Read the Conversation

EF: Please tell us about your career path. What attracted you to the field of ophthalmology?

FM: During medical school, I chose the specialty ophthalmology because it relates to the highly important sense of vision, which connects us with the outer world. In the appliance, this field has some very elegant surgical procedures, such as removing cataracts and vitreous hemorrhages. I have always liked diagnosing and treating retinal diseases.

During my residency in ophthalmology at the Hospital das Clínicas in Sao Paulo, the biggest public hospital in Latin America, I came across a huge public health problem. Diabetic patients looking for treatment were arriving too late. By the time we got to examine them as specialists, many had already lost their vision, and there was nothing else we could do about it. As doctors, we knew that this was an avoidable cause of blindness. This led me to a subspecialty, which is retina/vitreous.

I specialized in retinal surgery and became a specialist in retinas. During my time at a Specialty Center for retinal diseases in France, I noticed fewer patients requiring treatment because their system could detect and treat the conditions at an earlier stage. This experience reinforced my belief that the disease we dealt with could be prevented and managed differently. Upon returning to Brazil, I worked in various clinics and hospitals where I observed that diabetes was a highly prevalent disease. A significant portion of the workload for retinal specialists involved seeing patients with diabetes. Surprisingly, some patients exhibited no abnormalities in their retinas; their eyes were healthy. I made a connection and realized that the system´s lack of organization and coordination contributed to why patients were not receiving timely treatment.

Even previous to the pandemic, I had the opportunity to study telemedicine. This tool proved to be very effective for screening retinal diseases. All patients with normal retinas could be easily identified through retinal imaging, avoiding the need for in-person consultations. Telemedicine was a bridge to overcome gaps in our health system.

Brazil, being a vast country with continental dimensions, presented unique challenges. During my studies of telemedicine, I had the opportunity to connect with patients in Acre State, situated in the Amazon region. The public sector of that state lacked retinal specialists, prompting me to visit and assess the situation firsthand. I observed a segment of people with diabetes that presented no changes in the retina but had no access to a specialist to evaluate them. Had I not been there, they would have had to take a plane or a boat to travel with someone accompanying them to see a specialist. At the same time, such evaluation could have been performed remotely through telemedicine, saving a lot of resources.

I conducted my doctoral research on the application of telemedicine for screening diabetic retinopathy and published a paper detailing the results of a multicenter study conducted in Brazil. The study concluded that telemedicine was a viable approach for diabetic retinopathy screening in the country. This line of research inspired further investigations, leading to the publication of additional papers.  
With the pandemic, telemedicine gained significant attention, becoming a hot topic of discussion for everyone. During that time, I started to look into Artificial Intelligence.  

The first FDA-approved AI system in medicine was for detecting diabetic retinopathy through retinal images. Technology, including telemedicine with the assistance of a remote expert, AI, or their combination, allows us to close gaps in the system.  

Ultimately, the goal is to prevent avoidable blindness by enabling early detection and proper patient treatment. However, the diagnosis is only the beginning of the challenge. After finding the patient, we have to provide treatment, and this is not easy, particularly within the public sector, which serves a substantial proportion—around 70 to 75 percent—of the Brazilian population.

EF: How can we raise awareness about diabetes in the country?

FM: Education remains the main issue. We need awareness and education on diabetes itself, not only its complications. In Brazil, for every diabetic person, there is another person unaware of having the disease.  
It is important to educate everyone in the health ecosystem and raise awareness about the significance of testing individuals with risk factors. Additionally, we must actively promote health initiatives that encourage weight loss and regular exercise, thereby reducing the overall risk for individuals.

Secondly, we need to inform patients better of the complications, especially the silent ones like retinopathy. Retinopathy is asymptomatic during the early phases. As patients usually do not feel anything in this stage, they must know that they may have a vision-threatening condition and should be examined for that.

Thirdly, we need to provide healthcare access. Once the demand is created, we will have to have the means to diagnose patients, either in person, with telemedicine, AI, or all three combined. Recently, we conducted a pilot study in the impoverished northeast region of Brazil. We identified four small villages within this region, where we engaged with local health authorities and the mayors. Collaborating with another ophthalmologist, we implemented a screening initiative using advanced technology. Out of the approximately 2,000 patients on the registry, only 1,000 individuals attended the screening, demonstrating that, despite our efforts to overcome barriers by providing the service free of charge and bringing it closer to the residents, other significant barriers remained and have to be addressed.

On a structural level, Brazilian public authorities must formulate a policy ensuring the detection and treatment of patients, considering the hierarchical structure of our healthcare system (SUS) that comprises primary and specialized care. There is a gap where ophthalmology, as specialized care, should ideally be shifted to primary care for diabetic retinopathy screening. It is crucial to persuade the authorities that ocular disease screening should occur in primary care. With an estimated 15 million diabetes patients in Brazil requiring at least one annual retinal examination, collaborative efforts are imperative to ensure comprehensive screening and timely treatment for this substantial patient population.

Although the data available is not of the best quality, we determined that around one-third of patients with diabetes have retinopathy. Early screening would allow us to sort out the other two-thirds who do not require seeing a specialist, saving the healthcare professionals’ time and the limited public resources. It is very important to give a clear message to the medical community that if we screen more, we will detect more cases, and physicians will get to treat more patients. There is a misunderstanding that technology will steal patients, jobs, and income. It is quite the contrary because most patients are now below the radar. If we screen more, we will have more patients and ways to treat them both in the public and the private sphere of our health system.

EF: How can we open the medical community to actively using telemedicine and AI?

FM: A lot of fear comes from the wrong information and misbeliefs. We need to properly prepare and train the medical staff. There is a technological revolution happening. People in healthcare will be obliged to have E-health literacy; otherwise, they will not be able to perform in this new environment.

EF: What measures and precautions should be taken when opening the country to more clinical trials?

FM: Brazil already has a tradition of best practices for clinical trials and studies. All the measures are covered if we follow the best practices, have IRB approval, and have clinical research sites that obey those rules.

EF: What innovations are happening in the field of ophthalmology when it comes to treating diabetes?

FM: From a public health perspective and in terms of various imaging devices, the field of diagnostics is witnessing significant advancements. There are emerging types of OCTs (Optical Coherence Tomography) and multimodality imaging techniques specifically designed for retinal examination. These developments are highly intriguing. Recently, I attended a Research Congress in the US, where I witnessed groundbreaking technology that enables us to observe photoreceptor cells within the retina in vivo. Such capabilities were unimaginable just a few years ago, making it an exciting time for diagnostics. As for treatment, numerous industries are actively pursuing innovative pipelines involving new molecules and novel methods for delivering drugs within the eye.

EF: If you had to name three pillars needed to create a sustainable life science market in the country, what would they be?

FM: The first pillar would be to increase the capacity of primary care to solve problems. Secondly, we need to deal with access barriers created by our geography and socioeconomic disparities. The third pillar would revolve around education. Education is the key.

EF: What are the primary things that need to be considered when striving to improve the patient experience?

FM: Education serves as the foundation for empowering patients in managing their own health. Patients must become experts regarding their specific diseases. It is crucial to provide patients with comprehensive information about how their disease functions, potential improvement strategies, factors that could worsen their condition, common symptoms, and the recommended evaluation schedule. Once patients have this knowledge, discussions about shared decision-making and true empowerment can occur.

Adherence to chronic diseases poses significant challenges as it often involves missed work, waiting for appointments, and substantial financial expenses. We must tailor the treatment to everyone, and I believe that could be done with shared decisions, provided that the patient is educated and knows what we are talking about.

July 2023