Year : 1956 | Volume
: 4 | Issue : 4 | Page : 69--77
A Belgian ophthalmologist's studentship in India-Part-III
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Lebas P. A Belgian ophthalmologist's studentship in India-Part-III.Indian J Ophthalmol 1956;4:69-77
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Lebas P. A Belgian ophthalmologist's studentship in India-Part-III. Indian J Ophthalmol [serial online] 1956 [cited 2020 Sep 19 ];4:69-77
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Dr. Rambo of the American Mission Hospitals thinks there are one million operable cataracts, and only 100.000 cataracts are operated yearly. Cataract indeed is extremely frequent in India and for some reasons still un-known.
The munificent light and the many food deficiencies have probably a part to play; race also may have some influence and also precocious senility and weariness of people are things which strike the Westerner in India. A typically senile cataract, nuclear dark brown and mature is very common in people 40 years old, not uncommon in 35) years old, and I saw one bilateral in a man 26 years old. Maturation is generally quick, complete in a few months. The most frequent forms seemed to me to be ;
(1) The nuclear brown or black.
(2) The hypermature which is of two types ;
(a) Morgagnian ; intumescent, with stretched thin capsule.
(b) Membranous, dehydrated sometimes calcified with shrunken, flattened lens
(3) Cortical and other forms are relatively less frequent than in Europe.
(4) Congenital cataracts appear to be of about equal frequency as in Western countries.
Lens extraction is the most common operation in the Ophthalmological Services I paid a visit to. Daily they operated upon three to five cataracts in Bombay, 8 to 10 in Calcutta, 15 to 2o in Aligarh, 20 to 25 in Madras.
Couching is still practised by quacks who use two methods.
(1) the pseudoscientific; with a needle passed in the flame or not, they go through the sclera or more often the cornea, and couch the lens in the vitreous. These people work in the countryside, but also, I was told, in Bombay they operate on the pavement sometimes, in front of a crowd.
(2) the "magic"; the officiating recites cabalistic formulae and a meanwhile makes a lot of gestures which get shorter and shorter around the face of the patient; during one of them the short linger armed with a ring wearing a long and thin needle, makes with a wonderful speed the couching. The patient is so amazed by the prayers and gestures that he hardly feels the pain, and at the end of the ceremony, when he can count, fingers he is convinced of the magic power of the gentleman, he is less convinced a few days later, when end-ophthalmitis starts and he cannot complain, the magician having meanwhile got away towards other innocent patients.
In some states of India couching or operations by unqualified persons is forbidden, in others it is not It is a sad state of affairs because the argument advanced by the latter states, and there appears justification, is that it is better that the quacks can relieve 10% of the cases of blindness that they handle which would otherwise remain and die blind.
The preoperative preparations are more or less the same as in Western countries. Dr. Chaudhuary of Calcutta looked very searchingly for any focal infection, and pyorrhea in India is not a joke. The operative methods differ within narrow limits.
Sutures : I have seen all varieties, preplaced, postplaced, conjunctival only, sclero-cormeal with or without a conjunctival flap and even no suturing at all.
Incisions : Both classical incisions-the knife and Keratome-scissor incisions -and the former with either hand, are done with equal skill.
Iridectomy : Single or double peripheral or total, the latter particularly when there is high tension. In Dr. Cooper's opinion a peripheral button-hole prevents more a post operative glaucoma iris prolapse than by preventing seclusion of the anterior from posterior chambers through ring synechia as described by Barkan.
Extraction : The intracapsular extraction with forceps has not been universally adopted in India. In Madras particularly extracapsular surgery is the rule, where the operation is performed in an amazing short time and without application of sutures.
In Aligarh the classical intracapsular method is followed with the lens held at the 6 o'clock position and tumbled. A preliminary pressure with moistoned cotton is applied on the cornea all round in the juxtalimbic area preparing the way for zonular rupture. The hook is not used for counter-pressure, but more for levering the inferior pole up by applying the pressure on the posterior surface of the lens, once the inferior pole is detached. All the 10 Aligarh surgeons use the same technique and some of them with amazing skill and speed, the record being 15 such extractions in an hour.
In Bombay intracapsular is done particularly for unripe cataracts, extracapsular for ripe cataracts where the capsule is fragile and intracapsular expression (not extraction) by a modification of Smith's technique for the Morganian variety where the capsule is taut. I saw Dr. Cooper doing the latter for Morgagnian cataracts. He applies pressure with two hooks at the inferior pole. One hook makes a pendulum movement along the limbus breaking the zonule, the other maintains the lens pushed towards the wound. To me it appears to be an operation requiring a good bit of surgical skill and I was surprised to see the lens delivered without an incident and not the vitreous in every instance. Maybe I have not a sportive mind but I hesitated to execute it in a suitable case that I was offered to operate. Bell's erysophake is also used in some hospitals.
In Calcutta the technique used by Dr. Chaudhury whom I especially followed, was more complicated. He delivers an intracapsular under a conjunctival bridge. The tumbling is achieved not by a hook or expressor but by an iris forceps. While extracting the lens fixation is achieved by a fixation forceps at the limbus and not by the sup-rectus, stich as by the latter method the eye swings and partially annhilated the action of the forceps. An assistant applies centripetal traction on the bridge grasped as posteriorly as possible. This difficult extraction Dr. Chaudhury executed with a slow tempo but with a skill and brilliance with almost constant success. Iridectomy follows the extraction. No sutures are applied but a bridge is there for wound apposition.
Irrigation : Irrigation is done with normal saline, but at some places an additional antiseptic is used. In Bombay o.1% proflavin is used. In Aligarh they use a 1% solution of acreflavin. Besides its antiseptic value it helps identification of unwashed out lens matter and capsule as they are stained a faint straw yellow.
(1) Issue of vitreous is remarkably rare in India, but when it happens it is generally important. The average Indian Ophthalmic Surgeon, obliged to work quickly does not take the many precautions that we are used to consider as necessary. The fear of vitreous issue is much less developed in our Indian colleagues than for us and I must say that it becomes smaller and smaller for the Western operator who feels himself more and more secure after seeing a series of Indian eyes with modest vitreous escape and their not so had results.
(2) Hyphema : It may be a coincidence or not, but in Aligarh for some inexplicable reason I witnessed a large number of post-operative hyphema. In Bombay I was told that sometimes in a month you get a particularly large number of hyphemas Seasonal incidence ? I wonder
(3) Iris prolapses were mostly seen in Madras, where no stitches were applied, and the patient is made to walk to the dispensary on the third day after operation to get his pad removed. The treatment with galyanocauterization had not and did not get any approbation- One has to remember the large turn-over in Madras.
(4) Phacoanaphylaxis : As stated previously postoperative iridocyclitis was commoner in extracapsulars. Dr. Cooper is a great apostle of phacoanaphylaxis in India, and is at pains to take away patiently as much lens matter and capsule if it breaks during extraction. According to hint in extracapsular surgery postoperative hyphema on the 7th day especially taking place in the early hours of the morning is due to development of hypersensitivity to the lens matter. This persistent hyphema yields only to desensitization to lens proteins. He described other varieties, one with hypopyon and endophthalmitis, and the other chronic and persistent. His arguments in this matter are intersting. I understand lie is giving an oration on the suject at the next conference of the All India Society and it would be best to refer to it.
Consequently one of Cooper's pet treatment was the desensitization with lens proteins prepared from bovine lenses and used in 1/10,000 solution. I could see cases in which this treatment had effect may not be persuasive for some, but surely wonderful and eloquent. I remember of a 9 years old boy with corneo-sclero-crystallinian wound followed by persistent iridocyclitis suspect of sympathetic ophthalmitis and cured by desensitization with lens proteins only. And there were others.
In India as in Europe, the question of advantages and disadvantaes of intra and extra-capsular involves discussion. Some of our Indian colleagues although doing intra-capsulars with wonderful skill express reservations about intracapsular surgery as they emphasise the frequency of later complications
(1) the vitreous syndrome, where there is delayed rupture of the hyaloid face. I have seen a few patients with intracapsular extraction in one eye, and extracapsular in the other with remnants of the capsule and lens mater still remaining, satisfied with vision in the latter eye and bitterly complaining the floating black spots in the vitreous in the eye where an intracapsular was done.
(2) Secondary glaucoma of which the mechanism is not known. Could it he a pupillary seclusion, pushing forward of the vitreous, goniosynechia or torpid cyclitis.?
(3) Retinal Detachment.
Undoubtedly iridocyclitis is less common after intracapsular. On the other hand if one were to examine very systematically in every case of our intracapsular surgery we should often find overlooked lesions like choroidal detachments, retinal detachments, latent and non-progressive, as I found some in a fortnight of critical study in Calcutta. We must not forget that in intracapsular surgery we open half the eye, just as a corpse is cut open from neck to pubis at the post-mortem.
There are, I think, many differences between an Indian and an European cataract operation ; here are some of the differences I could gather during discussion with Indian Colleagues and after looking at many extractions and doing some myself.
(1) The wonderful stillness of the patient; a philosopher or still better a psychologist should analyse the causes and aspects of these patients, almost this resignation so striking in many patients. On the other hand I am convinced that in many Indians the threshold of pain is especially higher than in Westerners.
Psychic troubles by bilateral occlusion of the eyes are very rare. In Mobile units although both eyes are sometimes operated on the same day, that would be a mistake in Europe but it is not in India owing to the many difficulties met with doctors and patients, and a bilateral bandage is kept for 7 clays. There are rarely any psychic troubles.
(2) Patients are voting relatively; average age of people operated is 45 - 50. I was told. Unnecessary to emphasise the importance of such a fact.
(3) Undernutrition or bad nutrition make the fatty patients rather rare. The skin, very thin and extensible due to early elastosis, allows for good infiltration especially akinetic, and reduced to a minimum the ocular rubbing by the eyelids and the surgical field stands out well in relief. On the other hand, orbital fat is poor and the eye is often suken. The big perspiring and jigging lady with a shining skin stretched out by a thick adipous panicule with the eyes squeezed in an orbit full of fat is quite exceptional in India.
(4) The cataracts are mostly mature or hypermature ; maturation is much quicker in India. Bad vision is a negligible handicap for the small social and economic exigencies of the average Indian who has no books to hold, no newspaper to follow, no jammed traffic streets to cross. So the Ophthalmologist can wait down to dropping of vision to handmovements or light perception, except in big cities where competition between Ophthalmologists is more and the patients' exactitudes of vision more severe.
(5) Lens capsule except in cases of Morgagnian or intumescent cataract is less stretched and fragile, it seemed to me, than the European capsule. On the contrary the zonule seemed to me generally fragile. That explains the small percentage of involuntary extracapsular.
(6) Indian vitreous is remarkably peaceful. Much more often than in our countries, the eye at the end of the operation is soft and the cornea concave. Handling, considered imprudent here, can be done in India without any undue risk, especially the grasping with the forceps of capsular remnants under direct control of the vision after folding of the cornea. Hyaloid is concave, and the vitreous does not even attempt to escape. The relative youth of the patient is much important on this point of view, because it is a solid and not degenerated or liquefied vitreous that the Surgeon will meet.
Finally we must admit that the skill of the general Indian Ophthalmic Surgeon is superior to the one of his European colleague. We have not to be astonished that a manoeuver repeated many times every day, takes on a beauty, a safety, a confidence, a precision, that otherwise made once a week cannot acquire. I was told there was in India an Ophthalmologist having performed more than 1oo,ooo cataracts. The very simplified technique would just take one minute for the operation. On the other hand I think the Western surgeon less decided but more careful and may be conscious of the real gravity of the operation. However, one must not forget the extreme pressure at which the surgeons have to work, and to a Westerner what may appear a short-cut or an omission is dictated by the circumstances under which he has to work.
From a general point of view, according to statistics, results are the same in India and Europe.
It is unfortunately absolute glaucoma which is to be seen in India. Used to sufferance having not our fear for blindness and its consequences, thinking wrongly that a cataract is necessarily senile or essential, and can be operated only in cold season, the Indian waits, half in ignorance half in helplessness. Chronic simple glaucomas are also very frequent. This frequency of glaucoma in India is indeed a surprise and a subject to be pondered over if we have to admit that the psychopathologic characteristics so often found in our patients having glaucoma, have a play in the etiology of glaucoma and if we recognise that such characterstics are rare in Indian peasants so often full of patience, resignation, sweetness and gentleness and yet as often glaucomatous.
To explain this frequency of glaucoma in India, have we to consider a race, a food-factor, the rich pigmentation of the iris and the angle, the intumescence of the lens, I do not know.
In many chronic glaucomas, Dr. Sen Gupta from Calcutta noted the appearance of new vessels on the disc, establishing a communication between the central vessels or their branches.
Except in patients who can be trusted, surgical treatment is often directly applied and surgical treatment in Elliot's trephination which was born in Madras and may be partly due to this fact remains very popular. Indian Surgeons do it with attention to minute details and brilliantly.
Dr. K. Sen from Calcutta emphasises the mistake very common according to him of leaving in the hole of 'trephination the transparent Descemetic disc and of taking away only the opaque scleral part, therefore he carefully controls the hole at the end, of the operation to make himself sure that he is not leaving a descemetic disc which will close the trephination and make the operation unsuccessful.
Dr. Mutthaya from Madras emphasised the difficulty of performing the trephination when, the eye is relatively soft; the trephine if not quite sharp will deform more than cut the sclera, it will have to be applied with more pressure and hence the danger of accident is increased. Subconjunctival cortison is much used in Madras at the end of the operation for a doubtful purpose of keeping open the trephination and avoiding the postsurgical iridocyclitis.
Nevertheless iridenclesis is more and more coming into vogue. Some use it only in cases of hypertony less than 30 mm. Hg., and Elliot's operation according to them is indicated when the tension is more than 30 mill. Hg.
In cases described by Barkan as caused by a functional, pupillary seclusion involving a vicious circle by accumulation of aqueous in posterior chamber and Berger's space and reinforcing the physiopathologic pupillary block I saw Dr. Cooper make, according to Barkan, a small periphral iridectomy; success was evident in some cases, temporary in others, absent in other ones where however the mydriasis made previously for checking had a hypotonic effect.
Anterior sclerotomy, i.e. a scleral puncture with the knife close to the limbus at 4 and 8, opening 2 mm. broad, which should open the angle, gives temporary successes and complications which are not temporary; for instance persistant hyphemas, iris prolapses and quite probably goniosynechiaes because the anterior chamber is kept shallow for days and hyphemas probably cause the production of fibrous tissue in the angle. My personal impressions are not in favour of this operation which I saw performed many a time in Madras.
Glaucoma is not rare in aphakic patients, on the other hand cyclodialvsis, perforating or not perforating cyclodiathermy gave sporadic success, in a few cases. I think epithelialisation of the anterior chamber had to be considered.
Cyclodiathermy, and less often injections of alcohol retrobulbar are performed in the too many painful absolute glaucomas. As for Diamox, it is very expensive, too much for the many hospital patients.
Still a remark : it must be admitted that after Elliott cataract is not rare mainly in India where glaucoma is readily operated upon; it is however true that with or without Elliott, tendency of Indian lens to get cataract is great. (Equatorial cataract.)
Infantile glaucoma is not more frequent than in our country; iridenclesis is much performed in it. In one case where gonioscopy showed a closed angle with mesenchymatous tissue, Dr. Cooper made a successful goniotomy. Having no Barkan contact glass, he tried to visualise the angle by injecting air in the anterior chamber after draining it. He confessed that the view of the angle by this method was not very satisfactory.
Finally there is in India a peculiar type of glaucoma; epidemic drpsy glaucoma, first described in Bengal. It happens as pseudo epidemic in people eating mustard oil and therefore has a localised and familiar occurance.
Fields of plants from which mustard oil is extracted, are in some years parasited by Mexican argemon ; the seed of the latter contains a toxic substance sanguinarin which by provoking capillary hyper-permeability causes generalised oedema and especially of the heart and the ciliary body. Hence we find bilateral glaucoma without any pain, with rainbow pheonmena, little ciliary congestion, shallow anterior chamber in some cases, fundus and visual field generally normal. Ocular tension is between 3o and 70 mm. Hg. Tests of capillary permeability and of hematoocular permeability show the capillary hyperpermeability. Treatment against the latter with vitamin C, Rutine, calcium gluconate and of course suppression of the toxin make quickly normal the tension on which pilocarpin would be useless. Thanks to improved supervision over food, this glaucoma has become rare.
They can be seen almost daily, these daughters of uneducation, carelessness and mainly resignation. Dr. Cooper did not hesitate in panophthalmitis to perform enucleation the classical contraindication of which was according to hint, purely theoretical and never proved practically. It was argued that enucleation played a trifle part (1) of taking away the principal focus of infection and (2) of efficient drainage of the orbit by removing the eye which would be of no rise (3) shortening of convalescence. Dr. Cooper had done it in many cases without the slightest complication.
Many were the ocular atrophies and pthysis where with a blink and a word, diagnosis, prognosis and treatment were done. And for this blink and this word the patient had walked sometimes a hundred kilometers.
Concomitant squint seems very rare in India. Therefore synoptophores which attend every ophthalmic Service have to suffer more from the monsoon than from stirring patients or impatient doctors. Recession or shortening are reputed much more serious affair than a cataract and are generally kept for the Chief of the Service. I do not think I have seen half a dozen cases in one year. Squints secondary to amblyopia are very frequent. Paralytic squints are seen from time to time and whether it is a pure coincidence or expression of reality, I saw some due to a Gradenigo Syndrome; other ones to smallpox encephalitis; I have not seen one where malaria could be the cause.
The so called idiopathic detachement was rare although myopia was more frequent relatively than hypermetropia, it seemed to me. Most of the detachments were secondary to Eales' disease, some to a cataract extraction, almost always intracapsular.
Diathermic treatment does not deserve special mention, having in India the same technics, successes and failures as in our countries.
Lamellar sclerectomy was not popular and the perforating one was gaining attention, consecutively of course to the arrival of Professor Lindner who had his personal ideas about detachment which I have no time to speak about here.
They are the same as here; drugs are now easily available because India has her own factories and laboratories. For instance, sulphonamides, penicillin, aureomycin are synthetised in India. In big cities drugs are available free of charge in the hospitals for poor patients.
Proteinotherapy and mainly milk injections are much used by Indian Ophthalmologists. In Bombay Dr. Cooper was very fond of desensitisation with tuberculin (Koch purified) and lens proteins extracts of solution respectively 1/100,000 and 1/1o,ooo. Dr. Cooper before deciding for a treatment reminded us of "The sick eye in the sick body" and of an equation [Figure 1] and he planned the treatment in order to work on every fraction.
I would like in ending to express my gratitude to the many who made possible for me a fruitful stay in India. First my father who made the project, gave me the opportunity and accepted all the sacrifices with unselfish affection; Professor Appelmans who encouraged me, gave me advices and who with Professor Bruynoghe kindly wrote the appreciation asked by the Belgian Government for the Scholarship; Dr. S. N. Cooper and his Staff; Dr. Cooper replied to my first inquiry and later advised me for the different stays in India; he gave me a 4 months hospitality in his Service and the fruits of his balanced surgical and medical experience ; and yet I got from him and his assistants this typically Indian sweet and delicate friendship. Dr. Mohan Lal and his staff, in Aligarh Dr. Mutthayya and his staff in Madras, Dr. Kiran Sen and Dr. Chaudhury and their Staff in Calcutta who kindly received me and showed me a lot of cases.
Our countrymen, Dr. Hemerijckx, Dr. Vellut, Mesdemoiselles Liegeois et Eenberg, who are doing in India a magnificent work and received me in Polambak kam where I could see cases of ocular leprosy and took me to Chingleput Leprosy Hospital where Dr. Paul had kindly collected for me all the cases with ocular involvement.
Public Instruction -Ministry of Belgium and Education Ministry of India who awarded me the scholarship and made it a success and an unforgetable experience.
All the friends I meet in India and who taught me the many fascinations of this fascinating country and contributed to make my stay most pleasnt and fruitful from a medical and human -point of view.