Imaging the Future of Retina

Why ophthalmology – and why vitreoretinal surgery?

My medical degree taught me that I didn’t want to pursue general medicine! But as for what to do after qualifying, I couldn’t decide between ophthalmology and plastic surgery: both require some artistry, which appeals to me. After all, doesn’t the definition of medicine refer to the ‘art’ of healing? Anyway, I loved looking inside the eye, and when I was told that vitreoretinal surgery was the most complex subspecialty in ophthalmology, I knew it was the one for me. It was the challenge, I think.

You are currently based in Manchester and London. Where have you practiced previously?

Since graduating in 1990, I’ve been on the move: first, New York, and then London, Liverpool and Manchester, and now back in London. I made the move back down to London recently because of the exciting opportunity to work alongside Professor Dan Reinstein and his team in opening London Vision Clinic Retina.

How has your focus shifted over the years?

In New York, during my clinical research fellowship with Harvey Lincoff, I worked on ICG angiography for visualizing choroidal disorders, and on interferon (IFN) alpha 2a (IFN) pharmacotherapy for age-related macular degeneration (AMD) and choroidal neovascularization (CNV). At that time, IFN was usually administered subcutaneously, but Harvey had developed a novel balloon delivery device with a double-lumen catheter, which could deliver IFN directly under the macula. We showed that this procedure stabilized CNV for six months; given that the standard treatment at the time involved photocoagulation of subfoveal CNV, which is quite traumatic, this finding perhaps should have received more attention. Unfortunately, at the time we were all looking for a permanent cure, something we do not even have at present.

Subsequently, I started working on time-domain OCT technology with Zeiss Meditec, and then got interested in Topcon’s spectral domain OCT. Swept-source technology is marvelous: it enabled Prof. David McLeod and me to image the cortical vitreous in vivo for the first time. We could see the optic nerve, the macula, and areas temporal to the macula, all in a single scan – and we could visualize structures, such as the Bursa Premacularis and the Space of Martegiani. The variation in cortical vitreous anatomy could perhaps partly explain why not all patients respond to enzymatic vitrectomy – efficacy that perhaps depends on how much posterior hyaloid remains attached. It was just fascinating. Incidentally, I suspect that study may have had at the time the widest age-spread of any vitreous imaging study– our patients ranged from four to one hundred years old!

Familiarity with imaging systems was a great help in my later work, not least when we set up a monthly Paediatric Retinal Regional Service with Susmito Biswas in 2010. We developed a new treatment for exudative retinal detachment in Coats’ disease: namely, scleral/transchoroidal drainage of the subretinal fluid followed by ultra-widefield fundus autofluorescence angiography-guided laser treatment and anti-VEGF therapy. It has been very rewarding to see this technique being adopted by other hospitals. Furthermore, our widefield, swept-source OCT imaging studies revealed abnormalities in the fovea of the fellow eye – a novel finding that suggests we may need to rethink Coats’ disease, which has traditionally been considered a unilateral condition.

What are you working on now?

I am still interested in ultra-widefield imaging, but I can’t do everything, so at present I am focused on two main fields of work. I am UK Chief Investigator in a collaborative project with Professors Robert MacLaren and Graham Black focusing on gene therapy for X-linked retinitis pigmentosa. The approach requires complex surgery – creating a bleb in the retina for vector placement – but our Zeiss microscope-mounted OCT system is a great help, and everything is going very well.

The other main project is part of my long-standing collaboration with Bausch and Lomb, which started with work on improving small gauge transconjunctival vitrectomy and the development of the Stellaris platform in Europe, and then moved on to the development of the Vitesse hypersonic vitrectomy system. Vitesse uses a needle that oscillates at 1.5 million times/minute; essentially, it liquefies the vitreous by breaking up the collagen fibers into tiny fragments. We started working on this system in 2012, beginning with cadaveric eyes (porcine and human) before moving onto experimental surgery. Since then, I have performed the first ever hypersonic vitrectomy in humans in 2017 and then the first ever in Europe in 2018. The FDA approval for Vitesse was based on work we did in Manchester, at the University of Manchester and the Manchester Royal Eye Hospital; we had to, amongst others, do histopathology and electron microscopy studies after the use of both a guillotine and a hypersonic vitrector to study how the vitreous and the retina reacted to hypersonic energy, something not previously done, optimize vacuum settings, and determine how effectively it removed vitreous compared to a guillotine vitrector, and so on. It required a large, collaborative team effort, and was a great achievement. Certainly, a fascinating time in my career.

Over the course of 2018, I gradually expanded my private practice to 138 Harley Street, Central London. As my children are living in the South, this means I get to visit them more often and I am now finally seeing my patients here at London Vision Clinic Retina.

What next?

The team and I at London Vision Clinic Retina will continue working on expanding and enhancing the services we can offer to our patients.

I think I will always maintain an interest in medical and surgical retina, cataract surgery, eye trauma, R&D of new therapies, imaging, laser and surgical technologies – watch this space!