Ophthalmology-Simple,Complex-and Alternate

[Guest guest]

Hi fellow Ophthalmologists and the aliens in Medical fraternity,

Earlier it was much quiet on the Ophthalmologists' front.They were a

low-profile,peaceloving,even happy-go-lucky- creatures.Refractions were the

bread and minor eye surgery the butter,while cataract surgeries gave the

periodic jam.In fact many used to practise family medicine at the side or even

it used to be the other way round,general practise being the flagship of the

business.I remember my own old grampa (bless his soul) worrying about my

survival in the cruel world when I firmly put my foot down and refused to take

up his GP and stick to my " dolyacha dawakhana " (Eye Clinic)!.This was because

comparatively fewer eye specialists were venturing into surgeries and eye

surgeries being what they were then,still fewer patients ventured into having

their eyes cut open,mended and sewn back with 8-0 virgin silk.Cataract surgery

grew up,better medications for many conditions came in,diagnostic instruments

sprung up,and Ophthalmology slowly came of age.I sound like a scarred veteran

which I am not,but in any case I have seen at least fifteen years of

contemporary Ophthalmology now and have tried my best to keep abreast of things

happening.

Medical Oph,the subject of our chat, really emerged as a speciality with the

introduction of Photocoagulation and better understanding of diabetic and other

vascular retinopathies,around the eighties in India,maybe a bit earlier in the

Western world.

Similar advancing things happened in other fields in Medicine too

(Endoscopies,ECHO and USG,and a host of other things you then read in journals

and were surprised to find the same wonders ,forgotten soon after you put the

journal away,soon making their presence felt in routine practise-remember?)But

this particular discipline came to the fore from nowhere and suddenly

Ophthalmologists belonged to the Medical elite!There was a surge in the public

interest in and usage of contact lenses( Kishore,remember those hard days with

the uspfos?),more people became more and more aware of eye problems and more

people needed better and lasting vision.Cataract surgery became safer and

Surgeons surer of themselves,and then were ushered in the IOLs.Simultaneously

interest and work in the research was bearing fruit and some of the devastating

conditions gradually found a prevention if not a cure.Diabetic retinopathy was

one such,wherein people actually could contrast study the retinal circulation

and plan means and strategy to treat and prevent diabetic complications by a

strong light called the Xenon arc lamp.People who were trying these means didn't

know they were evolving into Medical Ophthalmologists,though.But the speciality

did develop fantastically and even did wonders and had an authenticity laying

down the norms,such as the Diabetic Retinopathy Study(DRS) group.

Lasers followed after the ancient Xenon arc and the Medical Ophthalmologists(or

the Ophthalmologist Physicians)claimed those too were their domain.Prospects of

medical and physical alternatives to knife work alike fascinated the public and

the eye specialists(less gifted with surgical skill,cynic surgeons

comment!).Diagnostic procedures,equipment and paraphernalia(Fundus

Cameras,Angiographies,Ultrasound et al) made their place in the clinics,and were

soon taken under the medical ophthalmologists' wings.

Refractive Surgery is at best a grey area and perhaps I would put it under

" surgeons " .Medical Ophthalmologists also were entrusted theresponsibility of

medically managing glaucomas and Uveitis,as they themselves say while the others

say this and such thankless jobs are dumped with them.

Perhaps the compartmentalization of " Clinical " , " Optical " , " Medical " and

" Surgical " Ophthalmology in today's native scene is artificial but will come to

stay in near future.Sankara Nethralaya was undoubtedly the first people in India

to separate these disciplines and develope them as subspecialities way back from

the early eighties.My fellowship days there began with the sheer thrill of

having different departments even in the Ophthalmology Department!Today however

I find it a course of routine when I refer a Retinal Detachment to my Posterior

Segment colleague and a toric contact lens fitting to an Optometrist,because I

consider myself a General Ophthalmologist with a tilt towards

Cataract,Glaucoma,Pediatric Oph and Strabismus!

Medical ophthlamology should today include the important Systemic

Ophthalmology,Neuro-ophthalmology et al.These are branches not understood by the

rest of the sub(or Super?)specialists because here comes the Internal Medicine

and,cross my heart,Neurology,which you are supposed to know before you take a

step in the appropriate Ophthalmic sub(or super?) speciality.So the Med Oph have

their revenge of having dumped into their laps the dirty work when they

condescendingly talk in a lingo Greek and Latin to others of systems all alien

to the simple surgeon restricting himself to the mundane complexities of the

ocular anatomy and physiology.

Then you have Pediatric Ophthalmology-dealing with all congenital and

developmental disorders and of course Strabismus.Throw in some congenital

cataracts if the Surgeons let you.

We have lately seen the formidable Ophthalmic Pathologist emerging on the

scene,as if we were not happy enough earlier with our own correlation of

clinical signs and symptoms and really had an inferiority complex about our

inability to decipher the histo slide under the oil drop objective!

Surgical Ophthalmology involving employing of established and trying out newer

techniques in surgery is neighbour's envy and owner's pride(or the eternal case

of the other guy's wife always being sexier).Eye surgery is mostly cataract

surgery but dentistry is not all tooth extraction like not all eye surgery is

lens surgery.This is because of the sheer population of cataract patients and

there being no medical cure for it.You of course have Glaucoma

surgery,Strabismus surgery,Oculoplastics,Corneal province in the Anterior

Segment Surgery-and VitreoRetina or the eerie Posterior Segment domain.Even the

age old cataract surgery has evolved from the Neanderthal days of knife-section

to the contemporary scenario where every surgery is a Refractive Surgery.This is

the reflection of the Surgeon's pledge that he will strive to make each patient

see even better and unaided than he ever saw.

And as Physicians or Internists like to look down upon lesser mortals the

Surgeons,and in fact all others,Medical Ophthalmologosits might think themselves

a creed apart( " After all what is Surgery but a little craftsmanship!Some

knife-luck and an inflow of patients willing to suffer the knife at your hand

and you have a Surgeon! " ).Mind you even the Royal College of Surgeons was " The

Royal College of Surgeons and Barbers " to begin with.In fact some of the(less

successful?)barbers turned into surgeons then-the surgeons being fortunate

getting to rub shoulders with the barbers,and surgeon's prestige way below that

of a hairdresser's on the social admiration scale!

Ideally any Physician(meaning the conventional " good doctor " ) is complete only

when he is a counsellor,clinician,pathologist,pharmacologist, surgeon and

rehabilitationist all at once.I have not used the adjective " good " to any of

these attributes here.The sheer pace of advances in any medical field and human

inability to cope with few of them at a time and personal interests and

acumen(The Surgical Hand!-I remember a colleague deriding another as the

Non-Oprating Surgeon as in the Non Playing Captain! ) and opportunity make you

what you get to become.

For the common population the concept of such compartmentalization is still

ridiculous,irritating because of the inconvenience to them and difficult to

understand-unless you provide them with multiple services under one roof,never

mind if in separate deaprtments.

But this is another issue altogether,and we might exchange views about group

practise and multidisciplinary coalitions later.

Meanwhile consider this-a friend and colleague-Vijay Ramdasi,who is an MGIMS

alumunus btw,told me he is considered a sort of superspecialist because he gives

fantastic results-with Homeopathy- without surgery to patients with chronic

stubborn styes.What is he?A Homeopath-Pediatric Ophthalmo-Dermatologist ?

Then we have in Pune a very successful and reputed establishment boasting of and

guaranteeing to managing any eye condition (be it chronic itching or progressive

night blindness- they have a huge menu-card ) with,hold your breath-Combination

of Allopathy,Ayurveda, Homeopathy, Yoga,Naturopathy,Reiki-and ASTROLOGY!

Super-duper Alternative Ophthalmology,this?

Sunil Nivargi