Published in Primary Care

Global Health: Practicing Ophthalmology in Low-Resource Settings

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18 min read

Discover how residents can pursue global ophthalmology and the value of practicing in low-resource settings to address disparities in eyecare.

Global Health: Practicing Ophthalmology in Low-Resource Settings
It is estimated that at least 2.2 billion individuals globally suffer from vision impairment or blindness, of which almost half of the cases could have been prevented.1
Moreover, it has been reported that the burden of distance vision impairment is four times higher in low- and middle-income countries (LMICs) than in high-income regions.1 In west and east Sub-Saharan Africa and South Asia, it is reported that blindness can be eight times higher than in all high-income countries.1
These statistics are set to increase in the coming years due to factors such as an aging population, evolving lifestyles, population growth, and climate change.2,3 There are multiple barriers associated with access to eyecare and treatment options.
These barriers may be patient-, physician-, and/or system-associated, which is why the concept of population-level thinking becomes important with respect to solutions. Considering these obstacles to care, there is a growing subspecialty that is aimed at addressing disparities in eyecare: global ophthalmology.

Global ophthalmology as a solution to eyecare disparities

Global ophthalmology is the practice of delivering eyecare in low-resource regions where there is a lack of equipment, supplies, and/or personnel. As early as the 1970s, the practice of global ophthalmology has existed to alleviate needless blindness.
Earlier practices of global ophthalmology, however, focused on mission services that were not aimed at building capacity for the region. Over time, this definition has taken a drastic transformation by recognizing the need to build sustainable networks.
This has led to the development of local training programs at underserved sites and the practice of building long-term relationships with outside academic institutes.

Overcoming barriers with global partnership

Global partnerships can help alleviate many of the barriers that stand in the way of providing quality care across the globe. The top five obstacles include cost, access, travel, rural development, and training.

1. Cost

The cost of performing eye surgeries can be a deterrent in LMICs, where it can be difficult to afford cutting-edge technologies and trained personnel. In these situations, nongovernment organizations and global medical groups can step in to support surgery.
For example, in places like Ethiopia, the cost of cataract surgery is largely subsidized and supported by nongovernment organizations and mission groups. However, indirect costs are an unaddressed topic that needs awareness.4

2. Access

Moreover, global industry partnerships can play a vital role in addressing the access to care. In some underserved settings, global ophthalmologists have been able to use equipment donated by industry to collect patient data remotely prior to assembling teams to arrive on-site. This has helped anticipate the need for specific subspecialties and equipment.
Global ophthalmologists have been integral in helping to create this partnership for local development as they have built trust with locals and helped facilitate industry support. Through this collaboration, data collection for research is another aspect that is being steadily addressed. With research specific to underserved populations, treatment options can become more personalized with greater emphasis on the prevention of certain practices or disparities unique to communities.

3. Travel

Travel is an additional barrier that patients must overcome in underserved and remote settings. Global partnerships have led to the establishment of ophthalmology residency programs in countries where none previously existed. This development has led to the retention of trainees by giving them opportunities to serve their home country and have international support to expand training initiatives.

4. Rural development

Rural development is another component improving with the advent of distant collaborations. Eye centers such as the Aravind Eye Hospital and the LV Prasad Eye Institute have recruited vision technicians from the local communities to manage rural clinics. This has improved local employment prospects, retention, and vision monitoring data for remote populations.
Presently, over 108 vision centers exist, with 23 specifically in remote and tribal rural locations.5 Over the past years, the centers have undergone many changes that have incorporated general health and eye screenings, allowing for the growth of telemedicine. This has also reduced the number of patients from unnecessary travel to more advanced service centers until it is absolutely required.

5. Training

Training is another key aspect that global ophthalmology has significant potential to address. The use of teleophthalmology has substantially addressed the lack of continuous mentorship and learning by providing remote access to expert consultations. This can be useful in surgical complications or even to help teach trainees in an LMIC ophthalmology residency. In one study evaluating the diagnosis of retinopathy of prematurity by trainees in Mexico, tele-education significantly improved the accuracy of ROP diagnosis.6

Another example is the Scottish Eyecare Integration Project, which is a global repository of imaging and clinical data.

This has led to the creation of two online master’s degree courses that help educate both ophthalmologists and allied-health professionals.7 Moreover, web-based training proved to be a vital tool in overcoming the travel restrictions posed during the COVID-19 pandemic. Organizations such as Cure Glaucoma Foundation and Cybersight were able to expand their operations and assist multiple trainees in continuing their education during this period.
It is important to note drawbacks to online learning, including longer preparation time for educators, issues with internet connectivity, difficulty in reaching technical support, and the lack of interpersonal networking that occurs with in-person discussions.7,8 Despite these drawbacks, the flexibility of tele-education has much to offer in under-served settings. Tele-education through the development of global ophthalmology as a field has an important role in standardizing education and improving competency.9

The role of the ophthalmologist in global health

The function of a global ophthalmologist in the context of international health has undergone a transformation, placing significant emphasis on capacity building. In the past, the common practice among ophthalmologists was for surgeons to perform a high volume of surgeries within a restricted time frame, termed “delivering care.”10 This, however, left patients reliant on foreign aid instead of building resources that could be accessed locally any time of the year.
Current initiatives in ophthalmology have contributed to establishing a more ethical role for ophthalmologists from developed countries interested in practicing globally. More specifically, the role of an ophthalmologist from a developed country can be multifaceted if focused on population health. Gaining knowledge about the healthcare model and delivery system can provide information for systemic solutions, elevating local and global efforts in addressing needless blindness.

Mentorship opportunities

An important role that can be served by more senior ophthalmologists is that of a surgeon mentor and educator.10 Knowledge transfer continues to be a growing arm of global ophthalmology as technology helps bridge the divide created by physical barriers. Global ophthalmologists can be valuable in disseminating updated clinical guidelines and applying research findings which ultimately improve the quality of care.

Surgery

Alternatively, surgeons from developing nations can also learn from ophthalmologists abroad. Surgical skills such as manual small-incision cataract surgery (MSICS), pterygium surgery, and many others can be practiced in higher volume in developing countries to help serve under-resourced patients back home.
Additionally, the experiences gained in navigating cases within resource-constrained settings can offer valuable insights into the issue of waste generation in developing nations, where accountability for essential resources may be lacking.

Research collaborations

Research can also be a very important field to advance in global settings. Global ophthalmologists can help build academic collaborations between institutes in developing nations and those in developed countries.
This can help identify effective interventions, encourage industry support, build convenient platforms for ethical clinical trials, and ultimately build on the knowledge that will scientifically characterize and support local communities.
From a public health standpoint, the development of research collaborations can diversify scientific perspectives, as resources are built to help local physicians who are culturally aware and knowledgeable about their environment design and interpret study findings.

Delivery of care

Lastly, delivery of care continues to be a needed role that can help support regions with a critical need for ophthalmologists. In parts of Sub-Saharan Africa, there are, on average, only 2.5 ophthalmologists per million people.11,12
Latin America is another place that has experienced poor distribution of ophthalmologists.13 In one study, it was estimated that the number of ophthalmologists per million people ranges from 3.7 in low-income countries to 76.2 in high-income countries, highlighting significant disparities in staffing.13
Organizations such as Orbis, the flying eye hospital, offer opportunities for physicians with at least 5 years of experience after completion of academic training to conduct surgeries in underserved settings. International training has also been implemented in several residency programs, allowing trainees to have early immersion in global health.
Experiences range from 2 weeks to 1 month, in which trainees may perform supervised surgeries or be able to learn from eyecare systems in other regions outside of the US. Global ophthalmology fellowships offer additional sub-specialization that is individualized to the trainee’s interest and can be academic in nature.

Reasons to consider global ophthalmology

International service that is focused on capacity-building can be a significantly meaningful activity for both trainees and experienced clinicians. At every stage, there are valuable pearls to be learned, as it is never too early or too late to contribute in this field. For a trainee, it can be an eye-opening experience that gives them a higher purpose for learning their skillset. Learning diversity in cultures and systems early on can also develop inclusive thinking.
For more experienced ophthalmologists, training others can amplify the impact of curing blindness in the area. In exchange, there is much to be learned from local ophthalmologists as well with respect to improvising in limited-resource settings. The lifelong relationships that one builds in a global health setting are something that can serve to connect not just people but communities.

Global ophthalmology educational resources

A multitude of educational opportunities exist to help train aspiring global ophthalmologists.

Higher education

For those interested in global public health, the London School of Hygiene and Tropical Medicine (LSHTM) serves to offer a master’s education that is solely focused on eyecare issues in underserved settings. To complete a shorter curriculum, certificate courses in global health also exist.
Alternatively, master’s courses in population health or any other discipline of public health within the US can be modified to support an interest in ophthalmology. This path can help understand local disparities in eyecare.

Global ophthalmology fellowships are also unique opportunities for trainees to continue their formal understanding of global health.

These are usually 1-year long and offer a structured path to making connections with renowned eyecare institutions worldwide. Each fellowship is unique with the combination of partner training sites and curriculum. But common among all fellowships is the purpose of preparing fellows to deliver eyecare in low-resource settings.
Residency programs have also expanded global health opportunities for young trainees. This has come in the form of observerships and externships in global settings for senior resident trainees. However, residents can also set their own global ophthalmology rotations with international hospitals and organizations. Some rotations can involve surgical experience, but others may focus on the eyecare delivery model.

Conferences

International conferences offer a collaborative environment that is excellent for learning and networking with leading experts.
Conferences such as the ones listed below offer global perspectives:
These also offer skills labs and other niche topics that broaden the understanding of global ophthalmology in practice.

Online

Lastly, Cybersight is an online educational platform that offers online courses, webinars, and Eye-Q modules to help train professionals and keep them updated on the latest developments in ophthalmology.

Four tips for success in global ophthalmology

Global ophthalmology can be a fulfilling specialty for those interested in contributing to its development.
Some tips to help individuals overcome uncertainty and make their global health experience successful include:
  1. Learn about global health policies: Especially within one’s country of interest, to avoid being surprised by systemic changes. Like any country, the political landscape can determine policies affecting medical care. For those wanting to build more established relationships with a region, it is important to learn more about the stability of healthcare practice and how challenging it would be to build sustainable frameworks for delivering eyecare based on government regulations.
  2. Develop cultural competency prior to engaging with locals: This can start with establishing contact with community partners such as local physicians and other key stakeholders. Learning about local perceptions of eyecare from a cultural and religious viewpoint can significantly help shape the way care is delivered. Moreover, these insights can further strengthen trust and mutual respect for one another’s culture.
  3. Seek mentors with a variety of training backgrounds: This helps shape possibilities in global ophthalmology and means finding mentors from various subspecialties and those who have had formal and informal training in global health. Requesting to work with them in a global setting and building rapport can allow mentees to gain valuable resources and connections.
  4. Gain a strong foundation in global ophthalmology prior to going internationally: Diving straight into an international environment may seem to be a no-brainer, but ultimately, it is more effective to have an informed understanding of your role and purpose in an international setting. This means familiarizing with global health concepts and familiarizing oneself with the ethical delivery of care. Whether it be in the form of research, public health, business, or surgery, any background experience can be a significant resource for underserved communities.

Conclusion

Global ophthalmology plays an important role in addressing disparities in eyecare and improving access to treatment in low-resource settings. The focus on capacity building, collaborative partnerships, sustainable networks, and global ophthalmologists can significantly improve efforts in curing needless blindness worldwide.
Technology in the form of tele-education and teleophthalmology continues to pave the way to improving remote consultations, education, mentorship, and equity that was previously challenged by physical barriers. The efforts of global ophthalmologists in establishing international collaborations, conducting research, and providing training have significantly enhanced the field, leading to impactful outcomes at the population level.
  1. World Health Organization. WHO launches first World report on vision. World Health Organization. Published October 8, 2019. https://www.who.int/news/item/08-10-2019-who-launches-first-world-report-on-vision.
  2. Williams LB, Prakalapakorn SG, Ansari Z, Goldhardt R. Impact and Trends in Global Ophthalmology. Current Ophthalmology Reports. 2020;8(3):136-43.
  3. Yu M, Khan I. Sustainability in eyecare: Climate action in eyecare. Published August 4, 2021. https://www.eyenews.uk.com/features/ophthalmology/post/sustainability-in-eyecare-climate-action-in-eyecare.
  4. Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect costs associated with accessing eye care services as a barrier to service use in Ethiopia. Tropical Medicine & International Health. 2004;9(3):426-431.
  5. Rao GN. The Barrie Jones Lecture—Eye care for the neglected population: challenges and solutions. Eye. 2015;29(1):30-45.
  6. Patel SN, Martinez-Castellanos MA, Berrones-Medina D, et al. Assessment of a Tele-education System to Enhance Retinopathy of Prematurity Training by International Ophthalmologists-in-Training in Mexico. Ophthalmology. 2017;124(7):953-961.
  7. Al-Khaled T, Acaba-Berrocal L, Cole E, et al. Digital Education in Ophthalmology. Asia Pac J Ophthalmol (Phila). 2022;11(3):267-272.
  8. Kaup S, Jain R, Shivalli S, et al. Sustaining academics during COVID-19 pandemic: The role of online teaching-learning. Indian J Ophthalmol. 2020;68(6):1220-1221.
  9. Campbell JP, Swan R, Jonas K, et al. Implementation and evaluation of a tele-education system for the diagnosis of ophthalmic disease by international trainees. AMIA Annu Symp Proc. 2015;2015:366-75.
  10. Mott M. Global Ophthalmology. Eyenet Magazine. Published January 2018. https://www.aao.org/eyenet/article/global-ophthalmology-2.
  11. Dean WH, Buchan JC, Gichuhi S, et al. Ophthalmology training in sub-Saharan Africa: a scoping review. Eye. 2021;35(4):1066-83.
  12. Johnson GJ, Foster A. Training in community ophthalmology. International Ophthalmology. 1990;14(3):221-226.
  13. Serge R, Van Charles L, Lindsey W, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): Will we meet the needs? Br J Ophthalmol. 2020;104(4):588.
Rizul Naithani, DO
About Rizul Naithani, DO

Dr. Rizul Naithani is currently an ophthalmology research fellow at the Duke Eye Center. She is passionate about global health and is also completing her Master's in Public Health at UNC Gillings School of Global Public Health.

Rizul Naithani, DO
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