Musings of an Ophthalmologist

From Coronavirus Fellowship to the Dangers of Democracy

by Andrew Sweeney

When the coronavirus pandemic ends, one of its most enduring images will be hospital hallways strewn with patients struggling to breathe. In the last months, images of people gasping for air, slumped over chairs or even lying on blankets on the floors became all too familiar. What’s more, they were filmed in European hospitals in countries whose public health services are considered among the best in the world.

Spain is one of the countries most affected by coronavirus, and it is only now emerging from one of the world’s most restrictive lockdowns. Medical personnel from all sectors were drafted to join the fight against coronavirus, and ophthalmology was no exception.

Elective surgeries will likely become possible again as coronavirus restrictions are eased. But how will such procedures be able to proceed without trained ophthalmologists? In Spain and many other countries, eye surgeons are more likely to be found in an emergency room, rather than at an ophthalmology clinic.

Like previous generations drafted into war, many ophthalmologists have joined the fight against this insidious enemy.

A need for a coronavirus fellowship program

Indeed, the pandemic has had a tremendous impact on ophthalmology as a whole. Young professionals just out of medical school were thrust into a high-intensity environment, fresh from their general medical training. More experienced professionals, prepared for the chaos of mass-triage, reported concerns about their skills not being updated sufficiently. Dr. Jorge Alio is one such ophthalmologist. An industry veteran with decades of experience, Dr. Alio is a specialist in cataract, cornea, and refractive surgery. Based in Alicante, Spain, he has been frustrated both by the inaction of governments in the face of coronavirus, particularly in the United Kingdom, as well as the lack of a framework to support ophthalmologists in general medicine.

Ophthalmologists in Spain like Dr. Alio are being thrust into the pandemic with relatively limited check-ups, which, in Dr. Alio’s case, is a biennial cardiopulmonary resuscitation test. He’s concerned that doctors are being placed in difficult positions with only theoretical preparation. Dr. Alio believes a fellowship system is the solution.

“You have to take a mini-fellowship with a practitioner you know” Dr. Alio said.

“That means that you become his or her assistant and you have to follow them. Meanwhile, you have to get a handbook on intensive care.”

He added: “We are very keen to help, we are ophthalmologists, but to be in the emergency room is totally different. Our skills have not been updated.”

Is democracy good for disease?

Dr. Alio was likewise critical of the response by many Western governments to the coronavirus. In particular, he criticized the handling of the crisis by U.S. President Donald Trump. Dr. Alio said the president is incapable of viewing the crisis as it is, as a medical crisis, and views it instead as a business issue. The impact on low-income individuals has been particularly acute both in the U.S. and other Western countries. Dr. Alio noted that an unexpected feature of the pandemic is that socialist nations like Vietnam and North Korea have weathered the storm better than their Western counterparts. Dr. Alio attributed this to a culture of deference within these societies.

“All the countries with authoritarian governments, such as North Korea, Russia, China and Vietnam, all of these countries are doing better because the authorities are making the right decision,” Dr. Alio said.

“They took the right advice and they followed it without thinking about political decisions, because political decisions are imposed on society. In those countries you don’t decide the politics, you suffer the politics and they did well,” he added.

Whether a more authoritarian or socialist form of government makes a country’s survivability during coronavirus more viable is debatable. But certainly, more decisiveness and clarity on the part of Western governments would be welcome.

Like all industries, ophthalmology needs support to return to normal once the crisis passes, while medical personnel working in the industry may need assistance in fighting the virus on the frontlines. Dr. Alio’s idea of a fellowship program could be easily implemented and would doubtless provide welcome support to ophthalmologists.

Editor’s Note:

This story is part of the ‘Q&A from Quarantine’ series of CAKE Talks, where Matt Young (CEO of Media MICE and Publisher of PIE and CAKE magazines), during the time of COVID-19 lockdown, reached out to KOLs and industry friends to evaluate and discuss the impact of this pandemic to the ophthalmic world. A version of this story was first published on cakemagazine.org.

INDUSTRY UPDATE

SNEC & SERI Launch Heroes Fund to Strengthen Defense Against Future Epidemics

It’s clear that COVID-19 has had devastating consequences worldwide — industries across every sector have been impacted, including ophthalmology.

Therefore, in an effort to deal with the ongoing crisis, and strengthen Singapore’s defense against future epidemics, the

Singapore National Eye Centre (SNEC) and the Singapore Eye Research Institute (SERI) have launched the Heroes Fund.

This campaign aims to raise $1 million by

January 31, 2021.

The campaign is named for SNEC and SERI’s frontline medical workers; funds will support the Centre’s healthcare workforce by providing them with the latest training, tools, innovation and methods of care in ophthalmology. This includes redefining clinical care to meet the urgent needs of patients; driving cutting-edge research to keep COVID-19 at bay; and maximizing healthcare knowledge for a future-ready frontline workforce. evolving needs of our patients, health care providers and research teams, especially during this period of enormous change and uncertainty,” said Adjunct Associate Professor Ho Ching Lin, Director of Philanthropy, SNEC. “While COVID-19 remains, there are many patients who are also suffering from eye diseases that may lead to vision loss. This is why it is critical that we focus on new ways to approach the crisis and with better preparedness. The funds will greatly enable us to improve on our clinical care processes and to develop cutting-edge research as we move forward.”

New models of care, like using technology to conduct tele-consultations for glaucoma patients, are already in place at SNEC. The Centre has also implemented a home monitoring service in an effort to decrease non-essential visits and proactively detect those who may experience severe visual symptoms and prevent blindness.

Funds raised will also help to develop e-learning programs to facilitate undisrupted training and upgrading of skills — ensuring that these healthcare heroes can complete their training and acquire the skills needed to treat increasingly complex eye diseases, and thus giving patients a better quality of life.

Speaking on the Heroes Fund, Professor Wong Tien Yin, Medical Director at SNEC said: “We must continue to be forwardlooking and future ready. COVID-19 has presented us with an opportunity to innovate and better equip ourselves to face what is ahead of us. Therefore, it is imperative to continue to channel our efforts to upgrade our existing model of care, develop cost-effective treatments and create breakthroughs in the research for COVID-19.”

The Heroes Fund is part of the VisionSave campaign, a philanthropic drive spearheaded by SNEC and SERI. Corporate, personal, or anonymous donations can be made to the Heroes Fund by visiting the online campaign website at www.giving.sg/shf-snec-fund/ heroes-fund.

Ophthalmology Post-Pandemic: A Glimpse Into the Future

by Sam McCommon

If everyone had a crystal ball, they wouldn’t be worth much.

From finding effective methods to store corneas to determining the efficacy of single-use surgical instruments — there are a lot of issues facing ophthalmologists today. Not to mention, how do we even start going back to “normal” after the pandemic or while the threats of coronavirus still looming on the horizon?

In a conversation with CAKE magazine CEO and Publisher Matt Young, Mr. Frederic Giulj, the export director of Moria Ophthalmic Instruments, gave us an insider’s view into the possible future of the ophthalmic industry. His company makes several specialized ophthalmic tools — and they certainly have a wealth of experience to share.

Below are highlights of their conversation — a wild ride through the industry and across regions.

Cornea transplants, a world apart

One of the most important ophthalmic sectors that have been affected by COVID-19 is keratoplasty. When the outbreak began, it was unclear just how the virus spread — and the possibility of it spreading through eye tissue was very real. It hearkened back to the darkest days of the early part of the AIDS epidemic in the 1980s. The United States may go from being the world’s leading exporter of cornea tissue to playing a much smaller role, especially considering the outbreak in the U.S. is far from over.

Questions still exist concerning corneas: How is it best to store them, considering surgery demand is far lower than it was months ago? How do you test corneas to make sure they don’t contain the coronavirus? How can you transport corneas when borders are shut in many parts of the world? This is a major concern for the cornea transplant market, especially when the U.S. is involved.

European countries, however, seem to have fared far better in managing eye banks. As Mr. Giulj put it, “I have feedback from German companies, and they’re telling me they’re going to go back to normal — they’re not really going to be affected. But concerning the American eye banks, the discussion we have internally with the U.S. guys is that they have not thought about it. They didn’t look at the testing issues or that the testing could be an issue. Are they going to find out, is COVID-19 testing on tissue going to be a problem for the American eye banks, or is it easy to make not a problem?”

He continued, “The problem is, the U.S. provides tissues to half of the world. If you look at the Middle East, Asia, and some European countries, it’s going to be quite a big issue for cornea eye banking. The U.S. seems quite messy right now and they have no clue about what’s going on and what’s going to happen.”

Eye banks in Italy may prove to be the gold standard for the entire world — and Italy was particularly hard hit by the pandemic. Mr. Giulj speculated that the reason for this was tied to the technical expertise in handling the virus in general.

“The eye bank in Venice is probably the best in the world for many reasons,” he said. “I was just reading an article about how Venice handled the crisis. They had an expert who contacted the governor and told them to put him in charge of the program and they’ve done a massive testing program. They handled the situation much better than the other regions. They said they could test the whole city in five days, and they did. It’s a coincidence — but I’m not

surprised because Venice’s eye bank is really the cream of the cream. I haven’t seen anyone so professional and so scientific anywhere else.”

Being professional and scientific is certainly something ophthalmologists everywhere strive for — which has led some to change the tools they use.

Disposable products: A double-edged sword

One option that has become much more attractive due to the virus is the use of disposable surgical products. These single-use products prevent the spread of the virus by, well, being single-use.

As Mr. Giulj said, “Regarding microkeratome surgery, there’s an opportunity we have right now to put more pressure on disposable products and therefore the development of a disposable line of cataract instruments. If you also have to do a lot of cataract surgeries tomorrow, you may ask if the sterilization system is going to interfere with the timing. If you have enough instruments and you want to do more surgeries, you may go with disposable products.”

Disposable products may seem like a godsend now, but they come with their own set of problems, including quality and availability due to supply chain pressures.

“The problem with disposable,” said Mr. Giulj, “is you have a whole logistical aspect to look at, and production-wise we’re at maximum capacity. And the quality of most of the instruments is not so good. So, is it going to push the industry of ophthalmology to generalize Chinese and Pakitanese cheap,

Is this sword stuck in a stone, too?

disposable and low-quality instruments, or is it going to create the demand for disposable products that are a little bit more expensive but of better quality? We’re at a crossroads.”

Asia wakes up first

The world is also at a crossroads when it comes to pandemic management. The end goal must be to return to some semblance of normalcy — and the first to do it will likely reap huge rewards.

In terms of which region comes back to normalcy first, Mr. Giulj was unequivocal: It will be Asia, for many reasons. “The way I see it, they handled the crisis much better than anyone else because they’ve been facing such a crisis for the past 15, 20 years,” said Mr. Giulj. “Everybody’s wearing a mask wherever you go in Asia. Lockdown, testing, quarantine — they do it and no one is raising any questions about human rights or about having the cops around or trying to take advantage of this. There’s a better understanding, they’re better prepared, they have more experience and maybe the mentality is more adjusted to the common situation and also to get things done.”

That doesn’t mean that other regions will be behind forever — Mr. Giulj pointed out that it “was in the American market’s genes” to catch up quickly to industry trends without a huge amount of investment. But the pandemic will certainly shape the future of the industry.

COVID-19’s long-lasting impacts on ophthalmology

Mr. Giulj drew comparisons between

the 2008 economic crisis’s effects on ophthalmology and the potential outcomes from the current crisis. He noted especially that femtosecondlaser surgery procedures peaked in 2008 and are down 40% since then — largely because the technology and the procedures are expensive.

While refractive surgery centers will be unlikely to reduce their prices, he said, demand will remain relatively flat post-virus. He speculated that some refractive centers will likely close down unless they find a way to reduce their prices.

He specifically pointed out that he believed femtosecond laser-assisted cataract surgery (FLACS) will go the way of the dodo due to its price and the negligible impact on surgery outcome the laser has.

Mr. Giulj said that, on the other hand, femtosecond lasers will continue to have a place in laser-assisted in situ keratomileusis (LASIK) treatments. The alternative is a microkeratome — which Moria makes. As Mr. Giulj said, the company is the last in the industry to make the tool and represents a wholesome ‘back-to-basics’ approach.

The world will return to “normal” at some point, but the effects of the virus will likely be felt for a long time afterwards. This may include a change in the patient marketplace, a change in the way tools are used, or even changes in what tissues are available where. Whatever the case, the ophthalmic industry is resilient and will bounce back — but individuals and businesses within it will need to adapt in order to survive.

Editor’s Note:

This article is part of the ‘Q&A from Quarantine’ series of CAKE Talks, where Matt Young, CEO of Media MICE and Publisher of PIE and CAKE magazines, reached out to KOLs and industry friends during the time of COVID-19 lockdown to evaluate and discuss the impact of this pandemic on the ophthalmic world.

ASCRS 2020 Pulls Off First-Ever Major Virtual

Ophthalmic Conference by Andrew Sweeney

Just as most organizers started postponing and canceling seminars and conferences lined up for the year, the American Society of

Cataract and Refractive Surgery Virtual

Annual Meeting (ASCRS 2020) boldly announced that they were going virtual. True enough — on May 16 to 17, ASCRS 2020 pulled off the world’s first-ever successful virtual ophthalmic conference during a pandemic.

Prior to the virtual seminar, expectations were high. There were mutterings that a purely virtual conference couldn’t cut the mustard. Many asked whether ASCRS was doomed to fail a major coronavirus litmus test.

Well, consider the mustard correctly cut and spread successfully over a superlative sandwich. Nobody expected a fully virtual conference to be just as good as one in the flesh, but the ASCRS proved itself superbly.

No lockdown can stop the tribe

Ophthalmology professionals from all corners of the globe chimed in on different topics — from coronavirus to cataracts to canceled treatments. And all were glad for the opportunity to share their experiences.

However, no matter how successful the event was, there was something left to be desired about virtual exhibitions. Sources noted the following challenges: 1) Missing in-person social connections that seem irreplaceable 2) Missed connections due to somewhat clunky communication methods inside the virtual space, and 3) A desire to find a better way to connect discussions about products with actual commercial sales.

These are understandable, of course, given that ASCRS was bold enough to put on the first real digital ophthalmology exhibition ever, challenges were to be expected.

Star(ship) appearances

The first day of the conference ended on a particularly high note — literally. After a day of statistics, reports, e-posters and more, the conference wrapped up with the 38 th Film Festival Reception and Awards Ceremony, featuring a special guest appearance by Jefferson Starship lead Singer Mickey Thomas, who treated viewers to his own special version of “I Can See Clearly Now,” by Jimmy Cliff.

Of course, most of the films were more related to ophthalmology. We particularly enjoyed Dr. Sergio Canabrava’s “Intrascleral Intraocular Lens Fixation Technique; No Flaps, No Knots, No Glue”. The surgical footage was as insightful (and gory to the uninitiated) as the name was long. Kudos to Dr. Canabrava for his two years of research.

Also on the first day of ASCRS 2020, the former U.S. FDA Administrator, Dr. Scott Gottlieb, covered the coronavirus in a symposium sponsored by Novartis. Dr. Gottlieb stated that the coronavirus infection rate in the U.S. is currently low and that it’s a safe assumption that most people infected with the virus will subsequently develop immunity, similarly to other coronaviruses.

This was welcome news for ophthalmologists stuck with shuttered clinics and desperate for more patients to feel safe enough to return. Dr Gottlieb also emphasized his view that telemedicine, which has experienced a

massive uptick, is here to stay, pointing to his own experience of improved productivity, thanks to video calls.

Of cartoons, predictions & telemedicine

Have you ever seen those episodes of The Simpsons that appear to predict the future, including video calls and the Trump presidency? The Jetsons was another prophetic cartoon, predicting telemedicine back in the 1960s. At least that was according to Dr. Ranya Habash, who spoke during the “Turning the Lights Back On: Part 2” symposium.

As a self-described telemedicine enthusiast and cartoon fan, to Dr. Habash, using telemedicine is more than just good practice — it’s a Darwinian crux. We’ve arrived at a sinkor-swim moment, and telemedicine is the life raft.

“This is simple evolution, if we are to survive we must adapt. It’s an opportunity to spur medicine forward, and we should embrace that,” Dr. Habash said.

Now, while we’re not likely to use The Jetson’s flying cars anytime soon, Dr. Habash is right. Telemedicine is the future of ophthalmology and a virtual conference is a good hint toward this. Technology offers a lot, particularly for those who find it difficult to access medicine, like the elderly and children with disabilities.

Interesting posters to note

Kids with Down’s syndrome in particular face particular challenges in ophthalmology. Their corneal thickness, for example, is usually 100mm thinner than average healthy levels, according to One Extra Chromosome X, Makes One Special Child-Don’t Miss out Mr X. This e-poster’s study screened children with Down’s syndrome over eight years old.

Five eyes were diagnosed with grade two keratoconus and one presented with acute hydrops. The children received treatment, which was described as rewarding, with better visual quality and accompanying cognitive and emotional

As the song says we’ll meet again, and we’re sure it won’t be long!

development. The study’s authors stated that close monitoring and screening can significantly help similarly disabled children, and overall improve their behavioral and emotional state.

These researchers called for targeted screenings and marksmanship, not unlike another standout e-poster from the conference. Rifle Marksmanship Following Small Incision Lenticule Extraction saw researchers team up with the U.S. Army to examine the effects of small incision lenticule extraction (SMILE) treatment for myopia.

The results of the study were fascinating. Out of four marksmanship categories, soldiers in the lower three performed the same or worse after SMILE treatment — yet expert shooters (the highest category) actually improved. The researchers concluded shooting was as good post-SMILE without correction as it was with correction preoperatively.

A start of a new normal?

The marksmanship in the military e-poster was in fact a fitting symbol of the overall atmosphere of the ASCRS conference. It succeeded because of the Blitz-spirit that the ophthalmology industry is experiencing. People from all areas of the industry are coming together to survive, to learn the best lessons we can from the crisis, and to thrive after it’s over.

Dr. David W. Parke, CEO of the American Academy of Ophthalmology, perhaps best summed up this zeitgeist. Churchillian in tone, he pointed out that in the U.S., 79% of baseline visits have been cancelled in ophthalmology — the worst affected medical sector.

However, he offered more than defiance in this present adversity. Rather, he offered optimism and pride. “The normal of the future will never be the normal of last January. We will always have the memory of how it is to shelterin-place, to furlough staff, and defer patient care,” Dr. Parke said.

“Years in the future, every ophthalmologist will be able to tell their grandchildren that they played an important role in blocking virus transmission and preserving scarce PPE,” he added.

If ASCRS 2020 Virtual Annual Meeting has taught us one thing, it’s that ophthalmology shall never surrender.

Editor’s Note:

ASCRS 2020 Virtual Annual Meeting — the world’s first-ever successful virtual ophthalmic conference — was held on May 16 to 17, 2020. Reporting for this article also took place during the virtual ASCRS 2020 conference, where CAKE magazine’s parent company, Media MICE, was the only exhibiting independent media. A version of this story was first published on cakemagazine.org.