The Hindu Business Line : A gift of sight

Perhaps it is providential that some of the most innovative procedures and breakthroughs in eye surgery at the Dr Agarwal’s Eye Hospital in Chennai have involved children. As he documents another world-first procedure at this hospital — anterior segment eye transplant or gifting half an eye to a child — the Managing Director, Dr Amar Agarwal, says, pointing to the sky: “We might execute new ideas but ultimately the direction comes from the top” ;.

Well, this time around, when the parents of an agony-ridden and screaming four-month-old boy knocked at their door for relief, the doctors were shocked to see that a good portion of the child’s eye was protruding, so it could not be closed. And instead of being smooth — after all it’s a mucous membrane — the surface of the cornea was rough, and the child was in immense pain. The conventional treatment would have been to remove the eye — the other eye was normal. But with Senior Consultant Dr Soosan Jacob suggesting to her boss to improve on a procedure he had done the previous year for a cataract extraction where he had glued the IOL (intra ocular lens) on the patient, a new idea was born… and successfully executed.

Dr Agarwal explains that in normal eye transplantation, “We do only the front cornea and, maximum, a bit of the sclera (white of the eye). But here it wouldn’t have helped because there is a cataract behind, as the lens was opaque and everything was bulging.”

This condition is a congenital deformity caused by malnutrition or Vitamin A deficiency; the child’s parents were coolies from Vellore in Tamil Nadu and were referred to him by the hospital’s Vellore branch.

Adds Dr Athiya Agarwal, Director, Dr Agarwal’s Eye Hospital, “It was a grotesque condition; the parents had not even named the child perhaps because they didn’t except him to survive. On the night of the surgery, when I came out of the theatre — a team of four doctors including Dr Amar, Dr Soosan, Dr Athiya and Dr Divya performed the four-hour procedure — the mother was sitting outside and sobbing, so I asked her to come into the viewing gallery and see the operation.”

After the operation, the child was able to close the other eye and the mother later told the doctors that for the first night in his little life Kailash — he was named by Dr Amar a few days after surgery; the name denotes Shiva’s third eye — had slept well and without crying due to pain.

First time ever

Dr Soosan Jacob, Senior Consultant, Dr Agarwal’s Eye Hospital, Chennai

Explaining the condition Dr Amar says, “We knew corneal transplantation was of no use because both the iris and lens were damaged. Then Soosan suggested why not extend the glued-IOL technology?” That was for a cataract extraction; in such an operation the lens is fixed inside a capsule. But that particular patient had no capsule, “so for the first time in the world we fixed a lens with glue.”

When the donor eye of a 55-year-old became available — the idea was to take an eye which would remain good for another 40-50 years — the doctors set about the task of restoring the child’s eye with a modification of the glued lens technology.

From the donor eye, the sclera and cornea were carved out, and using this as a bio prosthetic graft, a special lens with an artificially built diaphragm was glued to the sclera; the front portion of the eye was put in place, using tissue glue (which is tissue based and made from blood products, so it is really a bio-glue), and the eye was closed.

The immediate result was a dramatic improvement in the child’s look, he could sleep because the trauma and irritation of the protruding eye was gone, and now vision has started to return. The healing was faster because of the glue technology and absence of sutures outside which cause redness and trauma. From Day 1, the child has not only slept well but is smiling too! He has been discharged, but every day the mother closes the other eye for six hours “because the operated eye has to start performing its function only now.” There is evidence of vision as the child responds to brightly-coloured toys placed before the transplanted eye.

Dr Soosan says she dared to think aloud “because for nine years that I’ve worked here, I’ve seen new ideas being applied in the institution. When you work in an environment like this you tend to look for answers beyond textbooks.”

She presented this case at the recent Cairo international conference on ophthalmology, where “It generated a lot of interest and enthusiasm; others have seen such cases too and asked a lot of questions about the technique and how it can be done,” says Dr Soosan.

Dr Amar adds that he is getting enquiries from other places as “such a thing has never been done before. Till today technology has not reached a point where we can take out the whole eye and put another eye back, because the nerve of the eye is connected to the brain. And in this child the optic nerve was fine; only the front portion was protruding out.”

Landmarks of golden jubilee

Ask him about the landmarks of the hospital, set up 52 years ago by his parents, which now has 27 branches, and he says: “The first and most important landmark was Papa and Mummy coming to Chennai from Rajasthan with only Rs 60… to create a centre like this! It is mind-blowing.” Today, the 27 centres handle about 2,500-3,000 patients daily and in the main hospital about 100 operations are done daily, 90 of them cataracts. The second, he says, was doing cataract surgery through a 0.7 mm perforation in 1998. “This was our invention through the phaconit technique or needle incision technology. Suddenly people realised that you can do a cataract with a sub-one mm incision. The third is glued lens technology and now comes anterior segment transplantation.”

The father, Dr J. Agarwal, is amazed at the progress in technology which made Kailash’s operation possible. “Earlier, there was no IOL, no such glue. I remember that 40 years ago, we used to admit cataract patients for 4-5 days; for six weeks, they couldn’t work and had to come for check-up every week. Nowadays, some cataract patients go back to work the next day!”

Did he ever dream such progress would be possible?

“Yes, but only to a certain extent,” says Dr J. Agarwal, adding, “But I did dream of a hospital like this. When I travelled abroad, and Amar and Sunita (his daughter, an ophthalmic surgeon in Bangalore) were kids, they always fought with me because my suitcase would be full of instruments for the hospital!”

Child patients

Interestingly, many landmarks and technological innovations at this hospital are associated with child patients, but then children are most susceptible to eye injuries. Dr Amar recalls the case of Anandi, a poor four-year-old girl from Villupuram, who came a year ago with a cracker injury. “She was playing with a firecracker when it burst and damaged the lens; the cornea was also lacerated and the whole thing was a mess. It was like a mini war… a mini bomb injury.”

He was in a dilemma; just removing the cataract without fixing the lens would be of little use. “I needed to fix a lens in that eye. So suddenly we had an idea of fixing the lens with glue. The next day the little girl was playing and very happy. It struck me that in worst-case scenarios — cases where we can’t do anything else — technology has answers to offer.”

He adds that there are so many patients in this country who were operated 10 or 20 years ago and an IOL was not fixed then. “They all wear sodabutti (very thick) glasses. These people can all be treated today with an IOL fixed with glue.”

Another rare case he recalls is of a three-year-old boy, referred by a Mumbai ophthalmologist, who was born without the iris in both eyes. “There was excess light going into the eyes… it’s like having floodlights focused on your eyes all the time. We needed to reduce that.”

The patient also had a cataract which was removed; as the lens was very badly damaged, “we fixed an IOL with an artificial iris and glued it, so the child had an iris and IOL. Before the surgery he used to sit crouched all the time and shield his eyes with both hands, unable to bear the harsh light. Next day he was walking around the corridor.

Now Soosan, one of the most intelligent doctors I’ve come across, said why don’t we do the same thing and extend it further and do an anterior segment eye transplant in Kailash. Here we took the cornea, sclera and created a whole bio prosthesis or half an eye. This is the way science evolves,” adds Dr Amar.

Don’t his hands shake when doing such procedures… never done before?

“Oh, they shake hell of a lot... but you have to learn to control it,” is Dr Amar’s simple reply.

Response may be sent to rasheeda@thehindu.co.in

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Dr Agarwal’s to invest Rs 50 cr on expansion
No greater gift than vision
Towards clear vision

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