Cultural Barriers for Women in Surgery: How Thick is the Glass Ceiling? An Analysis from a Low Middle-Income Country.

BACKGROUND: This study aimed to highlight cultural barriers faced by surgeons pursuing a surgical career faced by surgeons at a tertiary care hospital in Pakistan. As more females opt for a surgical career, barriers faced by female surgeons are becoming increasingly evident, many of which are rooted in cultural norms. In Pakistan, a predominantly Muslim-majority, low middle-income country, certain societal expectations add additionally complexity and challenges to existing cultural barriers. METHODS: A cross-sectional survey was administered via e-mail to the full-time faculty and trainees in the Department of Surgery at the Aga Khan University Hospital, Karachi, Pakistan, from July 2019 to November 2019. RESULTS: In total, 100 participants were included in this study, with the majority being residents (55.6%) and consultants (33.3%). 71.9% of female surgeons felt that cultural barriers towards a surgical career existed for their gender, as compared to 25.4% of male surgeons (p < 0.001). 40.6% of females reported having been discouraged by family/close friends from pursuing surgery, as compared to only 9.0% of males (p < 0.001). Moreover, a greater percentage of females surgeons were responsible for household cooking, cleaning and laundry, as compared to male surgeons (all p < 0.001). Lastly, 71.4% of female surgeons felt that having children had hindered their surgical career, as compared to 4.8% of males (p < 0001). CONCLUSION: Our study shows that significant cultural barriers exist for females pursuing a surgical career in our setting. Findings such as these emphasize the need for policy makers to work towards overcoming cultural barriers.

Outcomes of Epi-On Collagen Cross-Linkage Procedure Assessed in Progressive Keratoconus Patients.

INTRODUCTION: Keratoconus is a corneal ectasia that causes astigmatism and reduced vision. Conventional treatment to stop the progression of ectasia involves debridement of corneal epithelium, followed by ultraviolet light and riboflavin drops to reinforce the collagen covalent bonds, called collagen cross-linkage (CXL). Epi-on (epithelium-on) is a modified technique without epithelial debridement and associated complications of pain, infection, and damage to the cornea. However, despite a good safety index and efficacy, Epi-on has not completely replaced the conventional Epi-off (epithelium-off) CXL. We aim to report our five-year experience and outcomes with Epi-on CXL Methods: In this five-year retrospective clinical audit, we included all patients who underwent Epi-on CXL from December 2014 to June 2020 at the Aga Khan University Hospital. Outcomes were based on best-corrected visual acuity (BCVA) and topographic indicators such as keratometry-max (K-max), keratometry mean (K-mean), pachymetry apex (Pachapex), and pachymetry thinnest (Pachthin) performed during pre-CXL clinical visit within one month of the procedure and were compared with the most remote follow up within three years post-CXL. A p-value of <0.05 was considered statistically significant. RESULTS: A total of 223 eyes of 134 patients had undergone CXL of which 32 eyes of 18 patients were included in the study based on the inclusion criteria. The mean age was 26.8 (+/- 6.137) years; nine were males and 16 were right eyes. Mean BCVA was 0.383 logMAR (logarithm of the minimum angle of resolution) units which improved to 0.292 units post CXL (p=0.02) and K-max decreased from 57.4 to 56.60 diopters (p=0.048), both outcomes were statistically significant. Pachapex decreased slightly from 471 to 460 micrometers (p=0.099), K-mean was almost stable from 48.8 to 48.7 diopters (p=0.9), and Pachthin also decreased slightly from 455 to 445 micrometers (p=0.117), however, these outcomes were not statistically significant. Other studies reported similar improvements in K-max and visual acuity. CONCLUSION: Epi-on CXL is an effective treatment for halting the progression of keratoconus. Our results showed significant improvement in visual acuity and K-max readings indicating a halting of the progression of keratoconus in our patients. Long-term follow-up is required for all patients to assess detailed outcomes. Further studies comparing Epi-on CXL with other methods may be carried out.

Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country.

INTRODUCTION: Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan. METHOD: A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons. RESULTS: 98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported 'significant' frequency of GD/bias during residency. A higher percentage of women reported 'insignificant' frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p < 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p < 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty. CONCLUSION: Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as "significant". Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research.

Vogt-Koyanagi-Harada syndrome.

Vogt-Koyanagi-Harada (VKH) syndrome is a rare multisystem disease of melanocyte containing organs. It is characterized by diffuse granulomatous inflammation involving various organs including eye. VKH syndrome is usually sporadic, but some familial cases have also been reported indicating a hereditary basis. VKH is not associated with mortality but it may result in long-term complications such as decreased vision associated with cataract, glaucoma and choroidal neovascularization. For successful outcomes, early aggressive treatment using systemic steroids with gradual tapering is essential. This report describes a case of VKH syndrome in a 26-year-old male of Pakistan origin who was successfully treated with systemic steroids. The case is briefly contextualised within wider literature.