Thirty Years of Singapore Ophthalmology

Dr Lim Kuang Hui

I, Tiresias, old man with wrinkled dugs
Perceived the scene, and foretold the rest -

"New year's eve (1962) was then traditionally celebrated on the quarter-deck of the training ship HMS Laburham - needless to say, it was the best do in town with all the ships in the busy harbour hushed at Cinderella hour to toot in the new year, and I can recall a sober moment during the revelry when Commodore Synnot, then Chief of our Naval Staff, singled me out for the red badge of courage that I wore on my epaulettes and promptly volunteered me for service as medical-officer for Malaysia's first frigate, KD Hang Tuah, to be commissioned in Portsmouth (UK) the following year. Movement orders marked "SECRET" soon came through - but all that is history now. The point I wish to make is that that party was a corner-stone in my rolling-stone life, for, to take advantage of the situation, I looked up the examination requirements for various subjects that were offered in England - ophthalmology seemed easiest, and so, I hurriedly arranged for a posting in the eye department at our General Hospital and, as events turned out, to later succeed as one of the heads of the department."

"A year of Service" by Lim Kuang Hui, published by Rotary Club of Queenstown, Singapore, 1980, p 26.

That was my rather fortuitous introduction to ophthalmology and the gist of a "classification talk" to my rotary club when I recalled how .... "I had mis-spent my youth at crossing the Bar and other misdeeds, or bold to sally forth in the good olde Cutty Sark to gain admittance into hallowed institutions on pretence of knowledge."

1963 - Then and Now

I start this account with the year 1963 because it was on January 11 of 1963 that the Society of Ophthalmology of the Singapore Medical Association (so named in its Constitution) was inaugurated, with Robert Loh as its founding chairman and Arthur Lim its founding secretary-cum-treasurer. It was on July 1 of that year that I started training in ophthalmology when I gained a "posting" to the Eye Clinic at the then General Hospital in Singapore, in circumstances alluded to earlier.

At that time, Robert Loh was the head of the eye department and Arthur Lim his chief assistant. The latter had just returned with an English Fellowship in ophthalmology. He was eager to teach and I was his only student. As always, Arthur Lim emphasised basic principles as he took me through the gamut of basic essentials from refraction theory to Queen's Square neurology, I could not have begun my career at a more propitious time.

For someone like me, who started his chosen medical speciality in 1963, and is now some thirty years down the line, what changes have I seen? The question may be asked in another way: For someone who would start ophthalmic training now, what is the difference?

Who will be favoured in the time differential in terms of circumstance, teaching methodology, career and promotional prospects, treatment modalities available to our patients, knowledge, and research opportunities?

In a way, I was fortunate to bridge the generation gap between my teachers of that vintage (i.e. Robert Loh, and before him Wong Kin Yip and A.D. Williamson) and the youngest set of new trainees, all of whom - the old as well as the young - I know personally, through my fortunate association with the service and teaching instituitions all these years.

Click here to view photos

Thirty years is about the average productive professional life-span of a medical practitioner in Singapore. The Singapore Society of Ophthalmology is also thirty years old. What have I seen? I am not qualified to talk about the thirty years prior to 1963, although ophthalmology as a speciality in its own right was started in Singapore as far back as 1934 (in the year that the author was born). But I can tell you about 1963 and the thirty years since then, be reminiscing about then and now.

Singapore Ophthalmology

Underlying this review, another question is posed:
Is there such a thing as Singapore ophthalmology?
It is hoped that this entire volume will provide the answer. Because ophthalmology as it is practised in Singapore is so unique to us (just as Singapore English is a unique variety), I did not hesitate to prompt the Singapore Society of Ophthalmology, on the occasion of its 30th anniversary, to place on record our meagre achievements.

What is the practice of ophthalmology in Singapore like? How is it taught? What are the ocular diseases in Singapore? Are there any special features or treatment regimen peculiar to us or advocated by us? What has been or are our prospects for research? What is the present status and future direction of our institutions - the Singapore Society of Ophthalmology, the establishment, the public and the private sectors? Who is charged with accreditation and specialist certification? What are the concerns for medical ethics, quality assurance, and peer review?

We have come though some where along the way. Where do we go? How will today's (1993) Government White Paper on Health affect Singapore ophthalmology in the next thirty years? In considering the vast amount of material available, I shall try to limit my discussion to certain main topics. Articles and papers published elsewhere in this volume will, I trust, provide answers to the rest of the questions.

The Eye Clinic at the General Hospital

The development of the Eye Department at the General Hospital is also the story of the early development of ophthalmology in Singapore as the Eye Clinic was the only government eye department then and it serviced the entire public sector in the country. Mr A.D. Williamson was appointed the first head of the Eye Clinic in 1934. His contribution to ophthalmology in our early years has been duly acknowledged in the 50th anniversary publication of the Singapore General Hospital (Singapore General Hospital, 1925-1976, by S.B. Kwa), extracts from which publications are reproduced elsewhere in this volume. Williamson retired after 23 years of service (including continuous service over the war years) in 1957, upon Malayanisation of the civil service. He entered private practice briefly in Singapore and then repatriated to Britain.

The physical structure of the Eye Department in those days (during the '50s to the '70s) was located at the first floor of the then Norris Block (now demolished) of the General Hospital at Sepoy Lines, off Outram Road. At one time the General Hospital as it was called then, was renamed the Outram Road General Hospital, but was renamed, yet again, after extensive redevelopment, the Singapore General Hospital, the massive complex which now stands. After the redevelopment of the new Singapore General Hospital, the Eye Department was located at the "L" Clinic (for outpatients), shared common operating theatres with the other surgical specialities, and occupied wards in "Block 6".

Prior to the demolition of the Norris Block, the Eye Department which was then housed there, comprised one large hall which provided an outpatient service (with long queues in those days). This large hall contained several partitioned-off rooms for investigatory services (such as refraction, field charting and darkroom tests), a tea room for the staff, and a private room for the consultant (who was also the head of the department). As part of the perks, the head also enjoyed a covered car park alloted to him and woe-betide anyone who tried to use his lot.

For the exclusive use of the Eye Department only there were two operating theatres which provided for major surgery and examinations under anaesthesia. The ward strength comprised "first class" and "second class" rooms for male and female inpatients, a "third class" large open ward for male patients and a separate open ward for women and children. The bed strength came to between 90-100 and, depending on occupancy, beds were also put up along the verandahs, as there were few day surgeries in those days. The warded patients were there mainly for cataract surgery, acute glaucoma and trauma, with a minority of severe uveitis and acute suppurative infections.

I remember going up to the Eye Clinic in the early 50s for chronic eye itch and trachomatous pannus, which was treated with silver nitrate cautery to the eyelids and also a massive dose of sulphadimidine tablets. My younger brother also had recurrent eyelid infections for which my mother paid a private practitioner dearly for a treatment package. We had contracted trachoma in early childhood from our domestic servant who came from China and had been my wet-nurse. She herself has been treated with buccal mucous membrane grafts for upper eyelid entropion "by the English doctor".

When Williamson retired in 1957, Wong Kin Yip (a returning Queen's Scholar) took over as the first local head of the Eye Clinic. Wong's account of cataract surgery in the 50s is reproduced elsewhere in this volume. I myself has brought up on the graefe's section for intracapsular cataract extraction and his account describes a classic operation in those days. With only one pre-placed suture, wound closure was poor and re-operations for iris prolapse were not uncommon. Patients had to come back on the tenth post-operative day for removal of sutures, which was usually done by the most junior doctor.

I also recall going up to the Eye Clinic in 1957 for a 10-day students' posting, when Wong introduced the students to the only two drugs in the entire pharmacopoeia: viz, "A3" (for Albucid 10% eyedrops three times a day) and "C4" (for cortisone 1% eyedrops applied four times a day). This regimen is still widely followed today for a variety of eye diseases.

Wong left for private practice in 1959 and was succeeded by Robert Loh, who had just returned after training at the Moorfields Eye Hospital and the Institute of Ophthalmology in London. Loh would wear a magnifying loupe around his neck when examining patients - such was the fashion and "high tech" of those days - just as a physician would hang a stethoscope around the neck as a kind of badge of office. Loh took me into the Eye Clinic in 1963, for which I am eternally grateful as trainee selections in those days were few and far between. His contribution to public sector ophthalmology for one decade (from 1959-1969) was significant and has been duly recognised elsewhere in this volume. He personally trained the eye surgeons that were to staff the department in his time. He also organised and was the congress president when the 3rd Asia-Pacific Academy of Ophthalmology Congress was held in Singapore in 1968.

Loh left for private practice in 1969 and Chua Sui Kim, who had just returned after training at the Royal Victorian Eye and Ear Hospital in Melbourne, took over. Chua also left for private practice in 1971 and subsequently emigrated to Australia.

I took over the headship of the Eye Clinic from 1971 till 1975. During those years, I was the only "qualified" (i.e. with fellowship) ophthalmologist on the establishment, as Arthur Lim, Robert Loh and Chua Sui Kim (in that order) has gone into the private sector. Including the qualified surgeons then at the private Balestier Eye Hospital, we could be counted on the fingers of one hand.

The Eye Department therefore embarked on a vigorous training programme and recruited additional staff. A.M. Charavanamuttu, from England, joined the department for some time, but left for Australia on completion of his contract. One trainee, Tong Heng Nam was awarded a one year scholarship to train at the Royal Victorian Eye and Ear Hospital in Melbourne. Another trainee, Raymond Phua, received a similar award for training in Queensland. Low Cze Hong, a promising young doctor, joined the department, and so did Chia Yu Tuan. After a year, Chia left for further training on his own to New Zealand but did not return. By about this time (1975), Ang Beng Chong had completed his training at the Sydney Eye Hospital and returned to join the department, which was depleted of manpower. Victor Yong, who had completed his training requirements locally, flew off to Edinburgh and returned with the fellowship. David Tan, who spent a long period in Melbourne on his own study leave, also returned successfully completing his studies.

When Leong Seek Kee, who had trained in London on his own and had gained considerable working experience there, applied to join the Eye Clinic in 1975, an adequately trained succession had been assured and I left for private practice.

Leong maintained headship of the Eye Clinic from 1975 till 1980 when he too resigned to go into the private sector. Victor Yong took over as head of the Eye Clinic in 1980 and held this office for a long time until his transfer to Tan Tock Seng Hospital in 1990, when Richard Fan took over. When the Eye Clinic at SGH was amalgamated with the Singapore National Eye Centre in 1993, Fan also resigned to go into private practice.

Establishment of other Eye Departments

Two new eye departments were created; one at the Tan Tock Seng Hospital in 1979 with Cheah Way Mun as its head and another at the National University Hospital in 1986 with Arthur Lim (appointed from the private sector) as its head. The appointment of private sector ophthalmologists as visiting staff to government or university hospital departments set a new trend and established a two-way flow of expertise which rapidly gave credibility and stature to the new departments at the National University Hospital and the Singapore National Eye Centre, which was to be inaugurated later in 1991. The National University of Singapore itself created an academic department in 1990 with the appointment of officers from the National University Hospital.

At the same time, many private eye clinics, attached to private hospitals or located in fashionable shopping centres, were established, following resignations from the public sector. With the demand for sophisticated, good quality medical care in Singapore, the scene was now set for the development of the ophthalmic subspecialities.

Subspecialisation

Apart from the training programme which was rapidly put in place during my years in office, the feasibility of subspecialisation was also studied. The Minstry of Health formed a Committee for Specialisation in late 1969 to explore the development of the subspecialities. The Eye Clinic already had on-going sections to study ocular trauma, glaucoma and the retina. Although recommendations were made, they were not implemented due mainly to a lack of manpower because of the exodus of trained personnel into the private sector. Subspecialisation was allowed to follow the natural course of events and the feasibility study although completed could not be implemented.

With the establishment of an academic department at the National University of Singapore in recent years and the inauguration of the Singapore National Eye Centre with its strong emphasis on research, the issue of subspecialisation has resurfaced with a sense of urgency.

Although all the ophthalmologists presently practising in Singapore are general ophthalmologists, in that they have not become so selective that they will reject patients who do not come into their area of expertise, a large number, especially the younger ones, are devoting more time to a particular area of interest.

Up till the present time, the concept of specialisation in Singapore context has been limited to the acquisition of specific skills. Skills can be acquired and we have trained very skillful surgeons on anterior segment surgery and on the vitreo-retina - two very important areas in sophisticated eye work as failure means blindness for the patient. Notwithstanding how skillful we may have become, we have not touched innovative surgery or research orientation to that level which can enable our surgeons to attend an international meeting and have peers listen to our work. That is the litmus test.

Innovation or originality need not be world-shaking. Capsulorrhexis is one simple example. We can learn the technique and have become accomplished in doing so (just as we have mastered other more complicated procedures in ophthalmic surgery), but did we think of it, as simple as the concept may be? We do not need to re-invent the wheel, but maybe our surgeons should, once in a while, throw away all routine work and allow their minds to expand through lateral thinking.

Prevention of Blindness

Prevention of Blindness (POB) has been adequately covered in a relevant section in this volume. POB is not an issue in Singapore as our own problems can be effectively resolved. In this regard, Singapore has now become a "donor nation" in POB programmes and has been invited by the relevant authorities to assist in POB programmes in China, Myanmar and Sri Lanka.

For our international relationship, Arthur Lim sits on the executive committee of the international Federation of Ophthalmological Societies. He was a vice-president of the International Association for the Prevention of Blindness (IAPB) and chairman of the IAPB (Southeast Asia Region). I am currently co-chairman POB programmes within the Asia Pacific countries.

International Ophthalmology

In addition to hosting the 3rd Asia-Pacific Academy of Ophthalmology Congress in Singapore in 1968 and the 26th International Congress of Ophthalmology Congress in Singapore in 1990, our members have also participated and served international ophthalmology in various capacities. In particular, Arthur Lim has held, and still holds, leadership roles and key appointments in numerous international organisations (listed else where in this volume).

Singapore National Eye Centre

The government established the Singapore National Eye Centre (SNEC) in 1991 as the first specialist medical centre in the country with the specific objective of achieving excellence in ophthalmic practice at an international level. Arthur Lim (who also functions as head of the eye department at the National University of Singapore) was appointed its medical director. Within three years, Arthur Lim has already established the SNEC as a top service centre with a strong emphasis on continued medical education, training, and research.

Manned by visiting consultants from the private sector and a large full-time staff, the SNEC is already making a mark in the region as a centre for tertiary eye care. Its strength was enhanced by the amalgamation of the Eye Clinic from SGH in 1993 with the latter's heavy public sector workload. In 1993 the SNEC established two separate departments with independent heads and teams of doctors. Apart from streamlining the administration, these two departments will also function as independent entities financially.

Government White Paper on Health

The government released its White Paper on Health in 1993 confirming the recognition and further development of the SNEC as a tertiary centre for eye care in the public sector in Singapore. This will mean that tertiary referrals and more sophisticated work will be concentrated at the SNEC.
At the same time the White Paper recommended putting a cap on the numbers of trainee doctors and specialists, as well as a cap on what patients could use from the medisave scheme to pay for private hospital fees. Whilst the implications of the above are not immediately clear, there is a general feelings amongst doctors that when these recommendations are implemented and become effective, there may be a loss in the incentive to do very specialised work and that this may lead to a gradual deterioration in the use of sophisticated procedures and eye care in the distant future. However, this fear remains to be realised.

Future Direction and the Singapore Society of Ophthalmology

Ophthalmology in Singapore is going where we want to take it but where and how do we want it to go? Thus, I conclude this introduction with a brief discussion of the status and future direction of the Singapore Society of Ophthalmology (SSO) as it will affect all practising ophthalmologists in Singapore.

Unlike the national ophthalmological societies in the USA, UK and Australia, whose membership are spread over vast territories, the SSO is concentrated and its membership can be contacted easily and rapidly. The societies mentioned earlier have a large say in and are powerful bodies with regard to training, examination and accreditation, before anyone can be admitted into their membership. They are also responsible to their governments on all matters pertaining to ophthalmic practice in their countries. This is not the case with SSO.

Perhaps these functions were not written into the SSO's constitution nor were they envisaged by its founding members; they at that time represented a handful of ophthalmologists mostly from the public sector. The founding office bearers were the same officials who drew up the government directives of the day.

During the first decade of its existence, the SSO was ipso facto the government department of ophthalmology (as there were no other interested parties) with the wider role of bringing in the private sector (which had no interest in policy matters). The senior government consultant of the day (normally the head of department) would also attend to government VVIPs and the top echelon of the establishment. Hence, he had an indirect lobby to the authorities of the day. There may or may not be some advantage in this approach, but that situation more or less prevails to today.

But like all organisations, the SSO has also had its "ups and downs" in enthusiasm and activities. Within its limited membership, the SSO very early on organised and hosted the 3rd congress of the Asia-Pacific Academy of Ophthalmology, of which our society was founding member. It then lapsed into inactivity except for the AGMs and occasional social functions.

Be that as it may, successive chairmen and committees have tried to revive the society to boost its image and give it more visibility. Cheah Way Mun organised a very successful international symposium on pediatric ophthalmology which was well attended by doctors outside our narrow specialty. Arthur Lim, a natural leader, at once brought in many innovations. He initiated the first joint scientific meeting with the Malaysian Society of Ophthalmology in 1981 (now to become an annual rotating event); published the first, and only, "Proceedings of the SSO" in 1982; took the society overseas with affiliation and corresponding membership with the Ophthalmological Societies of the UK and the International Federation of Ophthalmological Societies; and successfully bid, in the name of SSO, to host a meeting of the International Congress of Ophthalmology (the top meeting of all eye surgeons world-wide) in Singapore. Peter Tseng finalised an agreement with the National University of Singapore for a student's award of a gold medal and book prize to encourage undergraduate interest in ophthalmology. Ang Chong Lye recognised the society's 30th anniversary with a teaching seminar and a grand get-together of its membership, which included a publication of this commemorative book.

In the midst of all this, we must not deny the fact that the SSO is unique in that it has, in its membership, all the practising ophthalmologists in the country and can, therefore, provide a potentially powerful lobby as its speaks on behalf of all our ophthalmologists. But then, not all ophthalmologists in Singapore attend SSO meetings, which is as expected, or subscribe to its nominal annual dues which, to my knowledge, have not been collected for the past years, nor has any member been penalised for non-payment.

The SSO now enters a water-shed period in Singapore ophthalmology. It is not that it is lacking in strong leadership that can speak without constraints. With the emergence of the Singapore National Eye Centre as a tertiary institution of ophthalmic practice backed by government and the relegation of the other government departments, as yet unspelt, into secondary importance, more so with the ambivalence of private sector ophthalmology itself maintaining its traditional role of establishing excellence and exerting eminence vis-a-vis the talent and continuous migration of expertise from the public sector, will there be, in the event of failure of performance in the public sector or mass resignation of institutional staff, a balance of say in ophthalmic issues to be reckoned with by the relevant authorities? Who can speak on ophthalmic issues in the interests of all? The SSO can act not only as buffer but, in my opinion, also fulfill this role.

For the time being, it may be as well to remain silent. If our perceived role appears to be social and to host the annual rotating joint meetings, long may it so continue!