Page two of Articles posted by Doctor Ambati Blog

A nexus of curiosities about the eye, interesting patient stories, advances in eye care, discoveries in eye research, and adventures in outreach…

B vitamins and macular degeneration

Created on: Wednesday, January 28, 2015

Macular degeneration is the leading cause of blindness in the US and most Western countries, affecting over 10 million Americans.  About a million Americans have the advanced wet form of macular degeneration which accounts for most vision loss.  The AREDS studies showed some mild benefit for macular degeneration, but this large study on B vitamin supplementation showed significant benefit for early macular degeneration patients in terms of reducing progression to the wet form.  Adding a combination of folate, Vitamin B12, and Vitamin B6 seemed to dramatically reduce progression in women with heart disease or heart disease risk factors.  It's a very interesting study and worthy of follow-up in a full clinical trial. 

Dilated Eye Exams

Created on: Friday, January 23, 2015

You might think that because your vision is fine that your eyes are healthy, but visiting Dr. Ambati for a comprehensive dilated eye exam is the only way to be absolutely certain. During your visit both of your eyes will be closely examined for any signs of vision problems and eye diseases. The dilation of your eyes is a very important part of your comprehensive eye exam as it helps your doctor to get a clear picture of both your eye health and your overall well-being. 

What happens during the exam?
To dilate your eyes, special eye drops will be administered that cause your pupils to become larger. This makes it easier for your doctor to see the back of the eye. It takes about 15 to 20 minutes for pupils to fully dilate. The dilating eye drops may cause your eyes to sting. They may also cause you to experience a medicine taste in your mouth. 
Once your pupils are dilated, your doctor will then shine a bright light into your eyes to see various parts of the back of the eye. You’ll be asked to look up, down, left and right while the examination is performed. 
This helps your doctor see the inside of your eye entirely, including the macula (the center point of your vision) as well as your optic nerve, which sends messages from your eyes to your brain. Your doctor will look for signs of damage to the blood vessels in your eye that can be caused by diabetes and high blood pressure and will examine your optic nerve for signs of glaucoma. 
Other conditions that can be detected during your dilated eye exam include histoplasmosis, retinal tears or detachments, diabetic retinopathy, macular degeneration, and other potentially serious eye diseases and conditions. 
What happens after my eye exam?
Depending on the type of drops used, dilation may last for several hours. After your exam, you may notice sensitivity to light or that your vision is blurry. You may want to wear sunglasses to help protect your eyes from bright light. 
Who should have a dilated eye exam?
Whether eye dilation is necessary depends on the reason for your eye exam, your age, your overall health and your risk of eye diseases. Annual comprehensive dilated eye exams are generally recommended starting at age 60. However, African Americans are advised to start having comprehensive dilated eye exams starting at age 40 because of their higher risk of glaucoma. It’s also important for anyone with diabetes to have a comprehensive dilated exam at least once a year.
When determining the necessity of eye dilation, your doctor will take these items into consideration: 
The reason behind your eye examination. Certain symptoms may require a dilated exam to determine their cause. Some conditions requiring follow-up exams may not need dilation during every visit unless there are new concerns or symptoms. 
Your age. The risk of eye diseases increases with age. Therefore it is recommended that people age 60 and older have a dilated eye exam once a year. 
Your overall health. Certain diseases, like diabetes, increase the risk of developing eye disease. 
Your eye health. Having a history of eye diseases that affect the back of the eye, such as retinal detachment, can increase your risk of problems in the future. 

Greetings from Paris

Created on: Tuesday, January 13, 2015

I arrived last Thursday for the Macula of Paris conference, which convenes some of the best vision scientists in the world to discuss advances in macular degeneration.  The theme of the conference, and one of the exciting new techniques being demonstrated in Europe was the use of OCT angiography, a new way of looking at retinal blood vessels without injecting dye into a patient's vein. 

Such imaging would allow careful non-invasive monitoring of macular degeneration and other disorders (as well as yield pretty pictures). Ophthalmology remains a dynamic field on the cutting edge. 

Sadly, Paris has been through a lot the last few days, and the day of the conference was punctuated by police sirens every few minutes and breathless updates on the terrorist attack on the kosher supermarket a few miles away.  While we were never in any danger, it was a sorry sight to see Paris admitted into the sorrowful fraternité of other cities like New York, Mumbai, Tel Aviv, and London that have been similarly victimized. Yet the French are a strong people, and through their strength I am sure they will find the resolve necessary to sustain liberté

New Year's Resolutions for Your Eyes

Created on: Friday, January 09, 2015

Happy New Year to all of you! With the start of 2015 comes resolutions to be the best that we can be in the New Year. Many of us make goals related to health or exercise -- losing weight is one of the most common New Year's resolutions, but one part of our body that tends to get overlooked is our eyes. This year, whether you're looking to eat healthier, lose weight or bulk up; make it a point to get your eyes into the action.

Healthy vision can improve your quality of life. Keep this year's resolution to do what you can to ensure healthy eyes and vision. Here are a few things that you can do to achieve this goal in 2015.
Schedule a Comprehensive Eye Exam 
Be pro-active when it comes to having your eyes examined. Make appointments not only for yourself, but for your whole family. A comprehensive eye exam can detect vision issues as well as underlying health problems such as high blood pressure, diabetes, inflammations, infections and more. 
Don't Forget Your Sunglasses
Sunglasses aren't just fashionable; they also protect your eyes from harmful UV rays. Don't forget to sport your shades even on overcast days as those damaging rays can filter through the clouds and harm your eyes. Too much exposure to UV rays can increase your risk for cataracts as well as macular degeneration. It can also cause short term eye damage such as photokeratitis, which is a painful eye condition that results in a burn on the cornea -- kind of like a sunburn, but on your eye. 
Stop Smoking
If you currently smoke, quit. Smoking is not only injurious to your lungs, but it also increases your risk of developing cataracts and eye disease. 
Rest Your Eyes
In today's highly digital world it is not uncommon for our eyes to become strained, that's why it is so important to remember to rest your eyes. If you work on a computer, make sure you're following the 20-20-20 Rule: Every 20 minutes, take your eyes off your computer and look at something 20 feet away for at least 20 seconds.
Regular exercise does your body a whole world of good. A recent study tracked 41,000 runners over the course of seven years and found that consistent long distance runners were considerably less likely to develop cataracts than their more sedentary peers. Another study focused on age-related macular degeneration and found that distance runners saw a nearly 20% reduction in their risk of developing AMD. 
Eat Your Way to Healthier Vision 
Healthy vision begins with a balanced diet filled with fruits and veggies. Vegetables, especially leafy greens, contain many nutrients and antioxidants that help to keep your eyes performing their best. Fish a great source of omega-2 fatty acids that help to protect vision and assist in tear production -- helping to prevent dry eye. Omega-3's can also help reduce your risk of macular degeneration, glaucoma and more.
Drink More Water
Those recommended 8 glasses of water a day are not only great for your body, but they can also help to keep your eyes moist and nourished, which can aid in the prevention of dry eye.
Protect Your Peepers
An estimated 2.4 million eye injuries occurred in the United States in 2014. These could have easily been prevented with the use of proper eyewear. Whether you're playing sports of mowing the lawn make sure your eyes are protected with appropriate eyewear. 

Best Wishes for 2015 to All

Created on: Thursday, January 01, 2015

 A few weeks ago some good friends of mine called me as they were worried about their little girl. They had taken a picture of their 3 year old Sadie and in one of the pictures saw a white pupil (normally there should be a red reflection in a camera picture).  This was very concerning as a white pupil can sometimes occur in a cancer of the eye called retinoblastoma. I saw Sadie soon thereafter, dilated her eyes, and fortunately, her eyes were normal.  The light was probably just caught by the camera at a certain angle.  Anyway, here's to best wishes to Sadie and everyone for 2015!


One of my favorite patients (JPG FILE)

Last Christmas

Created on: Monday, December 29, 2014

 Hope you all had a wonderful Christmas with friends and family. Last Christmas Eve I had a patient who come in with a serious eye problem. She had been diagnosed with Stevens-Johnsons syndrome in summer 2013, and I had been fighting a desperate battle to protect her eyes, as SJS is rare but devastating, literally melting the corneas of patients. On Christmas Eve she came in with a perforaton, or hole int he cornea, which poses an imminent threat to the eye itself, let alone the vision. We performed an emergency "patch" for her cornea, followed up by crosslinking at a nearby center to stiffen both the patch and her other eye to prevent future melting.  I am most thankful that she has done remarkably well. Here is her story:

The Gift of Sight for a Young Boy with Down's Syndrome

Created on: Monday, December 22, 2014

 I had a patient who was a young boy earlier this year who had Down's syndrome, in which it is common for patients to rub their eyes a lot. Excessive eye-rubbing can cause thinning and buckling of the window of th eye, the cornea, transforming it from a sphere into a cone, which can compromise vision.  He was not able to tolerate a contact lens and was not a good candidate for cornea transplant, given his eye-rubbing.  I contacted one of my colleagues in Greece who is one of the leaders in new procedures called collagen crosslinking and topo-guided laser correction of the cornea, which together can reshape and strengthen the cornea (hopefully these procedures will be approved and available in the US in the next couple of years). Here is the story:

Remarks to the 2011 Medical School Inductees of the University of Utah Alpha Omega Alpha Medical Honor Society

Created on: Thursday, December 11, 2014

Below is the text of my remarks to the 2011 medical school inductees of the University of Utah Alpha Omega Alpha medical honor society delivered March 29 at Alumni Hall:

Thank you very much for a warm introduction and thank you to the students of AOA for the invitation to speak. It is my deep honor to spend this evening with you too, and to share my thoughts with the AOA Inductees of the University of Utah for 2011.

First, my hearty congratulations. After 20+ years of grueling study and work and school, college and med school, long hours in the hospital, and countless tests and trials, you are now recognized as the cream of your class, and more importantly, you are almost ready to start paying off your student loans!

But seriously, as you commence a new phase, it would be very nice to have a crystal ball. I don’t have one, but let me to take some time with you to do 3 things: caution you, counsel you, and challenge you.


Here are 4 notes of caution I’d like to strike. First, you are entering your profession in a time of treacherous shoals for medicine and for America. Fundamental insolvency of Social Security, Medicare, many states, and the federal government are real risks that are going to affect each of us in countless ways. All will lead to cost-cutting strategies premised on increased compliance enforcement, electronic medical records, and expanding scope of practice of non-physicians, each of which are daggers aimed at the heart of current clinical practice.

Second, the exponential growth of knowledge, medicines, technology, and media will strain your memory banks, stretch your attention, and overload your bandwidth. The ability to read, write, think, and ponder coherently and patiently is becoming increasingly rare and will be more prized as idea and vision become elusive with the fragmentation of thought and consideration.

Third, be conscious of the demons of desire and despair, and master them so they not disturb your peace yet still employ them to effect positive change.

Fourth, avoid the twin seductive sirens of greed and self-righteousness; humility is the best antidote to both.


Next, let me share some words of counsel. Although I am not much older than you – at 33, I may be younger than some of you, yet in medicine I am a dinosaur! I went to med school before there was Internet and finished 2 residencies before cell phones. So while my knowledge is probably obsolete, I hope my experience and battle scars may be of some use to you as you hone your own judgment; good judgment is an asset that will keep you out of trouble, help you take necessary and good risks, and evaluate opportunity vs. hazard. Contrary to what you may have heard, it is vital to NOT be non-judgmental. The hard part of judgment is, as Mark Twain said, “Good judgment comes from experience; experience, well, that comes from bad judgment.”

Of all the skills and qualities you have and will need to foster, focus on cultivating three in particular: good listening, equanimity, and nimbleness.

Good listening is the foundation for almost every facet of your professional career: building bonds with your patients, learning from your colleagues and mentors, being there for your staff and residents, and so much more. Any search for truth must begin with the words “I don’t know” and a willingness to listen and learn from others. When you don’t listen, you wind up in a bubble which leads to stupid decisions. You fail to appreciate the other person, where they’re coming from, and the importance of their perspective and thoughts; you lose the ability to put yourself in their shoes. You deny yourself a lot of important insight, and screw things up more. Being a good listener is something one has to work at, consciously. And it’s the basis of what patients are looking for. Doctors care about diagnosis; you need to be a good listener for that. Patients care about prognosis – and you need to understand the patient’s needs, perspectives, and values to truly be their guide and champion in their time of duress, which is what they really value you for and what they think makes you a good doctor or not, more than your competence, knowledge, or skill (all of those are assumed).

Equanimity is what Sir William Osler deemed the first among virtues for the physician: no matter the situation, mental calmness affords clarity and steadfastness. The Bible, in Ecclesiastes, states, “The race is not always to the swift, nor the battle to the strong, neither yet bread to the wise, nor favor to men of skill; but time and chance overtaketh them all.” One of the Geeta’s core precepts is encapsulated in this verse from Lord Krishna to Arjuna in a moment of doubt and despair, “You must perform the right action, but you are not entitled to the fruits of action. Let no desire of the fruits be your motive, and yet be not attached to inaction.” I first read this 11 years ago when I was a senior resident, and wrestled with the concept for a long time. It finally dawned that what it means is that in a crisis, you must focus on doing your best to do what is right, but be detached from the outcome. It helped me be a better surgeon by helping me concentrate in the moment during a case.

There’s a great book I urge you all to read, “How Doctors Think” by Dr. Jerome Groopman. It guides doctors and patients on a journey of what kinds of errors doctors can make and why and how to avoid and mitigate them; his discussions on different types of “cognitive traps” are illuminating. As a surgeon, I realized long ago how important it is to minimize mistakes and how it is even more important how you to react to mistakes. Panic and despair make you lose your mental equilibrium and you make further decisions which stack up and aggregate and make the situation worse. Sometimes no matter what you do, the outcome will not be good or what you want but you do the best you can anyway. As Dr. Groopman emphasizes in his book, lowering your emotional temperature in a tough situation is key to slowing down your thought, enhancing your perception and analysis, and thus permitting clarity to dispel clouded thinking. Pressing for a solution when none is apparent can be the worst course of action. “Picking up a scalpel and cutting can be just the wrong thing” when you don’t see the whole picture. The good surgeon is not defined by technical dexterity or superior hand-eye coordination, but by sound decision-making and judgment that enable clarity and effectiveness in the operating room. Understanding issues and realizing what intervention can and can’t remedy takes a while to learn in a surgical career. Groopman, an oncologist, relates one of his mentor’s quips, “Don’t just do something, stand there” as he counsels against the impulse to jump in and do things. It’s awfully hard to do that as a surgeon. We by nature are gamblers, risk-takers who have to have confidence (perhaps arrogance) in what we do. Especially because inaction is also a decision, and can sometimes be harder to correct than a wrong decision. It all depends on context.

Equanimity is also about righting yourself in hard times. If the present is dim & bitter, and the future seems cold & barren, it is tempting to forfeit hope and forget that your life is an integral thread in the universe’s tapestry. Remember: it could always be worse, and if it can’t, then it can only get better! Be grateful for your blessings – health, home, friends, faith. Cultivate equanimity with literature – Frost, Kipling, Max Ehrmann, and Osler. Foster also your hobbies – hiking, photography, meditation, or yoga. And while others can take away so much from you – your money, job, reputation, even people you love – be thankful for the things which can’t be taken away: personal honor, what you’ve learned, and the satisfaction of service.

Nimbleness encapsulates several qualities – resilience, courage, flexibility, versatility. Pandora released the world’s evils from her notorious box but the last thing that came out was hope. While sometimes memory and even hope can feel like a prison, in truth they are the roots of change. George Bernard Shaw said, “The reasonable man tries to adapt to the world; the unreasonable man tries to make the world adapt to him. Therefore, all progress depends on the unreasonable man.” Success does lie in effort as much as in result. The need for struggle is not grounds for avoidance. As Bruce Wayne’s father said in Batman Begins, “Why do we fall? So we can learn to pick ourselves up.”

What gives you the strength to do these things is both courage and possessing different skill sets. It is very easy to fall into a rut and never learn anything after residency or fellowship. But medical training does not end when practice starts; indeed, practice is just another phase of training. I urge you to consider developing interests and knowledge in other areas – whether it be business, engineering, genetics, or whatever. The best innovations happen at interfaces. Further, if you are good at just one thing, you are very vulnerable. Always ask yourself – what jobs need to be done in America by Americans? If you become so focused as to know just one thing, could your job be automated, outsourced, or insourced? By being versatile, you can differentiate yourself and lay a foundation for being independent of government or insurance. And you make your mind more open to learning new things in the future the more you experience and learn along the way. Nimbleness – it confers joy, recoverability, the ability to think broadly from other perspectives, the ability to persist and roll with the punches while holding fast to your principles, and the ability to take doubt and use it to find and know faith.

When in doubt here are 4 principles that help cover most things:
• Promises are made to be kept
• Rules are made to be bent
• Records are made to be broken
• Schedules are made to be changed

With your finances, exercise caution and think of any financial mistake you make as tuition. Think ahead – fail to plan, and you plan to fail. When you must make a choice that is hard, ask yourself 3 questions: Is it good for the patient? Is it good for the profession? And if the answer to both is yes and only then, ask, is it good for me? Last bit of advice –till now, your time has been judged worthless by others. From now on, the value of your time will grow – so guard it jealously from fools and irritants yet be generous with it to your family, your trainees, and community.


So I have sounded caution and offered counsel. Let me now throw down some challenges to you. First challenge is to get involved. For too long, physicians have been objects in health care battles. Learn about the issues and see if you can effect change. Perhaps some of these may capture your interest: tort reform, tax deduction for charity care (why can hospitals and sometimes lawyers write off charity work but not physicians), whether accountable care organizations will be anything other than capitation redux with its substituting of payments for services with incentives to do nothing, the Independent Payment Advisory Board impacting physicians in 2014 but exempting hospitals until 2020, forming a guild fund for medical education, encroachment on physician autonomy by hospitals (for example, physicians cannot own hospitals but no one says anything about hospitals owning physicians), and physician extenders (optometrists doing eye surgery, CRNAs replacing anesthesiologists). After all, neither hospitals nor ancillary staff take the Hippocratic Oath.

More importantly, to this point in time and for the next several training years, your path is clear. Landmarks of applications, tests, certifications, and so on are well defined. But once you are done, the road becomes hazy. You have to figure out what you want your own milestones to be. Will your primary goal be the personal maximization of wealth? There is nothing wrong with that, I encourage all of you to be capitalists, and you have a right to make money. But take a moment to consider – what is medicine to you? A job, a career, or a calling? If it’s a job, then you will make a living, and over time, coast with the least amount of effort to make the most amount of money. If that’s what you want, fine, but I hope all of your professors have not spent all this time training body mechanics. If it’s a career, you will set down several goals – papers, rank, awards, practice-building, etc. and hopefully achieve them. But hopefully, medicine is more than just a job or a career to you – I hope it will be your calling, an integral part of how you fulfill yourself as a person. And that is about things that aren’t dollars made or goals achieved, although money and achievement are important to secure. The original meanings of the word doctor are:
- One who makes things better and
- One who teaches

How will you make things better, make a difference? I think it’s about service – doing things beyond the remit of obligation or purview of compensation, things that you are not easily replaced for by someone else. Things like research, teaching, public health, overseas work, public policy. One of the most fulfilling things I do is to work with ORBIS.
Just wanted to show a video... :

To conclude, I’d like to share a quote, also from Mark Twain, “There are 3 types of people in the world: those who make things happen, those who watch things happen, and those who don’t know what happened.” To be truly worthy to serve the suffering, let’s all try to be of the first kind. Thank you very much.

Zambia: Monks among the Mosquitoes & Rumble in the Jungle

Created on: Thursday, December 11, 2014

(written in 2010)

It’s been a long while since I have posted; my apologies. After graduating from MBA school in May, it’s been a hectic summer. Last week, I went to Macha, Zambia for a humanitarian medical mission doing eye care and surgery. By way of background, about 45 millon people are blind in both eyes around the world (25 million from cataracts which is typically a straightforward surgery in the West and eminently treatable). I will share our experiences & impressions in a “log” form and then write a bit about what I thought about what we accomplished and some of the medical ethical questions that tug at your conscience.

Day 0 (land in Livingston, Zambia). My contact comes about half an hour after I reach arrivals. I had half a mind to get back on the plane and go home, but did not. We saw Victoria falls – it is duly spectacular. Lots of mist. At the nearby trail, baboon attacks 2 of our group 4 pushing 1 close to the edge (the one who’s afraid of heights). Later, a different baboon steals our bread by doing a Houdini over my shoulder , jumping into the back of our car, and then scurries away after taking the loaf of bread, evading 3 of us (Lloyd, the organizer, David the dentist, and me). After Victoria Falls, we went to mosi-o-tunya park; saw impala, giraffes, zebras, elephants, rhinoceros, darter. Mosi-O-tunya is the Chitonga name for Victoria falls, literally meaning storms & thunder. It was a self-driven ride, so it was tons of fun. The guards did escort us to the rhinoceros, who enjoyed a nice wallow in the mud.

Day 1: 80 patients. LOOONG Day. Crazy stuff – never have I seen so much trachoma (chronic scarring by an infectious parasite) and so many stick to the eye injuries. On the stranger side we saw an Intracorneal beetle shell fragment. Multiple previous ruptured globes which have healed on their own with traumatic cataract or iris incarceration. One patient was wearing an arctic coat and a scarf (ok it was Zambian winter but it was 75 degrees!). 35 cataracts. 5-6 foreign bodies. 30 or so trachomas (including one with Herbert pits). Took a tour of the dungeon ORs to get ready for the rest of the week. A few people just needed refraction. One hard cataract with really bad phacodonesis. Needed lots of doxy and erythromycin. Never ending sea of patients. Had 6 patients at 6pm. Saw 4 of then. Checked waiting room at 630, still had 6 patients! We scheduled a white cataract removal on a patient with full ptosis. Handwashing required going to room 2 doors down.

Day 2: Cows kept us up with clanging their bells overnight. 1st case; got vitreous loss. Whole day was hard. Last case (done by a visiting doctor who I was teaching some cataract maneuvers too) – we couldn’t put the lens in after taking the cataract out, and unfortunately, this was a functionally monocular pt . Really tough day. Is substandard medicine really better than no medicine at all? My nice instrument tray and instruments got mixed in and banged up with the rest. Cataracts are big and hard. 2nd microscope came but we had to sit on a microscope facing straight down. Everyone’s neck and back is sore. Some of the nurses are ok but most are just really inexperienced. The crew brought dinner back from restaurant but we had sheema from the nurses.

Day 3: No water this morning. Managed to wash face, brush teeth, and wash hands with 1 cup of water. Cases went better today. The lady who we left aphakic – I paid $60 and we gave a MA60 lens (I think) to get her travel covered to Zimba where they supposedly have a vitrector; will the patient really use the 250,000 kwacha to go to Zimba or for something else (she seemed a bit too happy at getting the money). Improvised a near-clear 6 mm wound (under peritomy) closed by a buried horizontal mattress suture. Worked pretty well I think for SICS. Flipped a huge lens out of the bag through a small pupil. The visiting doctor slowly got the hang of the capsulorhexis but one of them ran way out on both sides (flag sign). She recovered well. Cases coming into OR who we had never seen (can the scheduler do that? They can do anything).

Most notable case – this gentleman came in with a history of stick to the eye 10 days prior. He had a ruptured globe (iris prolapsed through corneal 5-6 mm cornea laceration). Try stuffing an iris back in with no general anesthesia, the patient moving, no assistant, bad scope, bad viscoelastic, and trying to close cornea too at the same time. Held iris back with iris spatula on my left hand and did no touch suture technique with my right hand on the corneal wound over the spatula. Nuts! Saw a girl with keratinized corneas (I mean, skin over her eyes – terrible). Got internet for a few precious minutes in the evening but Andrew hogged the bandwidth. Shirley (the med student from Holland) made a nice dinner for everyone. Andrew regaled us with stories of cabbages from the book Primary Surgery. Apparently I need to see the gods must be crazy.

Day 4: cows kept us up again. Power went down in clinic once. Lloyd apparently chased them away with dirtbombs. Today was minor OR day. Thought it would be easy. Postops were fine from day before. We cleaned up the clinic room. Lloyd did 2 bilateral lid eversions and a trauma repair of superonasal periorbita from stick to the eye (once again – that stick to the eye) (really tough as the poor kid was getting hit from wearing a winter coat and we had a surgical drape and just local anesthesia; no sedation). I did a double pterygium relocation (no AMT, no MMC, and better to leave superior conjunctiva for future cataract or glaucoma surgery). Then we had a couple of surface –omas to remove. 1st one was a squamous cell on an HIV patient. Without 5-FU, MMC, and poor systemic prognosis, I thought it would be best to close (no invasion seen after I took it off). Thought it would be easy. Once the tumor was off, microscope light 1 went down, then light 2 went down. Try closing conjunctiva with 10-0 or 9-0 nylon (the 8-0 was useless, and the 6-0 had a massive needle). Insanity! Only the 2nd time in my life I have cursed in the operating room (Lloyd was amused that I did that at a mission hospital). Lloyd and one of the helpers alternately helped with a direct and an indirect for some extra light. Managed to get it done and lloyd got the microscope back on eventually (after I had controlled the bleeding and got some stitches in). Last case was a melanocytic mass which we got off and closed within 20 minutes. Had dinner at the director’s house (a very interesting gentleman who has spent 22 years at Macha and is a native of Pennsylvania). His wife is very sad about leaving Macha. Learned a lot about NGOs, foreign aid, health care personnel market, medicine in Zambia. Shirley and Abby (the visiting nurse) made banana bread and chocolate cupcakes with icing and sprinkles!

Day 5: slept thru alarm. Woke up late. Took care of final things in Macha. Then Drive to Lusaka. Had a crappy half-donut in Zambia. Almost got arrested for taking picture of police car with cops riding in the back of the pickup truck. Found university hospital. Not bad actually. Got a nice tour of the place. In reasonable shape. Could definitely be a teaching facility.


My main ethical dilemma I faced is: is substandard medicine worse than no medicine? I don’t want to think about all the violations of sterile technique I encountered and was party to (flies settling down onto the instrument tray just as an example). We had a couple of complications which probably would not have occurred had we had the regular equipment and instruments – one of which was in a monocular patient. The first part of the Hippocratic Oath is to do no harm. Clearly we did some harm. Did we do more good than harm? I think we did. We were able to do 26 cases out of 40 or so cases we had hoped to complete. I think we helped the vast majority of those people, along with the 80 or 90 patients we saw in clinic who we treated for infections, foreign bodies, and so on. But of course I don’t know the postoperative outcome.

I console myself with the fact there is no ophthalmologist for about 200000 people in this catchment area of Macha (in the US there is usually one ophthalmologist for 16000 people) . A famous ophthalmologist once said 50% success is better than 100% blindness. Is that truly consolation to the fact that I know I did not the best that I could in normal conditions and that some people may have been better off by not having met me?

Why would people go to a place like Macha? Mosquitoes, intermittent water, intermittent power, bad internet or phone service, grossly inadequate equipment/instruments/infrastructure/pharmacy, inexperienced staff. There’s nothing in the way of fun or sights or so on. You get bruised – physically, emotionally, and you risk malaria and dengue fever. The cases I did were not showmanship by any definition – they were tough to get through and not pretty. Do you go to run away? Maybe, but this is not a fun place to run away to. Do you go to feel important? Well, you are far richer than the natives and they are very dependent on you for medical care, but the mosquitoes and living conditions bring you down to earth real fast. Do you go to do the Lord’s work? That is all I am left with. Hopefully you made a difference to someone in that instant when you were the only person in the world who could that surgery at that time. There is no one else around. For a few days are you an instrument of God? I hope so for that patients’ sake.
As for as job satisfaction, it eats you up that you know you can do so much better, but cannot because of limitations. You know the bar you set for yourself in normal conditions but here you must accept humble pie and frustration. It leaves a bitter taste in your mouth. The creativity of improvisation that you devise is but a momentary respite from the sea of suffering that hits you day in and day out. From a systems perspective, are we just a band-aid or a crutch? Does the presence of volunteers and NGOs reduce the country’s capacity or interest for self-reliance and development? Perhaps as there is the potential to feed a culture of dependency. But there are so many who need help. Is it ethical to walk away from the suffering in the here and now in the faint hope that a better future could arise if the country had to bootstrap itself?

The trick may lie in training and education. But there is an intrinsic conflict between maximizing surgical volume and teaching trainees. It is not easily resolved in the US, with the benefits of facilities, personnel, and resources. It is infinitely more complex when power is failing and flies are flitting about the operating room.

So I return home with more questions than answers. Part of me does not wish to go back after the bruising several days but part of me wants to go back for a rematch – normally we get to wage war on cataracts, but this time the cataracts waged war on us. We brought knives to a gunfight – running out of supplies and without the full complement of equipment and instruments; we were outmatched on more than one occasion by the pathology and outgunned by the intensity and lack of resources. Perhaps I should go back with a full team and full force of stuff that we need and could have used. Stuff to think about!

Sight for the Sightless

Created on: Thursday, December 11, 2014

I just got back from an intense week serving on a medical mission through the Sight for the Sightless Initiatve based at KK Eye Institute in Pune, India. This was a very different experience from any of my ORBIS missions or my Zambia mission in many respects. India is fascinating from a medical perspective in that it has first-rate physicians with some centers comparable to those of America but the population has masses of patients who have the health status of Africans. The country is in transition, with medical personnel & infrastructure highly capable yet simply overwhelmed by the sheer number of those in need, as well as hobbled by a lack of top notch equipment, instruments, and supplies.

For background, there are likely 20 million patients with at least one blind eye from cataract in India and about 8 million with corneal blindness. There are only 13,000 ophthalmologists in India, as opposed to 18,000 ophthalmologists in the US (which has only a quarter of the population). From a corneal perspective, donor tissue is much less available in India (unfortunately there is not as yet a well-developed culture of donation on passing away). So my objectives for the week were to do both service in terms of medical and surgical treatment of cornea and complex cataract conditions and skills transfer in advanced techniques and technology.

It was a physically grueling and emotionally exhausting week. With lectures, clinic, and surgery, we got done pretty much at 8 or 9pm each day (starting each day at 8am). Business dinners on future planning and needs followed, so I pretty much was going on 5 hrs of sleep each day. The most poignant moment was clinic on the first day during which we saw about 20 kids from the local blind school. For most of these children, I was a decade late and a dollar short. While I am a bit of a dinosaur in medicine (having finished medical school before the Internet and residency before cell phone), I was confronted by even more ancient demons this past week: children who had scarred corneas following measles infection when they were infants, children with wrecked eyes from Vitamin A deficiency. There are few things more heart-wrenching than telling child after child there is nothing we can do. There were 3 children who we thought we could help so we proceeded with transplantation later in the week.

Over the next several days, we performed (3 of these were children, the rest adults):
• An artificial cornea on a child who had lost one eye, and had a badly scarred cornea (barely able to see motion) in the remaining eye that was not a candidate for a standard transplant
• A combined cornea transplant with cataract extraction
• A partial thickness cornea transplant of the front of the cornea
• Two partial thickness transplants of the back of the cornea (one combined with cataract removal)
• A full thickness cornea transplant
• Several hard cataract cases and some amniotic membrane procedures

By comparison, I usually do 1-2 transplants a month in the US. These were all challenging cases given the complexity of the tissue damage on the eyes and the circumstances of available and (unavailable) equipment. But the best part (in addition to fixing the conditions and hopefully helping the patients) was teaching. I spent a lot of one on one time at the Institute with a very talented surgeon, Dr. Kapoor, and it was very rewarding to see her rapid progress over the course of the week mastering the techniques of chopping cataracts and picking up key elements of cornea transplantation. We also did some live surgery teaching the surgical maneuvers of some complex cataracts and the artificial cornea to a group of local ophthalmologists, and there were several excellent interactive small group sessions, surgeon-to-surgeon.

There were some funny moments during the trip. The hospital had arranged a press conference noting the complex cases being done that week and highlighting the need for corneal donation. During this, one of the reporters, whose first name was Nozia, came up to me and introduced herself as “Hi, my name is nausea.” It was all I could do to not burst out laughing and think of where else that joke could go. Then there were the episodes in the OR with the cotton buds with extra lint (which are a pain during eye surgery) which I nicknamed after the host and MC for live surgery, Ashiyana Nariani, who in turn promised to send me Q-tips for Christmas. Later on, I was trying to tell the patient to look down in broken Hindi, "Kali Baga Baba"; I apparently was not understandable and told Ashiyana my Hindi was worse than hers, and she told me I was actually speaking in Marathi (which I don't know either :( ). And then there was the ophthalmologist attending the live surgery and lecture workshop who requested to share his experience and promptly proceeded to regaling the audience with his life story, including the name of his childhood neighborhood street.

All in all, it was a fantastic trip. It was enabled by several groups and people to whom I owe great thanks and appreciation. The leadership of KK Eye Institute (Renu Wadhwa – CEO, who helped make things possible) and the international NGO Sight for the Sightless (founded by Dr. Ashiyana Nariani), the clinic and operative staff of the local hospital (especially Dr. Kapoor, Mr. Rohit, Ms. Madhu, Sister Pradhan, and Mr. Sachin), my mentor Dr. Claes Dohlman (the inventor of the artificial cornea who donated one for this trip), Sameera Farazdaghi of Tissue Bank International and Kelby Koop of Utah Lions Eye Bank, and my home team from Utah who organized things on this end: Jackie Simonis, Chandler Crane, and Tina Szarek.

I hope my fellow ophthalmologists and those interested in vision care will join the fight against needless blindness by contributing their time to service and teaching and making a difference where both short and long-term impact can be made. I also hope that developing societies as they develop focus resources on preventing needless blindness through awareness, encouraging eye donation, fighting diseases like the measles and malnutrition. Saving and restoring vision is probably one of the most important and cost effective things we in health care and societies as a whole can do. Especially for children, who are all too often neglected in the developing world.

The Lighthouse in a Black Hole of Calcutta

Created on: Thursday, December 11, 2014

Just a little bit after high noon under the Calcutta sun, the Irish woman was telling me (a South Indian desi who has never been close to being sunburned) that I was looking pale.

4AM.  Wake-up call.  The rough and unwelcome ring rousts me from the first comfortable sleep I have had in 8 days. I have had a busy and challenging week of cornea transplants and surgical skills transfer in rural Haldia (pictures here) as a volunteer on an ORBIS mission.  I am exhausted and rather enjoying the creature comforts of a nice room at the ITC Sonar, a treat for our last night in India. I really do not want to get up, but have promised my new friend (and ophthalmic surgical nurse) Ann-Marie that I will go with her to Mother Theresa House at 540AM. Plus, by waking up this early, I can catch up with Friday afternoon email back in Utah before all my colleagues leave work for a gorgeous fall weekend back in Salt Lake.

6AM. We get to Mother Theresa House and attend Mass. Although I am Hindu, the service is nonetheless moving in its beauty, humility, and simplicity. The melodious chorus of the nuns is soothing against the raucous boulevard outside. After mass, we stop briefly at Mother Theresa’s tomb, and then make our way downstairs to the assembly area, where we have a small banana (one of those nice baby tropical bananas) and tea for breakfast. I see a posted prayer entitled, “in preparation for going to the Apostolate.” It asks the Lord for “skill in my hands, clear vision for my mind, and singleness of purpose.”  I think to myself – how similar to the silent prayers of many a surgeon before any case, and how similar to some verses in the Bhagavad Gita. Ann-Marie and I trade personal backgrounds; she is originally from Boyle in Ireland but now works in Cardiff in Britain to be close to her children and grandson. After we all have tea, the sister in charge of volunteers arrives.  She assigns us to a team of 10 volunteers headed to the Kolaghat. Our group includes a French couple on honeymoon, some Korean and Japanese tourists, a Romanian backpacker, and some college students from hither and yon. After a harrowing 20 minute bus ride on a rickety vehicle straight out of your favorite Africa movie with exposed floorboards and a ramshackle roof, we reach our stop. We walk up the street and promptly get lost.  There are so many beautiful colors amid the squalor. As an outsider looking in, I am struck by how the people seem happy despite grinding poverty and oppressive heat. A friendly tea house shopkeeper directs us to the right street and after a 40 minute walk, we arrive drenched and tired to the Nirmal Hriday (the Mother Theresa Home for the Dying and Destitute), where the local sisters and staff engage us in their normal morning schedule.

9AM. First job is washing laundry (mostly green-colored sheets and pillow covers).  I have no idea if I am any good at soaping, rubbing, and washing the sheets and clothes, but guess that I am probably not, as they send me upstairs within 10 minutes).  Dejected at my evident lack of skill with hand-washing, I dedicate the next hour to rooftop clothesline duty, and get drenched in sweat again. Arranging the laundry carefully to optimize rooftop clothesline space and stabilize the hangings makes me appreciate what my mom did when we were little kids. And seeing the neighborhood from above is a treat reminiscent of childhood summers with relatives in India.

We have a short break for tea and biscuits, and peruse the history and teachings of Mother Theresa, who moved to India in 1937 and founded the Missionaries of Charity in 1953. After break, we go downstairs, and turn over the male and female open wards (each with about 50 beds). Clean beds, sheets, pillows, and pillowcases. Now I understand the relevance of laundry duty.  Despite all the filth outside, this place is kept in tip-top and immaculate shape.

11AM.   An agitated woman is brought in by wheelchair by Tamara, a Mexican physiotherapist who found her lying at the station. She is whisked to the female ward. After helping a different elderly woman walk to the bathroom, Ann-Marie goes to peel eggs in the kitchen.  The French husband on honeymoon holds the hand of an emaciated man on IV fluids. I look around for a little bit, noticing an unnerving sign on a cabinet (Dead Body Clothes), a medicine cabinet with an odd assortment of medications, and a sign that says “This place is not a hospital, but rather a place where the dying and destitute can go for comfort and dignity.”

Anne Marie comes down from the kitchen, and we chat for a little bit. One of the sisters asks if I am from India (I am the only Indian in the volunteer group that morning), and I let her know I was born in Vellore, but live in the US.  The sister moves on about her work, and then a few minutes later, finds me and asks me to go to the female ward, as the woman Tamara brought in is now unconscious. I go the female ward, but one of the attendants shoos me away, “no males here!” Ann-Marie, who has not raised her voice the whole week, counters, ”We need him, he’s a doctor.” Upon coming to the bedside, I am startled by an awful sight. This tiny, poor old woman is in acute respiratory distress, not responsive, foaming at the mouth, and struggling to breathe.  Tamara is crying and asks if the woman is going to die; I don’t want to answer that. I ask the head sister if we can transfer to a hospital; she says there is no such option. One of the sisters (Sister Adriana) has managed to put a nasogastric tube in, which is starting to remove kerosene from the poor lady’s stomach. Presumably she swallowed the kerosene in an attempt to kill herself. Her pulse is fast but thready. Listening to her chest reveals a lot of “junky breath sounds”, a racing heartbeat, and a fairly loud systolic murmur (I wonder if she has aortic stenosis).  I ask Ann-Marie to see if the staff can get suction (her British-Irish accent is much more understandable to the sisters than my thick American one), and she begins suction with resolve and grit.  The sisters ask how long they should keep irrigating the stomach, and having never dealt with kerosene before, I tell them to keep irrigating until clear, normal-smelling liquid comes back. I ask for activated charcoal but there is none.  Proceeding with the examination, I see that her pupils are small and non-reactive, and the sister informs me that the patient’s fingerstick shows a blood sugar of over 300. Crap. Not only are we fighting kerosene poisoning, this poor lady probably also has DKA (diabetic ketoacidosis).    I have to get an IV started, but haven’t done one in 16 years, let alone on a dehydrated patient in a poorly lit room in a crisis.  I find an antecubital vein in her right arm, and am handed the butterfly needle, tourniquet, and alcohol cotton ball. I put on gloves but they don’t fit and are the yucky, slippery, polyvinyl kind.  I position the needle, and before piercing skin, pray to God to please let me get this stick. Flash of blood in the cannula – thank goodness! I get the IV taped up and call for saline (the sisters ask whether it should be NS or DNS; this lady does not need any more sugar, so NS it is) and 10 units of insulin. “How much volume of insulin in a 1 cc syringe?”  Fortunately, just 2 days earlier in Haldia, I saw that an insulin syringe of 40 units corresponded to 1 cc, so that makes it easy to figure out the dose.  I listen to her lungs again, and she sounds better after suction but has probably aspirated stomach contents into her lungs.  Are there any antibiotics? Sister Adriana takes me back to the medicine room, and I am looking for a 3rd generation cephalosporin and clindamycin (to cover Gram negatives, upper respiratory flora, and anaerobes).  I search in the drawers – amikacin, nope, don’t need to risk kidney failure in this lady with DKA.  Sulbactam, nope, not powerful enough.  Ertapenem and piperacillin – totally awesome broad-spectrum antibiotics but probably overkill and don’t want to tempt resistance germinating to these “gorillacillins” in a Calcutta slum. Sister Adriana comes back – “ok, doctor, what antibiotics should we give?”  I find a cephalosporin drawer – great, but wait – cefotaxime, cefazolin, cefirizine, cefaperazone, ceftriaxone, cefipime, cefixime …Goodness gracious, why do cephalosporins all have to sound the same and why did they have to make so many new ones since I memorized the first 3 generations of them in pharmacology 20 years ago?! Ceftazidime – found it! – covers Gram negatives and Pseudomonas (which can cause a really nasty pneumonia) and Amoxicillin/clavulunate – a reasonable choice to cover oral anaerobes and upper respiratory flora.   I let Sister Adriana how often to give each one and go back to the bedside. I ask Tamara for a smartphone, and luckily one of the Koreans has a working internet connection.  After a little fumbling to get an English language interface, googling kerosene poisoning reveals that milk can be used to try to neutralize it (via the nasogastric tube).  Sister Adriana asks if we could put egg along with the milk, and pondering it, I remember that egg white has albumin, which is a molecular sponge, binding almost everything. Sure, I say, milk and egg it is.

As the staff readies the milk-and-egg concoction, the patient soils herself. The sisters and Ann-Marie change the sheets, and Ann-Marie expertly inserts a Foley catheter, draining normal-looking urine (a good sign).  However, in the jostling, the IV comes out of her vein.  I try her left hand with no success.  Sister Adriana tries her right elbow again and then her right forearm. No luck. I try her left upper arm, and get the welcome flash of blood, but then the needle slips from my finger and I lose the vein.  I begin to spy the patient’s external jugular vein, but Adriana tries the patient’s right hand and is successful – whew!. I take my gloves off; looking down at my hands, they have never been clammier.

12PM. Our patient is breathing more comfortably and looks better; she is starting to blink and move her eyes a little.  The sisters ask if we can stay for the afternoon; unfortunately we both have planes to catch. After leaving recommendations on fluids and antibiotics with Sister Adriana, and hugs and thanks all around, Ann-Marie and I walk back into the slum to hail a cab.  Ann-Marie tells me that she did not think the patient would last the hour and that I should be proud;  I tell her I am just relieved at how things turned out and grateful that Tamara, Sister Adriana, and Ann-Marie were all there with the patient at the same time.  It was only by grace of providence that a physiotherapist from Mexico, a medically self-taught nun, an Irish nurse, and an Indian-American eye surgeon crossed paths with a poor woman in pain on a Saturday morning in Calcutta.

While outwardly I tried to project calm, I had been terrified the whole time that this poor woman was going to die in front of us because her doctor was an ophthalmologist who had not taken care of general patients for 12 years.  Ann-Marie has been a nurse for 43 years, and I a doctor for 18; it is reassuring that my mentors were right - the time spent learning general medicine was not wasted, for our skills and memories decades past are still there, ready and useful. My hands are trembling, and Ann-Marie says that I look pale.  She says lunch is on her.  Getting back to the hotel, I have a nice long hot shower after the morning’s drama, and enjoyed the first good water pressure in a week. I put on my scrubs for the flight home, and ironically realize I should have put them on when I woke up that morning.

Suicide is an irredeemable sin in both Catholicism and Hinduism, and even though I worry about all the potential complications of kerosene ingestion, hopefully we have given our patient a chance at redemption, and in so doing, redeemed, in some small way, our own existence in a fallen world. For service is the rent we pay for living. The Sanskrit saying “Manava Seva, Madhava Seva”  parallels Christ’s admonition that “whatever you do unto the least of my brothers and sisters, you do unto me.” The Grim Reaper and God were both in that ward that morning, and hopefully we bought some time for our lady’s body and psyche to mend.   The morning evoked the exchange between Katsumoto and Cpt. Algren in The Last Samurai, “Do you think a man can change his destiny?” “I think a man does what he can, until his destiny reveals itself.”

The Mother Theresa Home is a lighthouse in a modern-day black hole of dashed dreams (villagers seek opportunity in the big city but often are stranded in the slum; the original Black Hole of Calcutta was a dungeon). Together, the sisters and staff offer a beacon of hope that helps wounded souls to heal.  Along with images from Mother Theresa’s life, the centerpiece of the home is a statue of Jesus on the Cross, saying “I thirst”.  While our patient attempted to quench her despair by kerosene, we all thirst for some small measure of peace, and by giving unto others, may hope to achieve it.  It is my genuine and deep hope that readers can help contribute by volunteering time and perhaps organizing some training and support in basic emergency medicine and care, as well as equipment, medicines, and resources for the sisters and staff there, who endow the word missionary with new spirit and old meaning every single day.   The sisters who provides relief to the surrounding society in its darkest hour of need can use all the help they can get.  And for those who have the fortune and privilege to visit and give of themselves, life and its preciousness and the smallness of our daily vicissitudes are all put into clearer perspective.

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