Hyderabad is a large city in the south-central part of India, which has always been familiar to me. I was born roughly 400 km from here in a small town along the Godavari river called Rajahmundry. Most of the family have since moved to Hyderabad, and as such, I have visited this city multiple times since I was a child. Every time I visit, I am humbled by the level of progress and development this city has experienced. Many now refer to it as “Cyberabad” thanks to the massive tech boom of the 2000s or the new high-speed rail that zips along with the city. But most importantly…..read more here, https://www.willseyeglobal.org/through-the-eyes-of-my-grandmother/ Please consider volunteering or making a small donation in support of Wills Eye Global here, https://www.willseye.org/center-academic-global-ophthalmology/donate-to-center-for-academic-global-ophthalmology/

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I left Hyderabad yesterday and already feeling a sense of “homesickness” that I always experience whenever I leave a place I really enjoyed.  My last four weeks at LVPEI learning MSICS were absolutely incredible and I look forward to building on this collaboration over the next few years.  I also look forward to seeing a few friends from LVPEI at the upcoming Academy of Ophthalmology annual meeting this fall.   Now, on to Madurai where I will have the opportunity to observe for about a week at the Aravind Hospital system.

Day 2:

I am greeted by Dr. Sankalp Singh, he is a cornea specialist who has graciously rearranged his busy clinical and academic schedule for the upcoming week to guide me through Aravind.   Madurai is medium sized city in southern India (it would be considered fairly large by U.S. standards) and serves as the flagship hospital for the Aravind system.  After a day touring the different clinic campuses in Madurai, I am again, awe-struck in the magnitude of patients treated.  Aravind treats over 50% of its patients completely free of charge and in 43 years has become one the largest hospital systems in India.  Its founder, a retired government ophthalmologist, Dr. Venkataswamy, started the hospital in 1976 as an 11-bed hospital in his hometown of Madurai.  Now, in order to reach those most at need, the network includes 7 tertiary centers, 6 secondary centers, 6 community centers and 75 vision centers.

The hospital system was one of the pioneers of the tiered payment system that has been remarkably successful in Southern India.  This model also been replicated by partner institutions in Africa and Asia.  In the late 90’s, Harvard Business Review looked at this model which was then followed by a frequently cited publication in Strategy+Business titled the “The Fortune at the Bottom of the Pyramid”.  The article showed how systems like Aravind could not only sustainably, but even profitably, fight poverty and work towards closing the socioeconomic gap.  Of course, all of the proceeds from Aravind go directly back to patient care and to allow the expansion of the system to reach those in need.

Day 4: Vision Screening Outreach

At 6:00 AM, I arrive at the hospital entrance.  Already the bus is idling and about 20 ophthalmic technicians (“Sisters” as they are referred to across the Indian healthcare system) are hurriedly loading all the supplies needed for today’s vision screening outreach.  Everything is brought aboard: makeshift room dividers, visual acuity testing lanes, trial lenses, ophthalmoscopes and even lens grinders.  Each weekend, many of these outreaches are happening concurrently, each reaching villages as far 5 hours away.  Most of the physicians are assigned 1 weekend per month to help lead these outreaches.  For our camp in the village of Kandanur, the bus journey is about 3.5 hours, interrupted only by a brief stop for tea.  Once we arrive at the village, we greeted by our hosts who immediately bring us upstairs for introductions followed by a breakfast of idly, sambar, rasam, a delicious “cane-sugar goo” (which I can no longer recall the name) and, of course, more tea.  The hosts are a family from the community who had been sponsoring the Aravind outreaches for their hometown for the past several years.  Much of the family now lives in Chennai and Wisconsin but they all come back every year to help host this event – a remarkable commitment to their community.

After about 15 minutes, the mobile eye clinic is fully up and running and there’s already a line about 200 people patiently waiting.   I asked one of our hosts how many people he anticipated coming and he was certain somewhere between 400-600 patients will be screened.  I was fascinated to observe how the Aravind method of patient care from the hospital setting was precisely replicated and minified to function in the outreach setting.

• Patients register and are given an identity card and examination form

• Vision is checked

• Pre-examination screening for gross ocular pathology
• Physician exam for cataract or other surgical needs

• If surgical, the patient will get lacrimal duct irrigation and eye pressure checked

• If not surgical, will get refraction and glasses

Every step, except for the physician exam, is done by a highly trained and specialized ophthalmic technician.  The workflow was remarkably efficient.  After 8 hours, with a brief break for lunch, nearly 600 patients were screened.  No one is turned away and any one who needs further care whether surgical, medical or just a refraction for glasses are treated 100% free of charge.  At the end of the day, a second bus from Aravind meets us and all of the patients that were offered surgery are taken back to Madurai where they will spend the night before their surgery the following morning.  Aravind will support the patient and 1-2 family members for 2-3 days to ensure proper presurgical planning and post-operative checks.  The outreaches are a vital resource to the community.  Without them, a majority of the community in Southern India would have zero access to eye care.

Perhaps no one understood this better than Dr. Venkataswamy as the outreaches have become a cornerstone to Aravind’s mission.  Each year, nearly 2,500 screening camps are held which generate around 40% of all cataract surgeries performed by the system.  After talking our hosts who helped sponsor this camp, this yearly event has become one of the most meaningful to his family.  Given the magnitude of patients seen through the Aravind network each of these villages may seem like a drop in the bucket.   However, at the end our long day in the vision camp in Kandanur our host sponsor remarked that he had recently noticed a yearly decline in the number members sent for cataract surgery.  He felt this was testimony that, for at least for his community, Aravind was turning the tides on blindness.

The Madurai Aravind Campus has 5 hospital blocks dedicated towards patient care, research and education.  A 2-3 minute walk down the street takes you to the international guest house were trainees and visitors are allowed to stay.  The accommodations were excellent and included breakfast, lunch and dinner.

The success of the hospital lies in its highly trained and specialized ophthalmic technicians.  These technicians are almost always women from nearby villages and the job provides a source of education and income for them and their families.  At the non-paying hospital block in Madurai, you can see screening lanes with technicians checking vision, intraocular pressure, refraction and performing a preliminary exam before the the treatment plan is finalized by the staffing physician.

Dr Sankalp Singh, a cornea specialist, graciously took the week accompany me as toured through the Aravind Hospital system.

Part of Dr. Venkataswamy’s vision was to make ophthalmic surgery economically accessible to masses.  To do so, Aravind started manufacturing its own intraocular lenses (IOLs) for a fraction of the price of the prevailing market.  They have since expanded to manufacturing sutures, blades, glaucoma drainage devices, antiseptics and pharmaceuticals.  I had the opportunity to tour the facilities (no pictures allowed inside), remarkable establishment.  As an aside, the manufacturing plant produces its own organic produce and 30% of their electric demands are generated by solar power.

A mobile eye camp, India serving 600 patients in one day

Approximately 200 patients had queued up before the camp had started.  By the end of the day, nearly 600 patients were screened for cataracts, glaucoma, diabetes and refractive error.

 

Our hosts provided breakfast and lunch for all of those involved in the screening camp.  I’m embarrassed to say that I cannot remember the name of each dish but needless to say my banana leaf plate was clean after a few minutes.  Delicious.

 

Ophthalmic technicians brought all the supplies from Madurai to setup mobile exam lanes.  Incredibly, the entire screening camp was assembled in less than 10 minutes.  They have done this so many times, everyone has their role and it’s a well-oiled machine.  Here technicians are checking for refractive error.

 

 

Even glasses are ground on site.

In the village of Kandanur (right adjacent to screening site) was a large temple which we all visited after the long day.

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 I arrived in India several days ago and immediately dived into the rigorous training schedule that is a hallmark of LVPEI.  As primarily an observer for these first few days, I’m starting to take in the scale and significance that LVPEI has for eye care in the region.

As a little background,

Established only 32 years ago, the hospital system serves a population of over 50 million from the southern Indian states of Telangana, Odisha and Andhra Pradesh.   The sheer magnitude and efficiency of the operations here are awe-inspiring.  To meet the needs of the region, the hospital system a central “flagship” hospital in Hyderabad as well as three other massive tertiary campuses in surrounding regions.   To access smaller cities and towns, there are 19 secondary sites, each with their vision screening programs, clinics, and operating rooms.

At these sites, fellows and residents each spend almost a year operating with complete independence: it is a core component in their training.   Surgically, these sites perform cataract extraction and pterygium excision primarily, however, they always have the safety net of any of the four tertiary centers to refer complicated cases, complications or patients who require subspecialty management.   Feeding into these secondary centers is an expansive network of 180 vision centers and “vision guardians” who are individuals from the community trained to recognize basic eye disease and visual deficits.  This network serves to connect small towns and rural villages to the secondary centers.  This pyramid of escalating care is a central part of how LVPEI can deliver such effective care to such a large patient population.  Over the next few weeks, I am excited to learn more about how the LVPEI system works as well as gaining familiarity with the Aravind model when I travel to Madurai next month.

Tomorrow, I have been assigned my first MSICS cases of this fellowship.  I will be operating under the mentorship of Dr. Swapna, and I look forward to challenges and rewards that lie ahead…

The featured photo is the main clinical wing; each floor is dedicated to one or two specialties.

These last two are the new wing for “sight savers” which is a higher payment tier that not only financially supports the hospital but allows for 50% of the patients to get treatment completely free of charge.  The hospital had a full-time artist commissioned who made all of the art for the hospital.  There are so many beautiful paintings around the hallways, and each clinic it would be impossible to capture them all.  There are so many paintings around the hallways, and each clinic it would be impossible to capture them all.  Also, I’ll see if I can get better external photos of the hospital, the lighting was odd when I tried this evening.

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During that experience, I decided to apply to medical school and subsequently moved back to Texas to study at the University of Texas Medical School in San Antonio.  My initial interest was in infectious disease, instead, however, ophthalmology found itself as the perfect fit for my interests and an ideal specialty to launch a career in global medicine.  Throughout the residency, Wills Eye Hospital has facilitated every interest and has provided every opportunity towards furthering this endeavor.  Since my acceptance to Wills Eye in 2015, I have been following the Academic Global Ophthalmology fellows’ blog while eagerly awaiting the opportunity to embark on this incredible year.

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There’s a steady flow of brilliant minds swarming the halls of LVPEI every day. The day begins at 7 am …sharp. As I walk over from the apartment to LVPEI, there’s a certain point after entering the main gate, where my path merges with the rush of residents and fellows heading into the building. Everyone silently speeds walks down the hall and up six flights of stairs to the lecture hall, squeezing through the doorway at 6:59 am as the staff have one hand on the doorknob, ready to shut and lock it right at 7 am. Phew, obstacle #1 overcome: made it to lecture on time. Obstacle #2: finding a seat. All of the attendings, trainees, and optometrists attend these lectures, so sometimes there are absolutely no seats remaining and you are directed to the overflow room to watch the lecture.  It’s quite incredible actually, that everyone makes it a priority to come to the lecture this early in the morning – it’s a testament to the dedication of these clinicians. After this, trainees will either head to the canteen for breakfast or to their respective clinics to see post-ops before heading to their assigned locations for the day. There are about 2000 patients who come through the Institute on a daily basis, so you can imagine that the days are long and busy. The institute is set up so that every step of the patient experience (from registration to ancillary testing to counseling before check out) is addressed in an efficient manner, which is evident in how many patients they are able to see per day. It’s remarkable. The institution is fully equipped with every subspecialty, including low vision and rehabilitation, ocular oncology and even an innovation lab. I spent most of my time outside of MSICS training with Dr. Sirisha in the glaucoma clinic. She is a very revered glaucoma specialist who is loved by her patients and trainees. She efficiently moves through the wave of patients with empathy, a positive attitude and manages to find time to teach along the way. It takes a few days to really get adjusted to the pace and the magnitude of all that goes on at LVPEI, but once you get a hold of it and see how much it has to offer, you can’t help but dive in and try to learn as much as possible.

MSICS Training: 11/3/18

MSICS training is well underway at this point, primarily under the guidance of Dr. Revathy. She spends most of her days with the residents and fellows in the training OR, teaching Phaco and MSICS. I couldn’t have asked for a better instructor. She is so patient and always gives constructive feedback to help you improve with your next case. It’s been nice having other trainees around as well, as we watch each other’s cases – learning from the challenges, celebrating victories and critiquing mistakes – to help each other grow. As with any type of surgery, after doing a couple, you start to understand how vital each step is to the success and ease of the case. Of course with MSICS there are several critical steps that make a huge difference, such as the integrity of the scleral tunnel and delivery of the nucleus, but it’s the seemingly less obvious precautions – such as the appropriate bend of the shaft and tip of the cystitome, quality of cauterization, length of the ACM port, amount of viscoelastic used – that has surprised me more as key components of a successful surgery. Many challenging cases later, and thanks to Dr. Revathy and team, I now feel comfortable with the MSICS technique and am excited about improving these skills and treating more patients both abroad and at home in the US with this surgery.

An OR day with Dr. Sirisha, myself and 2 other trainees observing glaucoma in the OR. Unfortunately, Dr. Revathy is not in any of the pictures

Myself and Dr. SIrisha on the last day of the rotation. A brilliant glaucoma specialist who I truly enjoyed working with.

A picture of the LVPEI main campus

Aravind: 12/1/19

I spent one week at Aravind Eye Hospital in Madurai, trying my best to learn what makes this hospital system so great. Dr. Balaji, a consultant at Aravind, was in charge of setting up my schedule for the week and he couldn’t have done a better job. I had meetings set up with the director of the vision centers, residency program director, LIACO (an initiative to improve eye care in other countries), aurolab (lab producing intraocular lens, sutures, eyedrops, etc) and many more. I also was lucky enough to visit a vision center and a cataract campaign. Every consultant I met was so dedicated to the mission and philosophy of the founder Dr. V, which has really penetrated through the entire hospital system. There are two areas that I want to highlight:

Vision Centers: These are very small, usually around 500 sq. ft, offices that are primary eye centers in small towns. The towns usually have a population of about 15,000 and no other major eye center is within a reasonable distance. In each vision center, there are 2 sisters (technicians), one is the administrator and the other is the provider for that center. Prior to their placement in the centers, these sisters are recruited (usually from the same village that they will then work in) and go through a few years training process at Aravind. They learn everything from retinoscopy and applanation to performing fundus exams and photos. Patients can walk in to be seen and the sister will do a complete exam and discuss every case (including showing slit lamp and fundus findings/photos) to a resident or fellow at the main hospital via video conference, who will then decide the management for that patient. They keep track of productivity each year, analyze the data and work on areas that need improvement. Each new consultant at the base hospital is assigned certain vision centers to manage, and luckily during my week, it was Dr. Balaji’s turn to check in on his centers. He observes the sisters while they are seeing a patient and presenting to the consultant over video call and grades their work. He discusses with them their strengths, weaknesses, and areas that need improvement. In this way, these centers are sustainable and continuously improving. This system has allowed Aravind hospital to reach populations who would be unable to seek eye care otherwise.

Cataract campaign: Aravind provides many different types of camps – cataract, refraction, diabetic, etc. I was fortunate enough to observe a cataract campaign during my week. A team is rallied and sent out to a village – 2 residents, technicians, counselors, refractionists, and so on. This particular camp was about 2 hours outside of Madurai. Between the two residents and the rest of the team, nearly 300 patients were screened in just a few hours! At the end of the camp, patients who were thought to have visually significant cataracts requiring surgery were provided transportation to the base hospital the same day, for surgeries to be performed the next day. Everything is covered during their stay in Madurai – boarding, nutrition, surgery, post-op medications. What struck me the most about this particular camp, is pictured in the image below. Boxes of various powered spherical and spherocylindrical lenses are brought along to the camp. Patients are refracted and given a prescription. Another sister takes this prescription, finds the appropriate lenses, then chips and grinds the lenses for the patient….right then and there to be fitted into their frames, SAME DAY. I was completely blown away by this. Hand ground lenses. This sister must have chipped and ground 50+ lenses that day, almost non-stop from morning until early afternoon. Now, this is outreach at its finest – giving sight in every way possible and as soon as possible.

Dr. Balaji and his team at one of the vision centers. The two sisters in blue are the sisters who run that vision center, doing a fantastic job for their patients.

A sister hand grinding lenses to be fitted same-day into a patient’s existing frames

Rwanda International Institute of Ophthalmology (RIIO): 12/20/18

Last stop for this travel block: RIIO, Rwanda International Institute of Ophthalmology. This is the first and only ophthalmology residency program in Rwanda, under the guidance of Dr. Ciku and Dr. John. The program currently has 4 first-year residents who are actively preparing for the first part of their ICO exam in April. My time here was spent focusing on lectures and refining clinical and surgical skills with the residents. They had an amazing opportunity to take an MSICS training course in Cape Town and returned at the start of my visit. With these skills fresh in their minds, we practiced suturing and scleral tunnels in the wet-lab, in addition to applanation, retinoscopy and gonioscopy in the clinic. Of special importance to me on this trip, was the opportunity to participate in my first surgical outreach camp of the fellowship year. I accompanied Dr. Francis, a local ophthalmologist in Kigali, and team members from the Fred Hollows Foundation, to a village about 2 hours away called Kiziguro. We arrived at the outreach site on Friday evening where we assessed patients for cataract surgery and then the next two days were operating days. What stood out to me was the number of patients with bilateral, dense cataracts. I’m talking bilateral count fingers to light perception vision…for years. These patients were traveling from hours away and needed the help of at least 1-2 family members for their every single move. It’s a feeling comparable to no other when you see a patient who was needing assistance and tactile guidance to get to the operating table before surgery, the very next day after surgery walking unaided with a huge smile on their face. One patient expressed in Kinyarwanda “if the surgery in my other eye will allow me to see like this one, I will jump up and touch the sky!” This surgery that takes little time and is of low cost, gave this gift to these patients and their gratitude is unmeasurable. This was an experience engraved in my mind. It’s a perfect reminder of what this fellowship is all about – improving eye care around the world and training ophthalmologists to go out and serve these deserving patients of their country. The more we transfer skills and knowledge to trainees and community ophthalmologists, the more sight we improve and preserve.

Dr. Francis and the team at the Kiziguro hospital along with members from the Fred Hollows Foundation. Supplies for this outreach was provided by the foundation.

2 pictures of bilateral dense cataracts in patients encountered during the outreach. There were many patients who had similar findings

RIIO first-year residents standing in front of their educational department

Dr. John and Dr. Ciku working hard in the OR on my last day in Kigali

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The livelihood of many rural Rwandans depends on their ability to harvest crops such as tea and sugarcane. The burden of blindness is especially cumbersome in these communities that rely on manual labor for their primary means of income. The work of Dr. Ciku Manthenge and Dr. John Nkurikiye is critically important in these communities, and highlight to the rest of the world the importance of giving back to those that have given so much to us.

To check out their work, and the future of Ophthalmology in Rwanda, please visit the Rwandan International Institute of Ophthalmology website at www.riio.org

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I first learned about LV Prasad well before my time here.  My grandmother was treated at its Kallam Anjali Reddy campus in Banjara Hills multiple years prior. It was the only place she trusted for her glaucoma, and once I entered into a residency in Ophthalmology, she would frequently recall her experiences as a patient there. She would often describe the impressive quality of the facility and the high level of treatment and care she would receive by the fellows and attendings.

With this in mind, I was overjoyed to spend a month here as a MSICS trainee. The first and foremost principle I learned at LVPEI is a dedication to the craft through high-quality research and patient care. LVPEI is and has always been a thought leader in many fields of ophthalmology such as the creation of the SLET technique for limbal stem cell deficiency after ocular burns. Thanks to the innumerable patients that walk through LVPEI’s centers around India, and the meticulous data collection through its proprietary EHR, LVPEI stands to make huge breakthroughs in the field of Ophthalmology through incredible data sets. Questions that other research institutes may not be able to answer through small sample sizes are virtually negated at LVPEI.

The next principle was altruism. LVPEI functions similarly to every major eye institute I have seen in America and Europe from prepping the patient to surgery to examining the patient postoperatively. However, LVPEI is able to deliver care to all backgrounds regarding their payor status. The way they do it is through the sight-savers program or a tiered payor system in which patients who are able to pay for their care subsidize the care for 4-5 “non-paying” patients. LVPEI also has a wealth of secondary cataract centers around the surrounding regions that host fellows and residents who can offer cataract surgery for all communities of all backgrounds.

The last principle was excellence. Every fellow is required to punctual, consistently well dressed and groomed, and to pay attention to every detail. This diligence is carried over to the clinical care of patients where every detail (small or large) is documented and attended to. This is especially true also in the surgical setting in which excellence is demanded and pursued by the consultants starting from installation of dilating drops, to delivery of the cataractous lens in MSICS. There is no doubt in my mind I am a better physician, surgeon, and person for participating in this culture.

On a more personal level, through LVPEI I was fortunate to see and treat patients with vision disabling cataracts through MSICS surgery. It was hard not to feel a special kinship with the patients I operated on. It was hard not to feel that the stories of my patients were ones of my own, of my uncle’s, of my grandmother’s. I am truly thankful to the chair of LVPEI Dr. Rao and LVPEI for being an incredible host and to Dr. Feldman and the Wills CAGO program for this special trip to the motherland.

Here are some attached photos of the trip including a photo with my co-trainee Ameeta who is a wonderful friend and surgeon who will be hopefully practicing in the Delhi area in the coming year and my surgical mentor Dr. Revathy who is a cornea, refractive, and cataract surgeon at LVPEI and easily one of the best surgeons I have ever seen.

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