The Next Chapter: Forging a Concept of International Retina Care
A new column in NRMD raises more questions than it answers—for now.
Devoting a section of New Retina MD to a discussion of international retina care assumes a central premise—namely, that one of the essential tasks of the young generation of vitreoretinal surgeons is to translate the many advances in our field into effective and sustainable patterns of care that can be applied in resource-deprived settings, most commonly through crossing international and cultural boundaries. This task, though, is one that requires considerable defining. Somewhere between the principles of not doing harm and justly offering equal care to everyone lies the yet-undefined work of international retina.
Thankfully, ophthalmology carries strong examples in this vein. The question of whether one can responsibly perform extracapsular cataract extraction (ECCE) in marginalized communities was raised by Sanduk Ruit, MD, at the World Ophthalmology Congress several years ago. Although now axiomatic for most trainees, the proposal met a number of objections initially: Wouldn’t the expense be prohibitive? Are you going to subject these people to undue surgical risk? Why attempt ECCE when intracapsular extraction already works in these settings?
A generation later, after hundreds of thousands of sight-restoring cataract surgeries have been extended to some of the most marginalized communities in the world, Dr. Ruit has been vindicated and, with him, the validity of ophthalmology’s involvement in international work. Yet extending these same lessons into retina care involves more than simply a change of scale or pathology. The work of retina differs from the work of cataract surgeons in critical ways. It involves
- a breadth of pathology that differs considerably by country and community;
- numerous pathologies that are time-sensitive in terms of visual potential—ie, one cannot wait a year (or a decade) with a retinal detachment and still anticipate visual improvement;
- technology- and pharmacology-dependent therapies that inevitably magnify cost and necessitate complex supply chains;
- the difficulty of procuring, maintaining, and continually sterilizing surgical equipment; and,
- technically demanding surgical techniques that require years of skills transfer.
These realities open up a number of areas for discussion. What retinal diseases warrant the greatest attention? Should preventive care trump interventional therapies? Should our role be primarily clinical, educational, logistical, or financial? How do we incorporate and innovate new technologies—the foremost of these being telemedicine—most effectively in delivering retina care? What place should these questions have in vitreoretinal training in the United States?
The answers to these questions, and many more, lie on the far side of extended, intelligent discussion by the upcoming cadre of retinal surgeons—all couched within the certainty that these challenges, although real, are no more prohibitive today than they were in the debates about ECCE. And, of course, these discussions require forums.
The primary goal, then, of this column is to serve as a forum—absent in the retina community until now—for hashing out the answers to two central questions: first, what should be the primary goals for vitreoretinal surgeons interested in engaging on an international scale? Second, what are the most responsible, effective, and sustainable means of achieving those goals?
This is a forum as much for story-telling as it is for debate. By highlighting individual successes (and instructive failures!), we hope to draw these diverse efforts into a broader discussion. For instance, the recent attempts by the only vitreoretinal specialist in Bhutan to use expansile gases in a high-elevation operating room elicit the understandings (a) that topography is a challenge to retina care that requires creative confrontation, (b) that supply chain logistics can be the foremost obstacle to appropriate retinal care, and (c) that creative solutions (in this case, a cartridge-based delivery system that could be delivered to high elevations) can move care forward in a stepwise manner—to the benefit of patients around the globe. In this sense, there is no attempt too modest, no success too trivial, to escape conversation here. Our hope is that this column serves as the beginning of an ongoing back-and-forth process, wherein interested readers supply stories that others can then analyze and critique.
The next chapter of retinal care is ready to be written, and the writing of it falls increasingly to young vitreoretinal surgeons. Whether progress is wrought by slow-and-steady application of foundational principles or by quick bursts of innovation remains to be seen, but, either way (or through both), exciting opportunities exist for anyone willing to engage here. Success in this arena means extending vision and its quality-of-life implications to ever-increasing spheres of patients around the world. This is a debate near to the heart of medicine.
If the ideas expressed above have resonated during your reading, I invite you to join the debate—write in, comment, critique, and share any revelation, from the broadest data analyses to the tiniest insights—and help write the next chapter of international ophthalmology. n
Section Editor Benjamin J. Thomas, MD
• vitreoretinal surgical fellow, Associated Retinal Consultants, Royal Oak, MI