Talk to ophthalmologists and three themes emerge very quickly — the influence of Fred Hollows; the beauty of the eye and the preciousness of sight; and an intriguing mix of medical and surgical work
One figure looms large over ophthalmology in Australia — Frederick Cossom Hollows, AC.
There is barely an ophthalmologist of a certain age working in Australia today who hasn’t been touched in some way by the gruff, pragmatic, straight-talking, all-action Fred Hollows, who began working to improve the eye health of Indigenous Australians in the early 1970s and established the National Trachoma and Eye Health Program (NTEHP) in 1976, with funding from the federal government.
Professor Hugh Taylor holds the inaugural Harold Mitchell Chair of Indigenous Eye Health in the Melbourne School of Population Health at the University of Melbourne. Fred Hollows was one of his mentors.
“Fred led me astray at an early age and I’ve been astray ever since”, Professor Taylor tells the MJA.
“The phone would ring and he’d say ‘Taylor, I need you out at Port Augusta’ … this was at the start of the NTEHP and, one way or another, I ended up spending the better part of a year as the assistant director of that program.”
Professor Taylor went on to help Hollows screen more than 60?000 Indigenous Australians for trachoma, before stints at the Johns Hopkins University in Baltimore and International Center for Preventive Ophthalmology at the Wilmer Eye Institute, where he developed the World Health Organization Collaborating Centre for the Prevention of Blindness and Visual Impairment, and started the first masters in public health program in preventive ophthalmology.
He returned to Melbourne in 1990 to take up the inaugural Ringland Anderson Professor of Ophthalmology — the chair named for his grandfather, a World War I army medic who trained in ophthalmology in Britain after the war.
In 1996, Professor Taylor founded and became the managing director of the Centre for Eye Research Australia. In 2007, he took up the inaugural Harold Mitchell Chair of Indigenous Eye Health in the School of Population Health at the University of Melbourne.
The beautiful eye
But why ophthalmology? Was it his grandfather’s influence?
“No”, he says. “I was aware of what my grandfather did but, no.
“The eye’s just a beautiful little organ, sort of like a jewelry box, and to take it apart and put it back together again was just beautiful.
“When you actually look at it and see it up close … people talk about the eye being the window to the soul but you can visualise all sorts of things in the eye that you can only see in an x-ray or a scan or a blood test for other organs … it’s a beautiful organ to work on.
“And, of course, the restoration of sight to the blind is almost biblical in its impact. The effects are immediate and pretty dramatic.”
It’s a common theme among ophthalmologists.
Professor Paul Mitchell is a medical retinal specialist and professor of ophthalmology at the University of Sydney, and Director of Ophthalmology for the Sydney West Area. He, too, was influenced early by Fred Hollows, who was his general surgery tutor as well as his ophthalmology teacher during his student days at the University of New South Wales.
It was the mix of both medical and surgical work which attracted Professor Mitchell to ophthalmology.
“It’s a wonderful mix”, he tells the MJA.
“Ophthalmology is a very satisfying specialty — I never thought I could do any better in any other specialty.
“Operating on the eye is very pleasurable and there is very great joy in the results. People are extremely grateful for the restoration of their sight.”
Highly competitive
Ophthalmology is historically a highly competitive field.
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) offers a 5-year vocational training program involving: 2 years of basic training where the trainee must demonstrate integrated clinical skills and knowledge in ophthalmic sciences (anatomy, physiology, optics, clinical ophthalmic pharmacology and emergency medicine) and ophthalmic basic competencies and knowledge; 2 years of advanced training where they must demonstrate integrated clinical and surgical skills and knowledge in each of the following clinical practice areas — cataract, clinical genetics and microbiology, clinical refraction, cornea and external eye, glaucoma, neuro-ophthalmology, ocular inflammation, ocular motility, oculoplastics and orbit, ophthalmic ultrasound, paediatrics, refractive surgery and vitreo-retinal; and a final year of evidence-based ophthalmic practice with a research component.
Associate Professor Mark Daniell, vice president of RANZCO and head of the Corneal Unit at the Royal Victorian Eye and Ear Hospital in Melbourne, said RANZCO had just over 800 Fellows based in Australia, and a total of 1400 including those who are retired or working overseas. There are 32 new training places available each year.
He, too, believes it is the combination of medical and surgical work which makes the specialty so appealing.
“It’s very satisfying”, he says. “There’s a problem you can fix with your own hands and usually very quickly.”
Professor Daniell leaned towards neurosurgery initially, but after doing some research in collaboration with a neurosurgeon, he changed his mind.
“I saw his life and realised it wasn’t for me”, he says. “Outcomes from neurosurgery are often poor due to the conditions being treated.”
Ophthalmology provides opportunities not just for public service, but also for working overseas, he says.
“About a third of our Fellows do work overseas and there is a strong trend in the specialty to work in other countries or in remote areas of Australia.”
And that’s where Fred Hollows returns to the conversation.
“Fred represented the ideal — medicine for the benefit of society. He was Hugh Taylor’s mentor and Hugh was mine as he was continuing Fred’s work.”
Exciting times
Professor Taylor knows exactly what he would say to a roomful of medical students contemplating their choice of specialty.
“Certainly about ophthalmology, but also about medicine in general, there’s never been a better time to be a doctor”, Professor Taylor says.
“There’s never been a time where we can do more to make sick people well, and keep well people healthy. It is a very exciting time and, of course, ophthalmology leads the field.”
Advances in the treatment of macular degeneration are particularly exciting, he says.
“The development of the antivascular endothelial growth factor drugs has transformed our ability to treat at least half the cases of macular degeneration.
“Before, people would go blind and there would be absolutely nothing we could do about it and now basically we can maintain their vision as long as they’re getting their regular injections into the eye.
“It’s a big deal, the injections take a lot of time, there are risks with it, so looking at ways to better give that treatment is a very hot topic.
“It’s also expanding from macular degeneration to the complications of diabetes and also other vascular problems in the back of the eye. So that’s a huge area where there has been tremendous growth in the last few years.
“There’s a lot of work being done too with cataract and refractive surgery using lasers rather than ultrasound to dissolve the lens. We’re looking at better intraocular lens implants that mean you don’t actually need to wear glasses or bifocals after surgery.
“That’s a field that’s been transformed in the last 20 years.
“There’s a law that says when science gets beyond a certain point it begins to look like magic and modern cataract surgery is just magical”, he says.
Stem cells are also high on the agenda of ophthalmic research.
“Instead of doing full thickness corneal grafts we’re instead transplanting layers of the cornea. Some of those are bioengineered corneas that are starting to be used. The role that stem cells may play in repairing retinal degeneration [will give us] a lot better understanding of the genetics of eye disease.”
Professor Taylor stopped doing clinical work in 2007 when he took over the chair of Indigenous Eye Health at the University of Melbourne.
“One certainly misses that patient interaction”, he says.
“Taking the bandages off someone you’ve done a corneal graft or cataract surgery on and suddenly they can see and the big smile on their face … or struggling with patients with herpetic keratitis who you really get to know well and actually keep them seeing well … there is a lot of good interaction.
“But if we can close the gap for vision it will be a tradeoff that was worthwhile.”
The full interview with Professor Hugh Taylor is available as a podcast at www.mja.com.au/multimedia/podcasts
- Cate Swannell