Talking heads

It’s time to stretch

Ahead of his first article for Vision Now, we talk to Stephen Lash about his journey from optometrist to vitreo-retinal specialist via an MBA and a year Down Under...

VN: What has driven your career journey decisions so far?

SL: Optometry was my first decision driven by a love of people and science – but I was always drawn more to the medical side. Would my job be even more interesting if I could diagnose and treat people? So I worked hard, won a prize, applied and got in to medical school.

Qualifying in medicine was the easy bit.

Next came more study, more delayed gratification and more progress. I needed to ‘fix’ things and so was drawn towards vitreo-retinal [VR] surgery. I was also interested in the future of medicine and how to perhaps influence healthcare in the wider arena. So I embarked on an MBA. I sat my last exam in January 2009, handed in my dissertation and then left for my VR Fellowship in

Melbourne, Australia, two days later.

Australia was an incredible year. I learned VR surgery, met lifelong friends and lived life ‘in colour’ with my growing family. When I returned to the UK to became a consultant, I thought I would finally feel settled – but I didn’t fit very well in a large bureaucratic organisation where I could see inefficiencies. I tried to make changes from within, then attempted to build a hospital. I got a long way down the road, raising £1.2m in investment, but ultimately the venture failed. It was a huge journey and I learned a lot along the way. I then worked briefly with New Medica/Specsavers but I was too much of an idealist. Next was a role with Optetgra as medical director – but the world would not quite fit my view of how medicine should roll out. At 50, I have finally realised that I want less – not more. I want to simplify and get back to what I really love doing, which is surgery and the reason I started my journey in the first place. I remain curious, however, and open to new challenges and opportunities.

VN: As a retina specialist, what’s your biggest pressure at the moment?

SL: Covid has had an immense impact on healthcare, some of it for the better. It has forced us into new ways of working. In surgical retina, the world is in evolution – but in other areas there is revolution given some of the huge demands and exponential growth. I really feel for my medical retinal and glaucoma colleagues. The pressure remains to deliver excellent care and excellent training, whilst using limited resources efficiently but in a risk averse environment that’s increasingly consumerist and demanding. All this pulls us in different directions. Perhaps

Covid has helped shift this risk aversion in a sensible direction. Who is the customer of the NHS? The individual or the population? Healthcare looks very different even when considering this basic understanding or assumption.

VN: How has telemedicine affected your work?

SL: Telemedicine has not, but virtual working, reviewing scans, speaking to patients on the telephone absolutely has. It is critical we get people in for surgery in a timely manner. The backlog has facilitated a perhaps more balanced view to risk, if we are to treat as many people as we can. It is not as ‘safe’ with current technology as we are face-toface in clinic and undertake direct examination, but I could see a time very soon when technology has improved, imaging is more complete and chat bots sort and stream patients.

VN: Is artificial intelligence (AI) making an impact in your work – and will it affect how independent practices work down the line?

SL: AI will make a huge impact in screening initially, but then it will inevitably grow in diagnostics and decision-making. I can see doctors working within a suite of technology, almost as the conductor of a team of technologists. Robotic surgery is here, but in ophthalmology I think it will more likely enable surgeons to perform surgery they cannot do at present due to physiological limitations. Sub-retinal drug delivery in stem cell or gene therapy is a good example. I still think that by the time the robot is positioned and set up and prepped, I am already finishing my phaco vity peel and remember the demand argument from earlier. For long complex surgery in other areas, it is already having an impact.

VN: How will independent practices engage with NHS primary and secondary healthcare services in the near future?

SL: The opportunity is clear: we need ‘super trained’ optometrists in the community stepping into the demand gap.

Optometrists have the training and access to kit, and I would encourage all to consider additional training in therapeutics and diagnostics, independent prescribing, glaucoma, age-related macular degeneration [AMD], cataract assessment and post-operative follow-up. Refraction will become increasingly automated as technology improves. It’s time to stretch.

VN: What is the most pressing eye health issue of the day, and how can independents help?

SL: There is huge demand in glaucoma and

AMD. With glaucoma, it is spotting the few patients who will rapidly lose sight amongst the many in whom it will never interfere with life. Early detection, monitoring and ensuring those who need surgery or laser get it in a timely fashion.

In cataract, we will increasingly see optometrists reviewing, referring and then reviewing post-surgery. We will certainly need better IT links between secondary care and optometrists, and electronic records that work and ensure the age-old issue of ‘referral, treatment and absolutely no feedback’ ends. Noone can improve in the dark, and refine their skills without feedback.