Lecture: 2021: The Changing Landscape of Global Ophthalmology

[Paul] Hi, welcome to this webinar. I’m pleased to be here. This will be a discussion on best practices in global ophthalmology, evolving partner needs, and new means to deliver training, capacity building resources such as simulation, telemedicine, and distance learning. I’m pleased to be here. I’m in Chicago with Dr. Ciku Mathenge from Rwanda, and you can see her here. What we intend to do is provide a couple of talks. But really this is intended to be a discussion. I encourage everyone here to engage in the chat and the Q&A. We will try to address questions with the group during our talks. But we should have about 15 to 20 minutes of discussion time after Dr. Mathenge’s talk.

With that, I’m going to get started with my presentation. The first thing we’re going to do though, however, is present some poll questions. Present the questions here, okay great. Before I give my presentation I like to see what everybody’s responses are to here, which are: Are you currently engaged in telemedicine for clinical care of your patients? Yes or no. The second question is are you currently using artificial intelligence platforms for screening of eye disease? And the third question, are you currently using Cybersight for online education? Perfect. It’s about split for telemedicine. Very few using artificial intelligence. And terrific, I think most people here are using Cybersight, and of course, many other platforms for online education. Okay, great. We’ll get started.

I’m going to talk a little bit about technology and innovation and how it relates to education. And also discussing some advocacy as well. I’m Paul Chan, I’m the chair of the Department of Ophthalmology and Visual Sciences at the Illinois Eye and Ear Infirmary, UIC in Chicago. I also serve as a number of leadership positions for our national and super national societies.

Here are my disclosures. None of it’s actually relevant to this talk.

I think that all of us, I always show this slide first because with anything that we do in global ophthalmology, or just in work, it takes a massive team to get things done. I think that during COVID and even before COVID, we’ve seen the power of partnerships and collaborations in the teams that we work with. And I’ve been fortunate to work with incredible people like Mike Chiang, Pete Campbell, and many others on the work that we’re going to talk about today.

We’re going to focus in the beginning of this discussion around COVID-19, and I think that was part of the focus of this webinar, pre-pandemic and now in the pandemic and coexisting with COVID-19. And I think there’s no doubt, on a global scale, that the pandemic has affected every part of our lives from clinical care, how we perform research, education, and even our advocacy efforts as we work with the government and so forth to create sustainable programs. But there’s no doubt that the pandemic has really accelerated our use of technology. I think especially in education and telemedicine.

One of the things that I think has been brought to the forefront is the discussion around artificial intelligence. Of course, in ophthalmology, we are leaders in the field. We have the first autonomous AI system which is now being used in many locations. I think that one of the things that we have to discuss then is what is the use of AI, what are the opportunities for AI, not just in clinical care, but in research and also education?

We’ve seen during the pandemic that data matters. And looking at data to do things such as tracking, forecasting, diagnosis, contract tracing, and so forth. And using data to answer questions. Ophthalmology’s no different and I think we are well-positioned in this space, especially as we have a lot of imaging modalities, to help us understand disease, diagnose the disease better, and classify a disease better as well. And also for predictive tasks.

Another type of field here is NLP, natural language processing methods, being utilized to analyze the increasing influx of COVID-19 articles and so forth. Again, using data to help us guide decisions and to do better work.

AI, this is really the hot topic for many of us. How do we use it? Especially during the pandemic, I think that this is one of the things we thought about a lot, especially with our global partners. As we’re seeing the workforce issues and access to care being major issues around the world, I think we’re all waiting for the promise of AI and implementing it. But it’s hard and it’s difficult. I think even in our local communities here, and when we think about global ophthalmology, we always say global starts locally in our local communities. Even here in Chicago, facing the issues of the underserved populations that we care for, thinking through how do we use technology to provide access to care, especially for those who can’t leave their homes or have to travel long distances? Again, I think the promise of AI is very appealing and thinking through how to do we get that?

Education, this is something that is very dear to me and how do we actually educate better? I think Orbis has done a terrific job as well as many other organizations, in providing and democratizing education on a digital platform. We’ve built out systems for tele-education for ROP, specifically, now also for diabetic retinopathy. And building out data management systems. And I think in the future, thinking about how do we build out intelligent tutoring systems? Systems that can actually be tailored to the learner. Again, this is going to take data, it’s going to take a lot of work to test these systems. But again, I think this is the future.

I’ve had the good fortune of working with the group for I-ROP with Mike and Pete. And we thought about these questions about how do we use AI, how do we use the system to improve education and access to care? And I think that that is still to be determined. But you can see that when people look at the AI score, the I-ROP DL score, and you compare the score to expert examiners, very often the system out-performs experts if it’s trained well. I think that for naive learners, for people who are just learning how to diagnose certain conditions, using AI systems or some output from the AI system, can potentially improve training by diagnostic ability for more junior ophthalmologists and eye care providers. There are also a lot of resources online and we’ve also built a case based training systems, as you can see here with the American Academy of Ophthalmology.

Orbis, during the course of the pandemic, it’s one of these things where during the pandemic we were able to get a lot of things done. And Cybersight launched this terrific course on fundamentals of ROP. Again, you can see here the number of countries that have enrolled, the number of people that have taken the course already since its launch earlier this year. There are a number of online resources that we have access to. And I think that this is, again, one of the things the pandemic brought out. Even though before, maybe we were using a lot of online learning. I think over the past year and a half, it has become critical to have online learning platforms. And they’re just going to get better. Going beyond just static courses, with the power of the internet is that you can constantly change the material, you can be innovative in how you deliver the education, in addition to simulation, and so forth. Going through the pandemic around research, data matters. And we can talk through this a little bit and I’ll share some examples in our real world programs. And in regards to education I think we’ve really evolved in accepting online learning.

Cybersight AI, again, this is another offering from Cybersight and Orbis. I love this expression and Hunter Cherwek always mentions this, “machine mentoring.” And this is akin to what I was talking about earlier with the I–ROP DL score and how potentially the eye assistants can help improve diagnostic performance by the human. And how to train eye care providers moving forward. And a number studies on AI that Orbis is leading the efforts on in numerous countries. And I think this is very exciting because implementation is a big question that we all have. You can develop these systems but how do you actually deploy these systems in the real world?

Which comes to this. This is a wonderful paper that was written by the task force on AI, by the American Academy of Ophthalmology. The lead author here is Pete Cambell. But it talks about the implementation. Implementation is still a critical issue on technology and also artificial intelligence.

We’ve been working with Orbis and many other non-profits for over 15 years looking at ROP care, help with ROP program development. Most of this using telemedicine methods. One of the things that we have to keep in mind is that as we talk about artificial intelligence and so forth, you have to have good infrastructure for telemedicine in order to deliver it. I think that that’s something we all have to think through. From the ROP perspective in the condition that we work with, you are seeing good infrastructure for telemedicine as we start to see increases in numbers of retinopathy of prematurity in children at risk for ROP.

Pre-pandemic we were working with many companies and camera systems to deliver and integrate telemedicine care in the programs we worked with here in Mongolia with Orbis. You can see here we started doing this program back in 2010. And this is pre-pandemic. And here we’re using just a simple platform like Google Hangouts. This is back in 2015, 2016, working with our partners there to review images, to help provide consultations. And again, telemedicine and telementoring is nothing new, this has just been accelerating our capacity to do so through the course of time, especially with a year and a half of the pandemic.

This is some of the things that we did, we collaborated with our group to set up telemedicine screening platforms. Now, what happened? All of a sudden in March 2020, the world shut down and our ability to make in-country visits, our ability to expand programs had some major challenges, but we continued to work through this. What we’re doing now. Through teleconferencing, through Zoom and other methods. What’s nice about all of this is we can stay connected. And now we’re looking at expanding into the Eyemax, through again, telemedicine methods. But using digital technology to put access to care. I think that technology is critical and countries have the infrastructure to do it.

In Nepal, similarly, we worked with Helen Keller. Same op, using telemedicine methods, using imaging technology, and then the world shut down. But again, maintaining our partnerships through teleconferencing just like we’re doing now. And moving programs forward, looking at expansion, looking at technology, thinking about AI diagnosis, and try to get the work done in the long term.

Aravind and our close friends and partners in Coimbatore, this is Dr. Parag Shah. Again, similarly, through the pandemic, providing access to care through digital technology, seen thousands of children. One of the things that comes up is data management. We’ve learned through the years, and again, through the past couple of years, how important this is about maintaining good data and having cloud-based systems that can be shared to basically look at the data and look at our outcomes and to share the data with the relevant parties. We developed this system called iTeleGEN which is a telemedicine meeting center as well as a data management tool. Looking to integrate the AI systems into it.

How good is AI? Again, through this pandemic, working through some of these questions. In the India population with Parag Shah and the group there, you can see here in this paper that the AI system they developed had high diagnostic accuracy as a screening device. And also, which I thought was interesting, showed that ROP severity was higher in the neonatal care units that did not have resources to monitor and doctoring oxygen. Could AI also be used as a predictor of what’s happening in the real world for management.

This system now is going through the FDA process, approval process, and it has received breakthrough status, again, pre-pandemic. But working through it over the course of the past year and a half to go through the FDA process.

In addition to AI, telemedicine, one of the critical pieces is, and I know many of you on this call are probably looking at developing more cost effective camera system, imaging devices, and I think creating integrated solutions has become more important. Clare Gilbert and many others are working through how to develop the best integrative solution and what will meet the needs of lower and middle income countries, and really everyone around the world.

Okay, with AI, this is the hot term in technology. One of the things that we’re become also very interested in. How do we provide education for ophthalmologists in general about what it is and best practices? There’s a lot of resources coming out. The academy’s also developing curriculum around AI and data science. So look for that, more to come. Again, I see it as AI, similar to OCT in a way. Where this is new technology, it’s a new tool that we can be using post-pandemic or within coexisting with the pandemic to manage our patients and provide access to care.

I think advocacy efforts, I want to touch on this a little bit as well. In addition to education, research, and just clinical care, technology has been well-utilized to maintain advocacy efforts around the world with many of the super national societies.

I had the good fortune of working with Siddhartha and Eddie Ghodi in Africa coming to this program for the AOC Leadership Development Program. But again, nothing stopped. I think this is really important. We all miss being together, no doubt, and being in person. But again, when we’re dealing with a crisis and we’re dealing with issues around being in person, we switch to teleconferencing. And we had to continue the work. Sid, in addition to Eddie and the group, they continued these programs for AOC, in addition to many of the other programs around the world that focus on leadership like the Asian-Pacific, Pan American and SOE.

I have to mention this and just as a discussion around global ophthalmology and changing landscape. Really this is just to honor one of my dear friends and mentors, Dr. Marilyn Miller, who many of you know on this program. Really one of the giants and luminaries in our field. Started to work in Africa many years ago, continuing on with really focusing on ROP care. And really had the foresight to look at technology. And how technology can be implemented for education and access. Unfortunately she passed away recently but her memory lives on with all of us, especially in Africa and Chicago and in ophthalmology in general.

In summary, I touched on a number of things about technology. I focused a lot on AI but discussing how AI can be part of the solution. And when we think about pre-pandemic, and now in the pandemic, the need for technology right now. We talked, we had a very nice discussion recently at the Academy meeting in New Orleans about how do we create or democratize tech? That can be quite expensive. More to come on that, I think that’s a very important discussion.

I think we can’t overlook the need to teach low-tech solutions to care. Even though we have all these interesting digital tools, we will have to, again, with this new paradigm, look at more cost-effective models. One of the things that I think we can’t also forget is about the discussion around health equity. There’s a lot of talk about, well, does the technology increase this health equity gap? I think that it’s complicated. It can also make that gap smaller. And I think that for many of us we’ve seen that. It really depends on how we use it and how we implement the technology in general.

Dr. Mathenge will touch base and talk to you all about education. But again telementoring, tele-education I think are critical and I think that’s all here to stay. And I, of course, never forget about the advocacy efforts that all of us are doing. Especially working with our NGO partners, like Orbis International, to provide better access to care and training workforce for the future.

With that I’ll finish from there and pass it over to Dr. Mathenge.

[Ciku] Greetings to everyone who is attending from across the world. I am Ciku and I’m joining you from Kigali in Rwanda where I run the Rwanda International Institute of Ophthalmology. And it’s really a pleasure to be part of my first Cybersight webinar as a presenter.

What I’ll cover in my talk and I really am grateful that Paul was able to cover his side of the talk, which is really a lot about what goes on in the thinking of providing global ophthalmology. I will approach it more as a recipient of global ophthalmology. My talk will be from the other side. I’ll look at some of the definitions, the facts, and the models of global ophthalmology that are currently in place. I will also go through some of the lessons that I have learned, the opportunities that I’ve seen global ophthalmology as a tool for education, and then look a bit at the global ophthalmology of the future.

But first, we have a poll. Lawrence? My first question is, global ophthalmology is ophthalmology practiced elsewhere outside where you call home. Is that true or false? The second question is about the magnitude of blindness. Proportionate to population, Africa has the highest burden of blindness in the world. True? False? It’s Asia, false, it’s some other place?

And finally, in your opinion, global ophthalmology should focus primarily, so I want a single choice answer here, and those are your three options. You can vote anytime. Okay, so there’s quite a spread of answers. I will run this poll again at the end. I think question number one was almost 50/50. Question number two, true, and question number three equally between disease and between training. Okay, thank you, Lawrence.

First, let us look at some definitions. And specifically, what is the difference between global ophthalmology and global eye health? And when I was asked to speak on Cybersight I asked my friends what they thought was the difference, because there was a lot of confusion between those two terms. And I got a myriad of answers from the very philosophical to the very cynical and almost rude.

My own interpretation is not based on any expertise here, but I think that global ophthalmology is more about things that we do every day while global eye health is around the world wide strategies that we talk about. And let me try and explain this a bit better.

On the right, are the top recommended indicators for monitoring global eye health. And you will notice that these are indicators that can be measured in any country in the world. The other side on the left, are things that are measured in more in individual programs or within individual institutions or organizations. My talk today is about global ophthalmology, it’s not about global eye health. However, I would like to say that as global ophthalmology practitioners, we must be familiar with the key documents that are related to global eye health because we are always contributing to that, no matter what we’re doing.

And the key documents at the moment are the World Report on Vision, whose purpose is to generate greater awareness in the extent of vision impairment and blindness with an expectation of increasing the political will and investment in eye care. The “Lancet Global Health” Commision on Global Eye Health summarizes things very well by looking at all the new and existing research in eye health. And it argues that addressing avoidable blindness with the very highly cost-effective treatments that exist will result in numerous benefits for society. The other document you should be familiar with is the global targets that were endorsed by the World Health Assembly. Because this is what will be measured no matter what you’re doing in eye health across the world. And these targets will play a key role in increasing global eye care coverage in future as we deliver our services.

What is my own definition of global ophthalmology? I like to think of global ophthalmology as making the practice of ophthalmology universal, equitable, and comprehensive. In simple terms, we practice global ophthalmology with the goal of making the same high standard of eye care available for everyone from everywhere at any time and for everything. But what are some of the things that we know about global ophthalmology practice today?

Global ophthalmology is often thought of as ophthalmology elsewhere. Perhaps this is because sometimes it seems that the needs are all is greater elsewhere. Or perhaps it’s because we perceive problems elsewhere as sometimes being easier to solve than our local problems. Or sometimes, perhaps, it’s because we confuse the space of our good intentions with the size of our ability to help. But as you think about elsewhere, you must not forget the inequities in eye health that exist in your own location. We must also remember that problems in eye care elsewhere are a complex mix of not just ophthalmology and the biological processes of eye health, but also some social influences that may be difficult to understand or solve. Who understands best why cataract surgery, for example, is still a blindness reversing operation in Africa instead of being a blindness prevention surgery as it is elsewhere?

I think the onset of COVID-19 has made global ophthalmology practitioners reflect on their role and to swing towards also meeting needs in the local level which is a good thing. But is it true that needs are greater elsewhere? And I think the answer is, definitely they are.

The global burden on eye disease data shows that it is the Asian countries that have the highest burden of visual impairment and blindness. And that, of course, is driven by the large populations. It also shows that proportionate to population, Africa is worse off despite the progress already made in eliminating trachoma and onchocerciasis. Definitely it is valid to think of helping elsewhere.

Let’s look at another fact about global ophthalmology today. Global ophthalmology often carries an implicit assumption of an expertise gradient which flows from those who know and have to those who are in need. And I think that is okay. As long as those who know and have use that privilege as a tool to build, they use the experience as building blocks. But we must be conscious that experience runs both ways and that the partial knowledge one may hold as an outsider can never be more effective than the vital expertise of the local team.

Also we must be aware that the success of our interventions is shaped not just by how good the intervention is, but also by the local culture, the social history, the politics, and these experiences are often best known by those who live them.

Let me tell you about my own experiences in global ophthalmology. And on this slide I put global ophthalmology in brackets because at this time the term did not exist. My first experience with global ophthalmology was at the university where I trained as a resident. We had a partnership with a university from Germany. And this university sent faculty for three year contracts and this faculty came with new skills and basically established the subspecialties in the department. They came with what they needed in terms of equipment and they solicited for more whenever they realized that there were critical gaps. In my opinion, they literally held the hand of the department from having two faculty and two trainees to one that has already produced over 200 graduates from over 15 countries in Africa.

I see numerous positive outcomes from this model of global ophthalmology. It created the largest residency program in east and central Africa, it introduced subspeciality care in cornea, in retina, and actually in all disciplines, including donating the equipment that was necessary to run these specialties. And it didn’t stop there. There was facilitation in faculty development so that the department could create its own specialists by allowing Kenyon ophthalmologists to go to their institution and train in the different specialities. The benefits were actually mutual, the doctors gained in their experience of ophthalmology in another world. And indeed one of the faculty that was there on the three year contracts, ended up leading the NTD department of a large organization for a long time after his contract ended. There were also some unexpected collateral benefits. Many of these ophthalmologists from Germany never went back home, they found wives in Kenya, and some are still living in Nairobi.

To me this was a model that was grounded on a long term vision and it worked.

And if I go back to my definition of what I think global ophthalmology is, this department of ophthalmology became accessible to all qualifying doctors in the region, to all patients because it’s based in a referral hospital for the region, the department of comprehensive services. And when I say comprehensive, they invested in training even orthoptists. They actually based orthoptists from Germany there for a long time until we had our own orthoptist. And the training of local faculty made it sustainable.

This was clearly explained to me recently as I prepared for this talk when I sent a text to one of the faculty in the department and said, “Does the University of Nairobi still cooperate with Munich and do they still send lecturers?” And her answer was, “Cooperate, yes. Send lecturers, no need now, we’re good.”

To me, I believe long term goals are important in global ophthalmology. Let me give you another example. This is me many years ago and I was on an outreach mission with my friend and colleague, Dr. Miguel, in Rwanda. In over three days we performed over a 100 cataract surgeries, this was the first such activity after the war in the country. We did well, everybody was happy, we even got to meet the president. Did we treat everyone? Definitely not, only those who could reach the hospital. In fact, every patient knew someone else who didn’t make it and who they wished who could have had the opportunity.

Did we treat people from everywhere? No, only from one district where the bus had gone to pick them. Are the services still available at any time? Once we left, the local doctor actually went back to square one. No equipment, no consumables. Did we treat everything? Not at all. I’ll always remember this young man standing in the corner who had come with his grandmother because he too had an eye problem and he had severe keratoconus and was hoping that this was the opportunity that would allow him to get treatment and go back to school.

The truth is that almost 20 years later, we still struggle in Rwanda to deliver good cataract surgery. And our main problem is lack of ophthalmologists.

I really believe that sporadic surgical volunteerism is not equivalent to global ophthalmology. And we must always look at its positive and negative aspects.

Sporadic surgical volunteerism helps a large number of patients and they can be helped in one go. Often the consumables that are left behind may help stock up the local team. That’s exactly how I survived in my previous station in Nakuru. And it can also help raise awareness around eye care issues if there’s good publicity before it happens and also during. However, we must be aware that it can also undermine local health systems. Whether its financing systems because of giving free service where governments have been trying to implement pay systems or insurance systems like the ones we have in Rwanda and Kenya. It can undermine what people think of the local ophthalmologists. I often wonder what they thought of the doctor who hosted us as he was not able to help them before we went and he was not able to help them after we left. It can also lead to neglect of non cataract conditions, as we saw for that young man standing in the corner.

Let me go to the same photo and demonstrate how the same activity, a sporadic visit, can generate better results. This is 2003 and this is when I met Miguel. Two years before he had come to my hospital for an eye camp as a team of three doctors. And as two of the doctors performed surgery, one doctor spent his time teaching me how to do small incision cataract surgery. It’s because of the skills that I learned that Miguel felt confident enough to include me on his mission to Rwanda two years later. Genuine skills transfer provides long lasting impact and should be included as a major component of global ophthalmology.

In my next few slides I would like to share some options of how global ophthalmology can offer an avenue for skills and knowledge transfer. As you’ll notice my experiences have alway made me link where global ophthalmology being a pathway for knowledge and skills transfer more than as a formula for service provision.

Global ophthalmology can be the platform for improving access to the latest e-learning technologies. Whether by pointing people in the right direction or by availing these resources for free of charge or supporting related costs. This global ophthalmology blindness course that is offered by the London School is offered free of charge because someone is paying for it on behalf of the learners. But on top of that for those who need a certificate, another organization subsidizes fees for learners from certain countries. It has become a staple course for many residents starting ophthalmology in low and middle income countries.

Other courses like this one on Cybersight, really improve access. Not only are they freely available, but many of them are translated to other languages making them accessible to non-English speakers. As we develop E-technologies, we must remember that today’s young ophthalmologists and ophthalmologists-in-training are native speakers of the online digital language. While those of us commissioning and producing these E-learning resources are digital immigrants who sometimes misspeak an outdated form of E-language. I really believe that E-learning is great because the resources for E-learning allow the same number of staff to educate a much larger and more diverse student body.

One of the partners has, for example, and my residency program has a partnership with the Wills Eye Center; they’ve given my institution access to attend their grand rounds. This is an opportunity for all of us, both residents and faculty, to learn. But especially an opportunity for my residents to learn presentation techniques from others, hear about pathologies that are not common in our region, but also to marvel at how cases which to them are everyday cases, are considered novel in other regions. Our next step is to have joint grand rounds. And I believe that this is a simple and non-extensive component of our global ophthalmology relationship with Wills. The pandemic has shown that the use of telemedicine is likely to persist even within all ophthalmology subspecialities.

Global ophthalmology is also grabbing the opportunity for telementoring more and more. This is the use of information technology to produce guidance and technical assistance. This can be real time as in surgery telementoring or at convenient times in teleconsultations. This is an example of a platform we have as the African Retina Society, and people send these different images every day on a WhatsApp platform and within minutes they have responses from about 25 different retina specialists on the continent and get an opinion on what to do with a patient. In my experience, telementoring works best when both parties know each other. And global ophthalmology can be the platform on which those relationships are built.

Another way that we can use global ophthalmology to aid education is by physical visits by faculty. The onset of COVID-19 has made global ophthalmology practitioners to focus on finding effective ways of virtual education, but physical visits can never be adequately replaced by virtual experiences. For me, effective exchanges must be bi-directional. This can be in the form of allowing your partners to attend conferences, meeting each other as external examiners, sabbatical experiences, inviting your partners to teach rare subspecialities. For example, you shouldn’t be struggling to teach tropical medicine or tropical ophthalmology when you have a partner who can teach that better. And rare subspecialities like ocular oncology, for example, don’t exist on the African continent. Those are the kinds of faculty that by having a visit really add value for us.

In these pictures I receive a senior ophthalmologist from Wills to come and teach my residents. And they, in turn, invite me to actually give a named lecture. These bi-directional experiences really add value to global ophthalmology experiences and will probably be the way to go in the future.

The third thing I’d like to talk about is using global ophthalmology to introduce new technology and to teach how to use it. Dr. Paul Chan has talked a lot about that and in better detail than I’ll give you. But simple things like this is a visit to Burundi, this doctor was willing to carry his laser machine and perform the first diabetic retinopathy laser camp in Burundi, and train the doctor there as well. And the doctor there, after learning, was happy to buy his own laser machine. This is the same gentleman who first taught me small incision cataract surgery. And many years later he visited me to teach me how to do cornea intacs and this became the first corneal intacs down in Rwanda with patients coming from as far as Kenya.

I believe that global ophthalmology should not be equated to cataract surgery. And in any case even within cataract surgery, things move so fast. As fellows in global ophthalmology travel to learn small incision, let them also take new technologies to the places they go. I recently hosted a fellow who wanted to learn small incision. But he, in turn, taught me how to use a gonioprism and how to perform the Kahook dual blade trabeculectomy. He even donated both a gonioprism and several blades. With the version of glaucoma that we have, you can imagine how appropriate this low tech technology transfer is.

You must never underestimate the ability of poor countries to update technology. This is our gate between Rwanda and the Democratic Republic of Congo. You have to scan your fingerprints, scan your documents, scan your irises. And when it was installed people thought how are people ever going to learn to use it. It didn’t take more than a week. And women with their wares on their head, babies on their backs, thousands of them cross this barrier every day. It took just a week for them to be familiar with it. Technology has the potential to be a great equalizer. But it is currently an accelerator of geographic divisions. And the severe inequities that burden the world of eye care are in many ways made worse by the technology-driven nature of ophthalmology that often favors the individuals from privileged backgrounds.

Let’s not forget about technology in wet labs. There is a big need to invest in technology for surgical training. From pig eyes, to simulators, to virtual reality, trainees of the future will expect training programs to invest in these technologies that allow surgical trainees to practice skills and operations in a safe and realistic environment. The global ophthalmology community can invest in different ways. You can invite residents from partner institutions to use your simulators. And even NGOs that are often very concerned about poor outcomes of cataract in their programs, perhaps you could replace one scholarship with one simulator, replace one outreach or some air tickets and donate a simulator to the nation’s training institution. Those who train residents know how difficult it is to do surgical training without a wet lab or without the technology that the wet lab needs.

Global ophthalmology is also about emerging technologies and we must embrace them. This is a report from our artificial intelligent screening program. It’s a study that we just competed in Rwanda. And even as we embrace these technologies, we must be skeptical when the AI devices are developed from narrow training datasets. I was lucky to work with Cybersight to teach and train this AI and be given the opportunity to be part of the training of the AI. Let us create opportunities in our programs to get more representative data.

My final point on global ophthalmology and education is on research. A lot of research in low income countries is initiated or funded by the global ophthalmology community. A lot of young researchers have been mentored over the first 10 years through education opportunities. This paper which was just published in October this year, is an interesting read on parasitism in authorship. We must advocate for equal partnerships in research. No one wants to be merely a data collector or to be stuck in the middle in publications.

What do I think global ophthalmology of the future will look like? I think accountability will be a big thing. There will be a demand for more transparency with all information available and accessible for public scrutiny, we’ll have to be more answerable, and we will be required to provide clear reasoning for all our actions and decisions. We will have to be compliant with monitoring and evaluation of all procedures and outcomes and how we report them. And I believe that there will be enforcement and sanctions for negative consequences.

I think the ophthalmology of the future will also have more equity. We are all in the same race against blindness but we are running in different lanes. Some have more resources and less disease, some have more disease and less resources. And in the same way that we don’t start in a straight line. We will all have a fairer chance to finish the race if through global ophthalmology we strive for more equity, more trust, more solidarity, so that those who need a head start get a head start and allow us all to finish on the same finishing line.

I will now ask Lawrence to play the poll again, and I thank you very much for listening to me. Ophthalmology elsewhere, 54%. Proportionate to size, Africa true. Yeah. Asia has more numbers but proportionate to size it is Africa. In terms of global ophthalmology being ophthalmology elsewhere, it often is. But the key is not to forget that need to look local also. And the last question was about where you would invest primarily and this is really your personal experience, but I’m happy to see that training has now taken the lead.

I think Victoria was asking about the global eye health indicators and wondering how programs are going to report on them.

[Paul] Correct.

[Ciku] That’s the effective refractive error coverage and the effective cataract surgery coverage.

[Paul] Yep, I just put the question in the chat if you want to take a look.

[Ciku] Yes. Yes, and she was asking who do you report to? I think when you run programs in any country, that program should be embedded in the national strategy for that country. And part of that strategy would be how they collect data and what the reporting channels are. Most developing partners are doing that really well today. I think the key is at the point where programs are being designed, you need to understand what the country needs in terms of reporting and whether that is done at a hospital level where implementation is happening or whether it’s at an organizational level. I would say it changes from country to country, but be familiar with what the government requires right from the beginning.

[Paul] Ciku, I enjoyed your final comments around the future. And I think that one of the main points you stressed was transparency. When you look at data reporting, I’ve always found this to be very heterogeneous. There’s a lot of heterogeneity around how partners collect data, report data. What do you think are potential solutions to harmonizing that in some way?

[Ciku] I think it’s difficult for individual partners and programs to do it. And like I said, there should be investment in developing the health management information systems of countries. Sometimes that’s not an area where resources are put in. Digitalizing those systems just makes data collection so much easier. And I think in the future that’s one area that global ophthalmology should invest in.

[Paul] And then, good. We have a bunch of questions coming in. Victoria followed up here with, in Rwanda how do people report their data to? Is it Ciku or someone at the MOH?

[Ciku] (laughs) Each program reports through the national reporting system. Then there is a focal person at the Ministry of Health that puts it together.

[Paul] Okay. I think these questions are more for you, Ciku. Here’s a question from Dr. Matalla from Bangladesh. Do you have any data in Sub-Saharan Africa trachoma-related blindness?

[Ciku] I think the trachoma people. Was it glaucoma or?

[Paul] Trachoma.

[Ciku] Trachoma? Did they ask about glaucoma or trachoma?

[Paul] Trachoma, with a T.

[Ciku] Okay, okay. I think the international agencies have done a really good job with trachoma and the atlases have a lot of data and I would encourage them to go, for example, to the IAPB website and get the latest data from there. But this is definitely a disease that is on its way to elimination in Africa.

[Paul] And I thought this was a very good question which I think is universal which is about, from Dr. Rajans. What’s the best strategy to initiate collaboration, teacher exchange programs or research projects?

[Ciku] The strategy that I’ve found working for us is one of transparency, again, one of mutual respect where you both start believing that there’s something to gain from each other. In any relationship you need to put all your cards on the table at the beginning and say this is what we need from you and this is what we think we’ll gain from you. And when it starts like that, then it’s easy for the collaboration to work well.

[Paul] I would just add that there’s a lot of online resources now with these databases of people who are open to collaborating and provide teaching and exchange programs. I’ll just speak from the American Academy of Ophthalmology side, there’s actually an online resource that’s called the Global Training Directory. You can access it, it’s open access, and it has hundreds of partners that you can connect with. I think another outlet also is our NGOs like Orbis. The folks at Orbis International know many of the people who are open to teaching and exchange, collaboration, research collaborations in addition to partnering with the non-profits. Ciku, go ahead, I think you were going to say something else.

[Ciku] No, no, no.

[Paul] Okay. Great. Just trying to see here. And then I’ll finish with this. I know we’re just at nine, but this relates directly to your talk from Keratay in Dalu. What is the clear demarcation between global ophthalmology and global eye health?

[Ciku] I don’t think there’s a clear answer to that. Like I said, I think global ophthalmology contributes to global eye health. Global eye health is really about what’s happening in the whole world. And global ophthalmology is the many activities we do in education, in service provision with technology. And all those contribute to making the indicators for global eye health achievable.

[Paul] Okay. Should we, Lawrence, should we finish with one more question or are we out of time?

[Lawrence] If you both have time, you can answer a couple more questions. I’ll leave that up to the both of you.

[Paul] Okay, I thought this was good, this is the last question, Ciku. This is, in countries where the human resources are lacking, specifically in terms of ophthalmologists, how can AI be implemented on a district level? And how is the population being responsive to the new system? That’s a great question.

[Ciku] (laughs) Yeah, well, that is part of what we were trying to investigate in our trial that we just finished. I think AI will be great for low income countries. A lot of the low income countries, for example, do not have diabetic retinopathy screening programs or ROP screening programs. And I know that, Paul, you’re an expert in ROP. And usually what happens is where screening is taking place, an ophthalmologist has to go there with his imaging devices and then give feedback to the patients. Which is not possible to do that very often. What we are trialing in Rwanda is whether if we put in an artificial intelligence system in a diabetes clinic, first of all, would people like it? And it was quite interesting to see when you ask people you can get your response from the computer or we can send your images to an expert, which one do you prefer? And we got almost a 50/50 split. It will be interesting to see what the populations think about artificial intelligence and how much they trust it.

But definitely the diabetes clinics love the technology because they felt they were adding value to the patient visit. And the patients loved the fact that with this one visit they got an answer about their eyes too. As I said, technology should not become a geographical barrier. And with the advent of artificial intelligence there should be the desire and the intent to roll it out across all income brackets.

[Paul] I think that you answered it perfectly. I have nothing else to add except for maybe just the fact that trust is of utmost importance in all communities. I think that we still have a lot to learn about the implementation of these algorithms and these devices.

With that, Ciku, unless you have any final comments?

[Ciku] I think there was a question somebody asked about Vision 2020 and whether it did succeed? Do you have any thoughts on that, Paul?

[Paul] What’s that?

[Ciku] They said did Vision 2020 was one of the questions.

[Paul] I didn’t see that question, but I will say whether or not it succeeded or not, is that your question?

[Ciku] Yes.

[Paul] I think this is a long discussion, but I think that everything that we do has a goal. And you have to set goals in order to actually move the needle. I think that we’re still continuing to push forward with these goals going further. Do we have to extend it to Vision 2030 or to Vision 2040? I think that we’re still moving forward but that foundation has been laid for us.

[Ciku] I think you’re absolutely right. But I also believe that one of the things that that campaign did is it was great for advocacy and in mobilizing people to work together, resources came from the government, from partners, from philanthropies. But also even the numbers showed that there was a real reduction in the number of blindness, despite the fact that the population really grew in that period. I think a lot of good things came out of that campaign.

[Paul] Yeah. Great. And I think that when you look at the “Lancet Global Health” Initiatives that came out, we’re still pushing forward as a community. I think that it’s not like we’re stagnant. But I think it’s like everything else that we do. Everybody wants to see 100% success out of these goals. But at the end of the day, if you’re making a difference that’s what matters the most.

There’s one other question here about the residency training in Rwanda and the cost. I don’t know if you see that here?

[Ciku] I would say go to our website, RIIO.org, and all the information will be available.

[Paul] Great. Thank you.

[Ciku] Thank you very much, Paul, this was a pleasure to share this platform with you and I really enjoyed your talk on technology because I believe that’s where global ophthalmology’s going. And it will actually end up being the great equalizer. Thank you very much and thank you, Cybersight.