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Beyond borders: Reflections on my glaucoma fellowship

My Health Manpower Development Plan (HMDP) journey was a rollercoaster before it even began! After a General Medical Council (GMC) registration delay, I first got to London in March 2020, but within a week I was on a plane back to Singapore as the world went topsy turvy. The second time around, I landed in London on a sunny July day in 2021, a day that was coined “freedom day” i.e. no more enforced Covid-19 restrictions which was a shock to the system.

Undertaking a Glaucoma and Anterior Segment Fellowship, I had the great fortune of working closely with some of the most eminent names in Glaucoma. In the first 6 months, this was with Professor David Garway-Heath, Principal Investigator (PI) of the United Kingdom Glaucoma Treatment Study (UKGTS) and inventor of the Garway-Heath map used in research for the structure-function relationship in glaucoma who taught me that there was much about visual fields and Optical Coherence Tomographies (OCTs) that I did not know; and Miss Winifred Nolan, known for her work in angle closure disease, an excellent surgeon and clinician and someone whose composure and bedside manner I hope to emulate. For the next 6 months, I was on rotation with Professor Gus Gazzard of LiGHT Trial fame, a study which has changed many treatment practices and whose analytical approach to management was a great learning experience; and Professor Keith Barton whose surgical prowess in complicated cases and uveitic glaucoma precedes him. For the Anterior segment portion of the fellowship, I had clinics and an Operating Theatre (OT) session with Mr Sajjad Ahmed from Cornea / External Diseases team, during which time I performed some corneal grafts, complicated cataract and anterior segment reconstructive surgery; finally the team based K-Pro clinic with Mr Mark Wilkins (Cornea), Professor Nicholas Strouthidis (Glaucoma), Miss Louisa Wickham (Vitreo Retina).

As an old and well established tertiary referral centre, the patient mix was vastly different from what I had encountered back home – both in ethnicity and in complexity. Many of the patients had late-stage disease and prior surgery, often at other institutions. Clinics were bursting with a long backlog from pandemic restrictions and often ran late into the evenings.  Tube surgery was a common procedure as was the revision of previous trabeculectomies and tubes and I also had experience repairing a few cyclodialysis clefts. As a large department with over 20 consultants who often run their clinics in the same physical space, I had the opportunity to observe and have lively discussions about their different approaches to patient management. There was also a large pool of fellows from all corners of the world and I learnt as much from them as I did from the seniors.

There were also virtual clinics to run and while they have a great set-up, because of the patient overflow, there were many patients that did not strictly meet the criteria for virtual review being sent there, to ensure that some form of review was still being carried out within a reasonable timeframe.

On my return, we have formally established a complex anterior segment service in SNEC (CASSIS) with a fellowship program and plans to increase research, training and education opportunities. This service is also available at two of our peripheral spokes – CGH and SKH. I have learnt new glaucoma techniques which have been demonstrated to my colleagues, with some considering adoption. There has also been discussion about how we can streamline and improve some of our services, particularly the GLOC clinics,  based on my observations during my time abroad.

Some question the need for an overseas stint. I think that despite Singapore being an advanced healthcare system, time spent within a different system is an eye-opening experience, which allows us to better ourselves and bring back not just new practices but also richer, fuller perspectives on how medicine is practised around the world. Furthermore, lifelong friendships are forged, making future research and scientific collaborations easier and something to look forward to.

With Winnie, Tina (who was visiting), Keith and Hari

Team Barton last day in OT together - myself, Keith, Diana and Soledad (2 other fellows)

With some of the Moorfields fellows at the Moorfields Internatonal Glaucoma Symposium, January 2022

Contributed by:

 Dr Yap Zhu Li 
 Deputy Head, SNEC Eye Clinic @ CGH
 Consultant, Glaucoma Department and Complex Anterior Segment Services 
 Singapore National Eye Centre


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