Keratoconus Day 2024: A Tribute to Yaron Rabinowitz

Keratoconus Day 2024: A Tribute to Yaron Rabinowitz

By Renato Ambrósio Jr, MD, PhD, FWCRS, PCEO

On November 10, 2024, we celebrated International Keratoconus Day with a landmark ISRS-sponsored webinar, a testament to our collective dedication and achievements in Ophthalmology.

This event was remarkable for being the first independent ISRS1 webinar and a heartfelt tribute to Dr. Yaron S. Rabinowitz, MD, a pioneer and visionary in keratoconus research. Just a year after his passing on November 6, 2023, his immense contributions continue to inspire us, guiding advancements in understanding and managing ectatic diseases.2

Isaac Newton once said, "If I have seen further, it is by standing on the shoulders of giants."

Dr. Rabinowitz was one of those giants.

His groundbreaking research revolutionized keratoconus diagnosis and treatment, profoundly influencing generations of ophthalmologists, including myself. My understanding of keratoconus owes much to his seminal work, beginning with his transformative study on computer-assisted corneal topography in 1989.3 The legacy of his discoveries and contributions is unparalleled. His 1998 review in Survey of Ophthalmology, with over 4,100 citations, remains a cornerstone for anyone studying corneal ectatic diseases.4 It shaped my early understanding and clinical approach to this complex condition. I believe it will continue to inspire and guide the next generation of ophthalmologists, including you, my esteemed colleagues.

A Legacy of Brilliance and Dedication Dr. Rabinowitz was born in 1953 in Cape Town, South Africa, where he cultivated a love for tennis and excellence. He moved to the United States in 1984 to pursue his dream of advancing ophthalmology, completing his residency and fellowship training with a unique focus on cornea, external disease, and ocular genetics.5 This dual expertise positioned him as a clinician-scientist to make extraordinary contributions to keratoconus care and research.2

Throughout his career, Dr. Rabinowitz managed to maintain National Eye Institute (NEI) R01 grant funding from 1991 to 2020, a remarkable achievement that speaks volumes about his dedication and the quality of his work. His collaborations with leading geneticists at UCLA propelled advancements in understanding keratoconus genetics, and his innovative work on corneal topography set new standards have paved our way for early detection and diagnosis.2-6

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Heartfelt Tributes from Esteemed Colleagues During the webinar, we had excellent talks. Moreover, we were privileged to hear heartfelt reflections from Yaron’s friends and colleagues, whose words truly captured his essence. Dr. Paolo Vinciguerra described Dr. Rabinowitz as a "milestone in ophthalmology," emphasizing his groundbreaking contributions to keratoconus detection through topography and imaging technology. Vinciguerra also highlighted Yaron’s humility, kindness, and open-mindedness, sharing how Yaron treated even young ophthalmologists with respect and encouragement. "He always had time to listen and discuss without envy or arrogance. That made him so unique," Vinciguerra said.

Dr. Stephen Klyce shared stories of their collaborations, recalling Yaron’s pioneering work in corneal topography and his groundbreaking exploration of the molecular basis of keratoconus. Klyce noted that Yaron’s 1998 publication remains the most cited keratoconus paper to this day, demonstrating the lasting impact of his contributions. He also shared personal memories of Yaron’s love for tennis and his pride in his family, especially his son Alec, whose progress in tennis brought him great joy.

My mentor, Dr. Steven Wilson, reflected on their 30-year friendship and Yaron’s ability to sustain an NIH R01 grant for nearly three decades—an extraordinary accomplishment for someone in private practice. Wilson described Yaron as a visionary who recognized the importance of topography early on, forming collaborations that paved the way for advancements in molecular genetics. He noted that one of Yaron’s final contributions, a review article on keratoconus genetics, remains highly impactful. This work, published in Experimental Eye Research, continues to inform and inspire ongoing research.6

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Collaborations and Gratitude I am also profoundly grateful to Dr. Ron Gaster, who has played an integral role in preserving Dr. Rabinowitz’s legacy through the Keratoconus Foundation. During the webinar, Dr. Gaster reflected on their 15-year collaboration, referring to Yaron as the "Keratoconus Slayer." They conducted numerous FDA studies and co-authored influential publications on crosslinking and ectatic diseases.7-9 Their camaraderie exemplified Yaron’s collaborative spirit, inspiring many in our field.

The Rabinowitz family’s moving tribute underscored Yaron’s enduring impact. His wife, Nancy, and their children—Leah, Alec, and Sara—expressed heartfelt pride in his accomplishments. "He will always be our champion," they shared, reflecting the gratitude of countless patients and colleagues. The love and admiration for Yaron extend beyond his professional achievements, rooted deeply in his devoted husband, father, and friend role.

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ISRS, Global Collaboration for Pioneering Contributions to Keratoconus Care

This tribute aligns with ISRS's mission, which embodies the spirit of collaboration and innovation exemplified by Dr. Rabinowitz. His commitment to advancing global ophthalmology resonates with ISRS’s dedication to sharing knowledge and fostering excellence in refractive surgery. As the 2020-2024 ISRS President, I honor his legacy through events like this webinar, which brings together the world’s leading experts in keratoconus.

Dr. Rabinowitz’s work challenged conventional thinking. He advanced the concept of "forme fruste keratoconus" to describe subclinical manifestations of the disease, which is fundamental when screening refractive surgery candidates.10 His insights on corneal topography and the future integration with corneal tomography paved the way for integrating artificial intelligence to enhance ectasia detection, a focus I have had the honor of expanding upon in my own research with Dr. Aydano Machado in the BrAIN (Brazilian Articicial Intelligence Network in Medicine).11-14

Moreover, Rabinowitz’s seminal research on the fellow clinically normal eyes of patients with so-called unilateral keratoconus was a key source of inspiration for me, highlighting the importance of advanced diagnostics in identifying subtle abnormalities in the contralateral eye.12 Nevertheless, I humbly suggested a revision in nomenclature, referring to these cases as VAE (Very Asymmetric Ectasia),13,14 as keratoconus is a defined bilateral disease. In contrast, ectasia can be secondary and unilateral.15 Interestingly, even diverse, the VAE cases remain the most relevant study group for developing and testing novel diagnostic tools such as corneal tomography and biomechanics.13,14 I will always recognize the foundational significance of his research. ?

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Carrying the Torch Forward

Beyond science, Dr. Rabinowitz’s dedication to educating patients and families inspired initiatives like the Violet June campaign,16 which raises global awareness about keratoconus. The importance of early diagnosis and education for not rubbing the eye has been promoted by different experts, including Prof. Damien Gatinel, with his conjecture, “No rub, no cone.”17

On International Keratoconus Day, we celebrate this work with the National Keratoconus Foundation (www.nkcf.org). These campaigns reflect his belief that informed patients are empowered patients, a philosophy that continues to guide our efforts. As Benjamin Disraeli said, "The legacy of heroes is the memory of a great name and the inheritance of a great example." Dr. Rabinowitz’s legacy is a shining example of inspiration, encouraging us to push boundaries, innovate, and improve lives. His life's work lives on through the ISRS community, the patients whose vision he preserved, and the countless professionals he mentored.

On this International Keratoconus Day, we honor Dr. Yaron S. Rabinowitz as a pioneer, mentor, and compassionate leader. His contributions to ophthalmology remain unparalleled, and his influence continues to guide us as we strive to advance the care and understanding of keratoconus. We celebrate his extraordinary legacy in this spirit of gratitude and remembrance.

References

1. Ambrósio R Jr, Dhaliwal DK. Embracing Independence: A New Chapter for the International Society of Refractive Surgery. J Refract Surg. 2024;40(2).
2. Wilson SE. In Memory of Yaron S. Rabinowitz, MD, 1953 to 2023. J Refract Surg. 2024;40(4) –e198.
3. Rabinowitz YS, McDonnell PJ. Computer-assisted corneal topography in keratoconus. Refract Corneal Surg. 1989;5(6):400-408.
4. Rabinowitz YS. Keratoconus. Surv Ophthalmol. 1998;42(4):297-319. [Over 4,100 citations as of 2024]
5. Rabinowitz YS, Yang H, Lass JH, et al. The genetics of keratoconus: a review. Refract Corneal Surg. 1990;6(6):422-429.
6. Bykhovskaya Y, Rabinowitz YS. Update on the genetics of keratoconus. Exp Eye Res. 2021; 202:108398.
7. Gaster RN, Dumitrascu O, Rabinowitz YS. Penetrating keratoplasty using femtosecond laser-enabled keratoplasty with zig-zag incisions versus a mechanical trephine in patients with keratoconus. Br J Ophthalmol. 2012 Sep;96(9):1195-9.
8. Gaster RN, Caiado Canedo AL, Rabinowitz YS. Corneal collagen cross-linking for keratoconus and post-LASIK ectasia. Int Ophthalmol Clin. 2013 Winter;53(1):79-90.
9. Gaster RN, Margines JB, Li X, Canedo AC, Rabinowitz YS. Results of corneal crosslinking in adolescents with progressive keratoconus: prospective study. J Cataract Refract Surg. 2021 Oct 1;47(10):1333-1337.
10. Ambrósio R Jr, Klyce SD, Wilson SE. Corneal topographic and pachymetric screening of keratorefractive patients. J Refract Surg. 2003 Jan-Feb;19(1):24-9
11. Rabinowitz YS, Li X, Canedo AL, Ambrósio R Jr, Bykhovskaya Y. Optical coherence tomography combined with videokeratography to differentiate mild keratoconus subtypes. J Refract Surg. 2014;30(2):80-87.
12. Rabinowitz YS, Nesburn AB, McDonnell PJ. Videokeratography of the fellow eye in unilateral keratoconus. Ophthalmology. 1993;100(2):181-186.
13. Ambrósio R Jr, Lopes BT, Faria-Correia F, et al. Integration of Scheimpflug-based corneal tomography and biomechanical assessments for enhancing ectasia detection. J Refract Surg. 2017;33(7):434-443.
14. Ambrósio R Jr, Machado AP, Le?o E, Lyra JMG, Salom?o MQ, Esporcatte LGP, da Fonseca Filho JBR, Ferreira-Meneses E, Sena NB Jr, Haddad JS, Costa Neto A, de Almeida GC Jr, Roberts CJ, Elsheikh A, Vinciguerra R, Vinciguerra P, Bühren J, Kohnen T, Kezirian GM, Hafezi F, Hafezi NL, Torres-Netto EA, Lu N, Kang DSY, Kermani O, Koh S, Padmanabhan P, Taneri S, Trattler W, Gualdi L, Salgado-Borges J, Faria-Correia F, Flockerzi E, Seitz B, Jhanji V, Chan TCY, Baptista PM, Reinstein DZ, Archer TJ, Rocha KM, Waring GO 4th, Krueger RR, Dupps WJ, Khoramnia R, Hashemi H, Asgari S, Momeni-Moghaddam H, Zarei-Ghanavati S, Shetty R, Khamar P, Belin MW, Lopes BT. Optimized Artificial Intelligence for Enhanced Ectasia Detection Using Scheimpflug-Based Corneal Tomography and Biomechanical Data. Am J Ophthalmol. 2023 Jul;251:126-142.
15. Gomes JA, Tan D, Rapuano CJ, Belin MW, Ambrósio R Jr, Guell JL, Malecaze F, Nishida K, Sangwan VS; Group of Panelists for the Global Delphi Panel of Keratoconus and Ectatic Diseases. Global consensus on keratoconus and ectatic diseases. Cornea. 2015 Apr;34(4):359-69.
16. Ambrósio R Jr. Violet June: The Global Keratoconus Awareness Campaign. Ophthalmol Ther. 2020 Sep;9(3):685-688.?
17. Gatinel D. Challenging the “No Rub, No Cone” Keratoconus Conjecture. Int J Kerat Ect Cor Dis 2018; 7 (1):66-81.