Thyroid Eye Disease

Thyroid eye disease (TED)- also known as Graves Orbitopathy or Thyroid Associated Orbitopathy- is an autoimmune condition of the soft tissue such as the fat and muscles surrounding the eyes. The disease is characterized by a period of inflammation and swelling of these tissues, followed by a healing response. Our body’s immune system usually fights off infection but in an autoimmune disease it attacks the body’s own tissues with antibodies. When an autoimmune attack starts on the thyroid gland, it responds by producing more of its hormones. At the same time the auto-antibodies attacking the thyroid gland also attack the tissues around the eyes. We often term this as

“The Thyroid and your eyes are victims of the same disease”.

As the soft tissue around the eye becomes inflamed, some of the following problems can occur:

  1. The eyelids become puffy and red (lid swelling).
  2. The muscles of the eyelids contract, producing a staring appearance (lid retraction).
  3. The muscles and fat surrounding the eye swells, pushing the eyes forward causing a bulge (exophthalmos).
  4. Lid retraction (staring look) and exophthalmos (protrusion of eyeballs) make the dry eye symptoms worse.
  5. The swelling of the muscles which move the eyes produce unequal movements and double vision (diplopia).
  6. The orbits may become painful, particularly on eye movement.

In some patients who have firm tissue, the eyes may not bulge forward. This results in the pressure inside the orbit increasing which in turn compresses on the optic nerve and causes sight problems. The optic nerve carries messages from the eye to the brain and can be damaged by this increase in pressure.

Smoking history is very important in TED because it is associated with poor prognosis and poor response to treatment.

With regard to treatment, a thorough work up needs to be done before embarking on medical or surgical management

What is important to understand in the pathophysiology of Thyroid eye disease is that Hyperthyroidism does not cause Thyroid eye disease. Both conditions are caused by the underlying immune dysfunction. A person with Thyroid eye disease may be Hyperthyroid (high levels of Thyroid Hormones, Hypothyroid (low levels) or even Euthyroid (normal levels). TED is a systemic disease and not a local disease.

The standard of care today in the active stage of the disease is high dose pulsed Intra-Venous Methyl Prednisolone (IVMP). This injection steroids modality has been proven to be superior to oral steroids by numerous studies done.

The success of TED treatment is based on team work of a number of sub-specialists- an Oculoplastic surgeon, Immunlogist, Otorhinolaryngologist, Strabismus specialist, Orthoptist, Hepatologist and a Cardiologist. The primary physician in the case of TED is the Oculoplastic Surgeon.

Any specific questions you might have you can directly message me or ask in the comments section of this article.

I do not have any financial interests to declare regarding the above article and it is intended to educate the general public including medical professionals about eye conditions.

The above article is based on an answer I wrote on Quora

What is Thyroid Eye Disease?

Retinoblastoma, A Success Story In The Fight Against Cancer

Retinoblastoma is a cancer of the eye. The cancer starts in the retina — the light sensing part of the eyeball on the inside of your eye.

Image Source: ​Retinoblastoma Labeled Diagram

Retinoblastoma is usually a cancer of young children, but in rare cases even adults can suffer from this cancer. It is the most common eye cancer of childhood. Incidence may vary from 1/18,000 births in developed nations to 1/12,000 births in developing nations.
It can be heritable as well as non-heritable. The non-heritable type is the most common type accounting to about 90-93% of all retinoblastomas.

What makes treatment of Retinoblastoma so successful than other cancers?
Reasons for high success rate are many

  1. Genetic basis of the tumour being identified
  2. Early diagnosis of the tumour
  3. Multiple treatment options
  4. Cutting edge basic and clinical research

Genetic basis

At the beginning of the 20th century the survival rate of children with Retinoblastoma was less than 17%. After modest success for many decades the discovery of the Rb1 gene mutation (1986) was game changing.More than 70 years ago, it was recognized that retinoblastoma sometimes has a genetic basis and that the pattern (when genetic) is classic Mendelian autosomal dominant. It was not until Alfred Knudson proposed his two-hit hypothesis and the subsequent molecular confirmation of his calculation that it was recognized that this autosomal-dominant pattern is caused by the loss of a normally occurring gene that is now referred to as the RB1. Although it was originally thought to be of importance only in retinal cancers, it is now recognized that loss of the normal RB1 gene is an important step in cancer development in most adult non ocular cancers.

Early Diagnosis
Early detection of Retinoblastoma is the key.

Leukocoria– which translates to white pupil- in other words whitish appearance from the centre of the eye is the most important sign of Retinoblastoma, which brings it to the attention of the parents to seek help.


Image Source: ​Medscape: Medscape Access

There are other signs too but Leucocoria  is the most common sign. This early sign and hence early diagnosis is also responsible for high cure rates seen in Retinoblastoma.

Treatment options
The biggest advantage in the treatment of Retinoblastoma is that it is responsive to mutiple options of treatment unlike other tumours.
The characteristics of the tumour is

  1. Extremely chemosensitive and hence it has high response to chemotherapy
  2. Radiosensitive, so Radiotherapy is an option even when the tumour has spread outside the eyeball.
  3. It is amenable various local therapy like Laser therapy, thermal therapy, cryotherapy and plaque brachytherapy. This is possible because we can visualize the tumour using an ophthalmoscope.
  4. When only one eye is involved, Surgery – Enucleation can sometimes give permanent cure from the cancer.

Pioneering research
As it stands today, in the best centers in the world for Retinoblastoma care, the success rates are staggering-

  1. 95% Life salvage
  2. 90% Eye salvage
  3. 85% Vision salvage

This is staggering because just 50 years ago, the rates of survival in children with retinoblastoma was less than 30% even in the best centers.

Today Retinoblastoma is treated using a team based approach. The team consists of an Ocular Oncologist, Pediatric Oncologist, Radiation Oncologist, Pathologist, Interventional radiologist and an Ocularist. This approach has resulted in fantastic success in care for children with Retinoblastoma.

February 15th was International Childhood cancer day. The motto for Retinoblastoma Awareness is:

“Fight the white”

I’ve written about Retinoblastoma talking more about Dr. Zimmerman family story and my personal experience in my blog post- Hope and Heartbreak: The two sides of Retinoblastoma

The above article is based on an answer I wrote on Quora

Why is Retinoblastoma so treatable and has such a high survival rate when compared to various other cancers? Are there any specific reasons for the same?

If you have any questions I would be happy to answer in the comments section.

I do not have any financial interests to declare regarding the above article and it is intended to educate the general public including medical professionals about eye conditions.


  1. David H. Abramson. Retinoblastoma in the 20th Century: Past Success and Future Challenges The Weisenfeld Lecture. Investigative Ophthalmology & Visual Science August 2005, Vol.46, 2684-2691. doi:10.1167/iovs.04-1462
  2. Collins MZ. Retinoblastoma: The Zimmerman Family Story. JAMA Ophthalmol. 2014;132(5):519-520. doi:10.1001/jamaophthalmol.2014.467.
  3. Xu K, Rosenwaks Z, Beaverson K, Cholst I, Veeck L, Abramson DH. Preimplantation genetic diagnosis for retinoblastoma: the first reported liveborn. Am J Ophthalmol. 2004;137(1):18-23.
  4. Abramson DH, Shields CL, Munier FL, Chantada GL. Treatment of Retinoblastoma in 2015: Agreement and Disagreement. JAMA Ophthalmol. Published online September 17, 2015. doi:10.1001/jamaophthalmol. 2015.3108.
  5. Retinoblastoma: Recent Update and Management Frontiers.
  6. Manjandavida, Fairooz P. MD; Honavar, Santosh G. MD; Shields, Carol L. MD; Shields, Jerry A. MD [Editorial] Asia-Pacific Journal of Ophthalmology. 2(6):351-353, November/December 2013.
  7. Alex Melamud, Rakhee Palekar, Arun Singh, Cleveland Clinic Foundation, Cleveland, Ohio Am Fam Physician. 2006 Mar 15;73(6): 1039-1044. 

Finding Superman: Changing a prolific surgeon to a social entrepreneur

December, 2015
This was my second trip to Sambalpur, a nondescript town-city in western Odhisha. I was introduced to The Vision Mission (TVM) by my colleague, Dr. Jayant Iyer when I was working in Singapore. He along with his friends (Avinash Jayaraman and Jason Lee) had established a non-profit organization to help under served areas in south and east Asian regions in providing eye care. They started their first project in Sambalpur trying to convert a modest hospital into a world class eye care center. They send a team of doctors from Singapore three times a year to help the partner hospital to improve services. This project is 2 years old now. When I returned to India, Jayant asked if I would consider volunteering for TVM. I readily agreed and have made two wonderful trips there thus far. The Vision Mission is bringing specialized eye care, education and training to Sambalpur. It’s partner organization in Sambalpur is Trilochan Netralaya (TN).

I want to talk about one man here- Dr. Shiva Prasad SahooFounder/CEO/Ophthalmic surgeon of Trilochan Netralaya, Sambalpur- the inspirational man behind this veritable institution. He was a man of limited means and yet he dreamt of providing eye care to the poorest of the poor in districts of Bolangir, Sambalpur and Kalahandi. He does about 12,000 cataract surgeries a year.

Dr. Shiva Prasad Sahoo- The surgeon for the forgotten ones.

He has built a hospital with OT facilities in the city of Sambalpur with another large hospital with OT in the outskirts of the city. It also houses “Betty Ashram” which is used to house patients before and after free cataract surgeries. They are fed, tested, sheltered and given medicines in that ashram. He does most of the 12,000 surgeries free of cost.

Betty's Ashram
Betty’s Ashram

The Vision Mission (TVM) is one of the supporters that Dr. Shiva has by his side. TVM’s main purpose behind having these mission trips is not so much to teach Dr. Shiva cataract surgery- which he’s obviously an expert when you see the numbers. TVM sponsors 1000 cataract surgeries every year thanks to their donors. TVM’s long term vision is to get Trilochan Netralaya (TN) match up to global standards of sub-speciality eye care and make it sustainable in the long run. They wanted to start with management of diabetic retinopathy (DR) and glaucoma as their focus areas to start with and then go on to develop other sub-specialities.



On my first trip in March they had just brought in new laser machines, fundus camera, OCT machine, Ultrasound and UBM machines. Instruments available in the best of eye hospitals in big cities in India. I was on the trip to assess whether Oculoplasty services could be offered along with the DR and glaucoma services. We conducted a CME and had training sessions in clinics and Laser. I recommended ways to get the Oculoplasty set up going. We thought we had done our bit and returned.

March trip
Some snapshots from our trip in March this year

 They had another trip with another team in October, 2015. They reinforced what was done the previous visit.

When we went this time in December, 2015- I realized the challenge Dr. Shiva was up against. He is obviously very driven to get better at running his hospital- to get his patients the best possible care. He had funds-now that Mr. Subrato Bagchi (CEO of Mindtree) has promised to support this cause. But I understood that just money and infrastructure would not help him build his dream. TVM had to help change this very prolific surgeon to a social entrepreneur. This is going to be hard since he spends most of his working hours doing cataract surgery and seeing patients. He had too much on his single plate. He needed more dedicated doctors and trained technicians to work with him to achieve his goals. He needed to be the guy moving the organization towards the right direction. As counter intuitive as it sounds, he needed to be less a surgeon and more an entrepreneur.

Dr. Shiva does not do these humongous number of cataract surgeries out of some ulterior motive to be a hero or to monetarily benefit from it. He does so out of a selfless desire to help people and the ambition to provide modern eye care to the community he lives in. In fact he and his family live in a room atop the hospital. Such is his dedication towards his work.

The numbers of patients are staggering and it never ends. The ashram is teeming with patients waiting to be gifted their vision. His day starts at 5am and ends at 11pm. Everyday. He is so burdened with work that he does not get time to go out of Sambalpur area for any extra training. It certainly is a herculean task to maintain this level of surgical work and yet try to build on what he has and get to the next level. I do have to marvel at what he has achieved despite this high surgical load. I as a surgeon mostly have to worry about my patients and my surgery. Not much else. Despite his busy schedule, Dr. Shiva has to ensure that everyone else does their part. This is the job of a leader. Every philanthropic work needs to apply principles of entrepreneurship to be successful. For example, Bill Gates can donate billions of dollars to charity but just throwing obscene amounts of wealth will not make his money work in the way he wants it to. So he has taken over the Melinda Gates foundation himself and ensuring that his vision is accomplished by giving direction as a leader. The challenge we have here in Sambalpur is quite similar.

Sambalpur is the biggest city/town in western Odhisha. The western Odhisha region-about 300kms radius around Sambalpur is one of the poorest regions in India having little or no access to even basic eye care. The extreme poverty is very apparent in the dusty roads leading up to the villages housing thatched dwellings with little access to safe drinking water or electricity. There are old people in these villages struggling to make ends meet with earnings of less than Rs. 20 a day. These are the people of India we forgot when we went on the road to progress.

PicMonkey Collage
Few images from the villages from which the patients are brought to Sambalpur for free surgeries

 Philanthropy, to be successful has to pay for itself eventually. The successes of the Aravind Eye hospitals, Shankar Netralaya, LV Prasad Eye Institute in India are testimony to this fact. TVM’s long term vision is to try to convert TN into a smaller version of the three big eye institutes. Even social causes such as this needs to be run like a business. The multi-tier payment model adopted by the big eye institutes in India is the way to go. Income generated by paying patients can fund the treatment of the very poor ones and also sustain the institution. In India we are lucky to have volumes of patients who can support such a model. These volumes will eventually drive down costs of healthcare for everyone.

Few scenes in Trilochan Netralaya in Sambalpur on the present trip

I hope that in time the TVM-TN collaboration results in something special for these forgotten parts of India. I feel privileged to be part of this process. I hope to add my small little contribution to the great work done by Dr. Shiva, his team in TN, the generous donors and TVM.
We need supermen like Dr. Shiva for healthcare in India. People who have to be physicians, surgeons, entrepreneurs, philanthropists and managers combined into one person. People who can take on multiple responsibilities in this endeavor without an almost non-existent government support and yet be driven enough to bring about a social change. We have found one, I’m sure we would find more.
Below is the documentary based on one of the mission trips by the TVM team

Photo credits: Ng SiRui, Avinash Jayaraman, Raghuraj Hegde, Jason Lee, Edric Wong, Jason Lee, Jayant Iyer.

How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I’m sure most interns would study anyway as a default. I wouldn’t stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student’s life.

To prioritize your medical career you need to use your internship as career sampling

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people’s opinions about what you should do. What you do is your business not your uncle’s or neighbor auntie’s.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head’s orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations….. You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I’ll never do it again so I’m thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn’t have good teachers for ophthalmology in my medical school but I didn’t let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one’s internship. Never lose that wonder.

Life of a 21st century doctor!

The medical science has seen a sea change over the last century…..more than what has been achieved in the previous 5 centuries put together. The change has been for the better for patients as people are getting cured of diseases which previously had no cures. In this state of change to expect the medical profession not to change is simply naive. I would like to enumerate the good, the bad and the ugly of the medical profession in general and the joys and challenges of doctors in particular. This is in no way a negative or cynical post. It is more of a perspective of how things are and how it is going to be.

Medical Education

Over the years the field has grown leaps and bounds and this being the era of super specialization… doctors are moving on to micro specialization. It has become harder for students to keep up to the whole gamut of information which keeps changing every few years so “specialization in minutiae is inevitable” is  the new world order for doctors. I agree with this in principle but the path to specialization especially in India is difficult, unrewarding and involves a lot of factors unrelated to your capability to be a good doctor. First on the list comes low pay right from the time a medical graduate passes out. This pay never reaches the amount appropriate to his/her level of expertize all through their career unless he/she indulges in any wrong practices or his/her family owns a hospital. Second is the high cost of medical education not only monetarily but in the quality of life a medical student has to endure throughout his student life. An equally capable professional in another field is pretty much well set by the time a doctor can come out to practice and by which time the doctor has a mountain of debt and an unforgiving society. There is very little incentive for a student in India to join the medical profession unless their family owns a hospital or have unending disposable income to spend. This puts the profession beyond the reach of the middle class since there are no returns for the incredible amount of mental and financial investment required from a doctor. So is it any surprise with the quality and character of the doctors of the new era. The brightest and smartest don’t want to become doctors since it’s simply not reasonable for a middle class family to sustain a medical student. This makes way for corruption and only the people with the insane amounts of money can become doctors in the new era. Are these the kind of doctors you want to trust your lives with? Those fortunate to be bright enough enough to secure a government medical/ residency seats which they can afford are treated so shabbily by the system. They are often put up in slum like living condition in hostels with bug infested rooms, mosquitoes and the works by government colleges. They are often made to work 80-100hrs a week resulting poor nutrition and low morale. A lot of them end up sick and in extreme cases even dead. On top of that, the added danger of flash mobs assaulting the emergency doctors on call. The general feeling is the residents are often disgusted with the system and with their seniors for perpetuating this unfair system. This is how the brightest in the field are treated by the society. Some links below which might give an idea of how big the problem is.

The specialist doctor problem

These days everyone wants to be treated by the specialist. To a lay person it might seem like the most correct thing to do and may feel that a super specialist is very accomplished hence also the most capable to treat his disease. In practice however it is a huge waste of resources. In most patient surveys around India and the world 80% of the sickness can be treated at the primary healthcare point. The consequences of making the cardiologist treat a common cold is that the patient is wasting a cardiologist’s expertise and overpaying his consultation as well. People don’t realize the importance of a general practitioner or general physician in their healthcare. This discourages newly minted medical professionals from taking up general practice. It is just not viable for them. What is the government doing about this problem. They are completely ignoring the issue and like they have treated primary education, they are treating primary healthcare with the same disdain. They aren’t hiring permanent staff for their rural areas and those hired are paid salaries once in 6 months. They are forcibly making new residents serve in rural areas. This again is a huge waste of valuable resources. Orthopedic surgeons are doubling up as midwives and delivering babies in rural areas since there are no other doctors. How will this change our primary healthcare in anyway? GPs are not average doctors as people would like to think. They have a different set of skills than a super specialist. While a super specialist is restricted to a very narrow field of medicine the GP is trained to look at the patient as a whole. More amazing diagnoses is made in a GPs chamber than a neurosurgeon’s. But in the new era this important medical community is dwindling.

Quality of life of a Doctor

I’m not saying it is the toughest job on earth but a doctors life now harder than it has ever been. Very few vacations- no money during student life and no time once you are practicing. Family suffers. My father is a doctor and all through my childhood I resented the fact that we took so few family vacations and that my father was never there for the most important events in school or others. All the while he was working day and night to make ends meet and ensure that we, his children get the right education, amenities and taken care of. This made sure that I was a reluctant doctor for the most part of medical school. I eventually found my calling and was “reformed” but it was a painful journey nonetheless. It is going to get worse for the future generations. There is this underlying myth that doctors make a lot of money during their careers which is really not true. I had a conversation with a friend from the money making tech industries and he had this to say “Doctors can’t contribute enough financially to the nation to command higher salaries. A doctor ONLY saves lives but engineers,financial analysts and CEOs create wealth which they distribute among themselves.” This is how much value saving lives commands. I was angry at what he said at first but later realized this is how the money creating industries think of doctors: overpaid and untrustworthy. Life and death can’t be quantified in stocks and bonds and hence that is not enough. It made me sad as to how this came to pass and this perception is precisely what the next generation of doctors will have to work against. Governments post newly minted doctors into rural areas on compulsory postings but on temporary jobs. It is cheap labor for the exchequer, vote banks are taken care of and they don’t have to bother about a permanent solution for a complex problem like rural health. What these people don’t realize is that by having this attitude they will ultimately increase healthcare costs and then everybody suffers. This inability of the society to acknowledge their altruism will be the reason to discourage the next generation of brilliant students from taking up this unforgiving profession. Doctors are no more demigods or authorities in their field. Their medical decisions will be altered by arm twisting untrusting patients, fear of malpractice suits, defensive medicine, target hounding corporate hospitals, a populist government and an inefficient tlaw system. All this stress while their family still suffers from the lack of their time and money.

Doctor and patient relationship

To a doctor who is just starting out I would say this: ‘ Your decisions will be questioned at every step. You cannot dismiss patients like you are doing a favor to them. You will have to get down to the level of the patient and sometimes lower’. It will be a big let down in a doctor’s life that they keep having their motives questioned every day of their professional lives. I think this is for the better as the doctor community has been too arrogant for far too long. They spend so little time with patients giving the excuse of long patient lists and surgeries. I think this is why people are so distrusting of what we do. Doctors of the new era have to respect the “new patient” who is educated, informed and has 1000 questions. There will be unreasonable patients just like other professionals have unreasonable clients. You have to approach it like how other professionals do. Any drug that you prescribe you should know all the side effects. Any surgery that you do you should know all possible complications. Ignorance is never an excuse anymore. Its your jib to know. Never be dogmatic and steadfast about your decisions or opinions. Learn humility, patients appreciate that. State your professional opinion clearly before educating your patient about his/her disease and give them more than one choice when possible. Let patients take ownership of the decisions that need to be taken. All this takes time and you would be well advised to give it to them in the first instance or you’ll be forced to give it in court. This sword of Damocles hanging over your head seems very unfair when all you wanted to do was do your job well. There is no point complaining about it and we have to make peace with our present day realities. If we want to be counted as professionals we have to be accountable. Period. Also you need to connect to every patient you meet. For you will have several patients but for a patient you are the only doctor at that point of time. Learn more about your patients and make them feel like you are their doctor rather than make them feel they are your patients. There is a world of a difference in that.

Doctors and the media

Doctors in India are the vilified lot and not for small reason due to the unrelenting attitude of the media to slam doctors at every given opportunity. Media misuse their privilege to become just the loudest voice in the room. Most of the popular channels give out gross wrong health advice, unhealthy diet fads and advertisements of dubious cures. If that was not enough we have enough doctor slamming shows like Satyamev Jayate. Shows like these invite doctors and patients to discussion forums and post recording heavily edit the discussion in a very biased fashion to suit only their pre determined point of view and to create sensationalism to increase the TRPs of their shows. Doctors are the favorite punching bags since doctors in India have no voice. They don’t form vote banks since they are an educated community which can’t be swayed by politicians. They don’t have a lobby to fight these instances of injustice since doctors in general don’t make enough money impact the finance of any political entity. The Indian Medical Association and its state counterparts sometimes have token protests against these wrongs which not surprisingly never gets reported in the media. Doctors in hospital emergency rooms get beaten up every other day almost in all instances for no fault of theirs. This almost barbaric treatment of junior doctors in hospitals across the country are never reported in the media and if reported would highlight “some mistake” on the part of the treating doctors and never anything defending the doctors. This is because in most instances these assaults on doctors are perpetuated or encouraged by media persons. And strangely if there is any instance of a doctor strike  protesting archaic quota system of medical education, low pay or assault of doctors in hospitals, the same  media will come raining down on the doctor community of holding people’s life at ransom. What I’m sad to see is that people don’t realize that doctors are not anarchists.They would be more happy treating patients rather than be in protest rallies and fight lathi charges. If they are forced to do these things one has to realize how desperate and frustrated they are with the system. Nobody else is fighting for them and doctors have no choice but to protest in what little way they can. It is sometimes heart rending to see doctors who are on hunger strikes still running emergency clinics in these protest areas since they don’t want people to suffer.

Doctors and Doctors

Over the years in the medical profession I have seen as a young doctor trying to make a mark that doctors work against doctors. There is too much professional jealousy and Godfather complex in the doctor community. There is a culture of disrespect which is passed on from the senior doctors to the junior ones. A senior doctor would not bat an eyelid before running down his junior colleague or rival in front of the patients. When you can’t respect your own profession how can you expect the patient to respect it. Doctors cannot treat their junior colleagues like slaves at their beck and call. If you don’t respect your colleagues the feeling will be mutual. So the first step in the new era will be respect for everyone from medical student to super specialist. While we are at it there should be respect for everyone concerned with your patients….every person in the health delivery system forms a vital cog in the machinery. The future of healthcare is in creating effective teams rather than hierarchy. Things have to change in the near future in India to prevent hierarchy from setting into a system. Only when you remove nepotism , favoritism and godfathers from the picture will we gain a meritorious medical community. Mentors are the need of the day. Only if the present stalwarts mentor the next generation of doctors will there be continued value of our art. But if these stalwarts are insistent on running their personal fiefdoms then its a bleak future ahead.

Finally the joys of being a doctor

Being an optimist has helped me still enjoy my profession in a positive way despite the injustices that are being done to doctors in India. Its been a very long road from being a reluctant doctor to an empathetic doctor and this journey has taught me a lot of lessons. One of the joys of being a doctor is having the power to change a person’s life and livelihood with one accurate diagnosis and appropriate treatment. A doctor may not move nations or even sometimes not even impress the patient he’s treating but power to positively impact another person’s life is incredible to say the least and I suspect is the reason why doctors still continue to perfect their art and science. Doctors may not make millions of dollars like lawyers, engineers, management consultants and businessmen but the value they give the society with their work is not measure able with any material affluence.

Hope and Heartbreak: The two sides of Retinoblastoma

I recently read an article by Dr. Mary Louise Collins …..She is the daughter of world renowned Ocular oncology researcher. She is an Ophthalmologist herself and she had written an article on Retinoblastoma from a personal standpoint in relation to her family. The link to the article is below.

She talks about how her father Dr. Lorenz Zimmerman got interested in Ocular Oncology and went on to do pioneering work in Retinoblastoma research. Not only her father but several members of her family were responsible for landmark discoveries in the understanding of this disease. Tragically Retinoblastoma struck Dr. Zimmerman’s family when his youngest son,Larry was diagnosed with the disease. Dr. Mary goes on describe how her parents courageously decided to go ahead with experimental treatment and had to fight several in the establishment to do so. Fortunately the treatment cured their son of the disease. Unfortunately the disease was to strike again on Dr. Zimmerman’s family when Larry’s daughter Perry was diagnosed with the same cancer. Dr. Mary then goes on to describe how the research done by her family gave them the courage to fight the establishment and in turn helped change the lives of their own family members and the millions of kids worldwide.

What struck me about this wonderful article was it was scientific in content but from the heart in form. The Zimmerman family struck me as both tragic and fortunate. Tragic due to the multiple times it was struck by the horrible cancer. Fortunate because the family was at the forefront of cutting edge research and at the best position to understand the disease and decide upon the best possible treatment. This is a wonderful article which I would recommend everyone to read.

But recently I saw another side of this terrible cancer. A 4 year old kid from Indonesia had come to us more than 8 months back with classical signs & symptoms of Retinoblastoma. It was diagnosed as such despite the child being out of the usual age group for retinoblastoma. But the parents strangely rejected our diagnosis and proposed treatment and went doctor shopping in Indonesia until they found a “doctor” who debunked the diagnosis and started treating it as something else injecting useless drugs into the eye. We came to know about this since the parents returned with the kid about 2 weeks back to our hospital. The kid by now had multiple metastatic cancer aided in no small measure by the criminal injections of the that Indonesian quack. We still offered the parents an aggressive treatment protocol which may yet save the child but the parents listened to us and disappeared again next day. This is the heartbreaking world of Retinoblastoma and I’m sure this happens in most parts of India as well where doctors treating this dreadful cancer have to fight superstitions, parental denials, costs, cultures, quacks and witch doctors.

These are just two stories on opposite sides of the spectrum. There are many more stories between and beyond them as doctors and researchers fight this dreadful cancer.

What is Ophthalmic Plastic Surgery?

What is Ophthalmic plastic surgery or Oculoplasty? I often get asked this question when I tell them what I’m specializing in. Most people are not aware that such a speciality exists  including majority of medical doctors. It’s a tedious exercise explaining it to people what my work comprises and one which makes my wife make fun of me when I explain because she’s heard it so many times. I thought it would make sense to pen it down.

Here it goes….Ophthalmic Plastic Surgery is a subspecialty of Ophthalmology which deals with the orbit (eye socket), eyelids, tear ducts, and the face. It also deals with the reconstruction of the eyelid, the eye socket, and surrounding structures. Lately as a natural progression this branch has been getting into Facial Aesthetics in a big way in the form of Brow lifts, facelifts,Botox, fillers and Facial Rejuvenation.The subspecialty of ophthalmic plastic surgery was born in the mid-twentieth century in the United States at the conclusion of World War II. The art of oculoplastic surgery, however, is centuries old, bearing its roots in antiquity in India,the Far East, and Europe.

The various procedures that have evolved over centuries can be divided into several general categories: reconstructive, restorative,and cosmetic.  Oculoplastic surgeons have perfected, refined, and pioneered new techniques of lacrimal surgery, ptosis repair and blepharoplasty, orbital surgery, lid malpositions, and flaps and grafts. With the close relationship of this speciality with Eye Cancer and eye reconstruction after removal of tumours,  Oculoplastic surgeons are de-facto Ocular oncologists. Since the treatment of the above conditions often requires multi-disiplinary approach the possibilities of this field are endless. It also requires good working relationship with other specialties and to create a valuable team to treat the patients.

Oculoplastic surgery became recognized as a unique subspecialty of ophthalmology at the end of World War II. Numerous orbital and periocular injuries were treated by general ophthalmologists without prior training or exposure to ophthalmic plastic surgery. More often than not, trial and error were keys in developing these procedures. Among the earliest pioneers was Dr. John M. Wheeler who established a full practice based on oculoplastic surgery. He is known as the father of oculoplastic surgery. His student Wendel Hughes was the next major force in this field. Further Hughes’ students Alston Callahan,Byron Smith and Crowell Beard propagated this field across the world. This group of Oculoplastic surgeons went on to found the American Society Ophthalmic Plastic and Reconstructive Surgeons(ASOPRS) in 1969. This was the first such society in the world for oculoplastic surgeons. Later more such societies got formed in other parts of the world. Europe (ESOPRS), Canada (CSOPRS), Asia-Pacific (APSOPRS) and even India (OPAI).

It is a relatively less known specialty. ( I myself did not know about it till I joined residency). There lies the challenge in this field and also the greatest opportunity to grow. The specialists in this field are there in it only for passion since the other sub-specialities in Ophthalmology are much more rewarding monetarily. This sub-speciality is quite hard to master yet it is incredibly satisfying. I am honoured and privileged to count myself among these stalwarts. Like I said the possibilities are endless and there is so much work to be done….

1. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery
2. Local Flaps in Facial Reconstruction by Shan R. Baker and Neil A. Swanson