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
providing quality eye care services to all the
population including the underprivileged ones
is a far-off dream that we saw. Although there
are quite a few world class centres in India
providing best of the facilities, there is major
lacuna in demand supply relationship. Moreover, majority of
the population in India belongs to rural and suburban areas,
in which places providing latest facilities is far from reality.
There is a lack of well-trained surgeons, infrastructure building
and maintenance and awareness to reach out to the available
facilities
India, the second most populous and the seventh largest
country in the world; a country where every year 3.8 million
people turn blind as a consequence of cataract; a country with
ratio of 1 Ophthalmologist for ~90000 population, a country
where 65% of surgeries are performed in private sector with
50% of Ophthalmologists being surgically inactive; a country
which houses 15-18.6 million blind people. The unmet need of
acceptably trained surgeons in the country is no clandestine.
Above scenario depicts the plight of the rural and the
underprivileged population in India in need of quality eye care
services. Majority of this population is unable to reach out to
the available facilities and if so, often there is much delay in
seeking the health care. The result is, many of the patients fall
prey to diseases, that could otherwise have been cured. Many
eyes lost, skilled manpower lost, it creates a social as well as
economical burden to the society.
Rationale: About 22% of India’s population belongs to the
category of below poverty line. The right to high quality eye
care for this under-privileged population can be served only
by providing them with a self-sufficient tertiary eye care centre
in government sector. There are only few such centres in India
proving comprehensive eye care facility to its underprivileged
population.
The availability of a tertiary eye-care centre in tier two
city of India is the need of the hour. Our aim was to build a
self-sufficient tertiary eye care centre in a government set up
that could provide basic as well as quality eye care services to
the population. In an institute that is in its developing phase,
we have tried to build a centre that could provide facilities in
multiple sub-specialities like Cataract and Refractive, Squint,
36 DOS Times - March-April 2019 Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre
Glaucoma, Medical Retina, Paediatric Ophthalmology and some
of the extra ocular procedures. From scratch to the current
scenario, too far away from reaching our goals this journey has
been a great learning experience.
Development of a tertiary eye care centre is no cinch.
Following are some of the practices that we incorporated in our
institution:
1. Acquiring trust of the patients: It requires a great deal
of perseverance to build an eye care system which is trusted by
the patients. This trust can be achieved only through personal
interaction with the patients. Many a times it is forgotten that
what we are treating is a patient not a disease. Small amount
of empathy is what is required sometimes in building trust. A
system which is trusted by the patients can create wonders.
2. Triage of patients: Whilst many a times, in a busy
OPD patients requiring special attention are overlooked, it
is important to ensure triage. The patients with chronic or
severe illnesses that require more patient compliance for the
management of their illnesses eg patients of glaucoma need
more attention, more counselling and more amount of patient
care. We have developed a three tier system of counselling
wherein the patients are being counselled by the optometrist,
the resident doctors and treating consultant. This helps in
picking up patients requiring proper attention and then
providing them with adequate information.
3. Audio-visual aids: We have incorporated audio-visual
system as an integral part of our counselling. This provides
patient with better insight to the disease process as well as
the management of the same. The audio-visual aids are being
used for individual counselling of the patients as well as a
public awareness tools. Information regarding common ocular
problems is being displayed on daily basis on television screens
in front of OPD.
4. Initiation of Post graduate course: Post graduate
students form an integral part of the work force of the
Department. Initiation of Post graduate courses add to the
integral manpower of the department. Once trained they form
the skill full workforce of the Department. Initiation of these
courses adds to the quality care to the patients.
5. Employment of sub-speciality trained Senior
Residents: Employment of sub-speciality trained senior
residents can if not substitute but aid to the quality of eye care

services that would have been otherwise
possible only in a well Developed eye
centre with Sub -speciality Units.
6. Running of multiple sub-
specialities with a small work force:
A comprehensive Ophthalmologist can
provide care to multitude of patients
which is of utmost importance for a
developing centre by organizing weekly
Speciality Clinics.
7. Short term Fellowships for the
Consultants: Anterior segment surgeons
can be trained in multiple sub – speciality
by opting for short term fellowships (2/3
monthly) annually during off-season
on alternate basis without hampering
routine work.
8. Developing neglected sub-
specialities: In the present time most of
the Ophthalmologists are interested in
Cataract surgeries only so practice can
be made more meaningful and impact
causing sub-specialities like Paediatric
–Ophthalmology, Medical – Retina, Dry
Eyes and Refractive services.
What needs to be done?
Setting up refraction services at
Primary Health centres, setting up a
separate ward in district eye hospitals
and dedicated ophthalmic theatres.
Regional institutes of ophthalmology
and selective medical colleges should
be developed into centres of excellence.
Substantial funds should be provided
to Centres capable of developing in RIO
and teaching hospitals for upgradation
through purchase of capital equipment.
Capital grants could also be given to select
voluntary eye hospitals in the NGO sector
to enhance their own infrastructure
capacity. A significant volume of
eye care in India is provided by the
voluntary sectors. Vision 2020 provides
a platform for all non-governmental
organisations to come together. This will
increase the effectiveness of advocacy,
influencing policy and promoting
best practices. Strong voluntary care
would also require a strong public-
private partnership. Government setup
would ensure significant volume in the
delivery of eye care and private sector
involvement would ensure reduction in
cost of treatment. Also public private
partnership would ensure staffing and
upkeep of the infrastructure. Planning
and execution would be strengthened by
the participation of all stakeholders.
Another important aspect of capacity
building is enhancing surgical skills
through training. A number of Institutions
Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre www. dos-times.org
need to be identified as training centres
which can provide productive training to
budding ophthalmologists. Infrastructure
development would include the provision
of good quality surgical microscopes, A
scan machines, ultrasound machines,
YAG laser machines which would make
the post graduate training worthwhile
and productive. Camps in outreach areas
can be arranged in association with
a tertiary care hospital which would
ensure that cataract surgeries happen in
hospital settings, clearly bringing an end
to surgeries in poorly equipped operation
theatres at camp sites and keeping
chances of Infections to a minimum level.
This would quadruple the number of
cataract surgeries performed on a daily
basis, ultimately reducing the burden of
preventable blindness.
Investing in human resource
development in the field of Ophthalmology
would yield great results. Ophthalmology
residency program has to improve
tremendously. The importance of para-
clinical staff- Optometrists, counsellors,
lab technicians needs to be emphasised. A
global exercise to review the distribution
of practicing ophthalmologists showed
that there is a wide gap between the need
and the existing human resource both in
high and low income countries.
Optometrist to ophthalmologist ratio
should be optimum, which would ensure
that the ophthalmologist engages himself
in more clinical work and surgeries
and the basic work is taken up by the
supporting staff. Formal and recognised
courses in optometry should be started to
accredit the training in this cadre and to
stipulate standards.
Overall a strong foundation has to
be laid for eye care. Primary eye care
still holds the key to universal coverage.
However there is a need for well-
developed tertiary care centres which
can provide comprehensive care, provide
training and engage in research.
The six main foundations of a health
system are: human resources, finance,
health information, governance, services
delivery and consumables and technology.
While not all eye conditions require
the most advanced treatment facilities,
neither can all eye care be addressed by
facilities lacking tertiary care expertise
and equipment. The concept of primary,
secondary, and tertiary levels of care is
needed for providing the appropriate
management of the patients.
Primary eye care would include
services or activities carried out at
Perspective
community level such as promoting
eye health in the community, screening,
case finding and referral, emergency
treatment, identifying and referring for
rehabilitation those who are already
blind, and providing commonly required
services like refractive error correction.
Depending on the services rendered,
the provider of primary eye care could
range from a general primary health
worker to a well-trained ophthalmic
technician. The vision centres are staffed
by vision technicians–paramedics trained
in ophthalmic evaluation, refraction,
dispensing spectacles, and diagnosing
potentially blinding conditions.
Secondary-level eye care is provided
by ophthalmologists and covers
comprehensive ocular examination,
cataract surgery, simple glaucoma
surgery, minor procedures, nonsurgical
management of other conditions, and
referral to tertiary care for cases that
require the attention of subspecialists
in ophthalmology and more advanced
facilities.
Tertiary eye care centres are staffed
by subspecialists and have the capability to
provide the complete spectrum of eye care
services like paediatrics ophthalmology,
retinal clinic, cornea clinic, glaucoma
clinic, oculoplasty, etc. Ophthalmologists
are generally categorized as ophthalmic
surgeons and medical ophthalmologists,
depending on their job responsibilities.
Medical ophthalmologists (also termed
specialist ophthalmologists) could
support consultant ophthalmologists
in comprehensive eye assessment
(basic work up) and medical treatment
of chronic, age-related diseases such
as diabetic retinopathy, glaucoma,
dry eye syndrome, etc., Consultant
ophthalmologists, thus, could focus
on surgical management of avoidable
blinding eye diseases. Thus, future
evaluation of manpower for eye care
should gather information on medical
ophthalmologists and ophthalmic
surgeons to ensure a rational distribution
of both subgroups. To meet the growing
need for tertiary services, we have had to
closely monitor the patient volumes per
specialist and enhance their numbers,
as well as the facility, through advance
planning. In addition, tertiary eye care
system can have a cloud-based platform
for remote screening of fundus images
for diabetic retinopathy. Such proactive
reach into the communities including eye
camps and serving these communities
will result in overall increase of patients
37
Perspective
who directly access the tertiary hospitals
and has served to further increase the
demand for subspecialty services as
well as the numbers of paying clientele.
The distance patients travelled to obtain
services according to the subspecialty
type, as a surrogate for demand for
services. In addition to reflecting very
substantial demand for tertiary services,
such a large proportion of long-range
travellers will require adjustments to
scheduling patterns, and may require
plans to facilitate overnight stays for
patients and accompanying persons. In
tertiary eye care institute we can tie up
from the available local NGOs and sub
specialist for providing the required care
for the patient management, this kind
of care has been successfully applied in
premiere eye care institute in our country
like LV Prasad, Narayana Nethralaya,
Arvind eye care institute, etc . A tertiary
centre approach also provides the
opportunity for a fertile interaction of
specialists across the watershed areas
between disciplines, which may lead to
bettering of focused, disease-specific
programs.
While the secondary-level have
centre been common and primary eye
care centres are being set up to reach the
unreached, setting up tertiary care centres
has been less aggressively pursued, as it
requires more investment and trained
staff, and there have been uncertainties
about the potential demand for such
services. Over time, with increasing
affluence and improved health care,
resources could be channelled elsewhere
towards developing other goals. One
such development is the emergence of
ophthalmic research. The combination of
high clinical load, extensive community
participation, and access to a large
network of eye hospitals provides ideal
opportunities for conducting clinical,
laboratory, population-based studies and
social and health systems research.
The basic research carried out
38 DOS Times - March-April 2019 Morya A.K. et al. Keeping the Hope Alive - Building a Tertiary Eye Centre
to understand the mechanism at the
genome, transcriptome and proteome
level. It is possible that the outcome of
the research could be translated back to
the patients in the clinic in terms of early
diagnosis or a drug target and how it will
be helpful in a better understanding of
disease process and improvement in the
treatment methods to attain the goals of
Vision 2020.
Research can dramatically improve
the work of mid-level eye health
personnel who want to provide the best
possible care based on accurate and
relevant evidence. This hierarchical
approach has been widely advocated over
the last decade since the launch of the
global initiative VISION 2020 the Right
to Sight, as a valuable design for eye care
infrastructure.
Tertiary-level centres also offer
training for the budding ophthalmologist,
post graduate courses and training
courses for optometrists and technicians
handling the ophthalmological
equipments. Increasingly, day care
surgeries and short hospital stays are
preferred. The diagnostic and treatment
modalities have also become more
sophisticated and less invasive. These
technologies need to be handled by
trained assistants, technicians, and
optometrists. Hence, more support staff
is required. Tertiary care services require
highly trained staffers (ophthalmologists
and support staff), in whom an institution
makes a large investment. Similar to
other professionals, ophthalmologists
generally seek opportunities for growth.
Keeping them engaged in a limited set of
basic services can become monotonous
over a period of time, and may lead to
losses of highly desirable personnel.
Providing ongoing training to them in the
latest technologies, as well as providing
the opportunity for sub-specialization,
is therefore important for retention as
well as for providing the best quality of
services. Tertiary centres are an ideal
place for training ophthalmologists, as
well as other eye care personnel, which
constitutes one of the several advantages
of creating such institutions where
they are needed. This expenditure has
not increased despite an increase in
population. Hence, optimum utilization
of available resources and improved
performance are essential to reach the
short-term national health objectives.
On one side, they are in the process
of developing high quality human
resources; and on the other side, they
have to address avoidable blindness due
to eye diseases on urgent basis in order
to mitigate a substantial backlog. To
some extent, this could be addressed by
hiring trained allied eye care personnel.
Additionally, experts could manage
blinding eye diseases at state of the art
institutions.
When designed and executed
properly, this hierarchy in services can
ensure both timely and cost-effective
treatment, and provides a paradigm
intended to ensure that the investments
in infrastructure, equipment, and eye
care personnel are utilized optimally at
all levels.
A long journey passed by and a long
journey to reach the destination, we
hope that this dream will sure turn into
reality so long live a hope to excel to serve
humanity optimally. Turn dreams into
reality.
Correspondence to:
Dr. Arvind Kumar Morya
Department of Ophthalmology,
All India Institute of Medical Sciences,
Jodhpur, India