Thinking Globally

Why ophthalmology?

In medical school, I found it very hard to make a choice between general medicine and ophthalmology. One of my mentors, Andrew Elkington, suggested I do general medicine training first, and try ophthalmology afterwards. It was a great piece of advice: by practicing general medicine, I learned so much about general disease and looking after patients, talking to them. I worked under a neurosurgeon, John Garfield, who taught me how to assess and make a diagnosis just by taking a history, without even touching the patient – a lesson I have used throughout my career. However, when I turned to ophthalmology, I enjoyed it enormously, and I knew that it was what I wanted to do. I love operating, developing and using novel techniques and technology, but also dealing with patients. Preserving and restoring people’s sight is incredibly rewarding, and the intricacies of the eye and vision discovered through research are fascinating. As a complete profession, ophthalmology is unbeatable.

And why glaucoma specifically?

My mentors, Andrew Elkington and Roger Hitchings, were great authorities on glaucoma. When I came to Moorfields, I was in a very privileged position, as every week, Roger Hitchings and I would sit for an hour and he would go through everything to do with glaucoma with me: pathogenesis, treatments, the use of modern technologies. It is such a common and complex disease, which causes so much blindness, and yet it was strangely misunderstood. It made me want to understand it better. The research that has been done over the years has helped us with this enormously. We now have potentially realistic solutions to deal with glaucoma globally.

How do you find the right balance between research and clinical practice?

Conducting research at the same time as practicing medicine and surgery is not easy, but, if you get it right, it is one of the most satisfying and rewarding things you can do. Discovering new findings that can change the lives of your patients is an unbelievable privilege. Having great mentors and being awarded a Wellcome Trust Fellowship enabled me to learn about science and lab work for three or four years. This changed my life, and taught me to always look for answers. These days, there are perhaps more support systems for young clinicians wanting to pursue careers in research, for example the National Institute for Health Research, which has revolutionized clinical research in the UK. On the other hand, there is now more focus on completing physician training rather than conducting research, and so, clinicians may be disincentivized from taking the research path. I believe this could be to the detriment of ophthalmology. The population is ageing rapidly, and incidence of eye-related disease is rising so quickly that current models of eye care will not be able to cope with future demands. The only way to cope is with new methods of diagnosing and treating people with eye disease. That is why research is not just an option – it is the only way forward – it is an absolute necessity, if we are to cope with the demand for eye care in the future.

Which qualities have helped you become a leader in your field?

I’ve always been very curious. All my life I’ve had the need to find out how things work, and how I can make them better. To improve things and make a real difference, you need knowledge and experience – and the willingness to learn new things. When I was President of ARVO in 2013, I had the task of setting the theme of the meeting, and had to figure out what the 15,000 members had in common. The answer? Making a difference to people’s lives. And that’s how the “Life Changing Research” theme came to be. Leaders need the desire to make things better. We also have to think globally. At Moorfields and the UCL Institute of Ophthalmology, we aim to change lives in London, in Britain, and in the world – this is our job and our responsibility. The way I see it, there is no point in building a new hospital site in London, if it’s not going to be used to improve lives in the whole country, and all around the world. Global thinking is important in every aspect of our lives, from climate change to ophthalmology.

What’s your proudest achievement?

My proudest moment stems from one of the worst. Many years ago, I treated a child with glaucoma, who was completely losing vision in one eye despite multiple operations. I operated using mitomycin C – a new technique at the time. The operation worked and the child was well for three or four years after that. But then she came back with endophthalmitis, and subsequently developed severe scarring on the retina. The retina shredded during vitreoretinal surgery and my young patient lost her vision. I knew that I could not deal with this scenario of bleb-related endophthalmitis   throughout my career, so I went back to the lab and redesigned trabeculetomy, introducing a much safer way of applying antimetabolites, which I called the Moorfields Safer Surgery system. The work changed the safety profile of the operation – markedly reducing the incidence of blebitis and endophthalmitis, and reducing hypotony. It was a change in technique, based on research, and it has been popularized around the world. This was helped hugely by Paul Palmberg’s advocacy of the technique; he also persuaded the developers of the Innfocus implant to use mitomycin with our technique, which has been critical in its clinical success. I am proud that I was able to help make glaucoma surgery safer for patients everywhere. 

Has your Knighthood made any difference to your career?

It has certainly made fundraising easier – and it has brought me into contact with a much wider selection of very interesting people. I am very proud of the children’s eye hospital that I helped raise money for, and of the Biomedical Research Centre – the only one in Britain specializing in ophthalmology, for which I led the funding application, and that I am now privileged to head up. But the most important thing about the title is the recognition of the importance of ophthalmology. To the best of my knowledge, there have only been two knighthoods for services to Ophthalmology in the last hundred years, the first one being Sir Harold Ridley for the first intraocular lens, though there have been a few other knighthoods for ophthalmologists for services to Royalty. I feel that medicine in general does not get enough recognition for changing peoples’ lives so dramatically. I hope many more of my colleagues will be recognized in this and other ways. For me, it is an acknowledgement of how important research is – and for that I am very grateful.

What do you consider your most important collaboration – now or in the past?

My most successful collaboration has been with my wife – without her I would not have achieved any of the things I have done. And, of course, the collaboration with my mentors including Roger Hitchings, Noel Rice, Ian Grierson and Gregory Schultz, and also the collaboration and support of my colleagues at Moorfields and UCL Institute of Ophthalmology, and our colleagues around the UK and the world without whom our center would not be the success that it is.

What keeps you motivated?

Thinking about how an organization can encourage people to make a difference. Developing our future building is another huge driving force – but it is going to be more than just a building. If we were just using bricks and mortar, it would be a waste of time and resources. We are developing a structure to equip us to move into the future, from artificial intelligence and advanced informatics – imaging, genomics, through to rapid diagnostics and therapeutic devices and therapies, using research and all our clinical strengths together to improve lives around the world.

Is there anything you do not enjoy about ophthalmology?

There is a lot of regulation, which makes our work harder and harder. The number of regulatory hurdles to go through when bringing something new to the field these days is phenomenal. Sometimes it doesn’t feel like the system works in our favor. The bigger the organizations, the more systems have to be built around them, which slows down important work.

Do you have time to pursue any interests outside of ophthalmology?

It is difficult to find spare time, but I used to be a keen drummer. I have played with some very interesting people – Greg Lake from Emerson, Lake and Palmer, for one! I also like mending things, so I make improvements around the house; if something mechanical is broken, I can usually fix it myself; in my early days, I played a lot with Lego and Meccano, which must have helped.

How do you think glaucoma care may change in the coming years?

My vision of the future is being able to get a portable non-invasive test of a patient’s visual function including fields and dynamic contrast sensitivity (a greatly neglected but critical functional defect in glaucoma) and structure. This includes having a detailed background function of the cellular components of the optic nerve (missing in current imaging) including bioenergetics, genetics, and assessment of their risk of developing the disease; then inputting the anonymized data into a standard communal database that can be accessed around the world and that will determine the risk of vision impairment over a period of time. We spend a lot of time trying to absolutely define glaucoma, but as our cellular and molecular understanding of the disease and its natural history progresses, we will be able to define this group of diseases as much more cellular and molecular defined entities.

Based on the data of millions of patients, and the individual’s data, we would be able to offer unprecedented accuracy diagnosis and prognosis, and choose the most appropriate treatment with the minimum follow up necessary. Importantly, we would not have to follow patients unnecessarily, as the ones who do not need frequent visits could be followed up remotely. With the advances of AI and information, this is something that could be achieved in the future.

I would also love to see a glaucoma surgical treatment that lowers pressure very significantly, and for a long time, according to the 10-10-10 target I set the glaucoma community: maintaining eye pressure of 10 mmHg (a level considered safe enough to prevent  glaucoma progression in over 95 percent of patients) lasting 10 years – and achieved safely in 10 minutes. There are so many glaucoma patients in the world, and the number is increasing with the ageing population. Unless we have a safe, quick and easily reproducible treatment that will last for a long time, we won’t be able to cope with the demand. This probably requires a microdevice that is easily inserted, coupled with anti-scarring therapy that can be easily delivered during surgery and can be titrated according to the anticipated healing response. Lasers may also help this, and the recent LiGHT trial is showing the potential of maintaining pressure for several years without medicines.

One final wish: to turn the clock back, and give my patients some of the vision they have already lost. Gene and stem cell therapy for glaucoma now has the real prospect of turning the clock back at least by a couple of years for patients with end-stage glaucoma. I am privileged to be involved in the discovery of the Moorfields-Institute of Ophthalmology Muller cell, which now has a real prospect of optic nerve therapy.

All of these dreams are incredibly ambitious, but the most amazing thing about them is that they are achievable; they are based on research done over the years. I often think back to the child who lost her vision – and I realize how much progress our specialty has made thanks to research advances.

What advice would you give to those following in your footsteps?

Be ambitious, be inspired. You never know what you might achieve if you don’t try – and it makes the future very exciting.