Surgeon brings innovative techniques to ophthalmologists worldwide
High in the reaches of the Himalayan mountains, Sanduk Ruit, MD, performs cataract surgery on an isolated and impoverished population. This region is like home to him and is a reminder of how he started on the path to ophthalmology.
Dr. Ruit was born in a remote Nepalese village in the foothills of Mount Kanchenjunga, the third highest mountain in the world. He was very close to his younger sister, and at 15, he was with her when she died from tuberculosis.
“This event gave me an inner determination to study medicine,” he told Ocular Surgery News.
After receiving a scholarship from the Nepalese government to King George’s Medical College in Lucknow, Dr. Ruit worked in the ophthalmic unit at Bir Hospital in Kathmandu. He was a medical officer in a team headed by Nicole Grasset, MD, that conducted a World Health Organization nationwide blindness survey in Nepal in 1980. “She was really inspirational in getting me interested in ophthalmology,” Dr. Ruit said.
He is passionate about his work. “One can do so much good for so many people in a short time and see the results,” he explained. “It is also technically very demanding, and I love microsurgery very much.”
Dr. Ruit received a WHO scholarship to complete a residency in ophthalmology at the All India Institute of Medical Sciences in Delhi. Madan Mohan, MS, FACS, FAMS, who headed the R.P. Centre for Ophthalmic Sciences, was Dr. Ruit’s surgical idol.
“I loved to see his beautiful hands moving like the rhythm of music. He had wonderful bedside manners that a doctor should learn,” he said. His thesis co-adviser, Prof. Hem Tiwari, nurtured Dr. Ruit’s interest in microsurgery, allowing him to work long hours in the lab honing his skills.
In Nepal, bringing eye care to the many distant regions of the country is a huge challenge. Although advances in electronics, imaging systems and laser technologies have improved eye care in the country, these developments “have come at a price for substantial increase in the cost of treatment,” Dr. Ruit said.
“The most important thing is that an attempt is made to provide the best surgical outcome even to the most underprivileged and in the most remote areas of the world and make it affordable for them,” he said.
Meeting community needs
Dr. Ruit continued his studies in Australia. There he worked alongside the late Prof. Fred Hollows, who was both a mentor and a friend. In 1986, they devised a strategy to use small-incision cataract surgery (SICS) in the developing world at the community level, through the use of low-cost IOLs. Dr. Ruit was the first Nepali doctor to use IOLs in cataract surgery.
He brought these techniques home to Nepal, where he met with some resistance to this new technology. He continued to develop his outreach practice by conducting eye camps in remote regions of the country, where he performed sutureless microincision surgery for impoverished cataract patients.
At that time, however, the high cost of IOLs made implantation out of reach for many poor cataract patients. Dr. Ruit acquired financial assistance from developed countries and international relief organizations, but he needed other options to continue his work. He started looking for alternatives to reduce the cost of IOLs, and in 1995 he devised an international standard IOL that could be produced for much less than those manufactured in developed countries.
These IOLs are now being used in more than 60 countries.
Dr. Ruit’s innovative small-incision cataract removal technique involves modifying the superior incision to a temporal incision. A sutureless external incision of 6 mm to 7 mm is enlarged to 10 mm internally with a keratome. The nucleus is then removed through the anterior chamber.
Dr. Ruit and colleagues published a study in 2007 of 108 outreach patients in Nepal with significant cataracts, randomly assigned to receive either phacoemulsification or SICS. Both techniques had excellent surgical outcomes and similar uncorrected visual acuity on day 1 post-op. At 6 months, 98% of both groups had best corrected visual acuity of 20/60 or better. However, patients in the SICS group had less corneal edema, and surgical time for the procedure was significantly shorter than that for phaco. The study concluded that the technique was significantly faster, less expensive and a more appropriate surgical choice for treating advanced cataracts in developing countries.
Indeed, thousands of doctors have been trained in this method, and later this year, U.S. military surgeons will train under Dr. Ruit as well, according to a news report.
The Tilganga Institute of Ophthalmology
In 1994, Dr. Ruit helped found and is currently medical director of the Tilganga Institute of Ophthalmology (TIO), which serves as a model for delivering high-quality eye care for the community and for developing an effective cost recovery scheme. This efficient model of eye care is now practiced in many parts of the world, he said.
“We work very closely with Dr. Geoff Tabin of the Himalayan Cataract Project, USA, and the Fred Hollows Foundation, Australia, to develop different systems and surgical techniques,” Dr. Ruit said. “TIO, in close conjunction with its partners, is proudly spreading this very effective system to many parts of the world, such as Africa, South America, Thailand, Bhutan, Myanmar, Cambodia, China, Pacific Islands, Bangladesh, India and Pakistan.” The institute has established community eye centers in about 11 districts of Nepal, as well as one community eye hospital. It oversees hospitals in Lhasa, Tibet Autonomous Region, and Xining, China, as well as one in Kalimpong, West Bengal, India.
Dr. Ruit said his ongoing research projects include “establishing norms for a reproducible and modern eye care model, improving SICS and trying to find better training methodologies, and simplifying the logistics of phacoemulsification surgery to find its application at the community level in developing countries.”
Increased corneal donation
Before 1994, corneal transplantation in Nepal was limited due to the lack of readily available corneal tissue. The establishment of the Nepal Eye Bank at TIO in 1996 helped revolutionize the concept of eye donation in Nepal, and now the country is moving toward self-sufficiency in maintaining corneal tissue for use in transplantation, Dr. Ruit said. But that only happened after tissue procurement was moved from the eye bank to the grounds of Pashupati Temple in 1997.
Up to 40% of the deaths in Kathmandu at that time occurred at home, and the bodies were brought to the temple for cremation. Because of their belief in reincarnation, Hindus and Buddhists in the region feared being reborn blind if cornea tissue was removed for donation. Dr. Ruit assured religious leaders that giving sight to the blind would increase good karma for the family, and thereafter he established corneal excision rooms in the crematoriums at the temple.
By 1999, the number of corneas distributed in Nepal had tripled, and corneal transplantations performed at TIO had more than doubled.
Growth of ophthalmology
Ophthalmology has seen substantial growth in Nepal over the last 30 years, Dr. Ruit said. “From having a small ophthalmic unit in a general hospital in the capital city, it has grown to accommodate 14 very well-functioning modern eye hospitals in the whole country,” he said.
There are now 150 eye doctors in the country, up from 10 in 1980, he said. Paramedics and ophthalmic technicians number nearly 500 now, compared with fewer than 20 in the 1980s.
“The cataract surgical rate is now a little over 3,000 as compared to about 500 in 1980. Most of these hospitals are delivering modern and high-quality eye care. All the cataract surgery done is mostly with SICS or phaco,” Dr. Ruit said. Many cataract patients come from neighboring India.
Dr. Ruit has received numerous awards for his groundbreaking research and outreach work, including the Prince Mahidol Award of Thailand and the 2006 Ramon Magsaysay Award for Peace and International Understanding, known as Asia’s Nobel Prize.
- Dr. Sanduk Ruit — Co-Director Himalayan Cataract Project. Himalayan Cataract Project website. http://www.cureblindness.org/who/dr-sanduk-ruit/. Accessed April 14, 2010.
- Heiden D. Dr Sanduk Ruit and corneal transplantation in Nepal. West J Med. 2002;176(1):71.
- Mason M. Nepalese doc is ‘God of Sight’ to nation’s poor. MNSBC.com website. http://www.msnbc.msn.com/id/35935864/ns/health-more_health_news/. Accessed May 24, 2010.
- Ruit S, Tabin G, Chang D, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143(1):32-38.
- Schultz J. Small incision manual technique fills need in remote parts of developing countries. OSN SuperSite website. /news/ophthalmology/20120225/small-incision-manual-technique-fills-need-in-remote-parts-of-developing-countries. Accessed April 14, 2010.
- The 2006 Ramon Magsaysay Award for International Understanding: Citation for Sanduk Ruit. Ramon Magsaysay Award Foundation website. http://www.rmaf.org.ph/Awardees/Citation/CitationRuitSan.htm. Accessed April 14, 2010.
- Tilganga Institute of Ophthalmology website. http://www.tilganga.org/research.php. Accessed May 24, 2010.