7. Day 4+5 - Cornea Clinics and Labs

Today marks exactly a week since I departed from London Gatwick Airport to travel to the city of Hyderabad, India, to participate in the incredible opportunity of an observational placement at LV Prasad Eye Institute. The trip so far has been thoroughly enjoyable, and the exposure I’ve had to the incredible amount of pathology has been an exceptional learning experience. On the 1^st day of my placement here, I’d already seen more eye-related conditions than I have in the previous 6 months of working in an optical practice in London – and the days subsequent to this have followed the same trend. I’m still at war with mosquito’s, which have been challenging my patience, with multiple bites up and down my body and 3 on my face being displayed as battle scars from my daily encounters. Also, it wouldn’t be possible to talk about to trip to India without mentioning the food, which I can assure you is beyond any blend of flavours you’ve introduced to your palette previously. Every meal, snack and bite, leaves a subtle after taste in your mouth that results in you craving more – often day dreaming about my next meal whilst I’m waiting for the next patient to arrive.

On a slight side note, it’s absolutely crazy to think that Christmas is only 11 days away, as the current heat and constant loud buzz of the city here is completely different to the normal surroundings that I find myself in around the festive period. I’m completely worlds apart from the usual freezing days paired with very limited hours of sunlight and a lack in will power to wake myself up in the icey mornings. It’s going to be a shock to the system when I arrive back home, to be greeted with a slap in the face from the gloomy days and 30 degree drop in temperature – but I’ll cross that bridge when I get to it!

I’ve spent the previous 2 days observing the cornea outpatient’s department and learning more about the success of the Ramayamma International Eye Bank (RIEB) here at LVPEI, which has gained global recognition. RIEB is the largest provider of sight restoring corneas across India, growing from strength to strength since their establishment in 1989. It’s incredible to see the advances that have been made in such a short-time scale, enabling many vision related issues to be resolved and alleviated, which effect a large proportion of India’s population.  RIEB have been so successful at gaining and harvesting donated cornea’s that the days of corneal transplant waiting lists have been abolished here at LVPEI, and they contribute significantly to corneal transplants elsewhere in Asia by providing a surplus of cornea’s to other institutes. I learnt how surgeons have a tight window of 8 hours to remove the cornea from the deceased patient and must convince the relatives to allow for this within this time period. To me, this does seem quite insensitive at a time of immediate mourning, however from my time at the hospital so far, I can see how there is a need for these corneas to help benefit others and help them resolve the issues related to their sight. Once cornea’s have been extracted, they’re kept in a MK medium to keep them well preserved, however they must be used within 4 days of being stored. For cornea’s that are transported the other areas, they are kept in a different medium that preserves the cornea’s for about 2 weeks to allow sufficient time for the journey and some time for storage.

In the cornea clinics I observed over 40 consultations across the last 2 days, many of which were post-operative follow-ups succeeding corneal graft surgeries a week prior to the appointment. It was good to have the opportunity to look at these patients myself under the slit lamp, seeing the sutures in place and the presence of varying levels of corneal oedema. A large proportion of patients had received therapeutic penetrating keratoplasty, which is a surgical intervention to replace the cornea using a graft from a donot, that they had received as a result of a fungal keratitis diagnosis that varied in severity between individuals, or another corneal related issue. The majority of other cases were abnormal findings of white or black spots on the conjunctiva, cases of irregular pupils with or without hazy vision, and corneal abrasions or scarring.

I’ll discuss two memorable consultations in slightly further detail, the first being a 59-year-old male who had rather extensive corneal scarring as a result of an infection that he had not attempted to seek treatment for at an earlier stage. This emphasised the important point that time is an important factor in the prognosis of many ocular related conditions. The gentleman was guided into the room holding the shoulder of his relative and being cautious of each and every step he took, once in the room his hand was placed on the seat of the chair, so he was aware of his bearings and could sit himself down. After removing the dark shades that had been covering his eyes it was clear to see the lasting effects of his infection were rather extensive, with his right eye especially appearing completely scarred and white in colour, as oppose to the normal dark iris you’d expect. After a closer examination it was apparent that his right eye was completely blind, as a result of scar tissue and excessive vascularisation. When using the slit lamp, it was impossible to view any structures that fell posterior to the cornea, as it was completely opaque. In addition to this, when assessing his vision through his right eye, the patient was unable to view the test chart at 3m and unable to see hand movements even when I was waving a matter of a few centimetres from his face. The patient wasn’t even able to respond to light perception – unaware and unresponsive when I was shining a bright pen torch in his right eye – denoting the seriousness of the damage. On assessment of his left eye, he still had some vision, though it was extremely poor as a result of scarring once again – but this time limited to the inferior-temporal region of the cornea rather than across the entire surface. The patient’s left eye was responsive to light and aware of hand movements when within a range of 30cm from his face – but unable to count fingers or view a test chart in the distance or at near. The optometrist explained how it was extremely disappointing that the patient had presented at such a late stage of their condition, especially after explaining he’d been suffering from gradual vision loss that initiated around 4 years ago – as this could have been saved to an extent.

The second patient I’d like to discuss was a 60-year-old female that had come in complaining of a pricking sensation beneath her right superior eye lid. Her extensive medical history included a cataract operation that she had undergone just under 11 months ago, and since she has been receiving this uncomfortable sensation. Again, I was allowed to have a look at the patient under the slit lamp and I found it useful to be able to use her left eye as a comparison, which was completely normal with good vision. The patients right eye seemed to have an irregular pupil, prolapsed iris and a dark spot superiorly above the iris under the eyelid (which is what caused the irritating sensation). The consultant explained that this was likely to be a result of her cataract surgery, where the iris has been incarcerated accidentally, passed through the surgical wound and resulted in an abnormal raised epithelisation. Although this wasn’t ideal, it had seemed to heal well with no sign of infection and the patient’s vision was extremely good at distance and near with her appropriate corrective spectacles. This case divided the team of optometrists within the cornea department, and the discussion that followed was intense, insightful and engaging. Some members of the staff suggested the patient should be sent for surgery to correct this issue and relieve her of the irritation she was experiencing. On the other hand, other members of the team thought it would be better to manage to condition with some refresher eyedrops to alleviate any irritation, without any surgical interventions as the patient’s vision was very good and did not think it was worth the risk of surgery – as this could possibly cause more harm than good. After going back and forth with various staff sharing their opinions, it was agreed to manage to condition using eyedrops and monitor the patient in 3 months time to see if things had worsened – if they had, the patient would be sent for surgery to resurrect the issue. The patient was sent for imaging including slit lamp photography and an OCT, so these results could be compared with her follow-up appointment in 3 months. It was intriguing to see how the members of the department consulted one another and shared their own professional views with logical reasoning to come to a conclusion and management plan, which acted in the best interest of the patient.

I found my placement in the cornea department to be very interesting and engaging, perhaps due to the fact that I was able to look at the majority of patients myself after the optometrists had done their assessment and were filling in notes. Seeing the diagnoses and conditions first hand was a valuable learning experience, as at University we currently only test on each other with the majority of us having ‘normal’ healthy eyes – turns out I’m actually the weird one in my class with my keratoconus, often feeling like the elephant man as everyone takes it in turns to come and have a look at my eyes. I’m not complaining though, I’m glad I can aid the learning and progression of my peer’s education, though I wish I could have a look at it myself!

Tomorrow the staff at LVPEI have arranged for us to travel away from the centre of excellence here in Hyderabad and visit a secondary centre in the community to see how the treatment and general running of the hospital differs. Although I’m looking forward to this venture, I’m dreading the 8-hour round-trip for more reasons than one.

I’m aware for some of you the blogs may start to sound quite scientific with all the clinical terms and jargon, if you have any questions feel free to message me and I’ll try explaining as best as I can – but I hope these are ok to follow overall.

Thank you for reading once again, and I’ll be back to share my experiences with you again tomorrow!