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From Establishing a World-Renowned Eye Institute to Integrating Ophthalmology and Optometry in China: The Story of The Eye Hospital of Wenzhou Medical University

Lu, Fan MD, OD; Chen, Wei MD, PhD; Li, Mengchen MSc; Zhou, Xiangtian MD, PhD; Qu, Jia MD

Author Information
Asia-Pacific Journal of Ophthalmology: March-April 2021 - Volume 10 - Issue 2 - p 135-141
doi: 10.1097/APO.0000000000000389
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Abstract

HISTORY

The Eye Hospital of Wenzhou Medical University (hereafter referred to as the Eye Hospital) is a relatively new hospital, which was established in 1998. Nevertheless, it is the first specialty center focusing on both ophthalmology and optometry clinical care in China.1 The Eye Hospital has made remarkable growth in the past 2 decades as it developed from scratch to one of the leaders in ophthalmic clinical service and research in the region. In retrospect, the Eye Hospital owes its great success to the vision and determination of the founders in developing an eye institute of international standards for patient care, training, education, research, and development.

The Eye Hospital inherited the excellent works of its founders. Prof. Tianrong Miao, a renowned Chinese ophthalmologist, founded the first ophthalmic optics laboratory in China at Wenzhou Medical University (WMU) in 1978, when the Cultural Revolution ended and the higher education system in China was resumed. Subsequently, the School of Ophthalmology and Optometry was also established at WMU in 1988. These laid down solid foundations for the later establishment of the Eye Hospital. Professor Miao was recognized by the international community of ophthalmologists and optometrists as the inventor of the logarithmic visual acuity chart. During his days, a standardized method for the evaluation of visual acuity was lacking. By virtue of Professor Miao's multidisciplinary knowledge in ophthalmology, optics, and mathematics, he developed a logarithmic visual acuity chart and a 5-score recording method, which used the logarithmic value of a viewing angle with a step rate 1010 to measure visual acuity. The recording method is set to l = 5−lgα,2,3 which has been confirmed to be the most suitable visual acuity measurement system. First developed by Professor Miao, the logarithmic step rate design of visual acuity measurement system continues to be the gold standard for evaluation of the visual acuity and has benefited countless patients worldwide through the decades.

Prof. Tianrong Miao, the founder of the Department of Ophthalmology.

Ophthalmology focuses on the study and treatment of ocular diseases, whereas optometry focuses on improving vision by means of optical aids. Since its establishment in the United States over 100 years ago, optometry was regarded as an independent and parallel discipline from ophthalmology. It nonetheless occurred to 2 students of Professor Miao that these 2 disciplines deserve closer ties and collaborations for the interests of advancing academic research and patient care. In 1986, a groundbreaking step was taken to combine them into a single discipline called “ophthalm-optomology” at the WMU. In 1988, their efforts culminated in the approval from the Education Ministry of Zhejiang Province to establish the Department of Ophthalmology and Optometry at WMU. The strategic combination of these 2 disciplines opened the avenue for a holistic and comprehensive approach to ophthalmic clinical service. Clinicians trained within this scope of design are equipped with knowledge and skill of both disciplines, which enables them to make rounded decisions so that this eye institute could provide the one-stop clinical service to patients.

Since its establishment, the department has been committed to the spirit of “making the impossible possible”. The founders developed the joint Department of Ophthalmology and Optometry with equal emphasis on the development of both arms. In 1992, with the staunch support from Dr. Minzhang Chen, China's Minister of Health, the Optometry Research Center of the Ministry of Health was officially approved and established at WMU in recognition of its efforts invested in advancing the development of optometry. The vision and endeavors of the hospital's founders also harnessed international interests and recognition. In 1994, Prof. Jia Qu, now the chief director of the Eye Hospital, was invited by the World Council of Optometry (WCO) to present the Chinese definition of the function and mission of optometry based on the experience and achievements in developing optometry at WMU.

In 1998, Prof. Jia Qu, Dr. Fan Lu, and Dr. Qinmei Wang led the establishment of the Eye Hospital—an affiliated hospital of WMU. This hospital combines ophthalmological clinical services and the visual function corrective services of optometry together, placing it within a unique niche as an eye care specialty hospital in China to fulfill the unmet demands from the society. Since its establishment, China's large population and pressing demand for quality ophthalmic care have catalyzed the rapid development of the Eye Hospital of WMU.

Although pioneering the “Wenzhou model” of higher education and clinical training, which emphasized the development of ophthalmology and optometry, advancing research in ophthalmology, optometry, and visual sciences to improve care of patient's vision is also core to the mission of the Department of Ophthalmology and Optometry in WMU. The department has adopted a multidisciplinary approach that highlights investigations of fundamental scientific problems. Researchers at the institute have been conducting rigorous investigations to understand and appraise the development of the visual system, the heritability of major eye diseases, and the pathogenesis and diagnosis of major eye diseases. These challenging questions of visual sciences have key implications in clinical decisions and outcomes. As a result, the work and knowledge gained by the team at the bench could be translated into actions at the bedside to impact patients at the Eye Hospital and beyond. By virtue of such background, the Eye Hospital is unique in China for being the only institution in the field of medicine which is home to 3 national research platforms, including a National Clinical Research Center, a State Key Laboratory, and a National Engineering Technology Research Center. In 2020, the Eye Hospital established another national laboratory, the Key Laboratory for Clinical Research and Evaluation of Medical Devices and Drug for Ophthalmic Diseases, which was designated by the National Medical Products Administration of China (NMPA). These centers address the need to improve both disease treatment and prevention in China, and serve as bases for innovation and technological advancement in clinical research, talent training, and translation of knowledge in the clinical setting.

Currently, the Eye Hospital is one of the largest public ophthalmic and optometric centers in China and offers a comprehensive range of services from 24 different clinical specialties. It has also topped the list in the nationwide ranking as a science and technology asset in China (originally designated as the China Hospital Science and Technology Impact Evaluation Ranking)4,5 by the Chinese Academy of Medical Sciences both in the categories of “Academic Impact” and “Technological Outputs”. In 2018, as the Eye Hospital celebrated its 20th anniversary, it was ranked first in ophthalmology among all medical institutes in the Nature Index Ranking 2018, and the total number of its research articles published by the Eye Hospital in the prestigious official journal of the Association for Research in Vision and Ophthalmology, Investigative Ophthalmology & Visual Science (IOVS), ranked seventh in the world. The SCI journal Eye and Vision sponsored by the Eye Hospital also celebrates a 5-year impact factor of 3.883, which positions it in the forefront ophthalmology as a highly esteemed journal in the field.

One of the main buildings of the Eye Hospital of Wenzhou Medical University

DEVELOPING SIX ROLES

The Eye Hospital of WMU has adopted the “Six-in-One” model to develop its comprehensive range of services and strengthen its impacts in the society. This model integrates 6 roles of a hospital: medical care, education and professional training, research, industrial translation, community works, and advocacy, into one service agency.

The Eye Hospital emphasized the dual biological and optical nature of the eye in its approach of medical care to all patients. This is an innovative design because it proposes a new framework that combines ophthalmology with optometry. To address eye diseases of all patients from both the ophthalmologist's and optometrist's perspectives, the hospital established a new clinical service system to provide personalized treatments in the eye and vision care at the Eye Hospital. The clinical service at the Eye Hospital is organized into both comprehensive eye clinic and subspecialty services, which have now been adopted nationwide. Today, it comprises 1 general eye care department, 24 subspecialty departments along with 6 clinical diagnosis and treatment centers. Subspecialties include myopia control and prevention, high myopia, presbyopia, low vision rehabilitation, contact lens, strabismic amblyopia cataract, glaucoma, refractive surgery, corneal disease, fundus disease, eye-nose–related disease, orbital and ocular oncology, ocular trauma, pediatric fundus disease, oculoplastic, uveal disease, genetic ocular disease, ophthalmology of traditional Chinese medicine, and more. In 2019, the annual number of outpatients has reached 948,000, and the number of surgeries performed in 2019 was over 64,500. As the Eye Hospital has become a national ophthalmic clinical diagnostic and treatment center, it is also a top-ranked eye hospital in China's Hospital Rankings.6 Its goal is to improve the accurate measurement and evaluation of vision deficits and visual quality. The Eye Hospital innovates and improves its equipment, methodology, technology, and procedures. Through the above, all aspects of patient care are greatly enhanced and validated to be safe, thereby increasing the accuracy of diagnosis and efficacy of the treatments.

In the past decades, as the prevalence of myopia dramatically increased in China, reaching 53.6% nationwide, myopia has become a concerning issue and gained attention of policymakers. The Eye Hospital has contributed great efforts to myopia control and its prevention in the Chinese ophthalmic community. It is now the chair institute in the national myopia control and prevention actions. Large-scale research focusing on the pathogenesis, underlying mechanism, and development of myopia have been initiated and conducted by the Eye Hospital.7 The results have significance for improving clinical nonsurgical correction and prevention. The Eye Hospital leads in establishing and popularizing the consensus for listing norms and standards.

Moreover, the number of cataract surgeries performed at the Eye Hospital is among the highest of all Chinese public hospitals. In the field of cataract and refractive surgery, the Eye Hospital introduced individualized detection and correction techniques to conduct precision cataract refractive surgery. The Eye Hospital has conducted clinical research on the objective evaluation of preoperative visual quality to determine the appropriate timing for modern refractive cataract surgery,8 and has been one of the first centers in China to introduce the femtosecond laser-assisted cataract surgery in 2013.9,10 Many of these techniques were primarily advanced by the Eye Hospital and popularized worldwide.11 Certain techniques applied in the Eye Hospital are benefited from its multidisciplinary design and have resulted in safer surgeries with higher efficiency. This is evidenced by the best correction in 3 different anatomical sites of the anterior segment namely the cornea, sclera, and intraocular after the implementation of such techniques,12 which is superior to pre-existing outcomes obtained at other domestic and international centers.

As one of the top cornea services centers in China, more than 4000 corneal transplantations have been performed here successfully. It engaged novel surgical techniques in its treatment procedures including closed penetrating keratoplasty,13 closed triple surgery,14 and manual wet-peeling deep anterior lamellar keratoplasty (DALK) techniques have been developed here,15 as well as the proposal of the 4 types of big-bubble theory. The first predescemetic automated endothelial keratoplasty (PDAEK) and injective descemet stripping automated endothelial keratoplasty (DSAEK) surgeries were performed by its team in China. Prof. Wei Chen, the director of the cornea service center, initiated the Boston keratoprosthesis surgery at Boao Super Hospital. For the best use of corneal grafts, the long-term safety and efficacy of using precut anterior lamellar cap for DALK has been demonstrated here.16 It is also one of the most recognized training centers in China, more than 120 trainees from across the country have completed their training in Wenzhou.

Its innovation in technology and scientific research led the glaucoma clinical center of the Eye Hospital to become one of the main consultation centers for refractory glaucoma in China. The glaucoma team put great effort on the management of angle-closure glaucoma (ACG), which is a big public health problem in China. Targeting at the restoration of the natural aqueous outflow in ACG eyes, the team introduced the endoscopy and gonioscopy-aided goniolysis as a main surgical strategy for ACG, even in eyes with extensive peripheral synechiae. The glaucoma team designed a pivotal procedure of penetrating canaloplasty that creates a direct conduit from the anterior chamber to the Schlemm canal in the eyes with diffusely closed angle. This procedure has now been successfully utilized in primary ACG, as well as various refractory glaucoma, providing a new option for the management of glaucoma in clinical practice. In addition, the glaucoma team put forward and systematically described the concept of translens pressure difference in the pathogenesis of ACG, based on which, the team innovatively explored the effect of low-dose transscleral cyclophotocoagulation on the treatment of ciliary block–related glaucoma. These strategies greatly changed the concept of clinical management for ACG. What is more, it significantly improved the outcome and quality of life for ACG patients and refractory glaucoma patients.

In the field of fundus disease, advanced equipment and technologies were brought in to help the diagnosis of difficult and complicated diseases, which include age-related macular degeneration, central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, macular edema, infectious fundus diseases, and fundus tumors. The Eye Hospital has led and participated in many multicenter clinical trials, as well as drafting and revising multiple consensus and guidelines for the diagnosis and treatments of fundus disease. Major projects include adopting induced pluripotent stem cells in the treatment of macular degeneration and performing research and development (R&D) on robotic fundus surgery, which is first being experimented with by the Eye Hospital.

Its innovative role in establishing an education model constitutes a new concept in cultivating talents for visual health care. This model is referred to as the “China Wenzhou Model,”17,18 whose establishment and development continually facilitate the normalization and standardization of educational objectives. As of today, WMU has educated and trained over 4000 specialists in all fields of ophthalmology and optometry. These graduates account for one-ninth of all ophthalmologists in China. The alumni work in educational, clinical, and research areas, and have become the core talents in the various fields related to ophthalmology such as medical care and medical device R&D.

The Eye Hospital is also proud of itself for being an institute equipped with more than 10 provincial and ministerial level platforms such as the National Clinical Research Center. It is one of the institutes that receives the largest number of funded research projects approval at the highest level in the Chinese ophthalmological system, which is still on the rise through these years (Figs. 1 and 2). In addition, it is the only ophthalmological institute that received the international ethical approval from the Forum for Ethical Review Committees in Asia and the Western Pacific (FERCAP). Accordingly, the Eye Hospital established 3 surveys studying its epidemiology in a population of 300,000 individuals. Based on the results, an innovative medical research convention ophthalmic platform was developed. This platform currently owns 8 representative registered products and ranks first amongst China's ophthalmology departments. Its strong clinical research staff and the innovative faculty allow the Eye Hospital to remain current with the newest medical technology in multiple areas that are available to the international eye care providers. For example, one of the seminal contributions by its faculty includes a series of studies on deep lamellar corneal transplantation. It is on the list of Top 10 Research Advances in Corneal Disease in the last 5 years. Other examples that can be included are the newly revealed identification of the retinitis pigmentosa association gene19 and the successful establishment of the world's first and most comprehensive gene database of the hereditary fundus diseases.

FIGURE 1
FIGURE 1:
Number of national research projects.
FIGURE 2
FIGURE 2:
Number of SCI publications.

The Eye Hospital also strives to transfer knowledge and findings yielded from its rigorous research and investigations to industry so that it can ultimately benefit the many patients in need. To achieve such an objective, the Eye Hospital has established close cooperation with the local government. Accordingly, they have constructed Eye Valley (an incubator and innovation hub for ophthalmology and optometry at Wenzhou). With the support from the local government, 800 million Chinese Yuan (about US $130 million) has been invested in constructing an 80,000 square meter central incubator park and more than 5.3 hectares of a science innovation park. This park is centered around a branch hospital of the Eye Hospital and envisioned to contain clinics, educational and research centers, incubators, and commercial enterprises. It can be divided into 6 major functional sections, including: a) ophthalmology and optometry international innovation center; b) optical devices, scientific innovation park; c) ocular instrument scientific innovation park; d) ocular pharmacology innovation park; e) biomaterial scientific innovation park; and f) smart medicine scientific innovation. Ultimately, they aim at building a Chinese “Silicon Valley” in the field of eye care. As of 2020, there has been over 70 companies in related fields settled in Eye Valley.

The Eye Hospital also actively engaged in social activities and public welfare work. Various charity projects such as conducting ocular screening and cataract surgery for people who live in remote regions such as the mountains of Sichuan and Qinghai-Tibet Plateau have been continuing for nearly a decade. Over the past 23 years, the professional team of the Eye Hospital has traveled more than 2 million kilometers in China, covering 17 provinces to conduct eye screening for more than 1 million patients as well as performing eye surgeries for nearly 40,000 people. In addition to providing medical services, the team also attached great importance to the training of local surgeons to help them become self-sufficient. What is more, as one of the official partners of the Special Olympics, the Eye Hospital sent a team of professional volunteers for the Health Athletes projects in every game season and established the first Special Olympics Health Center named after Eunice Kennedy Shriver at Wenzhou in 2003. In addition, a series of actions were conducted to protect school children's eyesight, which included large-scale screenings covering a population of over 1 million students within a month. Thanks to the unique model designed by the Eye Hospital, this large-scale screening was completed within a month and was repeated every 3 months to monitor students’ visual acuity.

In terms of mission advocation, the hospital actively plays an influential role via establishing branches, joint ventures, and strategic cooperation with partners from all sectors, sparing no efforts to promote the “China Wenzhou model” in clinical diagnosis and treatment as well as ophthalmology and optometry education. In 2018, the Eye Hospitals Group of WMU was founded. At present, the group has set up more than 10 branch hospitals such as the Wenzhou general hospital, Hangzhou branch hospital, and Suzhou branch hospital. Besides, an extensive global collaboration network has been established, among which the Bascom Palmer Eye Institute and New England College of Optometry are close working partners with the Eye Hospital toward the same vision and mission.

Prof. Jia Qu, MD, chief director of the Eye Hospitals Group of Wenzhou Medical University.

CULTURE OF COMMITMENT

Wenzhou is located on the east coastal line of China and is the third largest city in the Zhejiang province of China. Nevertheless, the Eye Hospital in this city has developed into the only Tier 1 Grade A specialty hospital of the province, with an affiliated academic department equipped with state-of-the-art national and state-level research facilities in just 22 years since its inception.

The success and achievements of the Eye Hospital are largely rooted in the motto and spirit of “making the impossible possible” inspired by the founders of the hospital since its establishment. Such belief of Professor Miao, who developed the logarithmic visual acuity chart with only limited resources in the early days of the department, continues to motivate clinicians and scientists at the institute to date to serve the mission of advancing eye care of patients with sight-threatening diseases. In addition, the department has developed a leading education and research platform for academics and clinicians based on its “Six-in-One” model, which complements and supports the operation of a comprehensive range of over 24 ophthalmology subspecialties and 6 treatment centers at the Eye Hospital.

The Eye Hospital has witnessed tremendous changes from its early days to become a modern eye center with national and global impacts. What remains unchanged is the strong spirit and faith of the people within who will continue to dedicate themselves and lead the Eye Hospital to the next level of excellence in the decades to come.

NEW ENDEAVORS

China is home to a population of over 1.3 billion, which is the largest in the world and a population with the highest prevalence of visual impairment and blindness globally. There are about 10 million blind patients in China at present, which accounts for approximately one-fifth of the global blind population. Besides traditional sight-threatening diseases such as cataracts and glaucoma, the urbanization of China in recent decades is accompanied by changes in landscapes in the fight against blindness, as new threats to sight such as myopia and diabetic retinopathy emerge. The current situation and challenges unveil opportunities for the ophthalmic and optometric communities to develop and thrive to advance our service to the society with unprecedented demand for eye care. The Eye Hospital of WMU is obliged to advocating visual health both locally and globally, and would seize the opportunity to accelerate its pace in research and development to closely meet the society needs. It is beyond any doubt that the Eye Hospital will continue exhibiting its spirit of “making the impossible possible” and emerge from challenges of the new era as a stronger eye hospital capable of shouldering the responsibilities of safeguarding the vision of the next generation.

The focus of academic research at the institute in face of the new challenges in eye care and prevention of blindness is in myopia, which has become not only a major challenge in the community of ophthalmology in China but also a universal public health problem globally. According to the World Report on Vision issued in 2019 by the World Health Organization (WHO), the incidence of myopia is highest in the Asia-Pacific region and East Asia, with rates of 53.4% and 51.6% respectively. The report also emphasized the alarming prevalence of myopia in urban areas of China (67%).20 To face the challenges brought by this issue, 15 ministries of China jointly commenced a scheme for myopia control and prevention in China. The Eye Hospital was appointed as one of the chair institutes for the implementation of this scheme. In the past 2 years, it has formulated and published the guidelines and proposals such as the National Assessment Measures for Children and Adolescents’ Myopia Prevention and Control, the Core Information for Children and Adolescents’ Myopia Prevention and Control, the Provincial Implementation Plan of Myopia Prevention and Control, and 3 other statements of consensus, for instance, Children and Adolescents’ Myopia Survey Workflow.21 It has also hosted the Myopia Prevention and Control Forum of the China Ophthalmology Society Optometry Group. All these new actions of the Eye Hospital served to harness professional awareness and interests of the latest challenge so that it could be addressed by concerted efforts. In addition, the Eye Hospital initiated a new model for myopia screening, which is realized by the information-based instrument and supported by the self-examination operated by school doctor or trained teachers. It is known as the “Zhejiang Model” of myopia prevention and control. By adopting this model, the Eye Hospital has successfully conducted massive screenings with high efficiency, which covers the whole population of students in Wenzhou (1,101,960 students). Each screening was completed within a month and was repeated every 3 months. Entrusted by the Ministry of Education, the hospital undertakes the task of developing a comprehensive education outline for myopia prevention and control in children and adolescents in China.

The hospital also took the extra step to lead the Chinese ophthalmology community in addressing the new challenges of myopia through its establishment of China's Myopia Prevention and Control Committee. The committee has built a comprehensive big data center of China's myopia prevention and control and set up the collection and sharing platform for children's and adolescents’ visual health and myopia. In September 2019, the Eye Hospital also hosted the prestigious Xiangshan Science Conference, which was the first time that such conference was hosted by the ophthalmology community. The conference successfully gathered more than 40 Chinese academicians and experts to conduct in-depth discussions on the current contexts and trends of myopia development in China, the prevention and control policies of myopia, latest research findings in myopia, and its translation in clinical settings for myopia prevention and control. In addition, the hospital established China's first eye health science museum, which demonstrated a new model of public education for the younger generation's myopia prevention and control.

The Eye Hospital continues making great strides in innovation and technology development. It has established an ophthalmologic medical center in China's Boao Super Hospital in the Boao Lecheng International Medical Tourism Pilot Zone in South China's Hainan province, which is the first ophthalmological institution in the Super Hospital. The Super Hospital enjoys 9 preferential policies such as the exclusive prelicensing medical care granted by the state, led by academicians in the field of clinical medicine and top medical discipline leaders. New medical technologies that have been licensed by other countries can be first tested there. Similarly, new drugs and new devices are evaluated through integrating domestic high-quality medical resources and forming teams that are members of specialized clinical centers. Currently, the expert team of the ophthalmologic medical center performs the most operations and attends to the care of the largest number of outpatients in the Boao Super Hospital. Utilizing the favorable policies aforementioned, the team from the Eye Hospital conducted China's first real-world study at Boao. On March 27, 2020, the first ocular medical device that uses data from real-world evidence (RWE) was licensed for marketing. This is followed by the second medical device, which is also an ocular device and has gained approval by RWE in December. Apart from introducing various new technologies, the center also strives to create an open, cooperating, and win-win platform with leading eye teams at home and abroad.

Furthermore, the hospital launched the first 5G ophthalmologic telemedicine program in China, enabling remotely located patients to enjoy the high-quality medical resources provided by the Eye Hospital. It also provides remote referral services for rural areas and western China which lacks medical resources. In 2018, it led to building the “National Ophthalmology and Optometry Alliance”. Currently, the Alliance comprises nearly 2000 organizations and institutions from 18 provinces, cities, and regions in China. This Alliance would coordinate cooperation and resource sharing in clinical service, telemedicine, subspecialty development, multicenter eye disease research, and personnel training to lead China's ophthalmology and optometry community to reach the next milestone.

In light of the rapid development of medical informationization, the hospital successfully implemented the “Chain Strategy” involving establishing linkages between information access and specialist operation, which continuously expanded “Internet capability”. These advances led to the establishment of the Ophthalmology, and Optometry Committee, Standard Committee, and Industry Alliance as a part of Chinese Health Information and Health Medical Big Data Society. Besides, as the National Clinical Medical Research Center, the Eye Hospital cooperates with up to 1000 hospitals in China, establishing a transparent and close eye disease prevention research collaboration platform at the state level. It intends to establish a database with more than 2 million eye biological specimens, as well as an Ophthalmological Pathology Center, a Big Data Analysis Center, and an Ophthalmological Video Center to fully utilize the advantages of the bioinformatics development.

The Eye Hospital has developed from scratch to strength since its establishment in 1998. Although the ways ahead are even more challenging, its heart and spirit in “making the impossible possible” to better serve patients in need remains the same.

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Keywords:

Eye and Vision; Eye Hospital of Wenzhou Medical University; eye valley; ophthalmology and optometry

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