Beyond the clinic: Tackling the global ophthalmology training gap

The global shortage of trained ophthalmologists is most acute in low- and middle-income countries, where cataract—the leading cause of avoidable blindness in the developing world—remains largely untreated for lack of subspecialty expertise and clinical infrastructure. Addressing that shortage requires more than equipment and facilities: It requires sustained investment in education, faculty development and training standards that hold up against international benchmarks.

David E. I. Pyott, CBE, MD(Hon), MBA, MA, spent 17 years as chairman and CEO of Allergan, Inc, working primarily with ophthalmologists in North America and Europe. When he sold the company, he deliberately chose to remain in ophthalmology, shifting his focus to young ophthalmologists in underserved parts of the world. Together with Bruce E. Spivey, MD, MEd, MS, former executive vice president of the American Academy of Ophthalmology (AAO) and a past president of the International Council of Ophthalmology (ICO) and Trustee of the International Agency for the Prevention of Blindness (IAPB); Jim Mazzo, BS, past president of Carl Zeiss Meditec and past president of AMO (Advanced Medical Optics); Hugh R. Taylor, AC, MD, FRANZCO, of Australia; and Berthold Seitz, MD, ML, FEBO, who leads the International Ophthalmological Fellowship Foundation (IOFF) in Germany, Pyott cofounded the Ophthalmology Foundation, a not-for-profit organization based in San Francisco, California, US, in 2020. Officers of the Ophthalmology Foundation today are Mazzo, Pyott, Bruce E. Spivey, Julia A. Haller, MD, CEO of Wills Eye Hospital in Philadelphia, Pennsylvania, US, and Peter J. McDonnell, MD, Director of the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland, US.

Ophthalmology Times Europe (OTE) spoke with Pyott about the foundation's programmes, the role European institutions play in hosting fellows, the launch of a new international examination and the digital tools reshaping how surgical skills are taught across borders.

Note: Transcript edited for clarity and length.

OTE: You spent nearly 2 decades at the helm of Allergan working with ophthalmologists in developed countries. What prompted the shift towards education and training in low- and middle-income settings?

David E. I. Pyott CBE, MD(Hon), MBA, MA: Many people in your readership will remember me as the long-term chairman and CEO of Allergan, Inc—a role I held for 17 years. When I sold the company, I made a conscious decision to remain in ophthalmology but to change my focus fundamentally: from dealing with ophthalmologists in North America and Europe to helping young ophthalmologists in particular in low- and middle-income countries.

I was able to leverage the fact that I know many people both in the medical community and across industry. And through my wife and our private foundation, the David and Molly Pyott Foundation, I also have the ability to give back to these causes directly. It was a conscious decision and it is one I have not regretted for a moment.

OTE: How did the Ophthalmology Foundation come to be, and who were the founders?

Pyott: The genesis was a group of people who had been involved in various capacities at the ICO. Bruce Spivey, Hugh Taylor and Bertolt Seitz were the progenitors. All of us had grown frustrated with the direction the ICO was taking. The first step was to assemble a world-class board of trustees, drawing top people from industry and academia from every continent with a particular focus on those who care about training and education in the countries with the greatest need: Africa, parts of South America and Asia.

We made what we believed was a compelling proposition, and just about all the volunteers who had previously worked at the ICO came with us.

OTE: What are the foundation’s core programmes?

Pyott: There are three main ones, with a fourth coming along. The first was faculty education, essentially a replacement for what had been known as a train-the-trainers programme. The goal is not to impart greater ophthalmic knowledge to the head of an eye department or residency training programme, but to make them better educators. We have all experienced brilliant professors who are not particularly skilled at sharing their knowledge in a way that others can absorb rapidly. That was the first strand.

The second followed quickly: the fellowships programme, run by Seitz in Germany. We joined forces with the IOFF, and since 2020, the programme has grown considerably. Today, it is the largest of its kind in the world—around 90 awards per year—funded through the generosity of American industry on the San Francisco side and a range of European donors contributing directly to the German-registered charity.

The third is the most recent: international examinations. We wanted to offer something in a modern format, so the exam is delivered entirely online. The most recent sitting on 28 March 2026 had approximately 90 host centres around the world and was backed by artificial intelligence–monitored vision capture in addition to in-person proctoring. The system can detect, for instance, if a candidate is consistently looking to the side, which is not acceptable during an examination. Results were returned to all candidates within 7 working days.

Candidates who complete all three sections are awarded the post-nominal Fellow of the International Ophthalmology Foundation, which will become increasingly recognized over time. We have been deliberate about making the exam accessible. Fees are tiered by country, so the cost in Bangladesh is lower than in Egypt, which is itself lower than in Europe or North America.

The fourth programme, just beginning, is accreditation for centres that want to demonstrate they are operating to the standard of leading institutions in the US and Europe—similar in concept to the Joint Commission International accreditation but at a cost that is accessible to centres in lower-income countries.

OTE: Within the fellowships programme, what impact have you seen fellows make when they return to their home healthcare systems?

Pyott: I can speak not only to the 5 years since the Ophthalmology Foundation joined forces with the German-based IOFF, but to more than 20 years of the programme’s history. The common denominator is that people massively increase their knowledge in whatever subspecialty they have chosen. The most popular placement is cataract, because that is the No. 1 cause of avoidable blindness in the developing world, but fellows go into everything from retina to neuro-ophthalmology and we work to match them appropriately.

We make it a prerequisite that candidates return to their home countries. I cannot think of a single fellow who has failed to fulfil that pledge. They return with more than clinical knowledge. They come back with observations on how health care systems function—patient flow, efficiency and patient satisfaction—gathered from time spent in the US, Germany and the UK, which are our three largest host countries.

The happy end to the tale is that 5 or 10 years later, a strong common denominator is that these fellows end up as heads of department. They become leaders in their national society, sometimes even in their regional society. Beyond the formal education, they make lifelong friends with their hosts and with fellow fellows who have gone through the same experience at different centres. It is a wonderful stepladder to watch.

OTE: European institutions are among the primary host countries for fellows. How do you see Europe’s contribution shaping the future of global ophthalmic care?

Pyott: The origins of the International Ophthalmology Fellowships programme lie in Germany and Switzerland, which is why Germany remains the largest host country. German is the native language but host centres understand immediately that the programme must be delivered primarily in English otherwise it becomes complicated. Anyone who has spent time in Germany will know the standard of English is very high.

At a broader level, many countries in Africa and Asia have deep historical connections with Europe. We are well past a post-colonial world, but those connections still exist in meaningful ways. Many countries have strong ties with the UK through the Commonwealth and beyond and we see the same with French-speaking countries, where we have hosting centres across France, Belgium and the French[-speaking part of] Switzerland. We also have Portuguese centres hosting and mentoring colleagues in what are called Lusophone countries, Portuguese-speaking nations such as Angola and Mozambique, where the need is real and significant.

OTE: The foundation’s examination is offered at a reduced cost for candidates in lower-income countries. Why was affordability such a priority, and how does access to an internationally recognized credential change the career trajectory of an early-stage ophthalmologist?

Pyott: For me personally, setting up the foundation was a way of utilizing the knowledge I gained as a commercial person over almost 20 years, and now I am more involved in this work than ever. My colleagues and I have seen that there are barriers for young people at the start of their careers, and we wanted to make a material difference.

We are a not-for-profit [organization], so our goal is not to generate revenue from examinations. In the initial years, while we are still growing volume, we are making a conscious investment and [are] prepared to operate at a loss, though not indefinitely, because that would be an unsustainable model. As volume increases, the goal is to break even, and if we are genuinely successful, to reduce prices further and make the qualification even more accessible. Everything we achieve is driven by volunteers. To those who donate their time because they care about improving the quality of eye care in some of the world’s neediest countries, the thanks cannot be overstated.

OTE: Looking ahead, what are the biggest challenges and opportunities in scaling training and education to meet the growing global demand for eye care?

Pyott: I am more of an opportunity person than a problem person. I always say problems are there to be solved with good people and the right amount of resources. The new world in advanced economies and everywhere else is about how we learn and educate, both virtually and through hybrid methodology, and reserve in-person experience for the things that truly require it.

I will give one example. Orbis, the Flying Eye Hospital, deserves enormous credit for establishing Cybersight, an online learning platform, about 5 years before COVID-19. When the pandemic hit, use of Cybersight went through the roof and the platform was already there. Today, as we move into the third sitting of our exam, the most common question we receive is: How do I prepare? Nobody walks into a serious examination cold turkey. Candidates need to study the syllabus and understand what they are required to know. Cybersight has turned out to be an excellent preparation platform, and we are now working with Orbis to offer preparation resources there, around 2,000 questions with plans for more.

What I find compelling is the potential of real-time remote mentoring. It does not require the Orbis plane to be on the ground. It can be a camera in the university teaching hospital in Lusaka, with a local surgeon being guided through a difficult case by a colleague in New York, Sydney, Düsseldorf or London. That is the beauty of the modern world. We can improve skills efficiently, providing we do it in a thoughtful and considered manner. Once you start getting scale, you work out what works, replicate it and sunset the things that work less well.

OTE: The foundation has built partnerships with national and regional ophthalmology bodies around the world. What role does that local dimension play in what you are trying to achieve?

Pyott: Our examinations are based on the Basic and Clinical Science Course of the AAO—a globally recognized standard—and we have been supported from the outset by Peter J. McDonnell, MD, of the Wilmer Eye Institute at the Johns Hopkins University School of Medicine in Baltimore, Maryland, US, and Julia A. Haller, MD, of Wills Eye Hospital in Philadelphia, Pennsylvania, US, who have provided an important check on quality.

But the quality backbone only works alongside local partnership. We established relationships with the Pan-American Ophthalmological Foundation—I have served on that board for close to 30 years—as well as the African Ophthalmology Council and particularly for the College of Ophthalmology of Eastern, Central and Southern Africa (COECSA). The first examinations my wife and I personally sponsored and financially supported were the COECSA exams. In the last couple of months, we decided to merge those with our own foundation exam, at least for the first two sections, so that candidates in Eastern and Southern Africa benefit from global standards at scale.

Beyond that, we have national society partnerships ranging from Bangladesh and Egypt and the young ophthalmologists of India to South Africa, Nepal, Mongolia and Turkey—large and small countries alike. There are several more partnerships close to being finalized, which I do not want to pre-empt, but the direction of travel is clear. This is a genuinely global effort, and it will only succeed if it is rooted in genuine local relationships.

For anyone in the readership who would like to be involved, whether as a host centre or as a volunteer in one of our programmes, I would encourage you to visit ophthalmologyfoundation.org. We are readily contactable, and the need for committed volunteers remains real.

David E. I. Pyott CBE, MD(Hon), MBA, MA

E: [email protected]

David E. I. Pyott CBE, MD(Hon), MBA, MA, is vice president of the Ophthalmology Foundation, a not-for-profit organization based in San Francisco, California, US, focused on improving global ophthalmic education and training. He previously served as chairman and CEO of Allergan, Inc, for 17 years.