Tejus Pradeep, BA

, known for its well-balanced blend of microsurgical procedures and medical treatments, is widely regarded as an elegant medical specialty. This is evidenced by a competitive residency application process and a track record of physicians who are extremely satisfied with their profession.

According to a recent annual survey, ophthalmology is among the top 4 specialties where physicians report being happy while at work. However, perhaps just as contributory to satisfaction at work, is the career longevity and health of the practitioner.

Much has been made in the past 2 decades about poor postures and long-term health effects caused by microsurgical procedures. 

 reported that more than 50% of ophthalmologists had significant attacks of back pain, with these numbers 

holding true in the US nearly a decade later

A 2004 presentation from Uday Desai, MD, at that year’s American Society of Retina Specialists (ASRS) Annual Meeting highlighted that only 15% of vitreoretinal specialists reported having no symptoms of pain as a result of their profession. Another 55.4% of the 1130 surgeons surveyed reported both back and neck pain.

In the 15 years following this report, our conversations about improving ergonomics remains just as important. At this year’s ASRS meeting in Chicago, IL, last month, Jennifer Lim, MD, director of Retina Service at the University of Illinois (UI) Health Center, led an instructional course session about techniques to improve ergonomics and mindfulness during retina surgeries.

For our next generation of ophthalmologists, it is vital to train residents about proper postures and ergonomic techniques, to prevent health issues midway through a physician’s career.

Luckily, many promising efforts are already underway. The implementation of educational ergonomics modules for improving slit lamp positioning 

 in reducing unwanted shoulder flexion and elbow abduction, and promoting neutral body postures among residents.

Furthermore, optical motion capture methods typically used by industrial manufacturers to electronically assess the ergonomic risks of products, are increasingly being applied to ophthalmic procedures such as strabismus surgery.

In 2008, TrueVision Systems launched the first 3D, ‘heads-up’ ophthalmic surgical system where users can avoid postural constraints of the surgical microscope. 

, in 2016, the release of NGENUITY, has brought this technology to the field of digital vitreoretinal surgery.

Although the outcomes of these novel methods have yet to be analyzed, harnessing innovative approaches to improve the health of future ophthalmologists is part of the ongoing evolution of the field.

With diligent effort, we can ensure that ophthalmologists continue to experience long and fulfilling careers—because there is nothing worse than when your job becomes a pain in the neck.

Tejus Pradeep is a rising fourth-year medical student at Johns Hopkins University, School of Medicine in Baltimore, MD. In 2016, he graduated from Rutgers University with a Bachelor of Arts in cell biology and neuroscience, and a Bachelor of Arts in psychology. After graduating medical school, Tejus would like to pursue a career in the field of ophthalmology. The piece reflects his views, not necessarily those of the publication.

Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Magazine® can reach the editorial staff by submitting a request 

Articles

Poor posture in surgical care has been long associated with worsened clinician health. It is no different in ophthalmology.

Ergonomics May Be the Key to Longevity for Ophthalmologists

Early treatment, meticulous follow-up, and maintaining treatment regimens are key to visual acuity improvements in neovascular age-related macular degeneration (nAMD).

David Boyer, MD, retina specialist with Retina Vitreous Associates Medical Group in Los Angeles, presented these important take-home points in his presentation, “The Average Patient Does Not Enter Your Office: What Can We Learn About Treating nAMD From Individual Patient Responses” at the 

2019 American Society of Retina Specialists Annual Meeting

He talked about results from a variety of clinical trials, including VIEW 1 and VIEW 2, and how patients in real life often do not respond the same as those in controlled study settings. Comparing patients who responded well to treatments to those who did not, he explained that decreases in central foveal thickness were poorly correlated to improvements in visual acuity.

Rather, he explained, the “groups of patients that did the best, the ones who ended up with 20/40 vision, were the patients that actually started with good vision, so early treatment is implied.”

Additionally, central subfoveal thickness was preserved more in the group whose vision improved to 20/40 — while those whose vision did not improve had 50 microns less of subfoveal thickness. The presence of intraretinal cysts were a poor prognostic indicator of visual improvements.

Treating patients until they are “dry”, or completely free of subretinal fluid should be goal for everyone, with “under-treatment representing the leading cause for decreases in visual acuity in the long term”.

A key takeaway is that barriers in access to care and issues with treatment adherence can have long-lasting functional impacts for our patients. As Dr. Boyer writes, “several large real-world studies show that dosing in perfect accordance with published trials is unsustainable in clinical practice, with a mean of 4.3 to 6.9 anti-VEGF injections given in the first year of treatment”. 

, “…data suggests that patients might not be aware that adherence to the treatment regimen is needed to achieve and maintain VA gains”.

 showed that for patients with nAMD, loss in productivity due to attending appointments was 4.4 hours each month, not included time lost by caregivers.

 showed that those living in the most affluent 5% of areas had half the odds of AMD as those in more deprived areas (OR = 0.56, p = 0.02).

Moving forward, it is essential that our screening efforts capture those at risk for AMD, that our interventions occur as early as possible, and that we address patients’ hurdles to continuity of care so that we may ensure optimal treatment outcomes.

If we work towards these targets as Dr. Boyer outlined, perhaps the results of patients in clinical trials will soon match those in our offices.   

Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Magazine® can reach the editorial staff by submitting a request here.

Early treatment and completing treatments key to visual acuity improvements in neovasculare age-related macular degeneration.

Learning About nAMD Treatment from Individual Responses

The rate of medical students joining the 

 field is a key determinant of the outlook of the profession. Estimates by the Association of American Medical Colleges (AAMC) project a shortage of ophthalmologists by the year 2025.

While many factors play a role in this shortage, the central crux of this issue stems from a supply and demand imbalance.

Increasing future demand for eye care services has been well-characterized, driven by the aging Baby Boomer generation, demographic shifts in the US population, and the increasing incidence of secondary causes of eye disease including diabetes and hypertension. An aging population needs eye care, and the 

 is senior citizens older than 85 years old.

The supply side of the equation is driven by professionals who can provide care. And while there are a range of professions that may play a role, this is mostly driven by how many individuals decide to become ophthalmologists. The trickle-down effect is that our medical schools and curricula play a tremendous role in molding which specialties students choose to pursue.

As a rising fourth year medical student interested in ophthalmology, I have observed firsthand how rare it is to gain adequate exposure to the field without seeking it out. There is a self-selection process where those who apply into ophthalmology are ones that either already knew they were interested, or ones that accidentally stumbled upon it during a third-year elective. From my experience, any brief exposure to ophthalmology usually came from first-year basic science lectures teaching visual pathways in a neurology course. These courses are often taught by PhDs who place a disproportionate emphasis on niche areas of research interest—which may seem less interesting to students who seek a clinical correlation.

Despite these factors, ophthalmology remains an extremely competitive residency. This is due to its appeal as a surgical subspecialty with a balanced combination of clinic and operation, fair compensation, controllable lifestyle, and opportunities for public health, global initiatives, and research.

To me, it represents the perfect field: offering a bit of everything, and the opportunity to focus on one of the most elegant areas of the human body. Moreover, restoring vision in an at-need patient is profoundly impactful and the ultimate privilege.

Naturally, I was shocked that very few of my classmates knew anything about the field, and often dismissed it without much consideration. 

In a study of fourth year medical students

 who did not choose an ophthalmology residency, a research team lead by Adrienne Scott, MD, a retina specialist at Johns Hopkins Hospital, found that the top 3 reasons students did not pursue the field were insufficient interest, lack of exposure, and a feeling that the field was too specialized.

Furthermore, the lack of underrepresented minority (URM) students in ophthalmology is especially striking. As primary author Marguerite Linz wrote in their paper titled, “Evaluation of Medical Students' Perception of an Ophthalmology Career,” none of 16 observed URM students chose ophthalmology—which is consistent with the 1.3% to 2.4% of URM students nationwide that chose the field from 2005-2015.

Compared to non-URM students, there was a significantly greater proportion of URM students who believed that there were insufficient same-race role models in the field. For URM students especially, this lends itself to a vicious cycle where URM students through lack of perceived mentorship fail to enter the field, leading to fewer URM mentors in the future.

In my opinion, the solution to all these issues lies in the form of a grassroots approach — one that captivates the undifferentiated first year medical student with the depth and breadth of the field, in a clinically-oriented way. While student organizations like ophthalmology interest groups and local community outreach programs like Sightsavers are a great place to start, change also needs to occur from an administrative and course-design standpoint.

I remember asking an ophthalmology mentor involved in curriculum design why his efforts to increase early exposure in medical school had been rejected so often. His answer was that medical schools are usually run by internal medicine and general surgery-based faculty, not subspecialists. His answer was interesting, but revealed a profound reality. Unfortunately, with such limited time and a vast amount of knowledge that medical students need to cover, a disproportionate emphasis is placed on preparing for Step 1 board examinations, with content that heavily covers the core medicine specialties, and barely scratches the surface of fields like ophthalmology, dermatology, otolaryngology, or other specialized fields.

Thus, real systemic change needs to occur such that students can prioritize exploring fields of interest and cultivating their passions, rather than overcommitting to test preparation at the cost of a well-rounded medical exposure.

It is no wonder that misconceptions about the field persist. I once believed the field was too narrow in its focus, with a lack of sufficient ‘medicine.’ Just 1 week into my ophthalmology rotation, I was floored by the depth of systemic manifestations of eye disease, the subtle nuances of the physical exam, and how an ophthalmologist could serve to screen and prevent disease, prescribe plans for medical management, and be a surgeon offering tangible solutions with often immediate results. Not many fields offer this balance, and not many students are aware of this early in training.

I wish I had been shown videos early in my education of cataract surgery, corneal transplantation, and a plethora of other elegant ophthalmic surgeries, involving technical microsurgical approaches and awe-inspiring precision.

I am confident that if students gain early exposure, the allure of the field will organically lead to higher rates of entry. But it can sometimes be difficult to distance ourselves from what we already know and put ourselves in the minds of an undifferentiated student. We may often take for granted realities about the profession that students may not be aware of.

For a field like ophthalmology, which is already notoriously underrepresented in medical school, being keenly aware and conscious about educating our peers becomes far more than just a thought exercise—the future of the field and health of our patients depends on it.

The field has a growing demand of care, and dropping rate of new specialists. The solution can start at medical schools.

The Future of Ophthalmology Depends on The Perception of Students

Diabetes, with all of its systemic disease manifestations, may cause more corneal damage than we previously understood. The latest findings concerning diabetic keratopathy were discussed this past weekend during a special interest group session conducted at the 

Association for Research in Vision and Ophthalmology (ARVO) 2019 Annual Meeting

Diabetic Keratopathy: An Understudied Corneal Disease

,” featured research by Dimitrios Karamichos, PhD, of the University of Oklahoma Health Sciences Center; Fushin Yu, PhD, of Wayne State University School of Medicine; Mitchell Watsky, PhD, of Augusta University; and Alexander Ljubimov, PhD, of UCLA.

Diabetes mellitus is the leading cause of blindness in adults of working age worldwide, with over 23 million Americans suffering from the disease. While diabetic retinopathy and neovascularization are well-characterized pathophysiologic entities, participants at ARVO 2019 raised awareness about the increased risk of keratopathy, including corneal erosions, epithelial defects, endothelial dysfunction, and punctate keratitis brought upon by the disease.

 showed that keratopathy may impact 47% to 64% of diabetics and that hyperglycemia causes subtle changes in all 5 layers of a patient’s cornea. However, despite these findings, 

 that these diabetic changes are underdiagnosed.

Further research is needed to characterize why these changes occur, as the mechanisms are not well understood. In the workshop sessions, Karamichos spoke about the role of peroxisome proliferator-activated receptor alpha (PPARa) in diabetes models, with agonists like fenofibrate showing possible therapeutic effects. Additionally, the therapeutic potential of topical Vitamin D in reducing chronic inflammation and promoting corneal wound healing was discussed by Watsky.

The sheer breadth of corneal involvement in diabetes is often under-represented, encompassing abnormalities in the epithelium, corneal nerves, stroma, endothelium, and tear film. The implications for this are significant. Poor corneal sensation increases the risk of corneal injury and hinders normal protective responses, while endothelial changes disrupt fluid regulation. Even the most common eye conditions like dry eyes may be exacerbated by tear film changes.

With these impacts in mind, Ljubimov pointed towards future experimental therapeutics such as topical naltrexone, insulin, aldose reductase inhibitors, advanced glycosylation end product (AGEs) inhibitors, and gene therapies. Yu’s work with genome-wide cDNA microarrays highlighted over 1800 differentially expressed genes in diabetic corneal epithelial cells compared to normal controls, and 

 as an especially promising therapeutic target.

Additionally, this understudied area is especially important in the field of corneal transplantation, where roughly 18% of transplanted corneas are from diabetic donors, leading to possible issues stemming from epigenetic changes.

For surgical techniques like Descemet’s membrane keratoplasty, corneal edema is increased in diabetics, possibly due to background dysfunction. It is therefore unsurprising that diabetics are responsible for 80% of corneal complications after cataract and refractive surgery, vitrectomy, and PRP.

Taken collectively, this session at ARVO 2019 highlighted the need for conscientious corneal screening during yearly diabetic eye visits and the prioritization of diabetic keratopathy prevention as a tangible predictor of surgical and visual outcomes.

Approximately half of all patients with diabetes suffer from keratopathy, yet diagnoses are still underwhelming. Annual screenings need to become more standard.