The Ikigai of Glaucoma Practice

Upon completing my fellowship in glaucoma, I was posted in a public hospital in my hometown of Seremban in the state of Negeri Sembilan to start a glaucoma service from scratch. My ambitions soared. The possibilities were limitless, and a myriad of questions filled my mind. I wanted to attend to every glaucoma patient in my hospital, provide early surgical interventions, and explore the realm of minimally invasive glaucoma surgery (MIGS) in cost-restricted public healthcare. I wanted to reach out to remote villages and offer glaucoma screenings.

When I shared my vision with my mentor, Aziz Husni, Head of the Glaucoma Service at the Malaysian Ministry of Health, he responded with a smiley emoticon and introduced me to the concept of ikigai. He advised me to “start small.”

My task was to understand the ikigai of glaucoma practice. The principle of ikigai is very simple: do what makes you happy. Get a hold on the motivation that gets you out of the bed every day. I delved into the principle and pondered how best to shape my practice for the benefit of both my patients and me. After 18 months as a glaucoma consultant, I now reflect on how these principles have refined my practice.

Starting small
 

The first pillar of ikigai – the concept of taking small steps – resonated deeply with me (1). I implemented this idea in two significant ways. I realized I needed to start from where I am rooted, rather than “going wide.” First, I focused on a specific niche within my eye department – advanced glaucoma patients on maximum medication and those suffering from ocular surface disorders because of chronic medication use. I offered filtering surgeries to improve their intraocular pressure control while minimizing the need for eye drops.

Second, I embarked on the MIGS path, starting with the smallest interventions in moderate glaucoma cases, such as excisional goniotomy, trabecular microbypass shunts, and hydrus microstents for eligible patients.

Releasing yourself
 

The second pillar of ikigai centers on self-acceptance – a profound yet challenging task in life. To me, this principle signifies letting go of one’s ego, pride, insecurities, fears, and sense of injustice. Instead, it involves focusing on others, listening, understanding, and empathizing. Each patient has a unique story to tell, and our fixation on intraocular pressure (IOP) might not always align with their concerns. One particular patient – with a high IOP despite being on maximum medication and lasers – comes to mind. He lost an eye from postoperative endophthalmitis several years ago. Surgery seemed like a viable option to me – I wanted to say, “We will do all we can do to avoid infection and make this surgery work for you.” But it would be very arrogant of me not to respect his fear of losing his precious remaining eye from another unfortunate event. He told me, “I’m just hoping to retain my vision until my daughter’s wedding.” I listened to him; I decided to optimize his eye drops and monitor his progress closely.

Harmony and sustainability
 

Amid the distractions of a competitive world, we sometimes lose sight of pillar three – the importance of collaboration and harmony. Initially, as I started my public practice, I felt overwhelmed, thinking I had to handle everything myself. However, I gradually recognized the benefits of working together with other subspecialty consultants, fostering collaborations by joining national and international organizations, and building communities. The Malaysian Glaucoma Society provided a supportive glaucoma community where collaboration triumphed over competition.

The joy of the little things
 

The fourth pillar is my favorite. Glaucoma patients suffer from chronicity of the disease. They’re often told they might lose their vision in later life if their condition is not properly managed. But at this point, their central vision may be good, they may be functioning well, and the only problem they really have is redness of the eyes from their prescribed anti-glaucoma drops. Sometimes they must have incisional surgery to prevent vision loss in the future. But they might feel worse after the surgery, and possibly have worse vision.

As a surgeon, it is quite demotivating when a patient cannot immediately feel the benefit of your work, even though we know that surgery was the right decision. The only way I could motivate myself was to find joy in the little things. For example, to see the white of an eye without the congestion from brimonidine. To see a well-functioning bleb. To see a patient smile when I say their IOP is within target range. Like the song from The Sound of Music, when something does not turn out the way I want, “I simply remember my favorite things and then I don't feel so bad.”

Living in the here and now
 

The fifth pillar emphasizes immersing oneself in the present moment. It underscores the importance of calming one’s thoughts, directing complete attention to the immediate circumstances. Dealing with chronic glaucoma patients can be emotionally taxing, as we tend to shoulder their burdens and share their fears. Our hearts sink a little every time when we face a failing bleb, worsening visual field, or persistent hypotony. The key is to exert control over our thoughts and emotions, conserving energy by not needlessly holding onto past grievances or worrying excessively about an uncertain future. We all have a “mental graveyard” that we occasionally visit to reflect on our mistakes, but it is vital to understand and accept that we cannot control the past; we can only govern our thoughts and our capacity for self-reflection. According to Ken Mogi – a neuroscientist and author of The Little Book of Iigai – children value the present because they lack a concrete concept of the past or future (2). Tapping into our inner child can help us appreciate the present moment and celebrate small achievements during follow-up visits, such as reaching the target IOP at the three-month or six-month mark or patients experiencing a slight increase in quality-of-life scores and getting recognized for our effort.

A guiding light
 

The principles of ikigai have not only refined my approach to glaucoma practice, but have also enriched my understanding of patient care, self-acceptance, collaboration, and the joy of the present moment. These principles serve as a guiding light in my journey as a glaucoma specialist, reminding me to start small, release myself, seek harmony, find joy in the little things, and live in the here and now.