Taking a Wide View with Nakul Shekhawat

The summer after his freshman year of college, Nakul Shekhawat volunteered with a cataract outreach group in northwest India. It was August, in a desert region he describes as “a very dusty part of the world.” The goal was to screen people in remote villages for cataracts and take the most advanced cases back to the city for surgery. “I was in this very rickety bus with a group of six ophthalmologists and optometrists, and we got to this village where there was a crowd of over 200 villagers waiting for us,” recalls Shekhawat.

As it turned out, the majority of the villagers had cataracts, yet the bus only had seats for 16. “We fit 61 people on that bus and took them back to the city with us. They all had cataract surgery that night, one after the other,” says Shekhawat. He watched the operations on the screen, spellbound.

The next day, when the villagers’ eye patches were removed, many of them were able to see for the first time in years. “Their dignity was restored, their ability to walk around, read, look their loved ones in the eye — all these things came back to them with this simple operation,” says Shekhawat.

While cataract surgery may have seemed simple to him at the time, Shekhawat is quick to point out that it’s actually a very complex operation — a fact he can fully appreciate today as an assistant professor of ophthalmology at Wilmer Eye Institute. Yet it was that operation, which changed the lives of all 61 people that night, that inspired him to pursue a career in ophthalmology. Along the way, he received some very prestigious awards as a young ophthalmologist, including the Best Paper Award at the American Academy of Ophthalmology annual meeting as an intern, and the Dohlman Fellowship Award from Harvard University, given to the top cornea fellow in the country.

Positioned to Make a Difference

Shekhawat is a relatively new addition to the Wilmer faculty, but he’s not new to Wilmer. During graduate school at Johns Hopkins, he conducted research with Sheila West at the Dana Center for Preventive Ophthalmology. “It showed me what’s possible, that when we combine the fields of ophthalmology and epidemiology we can maximize our positive impact not only for individual patients, but also for entire populations,” says Shekhawat. “It solidified my perception of Wilmer as the place where you can really make a huge difference,” he adds. The experience later drew Shekhawat back to Wilmer for a cornea fellowship, and then a faculty position in the cornea division.

Shekhawat will initially be spending much of his time at Wilmer’s Bethesda and East Baltimore locations, caring for patients with cataracts as well as corneal and anterior segment disease. But he also hopes to develop his research interests, which include improving methods to diagnose, treat and rehabilitate patients with corneal infections.

As he explains, infectious keratitis, or corneal ulceration, is a leading cause of corneal blindness in developing countries, particularly in young, working-age adults. Often, says Shekhawat, it occurs following trauma. In the U.S., however, the biggest risk factor for infectious keratitis is poor contact lens hygiene, such as sleeping in contact lenses, storing them inappropriately or wearing them too long.

However, infectious keratitis is both more common outside the U.S. and much harder to treat due to limited access to care. Shekhawat says solving this problem will require a multipronged approach that may include training more local eye care providers, creating awareness that it’s a serious issue requiring prompt attention, and improving people’s ability to access care in a timely manner.

But he emphasizes that it’s also important to generate evidence regarding which treatments are best — and to improve the actual treatments themselves. “That involves innovation as well as vigorous testing, and I think Hopkins is very well positioned to be a leader in that space,” he says. Shekhawat is collaborating with other researchers at Johns Hopkins to study new ways of diagnosing and treating microbial keratitis that could bypass some of the existing barriers to care.

Opportunity for Improvement

Innovation appears to be a recurring theme for Shekhawat. As a fellow at Wilmer, he worked with engineering faculty on the development of new tools for performing cataract surgery at low cost in low-resource settings around the world — an ongoing effort that he says could have a big impact on reducing the burden of cataracts worldwide.

He also has an interest in using big data from health care claims to better understand the epidemiology of eye disease. “There’s tremendous potential in analyzing nationwide claims data from millions of patients at a time to figure out who in the country has eye disease, what kinds of diseases they have, which patients tend to develop certain diseases more than others, and how we can either prevent or more appropriately treat these conditions,” says Shekhawat.

For example, by analyzing big data from a large nationwide network, he found that the majority of patients diagnosed with acute conjunctivitis, or pink eye, filled a prescription for antibiotic eye drops. Moreover, the data showed that most prescriptions were filled within two days of diagnosis, and revealed the kind of drops that were dispensed and the type of doctor who dispensed them.

“We were able to tell all that by analyzing diagnosis and treatment codes. If you put all those puzzle pieces together, you can construct a remarkable picture of health care delivery patterns across America. These insights are useful from a clinical care standpoint, and even from a health care policy standpoint,” says Shekhawat.

The problem with that particular pattern, he says, is that the majority of acute conjunctivitis is caused by viruses, so antibiotics would not be helpful, and the majority of bacterial cases resolve on their own without treatment. And in certain situations, eye drops might even be harmful. “Our data analysis showed that among the patients taking eye drops, one-fifth were using drops that contained a mixture of antibiotic and steroids,” he says. “Steroids have their own side effects, and they can actually make certain kinds of infections worse.”

The study also raises issues of cost and unnecessary spending in the health care system. “Sixty percent of these patients are immediately going to a pharmacy and filling a prescription for a condition that usually doesn’t require medication, and that’s an opportunity for improvement,” says Shekhawat.