Dr. Pathara Sukvaree MD, FICO

Ramathibodi Hospital, Mahidol university Bangkok

Thailand

I would like to express my sincere gratitude to the Asia Cornea Society for granting me this invaluable opportunity to participate in a 2-week observership elective program at the Kyoto Prefectural University of Medicine (KPUM) from June 2 to 13, 2025, supported by the ACS–Santen Educational Grant.

During my time at KPUM, I had gained extensive clinical experience in both the outpatient department (OPD) and the operating room (OR) at KPUM and the Baptist Eye Clinic, under the guidance of Professor Chie Sotozono, Dr. Kitazawa, and Dr. Fukuoka

My first impression was profoundly positive. A resident doctor warmly welcomed me at the main gate and escorted me to the cornea conference, where I was given the opportunity to introduce myself to the faculty. This warm reception helped me feel immediately integrated into the team and well supported throughout my stay in Kyoto.

At the OPD, I observed many cases, and I was impressed by how efficiently the clinic managed patient care. Medical records were handled through an electronic system linked to a clinical camera, allowing easy capture and retrieval of anterior segment photographs. This system enabled clinicians to compare current and previous images for anterior segment diseases, supporting appropriate treatment adjustments. Additionally, investigation reports such as OCT, tomography, and keratometry could be easily reviewed on the computer system.

One of the highlights of my observership was the exposure to numerous corneal and ocular surface disease cases, especially Stevens-Johnson Syndrome (SJS). KPUM is a leading center for Cultivated Oral Mucosal Epithelial Transplantation (COMET), and Professor Sotozono is a global expert in this technique. In Japan, COMET is government-approved and covered by insurance, facilitating patient access. I had the opportunity to observe a fascinating case involving a patient with advanced bilateral SJS and cataracts, where Professor Sotozono performed a combined penetrating keratoplasty (PKP), cataract extraction, and COMET. The surgical outcome was inspiring. The patient’s vision improved to functional levels for mobility and was further enhanced with limbal RGP lens fitting, which promoted tear exchange and ocular surface regularity. It was heartening to see patients regain independence and quality of life.

I was also fortunate to observe Professor Sotozono perform a dermoid excision and lamellar keratoplasty in a patient with limbal and bulbar conjunctival dermoids. Her meticulous surgical technique left a strong impression on me. KPUM has published long-term outcomes on tectonic keratoplasty for limbal dermoids, which I also had the chance to see it with myself. While surgery removes the tumor, combining it with amblyopia therapy is essential to maximize visual outcomes.

In addition to SJS and dermoid cases, I observed various corneal transplant procedures. Dr. Fukuoka, Dr. Kitazawa, and Professor Sotozono demonstrated numerous corneal transplantation cases, particularly Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), primarily indicated for bullous keratopathy and Fuchs Endothelial Corneal Dystrophy (FECD). There are many DSAEK cases in Japan with good outcomes, retaining more than 2000 cells/mm² for over two years. Interestingly, they frequently use PCR testing for herpes and CMV, with results available quickly and at low cost, facilitating their use in clinical decision-making.

I also observed post-operative cases of Human Corneal Endothelial Cell (HCEC) injection therapy, pioneered by Professor Kinoshita. This novel treatment for corneal endothelial failure—including FECD, bullous keratopathy, and post-surgical corneal decompensation—demonstrated promising results. Corneal edema typically resolved within one month, confirmed by tomography, and patient visual acuity improved significantly. Compared to conventional keratoplasty, the HCEC injection technique is less invasive and simpler, with growing application across Japan.

Another area that broadened my perspective was corneal dystrophies, which are relatively rare in Thailand but more frequently encountered in Japan. I observed cases of granular corneal dystrophy (GCD), macular corneal dystrophy (MCD), and Schnyder corneal dystrophy, treated with various modalities including contact lenses, PKP, and phototherapeutic keratectomy (PTK). Dr. Fukuoka showed me many of his PTK patients, and I was amazed at the immediate post-operative clarity of the cornea. PTK was used not only for superficial dystrophies but also for band keratopathy and even a case of concrete-induced chemical injury, which he recently published in a case report. Dr. Fukuoka’s dedication and kindness to his students inspired me. In the future, I aspire to become a supportive teacher like him.

I also observed Professor Sotozono performing a triple procedure—PKP combined with cataract surgery—in a patient with macular and Schnyder dystrophy. It was my first time witnessing continuous suturing in keratoplasty and open-sky phacoemulsification which were different from my training. The operating room was well-equipped and welcoming, even playing relaxing Studio Ghibli music to help the surgical team concentrate.

Ectatic corneal diseases were also effectively managed at KPUM through contact lens fitting and PKP. Dr. Kitazawa introduced me to KPUM’s contact lens clinic, which has been in operation for over 50 years. The rigid gas-permeable (RGP) fitting process was impressively efficient, offering a wide range of lens designs tailored to individual patient needs. Severe cases could be referred for keratoplasty. For elderly keratoconus patients who developed cataracts, special IOL calculations were used to optimize outcomes. KPUM truly serves as a one-stop service center for keratoconus patients.

One of the most impressive aspects of the program was the educational culture. Professors were always accompanied by residents and interns, who learned directly from their mentors during clinics. At the end of each clinic day, a summary session was held, using clinical photographs to review cases and extract key learning points - an excellent teaching method that preserved clinical efficiency.

Finally, I would like to express my deepest thanks to all KPUM staff and doctors. Everyone made me feel welcome and allowed me to fully experience this remarkable opportunity. I truly appreciate the hospitality and kindness extended to me throughout my stay. I highly recommend this program to young ophthalmologists and would gladly return to KPUM if given a second chance.

Thank you once again to the Asia Cornea Society for making this experience possible. I have gained not only valuable clinical knowledge but also lasting memories that I will carry with me throughout my career.