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.