Friday, 21 December 2012

Helping Baby Laasya Battle Squint and Cerebral Palsy

My daughter Laasya was diagnosed with Jaundice at birth. The jaundice was said to be at alarming levels, but she was treated in time and under proper medical supervision. But Laasya was diagnosed with Cerebral Palsy in her early development stages (below one year).

Thanks to my association with an NGO called PAWMENCAP , I was definitely moved  to start doing rigorous research on cerebral palsy conditions and most of all trying to pull the family together on accepting it first. This was a testing stage but I should thank many doctors who came along the way and helped us attain confidence.

 Cerebral Palsy is a special condition and this condition needs to be first identified and diagnosed properly. There is not just one stream of medicine and not just one sub stream of medicine that can make the life of the CP patient better. My experience has been that it is a collective effort and the parents play a very important role in pulling these efforts together.

Few of the people that I want to make a special mention here:
Dr. Patrick – Energy Healer
Dr. Michael Kokinos – Anthroposophy
Dr. Ramesh Kekunnaya - Head, Pediatric ophthalmology, Strabismus & Neuro ophthalmology , L V Prasad Eye Institute
Dr. Dhenuvakonda Sreeraama Murthy – Ayurvedic expert and a President’s award winner.
Ms Neeta, Dr Laxmi Prasanna - Sandeepani Healing & Curative Centre
Dr. Naveen – Head of Physiotherapy at NIMS.

Every experience has been a fulfilling one and has always taken us one step closer to giving a better life to Laasya, our child.

I would like to make a special mention  of Dr Ramesh Kekunnaya from L V Prasad Eye Institute for his efforts on one very critical element of the  entire 'healing cum curative' process - the eyes.
My child has Ataxic Cerebral Palsy, which results in balance coordination issues and tremors in muscles, and she was missing her developmental milestones.She also had squint , which is a result of  Cerebral Palsy. She was not able to get a perfect view of a subject, adding to  her troubles with “further resistance to achieving her developmental milestones”.

 Given our child's very tender age of less than two years, it was a very difficult decision to take; a muscle correction surgery with a success rate of 50% and in most cases - we were told - the surgery needs to be done twice or thrice.

It was very important for us to be educated on the success rate and recurrence of the condition; I must personally appreciate Dr. Ramesh Kekunnaya for having done a fantastic job of handling parent psychology with commendable ethical conduct of explaining the truth and not raising expectations but telling the truth; and of all things, handling the surgery successfully.
Maybe this is the specific reason the medical profession is still called a 'practice' in spite of  the success rates.

Laasya can now see objects, read properly, write with a little difficulty and recognize things. Our joy knew no bounds when post-surgery, Laasya identified the actor Mahesh Babu on a hoarding after watching a movie on TV and said “Mannatha babu!” as she could not pronounce that right.

Laasya still cannot walk but she stood 2nd in a class of 15 in the pre-primary that she has been going to for last few months. I cannot think of anything else but her ability to COMPREHEND purely due to the ability to see and repeat, thanks to the eye surgery. We haven’t been able to go back to the hospital due to the fear that Laasya has of seeing white gowns.  But she needs another surgery, and we will get that done soon.

The journey of successfully handling Laasya’s CP has been so fulfilling due to the good people around who give the right suggestions.  Personally, I am a fan of L V Prasad Eye Institute  which is doing such great service to the needy. My great grandmother was operated for cataract at 85  years of age and till her last breath, she did not need another surgery.

[The writer is Vinod Achanta, Laasya's father]

few photographs of Laasya -  pre and post surgery. 

A video of her being able to finally stand on her own.

Laasya’s latest photograph. 


Friday, 7 September 2012

Retinopathy of Prematurity: Baby Shivani's Vision Saved In the Nick of Time

The agonising wait to see two little feet did not end for this young mother when doctors confirmed twin babies following treatment for infertility.  Shivani and her brother were delivered by skilful hands in a hospital in Guntur.  The babies were too fragile due to premature delivery and only one of them survived the trauma.  After two weeks in Neonatal Intensive Care unit (NICU) fighting out the threat of infection, breathing problems, jaundice, lack of blood elements, feeding difficulties, etc the fragile Shivani weighing just 1000 grams was handed over to her mother, Narayanamma.

However, all the care givers were blissfully unaware of a looming threat that had started inside her eyes - in the retina. Because of the extreme prematurity and low birth weight compounded by the additional problems of oxygen use, infection and anaemia, the retina in her eyes had failed to develop normally. Blood vessels in the retina were growing abnormally and would soon bleed with no external signs visible to the doctors, the parents or the staff. Child appeared to have normal eyes; she was responding to light and moving the eyes normally as if searching around to see. Only about 2 months after birth, the child specialist recommended an eye test and suggested that the parents visit Dr.Chaitanya, an eye specialist in Guntur.

Dr.Chaitanya had returned to Guntur after completing her training at L V Prasad Eye Institute (LVPEI). The training was on how to take care of eyes of a premature baby, especially for the potentially blinding disease called ROP- Retinopathy of prematurity. LVPEI, helped Dr Chaitanya master the science of treating ROP. She spent one month visiting several NICUs in Hyderabad with the teaching faculty from LVPEI for hands on experience.  Examination of these babies required using an indirect ophthalmoscope to peek into the inside of the eyes of infants in incubators to learn what ROP looks like. She learned how to use laser in eyes where retinal bleeding was seen. Initially hesitant,  after a month, Dr Chaitanya was extremely confident to handle the tiniest of her potential patients.  She realised very soon that ROP is a time bound disease and the urgency to act swiftly. 

But training was not enough. Dr.Chaitanya had a much bigger obstacle to overcome before babies would come for treatment at the correct time- the obstacle of information and lack of awareness. She started a sustained and systematic campaign in her town aimed at creating education and awareness amongst the dozens of child specialists and fellow eye doctors. She printed flyers and distributed them to all concerned hospitals and clinics, she wrote articles in the local press; She arranged a CME (continuing medical education) on ROP for the practitioners where faculty from LVPEI gave lectures; again she followed up the CME with regular weekly telephone calls to all NICU asking if there were any babies to screen. One such call to Shivani’s pediatrician was what had awakened him to consider an eye checkup for the baby and motivated him to send the baby to Dr.Chaitanya on July 9th!

One look at the retina of the baby left Dr.Chaitanya aghast. She could see the ROP in a very advanced stage and knew that time was running out. Shivani had to undergo laser within next 2 days or things would go out of hand and chances of permanently losing her vision were very high.   Vision would never return for this baby who had survived such a stormy beginning to her precious life. The parents were advised to rush to LVPEI at Hyderabad, however, considering their poor economic background they visited Dr Rama Devi at Vishakha Eye Hospital in Vishakapatanam, another doctor who had undergone ROP training at LVPEI.  Under her best capability, Dr Rama Devi performed two sessions of laser treatment. But the challenge was far from over. The old blood was pulling on the retina that had started to detach in the periphery and in a week or so would reach the centre of the eye, leading to irreversible vision loss. The doctor knew that this was an extreme case of emergency; Shivani had to be sent to LVPEI in Hyderabad. Dr Rama was confident that ROP cases will be attended to without prior appointment at LVPEI so Shivani and her parents rushed to LVPEI at Hyderabad.

On presenting the referral letter, the receptionist who was fully aware of the emergency nature of ROP, processed their registration without any delay. They were whisked away to the third floor to the exclusive childrens’ centre where a nurse instilled the appropriate eye drops to make Shivani ready for examination in 20 minutes. The doctor, Dr. Subhadra Jalali, perfomed a detailed examination of Shivani’s eye. She explained with the help of RETCAM pictures and video indirect Ophthalmoscope recordings, what was happening inside the eye. For the first time the parents had the opportunity to actually see the complexity of the case in the back part of the eye- the retina.  After a series of consultations surgery was the next step. Within a short period of time, the surgery was conducted in both eyes uneventfully for stage 4 ROP. In the evening, Shivani was taking feeds and seemed comfortable. Bandages were removed the next day. Shivani was discharged with a reassurance that the battle was now decidedly won and the crisis was over, though the treatment was not. Two weeks later on re-evaluation the child was smiling at the doctor and responding to the whims of a lighted doll that lay before her. RETCAM photos now showed no blood or detachment. Shivani was referred back to Dr.Chaitanya in Guntur for further management that could be done closer to home. The importance of eye drops, checkups and optical glasses were explained.

Few years ago, before the SSI sponsored ROP network of services in Andhra Pradesh had been set up, such babies had no chance of retaining their vision. Their child specialists and eye doctors were not aware of the time bomb ticking away in premature babies’ eyes and such babies were brought to LVPEI only at 6-7 months of age with total retinal detachment (stage 5ROP). Heart wrenching stories of premature babies losing their eyesight over the lack of trained doctors and hospitals were a tale of the past. The story today is different. Shivani’s vision had been successfully restored from the brink of disaster. Better results could have been achieved if Shivani’s parents had been informed by their child specialist (Paediatrician/neonatologist) about the importance of early recognition and timely retinal screening before 30 Days of LIFE.

Surgery had been done at no cost to the poor parents and with facilities that were second to none in the world-thanks to the generous grant from the SSI that had facilitated a network of ROP services in the state of Andhra Pradesh. From Guntur to Vizag to Hyderabad a whole network of trained people had helped them achieve this wonderful result. Each link in this chain had been vital. Each mesh in this network had carried out its assigned role diligently with the result that the baby did not fall through but was carried forward to a successful outcome. For Shivani and many more future Shivanis’ in Andhra Pradesh the future is bright and life awaits them with open arms. Today, Shivani can see and play, tomorrow she will read and write in school, possibly unaware that the glint in her eyes was lit by a beacon generously donated thousands of miles away on the other side of the globe, through Sight Savers International.

Tuesday, 31 July 2012

Triumphant without sight! The inspiring story of Bhakti Ghatole

Little Bhakti is the epitome of an achiever, the role model for all youngsters.  Despite her visual challenge, she adapted and adopted various life skills and tools to deal with her loss.  Three cheers to the topper in the Secondary School Certificate (SSC) 10th Class Examination 2012 in Maharashtra! Bhakti attributes her success to the mountain of strength - her mother Sushma Ghatole, who ensured she learnt to read and write in Braille and use JAWS software - the two languages that the blind swear by. Sushma recorded her text books in Abrar mobile audio software in Marati and Hindi, accompanied her every evening to three tuitions in Sanskrit, Mathematics and English, and saw her through 26 chemotherapies, laser and cryotherapy treatments and two radiation therapy treatments. This is not an easy commitment and only a mother can execute all these tasks without a sigh or complaint.

Bhakti was diagnosed with retinoblastoma as a six month old baby. Her left eye had to be immediately removed to save her life. Retinoblastoma is an eye cancer that afflicts children below three years of age, at an age when the retina is still not fully developed. The doctors had told the parents that after age five, she need not return for follow up as she would be safe with a mature retina and a fully grown eye. And yet, most unfortunately, tragedy struck a second time, when Bhakti was nine years old – it was rare for the retinoblastoma to return at that age.

Bhakti was being treated at a hospital in Chennai and her doctors advised that her eye must be removed. Her father was too shocked to bear the predicament and refused to have Bhakti’s second eye removed. Two years passed before they heard that L V Prasad Eye Institute was offering a new treatment called Brachytherapy. Though Bhakti was found unfit for that particular treatment, she did have to undergo six cycles of chemotherapy to save her life. And yet again it was her mother’s initiative that ensured the correct steps were taken – when Bhakti’s father refused to face the trauma of having the second eye removed, it was her mother who brought Bhakti to LVPEI accompanied by her maternal grandfather.

These were trying moments not just for the family but more so for the young child.  At an age when she should be carefree, enjoying the pleasures of life, she was put to test.  A lot of negative emotions could have filled her mind, but this strong young girl willingly underwent eye surgery to have her second eye removed. From here on Bhakti had to consciously strive to hold her head high. She decided to learn yoga and pranayama to boost her spirits and help her concentrate better on her studies. Cheerfully conversing, attentively listening, narrating the long list of names of people who helped her clear her examinations in flying colours, this IAS-aspirant is a charmer all the way. In her avatar as a cheery and positive young person, Bhakti is a survivor in the truest sense.  

Bhakti Ghatole was diagnosed with Retinoblastoma (eye cancer) when she was a six months old baby. She has survived cancer, lost sight in both eyes and was a topper in class 10 exams. A true winner!

Bhakti with her mother, Sushma Ghatole, her pillar of strength.

Tuesday, 10 July 2012

An Eye to Success: Back on the road to mainstream living

The Story of Vijayadurga

Vijayadurga, a mother of two and a school teacher by profession, led a very active life at one point, catering to the needs of her husband and daughter - making breakfast, packing lunch, getting her daughter ready for school and then carrying on with the remaining household chores.  Vijayadurga started having trouble with her vision at the age of twenty-six and gradually started losing her vision due to an eye condition “Retinitis Pigmentosa” and had to quit her teaching profession   as she was not able to manage them any more. For a person who is used to being very active this sudden change in daily schedule due to vision problem was depressing.  Vijayadurga’s husband, a software engineer brought her to the tertiary Centre in Hyderabad.  Here, at the centre after preliminary investigations, doctors confirmed the diagnosis that neither spectacles nor intensive treatment, nor surgery could reverse symptoms. Her visual acuity was worse than 20/600, which means Vijayadurga had severe visual impairment and the residual vision is useful only for functional mobility during day light.  She cannot rely on print anymore.  The good news was that she was counseled by the rehabilitation counselors and was given a new hope to enhance her quality of life through rehabilitation intervention.  The rehabilitation centre offered her various skills training and supportive services for independent living and Vijayadurga has been using all of them for the last 6 years.

This is the advantage of having rehabilitation services within the hospital itself. The patient is able to get immediate psychological support through counseling and able to access the various rehabilitation skills training   without wasting their time or having to travel elsewhere.  Hence, rehabilitation services should be part of every eye hospital where patients with low vision or blindness seek care. However, LVPEI had built these services in its mission statement right from its inception about 25 years ago.

Setting a patient back on the road to mainstream living is a sustained task that requires patience, fortitude and unending optimism.  The first step is direct interaction which starts with assessment of vision, then identifying the needs of the person and prioritizing them. This is important because these needs vary for different people. 

Over the last 25 years, LVPEI has successfully rehabilitated over one lakh visually impaired clients with low vision and blindness across all age groups and strata of the society.  Vijayadurga was one of the many who were fortunate to be treated at this centre, which is the first of its kind in the country to offer comprehensive rehabilitation services within an eye hospital. It is also the first to make available state- of- the- art low vision devices and training programs combined with specially trained professionals. After the initial counseling sessions with the team, Vijayadurga’s family decided to go in for training in mobility, home management skills, money identification & management, computer skills, Braille skills and Daily Living Skills and also benefitted from our digital audio books services.  She is a regular participant of all workshops organized at the centre on advocacy, communication skills, personality development etc. We made home visits and assisted her in redesigning her kitchen for safe use. Vijayadurga never dreamt of leading a close to normal life when she started facing blurred vision problem.  Today, she helps her children with their studies by taking lessons orally and manages all household chores independently. She is actively looking out to secure a job and get back to normal routine.

Low vision is 4 times more common than blindness, a majority of the visually impaired have remaining vision that can be put to maximum use.  Setting a patient back on the road to mainstream living is a sustained task that requires patience, fortitude and unending optimism.  The first step is direct interaction which starts with assessment of vision, then identifying the needs of the person and prioritizing them. This is important because these needs vary for different people.  Together, the 2 Vision Rehabilitation Centres at L V Prasad Eye Institute -  the Meera and L B Deshpande Centre for Sight Enhancement and Dr. P R K Prasad Centre for Rehabilitation of the Blind and Visually Impaired provide comprehensive low vision rehabilitation services.  The training is available not only to patients who visit the Centre but also to those with low vision and blindness in the community who cannot access the services through community-based rehabilitation services. Keeping LVPEI’s philosophy in mind, we extend the rehabilitation services to the community, coordinating with the local people and pooling in local resources. From our experience, local community plays a big part in the smooth delivery of our services.  

Given that LVPEI has a physical presence in 107 locations across AP and that people in rural areas tend to have a higher prevalence of low vision and blindness, we aim to expand the low vision rehabilitation services across the LVPEI network so as to be able to cover the remotest regions of the state. By providing these services we intend to impact the lives of all those with low vision and blindness by improving their quality of life.

Monday, 30 April 2012

Happy and Priceless New Year!

Happy and Priceless New Year!

Although Ugadi marks the New Year for the people in Andhra Pradesh, in reality it is pretty much the same each year. But Ugadi on March 20, 2012 was really special for a team of doctors at L V Prasad Eye Institute.  They were  challenged, early morning that day, in the operating room number 8 in their KAR campus to perform a difficult surgery on Shravya ( name changed), a tiny baby weighing just 1400 grams suffering from a critical, potentially blinding condition of Retinopathy of Prematurity (ROP). What better way to start the New Year morning than help restore sight to a new born on the brink of a lifetime of blindness within a month of birth. 

Little did the parents of baby Shravya think that this prematurely born baby would develop a serious eye problem so rapidly and so soon, within 3-4 weeks of birth! Oblivious to what was happening around, the newborn was busy cooing in the mother’s lap, listening to voices but unaware of the tense surroundings.  Apprehensive, but happy to know that there is a hospital in Hyderabad where he could take his fragile , newborn baby for consultation, N Satyanarayana, a parent from Tarnaka area of Secunderabad entered L V Prasad Eye Institute carrying his baby, hoping that the disorder would be diagnosed and managed properly.  The referring doctor had told him the urgent and serious nature of the eye problem.

From 1999 onwards, LVPEI was the first hospital in India to start a city-wide, all inclusive NICU - centered ROP screening program. Under its Indian Twin Cities ROP screening study (ITCROPS) it has regularly been deploying a team of doctors who visit the Neonatal intensive care units (NICU) weekly once, in and around the twin cities, to screen pre-term babies for ROP. Till date more than 7000 babies have been seen and managed under the study. This experience came in handy when faced with the daunting task of doing microsurgery on this extremely fragile 1400 gram baby who had barely started taking the mother’s milk after days of life-threatening struggle for survival in the intensive care unit.

On careful evaluation, it was diagnosed that the baby was suffering from a critical condition of Retinopathy of Prematurity that was like a fire- ready to permanently destroy the Retina of both eyes if not operated within the next 3 days!  The physician realized the seriousness of the issue and informed the parents that an emergency operation needs to be done.  Risks and benefits were clearly laid out. But the family was not left alone to take the tough decision to hand over their baby to a team of doctors- doctors who were ready to do the best but it was a very risky affair even in the best of centres! The doctor gained their confidence by saying ‘we are in this together as a team with the baby in the centre of our endeavour at the moment and we have to join hands together and face any consequence together’.

On the verge of blindness with retinal detachment, the father had no option but to risk the life of his child who otherwise would succumb to leading a life in darkness. He could perceive the genuine interest the doctors had in his child’s vision and life- he agreed to stand by with the whole team with all the courage he could muster. After the initial counseling, the parent decided to have the surgery done on one eye.  With a lot of support from the team of doctors and support staff, the specialist explained the need to do the surgery in both eyes. It was a very risky life-threatening process but the doctors had faith and the little bundle of joy was getting ready to go through the test.

An emergency core LVPEI team was constituted to quickly move from the OPD to the surgical table – time was running out and a lot of preparation, hard work and critical decisions lay ahead before the baby could be moved to the operating table. Being premature, the baby was very weak with lack of blood (anaemia) and poor nutrition and a weight of only 1400 grams. Anesthesia and surgery in such conditions is risky.  Counsellors Praveen and Vijaya coordinated with the baby’s neonatologist and the parents getting all preoperative evaluations and paper work done quickly and safely without tiring this tiny life!

With dedicated team of neonatologists at the Sowmaya Children’s hospital (SR Nagar) and the Rainbow hospitals at Secunderabad and Banjara Hills all preparations were done within 48 hours to make the baby as fit as possible for safe anesthesia. Blood transfusion, lungs assessment, liver function, kidney function, nutrition and electrolyte balance, cardiac care---so much to be assessed and corrected at such short notice!

After barely 48 hours of entering LVPEI, the baby was now well prepared to go through the surgery.  Admitted one night prior, the ward nurse explained to keep the baby fasting from 3a.m. and along with theatre administrator Mr. Praveen ensured that the father and baby reached the operating room fully prepared with dilated pupils and all the necessary paper work and checklists completed (Oh! there were so many of these small things to check and ensure there are no mistakes) at 7.30 am sharp on Ugadi morning- New Year was just breaking out and seemed far away in the horizon.

Highly competent neonatal anesthesiologist, Dr. Ranjan Kumar Samantharay accepted the pivotal and risky role supported by the senior colleague Dr. C Vijay Mohan Reddy. Highly motivated anesthesia technician, Mr.Venkatnarayana doubly checked everything. Their role was pivotal to ensure smooth transition into and out of the anesthesia. The senior Theatre Nurse Jaisamma left her own small children still sleeping in bed to come for this critical surgery, beyond her routine duty hours, along with her colleague Sister Mariamma and made sure all instruments were kept ready for both eyes’ surgery. The team should ensure that baby was under anesthesia for the minimum time possible! No time could be lost in searching for this and that once the baby was anaesthetized. Coordination, concentration, clockwork like drill, total cooperation with a single focus- ‘the baby’, bound this group of men and women - a wonderful New Year which hopefully would not end in disaster or death!

Dr. Subhadra Jalali, retinal surgeon, made Microholes to enter the deep recesses of eye and reattach the detaching retina with microsurgical techniques. Operating a size less than 16mm eye without causing damage to critical structures like lens and the retina required surgical precision, dexterity and passion for perfection. In 40 minutes both eyes were operated with finesse and the surgical wounds closed with sutures that are the thickness of a hair! When the baby stirred out of anesthesia and cried with the first breath, the whole team inside the operating room and the anxious administrators, counsellors and parents outside, knew that their beautiful New Year had dawned!

Less than a month later, the healthy and blissfully happy baby spread sunshine on the return visit to OPD, as she smiled back at her doctor looking up with fairly good vision in both eyes!

What is Retinopathy of Prematurity?Retinopathy of prematurity (ROP) is abnormal blood vessel development in the retina of the eye in a premature baby. The blood vessels of the retina begin to develop 3 months after conception and complete their development at the time of normal birth, 40 weeks later. If an infant is born prematurely, eye development can be disrupted. The vessels may stop growing or grow abnormally from the retina into the normally clear gel (vitreous) that fills the back of the eye. The vessels are fragile and can leak, causing bleeding in the eye. Scar tissue may develop and pull the retina loose from the inner surface of the eye. In severe cases, this can result in complete and irreversible vision loss by 3-4 months of age- there is no cure for such blindness currently.
What new parents need to know –?
The treatable stages of ROP occur within 20-30 days of life of the preterm newborn. At this stage eyes look perfectly normal and child has no visible symptoms or signs from outside.

Only a dilated RETINAL examination can detect this dreaded condition. A well trained specialist is needed to do the retinal examination.

TIME IS VISION_ DO NOT MISS YOUR 20-30 days appointment with the eye doctor after birth of a premature baby. If Baby is still admitted in NICU, the eye checkup and laser treatment can be very safely done in the incubator itself by portable machines. Follow-up closely every 3-7 days after treatment or after screening till the doctor gives a green signal that disease is completely cured or resolved.

Symptoms of severe and almost irreversible ROP blindness include:
 Abnormal eye movements
 Crossed eyes
 Severe nearsightedness
 White-looking pupils (leukocoria)

There are 5 stages of ROP of which stages 1-3 are amenable to laser treatment within 1-2 weeks that can preserve vision. In stage 4, some eyes can be brought back from brink of blindness by urgent microsurgery. Surgery is risky due to General anesthesia which is needed.

 Stage I: There is mildly abnormal blood vessel growth.
 Stage II: Blood vessel growth is moderately abnormal.
 Stage III: Blood vessel growth is severely abnormal.
 Stage IV: Blood vessel growth is severely abnormal and there is a partially detached retina leading to severe loss of vision.
 Stage V: There is a total retinal detachment and here blindness is irreversible and permanent. Surgery may provide minimal vision in some cases.

The blood vessel changes cannot be seen with the naked eye. A detailed eye exam by evaluating the retina is needed to reveal such problems.

The Indian Twin Cities ROP study group has revolutionized the ROP blindness scene across Hyderabad and Secunderabad. Apart from the service of visiting neonatal units in the city, LVPEI also undertakes awareness programs for parents, maternity home personnel and doctors. All these efforts have now yielded results with a significant drop in reported cases of untreated and unscreened ROP Blindness in the twin cities of Hyderabad and Secunderabad.

Sunday, 26 February 2012

A Taste of India, An international fellowship experience at LVPEI, Hyderabad

The beginning
4 pm on a late September afternoon. A bluish back seat window of a Tata cab protects me from a very bright light which my eyes are not used to. However exhausted I am from the 10-hour long flight, I can’t stop looking at everything… unfamiliar advertisements in a curly script all along the road from the airport to the city; directions to unknown cities; a huge picture of a couple, a girl and a guy, with blue faces, covered in gold and jewelry — may be a movie trailer; a multitude of small white flat-roofed houses spread on the gentle slope of hills on the right and left side of the road; a mosque on the top of a hill; trucks carrying mountains of seeds.

Now in town, I see entire families traveling on a motorbike, strange vegetables displayed in stores. Traffic jams,People standing, people running, Overpopulation, Groups of women in bright colorful sarees crossing the roads. A goat comfortably seated in the back of an auto. Accompanying everything I see are the uninterrupted horns at different volumes and tones for my whole journey.

I love this exciting sensation of “first time”. It is my first time in India.

When the Italian Ophthalmological Society awarded me the Mario Gelsomino prize last May in Rome for “Best Poster 2010”, I thought I would use this prize to advance my knowledge in the field of pediatric ophthalmology, on which I have focused my practice the past year, after completing my residency in Ophthalmology. The prize is intended to provide young ophthalmologists with a learning experience abroad in a center of their choice. Why did you choose LVPEI? Many people asked me this question.

Mario Gelsomino Award, Società Oftalmologica Italiana, Rome, May 2011
Mario Gelsomino Award, Società Oftalmologica Italiana, Rome, May 2011

I remember I started noticing posters and the scientific activity of an institution called “LVPEI” at ARVO a few years back. I went on the internet and found that this Institution has a very fascinating history spreading across 25 years. The mission of the Institution, “Excellence and Equity” inspired me to discover more about the hospital and its history. Since I started medical school I have never abandoned the dream of a model of service delivery where the best health care can be a right for everyone, thought I had yet to experience how difficult this is in reality.

Even in countries where the latest facilities are available, such as the USA, the best treatment is affordable only by most privileged. However, in countries where medicine is provided free to the whole population, like in parts of Europe, the quality of treatment is often compromised by national budgets and financial constraints.

Therefore, I found LVPEI’s mission extremely interesting. I also thought India would be a perfect place for spending my award fund. I was not only looking for an optimal ophthalmology training course, but also the opportunity to experience a culture different from mine. The Indian culture, shaped by centuries of unique history.A vast area where hundreds of languages carry the heritage of a multitude of different populations that have crossed the land along the ages. A culture that has given much importance to spirituality, though perhaps less to individualism, generating personalities like Mahatma Gandhi and Rabindranath Tagore.

So here I am, the cab left me with several expectations and a couple of bags of luggage in front of LVPEI. I will be here for the next 3 months. After meeting the educational staff, the first person I meet is a senior fellow who kindly introduces me to the “rules”. No mobile phone during working hours, always keep your hair tidy, adhere strictly to the dress code, be prepared for 12-hour long working days, 6 days a week. On Sunday you will study and prepare for the classes. Apparently, the fellowship at LVPEI is known in all of India to be the hardest (but also the most fruitful). The first night, on the phone I confided in my Dad my fears about the hard life I expected in the next months. ”Chiara, you have not experienced the Army! Take this as a chance for a necessary life experience. You will make it and, in the end, you will be thankful for this experience.” He was right.

The Medical Record Department is impressive: millions of records indicate the multitude of patients seen every day at LVPEI

Life in Children’s Eye Care Centre (CECC) I OPD — the exposure to complex cases that you can get in a tertiary referral centre in India is probably unmatched to anywhere else in the world. The State of Andhra Pradesh accounts for 80 million inhabitants. The LVPEI network has over 100 centers spread out across the state. Anyone with a vision problem can go to the nearest center. If the disease requires more specialized treatment,
The patient will be referred to the appropriate center, where he will receive the best care available, no matter what his economic resources. LVPEI offers vision screening and provides glasses free of cost to all unprivileged kids below 16 years of age.

The Medical Record Department is impressive: millions of records indicate the multitude of patients seen every day at LVPEI

A standard day in OPD starts at 8 am, after a 1 hour class. The first patient of the day is an IT businessman, who started to see double after a car accident, as his driver fell asleep while he was coming from the airport, returning from a business trip to Chicago. Then I see a family from Dubai who wants an eye check-up for their children to be reassured that they can watch 3D movies. Now it is the turn of an 18-year-old woman who speaks only Telugu. She became blind suddenly, the reason is not clear. After one week of repeated examinations and tests, we have no doubt that she is malingering. We take her to a separate room and talk to her. She opens up and tells us that her husband used to beat her but her family is not allowing her to leave him. No education, no job, no easy solutions. Better to be blind?

The next patient who is brought to the OPD is a baby, six months old. I have trouble coming to a diagnosis. Dr Ramesh explains: “Chiara, a mild hyperopic refraction and a granular fundus in an apparently blind child is Leber’s Congenital Amaurosis. Now you have seen one case, don’t ever forget.”

Then I meet a girl who is on vacation from her PhD in Stanford University; she is here for a squint evaluation before refractive surgery.

Dr Chiara with Dr Amit Gupta in OR 5

Screening for ROP in a neonatal ICU

Right after this I examine a 12-year-old boy who does not like to attend school because he is teased by classmates about the shaking of his eyes (congenital nystagmus). Now comes a 22-year-old girl who wants her sensory exotropia corrected, because she is getting married soon. The next patient is a girl in rags — just 10, she does not speak a word, only cries continuously. She has severe mental retardation with bilateral congenital cataract and vitamin A deficiency. She also has microphthalmos (where the eyes are very small) and a congenital heart defect. This condition arises from congenital rubella syndrome. I had never it seen before, since all girls receive vaccination for rubella in Italy before they are 12. An 8-year-old boy comes now; he is deaf and dumb, very skinny and very poor as well. He has retinal detachment in one eye and uveal coloboma in both the eyes. But he is not scared at all by the unfamiliar place! Instead, he is curious about everything, so many doctors, incredible machines, and hey! Such colorful lenses in that box!

After that, I go to the next room in CECC I. This mother is very worried; her baby seems to be blind. We explain to her that the baby has cerebral visual impairment; the eyes are anatomically normal but the brain cannot integrate the visual information. We cannot do much to improve his vision, but we can promise a normal psychophysical growth through specialized child rehabilitation. This is a special training for blind kids and must be started as soon as possible so that the child will achieve the regular developmental milestones at the right time, have a normal social interaction and access to mainstream education. But no need to look for other hospitals. Child rehabilitation is inside LVPEI, third floor!

The next patient is a non-paying girl who comes for follow up, she was operated upon for bilateral congenital cataract, 12 years ago. She comes regularly for follow-up every 6 months and follows every prescription, glasses and patching advice strictly. She was very regular about patching and now her vision is 20/20. Poor, but very smart! Tonight, in the library I will review the literature to understand better the causes of myopic shift after pediatric cataract surgery.

This is OPD in LVPEI — a wide social range of people with different lifestyles and opportunities. But inside the OPD, all social differences are eliminated. All patients experience the same suffering, the same anxiety for their children and their future, the same feeling of vulnerability... Regardless of their economic status, they all receive the same level of respect and same treatment at LVP Eye Institute.

Extraocular muscles as seen by an Anterior Segment OCT.A case of familial bilateral optic nerve coloboma.Enlargement of Superior Rectus in a case of isolated myositis. The genetic history of patients gives a lot of clues about diagnosis in some cases. Families with more than 2 kids are rare in Italy and consanguineous marriages are exceptional because not permitted by law.

The LVPEI Experience

During my stay I discovered that working at LVPEI is like being part of a big family. The symbol of LVPEI is a pyramid, from a large base of vision guardians offering counseling and a preliminary eye check-up directly to the community, going up to primary, secondary and tertiary eye care centers. The sides of the pyramid are made by people, gestures, everyone working together and interacting with patients at different levels. I felt that all the employees at LVPEI were very dedicated and passionate about its mission. This was evidentevery time I needed assistance, for example to edit a surgical video in the CAVU department, or looking for some files for my projects in the medical record department. All the staff was very cooperative and willing to do more than just their routine work.

I did my fellowship at the very top of the LVPEI pyramid, the Kallam Anji Reddy campus, the Center of Excellence. Patients who are referred here have complex diseases, manageable only with the latest equipment and by super specialized doctors. As a fellow, I was trained by my mentor, Dr K Ramesh, not only to recognize specific diseases but also to develop a method of examination in non-standard cases. I was trained to build up advanced diagnostic skills and to plan customized treatments. Many clinical questions were stimulated by consultants, and I could always find material to deepen my knowledge in the library that is open, 24 hours a day, 7 days a week.

The library of LVPEI is a wonderful place, silent and peaceful at nights, full of bright light through the big windows on Sunday mornings. Here an immense range of books is available, with all the journals of ophthalmology, pathology and pharmacology. The fellows can even enjoy reading about the history of ophthalmology or ethics in their free time. Also, wi fi is available everywhere in LVPEI, 24 hours a day. Truly wonderful facilities! There is another thing of incomparable value that is offered to the fellows at LVPEI — better than the highest possible 3D resolution spectral domain OCT, better than the latest-model phaco machine, better than any DVD collection in the library. That is the opportunity LVPEI gives you to meet the most extraordinary people… people whom you would rarely meet in the outside world. Being a Center of Excellence means that only people who are the smartest and the highest motivators are employed at LVPEI. Many of them have an extraordinary background of clinical practice, across a 30-year career, with a commitment to challenge oneself and improve constantly.

I was given the opportunity of spending some time with doctors like Dr Anil K Mandal, who has dedicated his life to fighting blindness in children born with glaucoma. He has a very special touch with kids and their families. I was also given the chance to listen to Dr Virender Sangwan, an exceptional researcher and mentor, with the unique talent of seeing the fellows projected over a 10-year perspective, so he can guide their choices in career planning. I interacted with Dr Subhadra Jalali; she has developed guidelines for ROP in India. Years of her scientific efforts and extremely dedicated work have resulted in a substantial decrease in blindness caused by ROP in Andhra Pradesh.

The fellows here are also treated to an international ambience with guest lecturers by luminaries from all over the world. Only in a setting like LVPEI, in only four months, could I talk of research opportunities in Singapore, and share impressions about educational paths and career perspectives for ophthalmologists in Australia, Indonesia, Thailand, Hong Kong, Bangladesh, Zambia, Ghana, New York, Canada and the UK. I came to know about ICO examinations, about international fellowships. I had coffee with the smartest specialists from Brazil and met clinical researchers from Bascom Palmer Eye Hospital. I learnt of the latest advances in regenerative medicine directly from the researchers. Significantly, at LVPEI I met for the first time the most prominent Italian researcher in limbal stem cells: Prof Graziella Pellegrini, whose lab is located less than 200 km from the hospital where I currently work in Italy.

One morning all the fellows were introduced to the idea that ocular diseases can also be seen as a manifestation of nature, after we were shown pieces of artwork that gave a different perspective of the language of nature, using diseases and natural phenomena described in Indian traditional mythology! And I was very moved at the extremely positive message from two families who had lost their loved ones in terrorist bombings. They found an extraordinary way to survive the tragedy and spread a positive message to the rest of the world.

That’s why in these four months I rarely stepped out of LVPEI. I did not even visit the Charminar (something like living in Paris for 4 months and not seeing the Eiffel Tower! I guess I will go before leaving!). Being inside LVPEI is like travelling all around the world. Just something simple like eating dinner in the cafeteria offers you a global overview of ophthalmology: educational opportunities, community eye health programs, a leading clinical center, latest scientific discoveries...

My last words are for the pediatric patients I met at LVPEI. Indian kids are very cute and curious. Of course, despite my efforts to learn some Telugu, I admit to some difficulties with patients who spoke only Hindi or Telugu. Sometimes I missed taking down the medical history directly, by myself, without translational gaps. But I was also surprised to find that communication with children can be strikingly easier than it is with adults: communication with kids happens mostly by the tone of your voice, the way you approach them, and how you convey your understanding of their fear. Nothing will erase those precious moments of empathy with the kids I have met during these months! These treasures now belong to me, and are to be cherished for the rest of my life.

Thanks to everybody I met in LVPEI, I hope to be able to come back soon. The biggest thanks go to Dr Ramesh Kekunnaya for giving me this fantastic experience, with great appreciation of his generous ways of teaching and most important professional suggestions.

Not only Ophthalmology

1. A dinner with everyone in the Pediatric Ophthalmology Department.
2. Enjoying the backwaters during the All India Ophthalmological Society in Kochi, Kerala
3. Celebrating Pongal Festival in Secunderabad
4. Fusion 2012 meeting

By Dr Chiara Morini (13/2/2012)

Tuesday, 31 January 2012

An Eye on the Olympics

Jai Singh, 26, has had a passion for boxing for half of his life. His sights were set on competing in the 2012 London Olympics, when he suddenly found his vision becoming blurred! It was December 27, 2011 when Havaldar Jai Singh Patil, one of India’s leading boxers (75 kg category) found he couldn’t see very well from his left eye. He has represented India 10 times and had won the Silver medal at the Senior National Championship in Chennai recently. Now his career was at stake.

Acting quickly, the Army Sports Institute at Ghorpuri, Pune, where he has been since 2005, referred him to the Command Hospital in Pune. Realizing he needed specialized care, Major Pradip Kumar referred him to Col Sonia Puri at the Military Hospital in Secunderabad as an emergency case.

Jai Singh arrived at L V Prasad Eye Institute on December 31, 2011. Senior retinal specialist Dr Raja Narayanan diagnosed him with retinal detachment, probably caused a few days earlier by a glancing blow to his eye. He was immediately scheduled for surgery and operated upon.

Jai Singh Patil
A week later Jai Singh looked cheerful! His vision had already improved and was likely to improve further. He hopes to resume training for the selection camp for the 2012 Olympic Games. He is immensely grateful to the army for their support and encouragement – good training, good coaches, good food and facilities, he adds. He is also appreciative of LVPEI, saying that everyone has been exceptionally helpful to him. We wish him good luck and a successful career!   

Wednesday, 4 January 2012


At LVPEI, training and education are recognized as key factors that influence the reach, range and quality of eye health service delivery. Therefore, the institute strives to provide the highest quality of training and education through a committed faculty. Living up to its commitments and standing true to its words, LVPEI did its best to provide education to me and helped me achieve what I wanted to. Let me take you through my journey at LVPEI and how it changed my life!
I have always nurtured big dreams. I wanted to study abroad, and become a famous doctor. But the reality was very different. My father always made it clear that he could not afford higher education like medicine or engineering, or even graduation for that matter. He urged me to look out for early employment.
In 1993, I saw an advertisement about a course in LVPEI in the newspaper. My father wanted me to enroll for the course; therefore he got the application form for me. Though, I was a bit reluctant initially, but then after thinking of the benefits of the course, I applied for the course and I feel I took the right decision. LVPEI gives you the opportunity to grow, which is indeed commendable about the institute. If one works for 5 years, and shows his commitment towards his work, the institute offers the opportunity to pursue higher studies including PhD. This was a great opportunity for me as I could not afford to live my dream. LVPEI gave me the platform and the opportunity to fulfill my dream. This system was unique as you got to work and study simultaneously. Only with the help and constant support from LVPEI, was I able to live my dream. When I expressed my interest in public health to the Chairman in one of the meetings, he gave me a part time position at ICARE to allow me time for study. I went to the London School of Hygiene and Tropical Medicine, University of London, for my higher education in Public Health in eye care. Since then there has been no looking back. It has been a long journey and beyond doubt, this journey would not have been possible without the institute’s support.
Considering the financial background I come from, I could not have accomplished all of this. Being a first generation graduate in my family, hailing from a lower middle class background, and to reach the position that I am in today is a result of my persistent efforts, patience and the support of the institute. “You become more powerful, when you help the helpless in remote rural areas”. “When I started my journey, I was alone, swimming against the tides of the sea to bring quality eye care to India, and thought I will swim as long as I am tired, now 25 years down the line, I have several hands joining me to swim against the tide to make the difference.” These are the few of the many statements of Dr. Rao that gave me inspiration to move on. The satisfaction in everything that I do, and the feeling that I am part of the team that is bringing change among those who are underprivileged, remain my motivating factors.
I am not the only one who was given opportunities by the institute, the only difference is that others who got these opportunities left the institute and I stayed back to reach the position where I am today. One thing that I have learnt at LVPEI is, when you aim to achieve something, you should put in your best, be patient and focused single-mindedly towards achieving that goal.
I am greatly indebted to LVPEI for all the support that I have received over the years. I know it can never be repaid, but I want to do as much as I can and be a torch bearer to take the vision and mission of this institute forward.
As narrated by Dr Srinivas Marmamula who had joined LVPEI after his high school (Plus Two) as a student of the institute’s DOT (Diploma in Ophthalmic Technology) program, and went on to do his Masters in Public Health in eye care from the London School of Hygiene and Tropical Medicine, University of London, and then on to obtain his PhD from the University of New South Wales, Australia.
Dr Srinivas Marmamula is Associate Optometrist and Public Health Specialist at LVPEI’s International Centre for Advancement of Rural Eye care. His study programs abroad were fully sponsored by the Institute, and he was paid his remuneration in full during the entire duration of study so as to facilitate his pursuit of higher education.

A letter to LVPEI, straight from the heart

Dear Sirs, Dear Doctors, Dear all in LVPEI,

I have arrived safely at my home last night after almost 26 hours of leaving your wonderful institute. I am honoured and pleased to have spent the past month in your institute in which I have had the most fruitful and enjoyable experience of my life. A simple word as “Thank you” is not sufficient to express the amount of gratitude I bear to everyone in L V Prasad. Everyone has been absolutely kind and infinitely cooperative and friendly; you made me feel at home, like being amidst brothers and sisters. I wish to thank everyone belonging to LV Prasad, from the highest authority to that simple young man from the house-keeping who used to meet me with an inviting kind smile every afternoon as I saw him tidying my room in the guest house.

Dear Dr Mandal Sir, I wish to thank you from the depth of my heart, for you have given me the experience of my life. I came to you to learn just pediatric glaucoma, and I ended up taking home a lifetime of experience, a whole package of values and virtues and human touches. I will never forget your constant words “Be sincere, don’t show sincere, but BE sincere”. The way you deal with these poor children and their parents is in-itself a value to learn; how to LOVE what you are doing, and how you speak of your past teachers with such gratitude and appreciation.

Dear Dr G Chandra Sekhar, I wish to find words that describe my gratitude to you adequately, but my vocabulary falls short. To me, you redefine the meaning of the words “Teacher” and “Doctor”. You model the value of a teacher who conveys every single piece of his knowledge and experience with extreme faith and devotion .You think of your patient’s best as a human being and yet humbly say that “this is just the proper medical decision”. You recognize your students through their hand writing, a sign of utmost dedication.

Dear Dr Sirisha, you have given me a valuable lesson on how to maintain the impossible balance between hard work and calmness, between utmost knowledge, experience and humility. I really appreciate your elaborate answering of all my questions with patience and I hope I was not a nuisance! I wish to thank you for your excellent illustration of surgical dexterity and resourcefulness in complex surgeries. And above all Dr Sirisha, I and my wife are extremely grateful to you for that wonderful gift that you gave to my wife, it was very thoughtful on your part and we will cherish it always.

Dear Dr Nikhil, the short encounter that I had with you made me wish it was longer. I have learnt from you a new definition of “doing my best” in examining the patient. That single day that I spent with you has changed my view of the concept of patient examination and systematic thinking. The accuracy and thoroughness of examination, irrespective of time constraints, that you have shown me will definitely help me in my practice.

Dear Dr Subho, I have used a lot of your precious time. I have not responded about the participation of my institution in the genetic study because I had not (and still have not, unfortunately) received a response from my seniors. I appreciate you for presenting me with this opportunity. Please wish me luck with my seniors because I wish to proceed with these genetic studies for the sake of our poor patients, though I understand it is on the long run.

Dear Dr Ravi, Dr Paraj and Dr Shaeel. I don’t know how to thank you. You were like brothers to me. I have never known friends that were supportive and kind and sincere as you are. I envy your superiors for having such a great team as yours, and I envy your institute for having such great graduates. Dr Ravi, you have provided me with guidance and help from my very first moment, and I don’t think my stay in L V Prasad could have been that fruitful without your help. You’re a great person and one day I know I will be reading your work in a first class journal or book; keep up the good work my friend.

Dr Paraj, thank you for tolerating me in the OPD, and for answering all my questions. You were such great company and a helpful, knowledgeable guide; I wish you all the best in your career. Dr Shaeel, I will surely remember that calm smiling face of yours.

Dear Doctors in the education department, I wish to thank you all for the cooperation and help you provided from the very first moment, and even actually before I arrived at LVPEI. Madame Vijaya, my stay could not have been more comfortable, and your help made everything so easy.

If I sum it all, I have had the best experience in my life. From the very beginning, I was given the wonderful advantage of choosing the timing of my observership; I was helped with the Visa application with a letter directed to the embassy. A wonderful room was reserved for me in the guest house at a remarkably good rate, with a three meal excellent food at an excellent price. I have met the most knowledgeable consultants, the most excellent teachers and the most helpful and friendly fellows. I was helped by an extremely helpful administration in the education department up to the very last moment of booking the taxi to the airport. And there was definitely a lot more than I could count or remember. To my surprise, I did not face any negative issue. I don’t think I can attribute this to my luck, I know that this is a result of the excellent planning and faithful contribution of all the personnel in this wonderful place.

Thank you all for everything, thank you for accepting me in your wonderful institute and on behalf of all your patients, thank you for the great job you are doing.

Sincerely yours,

Nader Bayoumi.

Lecturer of Ophthalmology

Ophthalmology Department - Faculty of Medicine, Alexandria University

Alexandria, Egypt.

Tuesday, 3 January 2012

LVPEI, an Elective Posting to Remember

“Sure, come to India and see how we do it,” Dr. Sangwan from LVPEI warmly told me when I asked about a potential visit. Little did I know that my stay at LVPEI would leave such lasting impressions! For over three years, I had been researching about limbal stem cells and their properties. I had extensive experience in growing the cells and made exciting discoveries. Each time I spoke about or presented my work, I began with the devastating disease that is LSCD (Limbal Stem Cell Deficiency) and the unbelievable surgery that allows people with this disease to see. It was this amazing clinical application that drove my interest in my research. Each day, I knew my findings had the potential to enable someone who had lost vision to regain their sight.

When I saw Dr. Sangwan's keynote presentation at IOSS (International Ocular Surface Society), I was convinced that to see this work in person was the most fitting culmination to my full-year Doris Duke research experience. I could see that Dr. Sangwan was very driven and his passion to heal and cure was clear. Dr. Sangwan seemed somewhat of a lone voice at the conference, as many people were researching LSCD but few, if any, were putting this research to use in the real world.

My trepidation on the flight to India fell away as Dr. Sangwan smiled and introduced me to some of the fellows. I was anxious about being in another country and wondered whether I had made the right decision in visiting for an entire month. In our first two hours, we saw 25 patients, many of whom had ocular disease I had only read about and that I would likely never see back home. Within two hours of my arrival, I had seen a patient with LSCD! At the end of the day, I was a little jetlagged but running on adrenaline from the excitement of the patients I had seen that day - we had spent 12 hours and seen over 100 patients.

Each day, I was able to see cases that are extremely uncommon back home. I read ophthalmology texts daily and due to the sheer number of patients, I would inevitably see two or three diseases I had read about, hours after my studies. I cannot think of a better way to learn, I gained experience with the slit lamp and read much more enthusiastically, as everything, even the rarest of diseases, came up day after day in the clinic.

One of the things that impressed me most was that Dr. Sangwan and LVPEI place a lot of significance on knowing how all aspects of the system work. It was clear to me that this intricate knowledge of the basic workings of the hospital is both essential and invaluable. I decided to use this approach to learn more about all of the tests I would eventually prescribe to my patients. This proved to be extremely helpful. In one visit to the B-scan room, I saw 20 patients with all types of pathology, from RD to phthisis to normal eyes. The techs were surprisingly helpful and took time to explain each aspect of the test in detail. Similarly, I was lucky enough to lean about the OrbScan, Anterior OCT, and several other tests that allowed me to understand much more fully the applications and limitations of each test. LVPEI's specialized nature and high clinical volume make it a unique place in which this is possible.

The combination of a plethora of diagnoses and such a large patient load meant that I got to see more patients and types of diseases than I ever had before. I have no doubt that this experience put me well beyond my peers, as ophthalmology is a field where visual learning and memorization of visible pathology are invaluable tools.

The experience that gave me the most valuable insight into the LVPEI system was the day I spent seeing each part of the LVPEI pyramid. LVPEI has an unbelievably well thought out system for reaching every single person in the area. The system begins from the lowest level in the villages, one of which we visited. This level consists of one person per village who goes door to door measuring visual acuity (VA), glucose levels, height, and weight. The same information is recorded by teachers and headmasters, who are taught to spot children with low vision and given flashlights and VA charts to check their students. The data is then used to forward diabetes and low vision suspects to the next level of care that we visited, the village center. There, technicians measure vision, refraction, ocular pressure, and look at the patient using the slit lamp. Anyone with refractive error is prescribed glasses, free for those under 16 and very cheap for others. These centers see about 450 patients a month and give out glasses to 250 of them. Those who have a visual deficit that cannot be corrected using glasses alone are sent up the chain to secondary centers.

At the secondary centers, medical care, such as drops and medicines, and basic surgical care, such as cataracts, DCR, and pterygium, are handled. Students from the major/tertiary centers spend six months to one year being second doctor at these centers. These centers have an outpatient clinic and inpatients as well. The center we visited saw 1100 patients in clinic and performed 140 surgeries per month. If treatment at a secondary center is not able to correct the issue, they are sent to a tertiary center where things like glaucoma surgeries and vitrectomies are done. The most complex cases, in turn, are sent to centers of excellence such as the KAR campus at which I spent the majority of my visit. In all cases, patients pay what they are able. More than half do not pay at all, while some of the richest pay for luxury rooms and subsidize the cost in this way.

I spent one day seeing each of these components, and it was amazing. We drove two to three hours out from Hyderabad, a major city, to a tiny rural village. I'm glad I got to do this before leaving the country. I had a fantastic experience at LVPEI and would like to thank Dr. Sangwan and the other doctors, residents, and staff for welcoming and hosting me. I will most certainly be returning to LVPEI, especially once I have more experience working in the field of ophthalmology, as the experience will be invaluable to my growth as a doctor and a human being.

As narrated by Alexander Barash, a final year medical student from Mount Sinai, NY, who spent one with LVPEI for his elective posting.