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Educator, inventor shapes future of ophthalmology in India, worldwide
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 Amar Agarwal, MS, FRCS, FRCOphth, is the director and a consultant for Dr. Agarwal’s Eye Hospitals, Chennai, India. Image: Agarwal A
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For Amar Agarwal, MS, FRCS, FRCOphth, the numbers already speak to an accomplished career in ophthalmology.
He has written more than 50 ophthalmologic books and 250 national and international journal articles, and has presented more than 850 papers and courses at ophthalmology meetings around the world. Additionally, Prof. Agarwal has performed 115 live surgeries, devised 17 original inventions and innovations, and has trained more than 300 ophthalmologists internationally in his techniques and technology.
“New technology not only helps ophthalmic practice in India but all over the world,” he said. “But all the discoveries and inventions were made by the Almighty, not by me.”
Prof. Agarwal is the director and a consultant for Dr. Agarwal’s Eye Hospitals, Chennai, India. He is also the chairman of the scientific committee for the Intraocular Implant and Refractive Society of India, and program director for the International Society of Refractive Surgery of the American Academy of Ophthalmology refractive surgery subspecialty day in 2010 and 2011.
Each day, at the 27 hospitals that are part of Dr. Agarwal’s Group of Eye Hospitals, 1,200 employees, including 140 eye physicians, see 3,000 patients.
“The idea is to create an organization where the best people in the world are given a platform to work independently and creatively and, if needed, with guidance,” he said.
Parents and mentors
Prof. Agarwal was introduced to ophthalmology by his parents, Jaiveer Agarwal, FICS, DOMS, FORCE, and Dr. Mrs. T. Agarwal, founders of Dr. Agarwal’s Group of Eye Hospitals.
He said his parents taught him from an early age what the human eye was like. His parents taught him ophthalmic surgery and had him practice by suturing together onion leaves.
“I was so fascinated by all of this that I only wanted to be an eye doctor,” he told Ocular Surgery News in a telephone interview. “Ophthalmology gives you a combination of both medicine and surgery, as one should know medical treatment as well as surgical treatment of the eye.”
Prof. Agarwal received his MS degree in 1986 from the Civil Hospital Ahmedabad, Gujarat University, his FRCS in 1986 from the Royal College of Surgeons, Edinburgh, U.K. and his FRCOphth in 1988 from the College of Ophthalmologists, London.
In addition to his parents, Prof. Agarwal also credits Dr. P.N. Nagpal, a leading retinal surgeon in India, and Dr. Steve Charles from Memphis, U.S.A., as his mentors.
“All these people and so many more [people] have been my mentors in this journey of life. We learn every day from someone,” he said.
Innovations
Prof. Agarwal said of all his innovations, the four most significant ones are the air pump, glued IOL, 700-µm cataract surgery (phakonit and microphakonit) and no-anesthesia cataract surgery.
The use of an air pump — an idea from his sister, Dr. Sunita Agarwal — helped create gas-forced infusion for cataract surgery. A main problem in phakonit (microincision cataract surgery or bimanual phaco) was that the amount of fluid entering the eye was less, compared with the amount of fluid exiting the eye.
“The reason I consider the air pump so important is that surge never occurs with this, and the chances of posterior capsular rupture become nearly negligible,” he said.
Prof. Agarwal and his sister started by pushing air into an infusion bottle to get more pressurized fluid out of the bottle. When that worked, they connected an aquarium air pump to the infusion bottle via an IV set. This constant supply of air into the infusion bottle and the amount of fluid coming out of the irrigating chopper was enough to move from an 18-gauge irrigating chopper to a 20- or 21-gauge irrigating chopper. This was the first time that pressurized fluid was used in anterior segment surgeries.
“The invention of air pump was made in 1999, and since then, we have never looked back. We use the air pump not only in phakonit but in all our phaco cases. When we started microphakonit and moved to a 22-gauge irrigating chopper, the air pump helped us tremendously,” he said.
Prof. Agarwal said glued IOLs have changed worst-case scenarios for patients because in eyes with no capsule, ophthalmologists can glue a posterior chamber IOL with intralamellar scleral tuck using tissue glue.
“In such a case, there is no pseudophakodonesis unlike a scleral sutured posterior chamber IOL,” he said.
Phakonit and microphakonit
In August 1998, Prof. Agarwal had an idea of taking a needle in one hand, bending it like a chopper, and connecting it to the infusion bottle. He then performed cataract surgery with a bare phaco needle in the other hand.
“It was obvious that the amount of fluid entering the eye was not enough, compared to the amount exiting the eye,” he said, adding that the chamber would partially collapse whenever he would start to remove the nucleus.
So Prof. Agarwal shifted to an 18-gauge needle. To his surprise, the amount of fluid became balanced, and he then could chop the hard cataract, although not very well as compared with a chopper. But, he said, he knew the surgical technique would work with more refined instruments.
“Once the surgery was complete, I realized that this could be the next frontier in cataract surgery, as the incision was reduced drastically,” he said.
Prof. Agarwal named the procedure phakonit because he said it was phaco with needle incision technology. This was the beginning of irrigating choppers, and this technique has become known as microincision cataract surgery or bimanual phaco. A week later, he performed a live surgery of phakonit in front of 350 eye doctors for the Indian Intraocular Implant and Refractive Society meeting in Pune, India. Again, he had no refined instruments and no air pump, as they came much later.
With the eye being a small area to operate upon, accuracy in surgery is extremely important, Prof. Agarwal said. In May 2005, for the first time, he used a 0.7-mm phaco needle tip with a 0.7-mm irrigating chopper to remove cataracts through the smallest incision possible. The instruments were made with the help of Larry Laks from MicroSurgical Technology, U.S.A. Prof. Agarwal termed this as microphakonit to differentiate it from the 0.9-mm phakonit.
No-anesthesia cataract surgery
In June 1998, Prof. Agarwal was operating on a patient with a posterior polar cataract. He said, at that time, he performed extracapsular cataract extraction under pinpoint anesthesia or sub-Tenon’s anesthesia in which he would make a small nick in the conjunctiva and pass a cannula with Xylocaine (lidocaine HCl, AstraZeneca) under the conjunctiva and give anesthesia to the patient.
However, when he reached the operating theater, he decided to do phaco instead. In the middle of the case, as he was going to do sub-Tenon’s anesthesia for extracapsular cataract extraction, his fellow informed him that no topical anesthetic drops were instilled in the eye.
“The fellow was worried that I would be angry. But the fact was that I was actually shocked, as I was in the middle of the surgery and the patient was not having any discomfort at all,” Prof. Agarwal said.
He told his fellow that they would see what happens, as the patient did not seem to mind. When he finished the surgery, the patient got up, thanked him and left the operating theater.
“This set my mind working, as I knew this was abnormal,” Prof. Agarwal said.
Later that month, while in Ahmedabad, India, for an Indian Intraocular Implant and Refractive Society workshop, he decided to do live surgery without any anesthetic drops or intracameral anesthesia.
“I was apprehensive to do it, as I felt it was absurd. However, absurd as it may sound, it was true. In hindsight, I do not know what made me do the live surgery without anesthesia, as at that time, I did not realize how successful it would be,” Prof. Agarwal said.
When he returned to Chennai, he did a double-masked study with Dr. Vipul Lakhani of the U.S.A. and Dr. Athiya Agarwal, his wife. They operated on 30 patients — 10 were with no anesthesia, 10 with topical and 10 with topical plus intracameral anesthesia. The P values showed no difference between the three groups.
“Then I knew that no-anesthesia was a reality,” he said. “If there is a tough case or uncooperative patient, I would operate with a peribulbar block.”
Prof. Agarwal said no-anesthesia cataract surgery still shocks him today, and the importance may not be known until years from now.
“The day we can find out why this happens, we will open a Pandora’s box in ophthalmic surgery,” he said.
Community ophthalmology
Prof. Agarwal continues his efforts to eradicate and prevent blindness throughout India. He has conducted more than 5,500 eye camps in villages around Chennai and has treated more than 500,000 patients and operated on more than 200,000 patients for free. He was involved in vision screening, treatment and rehabilitation of blind due to cataracts and other eye diseases. The camps also were conducted with the help of Rotary Clubs, Lions Clubs and other non-governmental organizations.
“With a population of 1 billion people and more than 15 million to 18 million blind, eradicating blindness is a gigantic task in India,” Prof. Agarwal said.
Future plans
Prof. Agarwal said the goal of Dr. Agarwal’s Group of Eye Hospitals is to have 50 eye hospitals seeing 5,000 patients daily by the end of 2010. Currently, the institution is also opening its first international facility in Mauritius, an island nation off the coast of Africa.
“Our idea is to make every patient happy and be comfortable, so they can see to the best of their ability,” he said.
He also plans to continue finding new treatment modalities through his research and continue teaching with more lectures, courses, books and peer-reviewed journal articles.
“It is a constant education process, so others can learn. The more you educate, the more blind patients will benefit,” Prof. Agarwal said. — by Kristine Houck
- Amar Agarwal, MS, FRCS, FRCOphth, can be reached at Dr. Agarwal’s Group of Eye Hospitals, 19 Cathedral Road, Chennai 600 086, India; +91-44-28116233; fax: +91-44-28115871; e-mail: dragarwal@vsnl.com; Web site: www.dragarwal.com.