Looking out for the overlooked

Lawrence Tychsen, M.D., switched gears from English to eye surgery

As the only boy among nine children, Lawrence Tychsen, M.D., often was asked by his sisters to fix things and figure things out. As Tychsen grew, his hobbies involved designing and building things or taking things apart and fixing them.

It just seemed natural that Tychsen would become a surgeon who fixes vision of children with neurological impairments.

Lawrence Tychsen, M.D., examines Madisen Denman, who has congenital cataracts, before surgery.
Lawrence Tychsen, M.D., examines Madisen Denman, who has congenital cataracts, before surgery. “Because of his heart and passion to really help these kids and his scientific background, he leaves no stone unturned,” says Janice E. Brunstrom, M.D.

Tychsen is professor of ophthalmology and visual sciences, of pediatrics and of anatomy and neurobiology and is ophthalmologist-in-chief at St. Louis Children’s Hospital.

He intended to be an English professor, but when registering for his first semester of college, a physiological psychology course was offered in the time slot he needed to fill. Tychsen signed up for the course, and quoting the late Pope John Paul II, “In the designs of Providence, there are no mere coincidences,” he sees it as the first improbable step in his path to a career in medicine.

“The teaching was inspiring,” Tychsen says. “Out of nowhere, I became enthralled by the workings of the brain and fascinated by the philosophy of science.”

He earned an undergraduate degree in biology and philosophy at Georgetown University, then entered medical school at Georgetown with the notion of becoming a neurosurgeon. But a talk with an adviser steered him toward neuro-ophthalmology.

“He recognized that I was mechanically inclined, but also most interested in the workings of the visual brain; the groundbreaking experiments in physiological psychology were devoted largely to visual perception,” he says.

After completing medical school, Tychsen was invited to spend a year as a fellow in neuro-ophthalmology at the National Eye Institute within the National Institutes of Health in Bethesda, Md.

“One of the iconic figures in the specialty, Dr. David Cogan, took me under his wing,” he says. “The experience at the NIH clinched it. The surgery was elegant, the measurements and machines were precise and it was a great way to blend research with clinical work.”

Finding his calling

During his ophthalmic surgical residency at the University of Iowa, he began to discern that he had a knack for examining and treating neurologically impaired children. “No one else wanted to deal with them because they are often tough to examine,” he says. “It can be intimidating and frustrating, but I found it a challenge and rewarding; by finding and fixing what was broken, you could enrich a kid’s life permanently.”

One epiphany that Tychsen recalls from his early residency was an examination of a child with cerebral palsy who had been labeled as blind.

“After a detailed exam, I told the senior resident that most of the boy’s visual system was working — what he really needed was a good pair of glasses,” Tychsen says. “To which he responded, ‘Potatoes have eyes, but they don’t need glasses.’ The cynicism shocked me, but it was, in fact, a message: I was being called.”

Tychsen also came to realize that pediatric ophthalmologists spent most of their time talking about microsurgical techniques because the neural mechanisms for many of the visual disorders they treated were unknown.

“I saw, as an opportunist, that there was room for open-field running in this game,” Tychsen says. “Note to self, ‘Plunge in here, posing the right questions, and you can have a big impact.'”

He moved to San Francisco after residency to train as a fellow in pediatric ophthalmology at the University of California, San Francisco Medical Center. To sharpen his research skills, he then spent 18 months as a post-doc in the primate neuroscience laboratory of Stephen Lisberger, Ph.D.

“That time in San Francisco was invaluable,” he says. “Steve is a taskmaster and incisive thinker. I worked elbow to elbow with him and absorbed his rules: ‘Choose questions that will move the field forward. Don’t speculate, execute experiments with clear yes-no outcomes. Keep your eyes open for the unexpected. Then apply the seat of the pants to the seat of the chair and write cogently.'”

After paying back a four-year active-duty obligation to the U.S. Air Force as a flight surgeon, Tychsen was recruited to the School of Medicine’s pediatric ophthalmology department by then-chair Henry Kaplan, M.D.

“I could see there was a real opportunity at Children’s to start from scratch clinically and set things up the right way,” Tychsen says. “Hank had implemented a clear productivity model for his surgeons, and I’d have it no other way. And he’d let me run the division without micromanaging.”

Tychsen also says he knew he wanted to study primates because they are an excellent brain and behavior model for strabismus, or crossed-eyes. “The School of Medicine had a first-class reputation for primate research, and I could work with stars like Andreas Burkhalter and David Van Essen.”

(From left) Paul, Hugh, Diana, Kathy, Lawrence and Andrew Tychsen.
(From left) Paul, Hugh, Diana, Kathy, Lawrence and Andrew Tychsen.

Tychsen’s laboratory studies the neural cause of strabismus. “We’ve shown that babies do not get crossed eyes because of a muscle problem,” he says. “The eyes cross because an immature circuit in the brain failed to develop properly within a certain window of time.”

He also investigates the effects of early vs. delayed repair of strabismus.

“We can show that a specific connection is bad and show that it can repair itself if we restore normal brain activity by straightening the eyes early.”

Pioneering the field

In addition to research, Tychsen is a pioneer in working with children with neurological disorders, who often have severe vision problems. He does refractive (vision correction) surgery on children with cerebral palsy, Down syndrome and neurobehavioral disorders such as autism, as these disorders often lead to difficulty wearing glasses.

He also helped design and adapt specialized electronic testing to measure acuity in uncooperative children.

His work in this area took off after Janice E. Brunstrom, M.D., assistant professor of pediatrics and of neurology and director of the Pediatric Neurology Cerebral Palsy Center at St. Louis Children’s Hospital, prodded Tychsen to think more about how to repair the vision in children with cerebral palsy. He agreed to devote time to it and made room for them in his busy clinical schedule, Brunstrom says.

“These are kids who were legally blind and whom everyone had given up on,” Brunstrom says. “One by one, he has restored their sight by going over every detail and figuring out what is wrong and what he can fix. He is willing to tackle situations that used to be considered impossible or not worth the time.”

Tychsen and his staff perform laser-assisted subepithelial keratectomy, or LASEK, in which the cornea is reshaped with a laser. This technique doesn’t require a surgical flap to be cut in the eye, is safer for children and is able to correct much higher degrees of myopia, or nearsightedness, than the LASIK technique commonly used on adults.

For children with focusing defects so large that they are beyond the range of laser correction, Tychsen implants a phakic intraocular lens or performs a lens extraction technique. These techniques often can improve vision in a child with profound nearsightedness, such as 20/1,500 (nine times worse than legally blind), to nearly 20/20, Tychsen says.

To date, St. Louis Children’s Hospital is one of the only U.S. medical centers performing refractive surgery on these children.

Lawrence Tychsen

Family: Katherine, wife; children: Hugh, 25, who served in the Marine infantry in Iraq, is a Washington University alumnus and works for Enterprise-Rent-A-Car headquarters in Clayton, Mo.; Diana, 22, graduated from the University of Indiana music school with a vocal performance degree and works in marketing in Chicago; Andrew, 20, a junior at Saint Louis University; and Paul, 15, a sophomore at St. Louis Priory School.

Most satisfying part of his job: “As a surgeon, performing a surgery well that permanently improves a child’s vision.”

Something people might not know about him: Tychsen plays for a men’s ice hockey league at 5:30 a.m. twice a week and loves golf. He is also a Formula 1 Grand Prix auto-racing fan and takes his sons on an annual road trip to the U.S. Grand Prix, which he calls a “magical mixture of technological genius, machismo and international culture.”

“Dr. Tychsen is a very gracious man who has never really gotten credit for what he’s done for these kids,” Brunstrom says. “Because of his heart and passion to really help these kids and his scientific background, he leaves no stone unturned.”

“Dr. Tychsen is an extraordinarily talented clinician,” says Michael A. Kass, M.D., professor and head of the Department of Ophthalmology and Visual Sciences. “He has really built the pediatric ophthalmology service at St. Louis Children’s Hospital to a very high level. He is also a pioneer in the concept that it may be brain malfunction that causes strabismus in children and has done extensive work to study this phenomenon.”

Part of what is behind Tychsen’s compassion is his strong Catholic faith. “It allows you to view life with perspective and see medicine and science for what they are: tools, which on one hand, can be used to heal and reveal the glory of nature, and on the other hand, can be misused for egotism and power by treating Homo sapiens as disposable objects,” he says.

A member of Our Lady of the Pillar parish, he supports WRYT/KHOJ, the local Catholic radio stations, is involved in pro-life work and teaches adult catechism.

Joseph L. Demer, M.D., Ph.D., a professor of ophthalmology and neurology at the Jules Stein Eye Institute at the University of California, Los Angeles, says Tychsen is well regarded nationwide both scientifically and medically.

“He is of an extremely rare breed of physician/scientists,” Demer says. “He is very well trained in lab science and a fully competent and expert practitioner. He is really an example to all of what can be done.”

Demer also has had a glimpse of Tychsen outside of academia.

“I invited him to lecture at a conference in California, but he would only agree to do it at the same time there was a driving school offered at the Jim Hall Kart Racing School,” Demer says. “He’s very good, and quite a daredevil.”