“We are the Window to the World; We See What People Don’t See”
Human of Medicine #46
This publication is in conjunction with the public health initiative by MMI aimed at raising eye health awareness among Malaysians. Further information can be found at @mmi_social on Instagram.
About passion and pursuit
I am Datuk Dr. Nor Fariza binti Ngah, graduated from University of Malaya in 1991. Following that I pursued my master in Ophthalmology at Universiti Kebangsaan Malaysia. Being a female doctor and at that particular time I was about to start my family life were the main factors in my decision to choose ophthalmology. A work-life balance is what I'm after. Then, I completed my subspecialty training in Medical Retina and Uveitis at Moorfields Eye Hospital, UCL London, in 2003. I was the first to specialize in these fields within the Ministry of Health (MOH) Malaysia, with a brief attachment under Datuk Dr. Muhaya (UKM) at the Ikonik Eye Specialist. My gazettement was done in Hospital Kuala Lumpur (HKL), followed by my specialist posting in Hospital Selayang, the first hospital in Malaysia to use a fully integrated Hospital Information System. I served Hospital Selayang for almost 15 years (1999 – 2015) before I was transferred to Hospital Shah Alam.
It was never my dream to become a Deputy Director General of Health in MOH Malaysia. However, looking back at my experiences and exposures serving MOH as the Head of Department, Head of State, Head of Subspecialty and Head of Services for Ophthalmology as well as my vast experience in research, I believed that my qualifications merit consideration as one of the shortlisted personnel for the position. Despite my busy schedule leading the Research and Technical Support Program, I will still make time for my clinical practices at Hospital Shah Alam.
As the first trained Medical Retina and Uveitis subspecialist, I faced many challenges. I had to think about how to set up the service, where to get the budget for the equipment needed and also to secure the budget to purchase the latest medication to ensure that patients are getting the best treatment possible. The journey of getting MOH to agree to the requests was the beginning of my involvement in global research, which began in 2005/2006. Our Medical Retina team in MOH (Selayang at initial phase, then Shah Alam) has been recognized as one the study sites in this region after Singapore and Thailand.
One of my other responsibilities is to train more Medical Retina and Uveitis in MOH and Malaysia and to set up more centers within MOH and to give training to the masters students as well as junior Ophthalmologists the knowledge of medical retina and uveitis. Since 2005 whereby my first trainee was recruited, I have personally been involved in training 15 specialists in Medical retina and uveitis. The majority are still serving in MOH, and a few have chosen the greener pasture either in private or university. Yet, they are still actively making valuable contributions in the field of Medical Retina and Uveitis.
Another standout milestone was the establishment of a parallel pathway for the ophthalmology program, which the MOH endorsed in 2018. Watching young medical officers transform into skilled colleagues in ophthalmology, especially in medical retina, is incredibly rewarding. It is nice to see the seeds of knowledge we've sown blossom into a flourishing community of dedicated professionals.
Empowering change through translating research into clinical practice and via community services
As a Key Opinion Leader for nearly 20 years, my research has had a global impact, particularly in Age-Related Macular Degeneration (ARMD), Diabetic Retinopathy, and Diabetic Maculopathy. I am also into Artificial Intelligence (AI) and we have a team that created Diabetic Retinopathy AI screening which is currently in the pilot phase. For this study, we are looking at the capability of the system to be implemented in peripheral hospitals. On top of that, I also have my cornea team presently working on the AI for diagnosis of corneal conditions and this technology is expected to be accessible for usage by peripheral hospitals by the year 2026. Furthermore, my team and I have succeeded in bringing Malaysia into the eye of the World Health Organization (WHO) where they recognize our cataract monitoring activities and Malaysia is acknowledged as one of the leaders in cataract outreach services. I think all these led me to where I am here today. What I would like to say is, if you do your job well, you will reach somewhere.
DIABETIC RETINOPATHY INFERENCE with MULTI ARTIFICIAL NEURAL NETWORK TECHNOLOGY AUTOMATION (DR MATA) TEAM
ARTIFICIAL INTELLIGENCE for the DIAGNOSIS of CORNEAL ULCER (AI CORUL) TEAM
Since becoming an ophthalmologist in 1998, I have dedicated myself to community service. Working in hospital-based service, we mostly see patients with ocular problems, where the majority of them have already developed complications from their systemic illness such as Diabetes Mellitus or those with infection that presented rather later to the clinic. This led to our initiative to work with the primary care services, aiming to raise patients’ awareness of their conditions to ensure they get early treatment. The Retinal Disease Awareness Program, supported by Standard Chartered Bank, was established in 2012 to assist with the screening for diabetic retinopathy. We managed to get two fundus cameras to be used on rotational basis as mobile units for the healthcare facilities within Selangor. The activities were fully supported by the Jabatan Kesihatan Negeri Selangor, and we have been doing these activities as one of the community services for Ophthalmology fraternity in Selangor and Federal territory mainly and few other states in Malaysia.
Other screening activities that we have initiated also include the AVIS project (Amblyopia and Vision Impairment Screening) for the preschool children, providing free glasses to the underprivileged pre-school and school going children, and offering low-cost intraocular lenses to needy patients. These community initiatives are to ensure more populations can benefit with the amount of budget given to us.
We also celebrate World Sight Day annually with public forums and screenings to raise awareness about eye care, including topics on cornea donation, diabetic screening, contact lens care, ocular injury at the workplace and the latest recent topic of refractive errors. Our society also created two videos on awareness about Diabetic eye complication and age-related macular degeneration.
LAUNCHING WORLD SIGHT DAY 2019
Navigating Emerging Eye Disorders
In regards to the emerging eye disorders, the main conditions that I would like to mention are diabetic related ocular complications such as Diabetic Retinopathy and Maculopathy or Diabetic Macular Edema, Age-related Macular Degeneration and Glaucoma. This is because all these conditions require early screening to prevent permanent damage and irreversible blindness. From the prevalence of DM, we can see that it affects the younger age group and if untreated or the systemic condition is not properly controlled, patients will develop the ocular complication and vision impairment or blindness will definitely affect the quality of life and socioeconomic productivity.
Refractive error on the other hand, has always been taken for granted. It can have an impact on both young children and adults. Not giving the best of corrective glasses will negatively impact performance, both academically and professionally. In addition, rare diseases, especially inherited retinal disease, is another group of diseases of current interest, mainly due to the availability of the treatment option such as genetic and stem cell therapy. Even though it is at an early phase for Malaysia, it is something to look at in the future. For the above-mentioned condition, awareness on the most recent treatment option also has to be communicated to the patients, to get them to see the doctor as early as feasible for better response from the treatment.
As for cataract, it is not a newly emerging condition, but the new technology on implant availability is something that we have to share with the patients. I am proud to say that cataract services in MOH are very well developed, with all 47 hospitals with resident ophthalmologists performing the surgery as main core surgery. We also go to the community for our cataract camp and massive cataract surgery initiative program. And the best of all is that we are able to monitor all the outcomes of cataract surgeries done in MOH. We are currently in the process of getting the Universities as well as private ophthalmologists to contribute to the system.
VARSITY PULSE EVENT (14/2/2024) at KAMPUS UITM PUNCAK ALAM
From Clinician to Policy Maker
Regarding policies, I would not characterize it as policy top down. There are guidelines and we are also advising the policy makers on screening and early intervention to prevent patients from getting the disease. For example, we have a Clinical Practice Guidelines for specific eye diseases in which a fundus camera is a necessity in Klinik Kesihatan. However, not all Klinik Kesihatan are equipped with a fundus camera, but we are trying to improve on that. Though it is not there now, it is approaching. Therefore, it is not a policy because policy implies necessary requirements.
Moving on to the screening of infants. When the babies get vaccinated, we train the nurses to look for the eye movement, shine light on the eyes and check for any abnormalities. This is actually an opportunistic screening. Should anything obviously stand out, further referral is called for. As for now, these are also in the guidelines. We also conduct preschool child screenings. Not all are being screened; it depends on the level of activity in that area, or the demands made by the teachers. Wherelse the program for school health is a policy. The vision test is added in to be done for eye screening. For all community services, the non-governmental organizations (NGOs) usually provide us with very good support for eye activities. I think they see the need for vision.
To help the policy makers in their decision-making process, we collaborated with health technology assessment to develop several types of guidelines, including clinical practice guidelines, consensus guidelines, and preferred practice guidelines. These tools will assist ophthalmologists in effectively handling cases and ensuring that their standards align with those of other countries in the region or worldwide.
When it comes to evaluating, diagnosing, and keeping tabs on patients' health conditions, ophthalmology services demand a lot of equipment. And technology has rapidly advanced, especially in the field of artificial intelligence. Despite the financial constraints, our team tried our very best to keep up with the evolution. At the same ground, the research team is actively involved in both Industry Sponsor Research (ISR) and Investigator Initiated Research (IIR) projects, regardless of whether they have received the Malaysia Research Grant (MRG). The team consistently employs innovative approaches to enhance the quality of eye treatment for patients.
INTERVIEW WITH DATUK DR. NOR FARIZA BINTI NGAH AT HER OFFICE
Creating Research Interest among Young Ophthalmologists
It is a huge challenge to cultivate research interest among young ophthalmologists; but, I have observed their dedication and commitment. By appointing them to be in charge of the IIR, I have created a sense of responsibility, leadership, and interest in them. This allows them to expand their knowledge and broaden the scope of ophthalmology services in our country through research. I will make every effort to provide them with the assistance they require for as long as my contribution is required.
Throughout my service, I have encountered numerous unique experiences that have shaped a journey that I hold close to my heart. Being the first subspecialist to receive training in Medical Retina was a significant challenge, but I was able to overcome it. Next, research on artificial intelligence. I like to push myself with new challenges. I recall that during one of the conferences, people started talking about the use of artificial intelligence to screen diabetic retinopathy. I came back and suggested that we create our own, as it is costly to have someone come and set it up for us. I managed to get a few ophthalmologists who shared the same interest and befriended non-medical individuals who could provide assistance. The proposal was conceived, prepared, and accepted over the course of three years. It is one of the most rewarding experiences to see the product being developed and prepared for implementation.
HEALTH RESEARCH PRIORITIES FOR 12TH MALAYSIA PLAN
Eyes on wellness
I was telling one of the junior doctors that something distinctive about ophthalmology is that even when you have the same diagnosis, the findings might vary greatly. Take diabetic retinopathy as an example; there are varying degrees of severity and stages, but is the internal eye diagnosis identical? No matter how many various kinds of photographs I see, they will not be the same.
When it comes to ophthalmology, we are involved in both the medical and surgical fields. The surgery might be microsurgery, which involves working inside the eye, or it can be more visible, such as oculoplasty. In the medical field, there are instances when we have to look beyond the obvious that we can see. We can diagnose SLE first based on the findings in the eye before medical can diagnose as there are no systemic features that the patient presents with. We might be able to know the person is having diabetes before the symptoms flare up. We can also identify the patient is having a renal condition from the eye findings as well as we are able to know that the patient is having a brain tumor because there is papilloedema. Because of our unique perspective, we are able to perceive things that others miss.
You must remember, vision is the first organ you should take care of. However, it is always taken for granted. People won’t appreciate it until they experience vision impairment. If you have visual impairment, productivity is affected, family members are burdened, and quality of life will be poor.
A long time ago, I had a patient who was amputated. Then she was admitted for another amputation procedure. During that admission, she said she cannot see. When we examined her, we found that she had Advanced Diabetic Eye Disease (ADED). After we informed her of the diagnosis, she kept on crying. Then, I asked her “You’ve had this problem for some time now so why are you crying?” She told me “Being told that I cannot see anymore is more depressing than having to amputate my other leg”. It appears that we won’t appreciate it until we lose it. Similarly in the cases of refractive errors, parents do not see how wearing glasses can improve quality of lives for children. With glasses, they can perform and excel better as their vision will be clearer to see more.
The field of ophthalmology is highly captivating. See what we see, and you will get the idea. Vision is something we must care about. Vision is utmost important. This year, our World Health Assembly (WHA) focuses on All for Health, Health for All. They also highlight eye health as well. In addition, WHO also has launched WHO SPECS initiative for refractive errors to improve quality of eye health. Being an ophthalmologist, all ophthalmologists are also passionate about corneal transplants. Finally, we must make a difference and spread awareness in a way that touches people’s hearts to create an impact. And last but not least, I always remember my late father’s words where he said we must do something not for ourselves or for our own benefit, but for the people. We strive for the public’s well-being as our ultimate goal.
27th ANNUAL SCIENTIFIC MEETING FOR MALAYSIAN SOCIETY OF TRANSPLANTATION (10/5/2024) at HOTEL LE MERIDIEN, PUTRAJAYA
Arulselvi Manoharan is a medical graduate from Management & Science University.
Medicine is the fusion of science, technology, and art towards hope of life. Through writing, we empower it further.
Goh Li Lian is an aspiring medical student at IMU University.
In healthcare, we are united not only by action, but also words of intellect and altruism.
Consent has been obtained from the interviewee for the purpose of this publication. The author has rewritten the article with permission from the interviewee.
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