“Wherever the art of medicine is loved, there is also a love for humanity” – Hippocrates
Right from the beginning of my journey in ocular oncology, I was all set to explore a larger perspective and paint on a wider canvas. Having no earmarked destination to the journey but enjoying the journey at every phase has been my way of life. As the Indian Journal of Ophthalmology celebrates the life and times of two of my mentors—Dr. Jerry Shields and Dr. Carol Shields, I take this opportunity to express my sincere gratitude to all my mentors, and also thank my colleagues and well-wishers who have made this journey beautiful and gratifying so far.
Ocular Oncology Global Scenario
The incidence of cancers is on the rise worldwide and so is the occurrence of eye cancers. The recent American Cancer Society—Survival, Epidemiology, and End Results (SEER) study has estimated 3,360 new cases of eye cancers in a population of 329 million. It was reported that the incidence of eye cancer in the UK has risen by 36% in the past decade. As far as retinoblastoma is concerned, India and China account for over half the cases reported globally every year. When it comes to cancer, survival depends on the stage at presentation. Early detection improves survival.
In underdeveloped countries, lack of awareness and late detection pose a challenge in the management of eye cancers and affect the outcome. The 5-year survival rate is 85–90% if the disease is localized, and dips to less than 20% with a distant spread. The scenario is dismal in underdeveloped countries and the disparity with the developed world is glaringly obvious. The need of the hour is to instill awareness among the ophthalmologists in specific, and medical professionals in general, and above all, raise public awareness.
Ocular oncology is still considered a niche specialty. Most of the eye care centers are not fully equipped to optimally manage patients with eye cancers. Training is fragmented, with very few centers offering comprehensive training in ocular oncology. Yet another bitter truth is that other medical professionals have very little knowledge and awareness that ocular oncology is a standalone subspecialty of ophthalmology. Accessibility and availability of medical expertise is, therefore, a major challenge in dealing with eye cancers. This holds true worldwide, especially in underdeveloped countries. It is often impossible for the underprivileged population to access medical care in regional and international tertiary care referral centers due to financial constraints. Heavy financial burden also prevents professionals from these regions seeking training elsewhere. Not many international fellowships are funded or carry remuneration.
Ocular Oncology Global Outreach
Reaching out to underprivileged regions to render service and to train local teams can overcome some of the gaps in the clinical management and the availability of trained manpower. Being part of institutes in underserved countries and being active in voluntary organizations has fulfilled my dream of taking protocol-based ocular oncology services to the regions in need. I regularly visit China every month to help manage children with retinoblastoma [Fig. 1]. My periodic surgical missions in Mongolia are as part of the Virtue Foundation. I feel fortunate to be able to follow my passion and am grateful for the platforms provided and opportunities received. I live my two dream jobs—one to contribute to one's own society for a cause, and the other to help extend services to deserving communities beyond the borders. Fellowship training from a community service-oriented institute, and further international exposure at one of the best comprehensive ocular oncology services, I feel, have empowered me to chase my dreams.
Ocular oncology global outreach can be in the form of assistance to build a collaborative evidence-based ocular oncology service, render consistent services on a predetermined schedule, provide clinical and surgical training to local teams to make the service sustainable, and use teleophthalmology to guide and mentor from a distance. This can create a positive and progressive change in the detection and treatment of eye cancers. Invariably, partnering through a public health system is advantageous in addressing a larger population in most parts of the world. To start with, setting treatment guidelines and protocols helps standardize patient care with better outcomes and without the need for constant expert supervision. It also has the advantage of consistency in care, thereby optimizing the results and minimizing unforeseen complications. Treatment guidelines should ideally follow the current evidence-based standard of care but temporized and customized to suit available resources, facilities, and skills to have a sustainable and effective global outreach of ocular oncology. Cost-effective treatment is adopted and implemented. For example, either intra-arterial chemotherapy or intravenous chemotherapy can be interchangeably used in the primary management of majority of cases retinoblastoma. However, intravenous chemotherapy is affordable and is easily available. Hence, the choice of appropriate treatment depends on several factors including the socio-economic background of the target population and the overall support ecosystem [Fig. 2].
Local medical personnel are empowered by training sessions to engage in early detection, accurate diagnosis, logical decision making, and medical and surgical management. An interactive academic session with case discussion is the most powerful teaching tool. Surgical skills are imparted with hands-on training. As a part of a voluntary surgical teaching mission, we operate as a team, coming together and working with the local ophthalmologists, imparting and exchanging ideas and knowledge [Fig. 3]. Surgery is the primary treatment modality in most of the eye cancers. The rule is simple - respecting surgical oncological principles can significantly reduce recurrence rates and mortality. Ophthalmological centers sometimes may not be fully equipped. Once a functional department is set up, it is indeed not difficult to get essential equipment donated. On the other hand, we do face challenges in pathological evaluation especially when special staining techniques, immunohistochemistry, and genetic markers are mandated. In such a scenario, slides and tissue blocks or microphotographs are shared with experts available in tertiary care referral centers in the region or abroad.
Most important is to build a team of focused experts including medical oncologists, radiation oncologists, pathologists, and ocularists, the team itself headed and steered by an ocular oncologist. Timely communication within the team improves coordination, thus improving the quality of medical care in ocular oncology. Above all, ocular oncology global outreach paves way for future collaborative research and helps create future leaders in the field.
Although we live in a world where humans are separated by man-made boundaries, as physicians we care without boundaries. Personally, global outreach in ocular oncology has been a precious learning experience for me and has helped me grow as an individual. This journey would not have been possible without continuous encouragement by my mentors. Dr. Jerry Shields instilled in me the most important values in medicine—patient care with patience and the power of honest communication. The biggest lessons that Dr. Carol Shields taught me were to remain organized and consistent in work—be it patient care guidelines, practice pattern, or documentation, and the value of time. Cost-effective medical care, the power of systematic surgery with due respect to oncological principles and adherence to protocols are the lessons that I carry forward from my primary fellowship mentor Dr. Santosh Honavar.
I strongly believe in the mantra “Be the change you wish to see in the world” by Mahatma Gandhi and try my best to incorporate it in every sphere of my professional life. I very sincerely encourage all my colleagues to set aside at least 5% of their workdays for outreach medical missions sans barriers or boundaries—I am sure they will enjoy it and cherish it as one of the most treasurable professional aspects of their lives.
About the author
Fairooz P. Manjandavida is a specialist in Ophthalmic Plastic Surgery, Orbit and Ocular Oncology and leads HORUS Specialty Eye Care, Bangalore, India. Her passion for Ocular Oncology has taken her beyond the borders. She is part of the charitable surgical teaching mission, Virtue Foundation and also heads the retinoblastoma services in one of the public hospitals in China.
After completing MBBS from Trichur Medical College, she received training in ophthalmology at the Mysore Medical College and Research Institute. She then proceeded to complete subspecialty fellowship training program in Ophthalmic Plastic Surgery, Aesthetics, Orbital Surgery and Ocular Oncology at LV Prasad Eye Institute, Hyderabad, under the mentorship of Dr. Santosh G. Honavar. Thereafter, Dr. Manjandavida moved on to further train in Ocular Oncology with Drs Jerry A. Shields and Carol L. Shields at Wills Eye Hospital, Philadelphia, USA. She pursued further training in Oculoplasty with Dr. Don O. Kikkawa at the Shiley Eye Institute, SanDiego, USA.
Dr Manjandavida has received the American Academy of Ophthalmology (AAO) International Achievement Award in 2015, Asia Pacific Academy of Ophthalmology (APAO) Achievement Award in 2017, Best Paper Award at AAO 2015, 2014 and 2011, Best Poster Award in 2016 and, 2017, Best Paper Award in AIOS in 2015, and the first Gangadhar Sundar Award by the Oculoplastics Association of India in 2011.
Her major research interests include retinoblastoma, and conjunctival, orbit and eyelid tumors. Various scientific publications in the filed of ocular oncology and oculoplasty have earned her credit and acclaim in the academic front. She is actively associated with post-graduate teaching programmes across India. She recently graduated from the APAO Leadership Programme, and is the scientific chair for Asia Pacific Society of Ocular Oncology and Pathology. As the section editor, Dr. Manjandavida introduced One-minute Ophthalmology to IJO.
I am extremely thankful to Dr. Gullapalli N. Rao, Founder-Chairman, LV Prasad Eye Institute, Hyderabad, India for the inspiration. I would like to express my gratitude to Dr. Dennis Lam, C-MER Eye Hospital, Shenzhen, China for the guidance and grit. I thank Dr. Jing Zhang, Dr. Jiejun Xia and, other colleagues of Women's and Children's Medical Center, Guangdong, China for being a wonderful workforce and an endearing team. My most sincere thanks and appreciation to Dr. Ebby Elahi and Virtue Foundation, New York, USA for the precious opportunity to be part of the innovative and forward-thinking organization.