Sunday, 26 February 2012

A Taste of India, An international fellowship experience at LVPEI, Hyderabad

The beginning
4 pm on a late September afternoon. A bluish back seat window of a Tata cab protects me from a very bright light which my eyes are not used to. However exhausted I am from the 10-hour long flight, I can’t stop looking at everything… unfamiliar advertisements in a curly script all along the road from the airport to the city; directions to unknown cities; a huge picture of a couple, a girl and a guy, with blue faces, covered in gold and jewelry — may be a movie trailer; a multitude of small white flat-roofed houses spread on the gentle slope of hills on the right and left side of the road; a mosque on the top of a hill; trucks carrying mountains of seeds.

Now in town, I see entire families traveling on a motorbike, strange vegetables displayed in stores. Traffic jams,People standing, people running, Overpopulation, Groups of women in bright colorful sarees crossing the roads. A goat comfortably seated in the back of an auto. Accompanying everything I see are the uninterrupted horns at different volumes and tones for my whole journey.

I love this exciting sensation of “first time”. It is my first time in India.

When the Italian Ophthalmological Society awarded me the Mario Gelsomino prize last May in Rome for “Best Poster 2010”, I thought I would use this prize to advance my knowledge in the field of pediatric ophthalmology, on which I have focused my practice the past year, after completing my residency in Ophthalmology. The prize is intended to provide young ophthalmologists with a learning experience abroad in a center of their choice. Why did you choose LVPEI? Many people asked me this question.

Mario Gelsomino Award, Società Oftalmologica Italiana, Rome, May 2011
Mario Gelsomino Award, Società Oftalmologica Italiana, Rome, May 2011

I remember I started noticing posters and the scientific activity of an institution called “LVPEI” at ARVO a few years back. I went on the internet and found that this Institution has a very fascinating history spreading across 25 years. The mission of the Institution, “Excellence and Equity” inspired me to discover more about the hospital and its history. Since I started medical school I have never abandoned the dream of a model of service delivery where the best health care can be a right for everyone, thought I had yet to experience how difficult this is in reality.

Even in countries where the latest facilities are available, such as the USA, the best treatment is affordable only by most privileged. However, in countries where medicine is provided free to the whole population, like in parts of Europe, the quality of treatment is often compromised by national budgets and financial constraints.

Therefore, I found LVPEI’s mission extremely interesting. I also thought India would be a perfect place for spending my award fund. I was not only looking for an optimal ophthalmology training course, but also the opportunity to experience a culture different from mine. The Indian culture, shaped by centuries of unique history.A vast area where hundreds of languages carry the heritage of a multitude of different populations that have crossed the land along the ages. A culture that has given much importance to spirituality, though perhaps less to individualism, generating personalities like Mahatma Gandhi and Rabindranath Tagore.

So here I am, the cab left me with several expectations and a couple of bags of luggage in front of LVPEI. I will be here for the next 3 months. After meeting the educational staff, the first person I meet is a senior fellow who kindly introduces me to the “rules”. No mobile phone during working hours, always keep your hair tidy, adhere strictly to the dress code, be prepared for 12-hour long working days, 6 days a week. On Sunday you will study and prepare for the classes. Apparently, the fellowship at LVPEI is known in all of India to be the hardest (but also the most fruitful). The first night, on the phone I confided in my Dad my fears about the hard life I expected in the next months. ”Chiara, you have not experienced the Army! Take this as a chance for a necessary life experience. You will make it and, in the end, you will be thankful for this experience.” He was right.

The Medical Record Department is impressive: millions of records indicate the multitude of patients seen every day at LVPEI

Life in Children’s Eye Care Centre (CECC) I OPD — the exposure to complex cases that you can get in a tertiary referral centre in India is probably unmatched to anywhere else in the world. The State of Andhra Pradesh accounts for 80 million inhabitants. The LVPEI network has over 100 centers spread out across the state. Anyone with a vision problem can go to the nearest center. If the disease requires more specialized treatment,
The patient will be referred to the appropriate center, where he will receive the best care available, no matter what his economic resources. LVPEI offers vision screening and provides glasses free of cost to all unprivileged kids below 16 years of age.

The Medical Record Department is impressive: millions of records indicate the multitude of patients seen every day at LVPEI

A standard day in OPD starts at 8 am, after a 1 hour class. The first patient of the day is an IT businessman, who started to see double after a car accident, as his driver fell asleep while he was coming from the airport, returning from a business trip to Chicago. Then I see a family from Dubai who wants an eye check-up for their children to be reassured that they can watch 3D movies. Now it is the turn of an 18-year-old woman who speaks only Telugu. She became blind suddenly, the reason is not clear. After one week of repeated examinations and tests, we have no doubt that she is malingering. We take her to a separate room and talk to her. She opens up and tells us that her husband used to beat her but her family is not allowing her to leave him. No education, no job, no easy solutions. Better to be blind?

The next patient who is brought to the OPD is a baby, six months old. I have trouble coming to a diagnosis. Dr Ramesh explains: “Chiara, a mild hyperopic refraction and a granular fundus in an apparently blind child is Leber’s Congenital Amaurosis. Now you have seen one case, don’t ever forget.”

Then I meet a girl who is on vacation from her PhD in Stanford University; she is here for a squint evaluation before refractive surgery.

Dr Chiara with Dr Amit Gupta in OR 5

Screening for ROP in a neonatal ICU

Right after this I examine a 12-year-old boy who does not like to attend school because he is teased by classmates about the shaking of his eyes (congenital nystagmus). Now comes a 22-year-old girl who wants her sensory exotropia corrected, because she is getting married soon. The next patient is a girl in rags — just 10, she does not speak a word, only cries continuously. She has severe mental retardation with bilateral congenital cataract and vitamin A deficiency. She also has microphthalmos (where the eyes are very small) and a congenital heart defect. This condition arises from congenital rubella syndrome. I had never it seen before, since all girls receive vaccination for rubella in Italy before they are 12. An 8-year-old boy comes now; he is deaf and dumb, very skinny and very poor as well. He has retinal detachment in one eye and uveal coloboma in both the eyes. But he is not scared at all by the unfamiliar place! Instead, he is curious about everything, so many doctors, incredible machines, and hey! Such colorful lenses in that box!

After that, I go to the next room in CECC I. This mother is very worried; her baby seems to be blind. We explain to her that the baby has cerebral visual impairment; the eyes are anatomically normal but the brain cannot integrate the visual information. We cannot do much to improve his vision, but we can promise a normal psychophysical growth through specialized child rehabilitation. This is a special training for blind kids and must be started as soon as possible so that the child will achieve the regular developmental milestones at the right time, have a normal social interaction and access to mainstream education. But no need to look for other hospitals. Child rehabilitation is inside LVPEI, third floor!

The next patient is a non-paying girl who comes for follow up, she was operated upon for bilateral congenital cataract, 12 years ago. She comes regularly for follow-up every 6 months and follows every prescription, glasses and patching advice strictly. She was very regular about patching and now her vision is 20/20. Poor, but very smart! Tonight, in the library I will review the literature to understand better the causes of myopic shift after pediatric cataract surgery.

This is OPD in LVPEI — a wide social range of people with different lifestyles and opportunities. But inside the OPD, all social differences are eliminated. All patients experience the same suffering, the same anxiety for their children and their future, the same feeling of vulnerability... Regardless of their economic status, they all receive the same level of respect and same treatment at LVP Eye Institute.

Extraocular muscles as seen by an Anterior Segment OCT.A case of familial bilateral optic nerve coloboma.Enlargement of Superior Rectus in a case of isolated myositis. The genetic history of patients gives a lot of clues about diagnosis in some cases. Families with more than 2 kids are rare in Italy and consanguineous marriages are exceptional because not permitted by law.

The LVPEI Experience

During my stay I discovered that working at LVPEI is like being part of a big family. The symbol of LVPEI is a pyramid, from a large base of vision guardians offering counseling and a preliminary eye check-up directly to the community, going up to primary, secondary and tertiary eye care centers. The sides of the pyramid are made by people, gestures, everyone working together and interacting with patients at different levels. I felt that all the employees at LVPEI were very dedicated and passionate about its mission. This was evidentevery time I needed assistance, for example to edit a surgical video in the CAVU department, or looking for some files for my projects in the medical record department. All the staff was very cooperative and willing to do more than just their routine work.

I did my fellowship at the very top of the LVPEI pyramid, the Kallam Anji Reddy campus, the Center of Excellence. Patients who are referred here have complex diseases, manageable only with the latest equipment and by super specialized doctors. As a fellow, I was trained by my mentor, Dr K Ramesh, not only to recognize specific diseases but also to develop a method of examination in non-standard cases. I was trained to build up advanced diagnostic skills and to plan customized treatments. Many clinical questions were stimulated by consultants, and I could always find material to deepen my knowledge in the library that is open, 24 hours a day, 7 days a week.

The library of LVPEI is a wonderful place, silent and peaceful at nights, full of bright light through the big windows on Sunday mornings. Here an immense range of books is available, with all the journals of ophthalmology, pathology and pharmacology. The fellows can even enjoy reading about the history of ophthalmology or ethics in their free time. Also, wi fi is available everywhere in LVPEI, 24 hours a day. Truly wonderful facilities! There is another thing of incomparable value that is offered to the fellows at LVPEI — better than the highest possible 3D resolution spectral domain OCT, better than the latest-model phaco machine, better than any DVD collection in the library. That is the opportunity LVPEI gives you to meet the most extraordinary people… people whom you would rarely meet in the outside world. Being a Center of Excellence means that only people who are the smartest and the highest motivators are employed at LVPEI. Many of them have an extraordinary background of clinical practice, across a 30-year career, with a commitment to challenge oneself and improve constantly.

I was given the opportunity of spending some time with doctors like Dr Anil K Mandal, who has dedicated his life to fighting blindness in children born with glaucoma. He has a very special touch with kids and their families. I was also given the chance to listen to Dr Virender Sangwan, an exceptional researcher and mentor, with the unique talent of seeing the fellows projected over a 10-year perspective, so he can guide their choices in career planning. I interacted with Dr Subhadra Jalali; she has developed guidelines for ROP in India. Years of her scientific efforts and extremely dedicated work have resulted in a substantial decrease in blindness caused by ROP in Andhra Pradesh.

The fellows here are also treated to an international ambience with guest lecturers by luminaries from all over the world. Only in a setting like LVPEI, in only four months, could I talk of research opportunities in Singapore, and share impressions about educational paths and career perspectives for ophthalmologists in Australia, Indonesia, Thailand, Hong Kong, Bangladesh, Zambia, Ghana, New York, Canada and the UK. I came to know about ICO examinations, about international fellowships. I had coffee with the smartest specialists from Brazil and met clinical researchers from Bascom Palmer Eye Hospital. I learnt of the latest advances in regenerative medicine directly from the researchers. Significantly, at LVPEI I met for the first time the most prominent Italian researcher in limbal stem cells: Prof Graziella Pellegrini, whose lab is located less than 200 km from the hospital where I currently work in Italy.

One morning all the fellows were introduced to the idea that ocular diseases can also be seen as a manifestation of nature, after we were shown pieces of artwork that gave a different perspective of the language of nature, using diseases and natural phenomena described in Indian traditional mythology! And I was very moved at the extremely positive message from two families who had lost their loved ones in terrorist bombings. They found an extraordinary way to survive the tragedy and spread a positive message to the rest of the world.

That’s why in these four months I rarely stepped out of LVPEI. I did not even visit the Charminar (something like living in Paris for 4 months and not seeing the Eiffel Tower! I guess I will go before leaving!). Being inside LVPEI is like travelling all around the world. Just something simple like eating dinner in the cafeteria offers you a global overview of ophthalmology: educational opportunities, community eye health programs, a leading clinical center, latest scientific discoveries...

My last words are for the pediatric patients I met at LVPEI. Indian kids are very cute and curious. Of course, despite my efforts to learn some Telugu, I admit to some difficulties with patients who spoke only Hindi or Telugu. Sometimes I missed taking down the medical history directly, by myself, without translational gaps. But I was also surprised to find that communication with children can be strikingly easier than it is with adults: communication with kids happens mostly by the tone of your voice, the way you approach them, and how you convey your understanding of their fear. Nothing will erase those precious moments of empathy with the kids I have met during these months! These treasures now belong to me, and are to be cherished for the rest of my life.

Thanks to everybody I met in LVPEI, I hope to be able to come back soon. The biggest thanks go to Dr Ramesh Kekunnaya for giving me this fantastic experience, with great appreciation of his generous ways of teaching and most important professional suggestions.

Not only Ophthalmology

1. A dinner with everyone in the Pediatric Ophthalmology Department.
2. Enjoying the backwaters during the All India Ophthalmological Society in Kochi, Kerala
3. Celebrating Pongal Festival in Secunderabad
4. Fusion 2012 meeting

By Dr Chiara Morini (13/2/2012)