9. Retinal Clinics and Diagnostics

After enjoying a well-deserved day off, which I used as an opportunity to venture out, explore the city and some local tourist attractions – I found myself once again waking up early in the morning on the most dreaded day of the week. Monday 17^th December, the start of our second and last week here at LVPEI. I continued with my normal morning routine; turning off my alarm, closing my eyes again, enduring a 5-minute mental battle where I try to convince myself to get out of bed, and eventually make my way into the shower whilst playing some music to change my mood. I’m the certain type of individual that needs a shower every morning to start my day, often stumbling into the shower in a zombie-like manner and strolling back out a new and refreshed man, ready to face any challenges the day may provide.

Every morning my colleagues and I have enjoyed our first meal of the day at the on-site staff canteen, sampling a range of Indian breakfasts during our stay. Before travelling to India, I had the somewhat naïve belief that I would lose a lot of weight due to the strict vegetarian policy employed at the institute, but this doesn’t seem to be the case. I only have the flavoursome and inexpensive meals to blame, paired with my eagerness to indulge every time I find myself in the cafeteria. I’m probably being dramatic, and realistically don’t think I’ve put any weight on, but I’ll wait for my family to let me know when I get back – which I’m sure they’ll have no reservations in doing. Today I was placed in the retina department where I spread my time between both the clinics and the diagnostic rooms, which included a series of detailed imaging machines.

The first patient of the day was a 61-year-old female who was accompanied by her concerned daughter. As the patient walked into the room what was most apparent was the extreme thickness of her lenses, which stuck out from the side of the frame. Retinoscopy revealed the patient had extremely high myopia (‘short-sightedness’), with one of the main causes of this being a ‘long’ eyeball, with increased axial length. An extensive history and symptoms revealed the patient had suffered from a motorcycle accident 4 years ago, subsequently suffering from 15 days of vomiting and was on bed-rest for 3 months following an operation to remove a blood clot on the brain. Since this incident, the patient had reported floaters, which are little black specs that appear in your vision, however these had not increased in size, number or frequency until the last 3 days. The patient explained that she was now experiencing flashing lights, developed photophobia and had stubbed her toe over the last few days on multiple occasions because she was unable to see the steps. Retinal detachment was the immediate diagnosis that both me and the optometrist on duty jumped too, and the patient was given some eyedrops and sent to the waiting room for 40minutes as we waited for their eyes to dilate. As the patient returned to the room indirect ophthalmoscopy was conducted, revealing a superior retinal detachment – explaining all the symptoms the patient was experiencing, including the lower visual field loss responsible for the patient stubbing their toe and having frequent trips and falls. Patients with high myopia (a high negative prescription) are far more likely to develop retinal detachment, to explain; this can be thought of as the retina being ‘stretched’ as the eyeball is longer, and therefore more likely to separate from the surface its bound to.

Patient number 2 I’m going to discuss was a 51-year-old male, who had developed a fistula in the brain that was compressing his optic nerve and had led to sudden but painless vision loss. Concerns were first reported round 3.5 years ago, when he first noticed a rapid deterioration in his vision that has continued to progress. The patient was a known diabetic, initially being diagnosed with type 2 diabetes 12 years ago and had received medical care elsewhere. The previous medical history accompanied with the relevant documents explained that he was suffering from optic nerve atrophy as a result of the fistula in his brain tissue. I’m not sure of the exact science behind this and how the fistula leads to wasting away of the optic nerve, this is something I’ll need to look into further. On examination the patient had extremely poor vision, unable to see hand movements from as close as 10cm from this face. The patient did have perception to light, though he was unable to accurately describe the direction that light was coming from. Interestingly, the patient had developed a constant nystagmus, which is best described as rapid and involuntary movements of the eyes. This made it impossible for the optometrist to carry out a number of tests, including tonometry and ophthalmoscopy.

The 3^rd and final patient I’m going to mention was a young 10-year-old male, who had attended over 30 appointments across the last 2 months. He had been previously diagnosed with endogenous endophthalmitis. This is a very rare and potentially blinding ocular infection, which results from a spread of bacteria from a remote primary source. The prognosis of this condition is reliant on an early diagnosis and the immediate administration of treatment to obtain the best visual outcome. In ideal cases, the causative bacteria would be identified and managed, though in this case it hadn’t yet been discovered, which isn’t uncommon. The patient was on numerous antibiotic eyedrops, the majority of which were wide spectrum with the aim of destroying the present bacteria and resolving the symptoms as best as possible. The optometrist explained that a vitreous fluid biopsy had been taken and was hopeful the exact infective microorganism would be discovered.

Spending a short amount of time in the retina diagnostic room enabled me to view some state-of-the-art machines and understand how they work and allow us to diagnose conditions with high sensitivity and accuracy. Of specific mention are the ocular ultrasound and Topcon DRI OCT Triton, which contains a number of different imaging settings allowing you to view different structures of the eye using varied contrasts to allow the tissues to be viewed in more detail. I haven’t ever seen an imaging system like this and the quality of the images produced were extremely crisp and clear. During my time using this machine I was able to see some retinal angiography images, as well as a case of retinitis.

This day was quite interesting due to the complexity of the cases I encountered, however it was not as hands on as some of the other clinics have been. I spent pretty much all of my time in observation, which is the reason I’m here, but after a while this can get tedious as I prefer a more involved approach. Tomorrow I’m lucky enough to be posted in the operating theatre where I’ll witness some routine surgeries, and then will spend my afternoon in the glaucoma clinic.

I’d like to thank you all that are still following my journey, and I’m grateful for the support that has seen me receive over 1550 views on my page so far across the last week! I’ll be back with you again, around the same time tomorrow J

8. Visit to the Optometry School and Community Centres

After an enjoyable but tough week comprised mainly of early mornings and long days, spending time across a range of disciplines - it was arranged for us to travel out into the community. We visited the Bausch and Lomb school of Optometry and some of the primary and secondary centres, which are part of the LVPEI network. Why’s it always the case that when you know you have to be up bright and early, you continuously wake up throughout the night? I’m sure I’m not the only one who suffers from this issue time and time again. I wonder if there’s any science behind it? After a broken night of sleep, the painful yet familiar screeching of my iPhone alarm echoing around the room prompted the start of my day at 6am. I lay in bed for a good 15 minutes or so trying to get both my eyes to open and stay open - a task that seemed much harder than it sounds. I think my mood improved slightly as I went into the bathroom to realise I hadn’t been chewed on by mosquitos overnight, with no new bites immediately apparent. I thank one of my peers for lending me a small bottle of citronella oil, which I dotted around my room - known to repel mosquito’s. In other news, I should probably start charging for my travel tips, could become quite a profitable idea. After a quick shower to refresh and wake myself up, I dressed and met my colleague’s downstairs, where a car was arranged to collect us.

If I’m completely honest, I hadn’t been looking forward to this day as much as the other days that we had planned for us, due to the fact we would be spending around 8 hours of the day in a car. However, now that I’ve returned and made it back in one piece after travelling these Indian roads, I am glad we decided to go; as this trip proved to be extremely eye-opening and insightful. Our first stop off of the day was at the Bausch and Lomb Optometry school, located around 15km from the main centre of excellence here in Hyderabad. The campus is relatively small, but the greenery and bright coloured flowers that surround the buildings create a beautiful scenic view. The equipment on campus was of a high standard, with many of the diagnostic machinery being the same – if not better – than what we have at University. There were specific rooms designated to certain tasks, such as keratometry, slit lamp and focimetry. In addition to this, there were a small number of testing rooms that students would typically use in their final years of study, that would allow them to put together a full routine for an eye examination. The campus also included onsite single-sex accommodation for the students, a canteen and library. A new contact lens manufacturing lab had recently been opened, which was used mainly to make scleral lenses as these had previously been ordered from Boston, America, with waiting times being up to 2-3 weeks. Now however, with the new on-site lab, scleral lenses can be dispensed on the same day for half the cost.

It was explained that 3 programmes are offered here; a BSc in Optometry (4 years), a Diploma programme (3 years) and a Vision Technician scheme (1 year). Each of these programmes have small intakes of around 30-40 students per year, who are all trained to a great standard in their chosen area and placed into roles within this field. Interestingly, those who study a 1-year vision technician course are offered the opportunity to be placed back into their local community in a primary care setting, where they will run their own small practice. Here, the vision technicians would carry out simple refractive techniques to give patients accurate prescriptions and help them choose glasses suitable for their needs. As part of the LVP network, these primary care centres’ have iPad’s where they can take images of certain things that they’re unsure off and send this on, which will be received by an ophthalmologist in the tele-communication department at the centre of excellence. It will then be decided whether this patient should be prescribed any medication or referred to one of the secondary or tertiary centres to receive more extensive treatment – and the information will be conveyed back to the vision technician within a matter of moments. This for me, represents efficiency at its highest level, as it would be difficult for many of these patients to travel to another centre to be told they did not need treatment, and with a large proportion of these individuals receiving daily incomes it would be of a huge disadvantage economically to do so. Many of these primary centres also have regular shuttles throughout the week, which can take patients to the centre of excellence if required.

Set up of primary centre testing room

We were able to visit a primary care centre, which consisted of testing room and reception room that included a small range of spectacle frames for patients to choose from. I was shocked to see how cheap everything was, with frames ranging from 80-290 rupees (£1-£3.50) and single vision lenses being only 200 rupees (£2.50). This is a huge contrast from the frames we sell at Specsavers, with our cheapest frame being £25 and our most expensive designer frames being £169 – bearing in mind that Specsavers are considered the most affordable when compared to the large multiples. It emphasised the case that much more priority is given to patient care, rather than driving sales as a business to make money. Each of the vision technicians receives a monthly income from LVPEI, and the money they make from glasses is used to cover maintenance of the store. Typically, a primary care centre will see around 5-10 patients a day – and the one we were able to visit today had a board up that showed their statistics from the previous month. 66 patients had been screened, 18 required glasses, with 16 of these actually purchasing them. A total of 8 patients were referred for further care, however only 4 of these actually attended their scheduled appointments at their specified centres.

Moving on, we visited 2 secondary centres, which were extremely similar to one another with a high standard of care maintained throughout. They each consisted of multiple testing rooms used to screen the patients, operating theatres, a few beds for overnight stays and 2 separate waiting rooms – one for non-paying customers, and a slightly more comfortable one for paying customers. I found it intriguing how again, there were no trained optometrists as such; instead there were vision technicians who had a minimum of 5 years’ experience within the community, and an onsite ophthalmologist. One of the directors at the secondary centre’s explained how a simple consultation and screening costs each paying patient 100 rupees (£1.25). About 60% of their simple consultations were paying patients, with 40% being non-paying; this dramatically drops to about 25% of patients paying for surgery and 75% of surgeries unfunded. Again, reiterating the point I made earlier that the focus here really is on patient care. There is an option to be a ‘supporter’, which is a category that pays twice as much, however waiting times are shortened and you get a more luxurious waiting area – though these patients still see the same professionals and receive the same level of care.

I think it’s quite impressive how LVPEI have developed this incredible network of ocular care that spreads throughout Hyderabad and its neighbouring areas, ensuring eyecare is available, accessible and affordable to all. I love how all barriers that may have existed, which would prevent patients from visiting these institutes, have been removed – such as allowing patients to receive care free of charge where necessary, but also having individuals within villages and communities who screen patients and then refer them on to other levels of the pyramid system.

Tomorrow is Sunday, and my ONE day of rest before the second and final week of my placement! I’m looking forward the most to not having to set an alarm, and sleep until my body naturally feels it is time to wake up once I’ve gained an adequate amount of shut eye. I’m planning on going to have a little look at the city, scoffing down some lovely biryani that this city is so well known for, and being a tourist!

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!