Retina Society 2018: Award Winners and Scientific Program
This week for RETINA Roundup, we spoke with Dr. Peter Campbell of Casey Eye Institute and Dr. R.V. Paul Chan of Illinois Eye and Ear Infirmary. They have led global ophthalmology efforts in many capacities over the years, and have established meaningful multidisciplinary collaborations throughout the world. We discuss with Drs. Campbell and Chan why global ophthalmology matters, what inspires them, and updates from the field. We also received updates from collaborators Dr. Parag Shah (Aravind Eye Hospital in India) and Dr. Sanyam Bajimaya (Tilganga Institute of Ophthalmology in Nepal) to hear about their experiences and expertise.
How did you get involved with international work?
Campbell: I’ve been interested in working in lower resource settings since early in my medical training and spent an extra year in medical school obtaining an MPH degree. Public health practitioners and clinicians have the same goal, ideally, that is to reduce the burden of disease and improve quality of life of their patients (or in the case of public health, populations).
That said, medicine and public health often look at the problem and solutions differently, and I’ve found it helpful to be exposed to both perspectives. As my career has progressed, the way I am involved in “international” work now is not the way I thought I would be 10 years ago, and has taken the form of collaborative research projects with indigenous partners focused on improving the state of ROP care in lower resource settings worldwide.
Chan: It's been a wonderful journey for me, and global ophthalmology is something I grew up with. My parents are ophthalmologists with strong international connections, and both were dedicated to education.
I’ve also worked extensively with the American Academy of Ophthalmology and their Global Ophthalmology initiatives. Education in Ophthalmology is critical for improving patient care and increasing access to care for patients. In the United States, we’re fortunate that we have structured ophthalmology training programs with organize d curriculums. It’s not the same in many other countries. Training ophthalmologists who may not have benefited from structured programs can have profound effects. In today's world where it's easy to stay connected with colleagues from other countries, we can be more impactful without encountering as many barriers.
What's the best way for us to get involved?
Campbell: There are many models for how a U.S. based vitreoretinal surgeon can contribute meaningfully and positively to health care in lower resource regions, and the AAO has some great references for how to get started, and how to avoid common mistakes (https://www.aao.org/education-browse?filter=global-ophthalmology).
Chan: There are many ways to get involved with global ophthalmology. You can participate in clinical service, advocacy, research, and education. As Dr. Campbell mentioned, the AAO has a number of outstanding resources you can access. For example, we developed the Global Ophthalmology Guide (https://www.aao.org/global-ophthalmology-guide) which provides information about working internationally and global ophthalmology. You can also access the Global Directory of Training Opportunities (https://www.aao.org/training-opportunities) if you’re interested in participating in international training opportunities.
How do you work with nonprofit organizations?
Campbell and Chan: We have many essential collaborators in the nonprofit world. There are many great organizations such as Helen Keller International and Orbis International. It’s about relationships and having similar passions for wanting to help people and making a difference. We work with nonprofits, healthcare workers, and local governments, to add structure to and empower local efforts. As you know, there are epidemics of diabetic retinopathy and ROP throughout the world – our goal is to facilitate the formation of self-sustainable infrastructure, and working with NGOs can help make that happen. Making the impact long lasting requires life-long friendships and partnerships. It's not about an American person who shows up and tells people how to do things.
Drs. Bajimaya and Shah, can you tell us your ROP programs?
Bajimaya: The increase in hospital births in Nepal has increased the survival of lower birth weight babies and the demand for neonatal intensive care. Major hospitals and medical schools are now providing NICU services but there has been no ROP screening in the country. Tilganga Institute of Ophthalmology (TIO) has been implementing an ROP screening project at 3 government hospitals in Kathmandu valley. The main focus of the project is to raise awareness among health professional working in the NICU, antenatal care, pediatricians, parents of preterm babies and enhance wider range of screening facility using modern innovative technology (Portable RetCam with telemedicine). TIO has been implementing this project under USAID’s Child Blindness Program in partnership with Helen Keller International and University of Illinois, Chicago. We have trained and mobilized two technicians to visit each of the NICUs weekly to examine all newly admitted premature babies and those in the out-patient department who may have previously missed ROP screening. The decisions on the appropriate course of treatment for babies are being verified by both graders are recorded and discussed with the hospital ROP committees before proceeding. This process both introduces ROP screening and treatment in Nepal for the first time as well as ensures that the care provided is high quality.Dr. Bajimaya performing ROP screening with the team.
Shah: To serve the unreached in rural areas, Aravind ROP Tele-screening Project called Retinopathy of Prematurity Eradication Save Our Sight (ROPE-SOS) was launched in August 2015, funded by USAID and a generous grant from Mr. Subroto Bagchi. The project aimed to screen 2000 babies per year in the sub-urban and rural areas. Technicians are trained to capture fundus images of pre-term babies with help of digital retinal camera (RetCam). The team comprises of one manager, two trained technicians, one mid-level ophthalmic assistant and a driver. The team covers 56 NICUs of 18 cities in 12 districts of the states of Tamil Nadu and Kerala. The team visits scheduled district hospital NICU on specified days in a customized van with a RetCam shuttle. The technicians enter the babies detail in RetCam and obtain fundus images. The digital images of the fundus are then transmitted to the base hospital through broadband internet. Indigenously developed Aravind Diabetic Retinopathy Eye Screening (ADRES) software is used to transmit these images. The ADRES software was modified for ROP. At the base hospital, images are graded by a ROP expert (retinal specialist) and the report is sent back immediately to the NICU. The 4G network (which is now available in most parts of even rural India) is used for transfer of these images. The family is then explained about the baby’s eye status and given a follow-up date. The whole process for screening and counselling parents takes about 12-15 minutes per baby. If a baby requires treatment and if the baby is stable systemically, the baby is transferred to Aravind Eye Hospital Coimbatore for management. If the baby is not stable for distant travel, the ROP expert visits the NICU within three days to provide treatment. With the help of tele-screening, various other disease like cataract, corneal opacity and even retinoblastoma have been diagnosed and promptly managed by early referral. ROPE SOS covers a population of approximately 47 million and an area of 59,000 km2involving 56 NICUs. 11,912 were screened from Aug 2015 to Feb 2018. Any stage of ROP was seen in 2591 babies (22%) and 215 babies (1.8%) required treatment. Of the 215 babies (408 eyes), 4 babies (8 eyes) developed stage 4, of which six eyes needed vitrectomy and two stabilized only with laser. Two eyes of one case progressed to stage 5.
Why does global ophthalmology matter?
Chan: This is going to be personal and different for everyone. For me, there are many parts to why I’m so involved with global ophthalmology: A very personal aspect, the academic part, and the goal of bettering humanity.
Working in global ophthalmology is incredibly fulfilling at a personal level. You get to meet to people with different experiences and perspectives and make friendships that are lifelong and deep. Many of my best friends are people who I’ve met while working abroad.
The academic and research aspects are fulfilling as well. For example, we’ve worked with many partners on research collaborations that will ultimately help provide better care for children on a global level.
And of course I love doing it and I feel that the work we are doing will make a difference. For many of us, our motivation for wanting to become a doctor was because we just want to help people. So much of what we do is voluntary. We do it as a labor of love. We’re creating academic networks, building clinical bridges, and forging a community of people to reach our mutual goals.
Any advice for those interested in global ophthalmology?
Chan: For young ophthalmologists thinking about global ophthalmology, it's important to remember that the exchanges are bidirectional. It's not unilateral where you dogmatically tell people in low resource settings how things should be done. There are many ethical considerations as well and a discussion on this can be found at the Redmond Ethics Center for the AAO (https://www.aao.org/ethics-detail/advisory-opinion-ethical-issues-in-global-ophthalm)
You can start at any point in your career, but starting early and pairing up with a mentor can be very helpful. It's similar to establishing research programs.
Finally, you have to go. Nothing replaces actually going abroad and meeting your collaborators. We can rely on technologies to keep us connected, but there is incredible value in making personal relationships. Meeting in person will help build friendships and trust.
We thank Drs. Bajimaya, Campbell, Chan, and Shah, for sharing with us their expertise and experiences working globally.