Taking the Wider View

When did you decide to pursue ophthalmology?
 

It’s funny – both of my parents, as doctors, were involved in ophthalmology and I was determined I would not be following in their footsteps. So, I did my pediatric training before my ophthalmology training. But with both of those specialties I was struck by the fact that, as a doctor, you get to be involved not just with a patient's medical needs but their whole life course. And working with children, you get to care for your patients in the context of their family life too. So I settled on pediatric ophthalmology.

Which mentors have most influenced your career?
 

How many professors does it take to make an ophthalmologist? In my context, the answer is quite a few! I’ve benefited enormously from some exceptionally supportive colleagues and mentors. At the Institute of Ophthalmology, I have to mention Andrew Dick, current Director of the Institute, and Tony Moore. From my background and training in epidemiology, there is Catherine Peckham – the first professor of pediatric epidemiology in the UK – Carol Dezateux who co-supervised my PhD and my first supervisor, Claire Gilbert, an ophthalmologist who very much helped spark my interest in epidemiology and population studies in the context of childhood eye diseases. Of course, I have to also mention David Taylor, the leading paediatric ophthalmologist of his generation and Sir Peng Tee Khaw – both giants of ophthalmology who have been a consistent source of help and support. At my own inaugural professorial lecture, I got to look at the audience and see all of these people who had helped to shape my career.

What do you think of the growing interest in global ophthalmology?
 

I think it's a great thing. What I’m particularly pleased about is that we’re moving towards the idea of building capacity within lower income countries and away from the older model of flying in a surgeon to do a cataract surgery camp but not leaving any legacy. Although on the individual level, it’s obviously good that people receive the surgery they need, however, without building the systems to generate capacity, all those structural needs remain when you fly off home again. That’s not the way people approach things now. There are many of us – particularly when we are a little more senior in our careers – with the scope to help through partnerships, training programs, and other methods for building capacity. It can be a bit of a leap – there is a certain tendency for ophthalmologists just to talk among themselves – but I’m really interested in seeing if we can help encourage the eye and vision world to look outwards a little more.

Given your work with the World Health Organization, how important is macro-level policy making?
 

It’s vital! I’m increasingly directing my energy in that direction. Collectively, the eye and vision community has maybe not done the best job of explaining to policymakers why sight impairment matters. It’s still a niche. In the world of pediatric ophthalmology, that’s largely because most people have never met a child with a vision impairment. Blindness in adult life is more common, and yet we still don’t seem to be in the mix whenever people talk about chronic disorders that have a major impact on life.

Take the example of the COVID-19 pandemic. It was very difficult to manage if you had a vision impairment – how do you know if you are socially distancing appropriately? Schools moved online, but for children with visual impairment that was very hard and often they didn’t get the right provision. Where does the fault lie with stories like this? Well, to be honest some of it lies with the eye and vision professional community. We have to take this information to policy makers, which in the UK means Members of Parliament and government organizations. This requires time and a change in our communication style. From my point of view in relation to children in the UK, I would like to see initiatives for childhood visual impairment coming from – for example – the Royal College of Pediatrics in partnership with the Royal College of Ophthalmology rather than just from the eye world.

I’d like vision to be something that everyone involved with child healthcare thinks about. This goes across educational needs, environmental needs, social needs, as well as health care needs. Clinicians are already involved in policy decisions – the patients you see in your clinics determine those you don’t see. That’s a policy choice on a micro level. Our work has these wider implications and maybe we need to widen our perspective.

You are also involved with RCOphth; in light of the RCOphth staff survey, what do you think of the state of UK ophthalmology?
 

The survey puts numbers to the worries we’ve had in UK ophthalmology for a long time. With an aging population and the innovations, for example in treating AMD, there is more we can do about the causes of visual impairment than ever before. We have more patients than ever before, but just not enough resources. Quietly – a little behind the scenes – we’ve been particularly worried about pediatric ophthalmology and we have unfilled posts across the country. I think the numbers probably reflect what we see in the NHS generally, which is that there has been little by way of proper workforce planning. Any of the clinical specialties would have said that, with an aging population, demand is simply outstripping supply in terms of staff levels. Things are perhaps not as bad as other specialties – you need only look at mental health care provision to see some very stark numbers on waiting times and staffing levels. The UK Government is about to publish an NHS workforce plan, so let’s hope that offers some solutions to the workforce crisis.

It’s common to hear people say that these problems in ophthalmology can be solved with better partnerships with other health care professionals allied to ophthalmologists, but there is a limit to what they can achieve. Ophthalmologists are, after all, doctors. And yes, our colleagues in optometry, for example, can certainly do a great deal of clinical care, but that won’t entirely solve the problem. It takes five years of medical school and then a further nine years of training to produce an ophthalmology consultant – and that’s the quickest you can do it.

One of the issues that new President of RCOphth, Ben Burton, wants to address is the effect of large numbers of ophthalmic procedures, in particular cataract surgery being done by Independent Service Providers (ISP) – the private sector contracted to provide NHS care. This has destabilized many NHS ophthalmology units and has to be addressed urgently.

I chair the British Ophthalmic Surveillance Unit (BOSU) and a few years ago we did a study looking at harms from delays to treatment in adults. We’re repeating that study right now, doing so for children and hopefully this will help.

What changes in pediatric ophthalmology do you want to see in the next 10 years?
 

I would like us to be successful in really getting the message out that pediatric ophthalmology is a fantastic subspecialty to go into. Your impact really shapes a patient's whole life. As an individual clinician, the impact you have when you first see a patient as a baby is immense. Improving childhood vision means improving health and life chances across a life course – and that’s something unique. Academically, it has huge potential – you aren’t confined to just one set of diseases. We tackle eye conditions in the context of broad health systems. We interface with pediatrics, education, and with social care, so, in a way, the pediatric ophthalmologist is the last of the generalists. You do everything – you are defined by your patient population. Even that’s not static, as children grow and develop too. There’s a breadth you just can’t get from other specialties.

I think we see trainees far too late during their early training in ophthalmology – if there was one thing I’d change it would be to ensure ophthalmic trainees rotate to paediatric ophthalmology a little earlier and have more of a chance of experiencing this incredible subspecialty in its best light!