.” And then unfortunately, within 6 months to a year after the Academy meeting, he was killed in a car accident in San Antonio. I contacted the publisher and updated and revised it through another six editions (1) (Fig. 2). LK: These days using books is not a particularly popular way of learning. So getting the book through multiple Seay et al: J Neuro-Ophthalmol 2022; 42: 282-286 FIG. 2. Lanning Kline has edited three books including Neuro-Ophthalmology Review Manual, Optic Nerve Disorders, and Curbside Consultation in Neuro-Ophthalmology. revisions over three decades is certainly one of the things that I’m really proud of. But Frank Bajandas had built the framework. I added additional chapters, but kept it in a bullet point form, with simple but accurate diagrams. Kathleen Digre (KD): It still is a treasure today; it’s a very important book. LK: Drs. Vaphiades and Foroozan, who now serve as editors, were kind enough to rename it “Kline’s NeuroOphthalmology Review Manual.” MS: Tell us about after fellowship. What was your first job? LK: My first job is still one of my current jobs. My wife and I looked at a number of job opportunities. I had about 8 or 9 interviews. But really, my wife, Ricki, had the final say, and she thought that Birmingham, Alabama, was the most welcoming community (Fig. 3). So I took the job there, and although over the years, I looked at a number of other opportunities, the grass is not always greener and, subsequently, stayed at UAB in Birmingham. LK: Our son, who is married with two of our grandchildren, lives in San Diego, and a number of years ago we purchased a place in San Diego. I approached Robert Weinreb, who’s the Chair of Ophthalmology at the University of California San Diego (UCSD), asking if he could use some help in neuro-ophthalmology. Dr. Weinreb, said, "Yeah, we’d love to have you.” So I’m now fortunate to 283 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 3. Ricki and Lanning Kline. work part of the year with Peter Savino, also a neuroophthalmologist at UCSD. MS: So, you live in Alabama still? LK: We live most of the time in Birmingham, and several months in San Diego, as well. MS: When you took the job at Alabama after fellowship, did you envision yourself being there throughout your career? LK: You know, we thought “3 to 5 years and we’ll move on.” But, I never did. At that time I was the only neuroophthalmologist in Alabama. However, the ophthalmology department at UAB began to struggle. So I joined a private group, but was still involved in teaching and publishing. After 14 years in private practice, I was approached to become the Chair of the department and help transform it into a traditional academic department. LK: I did become the Chair in 1998, and served for 14 years. My successor is a glaucoma specialist, Christopher Girkin. He has done a spectacular job of growing the department, especially the research enterprise. MS: Is there anything you would go back and tell yourself in your early years, if you could? LK: No, I don’t think so. But becoming Chair of a department, requires a solid foundation at home. They’re grown now, but we have 2 children, and my wife is an incredible person. I was away a good bit and did a lot of work on the weekends. In addition to running the department, I was building my academic career. Without Ricki’s support, I doubt that I would have been successful. 284 MS: We know that you eventually became the editor of the JNO. Can you tell us about that? LK: There’s this lady named Kathleen Digre. Kathleen called me to ask me if I would consider being the editor of the Journal. Following Lawton Smith, Ron Burde, and Jonathan Trobe was going to be a pretty tall order. But as you probably know, Kathleen has a very persuasive way about her. I interviewed for the job one year at the North American Neuro-Ophthalmology Society (NANOS) meeting in Lake Tahoe and was fortunate to be selected. It, too, was another major accomplishment and it was a wonderful experience. Kathleen encouraged me to hire a managing editor and introduced me to Jason Roberts. He was serving as managing editor of the neurology journal, Headache. The managing editor does a lot of behind-the-scenes work including making sure the manuscripts flow properly and comes up with new ideas for the journal with the help of the editorial board. Jason was absolutely phenomenal. With Kathleen being the Chair of the publications committee, and Jason being the managing editor, and fortunately, selecting a really strong editorial board, it was sort of a nobrainer. Fortunately, we were able to improve the quality of the Journal. We doubled the impact factor in eight years, and Laura Balcer has continued to make the JNO even better. KD: You were the mastermind behind that journal moving forward. I know quality when I see it. LK: You’re very kind! I certainly don’t have any regrets about being the editor. It was a great experience, and I really believe that I made a meaningful contribution to NANOS and to neuro-ophthalmology. Rachel Calix (RC): In addition to that contribution, what else would you consider your biggest successes, either professional or personal? LK: Well, as I have already alluded to, I have a successful marriage. To me, family always comes before anything else. There are two other things that stand out as I think back on my career. First, I was involved with the American Board of Ophthalmology (ABO). LK: I served for an 8-year term and in my last year I was the Chair of the Board of Directors of the ABO. I think the Board made a number of important contributions to ophthalmology. One of which was, during COVID, we were able over a period of 6 to 7 months to reorganize the oral examination making it virtual rather than in-person. LK: The other thing I would say is that I developed a close relationship with Dr. Hoyt. I mentioned earlier, he was one of the giants, if not “the giant”, in North American neuro-ophthalmology. And in the late 1990s, I decided I’d go out to San Francisco for a week. When I was there, I’d see patients with him every day. It was an incredible learning experience. He was tough but fair. “You know, Lanning, you should’ve known that,” or “you should know that reference,” or “why don’t you know Seay et al: J Neuro-Ophthalmol 2022; 42: 282-286 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations that?” He never did it unkindly and he was doing it to encourage me, to teach me, and we became close over the years. Ricki and I were there when he had his 80th birthday party with a small group and I would try to spend a lot of time with him at NANOS. When Jonathan Trobe was the editor of the JNO, he emailed me or phoned me and said, “You know, we want to do an interview with Dr. Hoyt, and you’ve gotten close to him. Would you like to do the interview?” LK: I said, “I’d be honored to do it.” Dr. Hoyt never used to like to come to the American Academy of Ophthalmology meeting, but he came because I told him I wanted to do an interview for the JNO. So, we went to my hotel room and used a tape recorder at the time. We sat there and started talking, just like this for the interview. I got the tape recorder going and I’m making notes. Bill was pretty careful, he wasn’t really loosening up. He was not relaxed. We started about 4:30 PM, and I thought we’ll do this for an hour, hour and a half, I’ll cover everything, and we’ll be done. LK: I could tell I was getting the information, but not in a great way, so around 6 PM, I said, “Bill, why don’t we take a break? Let’s go for dinner, and then we’ll come back and we’ll do some more.” Well, at dinner, he had a better part of a bottle of wine. Then we walked back to the hotel, and continued the interview. He was phenomenal!2 One anecdote that I recall is when Frank Walsh wanted to revise his textbook of neuro-ophthalmology. He needed help and asked Lawton Smith, a resident at the time at the Wilmer. Dr. Smith said he was “too busy”, he had too many things to do; he couldn’t possibly help! So Bill accepted the job. Imagine: Bill admitted that he was second choice (Fig. 4)! KD: The book is a classic, and so important. MS: Do you have any advice for trainees starting out? LK: I would say that probably the most important thing, once you’ve decided on your career, and it doesn’t matter if FIG. 4. Left to right: Lanning Kline and William Hoyt. Seay et al: J Neuro-Ophthalmol 2022; 42: 282-286 it’s neuro-ophthalmology or movement disorders or retina or whatever your passion, the most important thing is to choose a really great mentor. Somebody like Dr. Digre, somebody like Dr. Hoyt, like Dr. Glaser, Dr. Smith, Dr. Galetta, or Dr. Balcer. I think that really can define your career in terms of what you learn. LK: It also can define your career in terms of the relationships you develop. Your mentors can introduce you to this person or that person, and that can make a big, big difference in your career development. MS: If you were trying to influence a young neurology or ophthalmology resident to go into neuro-ophthalmology, what would you tell them? LK: Well, you want the bad news? MS: Yes. LK: Well, the bad news is that while I’ve been on the faculty here for 40 years, I’ve had only three residents in all that time go into neuro-ophthalmology. Not for lack of trying or because they’re not smart. And if the individual enjoys surgery, then combining neuro-ophthalmology with pediatrics or oculoplastics is a great plan. Or find a situation where you can practice some general ophthalmology as well. LK: It seems that the NANOS membership is becoming more and more neurology-trained than ophthalmologytrained for whatever reasons. That’s not bad in any way; it’s just a fact. I think neuro-ophthalmology is in great shape going forward. The society is doing great. Medicine is just exploding in so many areas and that too has a positive impact on our subspecialty. LK: One other thing I would say, and I think Kathleen would agree, is that neuro-ophthalmology has managed to maintain a lot of unity. We’re all pulling in the same direction. I don’t think it matters if you’re a neurologist or ophthalmologist. We’ve got a common goal of delivering excellent clinical care and meaningful research. MS: On a personal note, what kind of stuff do you do in your free time? LK: Well, let’s see. What I really like to do is swim for exercise, read good books, hang out with my wife, my kids, and my grandkids. I do like to play golf, although I’m not very good at it. But it’s fun and keeps you humble! MS: What kind of books do you read? LK: Right now, I’m reading the biography of Earl Warren, who was one of the Chief Justices of the Supreme Court. I read an interesting book recently called Thunderstruck. You ever read anything by Eric Larson? He wrote another book called Dead Wake, which was pretty good. I read a bunch of different stuff. I’ve read quite a few books about the Holocaust, including The Tattooist of Auschwitz. The Alice Network, is about a spy network during the Second World War made up totally of women who were incredibly brave and did incredible things. I keep up with the journals, but my reading doesn’t really revolve around medicine. 285 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations KD: Lanning, this was wonderful and we’re so grateful for your time. LK: It has been my honor. New York, NY, to the Department of Ophthalmology and Visual Sciences, University of Utah. REFERENCES ACKNOWLEDGMENTS Drs. Seay and Digre are supported in part by an Unrestricted Grant from Research to Prevent Blindness, 286 1. Foroozan R, Vaphiades MS. Kline’s Neuro-Ophthalmology: Review Manual. 8th edition. Thorofare, NJ: Slack Incorporated. 2018. 2. Hoyt W. An interview with William F. Hoyt MD. [interview by Lanning B. Kline]. J Neuroophthalmol. 2002. 22:40–50. Seay et al: J Neuro-Ophthalmol 2022; 42: 282-286 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.