Is it true that you powered your laser iridotomies on Alaskan Inuits with a car battery?
No, not exactly! I spent some time with Norval Christy, MD, in Taxila, Pakistan, in 1978. Starting at 2:30 am, he would perform more than 300 cataract surgeries daily by himself. He would then screen other patients after breakfast. Most of them would travel more than 100 miles and bring their own bedding and food. They would sometimes wait a day to be screened. These patients had received no prior eye care. They were all blind and did not know the difference between glaucoma and cataract. I still remember turning patients away with relatively clear media but total cupping. This experience has been my inspiration.
Thereafter, I began my fellowship with Irvin Pollack, MD, who at that time had built, with the aid of the applied physics laboratory at Johns Hopkins University, one of the two Q-switched ruby high-powered lasers. This work motivated me to develop a high-powered laser that could “cure” glaucoma. I worked with a team at Coherent Medical headed by John Moore to develop a laser attached to a slit lamp that could be powered by a jeep battery in case we lost electricity. We took the prototype to an area of Alaska that Alfred Sommer, MD, and Sheila Arkell, MS, had identified as having a high concentration of patients with angle-closure glaucoma. We were able to treat these individuals' thick, darkly pigmented irides in school buildings and other various locations, but usually, we had power. I then carried the laser by hand to Kathmandu, Nepal.
What prompted your interest in glaucoma care in South Asia?
During my visit to Kathmandu, I met and worked closely with Sanduk Ruit, MD, a Sherpa trained by the Fred Hollows Foundation. Ruit and I proved that the aforementioned laser could work in Asian eyes. We also demonstrated that extracapsular cataract extraction and IOL surgery were possible in a developing country, and we achieved excellent results in eyes with hand motions and light perception vision. This experience laid the groundwork for Ruit's becoming self-sufficient and building his own IOL factory in the resource-poor country of Nepal.
Govindappa Venkataswamy, MD, visited Ruit and asked me to bring the laser to Aravind Eye Hospital in Madurai, India, which I did. We decided to build a glaucoma service that could train other glaucoma services. Our first step was to conduct a prevalence study based upon the Baltimore Eye Survey, and we worked closely with James Tielsch, PhD, and Joanne Katz, ScD, from the Bloomberg School of Public Health. For more than 20 years since, I have been involved in the training of dozens of doctors from India. The Aravind and Nepal teams have become my second family.
How is the model glaucoma teaching and training center for developing countries at Aravind Eye Hospital progressing?
We have succeeded. I have worked with individuals from multiple institutions as well as industry (including Mr. Moore and Jerry Cagle, PhD, formerly of Alcon Laboratories, Inc.). The Aravind team now trains 1/8 of Indian ophthalmologists. With the help of others, we have pioneered the use of mitomycin C. With the assistance of Paul Palmberg, MD, PhD, and George Baerveldt, MD, we have now developed the AADI, a low-cost (about $60) glaucoma drainage device similar to the Baerveldt glaucoma implant (Abbott Medical Optics Inc.).
We have answered some simple questions but are now tackling more difficult issues, including the development of an appropriate standard for both glaucoma and ophthalmic training in India. In addition, we are examining screening for glaucoma and diabetic retinopathy and an approach to addressing barriers to care in India and other nations.
Where do you think medical therapy for glaucoma is headed, and what are the current challenges?
In the past decade, much of my work has centered on barriers to adherence, which I have realized are the most important issue. Regrettably, this subject is not as lucrative as developing a new drug, so less funding is available. Current medications that require daily or more frequent instillation of drops must be replaced by longer-acting compounds and delivery systems. The long-term delivery of a medication may be more important than the agent itself.
Most doctors in the United States and Europe prescribe prostaglandin analogues as first-line medications, but the cost of these drugs is prohibitive in developing countries. Better but less expensive first-line medications are imperative, as are effective additive agents.
Despite your extensive time abroad, you are known as a family man. How do you manage that balance? Did you stop sleeping?
This is not the first time I have been asked this question, and it makes me chuckle. Yes, I sleep but not too much.
My experience with Norval in Pakistan really motived me. He was passionate, resourceful, and innovative, and he never tired from hard work. He was able to multitask and still focus. After returning to the United States, my life changed. I became focused on curing glaucoma (still have a long way to go). My wife understood and still understands my conviction and zeal. My thought was that, if people from a less developed country came here, they would appreciate our accomplishments but feel that what we have done could never be repeated under their circumstances, so they might just give up. Creating a glaucoma center of excellence in a less developed nation that would then train others, however, would pay large dividends in the long term.
Being quite naïve and having the full support of my wife, after my experiences in Alaska and Kathmandu, I set off for India and realized that a glaucoma center could be built there. In retrospect, the most important thing that I did was to develop deep friendships with my team. I have hosted many of the staff of Aravind as well as Ruit at my house for up to a month. My wife appreciated the challenge, and her hard work, organization, and personality facilitated my friendships with colleagues in India. I have been known to fly to India for 2 days or less so that we could complete or design projects and protocols. Many people joke about this.
Even so, my family became my priority, and I did not spend any additional time in India so that I could come home to them. I still remember a time when my daughter, now 34, was about 5 years old. I returned from India, kissed her good night, and promptly fell asleep at the foot of her bed before she dozed off! I still regret missing soccer, baseball, and lacrosse games that my children were in, but because of my wife, my family has always supported my work. All of them have been to India to see Aravind, and my son, Todd, flew all the way from Los Angeles to Madurai for only 36 hours to be with me when I received the Dr. G Venkataswamy Oration Award in the fall of 2012. He has also visited Ruit in Kathmandu, and I look forward to taking my grandchildren there.
