Mansour F. Armaly, M.D. (1927-2005)

Founder of glaucoma service and distinguished faculty member (1958-1970) at University of Iowa

Introduction

Dr. Armaly was instrumental in defining the natural history of glaucoma, in developing techniques of early detection and monitoring function loss in the eye, and in demonstrating the genetic character of glaucoma.

Early Life

Mansour Farid Armaly was born in Shefa-‘Amr, in Palestine on February 25, 1927.[1] He was the eldest of eight children, three boys and five girls. His father was a successful businessman and landowner. After the 1935 revolution against the British Mandate, the Armaly family moved to Haifa, Palestine.[2]

Education

Armaly completed elementary school and secondary school in parochial and public institutions in Haifa. In 1944, four years before the school was destroyed in the 1948 Arab-Israeli War. He then graduated with Distinction from the Government Arab College in Jerusalem,[1] the most prestigious school for Arab students. Immediately after, he went to study at the American University of Beirut, as a sophomore entering in pre-med.

While he was in medical school, the sudden founding of the State of Israel in 1948 left the Armaly family as political refugees and they followed Dr. Armaly to Lebanon.[2]

In 1947, Mansour Armaly earned a Bachelor of Arts in Medicine, (with Distinction,) from the American University in Beirut. He continued his education and (once again with Distinction,) graduated in 1952, from the College of Medicine at the American University of Beirut. (“A.U.B.”)

Dr. Armaly did his residency training in ophthalmology at the American University Hospitals in Beirut, Lebanon from 1952 to 1955. During his third year of residency, he realized that he wanted to make a career of research in ophthalmology, so he wrote to the Howe Laboratory of Ophthalmology of the Massachusetts Eye and Ear Infirmary, made application, and was promised a two year research grant. Armaly also wrote to Dr. Norman Nelson, his former Dean at AUB, who in 1953, had taken on the job of Dean at the University of Iowa College of Medicine, and Dean Nelson promptly wired back: “Why Boston? We have a first class eye department at Iowa. Await a letter from Chairman, Dr. A.E. Braley.”[2]

Thus, Dr. Armaly was offered a two-year research fellowship in Iowa City starting in July 1955.[3]

Dr. Armaly with Dr. Norman Nelson

Iowa City (1955-1970)

Dr. Armaly arrived in Iowa City in August of 1955 and his family followed one year later.[4] He was set up with a small research lab, some equipment, and financial support. Dr. Braley encouraged Dr. Armaly to explore all areas in the Eye Department, so Armaly systematically interviewed the faculty regarding their areas of expertise,[2] but it was his personal interest in mathematics and physics, that led him to ask questions about glaucoma and intraocular pressure.[2] His interest in glaucoma obviously pre-dated his move to the U.S. as he mentioned in his autobiographical notes that he had also had brought with him the 1172 page book by Dubois-Poulsen, Le Champ Visuel, which he noted that he had read in its entirety at least three times.[2]

The Armaly family shortly after their move to Iowa City 

Armaly in ERG research room

During his first year in Iowa he studied hard. His schedule in the Department was flexible so he was able to take advantage of the courses being offered at the University of Iowa, just across the river, and took many graduate courses: Boolean algebra and the Mathematics of Classes, Statistics and biostatistics, philosophy (logic and semantics), Behavioral Sciences and the analysis of non-numerical test output,[2] and Neuroanatomy. All of this academic endeavor eventually led to an Iowa M.S. degree in Ophthalmology. Dr Braley, impressed by his drive and determination, offered him a position on the Iowa Ophthalmology faculty.

The project called “Glaucoma Days” was becoming popular in the United States at the time. Through the support of the Lions Club, any small community could schedule a day or two for a mobile Glaucoma Testing bus to come and screen the citizens of the community for glaucoma. The Iowa State Department of Health had asked Dr. Braley to help to bring Glaucoma Days to Iowa.[2] Thus, the Iowa Lions Club Glaucoma Bus visited numerous cities over the years.

Iowa Glaucoma Testing Bus. (Sponsored by Iowa Lions and University of Iowa Department of Ophthalmology)[5]

In 1957, angle closure glaucoma was well defined. However, there was no single best test for open angle glaucoma.[1] The threshold for making the diagnosis was uncertain. Dr. Armaly took this opportunity, with the support of the Iowa State Department of Health and the University of Iowa, to study the criteria for making the diagnosis of open angle glaucoma. After the first year of study, preliminary data seemed to support the idea that tonometry and tonography could not be depended upon to detect glaucoma.

Dr Armaly’s first NIH supported study — The Des Moines Population Study of Glaucoma, 1957-1969 — made use of the “Glaucoma Bus”, and identified a normal range of intraocular pressure – a set of values that are still in use today. He emphasized that visual fields and optic disc evaluations were important in the detection of glaucoma[6] only because they were a record of the damage to nerve fibers that had already taken place. Dr. Armaly’s second year of study led to the development of the Collaborative Glaucoma Study (CGS), a wider effort to define glaucoma and ocular hypertension.[2]

From the CGS, testing techniques and examination interpretations were introduced to confirm the diagnosis of glaucoma. Quantitative perimetry was used to identify early visual field defects. This study also introduced (a) the idea of the “cup-to-disc ratio” as an indicator of optic nerve damage, and (b) the concept of doing selective perimetry, and (c) it introduced the Armaly-Drance visual field testing pattern. All this led to a much clearer definition for the term “ocular hypertension” (i.e., high intraocular pressure without evidence of nerve damage).[7]

Dr. Armaly kept trying to answer the persistent question about how the elevated pressure actually caused the visual loss in glaucoma, and each new question seemed to call for a new study. One of his early studies showed that the incidence of glaucoma was five times higher in patients with a family history of glaucoma.[8] Clearly the genetics of glaucoma would have to be studied. His report published in the Archives of Ophthalmology in 1963 on the effect of topical steroids on intraocular pressure is now one of the basic teachings in glaucoma. One of his first major research grants was The Des Moines Population Study of Glaucoma, 1957-1969, supported by the National Institutes of Health Grant.[9]

The productivity of Dr. Armaly’s research during these years at the University of Iowa was astonishing. In a 1988 report on the one-hundred publications most frequently cited in the Archives of Ophthalmology,[10] Armaly was first author on six of them.

By 1960, Armaly was promoted to associate professor and became full professor in 1966.[1] He was offered the position of Chairman of the Department of Ophthalmology at the American University in Beirut. He declined the position and chose to remain at the University of Iowa. And went on to develop one of the premier glaucoma programs in the United States.[2] When asked why he decided to stay at the University of Iowa, Dr. Armaly replied,

“I felt comfortable in Iowa. I had some great colleagues and good friends on the faculty there, but, more than anything. I found myself fascinated by the research process and I became completely engrossed in it. Looking back, I realize that the next step that I should take in my research always seemed to be inescapably obvious. It was as if I had caught on to a link in some endless chain of knowledge. Each link led automatically to the next link. I felt no need to beat the bushes in search of new ideas, or to be secretive about what I wanted to do next. The ideas were everywhere — more ideas than I would ever get to in a lifetime, so I spoke freely about what else needed to be done. I was just enthralled by my research, and the Department gave me all the support I needed to develop a first-class set-up.”[2]

During his tenure at the University of Iowa, Dr. Armaly trained many residents and fellows from around the world and many students came from Beirut to study. In addition to his devotion to glaucoma research, Dr. Armaly was an Associate editor for Investigative Ophthalmology, Archives of Ophthalmology, and Ophthalmology Digest. He also served on the Vision Research and Training Committee at the National Eye Institute.

Armaly lecturing to residents at the University of Iowa circa 1959.  Left to right: Uncertain identity, Dick Schultz, Jon Thorson, Bob Sexton, Bob Whinery, Uncertain identity, Wally Faulk, Willie Snyder, Mansour Armaly, Uncertain identity, Tom Sawyer, Cliff Hendricks, Frank Gregg, Roger Kirkegaard, John Lynn, Kaz Stivrins, Jim Hersey

Washington, DC (1970-1996)

In 1970, Dr. Armaly accepted the position of professor and Chairman of the Department of Ophthalmology at The George Washington University Medical Center in Washington, DC. He served in this position for 27 years, before retiring in 1996.[1]

In addition to his many duties as Chairman at GWU Eye he was active in the American Ophthalmologic Society, and served on the Selection Committee for the Lucien Howe Medal. From 1980 to 1987 he was the acting President for the Pan-American Glaucoma Society.[1]

Along with Bernard Becker, M.D., Dr. Armaly organized an annual glaucoma conference. This two-day multidisciplinary conference included about 20 invited participants from different basic science and medical disciplines to discuss glaucoma-related issues.

Dr. Mansour Armaly with Bernard Becker and others at an annual multidisciplinary glaucoma conference[2]

 Dr. Armaly also served as Consultant for the National Eye institute, the Veterans’ Administration Central Office, Walter Reed Army Medical Center, Surgeon General of the Navy, and he was Principal Investigator for numerous research studies.

As Chair he remained clinically active. He was on the team of physicians who operated on James S. Brady, the presidential press secretary who was wounded during the 1981 attempt on Ronald Reagan's life. Dr. Armaly operated on Brady's left eye and eyelid within minutes of the shooting.[11]

Of the many honors and awards granted to Dr. Armaly, perhaps his most prestigious honor was to be decorated in 1973, as a Knight of The Order of the Cedars (of Lebanon)[2,4] for his scientific achievements. The Order of the Cedars is awarded by the Lebanese Government for “great services to Lebanon through acts of courage, or of great moral value”.[12]

The Lebanese Minister of Health pinning the “Knight of the Cedars” medal on Dr. Armaly, 1973 | Medal of the National Order of the Cedars (photo)

The Armaly Lectures

Through a generous gift in 2004, Dr. Armaly’s wife Aida, his daughter Raya, and his son Fareed, established The Mansour F. Armaly Lecture at The University of Iowa to honor a glaucoma specialist who has devoted his/her career to the study and care of patients with ocular hypertension and glaucoma.[13] The Armaly family also endowed The Armaly Lecture at the American University in Beirut in 2012, where Wallace L.M. Alward, M.D. gave the inaugural lecture on May 18, 2012.[14]

Armaly family celebrating Dr. Armaly’s retirement

Dr Armaly's fellows: (left to right) Paul Baloglou, MD, first glaucoma fellow at Iowa; Roger Sayegh, MD; Wallace Lee M. Alward, MD; Samir Salamoun, MD; and Nabil Torbey MD. American University, Beirut 

Group Photo: (left to right) Paul Baloglou, MD; Roger Sayegh, MD; Wallace Lee M. Alward, MD;  Aida Armaly; Samir Salamoun, MD; Nabil Torbey, MD; Raya Armaly, MD; Fareed Armaly; Baha' Noureddin, MD(Chair of the Department at AUB); and Kazi Alward. American University, Beirut

Mrs. Aida Armaly at lectern, American University, Beirut

Dr. Armaly made many important contributions to our understanding of glaucoma: what the disease is and what it is not, how to use consistent terminology and meaningful descriptions of glaucomatous damage, how best to monitor glaucoma patients for vision loss, how to recognize early ocular damage, how to decide if some medical or surgical intervention is needed. Should the relatives be examined? Should certain other medications be avoided? In short, he kept asking himself how best to recognize and manage this potentially blinding condition, and then he “set the table” for the rest of glaucoma specialists.

 He trained many residents and fellows, and the results of his persistent search for answers are in constant use today for the detection and treatment of glaucoma.[15]

Mansour and Aida Armaly

References

1. Armaly MF. Curriculum Vitae.
2. Armaly MF. Autobiographical notes. 2004. With additional notes from Mrs. Aida M. Armaly. 2013
3. Hawkeye Year Book. Iowa City, IA: State University of Iowa, 1954.
4. Ancestry.com. New York, Passenger Lists, 1820-1957 [database on-line]. Provo, UT: Ancestry.com Operations, Inc, 2010.
5. Johnston KR. A Story of Success: Iowa Lions Mobile Screening 1965-2005 [unpublished personal observation]2013.
6. Armaly MF. The Des Moines Population Study of Glaucoma. Invest Ophthalmol 1962;1(10):618-28.
7. Armaly MF. Biostatistical Analysis of the Collaborative Glaucoma Study: Final Report on Contract No. 1-EY-4-2167, report PB80-135502. Washington, DC, National Technical Information Service, U.S. Dept. of Commerce. 1977.
8. Armaly MF. Genetic factors related to glaucoma. Ann N Y Acad Sci 1968;151(2):861-75.
9. Armaly MF. Effect of corticosteroids on intraocular pressure and fluid dynamics. I. The effect of dexamethasone in the normal eye. Arch Ophthalmol 1963;70(4):482-91.
10. Albert DM. Analysis of the Archives' Most Frequently Cited Articles. Arch Ophthalmol 1988;106:465-70.
11. Sullivan P. Glaucoma Researcher Mansour F. Armaly, 78, Dies. Washington Post (online). Aug. 25, 2005. 2005.
12. National Order of the Cedar. http://en.wikipedia.org/wiki/NationalOrderoftheCedar. Retrieved 10/20/2013.
13. The Mansour F. Lecture. Deepartment of Ophthalmology and Visual Sciences, University of Iowa. http://www.medicine.uiowa.edu/eye/Armaly_Lecture/ Retrieved on 12/4/2012.
14. Alward delivers Inaugural Armaly Lecture in Lebanon. http://iowaglaucoma.org. Retrieved on 11/30/2012.
15. Spaeth GL. Mansour Armaly, MD (1927-2005). Arch Ophthalmol 2007;125(3):439-40.

Articles by Dr. Armaly indexed in Medline 

contributors to this article include 

 John C. Lee, MD, Emily C. Greenlee, MD, H. Stanley Thompson, MD, W.L.M. Alward, MD  

We thank Mrs. Aida M. Armaly for her input and corrections to this article