Year : 1956 | Volume
: 4 | Issue : 2 | Page : 31--40
A Belgian ophthalmologist's studentship in India - Part I - General
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Lebas P. A Belgian ophthalmologist's studentship in India - Part I - General.Indian J Ophthalmol 1956;4:31-40
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Lebas P. A Belgian ophthalmologist's studentship in India - Part I - General. Indian J Ophthalmol [serial online] 1956 [cited 2019 Nov 17 ];4:31-40
Available from: http://www.ijo.in/text.asp?1956/4/2/31/40828
India offers the physician a huge field for study. but she gives the ophthalmologist the plum. It is not a wonder therefore, that ophthalmology, with medicine and surgery is one of the three main branches of medical studies in India.
Malaria. amoebic dysentery and tuberculosis are the all powerful trinity prevailing among 400 millions of Indians. The huge malaria empire is shrinking slowly. However I was a little astonished to observe that ocular manifestations of malaria are relatively rare. Tuberculosis takes a lot of victims, especially in a country of which the population is underfed and living in terribly poor conditions together with close promiscuity. Viral infections appear to be rarer than in Europe with the exception of small-pox and trachoma. A walk of a 100 meters in any street of any Indian town is enough to come across a face marked with this terrible disease.
Amoebiasis, leprosy. leishmaniasis. mycosis and many other tropical diseases enjoy an existence like in most tropical countries. Filariasis, prevails among the coasts in Bengal. Orissa. Bihar and Madras. It is of the Bancrofti variety, the manifestations of which though monstrous sometimes, rarely include ocular ones.
Among the diseases more commonly seen in Europe and less so in India are toxoplasmosis, brucelosis, rheumatism. cancer and disseminated sclerosis. A more careful search for these conditions is necessary and I am sure at least in the case of brucelosis the incidence should be higher because goat's milk and meat is freely consumed in India.
About malignant new growths the incidence of ocular carcinomas and tumours in the eye is very rare, though retinoblastomas are met with.
There are congenital anomalies in India, but it seemed to me that they are relatively less common than in our countries: may be the natural tendency of elimination of less gifted and less armed, is less corrected artificially and so the congenital anomalies are more quickly taken away from the requirements of pitiless surroundings in the Darwinian sense. Retrolental fibroplasia, a speciality of hyperdeveloped countries is, as far as I know. unknown in India.
According to human geography, the Indian is brown. Skin pigmentation unfolds in India the complete fan of its colour and shades, from white, completely white to black, completely black.
Conjunctiva is generally pigmented mainly close to the limbus. Conjunctival pigmentation lodges in and emphasises the palisade aspect of the limbus and in some cases the corneal epithelium itself in its basal layers may be pigmented.
Iris is most generally dark brown. however you can see blue or green iris, but only exceptionally, which attracts your eye and at the same time the popular compassion, because it spoils the beauty of the eyes and their bearers according to the canons of Indian aesthetics: the bearer has not necessarily a fair skin. Schlemn's canal is often not quite visible owing to the rich ciliary and trabecular pigmentation. The pigmentation at the angle (which comes under the consideration of pigmentary glaucoma) is statistically found to be no higher in pigmented iris than in unpigmented iris and ciliary body.
On the other hand the fundus has no typical appearance of a particularly rich pigmentation of the retinal epithelium or the uveal chromatophores as typified as a "Hindoo" fundus in Wilmer's atlas. Retinal grouped pigmentation seemed to me as rare in India as in Europe.
Are there really more albinos in India or are they more conspicuous? I do not know, but albinotic people are met everywhere in India, walking miserably in the light, so atrocious for them. Very frequent too is leucodermas even among the better class of people. Dr. Hemerijckx showed me a picture of an Indian, dark-skinned whose leucoderma involved only the physiological area round the nipples. That seems to hint at an endocrinologic factor, in some cases at least. Real opposites of leucoderma - localised hyperpigmentations, are not uncommon. involving mainly the uncovered areas especially the face: the skin usually shining brown because dull black. Many Indian physicians suspect in these cases a lack of vitamins particularly of B 2 and PP.
Noevi, melanomas. melanocarinomas, and melanosarcomas among choroidal tumours are rare; I have not seen one single case of choroidal melanosarcoma and was told that they are indeed rare. In view of the pigment excess of the average Indian population the rarity of melanotic new growths offer interesting grounds for speculation. On the other hand, I saw an iris melanoma so much pigmented that at first glance it simulated an iridectomy. and also a case of marked scleral melanosis.
Deficiencies and Avitaminosis
They swarm in India a country where cooking customs were elaborated more according to religious and philosophical thoughts than to reason, experience and dietetic imperatives. The typical diet mainly of carbohydrates is not well balanced.
Lipids, proteins, fruits and vegetables axe too often almost absent. Many Indian villagers do not know what it is to eat one's fill. It must be emphasised that in a country where the deficiencies are so many, so varied and so frequently associated. it is not easy to take them apart and to give each deficiency its rightful play. There may be still other deficiencies which we do not yet know. Moreover if the Indian diet is more monotype, rice being the base, and also often the roof, its dietetic value is not well known. Many plants, unknown by the west and its dieteticians, have perhaps nutritive values, the value of which is still unknown.
It would be a mistake therefore to attribute a lesion to a specific deficiency of a specific vitamin, when the same could be due to disfunctions or lesions due to lack of proteins, lipids or minerals. . For instance, rickets in India is, I think not due to avitaminosis D but to an insufficient Calcium intake.
Avitaminosis A.-On the day following my arrival in India when I confessed to my Bombay colleagues that I was seeing my first cases of xerophthalmia, they were amazed. Congo seems on this point of view more fortunate because Dr. Hemerijckx who also saw his first cases of avitaminosis /A in India. told me how rare it was in Congo thanks to the intake of palm-oil in Congo.
Average Indian diet seems to be poor in vitamin A and apparently only westernised Indians eat carrots. A popular and traditional treatment of babies' dysentery in Bengal consists in feeding the little patient with boiled water for days and sometimes weeks. Ignorance and false beliefs thus add to the disasters. Besides the insufficient intake, bad assimilation and storage consequent to intestinal and hepatic affections and an overuse of the retina due to the strong sun, complete the vicious circle.
Bitot spots are not necessarily associated with night-blindness and perhaps there is a primary or essential variety of xerosis, without hemeralopia or avitaminosis A. of unknown etiology.
Xerosis has an undoubted relation with exposure to air and light, as one witnesses its typically interpalpebral location; I had the opportunity to see a unilateral cicatricial superior palpebral coloboma in a xerophthalmic and xerodermic patient with conjunctival xerosis atypically situated at 12 o'clock position.
Bitot spots once appeared are medically incurable; vitamin A does not modify the aspect or size; the only therapy is surgical removal.
Avitaminosis A can act in an indirect way also as an additive factor in other ocular affections. It contributes much to the peculiar picture of diplobacillary (angular) conjunctivitis in India, which is often met with dermatitis of the adjacent skin areas and the angular ulceration occupies much more territory than the one it seems to do in Western countries. The use of Zinc sulphate only or antibiotics Only, does not improve the dermatitis. while the simultaneous use of vitamin A
Avitaminosis B-: It is chiefly in Calcutta I could see sonic of these cases. General health cannot be excellent in the really poor: what draws one's attention are anaemia, cheilitis and glossitis which are almost pathognomonic . In the eyes, I have not been able in any case to find a corneal neovascularisation: I must say I could use a slit lamp in a few cases only. but in those cases I can affirm : there was no neovascularisation. The patients coming to us, came for phlyctenular keratoconjunctivitis and diplobacillary conjunctivitis. The former typical from the start, take sometimes through treatment a peculiar appearance. They develop into marginal facets negative with fluorescein and without any conjunctival or perikeratic injection. According to Dr. Sell Gupta in Calcutta, ariboflavinosis gives sometimes the cornea a characteristic floury aspect.
Avitaminosis C.: It is very rare. I have seen very nice improvements in epithelial keratitis of unknown etiology, from intravenous injections of 500 mgr. vitamin C.
A vitaminosis B, : I have not seen or at least not recognised cases of avitaminosis B.. Owing to the fact that avitaminosis B, has been claimed as a factor of tobacco optic neuritis, I mention here that this affection is rare in India, although tobacco is freely used.
Trachoma in India is a serious medical, social and economic problem. I have seen very many trachomas in Aligarh, less in Bombay and only a few in Madras, Calcutta and Behar. It is only in a trachomatous territory and not in text-books one can perceive the pathetic character of trachoma, where you see them almost at all bus-stops, where you suspect trachoma lurking behind every lid that you evert of banal conjunctivitis, as teaches Dr. Tulsi Das of Amritsar, where the incidence of trachoma is highest in the school-going children.
Trachoma is not evenly spread in India. According to Cooper and his coworkers, trachoma while it affects nearly 80% of the population in Kashmir, Rajasthan and Punjab in the north-west, the incidence progressively decreases almost to nil as one goes south and west from this area of highest incidence. Again as one proceeds to the south one finds a greater incidence on the west side of the mountain ranges along the coastal line than on the eastern slopes. In central India in the midst of a highly infected region there is a pocket of very low incidence between two mountain ranges standing at right angles to each other, the Aravali hills stretching south to north and the Vindhya mountains stretching from west to east. Comparing the maps of the seasonal and regional incidence of trachoma in India with the different maps showing the prevailing winds, monsoons, arid fertile areas, population and the contour of the land makes Cooper and Ursekar to believe that the trachoma virus is borne on the south-westerly winds which prevail just before and during the monsoon and so the incidence is greater from June to September and most on the western than on the eastern slopes of the mountains that border the Western coast line. In the sweep north-eastwards of these winds across two deserts the incidence of trachoma rises. The wedge formed by the Aravalis and Vindhya mountains mentioned previously breaks the passage of these ill-winds across this part of the territory and makes it into a kind of oasis in a desertful of trachoma.
Although Lindner asserts the contagious nature of trachoma he states that the rich do not seem to catch trachoma even in countries where trachoma is endemic: I shall only add: the rich provided they employ their money. Dr. Ursekar has made it clear from a communal survey of the country that trachoma is not the privilege of any particular community.
A propagation factor energetically claimed by many Indian ophthalmologists is the Indian custom of blackening the palpebral edges. To improve their beauty both sexes put on the ciliary border. a black paste reputed to be antiseptic, called "surma" containing antimony; the black ring has aesthetic effect, doubtful for some but certain for many. Each family has often only one box of "surma" and one pencil. which travelling successively on the palbebral edges of the different members of the family offers the trachoma virus an opportunity of which it must take advantage. On the other hand, flies so common and audacious in Eastern countries probably act in trachoma dissemination by flying from one ciliary plateau to another.
I was taught in Bombay that trachoma will not take on all conjunctive. The conjunctivae bed must be so prepared as to be receptive to the trachoma virus. For example in Egypt the "Egyptian ophthalmic" means trachoma with a nonvenereal gonococcic ocular infection, where the bed is prepared by the gonococcus. and thus becomes highly contagious. In Punjab, Kashmir and Rajasthan the Koch-Week and other types of secondary infection seem to prepare the bed. and so also highly contagious. In Bombay one observes two types of trachoma, one imported from endemic areas, the Bombay city being the most cosmopolitan city of India, and the other where there are associated stigma of scrofulous diathesis. In the latter group which is resistant to the regular sulfonamide therapy and in which sometimes we get a spectacular result with tuberculin desensitization, the bed is prepared probably by allergy to tuberculin. Dusty atmosphere by causing repeated microtraumas to the eye and lids further add to the etiology and resistance of this scourge.
The unusual clinical features of trachoma I observed were:
Early pannus that can only be recognized by retroillumination.Conjunctivitis and corneal involvement though they run parallel in most cases. it is not always so. Infrequently the cornea escapes and conversely the conjunctiva escapes although the cornea may have a marked pannus and even Herbert's pits, but this rarely.Sometimes pannus assumes a pseudo-tumoral form.Herbert's pits, and Herbert's nodules which are the corneal equivalent of conjunctival sago-grain nodules are quite commonly seen.The fourth stage could be so disastrous that the lid border may turn in and roll into the corresponding fornix, helped by the blepharospasm and symblepharon and is tolerated by the patient because of the partial insensibility of the cornea and partial madarosis.Xerosis, closure of the tear-ducts and secondary infection compromise the situation by causing corneal ulceration, perforation and atrophy.The diagnosis in the second stage from follicular conjunctivitis can be difficult because in Bombay I have seen follicular conjunctivitis even in the upper lid and early trachoma can be discovered in the lower lid as described by Tulsi Das.Sago grain nodules on a fibrous conjunctiva can simulate very closely spring catarrh. Only a conjunctival smear may solve the diagnostic problem.Cockscomblike tuberculosis of the conjunctiva also can simulate trachoma.Trachoma associated with Vernal catarrh and tuberculous (phlectinular) Keratitis offers another difficulty in diagnosis.
As regards prevention of trachoma, it is not an easy matter in this country where customs die hard. Dropping the custom of blackening the lid border with surma is as difficult as trying to remove the custom of applying lipstick in the western countries. India is not yet on the same level as Egypt in the matter of preventive crusades. It is heartening to note that the Government with the help of WHO and UNICEF has launched a programme for the eradication of trachoma. In the therapy of trachoma, that advocated by Lindner is followed. The only unusual approach is seen in Bombay where desensitisation with tuberculin was attempted in cases of resistant trachoma. and sometimes there was a surprisingly good improvement.
Dr. Shukla of Aligarh has done away with the older methods of copper sulphate application, follicular expressions and scarification as he feels that these procedures help the dissemination of trachoma.
I saw some fine surgery of entropion at Aligarh where the lid defect was well studied and the operation well planned. Buccal mucosa was used in correcting some bad forms of entropions with intense pannus.
Leprosy is met mainly on the South East coast, in Orissa and Madras States. it is believed that there are 2 to 3 millions of lepers in India.
If my stay had not coincided with the opening of the "Belgian Leprosy Centre" in Polambakkam and if I had not enjoyed the kind hospitality of Docteurs Hemerijckx and Vellut. I would not have had the opportunity to see ocular leprosy, because in the words of Dr. Hemerijckx "the leprologist must go to the lepers because lepers do not go to the leprologist". Therefore, one of the activities of the Centre was to hold periodic sorties into outlying districts. I spent four days in the Belgian Centre but could not go through the huge field of ocular lesions in leprosy. Thanks to this and to my visit of the Indian Leper Hospital at Chingleput with 900 patients, of which the Superintendent was Dr. H. Paul, I learnt the ocular manifestations of leprosy.
The opinions about frequency of ocular lesions are different: to say the least, they swing indeed between 10 and 90%.
It is the lepromatous form which mainly involves the eye and its adnexas: in nervous, macular and trophoanxthegic and tuberculoid forms the eye is generally spared.
Madarosis is generally the initial ocular lesion, a little more often and sooner of the eyebrows than of the eye lashes. To me it appears to be the most frequent and a precocious manifestation of leprosy because I saw it in four young boys otherwise not much attacked. It was generally absent in even marked nervous or tuberculoid forms.
Lagophthalmos of insidious onset is seldom the result of facial palsy, usually of orbicular myoatrophy: it gives rise to the leontine facies with doll eyes and induces the keratitis. Ectropion, epiphoria, and corneoconjunctival xerosis.
The conjunctiva which the Hansen bacillus can go through when healthy would be an important relay for the bacillus on its road to the eye. The characteristic conjunctival redness is more often the result of the leprous reaction to the treatment than of leprosy itself. The leprous nodules in the conjunctiva are in fact scleral or episcleral. The limbus is the second relay through which the bacilli enter the eye. The bacillus induces there the fleshy pannus, peculiar to the lepromatous form, the intensity of which would determine the prognosis of further ocular lesions, most often it is superior, seldom inferior.
The cornea is very often involved in leprosy. I saw the following lesions
interstitial keratitis generalised or in sectors. deep punctate nodular conical leproma.sclerosine keratitis which advances quietly without ever receding.hyperplastic keratitis giving the pink fleshy cornea of the cameleon eye, with sometimes a pseudotumoral appearance.superficial punctate keratitis of which the leprous nature is doubted.lepromas riding on sclera and cornea which are very frequent and which may lead to ciliary staphyloma.I have also seen discrete pannus much like the trachomatous pannus.
The sclera is also often involved by way of episcleritis, scleritis and leproma.
Iritis and iridocyclitis which are generally torpid and not pathognomonic come next. Iris lepromas are not characterised and often confused with tuberculomas and gummas from which they can be differentiated only through laboratory tests of tuberculosis and syphillis. Ciliary body invasion by lepromas can also occur. Acute iritis cannot be spoken of as a part of the picture of ocular leprosy because it may be due to the leprous reaction described below. Most of the patients had old iritis with discrete synechia only some having pinhead sized yellowish iris nodules. Curiously I saw in Polambakkam in four days more ectopia of the uveal pigment than in years in Belgium. In the rest of my stay in India I only saw one other such case.
Fundus lesions of choroid, retina and optic nerve, described in many books cannot be considered as of leprous etiology without reservations until lesions due to syphilis or tuberculosis are excluded, except in cases of well-advanced anterior segmentitis of leprosy. According to Dr. Hemerijckx, the leper is often tuberculous and l: prosy makes the Wassermann positive. Tuberculous allergy seems to protect against Hansen bacilli but leprous allergy does not protect against Koch bacilli. On the other hand Dr. Hernerijckx noticed that when leprosy retrocedes,tuberculosis advances.
Actual fundus lesions in leprosy are very rare. Incidentally ophthalmoscopic examination is difficult because of miosis and iris synechiae.
One wonders why, when leprosy and tuberculosis are so close to each other on the clinical, bacteriological, histopathological and biological points of views are they so different in the fundus: why chorio-retina so hospitable to tuberculosis is so little hospitable to leprosy.
The leprous reaction, that is the reaction induced by the treatment of leprosy, causes in the eye conjunctival congestion and acute iritis, and it is partly through ocular survey that the leprologist estimates the intensity of the reaction to the treatment.
In a comparison of India and Congo, Dr. Hemerijckx told me that leprosy in Congo is tuberculoid, benign and not much contagious. and in India, in more than 80% it is fresh lepromatous and contagious. According to him lag ophthalmos through orbicular myoatrophy was more frequent in Congo than in India.
Treatment in Belgian Leprosy centre was with sulphones. Dr. Hemerijckx is astonished by the intensity of leprous reaction in Indians which includes a nodular iridocyclitis. He had started with the smallest doses. 25 mgm. a day i.e. 150 mgm. per week and had to drop to 10 mgm. a day i.e. 60 mgm. per week. Against this reaction antihistaminics are inefficient: ACTH and cortisone systemic are efficient but unserviceable because of the cost. According to Dr. Hemerijckx streptomycin is almost useless in Leprosy and subconjunctivally is much less efficient than in tuberculous iridocyclitis. I suggested the use of cortisone as eye drops or as subconjunctival injections.
Dr. Hemerijckx was astonished to see how the reaction to sulphones was more different from village to village than from people to people.
Southern India not much influenced by Muslim invasions remained Hindu and orthodox: caste with its many divisions and interdicts, its subt'e distinctions shuts much more than in Northern India. each individual inside the unalterable net of marriage. Southern India may surely be the often dreamt of field for the heredologist and it may be that in the reproduction in close quarters here that we have the explanation for the above two facts.
Propedeutics : Ophthalmological propedeutics are quite like ours and more like British schools. Medical instruments are not very different from ours surgical ones are more generally abundant.
A superintendent is at the head of most ophthalmological services in India. There are certain ways of examination which though appearing quaint to a westerner could be understood because of the speed required to dispose of the hundreds of cases. On an average in Bombay, there were a hundred consultations to be done per day, in Aligarh, a hundred and fifty, about three to four hundred in Madras and Calcutta, going up to nearly a thousand in winter. This explains the faithfulness with which one finds in Indian eye-departments two accessories unknown to our services-the high desk and the flash-light. Seated at this high desk the ophthalmologist, flashing a torch with or without a magnifier directs his patients to the various channels,-dark-room, treatment of external diseases, special examinations, minor operations, etc.
According to Dr. Cooper questioning the patient must come last and least. Other skies other ways. It appears a sound procedure in a population with at least 60 different dialects and languages. Besides the patient can tell little about his family history and is apt to misguide in the matter of his own history. Above all it cultivates the power of observation.
Biomicroscopy Was used in few cases, too seldom for me and sometimes I could with the biomicroscope, of which I was suspected to be a little fanatic complete a diagnosis. My Indian colleagues in Bombay took the hint and soon used it as fanatically as I did, which they handled on the other hand perfectly.
The ophthalmoscopic examinations are done with much care and competence. Perimetry is done with Forster perimeter and in the big hospitals often with Goldmann. Campimetry is common.
Refractions are done at least for hospital patients only under homatropin or atropin; obective part is performed without the ophthalmometer with the only help of skiascopy done at 1 meter with spherocylinders inserted in the trial-frame. It is long and irksome, done with much care done to ¼ dioptre fineness which is too much in my opinion. It seemed to me that myopia was more frequent than hypermetropia. I mention here the remark of Dr. Sen Gupta of Calcutta who often noticed that in difficult retinoscopies where the shadow has so much heterogenous motions that refraction is unascertainable, although the other examinations do not identify any opacity or lesion of cornea, lens, vitreous or fundus, or when objective and subjective data disagree, the patient had in preceding months or years a severe disease as cholera. typhoid or small-pox. Maybe we can suspect a disorder of lens metabolism with subsequent anarchic variation of refractive indices in the different lens fibres.
Tonometry, gonioscopy, fundus biomicroscopy, general or special examinations, laboratory tests, anatomopathological examinations are as often practised as in Europe.