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My experience at Aravind Eye Hospital

lowing1Small-incision cataract surgery (SICS) produces similar long-term post-operative visual acuity as phacoemulsification. However, it is significantly cheaper and requires less technology to perform, and has thus become invaluable in treating patients with cataracts in underserved areas around the world.

 

With this in mind, I spent nearly four weeks of elective time as a senior resident at Aravind Eye Hospital in India. I spent most of my time in Madurai- Aravind’s main site- though they have many hospitals throughout South India. One of my goals was to learn SICS in a structured setting. Notably, Aravind is a world leader in eye care delivery- in volume, cost to patient, quality and efficiency- and I was also interested in experiencing their model of eye care first-hand.

Overall, I performed 5 extra-capsular cataract extractions (ECCE) along with 23 SICS. I was also fortunate enough to participate in one of their frequent village camps, to visit their manufacturing site at Aurolab, as well as to visit some of their clinics.

 

SICS Training

American trainees stay in the Harmony Guest House- right down the street- and are fed three hot South Indian meals a day. Travel to India can oftentimes include significant culture shock- I’d been to India multiple times previously, but the home away from home was certainly welcome. In my time, I was fortunate enough to train with three stellar residents, also at the guesthouse- Glenn Yiu (MEEI), Elizabeth Tegins (Sinai) and Connie Chen (Wilmer). The latter resident mainly trained at the Pondicherry site.

The structure of the SICS training includes starting the day observing cases to get acquainted with the equipment and the flow of cases. The cases are projected on large flat-screen televisions. It is also an opportunity to watch some of the world’s most skilled cataract surgeons- some of whom routinely complete a phaco case in under five minutes. Given the sheer need, not only do anterior segment surgeons start their days with cataracts, but also retina and oculoplastics attendings- who are also very skilled.

For trainees, the day is structured with two cases. At the appropriate time, the resident will be called away to prepare for and then and scrub for the first case. Fortunately, for each case, there is an assigned trainer who proctors the case, and helps guide the resident through each step. At Aravind, the first five cases performed are ECCE, and then each case afterwards is SICS.

For those unaccustomed to SICS, there are several steps that may be challenging. While SICS has a steep learning curve, each main step may be seen as possessing its own individual learning curve.
As I see it, they are:

1. Creating a 6.5mm scleral groove and subsequent scleral and corneal tunnel, which must be of adequate size and depth. Pitfalls here include being too shallow, too deep, entering the anterior chamber too early, or not making the internal lip large enough to express the nucleus.
2. Creating a 7mm continuous capsulorrhexis using a cystotome only (after creating a sideport incision, and then entering the AC/enlarging the wound with a keratome). In a situation with a potentially shallowing anterior chamber, it is not difficult to have a capsulorrhexis radialize, especially given its large dimensions. Trainees will often understandably make the capsulorrhexis smaller than 7mm, which may make subsequent steps difficult or impossible.
3. Prolapsing the cataract into the anterior chamber and removing it with an irrigating vectis. A too-small capsulorrhexis can lead to posterior capsular rupture on attempted hydroprolapse of the cataract. The irrigating vectis may inadvertently contact the anterior capsule or iris and cause a zonular dialysis or iridodialysis on attempted removal of the cataract.
4. Manual irrigation and aspiration with a Simcoe cannula.

Though technically stable with no sutures, trainees close the wound with one 10-0 nylon suture.

After lunch, trainees spend time in the wet lab, practicing suture technique, creating scleral tunnels in goat eyes, practicing on the surgical simulator, watching surgical videos, or listening to improptu powerpoint lectures on SICS by the IOL fellows. The day generally ends with ward rounds, where post-op patients are seen together with fellows and/or attendings.

Aravind is able to serve so many patients by being both cost-effective and efficient. Certainly, SICS is one tool for serving a larger community in need. Another crucial tool is the “sister”, a highly-trained physician extender, usually drawn from young women in the community. They generally specialize in a specific area- functioning as a scrub tech or circulator, for instance. While a physician is operating, they are seamlessly preparing the next patient on the adjacent table, while another escorts the previously operated-on patient out of the room. In my experience, they often knew all of the steps of the case, and were able to offer me advice when things were not going exactly as planned. They are also the ones outside of the operating room registering, organizing and moving patients.

 

Camp Experience

Part of the reason so many are able to get care is through Aravind’s camp program. There are generally multiple camps held weekly, and these bring physicians and sisters out to specific distant areas in order to screen for treatable eye disease.

At the camp I attended, hundreds of patients were screened, and this was done with remarkable efficiency. Several stations were set up, including for visual acuity, on-site refraction and spectacle creation, as well as for eye exams with myself, Dr. Tegins and two Aravind residents. By the end of the camp, patients requiring surgery were bussed to Aravind be registered, seen as pre-op and scheduled for surgery.

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Aurolab

The visiting trainees also had an opportunity to visit Aurolab.
The tour of the factory was impressive. Aurolab is an ophthalmic device company outside of Madurai that was created as a non-profit charitable trust. Initially, they started making low-cost, high-quality intraocular lenses in 1992, and have since expanded to make ophthalmic eyedrops, sutures, surgical instruments and recently, phacoemulsification machines. Aurolab’s presence allows Aravind to minimize costs in offering ophthalmic care, to offer low-cost ophthalmic equipment in underserved areas globally, and to bring profits that benefit the many patients receiving free care at Aravind.


Clinics

As an SICS trainee, the day is quite busy. That said, trainees are encouraged to visit the clinics at Aravind whenever possible. There is ample subspecialty representation, including Retina, Cornea, Pediatrics, Oculoplastics, Neuro-ophthalmology, Glaucoma and Uveitis. As to be expected with large patient need, clinic waiting rooms are completely filled.

Given my interest in international ophthalmology, I wanted to focus my clinic time looking at infectious diseases, so I spent my few clinic days in Cornea and Uveitis clinic. I was able to see cases of TB and Leprosy, for example, and also to review clinical cases of Leprospirosis , Chikungunya, and West Nile Virus with the Uveitis attending. She, like the other attendings at Aravind, openly welcomed SICS trainees into their clinics.

 

Overall

My time spent at Aravind was a phenominal experience. I left feeling well-trained in SICS for the amount of cases I’d performed. As any resident knows, more cases are always nice and will come with time- that said, 23 cases is a great start, and I hope to gain more experience with SICS in appropriate clinical settings in the US and abroad.

The physicians and staff at Aravind are dedicated to eradicating needless blindness, and do so with innovative and low-cost solutions. In my experience, they also do it with both a sense of dedication to the greater cause, as well as a sense of joy in their work. Dr. Venkataswamy, the founder of Aravind Eye Hospital, once noted “Intelligence and capability are not enough. There must be the joy of doing something beautiful.” All were happy to teach me pearls in the operating room or in the clinic; several invited me to their homes for dinner, or out for a meal.

The larger community of people affected by Aravind is growing, as their methods and technologies- pioneered at Aravind and elsewhere- are being adopted in underserved areas around the world. This remains true not just for physicians, or patients, but for the global community at large- in my time, for instance, there was a team of MBA students from the University of Michigan who came to study Aravind’s business model.

I’m grateful for the learning and surgical training, along with the personal connections I made at Aravind Eye Hospital. I look forward to working internationally in the future, and using the lessons learned in new clinical settings.

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