omlog: a blog by Sankara Nethralaya, Chennai, India!

Molecular Medicine To The Rescue

Dr. Colins Barnstable, D. Phil, Yale University School of Medicine, USA and Joyce Tombran Tink, Ph.D., University of Missouri, Kansas, visited Sankara Nethralaya on April 4, 2005. They were taken to all the research labs and they spent little longer time in the departments where they had discussions on areas of mutual interests. They provided us with a soft copy of all their recent publications and have volunteered to help us with the data base information on the origin of the 88KD protein.

Later in the evening Dr. Colin Barnstable gave a lecture on "Growth factors and Neuroprotection in the retina" and Dr. Joyce Tombran Tink gave a lecture on "Control of cell death and cell survival in retinal diseases by PEDF," which was very informative as it elaborated on the therapeutic prospects of PEDF as an antiangiogenic and neuroprotective agent. A therapeutic intervention based on molecular medicine seems to be gaining momentum.

Mebiol Gel Applications

Dr. Yoshioka of Waseda University visited Sankara Nethralaya on April 5, 2005. He met with our Chairman Dr. S. S. Badrinath, Dr. Vasanthi Badrinath, Dr. Tarun Sharma, CEO. Dr. K. Ravishakar, Dr. Krishna Kumar and Dr. H N Madhavan. He discussed further research programs on stem cell cultivation in Mebiol Gel and its clinical applications. Dr. Samual Abraham and Dr. Premanandan, both of Yamanashi University, Japan, also attended the meeting.

Sankara Nethralaya's Telemedicine At Work

Here is a classic example of teleconferencing at work at Sankara Nethralaya. A 54-year female patient was reported to have signs and symptoms of corneal disease for the past four months. When she consulted Dr. Madhav Rao at Sankara Nethralaya's Bangalore center, at about 2.30 p.m. on April 5, 2005, he arranged for a teleconference with the cornea consultant Dr. Rama Raja Gopal at Sankara Nethralaya, Chennai. She suggested that a corneal scraping be taken immediately for microbiological investigations for a more accurate diagnosis.
 
On the advise of Dr. S.S. Badrinath, it was decided to send one of our staff members from our clinical microbiology department to the Bangalore center to collect the corneal scrapings specimen from the patient. Mrs. B.Mahalakshmi, Senior Research Fellow from Sankara Nethralaya's microbiology department volunteered to go to Bangalore to collect the specimen. She left Chennai with the collection kit and the culture media required for inoculation and reached Bangalore the next day at 5.30 a.m.

The patient was requested to come in for an examination at 7.00 a.m on April 6, 2005 and Dr. Madhav Rao collected the corneal scraping for direct smear and inoculated it onto all the culture media. Mrs. B. Mahalakshmi then flew back to Chennai by 11.30 a.m.
 
On examination of the KOH (10%potassium hydroxide) Calcoflour white stained preparation Acanthamoeba cysts were seen and thus the diagnosis was made within 10 minutes after reaching Sankara Nethralaya, Chennai. Dr. Madhav Rao was telephonically informed of the etiology of the corneal ulcer and the appropriate treatment was advised. The following drugs were provided: 0.02 % PHMB in Moisol (10 vials) was prepared at the hospital (as this is not commercially available) and was sent along with Golden eye drops (2 vials) and Neosporin ointment by courier around 3.30 p.m.
 
Thus the teleconference on the clinical ocular examination of the patient and the efforts put in by the well-coordinated teamwork of Sankara Nethralaya doctors and the microbiology team, resulted in accurate etiological diagnosis to enable initiation of appropriate therapy within 14 hours of reporting to the doctor at Bangalore Sankara Nethralaya center.

Vienna Visit

Dr. S. Bhaskaran, Dr. Rajiv Raman, Dr. Tarun Sharma and Mr. D. Senthil participated in the meeting organized by Eli Lilly Company at Vienna, Austria on January 27 & 28, 2005.

The Eli Lilly project is about using Protein Kinase C inhibitor (PKC-inhibitor), and oral drug: Ruboxystaurin Mesylate, 32 mg/day for 3 years and evaluating its role in minimizing the progression of non-clinical significant macular edema. Photographer, Mr. M. S. Krishna has been certified by the Wisconsin Photographic Reading Center for this project. European Optometrist Society has certified Mr. D Senthil. The project will start in India on March 10 and enrollment will be completed by October 2005, a follow-up by 2008 and results will be ready by 2009.

Research Matters

International Telemedicine Conference

In continuation of our efforts to create awareness and provide visibility among various professionals including the healthcare providers and equipment suppliers about the benefit of adopting this emerging technology, Sankara Nethralaya is going to participate in the forth coming International Telemedicine Conference from March 17-19, 2005.

ARVO's US-Indo Workshop

The idea to bring researchers from the US and India together began in 2002 when individuals at the Association for Research in Vision and Ophthalmology, or, ARVO gathered to discuss the research opportunities between the US and India. The goal of these programs, funded by a grant awarded in 2004 by the National Eye Institute, is the development of a research plan for collaborative projects incorporating methods for identifying fiscal, scientific (e.g. tissue, processes, population), and intellectual resources in the US and India that promote collaboration and identifying research areas where there is a need. This workshop will be held at Sankara Nethralaya on February 15, 2005. These meetings will also be conducted at L.V. Prasad Eye Institute, Hyderabad and at Aravind Eye Hospital, Madurai.
 
Dr. Lingam Gopal, Dr. H.N. Madhavan, Dr. J. Biswas, Dr. G. Kumaramanickavel and Dr. S. Krishnakumar will participate. Dr. L. Vijaya shall also be attending the workshop in Hyderabad.

Eli-Lily Picks Sankara Nethralaya

Eli-Lily and Company’s Ruboxistaurin Mesylate may reduce moderate visual loss in people with moderate to severe diabetic retinopathy. They have selected Sri Bhagwan Mahaveer Vitreoretinal Services of Sankara Nethralaya as one of the four centers in India to evaluate Ruboxistaurin Mesylate role in reducing the occurrence of center-threatening diabetic macular edema. The Sankara Nethralaya team includes Principal Investigator: Dr. Tarun Sharma, Ophthalmologist Incharge: Dr. Rajiv Raman, Physician Incharge: Dr. S Bhaskaran, Photographer: Mr. M.S. Krishna and Optometrist & Coordinator: Mr. D. Senthil Kumar.

"Thank God!"

Narrated by Ms. Renjini Madhavan, our Senior Optometrist

There are many reasons to thank God; but when I said this "Thank God," I felt I had never meant it more in a long time! Besides being happy to be a part of the Computer Vision Clinic, I felt great to be in a place where the rule was- no examination should be incomplete! But for this ideal of Sankara Nethralaya, one would have missed a disastrous diagnosis for sure!!

Now before one wonders what I’m talking about, let me explain.

I was having a few of our computer user patients turning up for their routine examination. Ideally one would not expect something too serious or life threatening at the evaluation stage in the Computer Vision Clinic. The Computer Vision Clinic is meant for all those computer users who have had an eye examination and have found the health of their eyes absolutely fine but are still not at ease at work and for those patients who want to see if there is anything wrong with the way their eye works while they are at their workstations.

Like any other person working for long hours in front of a computer monitor, they were in for surprises on how their eye worked. Most of them had 100% good vision but the muscles in the eye were not in any state to take up a lot of work, or their tears were not protecting their eyes enough. The way they used their work setup was also, to their surprise, not too good! That was about all that could be wrong.

But this one 33 year old who came in was a lot different. He complained of occasional blurring of vision, more so for the last 15 days, especially when he looked to the right. But the blurring was of no concern at the Computer Vision Clinic as most of the patients with eyestrain had this problem at least at an early stage. The patient reported of having prominent eyeballs since childhood. His general health was also reported as normal. So the routine testing process continued.

His uncorrected visual acuity was 6/6, N6. On retinoscopy, there was a small blurring of the hyperopic reflex in his right eye which was not too common. So I decided to evaluate the inside of the eye before proceeding with testing the muscles of the eye. The anterior segment of the eye looked normal, the pupils reacted normally, and the intra ocular pressures were normal too. His color vision was also normal. The fundus was what looked troublesome. The optic discs looked edematous (right eye greater than the left eye) and this was something we had to investigate. The patient was immediately referred to an ophthalmologist.

The ophthalmologist confirmed the diagnosis and also noted nerve fiber layer swelling. He was referred for an immediate Brain CT Scan. The patient reported the following day that the CT report showed a Space Occupying Lesion in the Posterior Fossa on the right, resulting in an obstructive hydrocephalus cerebellar astrocytoma. He was immediately referred to a neurosurgeon and advised a review after treatment for a visual field evaluation.

The patient went through a left sided ventriculo peritoneal shunt and right sub-occipital craniectomy and an excision of the tumor two days after our referral. The patient returned two months later with tear filled eyes and thanked us for having relieved him of the strain and trouble he had been suffering for a year.

Testing showed an uncorrected vision of 6/6 in both eyes. The field test as advised showed a minimally enlarged blind spot in both the eyes. He was advised to be under the care of a neurologist. He was returning to normal life thankful of his luck and the treatment he had received!

Thank God he had decided to get an eye evaluation for eyestrain and in turn had a discovery which, if it had been undetected, might just have been fatal.

Thank God!

Lamellar Corneal Surgery

Blindness due to corneal disease is a potentially devastating condition accounting for 4.6 million blind individuals in India alone, with a large proportion of the affected being children. Corneal transplantation is one of the chief modalities of treatment in such case.

Corneal disease, that could lead to corneal blindness could affect the full thickness of the cornea or could be confined to a partial thickness of the cornea. In either case, conventional corneal transplant, or penetrating keratoplasty involves the replacement of the entire thickness of the cornea. This involves a circular button of healthy corneal tissue from a donor cadaver eye replacing the full thickness corneal tissue from the unhealthy eye, being held together with 16-24 sutures, taking several months to heal and requiring the patient to use medication for about 6-8 months to suppress an immune rejection of the graft. The surface of the cornea is often rendered irregular by the sutured graft, having a deleterious effect on the quality of vision.

In the last decade, a modified form of corneal transplant called Lamellar Keraoplasty has become popular. This involves only a partial thickness of the cornea that is transplanted to selectively replace only the diseased portion leaving the rest of the healthy cornea of the patient undisturbed. It is therefore a less invasive procedure but involves finer surgical skill and more refined instrumentation. Lamellar keratoplasty is of two types:

1. Deep anterior lamellar keratoplasty (DALK)
2. Deep lamellar endothelial keratoplasty (DLEK)

Deep anterior lamellar keratoplasty (DALK) is a partial thickness corneal graft, that is used in eyes where the pathology is confined to the anterior (front) layers of the cornea, eg. Superficial corneal scars and certain congenital or developmental disease. The advantages of this technique over the ‘conventional’ full thickness graft are: fewer sutures, quicker rehabilitation, less medication, almost negligible chances of a graft rejection and a more secure wound.

Deep lamellar endothelial keratolasty (DLEK) is also a partial thickness corneal graft, that is used to replace the innermost layer of the cornea, called the endothelium, which is responsible for maintaining the transparency of the cornea. This layer is often damaged due to complications in cataract surgery, leading to poor vision. DLEK is a more intricate surgical procedure than DALK, and was introduced as recently as 1998 by an innovative Dutch surgeon, Dr. Gerrit Melles and popularized in the US by an Ohio-based surgeon Dr. Mark Terry. The benefits of the technique, over the conventional corneal transplant include a better quality of vision a more comfortable post operative period and a quicker visual rehabilitation. This form of corneal transplant can even be performed through a wound as small as a modern cataract wound and can be done without sutures.

Sankara Nethralaya has always believed in keeping abreast with progress in science and technology, and in taking the lead to bring the best of techniques and technology to patients in this country at an affordable cost. We had Dr Gerrit Melles from Rotterdam, Holland, visit our institution in 2002 and initiate the corneal surgeons at Sankara Nethralaya into the techniques of DALK. This procedure has been performed on several patients by the corneal team, with gratifying results.

Dr. Rajesh Fogla, a member of the team of the corneal surgeons at Sankara Nethralaya received intensive training in the procedure of DLEK, under the tutorship of one of the best known pioneers in this field, Dr. Mark Terry himself. He recently performed a successful DLEK, for the first time in India, bringing this technology to Sankara Nethralaya for the benefit of many more potential candidates for this surgery.

In order to disseminate this knowledge and expertise among our colleagues from different parts of the country, Sankara Nethralaya organized a 2-day international conference on “Lamellar Keratoplasty” of September 4 and 5, 2004. This meeting provided an update and insight into these and other recent advances in corneal surgery. Among the distinguished faculty for this meeting were Dr. Mohammed Anwar from Magrabi Eye & Ear Hospital, Jeddah, Saudi Arabia, and Dr. Mark Terry from Devers Eye Institute, Portland, USA, both world renowned corneal surgeons and pioneers in this particular field of Lamellar Keratoplasty.

Eyecare, a Tradition

Via Newindpress.com

TN can boast of Ophthalmic surgery traditions

CHENNAI: Medical case sheets of ophthalmic disorders, dysfunctions along with the treatment and results dating back to nearly two centuries have been dug out from the Saraswathi Mahal library in Thanjavur by a team of doctors from Sankara Nethralaya, Chennai.

Following an invitation from the prince, S. Babaji Rajah Bhonsle, a team of ophthalmologists from the hospital, including chairman Dr. S. S. Badrinath and head of the department of Pathology Dr. J. Biswas, camped in the district for more than three days this March to trace the roots of Ophthalmic medicine.

The team discovered that doctors in the state's cultural citadel, under the rule of Rajah Sarfoji II between 1798 and 1832, took special care to treat eye ailments.

''Our experience was truly humbling. We were surprised to note that they had meticulously recorded minute details of treatments along with the results. More than anything else, it was an inspiration,'' Dr. Biswas said. He presented the team's findings at an ophthalmic conference held in the city.

The case sheets and the findings of the team, he promised, would be published in reputed medical journals soon.

Prince Babaji Rajah Bhonsle, who had invited the doctors, was all smiles. ''I found these documents in our library. As I am an engineer, I could not figure out what they meant. Fearing that something precious could be lost in the recesses here, I invited the doctors for research. The discoveries are indeed heartening,'' he said.

The doctors, along with archaeologists and librarians, traced forty-four case sheets with 18 drawings of the eyes. While atleast half a dozen were written in Modi script, the remaining were in English. The ophthalmic terminology including lid, conjuctiva, cornea, lens, capsule of lens, posterior chamber were found in the case sheets.

Presenting samples of case sheets, Dr. Biswas said the doctors had diagnosed cases of ophthalmic purulentis, lentricular cataract, capsulolenticular cataract and leucoma. The patients were treated in Dhanvanthri Mahal, a multi-speciality hospital established by Rajah Sarfoji.

It also served as a research institute that produced herbal medicine for humans and animals.

The name of Dr. McBean, an English ophthalmologist along with Dr. Amrithalingam Pillai, figured in most case sheets. ''We went round the town but could not find the hospital anywhere. But some people guess that it would have been demolished subsequently. We were also told that there were herbal gardens that provided raw materials for preparation of various medicines. A pharmaceutical godown, Aoushadha Kottadi, was maintained to preserve drugs,'' said Dr. Biswas.

The doctors at Dhanvanthri Mahal practised Siddha, Ayurveda, Unani and even Allopathic medicines.