Power List Perspectives: Part One

Eduardo C. Alfonso

Chairman and Director, Bascom Palmer Eye Institute, Miami, Florida, USA

In terms of patient care, the implementation of the electronic health record (EHR) in the early 2000s was a huge breakthrough. Primarily used at its inception to gather and share accurate patient information, we now use EHRs to advance research studies, including large-scale studies that require extensive computing power. In 2018, for example, Bascom Palmer launched its first study using the American Academy of Ophthalmology’s IRIS Registry database, which compared real-world patient surgical data with the Tube versus Trabeculectomy (TVT) Study, to determine whether the TVT results could be replicated (1). Since then, more leading-edge studies using the IRIS “big data” repository and other analytic tools, such as artificial intelligence and genetic testing, are trying to solve the underlying mysteries of eye disease.

The development of anti-VEGF therapies for neovascular and exudative eye diseases was another huge breakthrough in ophthalmology. The treatment of these diseases with intravitreal Avastin therapy has prevented blindness worldwide and saved billions of dollars in healthcare expenses. The continuous advancement of optical coherence tomography (OCT) will also guide the diagnosis of eye diseases at earlier stages before irreversible loss of vision takes place.

For Bascom Palmer, the COVID-19 pandemic posed perhaps the biggest challenge that the Institute has faced in six decades – and changed the everyday practice of ophthalmology. In March 2020, the rapid spread of SARS-CoV-2 forced a shutdown in non-emergency clinical visits as a public health measure. However, within a few short weeks, our physicians began to offer telehealth consultations and assessments, followed by “hybrid” visits to maximize patient safety and minimize in-person clinical services. Although the pandemic also affected our research program, forcing a temporary halt to clinical trials and some projects, our scientists and clinicians still made significant contributions to timely COVID-19 studies regarding the impact of the virus on optical tissues. I mention our experience during the pandemic to illustrate our resilience and ability to adapt to changing conditions. The pandemic allowed us to critically examine our processes and develop new ideas, instruments, and protocols that will serve patients, education, and research – now and in the future. Virtual care will also increase patient access and use technology to improve outcomes; this is why  virtual education is an important component of our residency education program.

Stephanie Watson

Professor and Head, Corneal Research Group, The University of Sydney, Save Sight Institute; Co-Deputy Director, Industry, Innovation and Commercialisation, Sydney Nano; Head, Corneal Unit, Sydney Eye Hospital; Chair, Australian Vision Research (formerly Ophthalmic Research Institute of Australia); Chair, Advocacy and Outreach Committee, Association for Research in Vision and Ophthalmology, Sydney, Australia

The evolution of corneal transplantation has been a significant breakthrough. The ingenuity of the techniques developed has revolutionized surgery and improved patient outcomes. Patients with blinding corneal disease have had their vision restored quickly, avoiding complications.

When I was a corneal fellow at Moorfields Eye Hospital, London, UK, penetrating keratoplasty was the most commonly performed graft for patients with Fuchs corneal dystrophy. Following the surgery, time was then spent on managing the sutures and patient complications such as astigmatism and abscesses. On my return to the Sydney Eye Hospital in Australia, where I am now Head of the Corneal Unit at the Prince of Wales Hospital, endothelial transplantation was emerging. Initial techniques involved using scissors to remove a section of the host posterior stroma and endothelium and inserting the graft as a “taco.” Unfolding the “taco” and placing it in position was quite a challenge. With the emergence of Descemet’s stripping techniques and “pull” then “push” insertion of the graft without the need for folding, the procedure improved and patients benefited from faster and more successful visual rehabilitation, avoiding adverse events from sutures.

Just when Descemet’s stripping endothelial keratoplasty had evolved to a technique that most corneal surgeons were comfortable with, Descemet’s membrane endothelial keratoplasty (DMEK) was developed. Initially a tricky technique with a steep learning curve, DMEK is now part of routine practice for a corneal surgeon and can deliver rapid visual rehabilitation. The journey in corneal transplantation is continuing, with novel treatments, such as cell-based therapies, under development.