Physician works to improve several educational programs in ophthalmology

As a child of two ophthalmologists, Ravi Thomas, MD, did not have to go far to find his mentors in ophthalmology.

Ravi Thomas, MD, said that ophthalmologists visualize and diagnose on the basis of what they see. Image: Thomas R

“My choice of career and a career in teaching was influenced by my parents. I wanted to emulate them and make a difference to the lives of the sick and needy, and took up medicine because there was no direct course into ophthalmology,” Prof. Thomas told Ocular Surgery News in an e-mail interview.

Prof. Thomas is currently the director of glaucoma and education at the Queensland Eye Institute and professor at the University of Queensland, Brisbane, Australia. He was formerly head of the ophthalmology department, Christian Medical College, Vellore, and director of the L.V. Prasad Eye Institute in Hyderabad.

He was educated at Christian Medical College, Vellore, South India, and the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences in New Delhi. Prof. Thomas completed fellowships at the Tennent Institute of Ophthalmology in Glasgow, as well as Sydney University in Sydney. He is the author of more than 160 published papers in international journals and five textbook chapters, and he is on the editorial board of Ophthalmic Epidemiology, Journal of Glaucoma, International Ophthalmology, International Glaucoma Review and OSN India Edition. His special interests are glaucoma, clinical epidemiology and cataract surgery.

Prof. Thomas said he loves ophthalmology because what you see is what you get. Ophthalmologists visualize and diagnose on the basis of what they see — with nothing much left to the imagination. Ophthalmology appeals to him because it is easy to teach the specialty using the modern instrumentation. Also, ophthalmic surgery is a clean and usually bloodless specialty.

“To be part of the miracle of sight restoration is an indescribable feeling. To me, nothing else is so immensely satisfying,” he said.

First role models

Prof. Thomas’ parents were two of the few qualified ophthalmologists in India during the 1940s. At the time, most ophthalmologists were in large metropolitan areas. However, his parents refused the lure of a big city or a job with a prestigious medical college. They elected to settle down in Khurai, a little village in Bundelkhand in Madhya Pradesh. They worked in this small village in central India for 42 years — of which 20 years were spent without running water or electricity.

During his childhood, Prof. Thomas was sent to a boarding school in the mountains. With the heavy snow that ensued in the mountains, he was sent home for 3 months of winter holiday every year — a time he spent exploring and learning at his parents’ clinic.

“There was hardly anything to do in that little town my parents lived in. The area was lawless with the odd kidnap threats, so I had to hang around close to home or the hospital. I would run around and play in the clinic corridors for a couple of weeks. After I got bored, I would sit down and watch my parents examine patients and perform surgery. I grew up with Snellen charts, slit lamps and operating loupes,” he said.

As such, his childhood memories are of cataract, glaucoma and sac surgeries — coupled with Caesarean sections and other general operations, quinine for malaria, snake bites, and anti-rabies injections, procedures for which his parents had no alternative but to undertake in the small village.

“The response to anti-snake venom and intravenous quinine for cerebral malaria is dramatic, but there was nothing like the results of a cataract operation. Subconsciously, I had already chosen a career in ophthalmology,” Prof. Thomas said.

After he finished his basic medical training, his mother taught him cataract, glaucoma, sac and lid surgeries.

“She had the best pair of surgical hands I have seen to date,” he said.

His initial plan after medical school was to join his parents at their clinic in Khurai. However, his parents suggested that he work at the medical school that they had shunned in order to work at the clinic. He tried his parents’ suggestion for a year and then soon realized that he liked teaching ophthalmology.

Although he did not join their clinic, Prof. Thomas said he learned a great deal from his parents, including their approach of quality care for all patients.

“It has stayed with me. My parents spent their whole lives in the service of the poor and needy. There was no difference in quality of care between those who could pay and those who could not. They dealt with all kinds of prejudices. Their meticulous approach to surgery without taking any short cuts has also stayed with me,” he said.

Other mentors

Prof. Thomas chose to specialize in glaucoma and pediatric ophthalmology because the best teachers during his residency program were glaucoma specialist Prof. N.N. Sood and strabismus specialist Prof. Prem Prakash. He observed clinical and research logic in action and first heard of “Ockham’s razor” with Dr. Jeff Jay in Glasgow and learned pediatric ophthalmology with Prof. Frank Billson in Sydney.

His interest in clinical epidemiology was initiated and fueled by his friend and college mate Prof. JP Muliyel at the Christian Medical College, Vellore, where he worked for 20 years. He took Prof. Muliyel’s basic and advanced courses in clinical epidemiology and was hooked. Prof. Thomas eventually worked with Prof. Muliyel for 15 years on various projects, peer-reviewed publications and meeting presentations.

“The clinical epidemiology course provided me with a logical and common sense approach to diagnosis and treatment. I just loved it. It had all the tools we use in the practical application of evidence to the patient,” he said.

The two colleagues collaborated on the only population-based study of the progression of angle closure disease. They also used back-calculations to show that cataract blindness in India was overestimated, which meant that available resources could be used for improving quality of cataract surgery, rather than blindly increasing the number of operations, he said.

Projects and research

Prof. Thomas has worked on a number of research projects during his career, one of which is the role of relatively cheap modern technology in the detection of potentially serious eye diseases in a primary care setting. He also has worked on the Ex-PRESS miniature glaucoma shunt (Optonol) and is currently investigating modern imaging technology in the management of glaucoma. Most recently, he was involved in the first two pilot studies using a carbon dioxide laser for deep sclerectomy.

“Manual deep sclerectomy needs excellent surgical skills and has a long learning curve,” Prof. Thomas said. “The laser seems to take away the learning curve while providing the same results.”

Results of the wider trial of the carbon dioxide laser for deep sclerectomy were recently presented at the Asia-ARVO meeting in Hyderabad and will be presented again at the annual meeting in March of the American Glaucoma Society in San Diego, U.S.A.

Challenges and changes

Throughout his career, Prof. Thomas has worked to improve the quality of the residency programs in ophthalmology in India. His research studies have found that drastic changes in training, patient care and accountability are needed in most Indian medical college ophthalmology departments.

“Residency training programs have lagged behind. There are few training programs that follow minimum acceptable standards,” he said. “What we need is an Indian version of the Flexner report in the United States.”

The majority of programs do not teach modern ophthalmology, he said. Even in teaching hospitals, patients do not receive a comprehensive eye examination and may not be examined on a slit lamp. Prof. Thomas said that modern cataract, glaucoma and retinal surgery are not taught to residents, and they have to seek fellowships to learn standard techniques, such as phacoemulsification and manual small-incision surgery.

Indian ophthalmologists also face other challenges, he said, one of which is providing affordable and acceptable quality care to all patients, irrespective of their capacity to pay.

“In order to achieve this, [ophthalmologists] go through large volumes of patients. Many take short cuts, like not scrubbing between cases, and economize by not sterilizing instruments and phaco probes between cases,” he said. “Regrettably, this happens even in reputable teaching institutions, and students will do what they see their teachers do. Such shoddy practices cannot be justified, even in a poor developing country.”

However, Prof. Thomas said Indian ophthalmologists have been quick to adopt high technology.

“With this comes the danger of misuse and escalating costs,” he said.

Outreach programs

Prof. Thomas said he intends to help in Madanapalle, Andhra Pradesh, where one of his colleagues, Dr. Shobha Naveen, runs the Siloam Eye Hospital, a secondary center of the L.V. Prasad Eye Institute. He also plans to assist in the Chitrakoot Eye Hospital, located in the region where his parents worked. The hospitals have a high volume of patients but are working to improve the quality of care, as well as undertake teaching and research programs.

He said the earlier “eye camp” approach to treat blindness in India was needed as an interim measure to deal with the large volume of patients with cataracts. However, complications and poor outcomes occurred more frequently, so the current strategy is now to screen patients and conduct surgery in permanent facilities, he said.

“The operation site may have shifted to fixed hospital facilities, but the camp philosophy persists. These patients are screened and brought in for surgery but are still operated on en masse on a specified day, usually without following the usual operating room protocols that may be in place on other non-camp days,” Prof. Thomas said.

The benefit of moving to permanent facilities is that the camp patients will be spread over the regular operating schedule, he said.

“I have tried my best to practice all the values of my parents. This spills over into patient care. There had been paranoia about Hansen’s disease many moons ago and AIDS more recently. But thanks to my parents, I never had a problem treating non-paying patients, potentially infective patients or relating to any of them,” he said. — by Kristine Houck

• Ravi Thomas, MD, can be reached at Queensland Eye Institute, 41 Annerley Road, South Brisbane, Queensland 4101, Australia; +61-7-3010-3360; e-mail: ravi.thomas@pbf.org.au.