Can you speak about why you first decided to become a doctor?
Yes. When I was 12 I had a near fatal injury falling from a tree and a wonderful general surgeon at the Sunderland Royal Infirmary saved my life. I needed major abdominal surgery to repair a ruptured liver and lacerated kidney, and for good measure I'd also fractured my spine. Mr Banerjee was just amazing. He was a former army surgeon and so how lucky was I to be in Sunderland being operated on by a trauma surgeon who had so much experience dealing with these types of major abdominal injuries? When he discharged me from the hospital many weeks later he asked, “What would you like to do when you grow up?” Well, what was I going to say to that? “I want to be a doctor!” I replied without hesitation.
What are some of the main obstacles you have faced in your career?
Honestly, I really don't feel that I've encountered any obstacles at all. I've had a truly blessed and privileged career. Looking at the way it all panned out, I really couldn't have made it up! When I tell people about the various posts I was appointed to and their timing, how I was in the right place at the right time with the right background for each individual step of my career, I consider that I’ve been blessed.
Can you describe one of your proudest professional moments?
By far the greatest moment in my professional career was being appointed as a consultant to the Corneal, Cataract and Refractive Services at Moorfields in July 1995. I remember that day very well. Back then consultant jobs at Moorfields were very hard to get and I was very pleased – and relieved - to have been appointed. I remember going home and telling my wife who said, “We both knew you were going to become a consultant somewhere, at some stage, but I didn't think it would be at Moorfields!”
What are some of the changes to refractive/cataract surgery you have witnessed through your career?
I started my first SHO (Senior House Officer) ophthalmology job in 1986. At that time, there were still some centers doing intra-capsular cataract surgery with cryo-extraction. Following many years of extra-capsular surgery, phacoemulsification came in – and small incision cataract surgery – which was a complete paradigm shift. That said, the incisions really weren't all that small back then because we couldn't fold the intraocular lenses. Then, of course, lens technology caught up and we were able to use foldable and injectable lens implants that can now go through 2.4 millimeter incisions (or less) – minimally invasive with no sutures at all. That was just an amazing step forward.
In terms of refractive surgery, when I started in ophthalmology in 1986 radial keratotomy (RK) and other corneal incisional techniques were the main type of refractive procedures being performed, although admittedly by relatively few ophthalmologists in the United Kingdom. Radial keratotomy had first been described by Professor Sato in Japan in the 1930s to treat keratoconus, but it then became a more common procedure in Russia and the United States in the 70s and 80s, to treat myopia in the main. Refractive (and therapeutic) use of excimer laser technology was developed in the late ‘80s and early ‘90s and very quickly replaced radial keratotomy, being a much safer and more predictable form of computer-controlled corneal refractive surgery.
Of course, the very basic early excimer laser photo-refractive keratectomy (PRK) procedures have been completely transformed since I carried out the first PRK treatment in November 1989 as a research fellow at St Thomas’ Hospital, London, now being replaced with LASIK, LASEK, and Trans-PRK. We could only treat relatively small areas of the central cornea initially, using only four millimeter diameter zones (smaller than the diameter of most pupils), then five and then six millimeter zones. Flying spot lasers were then introduced which meant that we could cover a much larger area of the cornea. We also now have detailed analysis of the entire optics of the human eye using wavefront aberrometry, and, when combined with sophisticated 6 level tracking systems, we can treat exactly the right part (and a more than adequate area) of the cornea. All of this has come into play since the late ‘80s.
Looking forward, are there any specific developments that you would still like to see in the space?
Patients often ask me, “Should I wait a bit longer for surgery because there's always new technology being developed.” But with laser surgery on the cornea, I think it's reached a very high pinnacle already. One thing worth mentioning is that – with all of the algorithms, the high-tech lasers, the fantastic tracking systems and the wavefront aberrometry analysis that we now have – I still can't see us getting around the problem of individual corneal wound healing. Because no matter what you do with the most amazing technology available, how do you know exactly how an individual cornea is going to heal? And basically, you don't.
‘Back in the day’ our original publications – in the late ‘80s and early ‘90s – highlighted the considerable variability in refractive outcomes because of the relatively unpredictable way in which individual corneas healed. Since then, we've done a lot of work to try to control this variable, including algorithm adjustment using multivariate analysis and vastly improved laser technology, but ultimately we're left with a biological substrate, and I think there's not much further to go with that. If we are going to get even better results with predictability approaching 100 percent, I believe we will have to rely on a completely different type of technology – another paradigm shift. Unfortunately, I’m not able to predict what that would look like.
What are your thoughts on the integration of artificial intelligence into laser eye surgery?
With all of the imaging that we do in Medicine and Surgery today, anything with a digitized image can now be analyzed to the nth degree using AI. And then, of course, machine learning – and now deep learning – will allow us to find subtle differences in images that we previously might have missed or glossed over. This is very important in screening, early diagnosis and management, and in the treatment of corneal, cataract, refractive and retinal conditions AI comes into its own of course.
Back in September 2024, Lord Ara Darzi produced an amazing report on the state of the NHS in England, and part of this report focused on looking at community diagnostic hubs and using AI to help with diagnostics. There's been a lot of debate in both the House of Lords and the Houses of Parliament about AI, and I think they all agree that it's an amazing technology. The general consensus is that it just needs good regulation. In Ophthalmology and anything that involves analyzing digitized images, it's got a tremendous role to play.
Which mentors have influenced your career?
There are so many people who have been so helpful to me, but some have been absolutely instrumental in my career:
I was fortunate to gain a first in Optometry in 1978 and started work at Moorfields as a pre-registered Optometry student. Arthur Steele was one of the senior consultants in the Corneal and Cataract services, and the overall head of The Optometry Department. When I expressed an interest in pursuing Medicine, he acted, in a sense, as devil's advocate, and asked me why I wanted to change when I was already qualified as an optometrist. I ‘dug my heels in’ and answered all of his questions – hopefully convincingly - and he then actually took the trouble to write the reference on my UCCA (now UCAS) form and I got a place at University College London medical school. That was a truly amazing milestone and a turning point for me. I had no idea of course that ultimately I would return to Moorfields as a senior registrar, as a Corneal Fellow to Arthur Steele and then be appointed as a consultant in the hospital prior to Arthur’s retirement in 1995. I still do his NHS corneal clinic on Wednesday afternoons! Sadly, he passed away just short of his 84th birthday in 2019 and I still miss him – he was quite a character!
Then, I had a wonderful anatomy professor at UCLH called John Pegington. He was a remarkable man, who also sadly passed away some years ago. He had taught me in my first year at medical school and he then gave me a much coveted anatomy demonstrator post after I’d qualified five years later (these posts normally went to the budding orthopods!). Anatomy demonstrating was a very good way to get through general primary FRCS, which had a 10 percent pass rate.
Another key mentor in my career was John Shilling, a wonderful anterior segment surgeon at St Thomas’ Hospital in London who also had a specialist interest in vitreo-retinal surgery. He gave me that first, all-important SHO job in Ophthalmology commencing May 1986. It all went on from there. Around six months later I got onto the 3-year St. Thomas’ rotation where my first boss was Malcolm Kerr Muir, who was a truly amazing ophthalmologist and is also sadly missed. A sign that we are most of the way through our careers is when most of our former teachers have passed away!
I used to play a lot of squash in medical school, often either playing or training every day. I played for UCLH, London University, the Hospitals Cup and Cumberland Cup teams, and even entered The Middlesex Open a couple of times (didn’t get very far!). Malcolm was a very keen sportsman and he asked me if I would give him some squash coaching. So one Sunday morning we duly played squash and while getting dressed he said: “Now, you did an Optometry degree didn’t you? We've got a new laser coming, which is right up your street because it might possibly be used for corneal refractive surgery. Would you like to get involved in the research with this new ‘excimer’ laser – I think it’s called?” Of course I said yes (please) and he then introduced me to John Marshall.” John, who is now a good friend, and as many colleagues reading this will know, is an absolute ‘tour de force’ as far as ophthalmic research is concerned. It was truly a huge privilege to be his (and Malcolm’s) research fellow involved in the early excimer laser laboratory studies, then the clinical therapeutic applications and finally laser refractive surgery itself. I, and my family, owe a great debt to him, and all of the mentors who shaped my career.
It’s amazing, really, how these things can happen to change a career (and a life). Just by sitting in a changing room having played squash with a senior colleague. It’s almost the equivalent of something that’s been designed on the back of a cigarette pack.
What advice would you give to ophthalmologists starting out on their career journeys?
I would say be very enthusiastic in everything you do and in all branches or subspecialties of Ophthalmology, and keep an open mind as to what you might like to do later in your career. Be very enthusiastic when working with your mentors and with any of the doctors and colleagues who are training you in clinics and theatres.
And then, perhaps getting involved in clinical studies – anything that your consultant is working on or interested in – and helping with those studies. This may even be retrospective surveys (yes – I know!) - I did quite a few of those in the past.
I would also potentially think about undertaking a more formal period of research along the way. A two-year MD or, more commonly now, a three-year PhD program, before you finally end up in your chosen sub-specialist subject. This type of research can represent a valuable period of time that you might not be able to repeat (as Malcolm Kerr Muir told me in 1988) – certainly an opportunity which won’t necessarily occur again once you are appointed as a consultant. You could have a protected period of time where you can really get involved in research and decide whether you might want to follow a research career or perhaps work in the same clinical area later. Skills learned in formal research will stand you in very good stead in your career.
Do you have any hobbies outside of ophthalmology?
My dad – rest his soul – gave me his old 1930s Dakora camera (which had bellows!), when I was 10 or 11, and I've been keen on photography ever since. I have had a range of cameras over the years and now have a very high-end Canon 1DX plus all of the usual lenses and accessories. I get more involved with my photography on holidays when I’ve got more time and often more interesting vistas… My clinic in Wimpole Street looks like a travel agents’ office with all of my favourite photographs!.
When we did the first excimer laser trials in 1988/89 at St Thomas', I did all the photography of the pre-op and post-laser patients. This included standardised flash photography to record very subtle anterior stromal haze in the lasered corneas, which wasn't very easy to see in all patients by just looking at the slit lamp. So my photography experience came in very handy then.
Is there anything else you would like to add?
I would like to say what a privilege it has been to have had the opportunities I have had going back to my first degree in Optometry (1978), qualifying in Medicine (1984) and then in Ophthalmic Surgery (FRCS, FRCOphth, 1988). My training has allowed me to treat thousands of patients over the years, and seeing how many of these patients have benefitted from all of the developments that have led to modern ophthalmic surgery is truly a blessing. I have also had the privilege of working with many talented colleagues including all of those SHOs, SpRs and Fellows I have helped to train. I think I’ve lived the dream! Thank you.
