When I was a boy in Iraq, my grandmother told me that Babylon was where the world first learned to write things down. The astronomers there mapped the sky on clay tablets. The physicians wrote their diagnoses in cuneiform. They believed knowledge had to outlive the person carrying it. I think about this a lot, especially when I am traveling.

For the last 18 months I have been moving between two worlds. One is a German operating theater, where the lights are calibrated, the IOL inventory is barcoded, and the next case starts when a button is pressed. The other is a tent, or a converted classroom, or a borrowed clinic somewhere in Iraq, Morocco, Egypt, or India, where the lights sometimes flicker and the patient in front of you may have been waiting there since before dawn or since before the war.

It is the same job. I keep telling myself it is the same job.

From Babylon to Berlin

I am a product of European ophthalmology. My training is German and Swiss. My fellowship was British. My board is European, my surgical fellowship American. The precision with which I was taught to operate the half-millimeter tolerances, the post-op metrics, the audit culture is something I will never apologize for and never give up.

But I am also Iraqi. I grew up close enough to Babylon that the word “civilization” was never an abstraction; it was a place name. When I started doing humanitarian missions a few years ago, I expected to feel like a visitor. Instead, what I kept feeling was that the disease in front of me was the same disease I had just left in Düsseldorf. Only this version of the disease was seen at a later stage. Much later.

Cataracts that should have come out at 4/10 vision were instead coming out at hand motions. Diabetic retinopathy that we manage in Germany with quarterly anti-VEGF injections was reaching me as tractional detachments. Dry AMD that I would have entered into a clinical pathway at the early stage was already, by the time I saw the patient, a story about grandchildren whose faces had become blurry shapes years ago.

The lesson is not that the missions need more surgeons. The lesson is that, by the time most of the world meets an ophthalmologist, surgery is already the consolation prize.

Fifty before lunch

In total, I have personally performed over seven hundred surgeries during missions in the past 18 months. The number sounds dramatic. It is also, in context, almost beside the point.

What we have been trying to build is not a parade of itinerant surgeons but a system. Triage clinics that begin two days before the operating starts, so that the wrong patients are gently turned away and the right ones are ready. Parallel theaters with shared scrub teams, standardized IOL stocks, pre-printed consent forms in the local language. A defined pathway from the slit lamp to recovery so that fifty cataracts before lunch is not a miracle, it is a Tuesday.

There is a particular kind of focus that the high-volume day demands. You stop thinking about the case in front of you as one of 50, and you start thinking about it the way you would think about your only patient that morning, because for the patient it is a major event in their lives. The fatigue catches up later, usually on the drive back to wherever we are sleeping.

The harder, slower work is the part you cannot capture in photographs. Every mission ends with a named local surgeon - usually two - who can run the next clinic without us. We leave behind the protocols, the audit forms, the suppliers, and sometimes the equipment. The mission is a success only when the next mission to that town no longer needs us.

I learned this discipline, frankly, from the German system. I am simply applying it where it has historically been considered impossible.

The space between healthy and lost

The missions have changed how I think about my Tuesdays in Germany too.

The phrase that haunts me most in the consulting room is "wait and watch." We say it to patients with intermediate AMD. We say it to patients with early diabetic macular changes. We say it to parents of children with progressing myopia. But what we really mean is: we have nothing safe to offer you yet, so come back when things are worse.

That is the gap I have spent the last few years trying to close.

Photobiomodulation - PBM to those of us who use it - is a non-thermal therapy that delivers red and near-infrared light, in the 630–800 nm window, to the retina. It does not burn anything. It works at the level of the mitochondria, where cytochrome c oxidase absorbs the photons and the cell responds with more ATP, less oxidative stress, and a quieter inflammatory signal. In early dry AMD it is now the first regenerative modality with regulatory approval. The clinical signal is modest, but it exists and, crucially, it exists before photoreceptors are gone.

Subthreshold nanosecond laser (SNL) is the same idea from a different angle: a very short, very low-energy pulse that does not coagulate the retina, but seems to nudge the RPE into self-repair. Our Cologne cohort, published in 2021, looked at 64 treated eyes against 77 controls in early and intermediate AMD, and saw a measurable reduction in drusen area and number at six months. It is not a cure. It is something to do, safely, in the years when we used to have nothing.

I wrote a review of photobiomodulation last year, with colleagues from Düsseldorf and from Babylon, because I wanted to put a fair, sober summary of the evidence in front of clinicians who, like me, were tired of telling people "wait and watch."

What the missions taught the laboratory

The strange truth is that you can feel the absence of an early-intervention therapy more clearly in a rural clinic in Iraq than you can in a modern clinic in Berlin. In Berlin, "wait and watch" is annoying, an inconvenience. But in Babylon, "wait and watch" often means go home and lose your sight, because the patient cannot reasonably come back. The further the patient lives from a referral center, the more catastrophic our lack of an early-stage tool becomes.

This is the real argument, I think, for bringing modalities like PBM and SNL not only into European retina clinics but eventually into the protocols of the missions themselves. They are non-invasive. They are scalable. They do not require an operating theater. They are exactly the kind of tools that a sustainable, locally run program could one day absorb.

We are not there yet. The evidence base is still maturing and the hardware is still expensive. But the direction is clear, and the clinical urgency — for me — is sharpest in the places furthest from the major teaching hospitals.

Being named to The Ophthalmologist’s Power List this year was, in some ways, unsettling. I am 35. I do not feel finished. What I have come to believe, though, is that the laboratory in Germany and the operating tent in Babylon are not two careers running in parallel. They are the same patient, met at different points in their disease, and the project of my professional life is to close the distance between them.

Sight is not negotiable. Neither is the time it takes to lose it.