Great Conversation With Dr. John Keltner

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD Great Conversation With Dr. John Keltner Meagan D. Seay, DO, Rachel Calix, MD, Kathleen B. Digre, MD K athleen B. Digre (KBD): It’s my great pleasure today to have a conversation with distinguished professor John Keltner. Dr. Keltner is the Distinguished Professor of Ophthalmology, Neurology, and Neurosurgery at the University of California, Davis. Welcome, Dr. Keltner. We’re so glad to have you with us today, and we’re excited to learn about you. We wanted to start things off by asking you about your background before you even went to medical school. John Keltner (JK): I have amblyopia in my right eye, and that’s probably why I became interested in ophthalmology, but I always wanted to be a doctor since I was a little boy. I was going to be a vet. Somewhere in high school, I decided I should become a doctor, and that is when I became an orderly at Akron City Hospital. I was an orderly for 2 summers on the wards, and then 2 summers I scrubbed in surgery. I went to Ohio Wesleyan in Pre-Med where I met Nancy Jane Rickey (Fig. 1). KBD: Did you grow up in Ohio? JK: Yes, I was born and raised in Akron, Ohio. My parents voted for Barry Goldwater, I’m embarrassed to admit; I was born a Republican in Ohio and I’m going to die a Democrat in California (Fig. 2). [laughter] KBD: Yeah. JK: In high school, when I applied to colleges, I was really looking for colleges that had the best premed programs. Ohio Wesleyan, Oberlin, Wooster, and Denison were the colleges that I was considering. So, I drove 1 summer and interviewed at all of them but ended up going to Ohio Wesleyan. And the rumor was if you did well at Ohio Wesleyan in science, you could get into the medical school of your choice. I applied to 4 medical schools and was accepted at all of them but ended up going to Case Western Reserve Medical School in Cleveland. JK: When I graduated from CWRU Medical School in 1965, we were at the height of the Vietnam War. We had 550,000 troops in Vietnam, and I joined the Berry Plan in Medical School. I went to New York Hospital as a medical 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 D. Seay, DO, Department of Ophthalmology, Moran Eye Center, 65 Mario Capecchi Drive, Salt Lake City, UT 84132; E-mail: [e-mail] Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 intern and a medical resident (Figs. 3, 4) and I knew I was going either to Vietnam or Korea. So, I said I’ll go to Korea. I went to Korea for 13 months. I always had a strong love of neurology all through medical school and of ophthalmology just because of amblyopia in my right eye. At New York Hospital, in the days of Fred Plum and Jerry Posner, you wanted to be a neurologist. Kathleen has read the book: “Stupor and Coma,” by Plum and Posner. Fred Plum and Jerry Posner were probably some of the best teachers of neurology in the country. I remember the chief resident was in neurology. At the time, it was Claude Wasterlain, MD. I decided after the Army I would go into neurology (Fig. 5). JK: When I was a senior medical student, there was an intern at Case Western Reserve University Lakeside Hospital who became very depressed and had to drop out of internship. So, 2 of us became acting interns; as a result, I gave up my subspecialty rotations, so I never set foot in the eye clinic, ear, nose, and throat, or orthopedics while I was a senior medical student. I decided I had seen enough of case western reserve University Lakeside Hospital and went to New York Hospital. There is where I first met with Fred Plum and Jerry Posner. JK: While in the Army, I applied and was accepted to go into neurology at Bowman Gray School of Medicine in Winston Salem, North Carolina. At Bowman Gray, part of the neurology rotation was in neuro-ophthalmology and that is where I met John Stanley. John Stanley was an ophthalmologist who had trained both with Dave Cogan in neuro-ophthalmology and with Claes Dohlman in cornea. John Stanley was the 1 person who made me decide I should look at ophthalmology. I applied to several ophthalmology programs and decided on Washington University Barnes Hospital in St Louis. But I actually had to do my neuro-ophthalmology fellowship first because they had filled up the slots in ophthalmology at Barnes for the next year. I did a neuro-ophthalmology fellowship actually before I did my eye residency, and that’s how I started in neuroophthalmology. I was Andy Gay’s last neuroophthalmology fellow at Washington University Barnes Hospital in St. Louis. KBD: Wow. JK: Andy Gay had trained with Dave Cogan. When Andy was with Dave Cogan, J. Lawton Smith was also there. I’ll never forget the time I spent with Dr. Gay. When I looked in a patient’s eye and saw a swollen nerve and Andy Gay said, “What are you looking at?” And I thought. I 137 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 1. John and Nancy Keltner in 2017. didn’t know what it was. It was optic nerve drusen. I will never forget to think of optic nerve drusen again. KBD: So, you did a neuro-ophthalmology fellowship at WashU and then an ophthalmology residency at WashU? JK: Yes, at the end of that residency in ophthalmology, I went with Marshall Parks in Washington, D.C. I read his book and had to try and understand why I had a mild amblyopia in my right eye, and I decided to go with Marshall Parks. Marshall Parks was on the east coast and Dr. Art Jampolsky was on the west coast. They were the 2 major strabismus folks in the United States at the time. When I was a resident in New York Hospital, we had a lady with Vogt– Koyanagi–Harada syndrome, and I must have done 30 lumbar punctures on her by her discharge. As Kathleen knows, anybody who was at New York Hospital with Plum and Posner knew they wanted to become a neurologist, and that’s what I was going to become, a neurologist. But I could not take my children back to New York. We loved New York when we were there, but it’s a tough city. So that’s how I ended up at Bowman Gray and rotated there through neurosurgery and neuroradiology where we did pneumoencephalography, carotid arteriograms, and myelograms. This was all done before the days of MRI. KBD: Did you do a neurology residency too? JK: I did not. I was board eligible in internal medicine because I did 2 years of medicine and 1 year of neurology. At that time, neurology was nasogastric tubes and some Dilantin, but there were not many therapeutics in neurology back in the 60s. KBD: Yeah, that’s for sure. JK: I ended up in ophthalmology, which is probably 1 of the most therapeutic subspecialties in medicine. You put a pair of glasses on a kid who can’t see across the room, and they are just absolutely ecstatic. Andy Gay was like J. Lawton. I mean, he had the same sort of personality. That is 1 of the reasons we wrote a book on eye movements by Gay, Newman, Keltner, and Stroud (1). And you remember Nancy Newman, the original Nancy Newman who was a neuro-ophthalmologist at Pacific Medical Center in San 138 FIG. 2. John Keltner circa 1939. Francisco. She was in the eye residency at Barnes Hospital WashU and she went into neuro-ophthalmology. After the eye residency at Barnes Hospital WashU, I spent 3 or 4 months with Marshall Parks doing strabismus and I almost stayed in Washington, D.C. because Dr. Parks wanted me to do pediatric neuro-ophthalmology. But I instead went to Yale New Haven Hospital. Mike Kass had really recruited me to be the neuro-ophthalmologist and to do some pediatric ophthalmology at Yale New Haven Hospital in ophthalmology. So, I went for 2 years, but I FIG. 3. John Keltner and Merle Sande as first year medical residents at New York Hospital party, 1967–1968. Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 4. The entire house staff at New York Hospital when John Keltner was a first year medical resident, 1967–1968. John is in the third row, fourth from left with dark black glasses. Tony Fauci, as an intern, is directly in front of John. knew the minute I walked in the door I was not going to stay. Mike had announced to me shortly after I started at Yale New Haven Hospital that he was going back to St. Louis, and I knew that I was not going to stay with Marvin Sears at Yale New Haven Hospital. JK: Marvin is 1 of the smartest people I know along with Bernie Becker at WashU, but Marvin was a tough person to live with. We had 2 faculty meetings in 2 years. Both were over salaries and the usual. Following those faculty meetings Mike went back to St. Louis. Dan Albert went to Harvard. I went to University of California (UC), Davis, and I’ve been at UC Davis ever since. I did the neuro-ophthalmology here at UC Davis for all these years and did some pediatric ophthalmology until we hired a full-time pediatric ophthalmologist. The neurology residents rotated through with us on neuroophthalmology and occasionally we had a neurosurgery rotator. And I did not realize until I was in ophthalmology, how little neurology and neurosurgery residents know about the eye. KBD: Yeah, of course. JK: The subspecialty of neuro-ophthalmology has really taken off. I was concerned that I was going to be in Northern California with Bill Hoyt next door. Bill Hoyt could not have been nicer to me, and I talked to him often. I still have a love of neuro-ophthalmology and I always learn something at the NANOS meetings. It doesn’t matter how smart you think you are, you always learn something at NANOS. When I came to UC Davis, we started a Visual Field Reading Center (VFRC), and then an optical coherence tomography (OCT) Reading Center as part of our neuroophthalmology program. We were also the VFRC for the optic neuritis treatment trial (2) and ocular hypertension treatment study (3). I retired from patient care in 2017 and we hired a neurologist, neuro-ophthalmologist, who trained at Stanford, Allison Liu. She has done a wonderful job. KBD: At UC Davis, you had this visual field lab and you had all these other things, but weren’t you also the Chair there? JK: Yes, I was Chair of Ophthalmology for 26 years. I have to tell you, I feel sorry for the Chair now. Dr. Mannis is Chair in Ophthalmology but that was a different time Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 FIG. 5. US Army Major Ceremony, 1969. many years ago. I taught the Lancaster course in neuroophthalmology for 14 years and then taught the Stanford basic science course in neuro-ophthalmology for 8 years. KBD: Did you ever envision yourself being at this point in your career when you were just starting out? Did you have the vision that you were going to be a professor of ophthalmology, neurology, neurosurgery, a distinguished professor, Chair of the department, and live in California? JK: No, Nancy and I went back to our 50th Medical School reunion. It’s interesting to run into your old friends. I still attend our ophthalmology rounds on Friday and I go to neurology rounds every Tuesday. What you learn as you get older, and now that I am 82, is that it’s tougher and tougher to keep up. You just have to keep after it. I read 2 journals, JNO and JAMA. I don’t read the eye journals anymore; I look through the neurology journals. And 1 of the reasons I keep going to ARVO every year is it’s the young brains that are going to solve the eye problems of the future. KBD: What would you go back and tell yourself during your early career that could make a difference for somebody now who’s just starting out, trying to figure out where they’re going? JK: A wise person said, “Do what you love, and you’ll always be happy, you’ll never go back to work again because you do what you love.” And that’s 1 of the reasons I always love to read the Journal of Neuro-Ophthalmology. And Bill Hoyt used to say, “Once the MRI scan came out, we’d be dead in the water.” But you know what we spend most of our time doing? Interpreting neuro-negative MRI scans, right? And that’s what neuro-ophthalmologists do. When I retired from patient care, I just gave Allison Liu all my slides and said, “Here, I hope you could use them.” She does a good job and you know, Kathleen, that neurologists do not know ophthalmology and ophthalmologists sure do not know neurology well. JK: I still love to do neuro-ophthalmology, but I do not take care of patients any longer, and I gave up all medical 139 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations legal cases, but it is still wonderful to learn new things and refresh old knowledge. KBD: Early in your career, and when you’re just thinking about it, is there some part of your career you would have never guessed you’d end up doing? JK: I would have never dreamed I’d end up in ophthalmology. But it was really when I was doing that neuroophthalmology rotation in neurology at Bowman Gray that I realized how much I liked ophthalmology. JK: I gave the Bill Hoyt Lecture in October 2019 at the American Academy of Ophthalmology, titled “cancer associated retinopathy (CAR)-Unexplained Visual Loss.” The Bill Hoyt Lecture was never published. I still remember when I first saw my patient with CAR, cancer-associated retinopathy. Alan Roth, who was our pathologist at the time, and I presented this case at the Walsh Society. This was before NANOS and Walsh merged, and we presented a case of CAR. The histology was fascinating because it was as if someone had cut off all the photoreceptors. We published this case with our basic scientist Dr. Charles Thirkill (4). KBD: Right. JK: You don’t see very many cases of CAR (4) or MAR (melanoma-associated retinopathy) (5) very often. KBD: Right. JK: I talked to Grazyna Adamus in Portland at length before I gave the Hoyt Lecture on CAR and she really gave me valuable information on CAR. KBD: What do you consider your biggest successes because there is more than one? JK: Probably our VFRC and the OCT reading center (OCTRC) are 2 of our biggest successes. And I can still remember when we presented a paper on visual fields and optic neuritis (2) and people were shocked at the variation in field defects that you can have in optic neuritis. JK: When I went to ARVO, I would listen to all the main lectures because they are always the most excellent. There’s always much to learn, that’s the problem with medicine, and it’s just endless. KBD: That’s for sure. What other successes beside your reading center got visual fields and OCTs do you consider your biggest success? JK: I think taking care of patients is probably my biggest success. You think of all the patients you’ve helped over time. I remember I used to do the pediatric ophthalmology along with neuro-ophthalmology for years until we recruited a pediatric ophthalmologist. Now we are 2 deep in pediatric ophthalmology. But clearly, the patients are always your success, they’re the ones who you still get letters from occasionally and write to know if you’re still seeing patients. I say, “No.” But I’ll be happy to consult. My old fraternity brothers still write me. They think I know something. You have to inform them that you’re still a little rusty in a few things. KBD: That’s great. How do you spend your free time, John? 140 JK: I’ve read more books in this last year with the pandemic than I have ever read before. We’re still a racist society, unfortunately. As I said, I didn’t realize when I was in medical school, 61’ to 65’, how bad Jim Crow was in the South. I was just clueless. The North was better, but we still were bad, but the South was really bad. JK: And that’s how I spend much of my free time. And I just read all about the American League. Jackie Robinson broke the color barrier in the National League with the Brooklyn Dodgers with Larry Doby and eventually Satchel Paige breaking the color barrier in the American League with the Cleveland Indians. And I wasn’t into baseball, but my family was into baseball. Through my wife Nancy, I learned a lot about the National League. But reading has been a great refuge during the pandemic. There’s so much to read and I tend to read only true material. I don’t want to read fiction. Nancy reads all the fiction. She was an English major. Because she could read and read so well, that’s what I’m sure got me reading years ago. I spend more of my pastime now keeping up with the medicine in JAMA and keeping up on the current literature in neuroophthalmology and neurology (Fig. 6). KBD: Great. And don’t you have a cabin or a retreat too? JK: We do. We do have a place in Canada, but you know, Canada has been closed since the pandemic started. We haven’t been there, and this will be our second summer and I don’t know if Canada will open up this year. Nancy’s family had an island in Eastern Canada for years, and so that’s what made us start looking in Western Canada and we found this place years ago. It was just a rock and trees and now we have 5 cabins. The name of the island is Little Mist Island which is about 5 acres (Fig. 7). Little Mist is about two-thirds the way up Vancouver Island. We have electricity and we collect rainwater and so forth. Little Mist has been our passion for years. There’s only 1 problem, you know, when you’re roasting to death in California, you’re cold in Canada because it gets cold in the summer. FIG. 6. John Keltner’s office circa 2005, “not compulsive.” Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 7. Little Mist Island in Canada, 2017. KBD: That’s right. What advice would you give to those who are in early career right now? JK: I think the most important thing is to do what you love and if you do that, you’ll never go back to work. I have really come to appreciate our basic scientists, and we have a good crew of basic scientists. Medicine has truly changed so dramatically over the years, there’s no question about it. But I would tell everyone, “Respect your basic scientists.” JK: I’ve worked a lot with basic scientists over the years, but truly, do what you’re going to love. My older son is in psychiatry, he’s doing what he loves down in San Diego. My other son is in Boston, he formed his own company there. And then my third son is in Japan with his wife who’s Japanese. KBD: If you were going to try to influence someone to go into neuro-ophthalmology, what would you tell them? JK: I think in neuro-ophthalmology, you’ve got to have a love of both ophthalmology and neurology. You’ve really got to keep tuned in to what’s happening in neurology and ophthalmology. Remember, a third of the brain is devoted to visual function whether we’re seeing or doing eye movements. That’s what makes neuro-ophthalmology so exciting. Because you’re not only doing vision, but you’re doing the way the eyes move. Strabismus was so important to me because I studied it when I was in ophthalmology and then found out it was really a strong part of neuro-ophthalmology. You have to really understand the visual system and the oculomotor system to do neuro-ophthalmology well. JK: I remember going to some of those very first Walsh meetings, you would have 25, 30 people. And now you look at NANOS; there’s 700, 800 people in that room. That’s a huge gathering of folks. But there’s always more to learn. We are visual animals. I talk with my basic scientists a lot, as much as I can. Tony Fauci was an intern under me when I was in New York hospital (Fig. 4). And here he is with COVID, shooting to the head of the pack. KBD: Yeah, boy, that’s for sure. JK: But what I’ve found out is that most people are working on what’s going to be the next virus. That’s truly what we’re working on right now. Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 Rachel Calix (RC): I was wondering what your experience has been with learning neuro-ophthalmology earlier in your career and then teaching later on? Do you have any strong opinions about what’s important when you’re trying to learn and what’s important when you’re trying to teach someone neuro-ophthalmology? JK: You really need to understand the visual system. Not only how you see, but how your eyes move. You see patients with neuro-ophthalmologic problems. They’re coming in to see you because they’ve got something wrong with the visual system or they wouldn’t be there in the first place. We really must understand the brain function. It’s interesting, but I would tell anybody, when I used to go teach both the Harvard Lancaster course at Colby College and then the Stanford course, they really have to understand the visual system. But they really have to understand both, and it is hard. JK: Neuro-ophthalmology as a job, we don’t make much money, that’s why people don’t go into neuroophthalmology. And I made a little more money when I was doing strabismus, but you don’t make money like the retina people or even the cornea people. Kathleen, you know this, and I’ve learned this over the years. If you stay in academic medicine, you’re going to be okay. You’re going to actually do better than the folks that end up in private practice. But I would tell them, do what you want to do, and if you’re going to do neuro-ophthalmology, make sure you understand the visual system. KBD: That’s for sure. JK: NANOS has done a great job. The 1 thing we’re experiencing is we’re getting too big, and so people aren’t as anxious to answer questions as they used to be. KBD: Yes and speak up in the middle of the meeting. It’s a little intimidating. JK: Kathleen remembers, in the old early days of Walsh, you’d speak up and Hoyt would turn around and say, “You can’t be serious.” [laughter] Meagan D. Seay (MDS): Is there anything that you would go back and change in your career or in the places where you’ve lived or worked? JK: No, I think you know, your life sort of evolves and you follow what you like to do and do what you love to do, and that’s what you end up doing. No, I don’t think I would change anything. I always did Little League. I’ve enjoyed what I’ve done. I really love doing what I do. KBD: John, do you have any other advice for us? JK: No, except to follow what you love to do. And if you love to do it, that’s what you should follow. It may not bring you a lot of money; you may not be that rich, but you’ll be fine. Nancy finds, when she goes to the neuro-ophthalmology meetings, she loves the spouses, and it’s because people enjoy each other. And once you get money out of the equation, you can really sit down and talk about books and things you like to do. But I would tell people to follow their passion, follow what they love to do, and don’t get distracted by side things. That’s really the key. And you’ll be happy. 141 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations KBD: Yes. Well, this has been a wonderful conversation. John, we loved talking to you. Your energy is palpable. [chuckles] KBD: It comes right straight through. JK: Listen, Kathleen and I have been to a lot of NANOS meetings together over the years, and I’m just delighted to see you staying connected with this. KBD: Thank you so much for spending this time with us. JK: You’re welcome! Thank you, too, for taking the time. RC: Nice listening to you. MDS: Yeah, thanks so much. ACKNOWLEDGMENTS Drs. Seay and Digre were supported in part by an Unrestricted Grant from Research to Prevent Blindness, 142 New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. REFERENCES 1. Gay AJ, Newman NM, Keltner JL, Stroud MH. Eye Movement Disorders. St Louis: C. V. Mosby, 1974:156. 2. Keltner JL, Johnson CA, Spurr JO, Beck RW. Visual field profile of optic neuritis. One-year follow-up in the optic neuritis treatment trial. Arch Ophthalmol. 1994;112:946–953. 3. Kass MA, Heuer DK, Higginbotham EJ, Parrish RK, Khanna CL, Brandt JD, Soltau JB, Johnson CA, Keltner JL, Huecker JB, Wilson BS, Liu L, Miller JP, Quigley HA, Gordon MO. Ocular hypertension study group. Assessment of cumulative incidence and severity of primary open-angle glaucoma among participants in the ocular hypertension treatment study after 20 Years of follow-up. JAMA Ophthalmol. 2021;139:558–566. 4. Thirkill CE, Roth AM, Keltner JL. Cancer-associated retinopathy. Arch Ophthalmol. 1987;105:372–375. 5. Keltner JL, Thirkill CE, Yip PT. Clinical and immunologic characteristics of melanoma-associated retinopathy syndrome: eleven new cases and a review of 51 published cases. J Neuroophthalmol. 2001;21:173–187. Seay et al: J Neuro-Ophthalmol 2022; 42: 137-142 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.