What is Ophthalmic Plastic surgery?

“It’s better to do a dull thing with style than a dangerous thing without it.”- Charles Bukowski

What is Ophthalmic plastic surgery or Oculoplasty? I often get asked this question when I tell them what I'm specializing in. Most people are not aware that such a speciality exists  including majority of medical doctors. They ask me how can you be an Ophthalmologist and a Plastic surgeon at the same time. It's a tedious exercise explaining it to people what my work comprises and one which makes my wife make fun of me when I explain because she's heard it so many times. I thought it would make sense to pen it down. Here it goes....

Ophthalmic Plastic Surgery is a subspecialty of Ophthalmology which deals with the orbit (eye socket), eyelids, tear ducts, and the face. It also deals with the reconstruction of the eyelid, the eye socket, and surrounding structures. Lately as a natural progression this branch has been getting into Facial Aesthetics in a big way in the form of Brow lifts, facelifts,Botox, fillers and Facial Rejuvenation.

The subspecialty of ophthalmic plastic surgery was born in the mid-twentieth century in the United States at the conclusion of World War II. The art of oculoplastic surgery, however, is centuries old, bearing its roots in antiquity in India,the Far East, and Europe.

The various procedures that have evolved over centuries can be divided into several general categories: reconstructive, restorative,and cosmetic.  Oculoplastic surgeons have perfected, refined, and pioneered new techniques of lacrimal surgery, ptosis repair and blepharoplasty, orbital surgery, lid malpositions, and flaps and grafts. With the close relationship of this speciality with Eye Cancer and eye reconstruction after removal of tumours,  Oculoplastic surgeons are de-facto Ocular oncologists. Since the treatment of the above conditions often requires multidisiplinary approach the possibilities of this field are endless. It also requires good working relationship with other specialties and to create a valuable team to treat the patients.

Oculoplastic surgery became recognized as a unique subspecialty of ophthalmology at the end of World War II. Numerous orbital and periocular injuries were treated by general ophthalmologists without prior training or exposure to ophthalmic plastic surgery. More often than not, trial and error were keys in developing these procedures. Among the earliest pioneers was Dr. John M. Wheeler who established a full practice based on oculoplastic surgery. He is known as the father of oculoplastic surgery. His student Wendel Hughes was the next major force in this field. Further Hughes' students Alston Callahan,Byron Smith and Crowell Beard propagated this field across the world. This group of Oculoplastic surgeons went on to found the American Society Ophthalmic Plastic and Reconstructive Surgeons(ASOPRS) in 1969. This was the first such society in the world for oculoplastic surgeons. Later more such societies got formed in other parts of the world. Europe (ESOPRS), Canada (CSOPRS), Asia-Pacific (APSOPRS) and even India (OPAI).

It is a relatively less known specialty. ( I myself did not know about it till I joined residency). There lies the challenge in this field and also the greatest opportunity to grow. The specialists in this field are there in it only for passion since the other sub-specialities in Ophthalmology are much more rewarding monetarily. This sub-speciality is quite hard to master yet it is incredibly satisfying. I am honoured and privileged to count myself among these stalwarts. Like I said the possibilities are endless and there is so much work to be done....

References:
1. Smith and Nesi's Ophthalmic Plastic and Reconstructive Surgery
2. Local Flaps in Facial Reconstruction by Shan R. Baker and Neil A. Swanson

From Oculoplasty and back

“Just don’t give up trying to do what you really want to do. Where there’s love and inspiration, I don’t think you can go wrong.” —Ella Fitzgerald

Its been an incredibly long time since I've been active on this blog. Partly because I have been busy and mostly because I haven't been inspired to write in a long time. I was in Bhubaneshwar sometime back and it has kind of brought me back to a place where I almost gave up on Oculoplasty as a career. In my earlier blog posts I had professed immense interest in Oculoplasty and haven't really updated what happened afterwards. Its a huge story worth a potboiler at the very least (ha ha I'm kidding). Well I wont bore you with all the details.

But something incredible happened in the end of September 2013. I got an offer letter from National University Hospital, Singapore accepting me for their Orbit and Oculoplasty clinical fellowship program. I had applied to NUH after my residency  just like the many other institutions I had applied to. Somebody there had seen a spark in me and selected me. I was ecstatic and that hunger to get into the fellowship kept me from giving up during the protracted paperwork process to start my fellowship.

I'm now more than 4 months into my fellowship and its been an amazing experience till now and I feel I'm in the best place that I could be. I have finally found a mentor who could really shape my career the way I would want it to go. I'm learning new things everyday and things I never thought I'll be doing.

I'm training in navigational surgery of Orbital fractures,small incision endoscopic browlift, Aesthetic procedures, attending orbital fracture implant courses and a myriad things I hadnt even imagined I would be able to do.  I realize that i'm at the forefront of technology and innovation in my field here in Singapore. The real challenge will be to use the knowledge and training that I have gained here into a place like India where there are always impediments to one's growth. A lot of it is economic and most of the rest of it is politics and nepotism that thrives in my profession in India. I sometimes worry that I'm getting spoiled by all the high tech gadgetry that I see here in Singapore and I fear becoming obsolete in India. Also I'm recently married so to get the kind of solid support from my wife has been comforting but I understand the sacrifices she's making for my career and it sometimes troubles me.

But after a lot of reflection I realize that the basic emotion here is "Joy". Joy in what I am doing despite hectic schedules of this fellowship and finding happiness in an equally important marriage at the same time. This beats every fear that I'll ever have. I figure that if I'm enjoying what I'm doing I'll find a way to make a living out of it.

Careers, Decisions and Priorities!!!

I am like a wide eyed boy in a huge toy store who wants to find out what every toy can do before his parents take him home.  I'm passionately curious about the world around me since when i can remember and that trait has never deserted me even now.I tend to be fascinated with more things than i can probably give my full attention to. I remember as a child dismantling electronic equipment to understand how it works despite being punished for it later or reading extensively about some interesting story the day before some exam which would not be asked in any exam. I don't know whether this has been actually a good thing or detrimental  in my life but I guess I cant be anything else but me. Mine has been a life of curiosity and facination! I have this uncanny ability to find a sense of wonder in the things i'm doing which i think is a gift. All the elders in my life(parents,relatives,teachers) are very effusive that I make a career for myself but I dont really know if i have planned for a career as such.Some years ago I read an article by Shekar Kapur, the world renowned Director of Hindi and English language films.He said " I had removed the word career from my dictionary when i was 22yrs old as i find that word restricting" Well though i took more time than Shekar Kapur did to realize this I have come to the same conclusion too, more so in the last 3 yrs when I was doing my residency. I think i can be more than a single body of work. I can have multiple roles and do it just as well. Yes I would like to work as an ophthalmologist like i'm trained to but what i will eventually become will not depend on furthering a career or on monetary consideration but on what I believe i should be doing and how I think I can touch people's lives.

Now that i'm nearing the end of my residency I'm contemplating my next move from here on. During my residency I was first introduced to a sub-specialty in Ophthalmology called Orbit and Oculoplasty which initially did not much appeal to me until one day in the OT i saw a face being reconstructed after removal of a large mass of malignant tumour of the eyelid. It immediately caught my fancy. But i guess the turning point of my residency was when i assisted my boss in a procedure called Lateral orbitotomy where you have remove a tumour from the back of the eye after sawing through bone. I found that procedure so fascinating that I thought to myself,  thats what i want to do! That was when i first thought of pursuing Orbit and oculoplasty as my sub-specialty and over the years it has become my favorite sub-specialty. The interest is so apparent i don't think anybody in my institute has any doubt as to which specialty I shall pursue. When told of my plans, my parents though supporting weren't very enthusiastic. So were many of my professors and relatives. They told me "why do you want to do something where you wont have enough cases and there's no money in it?" or that "why would you want to do anything other than cataract surgeries when there are so many to be done and also so much money in cataracts? " Well I dont know how but i was able to ignore all these people and i applied for a fellowship in orbit and oculoplasty in LVPEI, Hyderabad which is the best place in India for that sub-specialty. As i write this i'm waiting for the selection results which may or may not go in my favour.

I recently attended a conference where 2 of the leading figures of Orbit, oculoplasty and ocular oncology, Prof. JRR Collin and Dr. Carol Shields were conducting a workshop in their subject of expertise. They are the very people whose text books we read and i was completely bowled over by their enormous knowledge and genius in their subject. The clarity and simplicity with which they spoke has been so inspiring. I've been touched by Dr. Shields' passion for her subject. Their talk probably removed the last shreds of doubt from my mind about orbit and oculoplasty.

I guess money has never driven me as much as passion has all my life. I have achieved whatever i passionately wanted to do and fortunately it has never really been for financial gain. So i guess my next step should be to do what I would love doing. That said i find even cataract surgeries and corneal  surgeries fascinating too and maybe would not mind pursuing that either if for some reasons I may not get to do oculoplasty...John Irving, one of my favorite writers once said "I could have been a lot of things and even good at it but if I had been anything other than a writer my life wouldn't have been quite as satisfying" I guess Irving echoes my feelings towards orbit and oculoplasty. My life wouldn't be as satisfying if i couldn't pursue it. But unfortunately there are not many fellowships in India for this upcoming sub-specialty( in fact only 1 vacancy each in 3 big eye institutes in south india). So it has been a huge risk on my part by not applying for anything else. Right now I remember a sentence my professor of pediatrics in medical college used to say "Always give your best because if suppose you do not succeed, find peace in the fact that you couldn't have done anything more than your best".... So i'm keeping my fingers crossed. :-)

Healthcare in India: myth busted

The other day i read that India is one of the top destinations for medical tourists.for those not in the loop this refers to foreigners mostly from developed countries like US, Russia, Germany, Singapore, Korea, etc who do not qualify for healthcare insurance in their home countries who come to India for cheap medical care so that they can get similar or better care for less than one tenth of the price in their home country.When i read this article i couldn't help but wonder whether we should really be gloating over treating foreigners for cheap while millions die in our country due to dire need for basic healthcare.We in India apparently follow a socialistic policy in healthcare. Is it really so?
I recently read an article by Dr. Devi Shetty,a famous cardiothoracic surgeon and leading philanthropist in the field of healthcare.He said only 8% of the people needing cardiac surgery actually get operated and in a country like India we have a huge backlog.In his own words this is ridiculous even for a developing country like India.He has bought down costs of heart surgery to less than Rs. 1lakh and he’s desperately trying to get it to less than Rs. 40k.He’s doing a commendable job and needs every bit of adulation and support he can get.But really where is the Government in all this? its conspicuous by its absence!
I work as a resident in the premier Govt. Eye Institute in West Bengal which incidentally is the top govt  eye inst in the whole of eastern India. we have top of the line instruments, microscopes, lasers, machines, diagnostic aids and first class infrastructure.we undertake all kinds of surgeries done in any of the top institutes of the country.This should in effect should help the masses.But unfortunately not everything is free.True cataract surgery covered by the national program for control of blindness in India is free but nothing much else is totally free of cost for the patient.the patient still has to buy consumables for surgery such as silicone oil or perfluro-gas(Retinal Detachment surgery),silicone prosthesis,sutures and many other consumables.A typical RD surgery costs the patient around Rs. 12,000 in our institute(only consumables).In other diseases for proper diagnosis CT scans,MRI,histopathology,expensive blood reports,immunohistochemistry,etc. needs to be done for which the patient has to shell out from his/her own pocket.All this and not to mention other daily expenditures in eye drops,costly antibiotics,pain killers and sometimes hospital fees.Drugs supplied by the govt. form a woefully short list or for the most part ineffective probably due to adulteration and poor quality control.So many expenditures in a Govt Hospital which is a premier institute at that in a supposedly socialised medical healthcare.This much expenditure to a man/woman who probably earns less than Rs. 100 a day.does it sound right? can our conscience make peace with this fact? if this is the state in a premier institute what is the state of peripheral hospitals.I’m not blaming the people who run our hospital for all this.they are doing a great job to the masses with the limited resources at their disposal.the costs that are being borne by the patients is due to the helplessness of these doctors and due to their endeavour to provide world class care to patients with limited expenditure to the society. In this scenario doctors are stressed to provide healthcare and the public blames them for any incident that happens. This is the reason why doctors in govt sectors are getting frustrated with the system. its not them but our healthcare policy that is to blame.It is flawed left right and centre!
I’m speaking in the midst of one hospital and i’m talking of ground realities in one govt hospital as i’m a part of one.But this is the story of nearly every govt hospital in India.it is just that the categories of expenditure changes.Our society will be judged by how we treat the weakest(read poorest) among us.And our country falls terribly short of an ideal.
As i have mentioned previously in my blogs,Indian govt. spends less than 1percent of our GDP on healthcare.Even countries like Bangladesh and Sri Lanka spend 16 and 32 pc respectively.UK spends 7pc and yet provides Universal free healthcare to every citizen and immigrant.In India 80pc of the health care burden is borne by the pvt. sector.We are quick to downgrade the insurance based healthcare of the USA but in India we neither have an Insurance based healthcare of USA nor a Socialised Healthcare like UK,France,Sweden,Denmark,etc. the common retort by the govt is India is a poor country and we do not collect sufficient taxes to sponsor universal healthcare in India.But this is a poor argument because though only 3 pc of the population pays income tax,we all pay tax in every other way.sales tax,wealth tax,property tax,road tax,service tax,luxury tax,custom tax,education cess,advertisement tax,service tax,value added tax,….phew just to name a few!!!! Only birth tax and death tax is left to be enforced.where does all this money go? We have a horrendous education system,pitiable healthcare and a treacherous bureaucracy and yet we have any non-descript politician worth his salt(not necessarily elected) being ridden across the country in a fleet of 10 cars or helicopters or jets! govt officials,bureaucrats and govt aides lead a life of extreme luxury.our politicians and bureaucrats must be among the richest politicians and bureaucrats in the world(and we are a poor country mind you!!!)No other country in the world has more black money in Swiss Banks than India.So who do you think owns all that money? the above people and also some huge businessmen. So do I still hear somebody call India a poor country. We now know who are the beneficiaries of these many taxes.
Solutions are quite often very simple but simple things aren’t done without a political will in this country.The masses don't demand healthcare because they have nothing to eat so why will anybody talk about health? Healthcare needs to be removed as a state subject and be transferred to being a union subject.Doctors and healthcare professionals need to be paid more as professionalism demands money.you can’t attract the best talent in any industry with pitiful pay packets.same should hold true for healthcare.Govt budgetary allocation to healthcare should increase to 5pc of GDP for a start and should eventually increase to at least 8pc.another 10pc to our education system because to sustain a healthcare this massive we need an educated population.All these budgetary allocation should come from defence cuts.We don't need bombs and missiles.we need medicines and medical care.there needs to be a stringent quality control body for healthcare delivery and of course for the quality of drugs and consumables being supplied.In effect we need a complete overhaul of our healthcare and education policy.Do these sound difficult. hell yes!!! because attitudes need to be changed,awareness needs to be increased and most of all corruption should be minimised.All this is easier said than done but it still is simple stuff no?
I sometimes feel really bad when patients suffer because they either can’t afford treatments or we are restrained from giving them the best treatment due to the many impediments i have mentioned above.There is a certain joy in treating patients and you need to have empathy to understand their varied problems.Its a hell of a tough job but there is nothing else in this world which gives the same high as that got by alleviating suffering of people.It is for this incredible satisfaction that most doctors work even in trying conditions,amongst apathetic govts.,and high personal sacrifices(both monetary and social).So if we doctors can treat our patients without worrying about whether the patient can afford the treatment we can at least bring back nobility to our profession.its not only the rich who deserve to get sick and be cured.even the poor have every right to lead a healthy life.So the next time you fall sick and get treated think about the millions who are not as lucky as you and be grateful for the same.Also try in your own way to do something about it.sometimes a simple thing such as a change in attitude will do.

17th April,2011                                  Raghuraj Hegde