In the first in a series of interviews by ECONA with RANZCO Younger Fellows, Sue Kweon spoke with A/Prof Chameen Samarawickrama, a consultant eye surgeon and chair of RANZCO’s Younger Fellows Advisory Group.
SK: Chameen, thank you for meeting with me today to talk about your work. Firstly, what made you choose ophthalmology as a career path?
CS: When I was an intern I actually wanted to do orthopedic surgery. But when I started doing the rotation through it, it just didn’t appeal to me and I switched to ophthalmology. The unique thing about ophthalmology is that it’s a combination of both medicine and surgery and we don’t get that often in medicine. Usually you’re either operating and you leave the medical management to other people, or, you’re involved only in medical management.
The more I delved into ophthalmology, the more I realized I liked it. Unlike many other kinds of surgery, it’s all microsurgery and requires a fine level of precision to get the best outcomes. Ophthalmology also appealed to how I think about solving problems, so it was a very good match for me.
SK: What made you choose the specialty you are in now?
CS: Being exposed to several world experts in anterior surgery early in my career really empowered me to become a confident young ophthalmologist. During and after my fellowships in Melbourne and London, I met a couple of surgical legends. When you see how their hands and brain work, it is just phenomenal! The cornea is approximately 500 microns thick but they can cut just 50 microns with a single glance of the blade. They make surgery look so easy, but actually the reverse is true. Observing them really motivated me. Their precision is a beautiful thing to watch and it is very reassuring to know this is the kind of skill behind the hands that perform microsurgery on our eyes.
SK: Chameen, what are your professional passions?
CS: I completed my PhD in 2012 and my research was focused on the pediatric optic nerve. I really enjoyed the experience and it was perhaps the most relaxed period of my life so far (laughs). So please enjoy your PhD life! It sounds very different to what I am doing right now, specializing in anterior eye health. You need to know what you are good at as well as what you enjoy doing. My PhD experience is really helping me now with my corneal glue research and teaching.
SK: You are chairing the RANZCO Younger Fellows’ Advisory Group. Could you briefly explain what it is and what you do?
CS: Just like ECONA, we created this group to empower and raise the voices of young ophthalmologists. The group represents the views and interests of Fellows within the first 10 years of obtaining their RANZCO Fellowship and is made up of representatives from Australia and New Zealand. Their opinions diversify and enrich future directions. I have ample opportunity to talk to other colleagues and attend meetings so I can unify the voice of these Younger Fellows and ensure that we play an active role in leading the future of ophthalmology.
SK: ECONA sees a wonderful opportunity for optometrists and ophthalmologists to foster strong, collaborative links from the very beginning of their careers, ultimately leading to better patient outcomes. Could you share your opinions about collaborative care?
CS: Collaborative care is the future and the direction we all need to pursue. Eye care especially is a team-based effort and hence we all need to think collaboratively. We have different skill sets and it is crucial that we utilize these to make sure we deliver the best eye care service for the public. We need to have an overarching goal. As an ophthalmologist, I really appreciate when an optometrist sends a letter with all the relevant information for a particular patient. Then I can start to think about possible treatment options even before I meet the patient.
SK: Can you go through what the key information is that you look for in a referral? Or what might be missing from some referrals?
CS: That’s a good question! The things that I look for in a referral are the vision, the pressure, and what the key problem is, i.e. the presenting complaint. I need to know which eyes are affected and the relevant medical history. So, for example, say someone’s got a case of proptosis. The relevant systemic condition is thyroid disease, so that’s the link that I’m looking for in the referral. And that relevant medical history is the thing that’s sometimes missing. It’s really important. For example in my anterior segment practice, keratoconus is a very common condition. The thing that I’m interested in is, are they atopic? Do they have allergies? That information is great to get in a referral.
SK: Given you would still go through medical history in your consult, how much value do you find in a detailed medical history in the referral?
CS: The thing that I’ve found is that patients need the information repeated multiple times. Let’s take keratoconus for example. Eye rubbing is a big problem. I love it when I say to a patient, you’ve got to stop rubbing your eyes, and they say, yes, my optometrist has told me that and I’ve been trying. Every time I see a patient I say the same thing: are you rubbing your eyes? You must stop rubbing them. They need that repetition, so the more times it’s explained, the better. If a referring optometrist has already gone through all of that with them, it really streamlines the process when they come to see me. They’ll say, my optometrist tells me that I’ve got keratoconus and I’ve also got hay fever, asthma, and eczema. This makes it very efficient on my end.
SK: In your practice, do you work closely with the referring optometrist at the pre or post surgery phases?
CS: I predominantly practice in Blacktown and also work in the Northwest area. We’ve got a really good group of optometrists who refer to us and who also have a lot of post-op involvement. For example, if a patient gets a monofocal intraocular lens and they need reading glasses, we refer patients back to the optometrist for their new glasses. We’ve got a great relationship with our referrers, and it works both ways, where we refer for specialty contact lenses like RGP or scleral lenses for keratoconus patients.
For advanced keratoconus patients, I know within my area which optometrists are comfortable with scleral contact lens fitting or RGPs, as it is not something that everyone does well. Patients who have a cross-linking procedure are often referred back to their optometrist to get contact lenses to optimize their vision. It’s critical that I see them around six months post-op, and they usually come in with their new contact lenses. After that, they usually return to me for their annual review.
SK: What is your preferred contact method for an urgent patient?
CS: It’s always best to call. It doesn’t necessarily need to be me, as long as you call the practice. Just pick up the phone – it’s easier, more efficient and just a nicer way to communicate. If there’s an emergency and I’m about to leave, I’m happy to stay behind to look after the patient. I’m also happy to text, and I’m comfortable giving my number out. If I’m not available, I can connect them to one of my colleagues who can fit the patient in and help them.
SK: We’re aware that many optometrists and ophthalmologists develop very close working relationships. How do you build a professional relationship with your referrers?
CS: Another great question! Apart from getting on the phone, I’m also a big believer in letters. I think they’re a great way to transfer information backward and forwards. Within our practice, we have information nights and social events. We’ve got a group of very loyal referrers and we know them because we’ve worked with them for years.
As well as talking on the phone and communicating via letters, our practice also sends out newsletters to our referrers to keep them updated with the latest developments in medical research. We read everything and turn it into a newsletter that’s more easily digestible so our referrers stay fully up to date. But we love the phone! Our referrers call us at the practice and say I’ve got a keratitis, can you see them urgently, and we will, or, if I’m not there myself, my colleagues can start initial management and I’ll follow up the next day.
SK: You work at a private practice currently. Have you ever worked in the public system and how does the care differ? Do you offer any low cost surgical options for patients of limited means?
CS: The quality of care is a little bit different. In the private system, patients get seen and treated by the specialist sooner compared to the public system, but it’s more expensive. In the public system, surgery is free, which is clearly an advantage, but the downside is that it takes longer to get through the system. The wait times could be a year or sometimes longer. There are also differences in quality of care. In the public system, the surgery is done by the registrar or Fellow, rather than by the consultant, unless it gets to a certain complexity, when the consultant has to take over.
With cataract surgery, if you look at the international literature, the average complication rate for public hospitals is about 2%. That’s the rupture rate, where the patient needs further intervention. Whereas in private practice, the rate is about half a percent. That’s a four-fold difference. But the numbers are still low – 2% is still a low rate. So, yes, there is a difference, but the difference is small if the pathology is minor. If there is major pathology, it becomes trickier and there is more thought that goes into deciding how to proceed.
To answer the second half of your question, we always offer discounted prices for people who have financial distress such as pensioners. I think most surgeons do. We try to help where we can.
SK: What is important to you outside of work?
CS: I always try to balance my RANZCO work, surgery and research, but having a young family needs a considerable amount of time and effort (chuckles). Family is the most important source of my happiness. As soon as I arrive home, I consciously do not open my email, which is actually very hard, so I can focus on my children.
SK: You seem very content and energized, how do you do that?
CS: I really enjoy what I am doing. I wear several hats in my academic, surgical, and research work and it really broadens the way I think. I believe this diverse experience serves me well in enjoying my life in general and allows me to be agile.
SK: Where do you see yourself in 20 years time?
CS: Interesting question, at this age, because I am young and still honing my surgical skills. I think there is a stage for all doctors, especially surgeons, when their hands do not work as they used to. Everyone is different but once I reach that stage, there are many other ways to contribute. I would hope to focus more on research and academic work at that stage of my life. I hope, by then, that I will have much to share with my students and registrars and that they will keep me ‘current’.
SK: Chameen, thank you so much for chatting with me today. We are greatly looking forward to having you on our Super Sunday program in October this year!
Sue Kweon is a founder member of the Early Career Optometrists NSW/ACT (ECONA) committee and co-chair of the ECONA Student Engagement subcommittee.
Dr Chameen Samarwickrama is a Consultant Eye Surgeon with expertise in corneal and anterior segment surgery, complex corneal diseases, keratoconus, corneal transplantation, cataract surgery and laser eye surgery. He currently works at Nexus Eyecare Blacktown, Nexus Eyecare Norwest and Concord Eye Specialists. He is also Associate Professor at the University of Sydney.
Having completed his ophthalmology training at Sydney Eye Hospital, he went on to complete his first advanced specialization in cornea and laser eye surgery at the Royal Victorian Eye and Ear Hospital (Melbourne). He was subsequently selected to complete a second fellowship at the acclaimed Moorfields Eye Hospital (London), where he worked with doyens in the field of corneal surgery including Bruce Allan, Stephen Tuft and Mark Wilkins.
Named one of the ‘Top 5’ Young Scientists of 2019, Chameen has made major contributions to ophthalmology research and is a leading clinician-scientist in his field.
Chameen is one of the featured speakers on the Super Sunday conference program on 10th October. Early Bird registration open until July 11th.