November 1997-March 1998 Sankara Nethralaya Number 17 & 18

CHANGE AND CONTINUITY

Dr. T.S. Surendran, Assistant Medical Director will soon become Medical Director, Medical Research Foundation, Dr. S. S. Badrinath who has been the Medical Director of the institution since its inception in 1978 will become the Chief Executive of the organization.

After 19 years of single minded service to the organization, Dr.S.S.Badrinath, Founder and Medical Director of Medical Research Foundation will be retiring from his present post on 24 February, 1998. Dr.T.S,Surendran, his successor, has been with the institution since 1979 and has served as Assistant Medical Director since 1990. He has qualified with a graduate degree in hospital administration from BITS, Pilani (in association with CMC, Vellore and Tulane University, USA).

Dr. S.S.Badrinath as Chief Executive will continue to be associated with all the activities of Sankara Nethralaya.

Free from the chores of the day to day running of the hospital, he will be more involved in teaching and research areas besides continuing to take a deep interest in patient care and planning the future direction of the institution. Dr.S.S.Badrinath will be handing over the post of Medical Director to make way for the younger Dr.T.S.Surendran, Being actively involved in the administration of the hospital for the past 7 years, Dr.Surendran will bring to his new post a wealth of experience in hospital management. Change amidst continuity will foster the further growth and development of the institution into the 21st century.

ISO 9002 for Sankara Nethralaya Finally we have it.

For implementation and management of quality systems with management of quality systems with respect to ophthalmic care and sevices, Sankara Nethralaya has been recommended for the prestigious ISO 9002 certification on December 19, 1997 by KPMG Quality Registrar USA, an accredited third party registrar of international repute. The Centre of Business Transformaton(CBT), the consultancy division of Aptech Ltd. Chennai was employed as our consultant for documenting and implementing the systems and procedure to meet ISO standards.

The ISO 9000 series standards define the formal system necessary to assure technical, administrative and human excellence according to internation standards. The comprehensive eye care services coming under the certification not only include administrative activities of the hospital but more importantly, professional ophthalmic practice, laboratory facilities, nursing, operation theatres, medical record keeping etc. all of which directly involve the patient. This cerftification formalizes our commitment to provide excellence in eye care.

Sankara Nethralaya will achieve a record of sorts by becoming the first eye hospital in Asia to have the ISO 9002 certification.

The One-Stop Shop

Patients visiting their ophthalmologists commonly have glasses prescribed and many of them would like to have their new spectacles made at the same place cutting short an additional visit to the optician’s shop. Keeping in mind this one-stop shop concept to providing total eye care , Sankara Nethralaya launched its optical dispensing service on August 15, 1997. The optical dispensing center is managed by GKB Rx Lens Pvt. Ltd. Which has over three decades of expertise in this field. The center is exclusively meant for patients of Sankara Nethralaya. The other purpose of starting this unit was to provide high quality lenses in both glass and plastic at affordable costs. Patients undergoing free surgeries at the hospital are also provided glasses free of cost. Mr. Jyoti Balaji of the Optical Services facility at Sankara Nethralaya is managing the shop.

NEWS BRIEFS

Meetings attended

The macula Meeting 1997 was conducted by Singapore National Eye Centre. Sankara Nethralaya took an active part in this meet, with Dr.S.S.Badrinath, Dr.lingam Gopal and Dr.Tarun Sharma forming part of the distinguished foreign faculty.

Dr. Jyotirmay Biswas was invited to deliver a keynote lecture on “Aetiopathogenesis of Eales’ disease – Research at Sankara Nethralaya” at the Fourth International Symposium of Uveitis (ISU) held in Japan in October 1997. Dr.Biswas is the only Indian to have been nominated as a member of the prestigious International Uveitis Study Group comprising 40 experts from all over the world

Dr.T.S.Surendran, Dr.Mahesh Shanmugam, Dr.G.Sitalakshmi and Dr.B.Shantha attended the 1997 American Academy of Ophthalmology Meeting in San Francisco and presented papers and Posters.

Community Service

Sankara Nethralaya introduced a new dimension to the community service programme by offering free treatment to all freedom fighters. This formed part of the 50 resolutions taken by the institution on the occasion the Golden Jubilee of Indian Independence.

Pammal Annexe Update

Sankara Nethralaya’s new extension at Pammal in the outskirts of the city has performed more than 2500 cataract surgery free of cost to the deserving poor since its inception in June 1997.

Pammal Annexe, as it is referred to, has 60 beds, and 2 Operation Theatres. 60% of the beds of this hospital are reserved for poor patients who are provided with completely free services. The remaining beds have been earmarked for paying patients who will be charged at concessional rates only.

Take moment to Read

Medical Research Foundation, Sankara Nethralaya has completed 19 years of service to the ophthalmic patients of our country.

We are in the process of expansion. We are planning to construct a Community Hospital at St.Thomas Mount, Chennai at cost of Rs.23 crores. We need funds and we request you to extend your helping hands and contribute generously, Donations to the above project are 100% exempted under 35AC of the Income Tax Act 1961.

Mission for Vision – Support our cause (for question and contributions)

In India please contact:

Dr.S.S.Badrinath, Medical Director, Sankara Nethralaya (Unit of Medical Research Foundation) 18, College Road, Chennai – 600 006. Tamil Nadu, INDIA Tel : (91-044) 826 1260, 8261265, 827 1036, 827 1616, 8279435 Fax: (91-044) 825 4180 Email : [email protected] Web Site: http://www.dynacs.com/-sankaranethralaya/

In USA please contact:

Mr.S.V. Acharya, Secretary and Treasurer, Ophthalmic Misson Trust inc. (OM Trust) 14613, Pommel Drive, Rockville, MD 20850, USA Tel: (301) 251 0378 Fax: (202) 293 0448

Available Back issues of certain volumes of Insight Journal. Insight is the scientific journal of Medical Research Foundation and carries articles on Ophthalmology and related Basic Sciences. Those interested in these back issues may kindly contact The Editor, Insight, Sankara Nethralaya.

Dr. H.N.Madhavan Honoured

Dr.H.N.Madhavan, Director – Research (Basic Sciences) and Vice-President, Vision Research Foundation has been elected as a Fellow of the National Academy of Medical Science(India).This award is an honour bestowed on him as an acknowledgement of his achievements in medical education and research in field of Microbiology.

Dr. Madhavan played a major role in the development of Department of Microbiology particularly virology at Jawaharlal Institute for Post Graduate Medical Education and Research (JIPMER), Pondicherry.

He is known intemationally for his research work in microbiology and has several research publications to his credit. Among the earlist contributors in the investigation of enterovirus infections of the central nervous system in India, his report on the outbreak of Coxsackie virus B6 infection being the first in the literature. He was awarded a Phd. By the University of Madras for his thesis on the role of viruses in myocarditis with particular reference to cell- mediated immunity in experimental Coxsackie virus B3 myocarditis.

As Director of Research at Sankara Nethralaya, he has organized excellent research facilities and continues his research work in ophthalmic infections and immunological diseases. He demonstrated the presence of high incidence of chlamydial ocular infections in patients attending Sankara Nethralaya, the first such report in our country. He discovered the existence of Mitomycin (MMC) “sensitive “ and “resistant” strains of Tenon’s capsule fibroblasts in human eye and showed their role in the outcome of the use of MMC in trabeculectomy in glaucoma. His work on virological investigations in retinal inflammation was the first of its kind in our country. He has pioneered rapid diagnostic methods in chlamydial and viral diseases of eye. Under his guidance the Microbiology Research Centre at Vision Research Foundation has developed the polymerase chain reaction, a new molecular biological method, as a tool in detection of several infective agents from clinical specimens.

On the occasion of 50 th Anniversary of India’s Independence, Life insurance Corporation donated Rs.13 lakhs to Sankara Nethralaya on 3rd July ’97. They also adopted 13 beds in the general ward. The Chief Invitees were Mr. P. Chidambaram Hon’ble Union Finance Minister, Shri G. Krishnamurthy, Chairman, L.I.C., Shri R.N. Tripathi, Managing Director, Shri B.R. Gupta, Executive Director (Investment). Shri P.V. Subramanian, Zonal Manager, South Zone, Shri H.Faruqi, Chief (PR & Publicity) and Shri R. Subramaniam, Chartered Accountant.

Ocular Tumour Meet

Medical and Vision Research Foundation organized a symposium on What’s New in Ocular Tumours on 7th & 8th February 1998. For the first time the important subspecialty of ocular tumours was dealt with in a separate symposium. For the first time ophthalmologists as well as experts from other disciplines like pathologists, oncologists, radiologists and radiotherapists delivered lectures and took part in interactive discussions of challenging cases. The internationally renowned foreign faculty included Prof. Narsing A. Rao and Prof. Ronald L.Green From Doheny Eye Institute, LA, California, Prof. Edward Howes from University of California, San Francisco and Prof. Jacob Pe’er from Hadassah University, Jerusalem, Israel. Reputed national faculty from various parts of the country also participated. The symposium was attended by 182 ophthalmologists from India, Sri Lanka, Bangladesh, Bhutan and Australia. For the first time, delegates received important duplicated slides of the various presentations made in the conference in addition to a detailed 170 page course book.

LASIK comes to Sankara Nethralaya

EXCIMER PRK & LASIK

NORMAL EYE MYOPIC EYE

Light rays focus(F) on the Light rays come to focus(F) retina in the back of the eye. in the front of the retina. . HYPEROPIC EYE ASTIGMATIC EYE

Light rays come to focus (F) Light rays do not reach behind the retina. a common focus(F1 and F2 ).

The cornea is clear glass-like structure in the front of the eye. The precisely removes corneal tissue alterning the corneal contour. Now light rays can focus on the retina. This procedure is called PPK (Photorefractive Keratectomv)

MYOPIC PRK HYPEROPIC PRK ASTIGMATIC PARK

Central corneal tissue removed (Shown in dark blue). To correct tissue is removed in a circular fashion Astigmatism is corrected by removing tissue in an elliptical manner. Hyperopia is corrected by removing a ring of tissue in the mid-periphery of the cornea.

PRK’s predictability is reduced with very high refractive errors. Moreover, increasing removal of corneal tissue required to correct high refractive errors produces haziness of the central cornea with poorer results. Corneal haze

LASIK

The keratome creates a flap of The flap of corneal tissue is lifted superficial corneal tissue. exposing the deeper stroma.

The storma is then exposed to After the laser delivery is completed the excimer laser beam. the corneal flap is repositioned without stitches.

In December 1993, Sankara Nethralaya became the first hospital in India to introduce excimer laser PRK treatment for the correction of refractive errors. LASIK, its new refinement was also recently introduced. With these two procedures. Sankara Nethralaya now offers state-of the – art – treatment for a permanent cure for myopia, hyperopia and astigmatism. Freedom from glasses at last.

Eyelights reviews these two revolutionary treatment and also interviews the man who co- discovered excimer laser PRK – Dr. Rangaswamy Srinivasan.

Refractive Errors

Normally, rays of light entering the eye are brought to a precise focuse on the retina – the light sensitive layer lining the back of the eye. When such a focus is not achieved, a refractive error results and vision in not clear.

When light rays are focused in front of the retina, the resulting condition is termed myopia (short – sightedness). In hyperopia (long – sightedness) , the light rays come to a focus behind the retina. Astigmatism (cylindrical error) occurs when incoming light rays are unable to reach a common focus within the eye.

How are Refractive Errors Corrected?

Non-surgical opitions for the correction of refractive errors include Spectacles and Contact Lenses. Spectacles contain lenses that suitably alter the incoming rays of light and enable them to focus on the retina. Contact lenses perform the same function but are placed on the cornea – the clear front portion of the eye. Hence, they provide better cosmesis and improved quality of vision in the higher refractive errors.

Surgical procedures attempt to eliminate the dependence on external aids like glasses and contact lenses. In Radial Keratotomy, 4 to 8 corneal incisions are made in the peripheral cornea involving 90 to 95% of the corneal thickness. The weakened peripheral cornea is pushed outwards by the pressure within the eye. This results in a flattening of the central cornea which corrects a myopic refractive error.

Similar operations like Hexagonal Keratotomy and Astigmatic Keratotomy can correct Hyperopia and Astigmatism respectively. However all these incisional procedures weaken the structural integrity of the cornea. This theoretically result in an increased tendency for corneal rupture following trauma.

Removal of cornea tissue alters the corneal contour. By specifically removing tissue from different portions of the cornea the surgeon is able to correct the different refractive errors. Removal of central corneal tissue in a circular fashion results in the central flattening and corrects myopia.

When central corneal tissue is removed in an elliptical fashion, astigmatic refractive errors can be corrected.

To Correct hyperopia, a ring of corneal tissue is selectively removed from the mid-periphery resulting in central corneal steepening.

Excimer photorefractive keratectomy (PRK) has been in use all over the world since 1987 and has proven to be safe and effective, particularly in the treatment of myopia and astigmatism. However, when very high refractive errors are treated by excimer PRK, the predictability of the procedure is reduced with increased occurrence of undersirable side-effects.

A recent advance in the treatment of such high refractive errors is a procedure termed Laser In-situ Keratomileusis (LASIK). In this surgery, a flap of superficial corneal tissue is cut using a motorized blade.

The flap is lifted exposing the underlying corneal stroma. The excimer laser is then used to perform the appropriate tissue removal in the corneal bed. At the conclusion of laser delivery, the corneal flap is repositioned in its original position. The flap adheres to the underlying corneal stroma without the need for sutures.

Since the corneal epithelium is retained and corneal healing occurs within the corneal layers, the safety and predictability of the procedure is improved, in eyes with high refractive errors.

Both PRK and LASIK are performed as out-patient procedures using topical anaesthetic drops only.

Exquisite Precision

he use of the EXCIMER LASER in corneal has greatly increased the safety of the procedure as the refractive correction is achieved by the removal of as little Tas 10 to 20 % of the total corneal thickness.

The word “excimer” is contraction of “excited” and “dimmer”. Dimer refers to the combination of atoms of argon and florine gases, to form an unstable molecule. When this unstable molecule breaks down, it emits photons of ultraviolet light which are used in the laser.

The excimer laser is a “cool” laser, and does not generate heat in the cornea. The laser energy destroys intermoleculas bonds in the corneal tissue resulting in tissue removal by a process termed “photoablative decomposition”. The exquisite precision with which tissue can be removed and the absence of thermal damage render this laser particularly suitable for surgery on the delicate cornea.

Who is a suitable candidate for Corneal Refractive Surgery?

You must be at least 18 years of age, with stables refraction for the past 6 months. You should not have any serious eye diseases eg., rtheumatoid arthritis

If you fulfil the above criteria and are interested in undergoing refractive surgery, please contact the following department and demand expeditious service.

EXCIMER LASIK CELL – SANKARA NETHRALAYA 18 College Road, Chennai – 600 006 Phone : 8271036, 8271616 Fax: 91-044-825-4180 E-mail : [email protected] With Clarity of Vision – Dr. Rangaswamy Srinivasan

SankaraNethralaya was honoured with the presence of Dr. Rangaswamy Srinivasan, the man who co-discovered excomer laser corneal refractive surgery which has allowed thousand of people around the world to see clearly without glasses or contact lenses. Eyelights spoke to this remarkable Indian about his landmark discovery.

This is his fascinating story.

here are two breedsof scientists, generally speaking. One can’t help but notice the first species. The media happy and savy types who easily impress us with thir commanding Tp resence and just that hint of scholarly air. The other kind of genius is publicity shy and awkward in general company. These backroom boy are happiest holed up in their labs comfortable in the company of impersonal microscopes and the test tubes.

So, which one of these would Dr.Srinivasan be, I wondered as I went to interview him. As it turned out,neither. Or a bit of both maybe?

Appearances are deceptive and this could not be more true than in the case of Dr. Srinivasan. He could very easily have been R.K.Laxman’s Common Man. Dr. Srinivasan was modest and matter of fact when talking about his work. His answers were not only laced with humour but revealed a clear ordered mind, the hallmark of a man of science.

This was the Man who discovered the photoablative effect of ultraviolet light. The man whom millions of people in over fifty countries around the world had to thank for helping them get rid of their spectacles forever. Freedom at last from short sightedness. This was Dr.Rangaswamy Srinivasan, the father of excimer laser PRK (photorefractive keratectomy).

Dr.Srinivasan started his academic life in Madras in the Sri Pennathur Subramaniam High School and later Loyola College where he graduated with B.Sc Honours degree from the University of Madras in Chemistry in 1949. Leaving for western shores he arrived in USA and set about earning a Ph.D degree in protein chemistry at the University of Southern California. He then specialized in organic photochemistry at , New York. Aftr a short stint at the institute now known to us as the Bhaba Atomic Research Centre, Dr.Srinivasan returned to USA to join the IBM Thomas J Watson Research Centre for Physical Sciences in Yorktown Heights, New York, where he worked till his retirement, in 1990. This research institute was well known not only for its favourable scientific environment but also for producing five Nobel laureates.

Because of his interest in photochemistry Dr.Srinivasan was working on ultraviolet light and its photochemical effects. Ultraviolet light had the power to after organic compounds by a process called photodecomposition. This well know effect was utilized by the computer industry for creating for silicon chips by a technique called photolithography.

SRINIVASAN’S LAW “People discover only what they are looking for”

“You don’t lie awake at night waiting for the Nobel Prize. You might lose a lot of sleep”

Among the many sources of ultraviolet light used in experiments at IBM was the excimer laser. A veritable ugly duckling of its time, the first excimer was a big monster of a machine made in Germany. “It was acquired by one of my colleagues who discovered later that he did not know what to do with it,” recalls Dr.Srinivasan, “so he gladly handed it over to me.” While working on higher wavelengths of ultraviolet light such as that produced by the excimer laser, Dr.Srinvasan found to his astonishment that not only was there a photodecomposition effect but a photoablative effect as well. The material exposed to the ultraviolet light emitted by the excimer laser was slowly being vaporized, vanishing into thin air, all this occurring at a microscopic level. Magnified hundreds of times the photoablative effect of the excimer laser looked not unlike an atomic explosion complete with a mushroom cloud, in miniature of course. “I first tried the excimer laser on biological tissue on Thanksgiving Day and the most handy biological tissue available on that day was the Thanksgiving turkey, a dish I was not particularly fond of. “Dr.Srinivasan later tried the excimer laser on other tissues – a dragonfly’s wing and even his own hair. The effect was visually electrifying. The laser could make precise cuts on a single hair without damaging adjacent cells. The precision was at the level of microns. He spoke about his findings to his fellow scientists at IBM. Initially skeptical, their doubts were laid to rest after further studies proved Dr.Srinivasan right. “My loss of hair is partly due to the number of times I have had to repeat my experiment, “ admitted Dr.Srinivasan, a trifle ruefully.

In 1983, IBM published Dr.Srinivasan’s discovery in its periodical news release. The Story was picked up by the media and received much attention around the world. The natural question now was how this effect could be put to practical use.

“All surgical advances in instrumentation have to do with two procedures, namely cauterizing tissue or cutting tissue, concepts that were put forward by Sushruta many centuries ago. Laser is the newest cutting instrument discovered. Several trials to explore the use of excimer laser on human tissue were initiated including attempts to remove atherosclerosis plaques on the arterial wall in human cadavers. But none of these really worked. Then, through a mutual friend at the Columbia Presbyerian Medical center, I got in touch with Dr. Stephen Trokel the ophthalmologist.” After several trials Drs. Trokel and Srinivasan were able to show the world the effect of excimer laser on human corneas and later its applications in correcting refractive error such as myopia by remodeling the corneal surface.

Until then, the treatment of myopia has been the well established glasses and contact lenses. Glasses were cosmetically unacceptable and contact lenses were difficult to wear and a nuisance to maintain. Many centers around the world were offering a surgical alternative called radial keratotomy or RK, first popularised by the Russian ophthalmologist Dr.Fyodorov. Although by and large successful. RK was still a surgery and had its attendant occasional untoward results and complications. With its virtually non- surgical, safe and accurate method of correcting refractive error, excimer laser PRK quickly became the talk of the world’s ophthalmic community. With intense public interest in this new treatment. PRK spawned an industry that is now worth billions of dollars worldwide. “There are about 2200 excimer machines around the world today with about 600 in USA alone,” said Dr.Srinivasan. The first modern excimer laser machine for performing PRK was introduced in India by Sankara Nethralaya in late 1993.

“Unfortunately excimer laser machines are outrageously priced,” deplored Dr.Srinivasan who found this commercialism upsetting. “Chaeaper models can be made in India as the country is technologically capable with no dearth of “super-smart” people. The parent held by Dr. Trokel is valid in USA only”.

Ophthalmologists today continue to search for perfection with their sights set on a world free of refractive errors. Excimer laser PRK and its refinement LASIK (Laser Assisted In Situ Keratomileusis) comprise the state-of the-art treatment for the correction of myopia and other refractive errors., ushering in new vistas in the fast developing speciality of refractive corneal surgery. With LASIK, recently introduced in Sankara Nethralaya, higher degree of myopia, hyperopia and even astigmatism can be corrected with a great degree of accuracy.

In 1998, Dr. Rangaswamy Srinivasan was chosen by the American Physical Society for one of its highest honour in the field of biological physics “ for the development of an understanding of the effect of intense ultraviolet light on biological materials leading to an abilityto “Photoetch” tissue surfaces precisely and safely, and for his role in developing applications to medicine in angioplasty, ophthalmology and dermatology”.

Dr. Srinivasan’s discovery of 1983 now belongs to the world. But the man who virtually invented excimer laser surgery does not rest on his laurels. Dr.Srinivasan has moved on to newer interests in the field of genetics. By virtue of its precision cutting abilities, the excimer laser has found novel applications, in cellular surgery, in vitro fertilization, DNA fragmentation, genetic engineering and even cloning.

Notwithstanding his new found love in genetics, does Dr.Srinivasan still continue to keep track of his initial interest – PRK?

“Of course, “ he said without hesitation, “it ‘s my baby.”

Well said, Dr. Srinivasan. You could not have put it better. IN MEMORIAM

Both Sri Sadasivam and Smt. Lakshmi Ramanathan have been inextricably woven into the very fabric of Sankara Nethralaya Like many others., we have been the beneficiaries of their philosophy in life which has been, “We grow rich by what we give.” Reproduced below are excerpts from Dr.Prema Padmanabhan speech at a condolence meeting in memory of Sri Sadasivam. Also reproduced in the original Tamil Version is the heartfelt grief expressed by the poor residents of the locality where Smt. Lakshmi Ramanathan resided. Dr.S.S.Badrinath, Dr.(Mrs) Vasanthi Badrinath along with Sri. V. Vaidyanathan attended the condolence meeting on behalf of Sankara Nethralaya. Our feeling are well expressed in the following condolence messages.

It is said by physicist and philosopher alike that man is no more than a speck of stardust. And yet, What was so special about this particular stardust, whose demise left each of us feeling a sense of personal loss? I have thought of Sadasivam Mama as a gigantic tree deeply rooted in his convictions, its branches outstretched in benediction to humanity giving shade and shelter, support and strength to every passer by. In its branches sits a nightingale whose music fills the air, enters every heart and uplifts every soul.

SRI T. Sadasivam

What struck me and filled me with awe admiration was the diginity of his simplicity. Simplicity for some, is a mask that is pretentiously worn and for others is a laboured effort. But simplicity for Sadasivam Mama and Subbulakshmi Amma come as naturally as it does for the sun to shine or the stars to twinkle. What can I say to the grieving family except to repeat what Mama himself told me, not too long ago, when I suffered a bereavement.

And yet in a sense there is no death. Some people live longer then they live. Be a life short of long, its completeness depends on what it has been lived for And we all know that for Sadasivam Mama, life began as a voyage as it does for all of us. It was soon to become a battle as it does for some of us, but finally turned into a pilgrimage which it does for a chosen few. For a pilgrim, death becomes a birth into a higher dimension. Such people can never die. In fact, for him, age was only biological. Ever since he crossed ninety, he had this charming habit of reversing the digits of his age, whenever he was asked how old he was. His ready wit, his toothless grin, his boyish chuckle, his disarming ways… how can they ever vanish. For him the words of this unknown poet seem very apt.

“ I will not say, I cannot say That he is dead. He is just away. With a cheery smile and a wave of his hand, He has wandered into an unknown land.” We rejoice that we have known such a person, even as we grieve that we have lost him.

Smt. Lakshmi Ramanathan

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ANNUAL DAY 1997

On September 6th 1997, Sankara Nethralaya celebrated its 19th anniversary, Every year, the hospital has observed this day in a different way. Open-house, public exhibitions about common eye ailments have been held in the past. On another occasion, the hospital organized a guided tour of Sankara Nethralaya, from the operation theatres to the research laboratories for nearly 200 school students. Annual Day 1997 was observed with an International Vitreo-Retinal Surgery Symposium, the Venugopal Memorial Oration and the Sankara Nethralaya Alumni Meeting.

* * *

The Annual Alumni meeting was held on 7th September at Chennai thanks to the unflagging enthusiasm of Dr.S.Natarajan of the Aditya Jyot Hospital,Mumbai. Guest lectures were delivered by Drs. S.S.Badrinath, K. Anandakannan, L.Vijaya and Navin Jayakumar. Nearly 20 free papers were presented by former post-graduate students and fellows of Sankara Nethralaya. The best free paper prize was won by Dr.Cyrus Shroff (New Delhi).

Global Meet on Vitreo-Retinal Surgery A Global Meet on Vitreo-Retinal Surgery held on September 5th , 6th and 7th 1997. The impressive faculty drew a large number of delegates from all over India including a few from nighbouring countries. Many of the delegates were alumni of the institution, former fellows in vitreo-retinal surgery for whom the meeting also provided an occasion for glad reunions and fond reminiscences.

The inter-natonal faculty were: Drs. Carl Claes (Belgium), Carlos Mateo (Spain), Charith Fonseka (Sri Lanka), Fumitaka Ando (Japan), O.K. Malla (Nepal), Ronald Yeoh (Singapore) and Thanassis Nikolakopoulos (Greece). Besides the host faculty, the national faculty were: Drs. Atul Kumar (New Delhi), Babu Rajendran (Chennai), M.R. Dogra (Chandigarh), Hemanth Murthy (Bangalore), T.P. Ittyerah (Angamally), N.S, Muralidhar (Bangalore), P.Namperumalsamy (Madurai), Taraprasad Das (Hyderbad) and H.K.Tiwari (New Delhi). As in the past, Dr.Tarun Sharma of the vitreo-retinal department donned the role of program co- ordinator with finesse and efficiency which was clearly apparent in the smooth conduct and immense success of the conference.

Sri V.Venugopal Memorial Endowment Lecture

The fourth Sri V.Venugopal Memorial Endowment Lecture was held on September 6th, 1997. Since their inception these lectures organized by Sankara Nethralaya have attempted to present advances in ophthalmology and related sciences in a manner that can be appreciated by the society at large – their aim being to inform, to provoke thought and to inspire us all.

Sri V. Vengopal, in whose name the orations were delivered was highly respected business leader and philanthropist of yesteryear. His vision of setting up an exclusive ophthalmic hospital to extend expert preventive and curative to both haves and have-nots, were transformed into reality by his son Sri V.Mohan Rao (President, Medical Research Foundaion) by extending continuous financial support to Sankara Nethralaya.

This year the theme of the oration was “What does the society expect of medical men?” The topic, as expected, generated much thought and emotion interspersed with wit and was brought to life by the three invited speakers: Mr.R.Poornalingam I.A.S. (Home Secy., Government of Tamil Nadu). Ms. C.Sivasankari (Writer and Activist) and Dr. K.P. Misra (Cardiologist). Light at the End of the Tunnel

At 5.00 pm local time on 28th August 1997, Dr. H.N.Madhavan, Director of Basic Science Research at Vision Research Foundation received an overseas call from New Zealand. The caller was Dr.Michael J Denton from the University of Otago, New Zealand with whom Sankara Nethralaya had been collaborating on research in genetic disorders affecting the eye.

A tumultuous Dr.Denton had phoned to convey news of the discovery of a new gene causing retinitis pigmentosa (RP), a blinding genetic eye disease.

This discovery would have far reaching implications in the management of the condition and hinted at a possibility of saving vision in these unfortunate patients.

What is Retinitis pigmentosa? Eyelights brings you information on this dreaded disease. We also interview our genetic scientist Dr.G.Kumaramanickavel about the significance of the new finding.

“I had trouble walking on the street. I’d run into people because I couldn’t see them.”

“I had a lot of difficulty in darkened rooms and restaurants. I would bump into tables and waitresses.”

“I found myself constantly apologizing. In the final stages I didn’t know from one day to the next how much vision I’d have.”

These are the experience of a patient who had retinitis pigmentosa. He lost his vision completely by the age of thirty. The last thing he saw was the face of his new born child.

This photograph of the inside of the eye shows a retina affected with back clumps of pigments in the mid periphery giving the disease retinitis pigmentosa its name.

What is RP?

What is this dreaded condition called retinitis pigmntosa that causes a slow but progressive loss of vision/ Often hereditary, retinitis pigmentosa begins with night blindness (difficulty in seeing in the dark) and gradual loss of side vision. As the disease progresses, the field of vision gets more and more restricted resulting in “tunnel vision”.

Why does RP occur?

RP as the condition is commonly called, affects the rod photoreceptors and the retina. The retina is the light sensitive multi-layered film inside the eye. The rod photoreceptors are light sensitive cells that are important for night vision and peripheral, or side vision.

Just beneath the retina is a lining of cells called the retinal pigment epithelium (RPE, for short) The RPE nourishes the rods and provides them with Vitamin A mobilized from the circulating blood.

Vitamin A is combined with a protein called opsin to form a molecule called rhodopsin inside the rods. Rhodopsin is a visual pigment that undergoes a chemical change when light falls on the rod. This chemical change sets off an electrical impulse that travels along the nerves to the brain enabling us to “see”. Vitamin a, therefore, is absolutely essential for the normal functioning of the photoreceptors.

In RP, the rods and the RPE fail to perform normally as a result of a degenerative process. As a result the patient experiences night blindness and loss of side vision in the early stages. Gradually the entire retina begins to shut down.

How is RP managed? Visual field chart with the normal field outlined in blue. The field of the affected person is constricted to a small central island (yellow). The black area represents the blindbess in the perpheral vision.

For people with RP there is little that ophthalmologists can do at present. Lost sight can seldom be restored.

Practically, specially glasses and optical devices collectively called Low Vision Aids can artificially improve vision by magnifying images or expanding the available field of vision.

Various forms of treatment, including a yeast preparation called Encad, electrostimulation and even surgery to improve blood circulation to the retina have been attempted without proven success. A recent study has shown that supplemented Vitamin A could slow the progress of disease of a common form of RP. The treatment however requires the supervision of an ophthalmologist.

How does RP runs in families?

RP most often runs in families and is inherited in different ways.

Every human cell has 23 pairs of chromosomes (46 in all) that define an individal completely. For each of the 23 pairs, one chromosome comes from the mother. Each chromosome contains thousands of genes which are small bits of genetic information in the form of a complex molecule called DNA, Defects in genes cause the disease.

In some forms of RP, a defective gene in just one of the chromosomes in a pair is enough to make the disease apparent even though the fellow chromosome is normal. This is called the autosomal dominant pattern of inheritance.

In other instances, the defect must be present in both the chromosomes for the disease to manifest. This is called autosomal recessive pattern of inheritance.

A person who has one defective gene in a pair, with the other being normal, will not have the disease, but is described as a carrier of the disease because he or she is capable or transmitting the defective gene to their offspring.

Some genetic disorders are transmitted only through defects on the 23rd pair of chromosomes, X and Y, that determine the sex of the individual). This pattern of inheritance is therefore called x linked inheritance. In X linked inheritance, only the males are affected while the females are carriers of the disease.

RP can be inherited by any of the above forms of inheritance. Intermarrying within families cause defective gens more chances to cause the disease.

In a majority of cases however, the defect in the gene occurs as a sporadic or isolated instance without other family members being involved.

RETINITIS PIGMENTOSA Scientific Research from Sankara Nethralaya Chand A, Kumaramanickavel G, Abraham M, Gahlot DK, Apte BN, Denton MJ (1991): Indian recessive pedigrees with recessive retinitis pigmentosa: A potential for homozygosity mapping in Degenerative retinopathies: Advances in Clinical and Genetic Research (Eds. Humphries P, Bhattacharya S and Bird A). CRC Press, Florida, pp 35-40.

Kumaramanickavel G, Maw MA, Denton MJ, John S, Srikumari CRS, Orth U, Ralph O, Gal A: Missense rhodopsin mutation in a family with recessive RP. Nature Genetics 8: 10-11, 1994.

Kar B, John S, Kumaramanickavel G: Retinitis pigmentosa in India: A genetic and segregation analysis. Clinical Genetics 47: 75-79 1995.

Gu S., Thopson DA, Srikumari CRS, Lorenz B, Nicoletti A, Murthy KR, Rathmann M, Kumaramanickavel G, Denton MJ, Gal A: Mutations in the RPE 65 gene, encoding a retinal pigment epithelium specific protein, in autosomal recessive childhood-onset severe retinal dystrophy. Nature Genet 29: 194, 1997.

Interview with a Geneticist The Sankara Nethralaya Retinitis Pigmentosa Project got seriously under way in 1992 with collaboration between Dr. Denton, from the University of Otago, Dunedin, New Zealand.

The first breakthrough came in 1994 with the discovery of a mutation of a rhodospin gene in autosomal recessive retinitis pigmentosa. After three years of continuous work on the project, the present important discovery of a new genetic defect causing the disease was announced in the prestigious scientific journal Nature Genetics in October 1997.

Eyelights interviews Dr. G.Kumaramanickavel, genetic scientist at the Genetics and Molecular Biology Laboratory, Vision Research Foundation on the significance of the recent discovery.

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From left ; Dr. G.Kumaramanickavel, Dr. S.S.Badrinath, Mr. V.Mohan Rao, Dr. Michael J. Denton and Dr.H.N.Madhavan

What is the nature of collaboration between Sankara Nethralaya and the University of Otago in New Zealand?

Genetic diseases are prevalent in families in which consanguineous marriage are an accepted social custom, Retinitis pigmentosa is one such disease.

When a patient with retinitis pigmentosa comes to Sankara Nethralaya for an eye examination, he is extensively investigated to find the extent and nature of the condition. He is then referred to our genetic clinic where we try to find out what type of inheritance the disease has in the his family.

We collect blood samples from the patient and all available affected and unaffected members of the patient’s family. The DNA in each of the blood samples was studied here and by DR. Denton in New Zealand. We received permission of the Indian Council of Medical Research to send blood samples for genetic analysis to New Zealand for our studies.

What is present discovery? By using DNA probes the blood samples were studies for genetic mutations by processes called linkage analysis and mutational screening, we proved the existence of an altered genetic sequence in Chromosome 1 in all affected patients with retinitis pigmentosa and the fact that this alteration is not present in all unaffected members of the patient’s family.

This mutation in the short arm of chromosome 1 that causes a defect in a protein called RPE 65 found in the retinal pigment epithelium (RPE). The RPE is responsible for the nourishment of the rod photo-receptors that are the image sensors necessary to initiate the complex process by which we see. The RPE also processes the Vitamin A circulating in the blood and transmits the vitamin to the rods.

How significant is this discovery?

Till date about 20 genetic mutations have been documented in retinitis pigmentosa, all involving the neurosensory retina (the part that is actually concerned with sensing images of the outside world and sending them to the brain so that we can ‘see”). Unfortunately the neuro-sensory retina cannot be replaced if damaged or defective. The present finding is the occurrence of a genetic mutation in the RPE which lies just beneath the neurosensory retina.

Transplantation of RPE is likely to be a very real possibility in the near future once the techniques to perform this procedure are refined. The RPE is responsible for delivering Vitamin A to the rods and this function may be impaired in patients with retinitis pigmentosa caused by the chromosome 1 mutation. Vitamin A therapy, by supplementing dietary Vitamin A, may overcome the impairment in the RPE thus offring some hope for the particular subset of retinitis pigmentosa patients who have the disease caused by this genetic mutation.

This issue of Eyelights is sponsored by : M/s. Rampion Eyetech Pvt.Ltd., Kalash, New Sharda Mandir Road, Paldi, Ahmedabad – 380 007 M/s. Apex Laboratories Pvt. Ltd., 44 Gandhi Mandapam Road, Kotturpuram, Chennai – 600 085 Edited & designed by Dr.Navin Jayakumar. Typeset by S.Ramakrishnan. Printed at Gnanodaya Press, Chennai – 600034 For Private Circulation only