Dr. Durr is an Associate Clinical Professor at the University of Montreal and Director of the glaucoma fellowship.
Please share with us your background.
Montreal has always been my home, as I was born there and lived there for most of my childhood. But, when my parents initially immigrated to Montreal from Lebanon, my father was completing his residency in otolaryngology and was required to work in rural Quebec before returning to the big city. Although I was young, we spent 7 unforgettable years in Rouyn-Noranda, a mining town in Abitibi-Temiscamingue, Quebec. There, I learned all about ice fishing, skidooing, skiing, and the true meaning of the saying, “Nothing burns like the cold.”
Growing up, I always knew that I wanted to be a doctor. After obtaining a bachelor’s degree in biomedical sciences, I endured many months of uncertainty before being accepted to medical school at the University of Montreal. Throughout medical school, my interest in ophthalmology grew—although, I must say, I was tempted by internal medicine (I know!) and general surgery. I completed my residency in ophthalmology at the University of Montreal, where I was fortunate to be inspired by many subspecialists across the field. After residency, I completed a 2-year fellowship in glaucoma and advanced anterior segment surgery with a group of talented surgeons at Prism Eye Institute in Toronto.
What drew you to ophthalmology and, specifically, to your field of interest?
Growing up in Rouyn-Noranda, my uncle served as the lone ophthalmologist in the region. He performed all sorts of surgeries, from strabismus to cataracts to glaucoma. I learned about the field of ophthalmology through him, and I saw the long-lasting impact he had on the region. Even though he hasn’t worked in Rouyn-Noranda in more than 20 years, the local patients still talk about him.
As I navigated through different specialties, no option was as appealing to me as ophthalmology. The fast-paced nature of the specialty resonated with me. There are so many ways of using various examination techniques and tools to quantify and measure a disease state and patients’ visual needs; at the same time, there are many unknown, unmet, and abstract areas of the field that keep us hungry to learn more and push the boundaries further.
When I was in medical school, I heard Iqbal Ike K. Ahmed, MD, FRCSC, speak at the Sally Letson Symposium in Ottawa. I vividly remember his surgical videos, questions, innovations, and no-holds-barred attitude. After the conference, I told myself, “That’s the person I want to learn from, and that’s what I want to do.” Unlike in years past, the field of glaucoma is now effervescent and fashionable. There’s a buzz at every conference, thanks to all of the new innovations and diagnostic technologies. For all of these reasons, my path eventually led me to complete 2 life-changing years of fellowship training with Ike; Devesh Varma, B Eng, MD, FRCSC; and Diamond Tam, MD, in Toronto.
Please describe your current position.
Upon my return from fellowship, I was fortunate to join the faculty of the University of Montreal in the Centre Hospitalier Universitaire de Montréal (CHUM), right in the heart of downtown Montreal. This hospital has been a working project for the city for more than 20 years and combines three hospitals into one: Hôtel-Dieu, Notre-Dame, and St-Luc. The hospital has already won several architectural prizes for its avant-garde design. It is a privilege to go to work every day in a brand-new, state-of-the-art facility.
I also joined the team of ophthalmologists at the University of Montreal, where I have the opportunity to pursue research in glaucoma and anterior segment surgery as well as teach residents and fellows. Teaching is one of the main reasons I aspired to pursue an academic career. Trainees push us to stay current and to rethink how things are done. They challenge us and allow us to grow and make a lasting difference. Inspiring a medical student or resident is truly special. Although I don’t have a lot of experience yet and know there can be challenges in teaching, my interaction with trainees has been one of the most rewarding aspects of my job.
I also work in a private clinic just outside the CHUM called the Clinique Ophtalmologique Berri. The owner, Younes Agoumi, MD, FRCSC, is a colleague of mine at the CHUM and has been a great supporter and friend throughout my transition to staff life.
Who are your mentors?
Fortunately, I have had many influencers (for the millennials out there) in my life. My father and my uncle, Salim Lahoud, have both been instrumental in my career choices. They have always been there to guide and counsel me, and most of the critical decisions in my career have been made after seeking their advice. I truly believe that proper mentoring is essential for flourishing in any profession.
Many other mentors from my training also come to mind, including Paul Thompson, MD; Paul Harasymowycz, MD; Mona Harissi-Dagher, MD, FRCSC; and Arsham Sheybani, MD (I had to include one American in there). To this day, these individuals serve as role models for me to learn from and try to emulate.
Recently, my fellowship preceptors have given me an abundance of new tools to treat my patients in clinic and surgery, but, more importantly, they have taught me how to be a better communicator and to advocate for my patients. My second year in fellowship was truly a unique experience. It allowed me to take a step back and rethink how and why we do certain things. I had time to reflect on difficult cases, complications, and potential struggles. I owe much of this to Ike, who has been monumental in my professional and personal development. He modified how I think about certain problems, pushed me to surpass myself, and allowed me to grow. Although he plays the role of mentor to many (because he’s so good at it!), I am fortunate to have also gained in him a lifelong friend.
What has been the most memorable experience of your career thus far?
Being an invited speaker is always an honor. Thanks to Ike and many others who believed in me, I have had the opportunity to speak at several conferences across Canada, the United States, Mexico, and Brazil. Being able to present my research or teach on new techniques or technologies has been a privilege. It requires a lot of hard work to prepare for these talks, but you learn so much from your own review and even more from the interactions afterward with those in attendance.
Last year, I took a particularly unforgettable trip to Brazil to present at the South Brazilian Congress. In this unique setting, the organizing committee had created an arena-like conference with three presenters giving talks simultaneously. Headsets were distributed so that attendees could listen to their preferred talk. The lectures were mostly in Portuguese, so I could not follow much, but I found the format original! This unique experience opened my eyes to a whole world of potential for future opportunities.
What are some new technological advances that you have found particularly exciting? Which advances in the pipeline are you most enthusiastic or curious about?
MIGS has brought the “sexy back” to glaucoma. There is now an abundance of new treatments, from trabecular meshwork bypass devices to subconjunctival MIGS. The range of devices and techniques that have entered this space can be overwhelming for the budding surgeon and seasoned veteran alike. A stepwise algorithm to glaucoma care now allows us to be excited about all of the different options. We can begin treatment with the less invasive devices and then progressively move toward more invasive solutions if the disease is more severe or uncontrolled. As a glaucoma surgeon, I’m excited about having all of these options—the ability to customize treatment from one patient to the next is what we should strive for in glaucoma care.
There are many interesting future developments in the glaucoma space, such as AI and machine learning algorithms, which are being used to predict which patients will progress or develop glaucoma. This is a fascinating area of research. Additionally, I am hopeful that during my career we will gain access to stem cell therapy to help reverse or treat glaucomatous neuropathy. This approach may still be at an embryonic stage, but its potential is immense.
What is the focus of some of your research?
The majority of the research I’m involved in are clinical projects, both retrospective and prospective. Currently, we are working on many investigations of MIGS devices, such as the Omni Surgical System (Sight Sciences), Xen Gel Stent (Allergan), and Preserflo MicroShunt (Santen). With any new device, there will be many unanswered questions. We need time and experience with these technologies to improve surgical outcomes and, more importantly, optimize patient care.
At the CHUM, studies have indicated that insulin may regenerate dendrite and synapses in the retina. We are currently involved in a trial evaluating the systemic effect of insulin drops. Eventually, we plan to test whether this treatment has a neuro-regenerative effect in patients with terminal glaucoma.
What is a typical day in your life? What keeps you busy, fulfilled, and passionate?
Typically, I start the day off by hitting snooze on my alarm clock a couple of times. When I wake up, I try to respond to any emails I can and flag those that require more time to answer. Then, I grab coffee and a light breakfast and off I go. I aim to work two to three clinics and 1 to 2 days in the OR per week. It’s nice to have a balance between clinic days and surgery days.
The demand for glaucoma care was high when I returned from fellowship, and this area has kept me the busiest. However, the most challenging cases that I encounter are typically anterior segment–related. These are the most enthralling cases, as they require out-of-the-box thinking and proper planning. It may take weeks to make the necessary surgical and mental preparations, from securing the OR materials to ensuring all backup options are ready as needed.
What I enjoy most in my practice so far is the variety of cases that I encounter. I may see a 16-mm nanophthalmic eye in the morning and a posterior polar cataract in a 32-mm eye in the afternoon. Sprinkled in between, I may see patients with progressing normal-pressure glaucoma and IOPs of 10 mm Hg and patients with neovascular glaucoma and IOPs of 40 mm Hg, not to mention iris reconstruction cases and unhappy IOL patients.
Teaching and research are also a large part of my current practice. These responsibilities keep me on top of my game, and I would find it hard to go about my career without trainees and research projects.
What advice can you offer to individuals who are just now choosing their career paths after finishing residency or fellowship?
First, make sure you have a good mentor to guide you and offer you advice. You will find that you often have a different take on things after talking with someone who understands where you are coming from. Then, choose a path you are passionate about. Focus on what will make you happy and keep you interested. Most important, keep an open mind and don’t make assumptions. Learn to question even the most basic procedures or dogmas. Finally, be pragmatic. Think of your personal life and professional life. It is sometimes hard to balance work and family, but it is even more difficult to be fulfilled in life if you’re neglecting yourself or your loved ones.
Tell us about an innovative procedure you are performing or a new imaging/diagnostic tool that has improved your practice.
The field of glaucoma is constantly advancing, and many of the devices and technologies that I work with daily have helped shape my practice. Recently, I’ve gained some experience with home tonometry and the water-drinking test, both of which are methods for assessing peak IOP as well as IOP outside office hours. This changes how we view IOP in patients with glaucoma. IOP plays a large role in the choice of procedure for a given patient, but the measures we take at every visit are only a drop in an ocean of IOP measurements outside the office.
For example, I was referred a 50-year-old Japanese patient for normal-pressure glaucoma with in-office IOP measurements between 12 and 14 mm Hg on no medication. She had a typical nerve fiber defect in both eyes and early nasal steps. Before starting treatment, I wanted to assess her peak IOPs. We performed a water-drinking test, and her IOPs increased to 21 mm Hg and 22 mm Hg. Does this patient still have a diagnosis of normal-pressure glaucoma? These alternate methods of measurement provide additional information on the patient’s disease and can help us better monitor treatment response and progression.