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Ophthalmic Update from the Middle East and North Africa

One thing that a crisis is good for is spurring innovation — and that’s certainly been the case in the field of ophthalmology recently. From changes in glaucoma management to the advent of telemedicine, the ophthalmic industry has had to rapidly adapt to a changing market while continuing to meet patients’ needs. 

The Middle East and North Africa have proved to be resilient in the face of COVID-19, so they’re emerging from the pandemic faster than many other regions. Because of that, they prove an interesting testing ground for the future of the industry and may be a bellwether for ophthalmology in general. 

PIE magazine CEO Matt Young spoke with Bassem Bouhabib, VP of international sales at Iridex, based in Lebanon; Dr. Ziad Khoueir, an ophthalmologist also based in Lebanon; and Dr. Sana Saydi, an ophthalmologist based in Tunisia. 

Changes in Glaucoma Treatment

Ophthalmic Update from the Middle East and North Africa
Lasers can help relieve pressure in more than one way.

Dr. Khoueir is a glaucoma specialist, and discussed the complications of managing glaucoma treatment during a period when doctors and patients are trying to see each other as little as possible. Glaucoma treatment, however, can’t wait as high intraocular pressure (IOP) can damage ocular nerves. 

Even before the pandemic, changes were underway in glaucoma treatments. “During the last five to ten years, there was a huge revolution in the way we treat and manage our patients,” said Dr. Khoueir. These included laser therapies, glaucoma pressure valves and more. The treatments that don’t require lots of follow-up may take center stage. 

Trabeculectomy is still considered the “gold standard” of IOP management, Dr. Khoueir said. But with potential complications and intensive follow-up procedures, it may not be the most desirable when dealing with a pandemic. 

“I think there was a shift towards certain types of procedures that do not require a very intensive follow-up. This is where future developments in terms of glaucoma management will happen whether it’s surgical, laser or something else,” he said.

He suggested micropulse laser therapy as a solid option to bridge the gap between doctor’s visits. “Why not do micropulse? It’s going to probably lower the pressure for the next month or so and this will give us some time to breathe. If the patient will need surgery afterwards, the circumstances will be better and if the micropulse works it’s a win-win situation.”

Mr. Bouhabib followed suit with Dr. Khoueir’s statement, and noted a specific example. “I think we have a solution because the transscleral laser therapy has a good result on lowering the IOP, so the return-on-investment on millimeters of mercury drop and IOP is very favorable — and it’s fast as well as minimally-invasive.”

He also noted that, following micropulse laser therapy, patients need to follow-up with a doctor a month later rather than two weeks later for invasive surgeries — a boon for doctors and patients alike, as it keeps face-to-face contact to a minimum. 

Dr. Saydi further concurred that minimally-invasive treatments for glaucoma represented a step in the right direction. “I think the coronavirus may help to accelerate big changes like glaucoma surgery. People are going to automatically choose non-invasive techniques over classical and invasive techniques just to get adapted to the situation.”

Simply put, the short-term, simple solutions that are feasible during a pandemic may indeed be the way forward when the pandemic is over — or at least an alternate way forward. 

That doesn’t mean trabeculectomy will go the way of the dodo anytime soon — it will retain the title for some time according to Dr. Khoueir, largely because of its cost and ease. “For trabeculectomy to lose its gold standard, it’s going to take a lot of time, a lot of randomized controlled trials and also there is the cost issue. This is something that you should not forget — for trabeculectomy you only need a couple of sutures and that’s about it. You’re not using implants,” he said. 

He continued, “I practice ophthalmology in a developing country and cost is a big issue. You know plugging in implants that cost $1000, $2000 or $3000 and up is expensive. At the end of the day, from a global perspective, will all glaucoma patients be able to get access to this in the near future?”

Any sea change takes time, but it’s good to know there are options on the table. 

Telemedicine: The New Buzzword

Ophthalmic Update from the Middle East and North Africa
House calls are even more obsolete now.

The ophthalmic industry has made much ado about telemedicine, which represents another potential long-term change to the industry. Much of the small stuff that previously took office time — data sharing, surgery prep, even consultations and assessment — has been shifted to telemedicine. While it is impossible for all of ophthalmology to be done remotely, the trend doesn’t seem  to be abating. 

Mr. Bouhabib sees it as an opportunity for the industry. “I see how it is important nowadays for people to manage to test themselves remotely — either virtually or using more portable devices that they can use at home or they can use in close communities within a family or certain community. They can make the diagnosis online or with those small gadgets and, if possible, to do the treatment themselves.”

A tonometer, for example, could be used by a patient at home to measure their IOP and then report the information to a doctor. This could be a huge time-saver for every party involved — as long as the patient knows how to make the measurement correctly. 

The caveat, however, may be red tape. Mr. Bouhabib noted that changes would require significant amounts of legislation and regulation, so the change may take some time. 

Dr. Saydi isn’t so sanguine on the future of telemedicine, and sees it playing a more minor role. “Telemedicine won’t be easy for ophthalmologists because we just need to see to judge, to do the diagnosis and to manage this disease — but we can always try,” she said. 

“We are starting to try telemedicine for coronavirus for retinal diseases. So some people can use a retina graph that an ophthalmologist created, and they may just learn to take retina fundus photographs. Then the patient just sends them to the ophthalmologist to observe and decide if the patients stay at home and get controlled in a few months, or if they just should get to a clinic. This process can then give them the time of the meeting.” 

She specified that the practice would be relatively specialized. “This is for retinal diseases,” she said. “In other fields I don’t think that it will be really easy to do telemedicine.”

What’s Next as the Panic Subsides?

Ophthalmic Update from the Middle East and North Africa
Time to move forward in the Middle East and north Africa. 

All three interviewees noted that things were beginning to get somewhat back to normal — clinics were re-opening and people had a chance to catch their breath. So what’s next?

Major conferences, like the World Ophthalmology Conference (WOC 2020), will still be held — but online rather than in person, as was intended in Cape Town, South Africa. 

Mr. Bouhabib has done considerable charity work in ophthalmology in sub-Saharan Africa, and noted that more needs to be done. “I was so happy to learn that WOC in Capetown wasn’t canceled but it’s switched to online because really, especially those doctors in sub-Saharan Africa, they need that meeting to improve their skills, to educate themselves,” he said. 

“It is our duty as industry players to support and make equipment available for them. So our message is keep it up — we are on board with you in Africa. We know how difficult it is to treat and to give the proper care for patients. We’re trying from many humanitarian missions to give them special prices or even free of charge devices to treat the patients and we would continue doing that because they deserve it and they need it.”

Crises end, and this one is no different. The world will hopefully emerge kinder, wiser and smarter. That certainly seems to be the case, partially in thanks to these three key players. Cheers to them. 

Editor’s Note: This story is part of the continuing “Q&A from Quarantine” series of CAKE Talks, where Matt Young (CEO of Media MICE and Publisher of PIE and CAKE magazines), during the time of COVID-19 lockdown reached out to KOLs and industry friends to evaluate and discuss the impact of this pandemic to the ophthalmic world.

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