Year : 1984 | Volume
: 32 | Issue : 5 | Page : 261--268
All India ophthalmological conference
SN. Medical College, Agra, India
Emeritus Professor of Ophthalmology, S.N. Medical College, Agra
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Avasthi P. All India ophthalmological conference.Indian J Ophthalmol 1984;32:261-268
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Avasthi P. All India ophthalmological conference. Indian J Ophthalmol [serial online] 1984 [cited 2021 Sep 26 ];32:261-268
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It is my pleasure and privilege to extend a most cordial and hearty welcome to our honoured chief guest, who inspite of his many pre-occupations has found time to be in our midst, to inaugurate the 1984 All India Ophthalmic Conference. We feel honoured. This is a proof of his deep interest in the welfare of our people, especially of those who are afflicted with some ailment in the most vital of their sense organ, the eyes. On behalf of my fellow ophthalmologists, I give you Sir, an assurance that we will not leave any nerve unstrained in our effort to alleviate their suffering through the application of curative and preventive measures. It is a reflection on our nation that out of thirty million blind people in the world, nine million, about one third of the total should be in India. It is not fully realised that apart from human suffering, which must remain the first concern, the blind are an economic liability. Many of them are able-bodied persons and could add to the wealth of the country. The most important thing to do is to arouse the nation to its sense of responsibility and make it aware of the possibilities. But before indicating these I must express my deep sense of gratitude to the members of the ophthalmic society for having conferred on me the greatest honour they could by electing me their President. The chair has been occupied in the past by the most distinguished ophthalmologists in the country. I am very conscious that I do not deserve a place in that galaxy but having bowed down to your wishes, I promise to do the best I am capable of to justify the trust reposed in me.
Disregarding the advice of Cromwell who said in a similar situation, "you have done all the good that you can but it is time for you to go out." I promise that I will continue to serve the cause for which our society stands till the end.
May I also, as the President of the Society, express the gratitude of the Society, of the foreign delegates and my own to the Cochin Ophthalmic Society for the kind invitation to host the conference in their beautiful historic city. Hosting a conference of this national stature necessarily entails a great deal of inconvenience and expenditure. In return all we can promise is that we will look back to this occasion with joy and gratitude.
I revert to the main theme for which we have gathered here - Prevention and cure of ophthalmic diseases, the most serious of these being blindness. As stated earlier out of thirty million blind people in the world, nine million are in India. The major cause of blindness in our country is cataract which accounts for 55 per cent of the cases, followed by trachoma and associated infections which accounts for 25 per cent of the cases, the remaining 20 per cent are ascribed to malnutrition, injuries and glaucoma. The efforts to solve the problem have been very inadequate. The target fixed for cataract operations for the year 1982-83 was 12,93,630 but only 7,83,533 operations were performed. Likewise the decision to start 37 centres for training only 32 have started functioning.
Field work and research should be intensified and human knowledge fully utilized to make clinical ophthalmology more effective. A greater degree of support and cooperation must be sought from basic knowledge to look into the causes of the different diseases. We know so little about the fundamental, causes of cataract, glaucoma, uveitis and other degenerative ocular diseases. It is most essential that trained clinical ophthalmologists join hands with persons well trained in the advanced tools of physics, chemistry, bioscience and bio-chemistry to find an answer to many of the unsolved problems. Then alone we can effectively devise mechanical, surgical, clinical and bio-chemical means to remedy them. Just imagine how many people would go through life cheerfully if through the help of research findings the beginning of cataract could be delayed say by ten years. It is heartening to believe that answer to diabetic cataract is in sight. It has been found that in human diabetic cataract, there is elevated levels of sorbital, glucose and fructose as compared to nondiabetic cataract Varma in 1980 and Sharma (1981) by inhibiting aldose reductase could slow down or prevent diabetic cataract by administering Flavinoids, Sulindac.
The control study had established that people with high blood urea level or those who are heavy drinkers and smokers or on low protein diet or exposed to heat as in north India are more prone to cataract The identification of these factors being associated with cataract and same of the interactions between them should lead to testable hypotheses.
Eye Relief Camps
The eye camps properly conducted can help in reducing blindness. Mobile eye unit has a great role to play both in preventing and curing eye diseases. There should be a code of conduct for eye camps. The surgeon must have atleast 5 years experience in cataract surgery. A junior doctor should stay in the camp till all the patients are discharged and the patients should be examined again after 15 days. It will be advisable that a local ophthalmologist conducts eye camps in his own locality so that patients after operation may know where to go. When a surgeon comes from outside the area to operate the confidence of the people in the local ophthalmic surgeon is reduced. It will be advantageous, if the work of the local ophthalmologist is supervised from time to time by the senior ophthalmologist of that region. These camps should be conducted in rural areas from where patients are unable to come to central hospital. I have known of eye camps being held next door to a Medical College.
It is my firm belief that Medical Colleges should be kept away from these eye camps. Their work should be teaching, research, patient's care in their hospitals and to produce competent doctors. Due to shortage of staff in the Medical Colleges any work assigned to them outside their campuses is bound to effect adversely, the quality of their teaching and research. The aim of the eye camps should be to cover every village and this can be done only through the visits of the mobile eye units. They should also educate the people about the hygiene of the eye. This can be done by showing various films on the subject. Trachoma and infectious diseases are among the major causes of blindness. These can be considerably reduced by proper education of the masses. Thanks to antibiotic, trachoma has been considerably reduced. Malnutrition leading to keratomalcia is common in south India and also in north during summer after acute diarrhoea in children. The malnutrition and poor economic condition of large number of our people is due to explosion of population. In 1947, the year of independence we were thirty four crores, today we are 70 crores. The population explosion gives rise to poverty and poverty is the root cause of subhuman living conditions, which is the cause of many diseases. Hence unless the population is controlled it is difficult to imagine that the desired results shall be achieved.
Very little has been done to provide ophthalmic facilities for the tribal population, which mostly live in the north eastern, the central or southern regions of the country and in Andaman and Nicobar. Their general health including eye conditions have deteriorated due to deforestation. They constitute seven per cent of our country's population.
The blindness is also caused due to ignorance, superstitions quack's practices, home made remedies and surgery by unqualified persons. What can a poor villager do? He is too poor to go to town to consult a qualified doctor and a doctor would not go to a village. When he manages to go to a town he is fleeced. The economic condition of the masses must improve, the control of population is the answer. Let each one of us resolve to educate at least one villager about ocular hygiene. The villager so educated should be required to pass on the knowledge to at least ten villagers. The problem of blindness is too colossal to be handled by the Government alone. The public must come forward to offer cooperation. The social organisation can play a key role but the responsibility of ophthalmic surgeon would be greatest.
A specialised ophthalmic service should be made available to school children. If this is done many school going children can be saved from getting blind through proper treatment and preventive education. For glaucoma the public has to be educated. If glaucoma is detected at the proper time the disease can be controlled. Many glaucomatous patients do not get it treated presuming it to be cataract.
The Government of India deserves our congratulation for establishing various mobile eye relief centres to eradicate blindness. The prevention of infectious diseases can be made effective with proper efforts. But the problem of cataract and glaucoma which afflict old people will perhaps remain unsolved and so will diabeties, hypertension which is generally the disease of rich people. The genetic factors which affect the eyes should receive the attention of the researchers.
The problem of blindness varies depending upon geography, economic condition, industrial occupation, age etc. It is essential that those of us who have dedicated ourselves to this cause, pass on not only our accomplishments and failures but also indicate the nature of the problems we have failed to solve. That will beour assignment to the coming generation of ophthalmologists.
It is retrograde step of the Medical Council not to prescribe ophthalmology as a separate independent subject of study. The result is that the coming generation has very little knowledge of the subject. The medical education should be patient oriented. It is also essential that our standard of M.B.B.S. education be the same as anywhere in the world. Since entrance to the college is through competitive examination, the very best students should be selected. There should be no reservation if the standard of the medical educar tion is to be preserved. Some rich who fail to pass the competitive examination get entry into Donation Medical Colleges by giving large amounts of money. Later they get themselves transferred to regular medical colleges in their states. This practice not only lowers the standard of education but also gives recognition to donation colleges.
Reservation of seats in favour of any category of weak students is not desirable. Under reserved category students even with 40 per cent marks get admitted. This is a very important cause of lowering the standard of education in Medical Colleges. Due to reservation some very good students are denied admission, which is injustice for them as well for the public. It should be realised that we are training people to deal with human lives. For such a profession only the very best should be selected and given the medical education of highest standard.
Post Graduate Studies and Degrees
The M.S. is the highest qualification in the country. Only those institutions which are well equipped should be allowed to conduct M.S. training. The admission to M.S. study should be open only to those with good academic M.B.B.S. career. The subject of statistics should be apart of M.S. study. Before taking M.S. examination the students should have worked for at least three months with a Neuro-surgeon, Neurophysician and one month in the E.N.T. department The research subject should be well planned and only teachers with at least 5 years Postgraduate teaching experience should be allowed to guide research. The M.S. students should have good knowledge in all branches of ophthalmology competent to deal with any emergency. It will be to his advantage if he can visit various ophthalmic centres in the country to acquaint himself with the best that is going on in any institution. From among the M.S. students will emerge the future teachers of medical colleges and researchers. Therefore, their training must be of the highest standard. Politics must be kept away from the medical education.
The M.A.M.S. started by the academy has not made much headway and is not very popular with students. I have examined M.AM.S. students and I am in a position to suggest that there is nothing special about it. However, I am of the opinion that there must be one Postgraduate examination with same standard throughout the country.
Medical college teachers should be apointed from the very best available with brilliant academic career and not necessarily from the provincial medical service, they should have an aptitude for teaching and research. The post of the professor and the Head of the Department should be a non-practising one. It should be entirely academic cum clinical appointment. His contribution to the science may be periodically assessed. The rest of the staff may be allowed private practice in nonworking hours. Their work should be computerised at the end of the year regarding care of patients and contribution to science and teaching. Those who do not come to the expected standard should be dropped. The students should have some share in judging the ability of the teacher. It will be desirable tosub set up a fullfledged eye institution in each state. Such an institution shall be required to conduct research of the highest academic nature and be expected to solve the problems which confront us. The super specialities must have very qualified staff to train other doctors who too should have very high academic back ground. These institutions should be real centres of medical education and research.
It is high time that a teacher forum be established under the society to make possible enlightened consideration of the problem of research, advancement of education in the field of ophthalmology and standards of Post graduate education.
The de-recognition of our degree by the more advanced countries should be a matter of the highest concern to the profession. In recent years a number of medical colleges with poor equipment, inadequate hospital facilities and ill qualified teachers have sprung up. There has been a mushroom growth of such colleges. The accrediting system provided in the country has proved too weak. It may be advisable to have a medical university in the states which have a number of colleges. The university should insist on a minimum standard. However, to recognise that this will depend on the attitude of the Government concerned and therefore, I have said earlier that politics must not enter medical education.
There has been a terrific advancement in medical science in the past few years if we do not catch up, very soon we shall be left far behind.
Argon Laser for Glaucoma
The peripheral iredotomy or trebeculoplasty can be done on out door patients, with advantage.
The Laser treatment for posterior segment is a great advance in surgery. But only a particular pathology can be treated without damaging surrounding tissues.
The procedure, has major complications of corneal degeneration, opacification, its chronic inflammatory effects and associated cystoid macular oedema have resulted in efforts to overcome the problem of glasses
A recent development has been the posterior chamber lens to be inserted after extra capsular cataract procedure. Paradoxically, ophthalmologists spent the first three quarters of this century converting, updating and perfecting the intra capsular procedure. Only now to find strong advocates of the extra capsular procedure, as the procedure of the choice for the posterior chamber I.O.L. However, the opacification of the capsule that follows the lens implant nullifies the benefit of the operation, needs the second surgical procedure to cut the membrance by YAG (Laser).
The use of Healon and chondroitin Sulfate (CDS) is of a revolutionary nature and very effective in protecting corneal endothelium during intra-ocular lens implant. Its exact relationship to the chronic iritis cystoidoedema syndrome after I.O.L. implantation is still unknown and argument that is now entwined with the relative merit of intra capsular cataract extraction versus with extracapsular cataract extraction, the controversy will probably continue for number of years to come.
It is a valuable method for the diagnosis and treatment of various anterior and posterior segment of ocular conditions and some systemic disorders. The early removal of vitreous has provided material for microbiological study of patients with suspected endoophthalmitis. Early diagnosis can save the eye. Vitrectomy has also made available tissues for diagnosis reticulum cell sarcoma and some lymphomas. Therapeutically have benefitted patients with diabetic complications of retina vitreous haemorrhage, retinal and vitreous memberance, tractional retinal detachments, trauma and surgical complications from the retinal detachments and anterior segment surgery.
Certain improvement in vitrectomy technology has made it possible to redress types of posterior segment pathology which was not done even 5 years of ago. These improvements include tiny fibro-optic intraocular light sources that are introduced into the vitreous, fine instruments for cutting and pealing vitreous and retinal membrance, surgical microscopy and intraocular Laser devices for controlling bleeding and destroying the abnormal vessels and tissues. Laser treatment of posterior pathology is another great advancement. For example, blue lift (Argon Laser) is not feasible for macular treatment because its absorption causes retinal damages. Green (Argon or Krypton) and Yellow (Krypton) light are useful for macular and vascular lesions.
The Red (Krypton) light poorly absorbed by blood in retinal and sub-retinal vessels and minimally by Xanthophyll. The use of these principal and expanded treatment experience have resulted in a single laser which generates various wave lengths to treat different tissues with safety to their absorptive characteristics.
Orbital operations which were frequently done with some difficulty and often involved a "Needle in a hay stack." Now the approach has become more exact largely due to computed tomography both axial and coronal, which combined with ultrasonic and combination of radiological studies, usually makes diagnosis possible for approximately 90 per cent of cases. The operation can be performed with minimal residual effects.
It is usually done to minimise the optical problem of Myopia, Aphakia, Keratoconus, Hypermotropia and Astigimatism. Keratophakia and keratomileusis are done with great effectiveness by some surgeons. It requires expensive cryo-lathe, a cryolathe technician, computer capability and requires great skill on the part of the surgeion. Radial keratotomy has been introduced to reduce the myopia. These are all in experimental stage and performed on the healthy cornea.
It is a highly controversial procedure. It was first practised by Sato in Japan in 1950. It resulted in subsequent corneal degeneration. The procedure was introduced for the professional use by `Fyodorov" in 1973. A large series might well show a little substantive improvement or such a small number correction that result could be disappointing with many other complications. The further use of extended wear soft contact lens might well be done of the non-surgical alternative for serious refractive errors.
One does not know what is going to happen to these eyes in future. To caution us, I am reminded of a Napoleon's saying, "He who changes the old road for the new knows what he leaves, but does not know what he finds."
Until this predictability is improved and the unknown long-term complications have been studied, I believe radial keratotomy should be continued as a clinical investigation project under research protocol.
Another improvement in the modern therapy is the contact lens which can be worn and left in place for days, weeks and even months, would be ideal for children with monoocular aphakia. These are made of greater variety of polymer of soft plastic and silicone which allows gas to permeate for the corneal nutrition.
A large number of our bright students go out of the country for better living. They have to do so, because they get job satisfaction and better living condition out side the country. I do not blame them. If they come back after advance training, they find that the facilities are very inadequate for the kind of work which they would like to do.
We are grateful to foreign ophthalmologists who visit our country either on -sub their own or on our invitations. We derive benefit from their experience. Sometimes, however, they give a press conference, which proves very derogatory to Indian Ophthalmology and misleading to patients. It is my earnest request that before giving any press conference a foreign visitor should acquaint himself with Indian conditions and the Indian soceity. It is also my request to Indian ophthalmologists who invite them to associate in some form or another the ophthalmological society which should utilise the services of the experts to greater advantages .
This great national organisation to which we have the honour to belong, unlike the British Ophthalmological Society or American Academy of Ophthalmology has hardly any voice in decision making in regards to health care schemes of the Government. One of the reasons is that our membership is limited. A large majority of Ophthalmic men and women are not members of the Society. It should be our endeavour to increase the membership to the maximum. The society should be considered the proper channel to express the difficulties of ophthalmologists in the country. We's'hould have a central office in Delhi and get more involved in the socio-political activities. The Society should monitor legislation and interact with leaders and decision makers in Government, to ensure that Ophthalmology is well represented. To attract the attention of the public and Government we should launch a successful campaign against blindness, which is the greatest enemy of the man-kind. We must unite for this common cause. Every ophthalmologist should take an oath that he will take an active part in reducing the number of blind people in the country. I congratulate Prof. Venkata Swami for establishing a very good eye institute in Madurai and Dr. Badrinath for establishing Shanker Netralaya in Madras. Both have been honoured by the Government of India with Padam Shree. Dr, Jaivir Agarwal and Dr. Nagpal have also established good eye institutes in Madras and Ahmedabad respectively. The deserve our congratulations.
These days, many of us are engaged in profession only to gain financially. We work very hard for our professional advancement so that wo could earn more and win appreciation for our expertise. If all success and glory is self centred then it could not give as real work satisfaction of the noble profession in which we are engaged. We are in a position to help the suffering humanity. It is a God given opportunity for us to give sight and to save many from blindness. All the beauty of this universe is meaningless without sight. Let us work hard to remove the darkness from the lives of many.
Ladies and Gentlmen!
We have been working together for the prevention of blindness. It is heartening that the number of delegates to this conference has increased steadily every year. It is true that these meetings do not always produce immediate result true that they cause the participants a great deal of inconvenience in travelling and sometimes lot of work, true that when you return from the conference you find a pile of work upon your desk or problems which have accumulated in your absence; true that sometimes you feel, you have learnt nothing new. I hope none of these thoughts or feelings will rise in your mind when you return from this conference because even if you have not learnt any thing new but perhaps you will have added to the knowledge of others. In any case you will have made friends which you may find very satisfying. You will have understood the professional and personal problems of others and may be, you will have contributed to their solution. In the end you will go back with a feeling of comradeship with fellow medical men and women in other parts of the country and the world. You will go back with a feeling that you belong to a profession of which the key word is cooperation and not competition. These will be the assets in your balance sheet If remain be satisfied with the attempt which has been made. It has at least brought so many of us together and given us a feeling of brotherhood. Is it not enough?
I suggest that we should fit ourselves in the larger perspective of the development of the nation. What is our national ambition? A happy and prosperous nation can not afford the blindness of so many people. A lot of work has been done but a lot more still remains to be done. It is befitting to repeat the versus by
Robert Frost for future action:
"The woods are lovely, dark and deep, But I have promised to keep. And miles to go before I sleep, and miles to go before I sleep."
In the end, I wish this conference to be a great success and hope that as a result of our deliberations and the resolutions which may be adopted, ophthalmic education, research and service to the country will get a great incentive. It is my hope that we will be strengthening the foundation of integrated programme of teaching, research and prevention, rehabilitation and cure of eye diseases.
Ladies and Gentlemen,
I thank you forgiving me a patient hearing. I would request you to remember the basic principle of purposeful living. We shall not be asked how much pleasure we had in it, but how much service we gave in it, not how full it was a success but how full it was a sacrifice, not how happy we were, not how much ambition was gratified, but how much was served?
I quote Virginia Moore:
The speaker bores you, gentlemen, He's also boring me.
But praise him gently when he's thru, He comes to us for free.