Dr. Jittraporn Worrawitchawong walked casually down the halls of the Asia-Paciﬁc Vitreo-retina Society (APVRS) congress in Bangkok when we stopped her with an extremely unusual request.
While other APVRS attendees had passed on our request, Dr. Worrawitchawong, a 3rd year resident, Department of Ophthalmology, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand, was game.
PIE Magazine – and we needed her help…by taking a real pie in the face for the cover of our magazine.
“You see, our magazine is called PIE, which stands for Posterior Segment, Innovation and Enlightenment,” said Matt Young, CEO and Publisher of Media MICE Pte Ltd, which Mr. Young also runs in Singapore. “For 13 years, I worked with other ophthalmology media, and ‘conventional’ is the main word I would use to describe them. While there’s nothing wrong with that, we in the media have one main power. We have a spotlight, and it is our duty to shine that spotlight on our area of focus, which in this case is the posterior segment, and related innovations and knowledge for Asia-Paciﬁc. We will do what it takes to get the attention of people in our industry and region on issues of critical importance. We thank Dr. Worrawitchawong for helping out, by taking a very real pie in the face for what is certainly a ﬁrst among ophthalmology magazine covers. After all, almost everyone loves pie, which rhymes with eye, and we hope they also love PIE Magazine.”
“The medium is the message,” wrote Canadian philosopher Marshall McLuhan in 1964, whose body of work is considered a keystone of media theory.
“In 2017, we practice Mr. McLuhan’s theory at PIE Magazine,” said Mr. Young, whose company Media MICE focuses on innovative ophthalmology content and also previously published the APAO Show Daily in Taipei and APVRS Show Daily congress newspapers in Bangkok and Sydney. “We keep what needs to be serious serious – like clinical data – and we stylize the rest, for the ultimate beneﬁt of ophthalmologists and their patients.”
So, why is Asia-Paciﬁc’s ﬁrst posterior segment magazine launching? Why are matters of the posterior segment critical in Asia-Paciﬁc at this moment in time? We asked three ophthalmologists about their views on the importance of the posterior segment in the region.
Dr. Stephen Teoh, MBBS M.Med (Ophth) FRCS (Ed), FAMS, Senior Consultant Ophthalmologist and Director of Vitreo-Retina Services, Eagle Eye Centre, Singapore, says:
From a retinal surgeon point of view, there would be an increase in retinal problems such as age-related macular degeneration, diabetic retinopathy and retinal vascular
diseases. These are age-related problems (increasing with our increased life span, changes in lifestyle and diets) and diabetic issues (also increasing with our changes in dietary habits).
These pose signiﬁcant visual morbidity to the patient and take up signiﬁcant resources in the treatment and control. Many developments in pharmaceuticals are targeted at ﬁnding drugs that can better control these conditions. Research are also targeted at trying to ﬁnd out the pathogenesis of these conditions so as to better prevent (and treat).
Increasing myopia in the Asia-Paciﬁc region also increases the risk of retinal and posterior segment problems in the long-term such as retinal detachment and myopic choroidal neovascularization. There are other posterior segment retinal problems such as uveitides and ocular inﬂammation that cause acute sight-threatening diseases. Infections such as CMV retinitis in AIDS are fortunately decreasing in the developed countries where resources for HAART and anti-CMV treatments are more readily available. However, in many developing countries in the Asia-Paciﬁc region, ophthalmologists are just starting to learn to recognize this complication, but treatment remains a problem due to the unavailability of anti-CMV treatment, or inaccessibility. As such patients continue to go blind from this condition.
Cataract and refractive surgery will always be popular due to the ‘wow’ factor for the patient. However, retinal and glaucoma subspecialties are fast becoming the next ‘hot’ topics worldwide! These problems are sight-threatening diseases that, if prevented, have a far greater beneﬁcial impact to society and the individual. Treatment and the prevention of progression is the prevention of blindness in these people.
Dr. Vishali Gupta, M.D., Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India, says:
Posterior segment diseases including diabetic retinopathy, myopia, trauma and infections, are on the rise and do need an expert with a well-equipped setup for the proper diagnosis and management. So far, the majority of the eye clinics focus on creating a setup for the management of anterior segment diseases including cataract, glaucoma and refractive surgery, as these areas offer a relatively low investment with more returns. But if we consider our duty to society and think beyond a business model, establishing posterior segment resources at multiple levels is the need of the day. At present, these resources are limited only to major hospitals that results in signiﬁcant delays and inconvenience to the patients, resulting in visual loss and blindness in many of these eyes.
As I mentioned, there has been a signiﬁcant increase in the diseases of the posterior segment. Myopia is on rise in the Asia-Paciﬁc region. We in India are overburdened with a burgeoning load of diabetic retinopathy. The trauma of the posterior segment too has increased. Also due to increased life expectancy, we have a signiﬁcant ageing population that adds to the load of age-related macular degeneration. Several infections including HIV, viral, tuberculosis, and toxoplasmosis too affect the posterior segment of the eye and are on the rise. This burden can no longer be handled at the level of tertiary care institutes only. So we need to decentralize the services and create state-of-the-art posterior segment resources at every level, making it as close to a patient’s doorsteps as possible. This also includes creating more super-specialists with vitreo-retina training.
Retina and glaucoma offer challenges to the physician as each case is different and requires customized care. This is where the experience, training and skills of the treating physician come into play in making the right decision for the patient. Cataract and refractive surgeries have a set protocol with a standard treatment protocol. Retina and glaucoma remain hot topics as physicians want to share their challenges as well as experience.
It is a collective responsibility of the government, non-government organizations, companies and physicians. We all need to join hands to do the best possible for our patients.
Dr. Paisan Ruamviboonsuk, M.D., Immediate Past President, The Royal College of Ophthalmologists of Thailand; Regional Secretary, APAO; Council Member, APVRS; Secretary General, ASEAN Ophthalmology Society; Previous President, Thai Retina Society (2009-2014), says:
While there is concern about the cataract backlog in Asia-Paciﬁc, there is some concern about the backlog of retinal surgery as well. But it is a different kind of backlog. In reality, when we try to do surgery on retinal disease, we have to attend to surgical retinal cases as soon as possible. We cannot leave them too long, like with cataract cases. If not, you are not going to get the ideal result.
With retinal detachment, for example, you can only wait for two weeks for the surgery. Most retinal surgeons try to put that case into the operating room as soon as possible. Now for epiretinal membrane issues, a patient can wait for one-to-two months. In those cases, you may have a backlog as well.
Fortunately, new retinal instruments are available. This makes a retinal surgery faster and give access to more patients, compared to the past. For surgical outcomes, even 3D surgery [such as the NGENUITY 3D Visualization System, Alcon, Fort Worth, Texas, which is designed to enhance visualization at the back of the eye] is available to improve surgical results.
Diabetic retinopathy is still one of leading causes of blindness in Asia-Paciﬁc. For diabetic macular edema, we also use anti-VEGF drugs – the same medications as using for macular degeneration, although the treatment protocol may be differently. Meanwhile, laser still has a role
for pan-retinal photocoagulation in proliferative diabetic retinopathy. Retinal detachment and retinal breaks can also be treated with lasers.
How do retinal surgeons practice in Asia-Paciﬁc to combat these pathologies? If you are in a public hospital, there is a lot of work for you. But retinal surgeons generally need cases from referral. Patients go through general ophthalmologists because they don’t know they have retinal disease or because of the insurance system.
General ophthalmologists who screen retinal cases actually take a look at these patients ﬁrst. They should have knowledge of the posterior segment as well as identifying referral. General ophthalmologists do attend retinal meetings.
There’s also crossover in Asia-Paciﬁc.
In the United States, retinal specialists don’t do cataract surgery because if he or she does no one will send those retina cases to you. But you can still do both cataract surgery and retinal surgery in many countries in Asia-Paciﬁc.
Sometimes, glaucoma also may be a complication of retinal disease. Like with diabetic retinopathy in the end-stage, those patients probably have neovascular glaucoma. In the majority of these cases, we [retinal surgeons] can deal with it by putting patients on anti-glaucoma medications. You don’t have to consult the glaucoma doctors for treatment usually – only in some cases where the eye pressure cannot be controlled with medications.
When it comes to the posterior segment, the retina and vitreous are related. Retinal detachment in many cases – especially with retinal breaks – is caused by vitreous traction. They are related.
Physicians interviewed for this article provided answers to questions about the posterior segment. Their comments should not be considered an endorsement of PIE Magazine.
Editor’s note: 3,000 hardcopies of PIE Magazine are available at APAO Singapore, free of charge, at Media MICE Booth #E55. PIE Magazine also is published quarterly (March/April, June/July, September/October, December 2017/January 2018) as a free ebook, and sent to 15,000+ ophthalmologists in Asia-Paciﬁc by email. Our website is under construction, at piemagazine.org. Visit booth #E55, or email firstname.lastname@example.org, and start your free PIE Magazine ebook subscription.