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One To Watch | April '13

One to Watch: Nicole Fram, MD

In case there was ever any doubt, the future of ophthalmology is in good hands! Millennial Eye presents the first in a series that will highlight “One to Watch.” In each issue, we will profile a rising star, one who may not be advanced in years but one who has already made great advances in our field.

Nicole Fram, MD

Nicole Fram, MD

Nicole Fram, MD, is an ophthalmologist specializing in corneal and external disease. She is a clinical instructor of ophthalmology, Jules Stein Eye Institute, UCLA, and has expertise in cataract surgery, anterior segment reconstruction, refractive surgery, and cornea and external disease.

Dr. Fram received her medical degree from Thomas Jefferson University, Jefferson Medical College in Philadelphia, Pennsylvania, and was elected to the Alpha Omega Alpha National Honor Medical Society. She completed her residency at the prestigious Wills Eye Institute in Philadelphia, where she served as chief resident. Following her residency, Dr. Fram completed a 1-year fellowship in cornea, external disease, and refractive surgery at the Francis I. Proctor Foundation, UCSF, where her research interests included innovative corneal transplantation techniques.

Dr. Fram is an active member of the AAO, ASCRS, and The Cornea Society.

Nicole, thank you for accepting our invitation to be our first “One to Watch.” Please share with us your background: what drew you to ophthalmology and subsequently to cornea?

In medical school I was convinced I wanted to be a surgeon, however, I had no idea on what area to ultimately focus. General surgery was my first rotation. I quickly ruled it out after my attending hit me on my knuckles with scissors and told me to get out of the OR and practice on a chicken. Although this experience was decidedly effective and I learned to suture that day, I found it a bit harsh.

Across the street was Wills Eye Hospital [in Philadelphia]. During my rotation in the Wills Eye emergency department and specialty clinics, I recall feeling so relieved that I had found a field of medicine where people were happy. I was fortunate to be exposed to incredible pathology being treated by skilled residents, fellows, and faculty. Most striking was the sheer number of kick ass female surgeons not only in the residency and fellowship program but heading the departments as chairs. This was unlike any surgical subspecialty at that time.

I was fortunate enough to match at Wills Eye and continue the journey. I was drawn to cornea and external disease primarily because of my mentors on the Cornea Service. I found the integration of infectious disease, rheumatology, and corneal dystrophies fascinating. Surgically, I was training at a time when lamellar keratoplasty was making a comeback. I watched skilled attendings and fellows acquire new skills such as endothelial keratoplasty and deep anterior lamellar keratoplasty. I still hear my attendings’ words of wisdom in the OR to this day.

How would you describe your practice, both clinically and academically?

Our practice is best described as a private practice with an academic edge. The founding partner, Samuel Masket, MD, is an incredible mentor, cataract surgeon, and clinical researcher. Our practice is high volume with a focus on cataract, complex cataract, cataract related complications, cornea and external disease, and glaucoma management. We recently added a talented glaucoma surgeon, Juliet Chung, MD, to care for our glaucoma patients. The complex nature of the surgeries we perform such as surgical treatment of malposition IOLs and corneal transplantation often result in associated secondary glaucoma. The addition of a glaucoma surgeon gives our patients comprehensive care under one roof. We are all adjunct clinical faculty at Jules Stein Eye Institute, UCLA, and teach medical students and residents on a volunteer basis.

Annually, we contribute to AAO and ASCRS and attempt to publish a peer-reviewed paper as often as possible. We have ongoing clinical trials and in-house clinical studies. We recently had an amazing international fellow and hope to continue this tradition. The balance of private practice and clinical research can sometimes be difficult and daunting. However, the reward of providing cutting edge medicine and contributing to the literature has always been a professional goal of mine.

What are some new technological advances that you have found particularly exciting in their application?

I was drawn to ophthalmology because the field is constantly evolving. This year alone, I have introduced five new procedures into my practice: (1) laser cataract surgery; (2) a glued IOL technique for secondary and malposition PCIOL management; (3) Descemet membrane endothelial keratoplasty or DMEK; (4) femtosecond laser-enabled keratoplasty; and (5) corneal collagen cross-linking or CXL for corneal ectasia. Although there is a steep learning curve with many of these procedures, they all add the hope of progress and a layer of elegance to the way we treat current pathology.

The ethics of whether this new technology is “better” is an appropriate and important consideration. The only way to answer this question is to apply the technology in a responsible manner. In our practice, we perform the cases and review our data, retrospectively. There are techniques we have abandoned due to poor outcomes and techniques we have acquired as commonplace. This practice pattern allows us to stay objective as possible.

Who were/are your mentors?

I have been blessed to have many meaningful mentors in my life. The attendings, upper-year residents, and fellows during my residency at Wills Eye and genius faculty during my fellowship at the Francis I Proctor Foundation, University of California, San Francisco (UCSF), have all shaped my development as a young surgeon.

My greatest mentor to date is my partner, Samuel Masket, MD. It is absolutely remarkable that I am in a true apprenticeship. He is not only an unending source of knowledge, a talented surgeon and a true gentleman; he is an inspiration. During my first year of practice he proctored every surgical case and reviewed videos to assist me with technique. Can you imagine? He always says, “You’re only as good as your next patient.” He is never satisfied, and he is always perfecting his technique. These are traits we have in common.

To what do you attribute your success?

I like to describe my circumstance as the perfect combination between hard work and a lot of luck. I was lucky enough to go to a medical school across the street from Wills Eye; I was lucky enough to be chosen as a fellow at UCSF; and I was lucky enough to have my chief at Wills Eye introduce me to Samuel Masket, MD.

I believe I am successful because I never give up. I tell patients that I will do my best and then work even harder for them.

What does some of your research focus on?

Currently, we have ongoing research in the area of cornea/external disease and cataract/complex cataract. The cornea/external disease projects include genetics in Sjogren disease; CXL for keratoconus and postrefractive corneal ectasia; the safety of hydrogel punctual plugs for future drug delivery; and Rapid Pathogen Screening (Rapid Pathogen Screening, Inc.) for adenovirus mediated and allergic conjunctivitis.

Our cataract projects include etiology of negative dysphotopsia; amasked randomized trial of the use of atropine in intraoperative floppy iris syndrome; HumanOptics CustomFlex (artificial iris); intraoperative aberrometry in IOL power selection and the comparison of multiple formulae; and intraoperative aberrometry and optical coherence tomography-based IOL power calculation in postlaser vision correction eyes undergoing cataract surgery.

Our research interests, although varied, relate to the anterior segment focus of our practice. We are fortunate to have an adequate volume of patients to perform meaningful clinical research in a private practice setting.

What publication are you most proud of or feel has been the most important to your career?

The research we have conducted on the etiology of negative dysphotopsia (ND) in the Journal of Cataract and Refractive Surgery, July 2011, has been our most significant publication to date. ND is characterized by a persistent dark temporal crescent after uncomplicated cataract surgery. Dr. Masket has been working on this topic for some time and developed certain surgical strategies to improve symptoms of ND. During the data collection and review of ultrasound biometry measurements, it became clear that there were specific surgical interventions that worked and certain interventions that did not. This investigation provided clues to the treatment and possible etiology of ND. Although this complication of cataract surgery is multifactorial and continues to be under much debate, the patients and physicians that e-mailed us for help after this publication moved me. Through our research, we have been able to assist patients and physicians with this, sometimes, debilitating side effect of present-day cataract surgery.

What is a typical day in the life of Nicole Fram? What keeps you busy, fulfilled, and passionate?

I wake up at 6 am and bring my 10 month-old-baby, Zach, in bed to snuggle for 10 minutes (if he’s up). My husband makes the bottle, and we feed and play with him for 20 minutes. I frantically get ready for work, give a big kiss to the baby (and the husband) and I’m off to work by 8 am. During the course of the day, I care for patients, work with research technicians to coordinate our clinical studies, call referring doctors, and perform short procedures. I operate all day once a week, and the lineup is typically a combination of cataract extraction, malposition IOL/complex cataract and corneal transplantation.

I make sure I’m home to give Zach a bath, read his favorite books, feed him, and put him to sleep. I try to work out (or not) make dinner (or not); work on dictations or research (or not) and then pass out. My life is busy, but fulfilled. Balance is always the challenge and sleep is sometimes overrated.

Any advice for even-younger ophthalmologists? What would you tell someone just now choosing their career path after finishing his or her residency or fellowship?

The younger generation may feel uninspired by the current climate of health care. I urge them to find a mentor that is still passionate about patient care and disregard the pessimism. When I was deciding to go to medical school, many physicians I spoke with felt I was making a mistake. I am the first doctor in my family, and many of my friend’s parents were physicians. Needless to say, they were less than encouraging—except for one incredible man. The young ophthalmologist should find that one person and block the others out. It is important to be informed and prepared for the changes in health care; however, this should not stifle the significant accomplishment of becoming an ophthalmologist. Joining a talented more experienced surgeon in the operating room or clinic and asking mentors to make introductions is appropriate and necessary. Ophthalmology is an extremely fulfilling career and I couldn’t imagine doing anything else with my life.

From the Author

My 8-year-old daughter was asked to write a report about a “hero.” She was offered George Washington, Abraham Lincoln, Mother Theresa, and other such inspiring historical figures as an example. She, in her sweet-yet-assertive way, had a different idea … she chose to write about her mom! When asked why, she shared the impact bedtime stories I would share with her about my day at work had on her. She remembers stories about tears shed when a patient was able to see again, the hugs exchanged between her mom and the patients and patients’ families, and thank you cards from patients using descriptors such as “hero” and “angel” to describe the person she knew as simply “mom.” As you can imagine, I was deeply touched and inspired by her decision to write about me as her hero. I was also reminded of how incredibly lucky I am to be given the opportunity to practice ophthalmology at a time when surgical and clinical innovation and technological advances are gaining accelerated momentum, giving me tools to practice the art with greater creativity and dexterity. I absolutely love what I do and the direction my career has taken both academically and clinically. The advances in lamellar surgery in the form of DSEK, DMEK, and DALK have truly invigorated the field and my experience as a corneal transplant surgeon and have allowed me to offer amazing results to patients. The advances in technology such as laser cataract surgery and IOL options; imaging modalities such as anterior segment OCT; new diagnostic and treatment tools for tear dysfunction; and CXL, to name a few, have all enriched my clinical and academic practice of ophthalmology with great potential for further growth. With the help of innovators, mentors, and collaborators and our own drive to be our patients’ most important advocates in offering cutting-edge care, we have an opportunity to touch the lives of our patients and their families, make an impact in our field, and maybe be named a “hero” in a second-grade school project. This, no doubt, is an incredibly exciting time to be an ophthalmologist!

Neda Shamie, MD

Neda Shamie, MD, is an Associate Professor of Ophthalmology at the Doheny Eye Institute, University of Southern California Keck School of Medicine, and the medical director at the University of Southern California Doheny Eye Center-Beverly Hills. Dr. Shamie may be reached at nshamie@doheny.org.

April '13