What does the future look like for technology and cataract surgery?
Robots have a mixed history in popular culture. From the giant Gort in The Day the Earth Stood Still (above) to the terrifying Daleks of Dr Who, from Ted Hughes’s Iron Man to Futurama’s Bender, they have been at turns terrifying, menacing, compassionate and comical. In the real world, their history is more mundane. While we may think of robots as being humanoid in appearance and nature, that’s not necessarily a given.
An editorial in the Paris Innovation Review defined robots as such: “[They] have a material existence inasmuch as they are endowed with perception (via sensors), can make decisions (via appropriate use of processors) and can undertake physical actions (using integrated motors).” The key example of a robot that has made inroads into the everyday is that of robotic vacuum cleaners like the iRobot Roomba or Dyson 360 Eye, and we can see the onset of driverless cars in our media and television.
Automation has led to greater efficiency in the areas of manufacturing, agriculture and communications, to name but a few. Such advances, however, are happening at different paces across the healthcare sphere. In some places, computers and iPads have replaced front-end staff, allowing patients to check-in digitally. In surgery, things are not quite there yet.
In a recent Eye Contact interview, Dr Richard Packard was asked if he saw robotics coming into the area of cataract surgery. He doesn’t see it happening any time soon.
“When you’re dealing with cataracts and the patients, patients are patients. And you can’t necessarily predict the way that their tissues are going to behave. We also know that there’s a significant cohort of complex patients out there that robots will simply not be able to deal with. The other issue is that if there is a problem during surgery, even if you’re a robot, your ability to adapt to the situation that you find yourself in is going to be quite difficult.”
Other doctors are more wary. Sorcha Ni Dhubhghaill MD believes that surgeons live under the same threat of automation as those in other industries. “If I think long term, I believe that a sophisticated diagnostic algorithm will eventually replace the clinician’s diagnosis just as a sophisticated robot will replace the surgeon.”
She believes that the current technical limitations, as envisaged by Dr Packard, will be overcome in time by improvements and refinements. “I don’t think it is unreasonable to think that a robot will ultimately be able to perform every move a surgeon can, but better, with no tremor and no need for a lunch break.”
Where next for the surgeon, so? Dr Ni Dhubhghaill believes a pivot is necessary. “While the robots are seeking to perfect the established techniques, the humans will have to innovate and introduce new ideas.” Human-robot co-operation will ensure the value of each working towards an enhanced patient experience.
“I would envision a robo-surgeon and innovative ophthalmic surgeon working as a team. The robot to provide the best results technically and the ophthalmologist to push the boundaries of the technology.”
Where the patient fits in remains to be seen. Would automated surgery be cheaper than the current standard? Would such a robot have automated colleagues, such as robot anaesthetists and nurses?
O brave new world, that has such… machines in ‘t!
We look at the impact smartphones and apps have had on the world of ophthalmology
In 2017 the iPhone celebrated its 10th birthday. While it was not the first smartphone in existence, its innovations helped change the landscape of personal technology like no other. Its use of a touchscreen keyboard instead of a physical keyboard, like that used by Blackberry, followed by the opening of the App Store in 2008, were great leaps forward that would change the market – and the world – forever.
iPhones paved the way for the era of the smartphone, with Google’s Android following suit and taking a huge share of the market across a variety of different devices. We call them smartphones, but essentially, they are pocket computers – we depend on them more for the news or weather, for example, than for ever actually talking to someone. The same goes for doctors.
Clare Quigley, a third-year Resident at Mater Misericordiae University Hospital in Dublin, says that while she does use her Samsung smartphone for communication purposes, she also uses it for planning ahead, be it putting her on-call dates in her calendar or preparing for upcoming meetings. She has a specific folder designated for ophthalmology: “I have Crystal.Toric for verifying my pre-op limbal markings when I use toric IOLs. I have PDFs of books that I might need to reference, including The Wills Eye Manual and Kanski’s Clinical Ophthalmology. I also have the hospital antimicrobials guide, and also the EuroTimes app for browsing.”
Most interestingly, Dr Quigley uses apps to distract or settle young children when trying to catch a view of their fundi, be it the Kids Top Nursery Rhymes app or simply YouTube for the likes of Peppa Pig. She also uses an Ishihara app when dealing with bed-bound patients who are unable to attend clinics.
Rahil Chaudhary, Managing Director at the Eye7 Chaudhary Eye Centre in Delhi, India, uses the TorEye app on a daily dasis. “It is basically a toric axis marking app that eliminates the need of devices like bubble markers, and the accuracy of which is comparable to digital axis marking devices like the Verion.” Dr Chaudhary even presented a free paper at the XXXV Congress of the ESCRS in Lisbon on the accuracy of this app, so enamoured he is with the technology.
Arthur Cummings, Medical Director and owner of the Wellington Eye Clinic in Dublin, has incorporated smartphone technology into all aspects of his practice. He can play a patient’s choice of music on Spotify, as well as remotely changing the lighting in the laser suite to any colour of the rainbow. On the surgical side of things, he uses an app called Axis Assistant for marking the cornea for toric IOLs.
“This app allows exquisite accuracy as you don’t have to place the marks exactly at 180 degrees for a reference. Instead you mark the patient freehand at what you think 180 degrees is. You then check using the app while they are upright and measure the exact location. The axis alignment for the IOL is then measured from this reference point and marked with a toric marker to the desired axis.”
He also uses apps to track analytics for the Clinic’s website and as well the various social media channels to communicate with patients and anyone else following the Clinic.
While this technology helps Mr Cummings in his work, there is also a Wellington Patient Journey app, which breaks down the various procedures available as well as advising patients on postoperative behaviour and providing push notifications for medication and appointments. Such innovation shows a willingness to use technology not only to improve surgical outcomes but also to enhance the overall patient experience.
Despite these vast advancements, Mr Cummings says it’s something much more basic that impresses patients most often. As his slit-lamp camera is in a different room to where he regularly consults, he generally uses his smartphone to take a photo through the ocular of the slit-lamp in his consultation room. He then sends it to his computer and shows the patient and save it on their file, and this is what elicits a comment on the wonders of modern technology.
From this small selection of doctors it’s clear that the smartphone has had a massive impact on the day-to-day workings of ophthalmologists. We can only wonder what might be round the corner, let alone what may be available in 10 years’ time.
The 22nd ESCRS Winter Meeting convenes in Belgrade, the capital of Serbia
The 22nd ESCRS Winter Meeting http://www.escrs.org/ convenes in Belgrade, the capital of Serbia, a country with one of the most tangled histories in Europe.
If, like myself, you find the intricacies escaping you- and you’re heading for Belgrade- a worthy travel companion is the paperback by British journalist Tim Judah, The Serbs: History, Myth and the Destruction of Yugoslavia.
Judah, a reporter for the Economist, is one of the most knowledgeable commentators on the area, having lived and worked in Serbia for years. His book outlines the history of the region and explains its effects on today’s Serbs. There’s an updated section on post-war Serbia.
For fictional insights into the White City, try The Houses of Belgrade, by the Serbian literary icon, Borislav Pekic. Born in 1930 in Podgorica, Yugoslavia, Pekic began his writing career in prison after his 1948 arrest for terrorism and espionage. In the early 1970s he emigrated to London, where he wrote The Houses of Belgrade in 1994. Interwoven into the story of an old recluse’s infatuation with the houses he owns (he gives them female names) are memories of the last time he ventured outdoors.. 27 March 1941, the day of the coup d’etat that followed alignment with Hitler.
The Diary of a Political idiot is a memoir of a Serbian civilian caught up in the NATO bombardments in the late 1990; it’s an extraordinary account of daily life under fire by Jasmine Tesanovic, a feminist writer and activist, She is a contributor to the Huffington Post where some of her blogs return to the theme of this book.
A 3-hour Belgrade walking tour dedicated to the Communist era leaves every Tuesday, Thursday and Sunday at 3 pm from Belgrade’s Republic Square. Participation, including entrance to the Museum of Yugoslavian History, is €10 . No need to book..look for guide wearing or carrying ‘something yellow’ behind the monument. According to the website (belgradewalkingtours.com) you’ll hear interesting stories of former Yugoslavia, World War II, Tito’s life, conflicts of the nineties, NATO bombing of Serbia and Montenegro in 1999 and democratic changes at the beginning of the third millennium.
There are lots of New Year’s dates to choose from. March is among the most popular
What are you doing New Year’s Eve, a song written in 1947, is still being recorded. It sums up one of the major angsts of every young person, including young eye doctors, to have someone to kiss at the turning of the year.
The good news for those who don’t automatically have a partner sorted, is that there’s no rush.. Just choose to celebrate new year’s in your own time.. Wikipedia has a list of New Year dates as celebrated somewhere on the globe with a selection for almost every month.
Admittedly, 1st January is the most common.. but only since the 1500s and for those who follow the Gregorian calendar. For others, there are lots of New Year’s dates to choose from. March is among the most popular and that’s when the Babylonian’s celebrated with eleven days of festivities..
It’s the Babylonians we have to thank for the custom of making resolutions, too. They resolved to pay their debts and return borrowed farm equipment as part of their New Year’s schedule. Returning farm equipment has slipped down on the ‘most popular resolution’ chart; currently the most popular -at least in the western world, – is ‘lose weight’. Not surprisingly ‘It is also the most commonly broken, which may account for the ‘obesity’ problem currently plaguing so many countries. The next most popular resolution is to exercise more.
A friend of mine wears a ‘fitbit’ to help her do that.. This is one of those ‘blind’ looking watches that come to life when you touch them. And then – but you probably already know all this – it tells you your heart rate, how long you slept (and how long you tossed and turned), how many calories you’ve consumed, how many stairs you’ve climbed, how many steps you’ve taken.
I have heard that people have been known to walk in circles at the end of the day to get up to the ‘goal’ of 10,000 steps. I’ve also read that playing the maracas can fool the device into thinking you were actually walking while only shaking your arms.
Whenever you choose to start the clock in your own time, I hope you have a very happy New Year, wherever you are…
As high achievers who love a challenge, it’s not surprising that many doctors (and eye surgeons) seem to have a natural affinity with golf.
As high achievers who love a challenge, it’s not surprising that many doctors (and eye surgeons) seem to have a natural affinity with golf. Admittedly, finding the time a game involves can be more of challenge than the game itself, but the effort pays off in a boost to the spirt that more than repays the effort.
I once arrived for a conference in the Azores, those green islands (way) off the coast of Portugal, with a group of doctors most of whom were golfers; we were teeing off on the Batalha course within a half hour of the plane’s touching down in Ponta Delgado airport.
Somewhere around the 7th hole, as my partner disappeared again in search of his ball, the caddy had something to tell me: ‘Your husband improves the lie of his ball every time he’s in the rough. You should have a word with him.’
Happily, he was not my husband .. and as for having a word with him..not likely! In fact, I wasn’t even surprised. I once read that more than half of PGA Tour caddies have witnessed a player cheating during a Tour event.
A GOOD WALK SPOILED
The incident came back to me recently as I tried to come up with a really special gift for the golfer who has everything,. Clearly, something to trim strokes off the score- legitimately, without the need to reposition the ball- would be ideal.
A quick trawl reveals lots of such gadgets out there. How about a ‘performance tracker..’ ? According to the manufacturer, ‘the system records every shot a golfer makes, analyses the data in real time and reveals strengths and weaknesses to enhance on-course decision-making.”
Or perhaps a device to analyse his swing. One such app displays ‘an interactive 3D visual of the swing along with key data’. It includes a ‘virtual coach to enable users to receive personalised lesson plans with tips and drills from golf’s top instructors’.
But what about a Plan B? It’s an old cliche, but golf has been described as a good walk spoiled. A holiday in the Azores sounds better. Expensive but better. With a base on São Miguel and a hired car, a golfer would be a quick drive from the 27-hole Batalha course. In his down-time, there would be sight-seeing or dolphin watching, the opportunity to sample fresh fish and local wine.
‘Enhanced on-course decision making’ and ‘drills from a top instructor’ could wait until next year.
In October 2017, Canadian investment firm LCG Capital signed an option with AAA Trichomes to acquire an interest in a new cannabis processing facility to be built in Quebec. Canadians who have been authorised by their healthcare practitioner are allowed purchase or produce limited amounts of cannabis for their own medical purposes. At present there are 69 producers licensed by Health Canada, and following investments in Australia and South Africa, LGC are hoping to make inroads into this growing market.
Several states worldwide have decriminalised cannabis use for medical reasons, without defining clearly what conditions warrant its use. Since the 1970s it has been suggested that cannabis use can help treat glaucoma. This has been disputed for almost as long, however. In short, smoking marijuana has proven to be effective for lowering intra-ocular pressure (IOP), a key element in glaucoma treatment. Its effects last for just three-to-four hours, and patients need a 24-hour reduction in pressure, so one would have to be smoking six-to-eight times per day.
In a study carried out to observe the effects of cannabis on IOP, researchers noted that seven of nine participants lost any beneficial effect of the drug due to tolerance. Furthermore, smoking can have negative effects, such as dizziness, sleepiness, distortion of perception and anxiety.
“Synthetic analogues of cannabinoid with more potency and longer duration of action, sensible utilization of novel drug delivery systems namely nanoparticle approaches, and combination of cannabinoids with other conventional drugs to control glaucoma could be alternative solutions,” write the authors of a detailed paper entitled The arguments for and against cannabinoids application in glaucomatous retinopathy.
In another study, entitled Cannabinoids and glaucoma, researchers pointed out the difficulties of attempting to administer cannabis via eye drops. “After instillation of an eye drop of any medication, loss of the instilled solution via the lacrimal drainage system and poor drug penetration results in only <5% of an applied dose reaching the intraocular tissues,” the authors write. As well as this, natural cannabinoid extracts “are highly lipophilic and have low aqueous solubility”, making effective application even more difficult.
While cannabis has proven effective as an appetite stimulant, a spasticity relief and pain relief for a variety of conditions, it remains the case that more traditional remedies such as eye drops or surgery, based on current research, may continue to be appropriate for the treatment of glaucoma.
Meditation is not for everybody, but it may help to relieve stress. Maryalicia Post reports
At a party recently the question of ‘stress’ came up.. who had it, what they do about it. When I was asked if I suffered from stress – my first reaction was to say ‘no’.. After all I’m not an air traffic controller – or an eye surgeon! The most stressful thing I would normally face is a long queue at airport security or a cancelled flight.
So for a moment I thought I might just say ‘no’.. but somehow that seemed pretentious.. as if I were implying I was too well organised to experience stress. Or perhaps it would suggest I was a lady of leisure, which I’m not.. So I said ‘yes.. and then the young man who’d asked the stress question had the chance to ask another.
“Have you thought about meditation?’
Now I could say ‘no’ without a second thought..
‘I’m not sure what religion it’s based on,’I explained, ‘but it’s not mine’.
‘Okay…said he…’you don’t need any specific spiritual belief. I don’t practice a religion and meditation works for me.’
’Well,’ I confessed.. ‘I can’t imagine sitting still – trying not to think about anything – for any length of time. It would drive me crazy.’
Turns out that’s a common misconception. He assured me it’s not about stopping your thoughts… Its about becoming more aware of them but not dwelling on them. You focus on your breath and on your sense perceptions. You let your thoughts pass by like clouds. Label them and let them go.
‘It’s a gentle procedure.. ,’ he added..”not sombre at all.’
I asked him what he’d gotten out if it.
‘In my case- it varies with the individual -after about a month I noticed my mind was clearer and I had developed a heightened sense perception. Ultimately, I experienced a feeling of relaxation, of being uplifted.’
‘Sounds great,’ I stonewalled, ‘but I wouldn’t have the time…’
‘Ten or 15 minutes a day…’
Since that evening I’ve been noticing the posters – taped to trees along the footpath, pinned up in my local supermarket and in the Post Office – offering ‘meditation’ sessions in my locality. And, at www.goodreads.com, I came upon a book called Teach Yourself To Meditate by Eric Harrison which got great reviews.
What have I got to lose? A few Euro for a book – or a course, and 15 minutes a day. I’m thinking about it……
EuroTimes Contributing Editor explains how he made the transition from writing about football to covering ophthalmology meetings
Former Republic of Ireland international soccer player Fran Stapleton(left) being interviewed by former Tallaght Echo reporter Dermot McGrath in 1991 outside The Burlington Hotel, Dublin, Ireland. Image courtesy of Brian MacCormaic.
My son has never really forgiven me for becoming a medical journalist. My mistake was telling him that I used to be a sports writer, or perhaps more accurately “a fan with a typewriter”. Why on earth would anyone give up watching and writing about sport, he wondered. Telling his friends in school that his dad was a sports writer seemed vaguely cool, whereas telling them that he wrote about eye diseases was considerably less cool and definitely more “nerdy”.
Yet this nerd has no regrets about career choices, even if I understand my son’s point of view only too well. This year’s gathering in Lisbon marks the 35th Congress for the ESCRS and the 15th for yours truly.
It’s an adventure that began on a freezing February in Rome in 2003 when George W. Bush was in the White House and Ulf Stenevi was ESCRS President. I was ushered into a darkened hall at the ESCRS Winter Meeting where some live surgery was being relayed by video link from a nearby hospital. It was a cataract operation and I managed not to faint as the eye was prepped and the phaco needle worked its magic. “So, do you think you can write about this stuff?” my editor asked with a smile.
I managed to hold on to my lunch, sat in later on a few sessions and soon did my very first EuroTimes story. It was a short article on vitreous floaters, a persistent problem then as now for many patients. I went to interview the doctor concerned, hoping he wouldn’t realise how clueless I was.
When things got too technical, I hit him with my failsafe, fall-back question: “Okay, that’s fine, but what will this mean for the average patient?”. His answer to that very question provided the backbone for the article and the “average patient” question has served me well ever since – it often serves to scythe through the extraneous detail and marketing hype to get to the heart of the topic at hand.
A lot has changed in the 15 years since my initial floaters article. The ESCRS Congress has evolved from a principally European gathering to a truly global event. Some “hot” new technologies and surgical techniques have come and gone.
Femtosecond lasers are now a routine part of ocular surgery. The keratoplasty field seemed to gain a new acronym every few years (DALK, DMEK, DSAEK etc). Anti-VEGF drugs revolutionised the treatment of AMD. Cataract incisions continued to shrink as IOL materials and designs improved. Gene therapy and retinal implants are no longer the stuff of science fiction.
Through all this evolution, watching and reporting from the sidelines on everything from A-constants to zonuloysis has been a fascinating and educational experience. It might not excite my son’s imagination, but the perennial game of science versus pathology played on that smallest of pitches, the human eye, compels its own respect.
The “players” – those ophthalmologists, surgeons and researchers that take to the field every day in an effort to save sight, improve vision, treat disease and improve the quality of life of their patients – deserve every support and recognition for their endeavours. After all, they’re playing on behalf of all of us, even if occasionally they still need to be asked that irksome question “so, what does this mean for the average patient?”
It’s a question I hope to keep asking for a good while longer.
- Dermot McGrath is a Contributing Editor with EuroTimes
Take a break from technology – and your phone – and enjoy interactions with colleagues in Lisbon
Everything I needed to do to be present in Lisbon for the ESCRS meeting, I did with my phone. I sent an email to our department secretary to request a few days off, and when my conference visit was approved, I notified my colleagues via WhatsApp that I would be absent this weekend. I booked my flight via the Momondo app, downloaded a barcoded e-ticket on to my phone and, the day before my flight, checked in remotely.
I found and booked an apartment on Airbnb and, upon arrival, received an SMS with the code to the apartment’s front door lock. I checked the weather (very nice!) via the weather app so I would know what to pack. Once I got on the plane, I put on my noise-cancelling headphones and read The Economist on my phone while listening to a drum & bass playlist that I had created on Spotify and downloaded on to my phone.
When I arrived in Lisbon airport, I took one look at the long line of people waiting endlessly for a taxi and immediately summoned a car via Uber. I reserved a Harley Davidson motorcycle online and then used Google Maps to get from my apartment to the rental agency and from there to the conference centre, where I downloaded the ESCRS app to help plan my days at the conference.
I wrote this column on my computer (sorry, writing on a phone is just too slow) and I could probably find many of the presentations online after the conference. It’s all so simple, all so convenient. So why am I even here? What motivates me to fly to continental Europe’s westernmost capital (according to my phone’s Wikipedia) to attend a conference?
I guess it’s for the human connection, the discussions, the interpersonal interaction that can only occur when I put down my phone, take off my headphones, close my computer and look around at who’s sitting across from me during lunch, who’s walking towards me in the exhibition area, who’s standing behind me in the line to get an espresso.
Maybe it’s because I’m sure I’ll bump into Nic Reus, the cataract specialist who supervised my first complete phaco early in my residency, and Bart Zijlmans, a surgical mentor whom I credit with upgrading my phaco skills from “beginner” to “intermediate” in just a few months. I think it’s important to maintain some sort of contact, however brief, with mentors and those with whom I trained, not only via Facebook but also in real life.
I’ll also meet up with Thierry Derveaux, my current colleague at Ghent University and, for my combined phaco-vitrectomies, my IOL-power-calculator extraordinaire. It’s thanks to his calculations that patients referred to me after complicated cataract surgery often end up emmetropic, even after vitrectomy and retropupillary enclavation of an iris-claw lens.
I always find it fun to see people in a different environment. Especially if that environment happens to have outdoor restaurants with ocean views, vinho verde and aromatic olive oil.
We appreciate the opportunities and conveniences that technology has made possible. But we all came to Lisbon to take a break from technology and enjoy interactions with colleagues in an enjoyable environment.
- Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium and a Medical Editor of ESCRS EuroTimes
THE French have an expression that says Lever le nez du guidon. It’s perhaps unsurprising that the country that gave us Le Tour de France also gave us this gem, but for me it truly captures the spirit of the ESCRS summer meeting.
Literally translated, it means “To raise your nose from the handlebars”, and it couldn’t be more visually representative of its figurative meaning, which is to take a moment to pause and reflect on a situation that you are actively involved in. Taking a step back, as it were, and looking at the bigger picture. I always picture a heroic cyclist making his way through one of the gruelling mountain stages of the Tour de France. Bent deeply over his steering wheel, tirelessly chipping away metre after metre of a seemingly never-ending strip of asphalt draped like spaghetti over the French Alps. After they’ve made it around yet another hairpin turn (they are the steepest parts!) they raise up their upper body to for a brief moment to stretch their backs, glancing out to the formidable challenge still ahead, but also looking back to the road below them that they’ve already conquered.
A life in ophthalmology can feel like a mountain stage. Training to perform surgery is a long and winding road, and when you consider exams and fellowships and all the sacrifices that you make, there’s a lot more uphill than downhill, to say the least. As you are bent over the steering wheel of your career with yet another mountain to climb ahead of you, it’s important to remember to stretch your back, as it were, to take stock of what’s ahead, and take a moment to appreciate the road you’ve already travelled. You remember the first incision your trainer let you do alone, the first capsulorhexis you weren’t embarrassed by, and the first case you completed yourself even though you were so nervous that your sweat made your scrubs stick to you.
The ESCRS meeting gives you time to think and reflect, something that is often missing from our hectic clinics. The coffee breaks between sessions are there for a reason – they let you meet and chat with your peers and your idols. This will help you realise that while your goals lie further up the mountain, the hairpin turns you have conquered still lie ahead for many of your younger colleagues. Trainees flock to the meetings, and helping them to success in their wetlabs and courses can give the same sense of achievement as the first time you did it yourself. Even though I am not a trainee any more, I am still learning. We all depend on those ahead of us to show us the right way to go. We owe at least that to the riders behind us.
In other words, you don’t have to know everything before you’re allowed to share something. You’ve already made part of the journey, and others who are behind you are more than happy to hear from you. At the ESCRS this year why not try to encourage the trainees to speak up. They are the future
of the Society, and if we want the future to be bright we have to make them even better than we are.
- Sorcha Ní Dhubhghaill is an anterior segment surgeon and guest lecturer at Antwerp University Hospital in Belgium.