The focus of the talk is on Global Ophthalmology and Sustainable Glaucoma Interventions. The Global Burden of Glaucoma is Great Humanitarian Missions are not exclusive to international locations:
- Customize approach to each situation (urban vs rural)
- Skills transfer is the most sustainable route (sustainability)
- Connect with an existing group
- Maintain connection with local resources (teach & support)
Speaker: Dr. Malik Y. Kahook, Professor of Ophthalmology, University of Colorado, USA
Hello, everybody. This is Malik Kahook. I am professor of ophthalmology and Vice Chair of Translational Research at the University of Colorado School of Medicine. I’d like to thank Caro and the rest of the organizers for inviting me to give this talk. I wish I could be with you in person, but I’ll do the second best thing and record this talk for you.
The topic today is lasers, migs, and tubes, what is appropriate, and what is sustainable. Really, the focus of this talk is if I’m traveling and teaching or helping with surgery in areas that might be resource depleted or not have access to all of the devices that we would want access to. What is the most appropriate pathway to taking care of patients?
These are my disclosures.
The number of people with glaucoma is increasing. We know that glaucoma is the third leading cause of blindness globally. We also know that eleven million were bilaterally blind from glaucoma in twenty twenty. This is when the total cases were around eighty million or so. We also know that the number of cases are going to increase dramatically to around a hundred and eleven million by twenty forty. So you can imagine the burden of vision, issues, and Frank Blindness are only gonna increase with time.
There’s a general lack of glaucoma centric evidence based medicine that explores health outcomes after global outreach. Typically, what happens is there’s a global outreach, event that happens, and the outcomes are not followed as closely. There are no specific recommendations for what type of surgery to do, how to address specific patient populations. And we know that this can vary dramatically based on the location, the training of the various surgeons either local or visiting surgeons, and my talk represents really my own experience with how best to deal with this.
Some of the factors that should be considered include location. Is it urban or rural and your access to different devices, different diagnostics will be very different depending on your location.
What is the need? What is the burden of disease? The burden of coma isn’t the same from one area to another, especially if you’re looking across the globe. And I think that’s something that should be kept in mind.
What is your skill set? That’s something that you should be honest with. What can you teach? What can you offer the, specific patient population?
And what do you need to learn from other local or visiting surgeons. And what’s the skill set available on the ground? So what is the skill set of the surgeons who are there day to day and will be taking care of patients for a long period of time. What are the resources that are available, including not just surgical devices, but microscopes, diagnostics, medications, What can you take with you?
Is it something that’s easy enough to, carry on a trip where you’re visiting, either a location that is not central to your city if you’re going out into a rural area.
And, if you’re traveling from one country to another, the regulations differ, and, it’s not as easy to take some things versus others.
What can you leave behind what’s sustainable? So if you’re going to teach specific surgeons clinicians on how to do a specific device, Will they have access to that device long term? Is it even worth going through that training? What are some of the costs of the interventions?
Is it realistic to consider that that cost can be maintained for a long period of time. Are you going back? Are you just gonna go for one visit? Are you just going to, outside of your clinic, let’s say, in the city to a rural area for just one time or something that’s going to be sustainable.
And can you communicate afterwards? This is one of the things I enjoy the most when I’m traveling, to, visit with colleagues. Is it something where you can have a WhatsApp group that is maintained for multiple years afterwards, and and both sides can learn significantly.
When I talk about location, urban versus rural, there are some considerations that I think are important. In urban areas, there’s a higher concentration of skilled surgeons just by virtue of who’s living and who concentrates in cities, You have better access to medications, access to ORs and surgical microscopes, but you have limited access to skilled transfer. There’s not a lot of teaching that goes back and forth in certain areas. And limited access to new devices either from a regulatory standpoint or from a cost standpoint. Diagnosing is often a major barrier. Do you have access to OCT visual field, the modern software.
Now on the rural side, it’s a it’s a different story, limited number of trained surgeons, limited access to medications, The solutions are often surgical because you’re not gonna have access to laser or to the repeated use of medications, and there’s a high likelihood of presenting with end stage disease because of the lack diagnostics.
So you have to really wonder, as you’re going into a specific area, what are the specific needs, and it could be it could be dependent on geography or, city versus rural.
What is your skill set? This is something that’s really important to know know thyself.
Knowing what you have to offer, offer up your best, whether it’s traps, tubes, avocado procedure like Miggs, teaching is best, the gift that keeps on giving. So you’re not really there if you’re visiting a colleague in a rural area or if you’re going from one country to another, The best thing that you can do is to teach, because you’re not gonna be there on the ground every day, and super important to have that skills transfer. Look for places of maximum impact pediatric glaucoma is one. That’s a skill set in doing that type of of surgery.
That’s not available to all. So I think, looking at pockets of care that will be unique and that can be sustained over time. Should you have minimum experience first? I I’m a big believer in this.
I think you have to have a minimum of around five years of practice with deep surgical for teas before you start trying to do the skill transfer.
And that, of course, there are caveats to that. There are exceptions. But oftentimes, it’s important to have a good foundation yourself before you’re starting to travel and, exchange some of the more fundamental knowledge when it comes to surgery and clinical care.
When a younger person is going, which I think we should all be open to. That’s more of a back and forth learning from the from the travel from looking at a different patient population, and that certainly has its benefits as well.
Knowing what local clinicians can offer, is there a trained surgeon available that you then upscale?
What are their local stressors? Is it economic? Is it governmental? Is it financial? All of these things?
The answer is often yes. It’s all of these things. And is there a long term partner, looking for knowledge on the ground where they could potentially visit with you, you can visit with them. You want something that again is sustainable.
What are some of the options? We know that cataract surgery is, routine and reproducible and also lowers intraocular pressure. There are other aspects to therapy to treatment like laser trabeculoplasty, different mix procedures, glaucoma drainage devices, as well lasers, both ECP and CPC.
What is the best approach? Implants, I think the consideration here is that implants are expensive and not They’re not available to, every locality around the world. Lasers, whether it’s SLT or ALT.
It’s not necessarily just the cost of the device, but also the cost the upkeep, lack of engineers, to make sure that they can fix a device if, if it breaks down. The upkeep cost itself can be a burden And then there are often disposables that go along with some of the devices, that, whether it’s a goniosol, a coupling agent, the lenses that we use for SLT.
Some of these things can add to the cost long term. If you’re doing trabeculectomy, what is the availability of an anti fibrotic like my and see. I’ve been surprised in some travels to have my demycin freely available, easily accessible, more easily than what I can get, in my OR here in Denver, But there are some areas, many areas around the world that don’t have access to anti fibrotics.
And then novel devices, this is where I feel very strongly outreach is not for research. You shouldn’t be trying something new on a patient population that you don’t know. You should minimize the unknowns and go back to what I had said earlier in earlier slides, stick with what you know and what you’re best at.
The real thought here is what is sustainable. What is something that you can teach that then the local, surgeons can continue to do even if you’re not there.
Catteric surgery alone, I think it’s worth saying, again, that it could lower in low pressure. This is an example from the hydro stent, but this can go across, different devices, where any implantable or angle procedure like a goniotomy.
All of these can be coupled with cataract surgery, whether it’s cataract surgery alone or combined with mix. All of these can lower intraocular pressure. Kedric surgery alone is often accessible, in many parts of the globe, but some of the mixed procedures are not necessarily accessible. And I think that’s worth some thinking before going that route of education.
Preoperative characteristics and compliance with follow-up after trabeculectomy surgery, this is a specific case to Southern China, just talking about a different type of approach with filtration surgery.
Evaluation of pre operative characteristics and follow-up in patients after trabecal ectomy a focus of the study, and they looked at two hundred and twelve eligible patients with a follow-up, at one month equal to twenty six point nine percent. So you can see that follow-up was an issue And when you’re talking about trabeculectomy, not having great follow-up can lead to disasters, envision and for, for each specific patient. Patient predictors of poor follow-up included, education level, belief, follow-up was not important. So poor education, of the patient at the time of surgery, lack of accompanying family.
If there’s a family member, they’re more likely to come back with that family member, annual income under eight hundred dollars, US, and not requiring removal of scleral flab sutures. So there was no specific reasons, I’m told to the patient to come back for a procedure that needs to allow for that filtration procedure to do better. Factors unrelated to poor follow-up included agent sex, employment, travel distance, time and cause, which surprised me. I thought that would be a factor.
Clinical factors across the board, as well as physician factors. None of those really played into it.
So what’s my choice? Just for the sake of time, I think getting into this is is important before we finish up cataract surgery alone, extra cap, or FAC, add non device angle based surgery like gonyotomy.
This can be very cost efficient in specific patient populations.
It comes to trabeculectomy, less resource dependent than a device, like a glaucoma drainage device, lower IOP target is often necessary, but there’s a high failure rate, especially you’re not using mitomycin C, but it’s often the only choice available, and it’s a good skill set to transfer to the local clinicians who may not be doing it.
My wish list in a perfect world would be glaucoma drainage device. AGV is likely the best option due to low maintenance, overcomes many of the disadvantages of trabeculectomy.
You can partner with on the ground eye care professionals to train them and ensure supply of devices when that’s possible. It’s nice to have a partner like New World Medical who makes the AGV who is, very quick to give free devices in areas that need it. Traveculctomy is a distant second to glaucoma drainage device due to the complications and high affiliate, especially when you’re not using mydomycin.
CPC would be at the top of my wish list because it is not implant based and it’s possible to use with very low maintenance. It’s just hard to get that device because of the initial cost, as well as the disposable probes that are used but in a perfect world, we’d have access to it routinely.
We didn’t really get into this, but the diagnostics part of it is is a huge issue. It’s perhaps more important, a more important need than doing surgery to actually identify and treat these patients in expensive ways to diagnose may involve online testing strategies, telemedicine AI, all of these still cost money and have not been validated in specific patient populations around the world. One thing I will say is that the cheapest form that we can do is the optic nerve head photo. Unfortunately, that’s where there’s the most variability and lack of progression analysis. So there’s a lot of work being done, including here at the University of Colorado to try and get basic optic nerve head photos to be analyzed by software to look at disease detection, make it more reproducible, as well as look at longitudinal progression with multiple photos. And I’m I’m looking forward to talking about that more in the future.
There are multiple partners that are out there, and I think that’s one of the beauties of being an ophthalmology companies from across the the the globe and across the spectrum of, devices and medications are always happy to help. And I think, accessible through online portals, looking at email and contacting these companies when you need some help. I just wanted to put that there that we do have good partners in industry.
The global burden of glaucoma is the issue here. We can’t all be superheroes in fixing it. So there are certain things we have to think about. Humanitarian missions are not exclusive to international locations.
We should each look, you know, if you’re in in Guatemala and you’re in the city and you can go to a rural area that that doesn’t have access to the surgical skill set that you have. That is something that is very, very worthy. Customized approach to each situation, again, urban versus rural, looking at what’s what are the facts on the ground. Skills transfer is the most sustainable route, look for partners on the ground who are going to be there every day and see if you can upscale them.
Connect with an existing group that might be on the ground. For example, me in Guatemala, HDF, and the group that does great work in that area, is important for me because I can have access to learning what they’re doing, and I can also offer up any of my skill set for sustainable education and support, and then maintain connection with local resources.
Teach and support. That should continue after a visit to a specific area, whether it’s on WhatsApp or email or videos like this where you can go over surgical videos and maintain that connection.
So what this is a topic that’s near and dear to my heart. I’m very thankful that I got a chance to share this information with you. I thank you and hopefully I can visit live and and share more talks with you in the future. Thank you very much.