Eye specialist sees the big picture

Eye specialist sees the big picture
The eye is an architectural wonder, says Associate Professor Wong Hon Tym, who received the National Healthcare Group’s Outstanding Citizenship Award for his initiatives, including one that reduced crowding at specialist eye clinics.

Q:You have been an eye doctor for 16 years, choosing to specialise in ophthalmology soon after you graduated with a Bachelor of Medicine and Bachelor of Surgery in 1992. Now, you are the medical director of the National Healthcare Group Eye Institute at Tan Tock Seng Hospital (TTSH). What is it about this branch of medicine that fascinates you?

Well, first of all, we all know the importance of the eye. Many patients have told me that they would rate vision far over other aspects of life, such as the use of limbs, so I know I am dealing with something extremely important. The eye is also an architectural wonder - there is still so much we do not understand about it.

There are many nooks and crannies within the eyeball that we cannot see, so our understanding of eye diseases is not complete. But eye doctors here are very active in research, in trying to understand the mysterious organ, and how we can fix it when it goes wrong.

Whether you are a doctor or banker, it is exciting to be able to learn within your lifetime new things that can change the way you work, or in my case, be better able to treat eye conditions.

Q: What are some breakthroughs that have changed the way eye diseases are treated here?

There has been a huge evolution in the way that cataract surgery is performed here. Cataracts are a clouding of the lens of the eye, caused by the oxidation and degeneration of the lens proteins and fibres. The lens helps to focus light rays onto our retina, which is what helps us see clear images, and it should be completely transparent. But with ageing, it sometimes gets cloudy. This cloudiness makes the lens less able to transmit light, and this causes the patient to experience blurred vision.

Before the mid-1990s, the standard surgical technique involved squeezing the entire cataract out through a 10mm to 12mm wound which spanned almost half the length of the eye. But technology has allowed us to perform it more safely and efficiently. Now, doctors break the cataract into smaller pieces using ultrasound and, more recently, laser.

They then remove these fragments through a 2mm to 3mm wound, so no stitches are needed any more. Patient recovery time is also shortened significantly.

Q:Three years ago, you piloted an initiative at the National Healthcare Group's 1-Health facility in Ang Mo Kio that streamlines non-complex cataract surgery via a consistent surgical workflow. Patients now spend an average of 20 to 30 minutes in the operating theatre, from the time they enter to the time they leave - roughly a 20 per cent reduction from before. Can you tell us more about this, and why it will help?

Cataract surgery is the most common eye surgery performed in Singapore. And as our society ages rapidly, we anticipate that more such operations will be performed.

We must be well-oiled to take this load. The surgery is also very uniform - about 80 per cent of the cases are standard ones, which means the difficulty level of each patient is more or less the same. We owe it to these patients to be consistent in managing them. But if we work in a way that accommodates every preference of each surgeon, we will not be efficient.

Before the streamlining, the nurses and supporting staff in the theatre had to memorise the preferences of each doctor, such as whether he prefers to receive an instrument in the right hand or left, the lens he prefers to use the most, or the sequence of procedures he usually takes.

But with the streamlining and a fixed set of processes for this group of patients, the nurses have found that the operation is consistent and safe, with very few surprises. And in the end, you get a whole team that is in sync - always. It also allows our staff more time for patient interaction and reassurance. Our patients have responded very positively.

Q: Are you looking to roll out similar processes for other types of eye diseases?

Yes. This can only be implemented in procedures that are easily repeatable and with a very short turnover, like in the treatment of age-related macular degeneration. The disease affects the macula - a small zone near the centre of the retina and the part of the eye needed for sharp vision and for seeing straight ahead.

Patients may experience blurred central vision that gradually gets worse. In its severest form, it causes bleeding and swelling of the retina. And if not treated, it can even cause blindness. Its treatment involves the injection of medication into the eye. The intra-vitreal injection helps to reduce the swelling and bleeding.

Eye specialists here will soon be performing far more injections than cataract surgery, so we must make it as safe and efficient as possible for our patients.

I think that by the end of this year, we can expect a more systematic workflow. Q:Besides streamlining cataract surgery, you have also pioneered other initiatives that help reduce the crowding at the specialist eye clinics, freeing up resources for doctors to deal with more difficult cases. These successful initiatives won you the National Healthcare

Group's Outstanding Citizenship Award at a ceremony last week. Can you tell us how these initiatives help?

There are two main projects, both of which involve primary eye care provision in the community. The first relates to refining the inflow of patients into the specialist eye centre. Many patients crowd the eye clinics as they think that every eye condition must be treated by a specialist.

But we have found that about 20 per cent of the 130,000 outpatient visits we get here every year do not require specialist treatment.

So we started thinking about how we can ensure that the right care is delivered at the right venue to the right patient. And the answer is: through tele-ophthalmology.

Patients first have a retinal scan of their eyes taken at a polyclinic. This is facilitated by supervised optometrists, who conduct the examinations and transmit their images to eye doctors from the National Healthcare Group Eye Institute at TTSH for their opinion and management. This ensures that patients with more urgent needs can quickly come into our care, while those with mild conditions can receive treatments near their homes.

Since this was rolled out at the Hougang Polyclinic in 2011, and Toa Payoh Polyclinic last year, it has reduced unnecessary patient trips by up to 40 per cent.

Q: What about the second project?

The other project relates to the outflow of patients from the specialist eye clinic.

Many of our patients are reluctant to be discharged, and understandably so as there is still not much primary eye care available outside of the hospitals. Therefore, only 3 to 5 per cent of our patients end up being discharged from further specialist follow-up and many remain in our overcrowded clinics. My department has piloted a "step-down" clinic, called the stable eye condition clinic, to monitor and treat patients with straightforward and mild diseases.

This could include early cataracts, early age-related macular degeneration, and early diabetic eye disease. We have trained a team of optometrists in the hospital to monitor these patients, while under the supervision of an eye specialist. It has been running for about a year in TTSH, and we will soon be ready to transplant them out into the community.

Q: There are fewer than five guide dogs in Singapore. As a board member of the non-profit Guide Dogs Association of the Blind, what do you think are some obstacles to their widespread use?

Singapore is very good in screening, preventing and treating eye diseases.

But when it comes to patients who have already lost their eyesight, there are not enough social support and rehabilitative facilities for them. It was strange for me to hear that Singapore, as a First World nation, has only three or four guide dogs when it has been proven time and time again that they are so useful and life-changing for patients.

Things are a little better now, but guide dogs and their owners continue to face discrimination on many levels in society, from the man in the street to large corporations.

A lot of it is unintentional and some people are uninformed, but thanks to a growing number of allies, social media and the Islamic Religious Council of Singapore (Muis), who have clearly expressed their support, we hope that attitudes will change for the better.

Doc with a three-legged dog

Associate Professor Wong Hon Tym, 47, is medical director of the National Healthcare Group Eye Institute. He studies the eye and its functions, and treats diseases related to it.

But he also enjoys travelling, food and art; and loves dogs.

After graduating with a Bachelor of Medicine and Bachelor of Surgery from the National University of Singapore in 1992, Prof Wong obtained his fellowship from the Royal College of Surgeons of Edinburgh and his master's degree in Medicine in Ophthalmology in 1999.

Prof Wong has also been an active board member of the non-profit Guide Dogs Association of the Blind for the past three years. He considers his participation there as a natural progression of his work as an eye doctor.

"Singapore provides world class eye care, but in terms of rehabilitating a patient who has already lost his vision, more social support is needed," said Prof Wong, who is single.

At the association, he advises therapists on aspects of a patient's suitability for a guide dog, such as the extent of blindness and visual disability.

He also adopted a three-legged dog, Ari, from local animal welfare group Three Legs Good in December 2013.

"We went on a play date and found that we had good chemistry - I'm not a hyperactive person, and Ari is also quite chilled, so we don't bother each other," said Prof Wong. Ari, a mongrel, was found in October 2013 near the zoo in Mandai, and its left front paw was already missing.

Although Prof Wong did not know how Ari lost its paw, he was impressed by the dog's resilience. He said: "Ari may be disabled, but it doesn't know it. There was no 'sadness' after it lost the paw, and after the wound healed, it was up and running again.

"Its resilience is inspiring."


This article was first published on May 31, 2015.
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