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The Knox Legacy

The Knox Legacy

 

When grand rounds at Wilmer Eye Institute, Johns Hopkins Medicine resumes as an in-person gathering, a familiar face will be missing. David Knox, a neuro-ophthalmologist who spent more than six decades at Wilmer, passed away Feb. 1 at the age of 91. Knox was a fixture at grand rounds, and typically could be found seated beside Wilmer Director Peter J. McDonnell, his familiar inquisitive questioning at the ready.

Colleagues speak fondly about Knox’s dedication to Wilmer. “Wilmer Eye Institute lost its number one fan when David died,” says Peter Gehlbach, M.D., Ph.D., the J. Willard Marriott, Jr. Professor of Ophthalmology at Wilmer and a colleague of Knox’s for about two decades. “He had an unconditional love for the institute. When it succeeded, he was thrilled, and when it showed failings, he was greatly disappointed.”

When Knox was a medical student at the Baylor College of Medicine, he became interested in ophthalmology. However, after graduating in 1955, he was an unmatched intern. He ended up getting a job as a private medicine intern in pediatrics at The Johns Hopkins University. There, he would spend time with the ophthalmologists, and was inspired by the late Wilmer director Ed Maumenee to join the Army after Maumenee told him that those with military experience were more likely to get a job. After completing a two-year stint as a general medical officer in the Army, Knox started his ophthalmology residency at the Wilmer Eye Institute in 1958. Afterward, he did a neuro-ophthalmology fellowship at Harvard University. It was there that he met a fourth-year medical student named Morton F. Goldberg, whom Knox took under his wing.

When Goldberg went on to do a residency at Wilmer, Knox, who was by then a faculty member, continued to help him. Goldberg wrote in a letter to his parents that Knox was like a big brother to him. “He regularly steered me in intelligent and fruitful ways, offering totally unvarnished, honest advice that was always in my best interests,” Goldberg says. The two remained colleagues and friends until Knox’s passing.

Goldberg, a retina specialist who went on to become Wilmer’s fifth director, from 1989–2003, says Knox was compassionate, devoted to his patients and, above all, honest and ethical. “David’s natural traits were enviable and, in the aggregate, created in him an admirable role model for me and for many others,” he says.

Colleagues describe Knox as a top-notch clinician and scientist who made seminal observations and discoveries in neuro-ophthalmology and ocular immunology. He was also the first person to understand and report on what is now known as ocular ischemic syndrome, which occurs in patients with too little blood supply to the eye, presenting high risk not only to vision, but to life itself.

Knox took pride in thinking beyond the eye to how systemic diseases manifest ocularly. “He described himself to me as an out-of-the-box thinker, and I don’t think he even knew there was a box,” McDonnell says, adding that Knox was decades ahead of other ophthalmologists in thinking about the whole body as opposed to just the eye. “He was not in any way constrained by what he read in textbooks or what his professors taught him.”

For example, he was the first to diagnose and describe in detail the ocular manifestations of and therapy for a severe, but previously misunderstood, gastrointestinal inflammatory disorder called Whipple’s disease. He also pointed out the direct relationship between abscessed upper teeth and their contiguous anatomic connection to the eye and its socket.

In particular, Gehlbach says, Knox was a proponent of people with unexplained inflammation eliminating caffeine, cigarette smoking and milk products from their day-to-day life. “I don't think we know which of those things any individual patient was responding to, because he would eliminate them all at once,” he says. “But there were patients who had seen him 30 years ago and say that he's saved them from a life of misery, because when they eliminated those things, their skin conditions, like psoriasis, would improve and their eye inflammation would improve. They were quite taken by him.”

Knox treasured the close doctor-patient relationship and was compulsive when it came to evaluating patients. Goldberg compared him to the fictional detective Sherlock Holmes. “Sherlock Holmes was a sleuth, always searching for the truth, leaving no stone unturned,” he says. “Also, again like David, he was known to be compassionate and hard-working, and he was particularly noted for drawing important conclusions from minute clinical observations. His observational and deductive powers were phenomenal, again, like David.”

Knox was also extremely loyal to Wilmer and those who worked there. He formed friendships with many faculty and staff members throughout his tenure and was supportive of younger doctors. Among them was Megan Collins, the Allan and Claire Jensen Professor of Ophthalmology at Wilmer. Collins, who specializes in pediatrics, says Knox was interested in supporting and building a community between junior and senior faculty members at Hopkins. “He was truly intellectually curious and loved to know what was up with people and loved to learn and contribute,” she says.

Knox had a love for teaching — McDonnell says with Knox, “there was no such thing as a silly question” — and was a loyal attendee at Wilmer grand rounds for decades. He was also known to visit divisional rounds, even outside of his subspecialty, to broaden his own scope of knowledge. Prior to grand rounds becoming virtual due to the COVID-19 pandemic, Knox could be found each week in the second chair to the right, next to McDonnell, regularly asking questions of the young residents. “He loved to learn, he loved to teach and he loved perplexing problems,” McDonnell says. “He just had this great, curious mind.”

Collins says those presenting during grand rounds would start the year intimidated, but as time progressed, they were more confident in answering his inquires. “He would ask these very thoughtful questions that I think force people to think beyond the eye,” Collins says. “I loved that he was always sort of pushing the discussions for the residents to think ‘this is not two eyes, this is two eyes connected to a human being and what's happening in the rest of the body, and what you might be putting into your body or other medications you take, could all affect the eye.’”

And while Knox had many accomplishments in ophthalmology, his proudest — as he said in a 2021 interview with the Journal of Neuro-Ophthalmology — was undoubtedly establishing the Frank B. Walsh Society in 1969, named after the father of the neuro-ophthalmology discipline, and Knox’s own Wilmer mentor. The first conference had 29 attendees. Now, decades later, more than 650 ophthalmologists attend annually to learn the newest information about the subspecialty. “Thanks to David’s continuous nurturing, the ripple effect of teaching one generation by another continues unabatedly,” Goldberg says.

Colleagues remember Knox as someone who was passionate about both ophthalmology and the Wilmer Eye Institute. “It’s no accident that he was at Wilmer for some 60-plus years,” Gehlbach says. “It was clearly his pride and joy.”

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