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Perspective

Keeping the Hope Alive - Building A


Tertiary Eye Centre
Dr. Arvind Kumar Morya, Dr. Anushree Naidu, Dr. Sonalika Gogia, Dr. Sujeet Prakash, Dr. Sulabh Sahu

Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, India

“A small seed in high spirit becomes a plant and that plant with courage and determination turns into a Giant Tree to serve
many lives almost to the eternity “ -AKM

A
Comprehensive tertiary eye care centre Glaucoma, Medical Retina, Paediatric Ophthalmology and some
providing quality eye care services to all the of the extra ocular procedures. From scratch to the current
population including the underprivileged ones scenario, too far away from reaching our goals this journey has
is a far-off dream that we saw. Although there been a great learning experience.
are quite a few world class centres in India Development of a tertiary eye care centre is no cinch.
providing best of the facilities, there is major Following are some of the practices that we incorporated in our
lacuna in demand supply relationship. Moreover, majority of institution:
the population in India belongs to rural and suburban areas, 1. Acquiring trust of the patients: It requires a great deal
in which places providing latest facilities is far from reality. of perseverance to build an eye care system which is trusted by
There is a lack of well-trained surgeons, infrastructure building the patients. This trust can be achieved only through personal
and maintenance and awareness to reach out to the available interaction with the patients. Many a times it is forgotten that
facilities what we are treating is a patient not a disease. Small amount
India, the second most populous and the seventh largest of empathy is what is required sometimes in building trust. A
country in the world; a country where every year 3.8 million system which is trusted by the patients can create wonders.
people turn blind as a consequence of cataract; a country with 2. Triage of patients: Whilst many a times, in a busy
ratio of 1 Ophthalmologist for ~90000 population, a country OPD patients requiring special attention are overlooked, it
where 65% of surgeries are performed in private sector with is important to ensure triage. The patients with chronic or
50% of Ophthalmologists being surgically inactive; a country severe illnesses that require more patient compliance for the
which houses 15-18.6 million blind people. The unmet need of management of their illnesses eg patients of glaucoma need
acceptably trained surgeons in the country is no clandestine. more attention, more counselling and more amount of patient
Above scenario depicts the plight of the rural and the care. We have developed a three tier system of counselling
underprivileged population in India in need of quality eye care wherein the patients are being counselled by the optometrist,
services. Majority of this population is unable to reach out to the resident doctors and treating consultant. This helps in
the available facilities and if so, often there is much delay in picking up patients requiring proper attention and then
seeking the health care. The result is, many of the patients fall providing them with adequate information.
prey to diseases, that could otherwise have been cured. Many 3. Audio-visual aids: We have incorporated audio-visual
eyes lost, skilled manpower lost, it creates a social as well as system as an integral part of our counselling. This provides
economical burden to the society. patient with better insight to the disease process as well as
Rationale: About 22% of India’s population belongs to the the management of the same. The audio-visual aids are being
category of below poverty line. The right to high quality eye used for individual counselling of the patients as well as a
care for this under-privileged population can be served only public awareness tools. Information regarding common ocular
by providing them with a self-sufficient tertiary eye care centre problems is being displayed on daily basis on television screens
in government sector. There are only few such centres in India in front of OPD.
proving comprehensive eye care facility to its underprivileged 4. Initiation of Post graduate course: Post graduate
population. students form an integral part of the work force of the
The availability of a tertiary eye-care centre in tier two Department. Initiation of Post graduate courses add to the
city of India is the need of the hour. Our aim was to build a integral manpower of the department. Once trained they form
self-sufficient tertiary eye care centre in a government set up the skill full workforce of the Department. Initiation of these
that could provide basic as well as quality eye care services to courses adds to the quality care to the patients.
the population. In an institute that is in its developing phase, 5. Employment of sub-speciality trained Senior
we have tried to build a centre that could provide facilities in Residents: Employment of sub-speciality trained senior
multiple sub-specialities like Cataract and Refractive, Squint, residents can if not substitute but aid to the quality of eye care

36 DOS Times - March-April 2019 Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre
Perspective

services that would have been otherwise need to be identified as training centres community level such as promoting
possible only in a well Developed eye which can provide productive training to eye health in the community, screening,
centre with Sub -speciality Units. budding ophthalmologists. Infrastructure case finding and referral, emergency
6. Running of multiple sub- development would include the provision treatment, identifying and referring for
specialities with a small work force: of good quality surgical microscopes, A rehabilitation those who are already
A comprehensive Ophthalmologist can scan machines, ultrasound machines, blind, and providing commonly required
provide care to multitude of patients YAG laser machines which would make services like refractive error correction.
which is of utmost importance for a the post graduate training worthwhile Depending on the services rendered,
developing centre by organizing weekly and productive. Camps in outreach areas the provider of primary eye care could
Speciality Clinics. can be arranged in association with range from a general primary health
7. Short term Fellowships for the a tertiary care hospital which would worker to a well-trained ophthalmic
Consultants: Anterior segment surgeons ensure that cataract surgeries happen in technician. The vision centres are staffed
can be trained in multiple sub – speciality hospital settings, clearly bringing an end by vision technicians–paramedics trained
by opting for short term fellowships (2/3 to surgeries in poorly equipped operation in ophthalmic evaluation, refraction,
monthly) annually during off-season theatres at camp sites and keeping dispensing spectacles, and diagnosing
on alternate basis without hampering chances of Infections to a minimum level. potentially blinding conditions.
routine work. This would quadruple the number of Secondary-level eye care is provided
8. Developing neglected sub- cataract surgeries performed on a daily by ophthalmologists and covers
specialities: In the present time most of basis, ultimately reducing the burden of comprehensive ocular examination,
the Ophthalmologists are interested in preventable blindness. cataract surgery, simple glaucoma
Cataract surgeries only so practice can Investing in human resource surgery, minor procedures, nonsurgical
be made more meaningful and impact development in the field of Ophthalmology management of other conditions, and
causing sub-specialities like Paediatric would yield great results. Ophthalmology referral to tertiary care for cases that
–Ophthalmology, Medical – Retina, Dry residency program has to improve require the attention of subspecialists
Eyes and Refractive services. tremendously. The importance of para- in ophthalmology and more advanced
clinical staff- Optometrists, counsellors, facilities.
What needs to be done? lab technicians needs to be emphasised. A Tertiary eye care centres are staffed
Setting up refraction services at global exercise to review the distribution by subspecialists and have the capability to
Primary Health centres, setting up a of practicing ophthalmologists showed provide the complete spectrum of eye care
separate ward in district eye hospitals that there is a wide gap between the need services like paediatrics ophthalmology,
and dedicated ophthalmic theatres. and the existing human resource both in retinal clinic, cornea clinic, glaucoma
Regional institutes of ophthalmology high and low income countries. clinic, oculoplasty, etc. Ophthalmologists
and selective medical colleges should Optometrist to ophthalmologist ratio are generally categorized as ophthalmic
be developed into centres of excellence. should be optimum, which would ensure surgeons and medical ophthalmologists,
Substantial funds should be provided that the ophthalmologist engages himself depending on their job responsibilities.
to Centres capable of developing in RIO in more clinical work and surgeries Medical ophthalmologists (also termed
and teaching hospitals for upgradation and the basic work is taken up by the specialist ophthalmologists) could
through purchase of capital equipment. supporting staff. Formal and recognised support consultant ophthalmologists
Capital grants could also be given to select courses in optometry should be started to in comprehensive eye assessment
voluntary eye hospitals in the NGO sector accredit the training in this cadre and to (basic work up) and medical treatment
to enhance their own infrastructure stipulate standards. of chronic, age-related diseases such
capacity. A significant volume of Overall a strong foundation has to as diabetic retinopathy, glaucoma,
eye care in India is provided by the be laid for eye care. Primary eye care dry eye syndrome, etc., Consultant
voluntary sectors. Vision 2020 provides still holds the key to universal coverage. ophthalmologists, thus, could focus
a platform for all non-governmental However there is a need for well- on surgical management of avoidable
organisations to come together. This will developed tertiary care centres which blinding eye diseases. Thus, future
increase the effectiveness of advocacy, can provide comprehensive care, provide evaluation of manpower for eye care
influencing policy and promoting training and engage in research. should gather information on medical
best practices. Strong voluntary care The six main foundations of a health ophthalmologists and ophthalmic
would also require a strong public- system are: human resources, finance, surgeons to ensure a rational distribution
private partnership. Government setup health information, governance, services of both subgroups. To meet the growing
would ensure significant volume in the delivery and consumables and technology. need for tertiary services, we have had to
delivery of eye care and private sector While not all eye conditions require closely monitor the patient volumes per
involvement would ensure reduction in the most advanced treatment facilities, specialist and enhance their numbers,
cost of treatment. Also public private neither can all eye care be addressed by as well as the facility, through advance
partnership would ensure staffing and facilities lacking tertiary care expertise planning. In addition, tertiary eye care
upkeep of the infrastructure. Planning and equipment. The concept of primary, system can have a cloud-based platform
and execution would be strengthened by secondary, and tertiary levels of care is for remote screening of fundus images
the participation of all stakeholders. needed for providing the appropriate for diabetic retinopathy. Such proactive
Another important aspect of capacity management of the patients. reach into the communities including eye
building is enhancing surgical skills Primary eye care would include camps and serving these communities
through training. A number of Institutions services or activities carried out at will result in overall increase of patients

Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre www. dos-times.org 37
Perspective

who directly access the tertiary hospitals to understand the mechanism at the place for training ophthalmologists, as
and has served to further increase the genome, transcriptome and proteome well as other eye care personnel, which
demand for subspecialty services as level. It is possible that the outcome of constitutes one of the several advantages
well as the numbers of paying clientele. the research could be translated back to of creating such institutions where
The distance patients travelled to obtain the patients in the clinic in terms of early they are needed. This expenditure has
services according to the subspecialty diagnosis or a drug target and how it will not increased despite an increase in
type, as a surrogate for demand for be helpful in a better understanding of population. Hence, optimum utilization
services. In addition to reflecting very disease process and improvement in the of available resources and improved
substantial demand for tertiary services, treatment methods to attain the goals of performance are essential to reach the
such a large proportion of long-range Vision 2020. short-term national health objectives.
travellers will require adjustments to Research can dramatically improve On one side, they are in the process
scheduling patterns, and may require the work of mid-level eye health of developing high quality human
plans to facilitate overnight stays for personnel who want to provide the best resources; and on the other side, they
patients and accompanying persons. In possible care based on accurate and have to address avoidable blindness due
tertiary eye care institute we can tie up relevant evidence. This hierarchical to eye diseases on urgent basis in order
from the available local NGOs and sub approach has been widely advocated over to mitigate a substantial backlog. To
specialist for providing the required care the last decade since the launch of the some extent, this could be addressed by
for the patient management, this kind global initiative VISION 2020 the Right hiring trained allied eye care personnel.
of care has been successfully applied in to Sight, as a valuable design for eye care Additionally, experts could manage
premiere eye care institute in our country infrastructure. blinding eye diseases at state of the art
like LV Prasad, Narayana Nethralaya, Tertiary-level centres also offer institutions.
Arvind eye care institute, etc . A tertiary training for the budding ophthalmologist, When designed and executed
centre approach also provides the post graduate courses and training properly, this hierarchy in services can
opportunity for a fertile interaction of courses for optometrists and technicians ensure both timely and cost-effective
specialists across the watershed areas handling the ophthalmological treatment, and provides a paradigm
between disciplines, which may lead to equipments. Increasingly, day care intended to ensure that the investments
bettering of focused, disease-specific surgeries and short hospital stays are in infrastructure, equipment, and eye
programs. preferred. The diagnostic and treatment care personnel are utilized optimally at
While the secondary-level have modalities have also become more all levels.
centre been common and primary eye sophisticated and less invasive. These A long journey passed by and a long
care centres are being set up to reach the technologies need to be handled by journey to reach the destination, we
unreached, setting up tertiary care centres trained assistants, technicians, and hope that this dream will sure turn into
has been less aggressively pursued, as it optometrists. Hence, more support staff reality so long live a hope to excel to serve
requires more investment and trained is required. Tertiary care services require humanity optimally. Turn dreams into
staff, and there have been uncertainties highly trained staffers (ophthalmologists reality.
about the potential demand for such and support staff), in whom an institution
services. Over time, with increasing makes a large investment. Similar to
affluence and improved health care, other professionals, ophthalmologists
resources could be channelled elsewhere generally seek opportunities for growth.
towards developing other goals. One Keeping them engaged in a limited set of
such development is the emergence of basic services can become monotonous
ophthalmic research. The combination of over a period of time, and may lead to
high clinical load, extensive community losses of highly desirable personnel.
participation, and access to a large Providing ongoing training to them in the Correspondence to:
Dr. Arvind Kumar Morya
network of eye hospitals provides ideal latest technologies, as well as providing Department of Ophthalmology,
opportunities for conducting clinical, the opportunity for sub-specialization, All India Institute of Medical Sciences,
Jodhpur, India
laboratory, population-based studies and is therefore important for retention as
social and health systems research. well as for providing the best quality of
The basic research carried out services. Tertiary centres are an ideal

38 DOS Times - March-April 2019 Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre