Surgeon pushes limits within ophthalmic surgery, conforms technology to situation
Daljit Singh, MBBS, MS, spent his childhood learning about the written word from his father, a professor at Khalsa College in Amritsar, until a comment from a family member changed his course.
“When I joined high school … my elder brother’s wife said to my father, in my presence, ‘Father, you should make Daljit a doctor. Not only that, he should become an eye doctor.’ My father agreed instantly. Next day, I took medical subjects,” Dr. Singh told Ocular Surgery News.
The proposition of becoming a doctor was “like an electric shock,” he said.
Image: Singh D
“The idea of becoming a doctor and an eye doctor — I had no idea what it was — made me a serious person overnight. I had a duty and a mission, and I had to prepare myself,” Dr. Singh said.
He completed high school and pre-medical courses, obtaining admission to and graduating from the Government Medical College in Amritsar.
After receiving his bachelor’s of medicine and surgery, Dr. Singh performed a “house job” in ophthalmology and later received his ophthalmic diploma, starting his master’s degree studies.
“Without completing my master’s degree, I decided to get a taste of real life. I joined a primary health center that had earlier been an eye center, too. There was no electricity, no running water in that village,” he said.
Here, for more than 2 years, Dr. Singh worked as a general practitioner, as well as an eye surgeon.
“While serving in the villages, I saw the real, raw life with all the limitations and privations of the people. There was no electricity, no telephone. … A bicycle was the main personal mode of travel,” he said. “I learned how difficult it is for a village person to travel to a city for getting treatment —where to go, who shall take you, who shall pay for the journey, and who shall pay for the doctor and the medicines. These factors weigh so heavily that all treatments are delayed and complications are created. I never ask a rural patient, ‘Why have you come so late?’ or ‘Why have you not taken treatment earlier?’ I know that if I were in his situation, I might even do much worse. The treatmenthas to start immediately, without blaming the patient for his ills.”
In May 1964, Dr. Singh returned to Amritsar as a senior lecturer in ophthalmology and then transferred to Medical College, Patiala, for 5 years.
In 1972, Dr. Singh returned to Amritsar as an assistant professor and spent the next 4 years improving incisions and suturing for cataract and doing retinal detachment surgery. In 1976, he became second professor and controlled half of the department activities, but despite his continued achievements, he was unhappy in his overall position.
Not long after, Bolivian ophthalmologist Ed Olmos, MD, visited and stayed with Dr. Singh.
“He saw my life from close quarters. He said, ‘Dr. Singh, you are a fool. If you cannot help yourself, you cannot help others. It is impossible to go any higher, if economy and pay remains the same,’” Dr. Singh said. “I always remembered his words, but it took me another 5 years to make up my mind to take voluntary retirement.”
As head of the eye department, Dr. Singh had tried to improve the department.
“The support I got from the government was simply zero,” he said. “One day, in February 1985, I was lazily rocking in my chair. … I closed my eyes and pictured my day of retirement after 9 years. I asked myself, ‘These 9 years shall pass in no time, and then you shall have to do something for a new life. Why not now?’ The answer was instant.”
Dr. Singh left his government post and started his own hospital in a tiny rented place with minimum facilities that were only somewhat better than the college hospital.
“I had no plans, except to earn my living and have some peace of mind. It attracted people beyond my expectations,” he said. “To meet the challenge, I had to continuously enlarge and upgrade it, increase the staff, etc. … Now we have 10 ophthalmologists, including five from my own family. We have a supporting staff of 60 people. The hospital has been considerably enlarged and improved. It can boast state-of-the-art equipment for every subspecialty.”
Adapting, creating technology
Throughout his career, Dr. Singh has adopted and created technology when he needs to accomplish his goals.
“I have all along advocated the cause of appropriate technology for the Third World situation. That is the only way to reach all the people. I do not consider anything primitive if it serves the purpose in a particular situation,” he said.
As senior lecturer, Dr. Singh developed a single-lens reflex camera for the eye by reversing the camera lens and adding a 5-cm extension. He attached a reduced aperture electronic flash, experimented with a few films and created a perfect system of photographs, which he developed at home to the decimation of his salary, he said.
While in Patiala, Dr. Singh discovered the use of blade and scissors for better cataract incisions. Here, he developed a three-plane incision, “which made the incision closure near perfect,” he said.
While doing retinal surgery, he had a high-illumination, indirect ophthalmoscope made locally, and he used a homemade, hand-held diode light keratoscope to control astigmatism during large cataract incision closure and correct pre-existing astigmatism.
Jan Worst, MD, taught Dr. Singh to make his own tools, as well, a skill he passed on to others in India.
“I taught hundreds of ophthalmologists how to make their own stainless blades, irrigation and aspiration cannulas, irrigation cannulas and especially how to make their own sutures,” he said. “In my institution these days, I make frequent use of homemade atraumatic needles with 40-µm stainless steel sutures. The needles are made out of disposable hypodermic needles of 32 gauge and 30 gauge. In earlier years, when phaco surgery was not common, we could save enough money in a year to buy major equipment.”
Dr. Singh said there is no formula for choosing appropriate technology because each situation calls for something different.
“I put myself in the position of the patient and ask myself, ‘How can I help myself?’ Every technique I work on has one aim: Do not harm. So if the technique fails, it can be repeated or you can go back to the current standard technique,” he said. “Failures are not road blocks but building blocks for me. I do not care what others think of me, but my image in my own eyes is most important, and I am merciless on myself.”
A large focus of Dr. Singh’s research and practical work has been in an area that he said many do not realize exists — lymphatics.
It began with his work in trabeculectomies, using gonioscopy to see that the inner opening was anterior to the trabecular meshwork.
“My question was: Why not pre-trabecular filtration, which avoids diseased area and gives similar results? That technique stuck with me for the next 8 years,” he said. “I believe that there is ignorance about the presence of lymphatic’s under the conjunctiva and the role that they play in the normal drainage of the aqueous and after glaucoma surgery. … Today, I believe that the major causes of subconjunctival scarring are injury to the Tenon’s capsule and the lymphatics.”
In November 2000, Dr. Singh injected trypan blue to visualize the lymphatics and saw the extent of their reach.
“Lymphatics have forever been there under the conjunctiva,” he said. “They have been mentioned even in the basic anatomy books, but their visualization and importance have not been realized by ophthalmologists, not even the glaucoma surgeons.”
That same year, Dr. Singh first used the Fugo blade (Medisurg), a new technology he discovered, for his now well-known technique of transciliary filtration.
Still, he said he is not fully satisfied.
“I do about 300 glaucoma operations in one year. I am not happy with any technique for many reasons,” he said. “Dissections, cautery and even mitomycin damage the anatomy of the tissues, resulting in scarring, Tenon’s cyst formation.”
But his quest is not over, and Dr. Singh said he is getting encouraging results with a new technique he calls “pre-Tenon filtration,” done either from the outside or inside.
“The techniques are being fine-tuned to the needs of the individual patients. Both techniques need a patent peripheral iridectomy either before surgery with YAG laser or intraoperative iridectomy either with forceps and scissors or with Fugo blade,” he said. “Currently, I am focused on ab interno filtration. If done accurately, there is little or no trauma to the subconjunctival tissues, especially the Tenon. I am looking for a way to have the Fugo blade incorporated to an endoscopic tip to make the surgery not only safer but also simpler.”
Dr. Singh said he visualizes the lymphatic system as a connected sponge soaked in aqueous, with the quantity of fluid differing throughout, depending on the anatomical texture of the tissue.
“The lymphatics are responsible for the uveoscleral outflow drainage and for mopping up the leakage from the arterial ends of the capillaries and from the aqueous veins,” he said. “Alas, in spite of my big efforts over the past 8 years, the lymphatics have yet to remain recognized.”
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While studying the lymphatic systems, Dr. Singh said he became aware of channels in the cornea.
“They were a kind of network, and they seemed to end peripherally in the area of the so-called lucid interval,” he said. “I have come to the conclusion that the cornea is normally permeated by sinusoidal channels in the form of a network. This network reaches the periphery of the cornea, where there is the place for the lucid interval. The fluid in the periphery of the cornea is drained to the limbal and from there to the subconjunctival lymphatics.”
This led Dr. Singh to operate on what looked to be a lost case of corneal edema.
“No donor cornea was available, nor was one expected in the near future. The patient had come from almost 1,000 miles away. An idea came to me: Can we drain the edema into the conjunctival lymphatics, if such a connection existed?” he said.
He made pits in the cornea using a 400 µm Fugo blade tip of 100 µm width, leaving the center of the cornea untouched. The patient’s eye improved daily, and the patient could navigate with some confidence on the 10th day. After 2 months, the patient returned.
“I looked at the eye, and it was the happiest moment of my life — the cornea was completely transparent, except for the spots that marked the points of Fugo blade pits. His corrected vision was 6/9, and his endothelial cell count was around 850 cells/mm2,” Dr. Singh said.
Today, he has performed 40 cases such as this one, and he said every patient has shown improvement.
“This technique could have immense application in the worldwide scenario,” Dr. Singh said.
In 1976, Dr. Singh started to perform lens implantation, another area in which he had early success.
“I still have some of the patients of those days with good endothelial cell counts and vision,” he said.
Ten years later, Dr. Singh said he was the most experienced lens implant surgeons in the country, having done nearly 2,500 IOL implants.
“Lens implant surgery was viewed with suspicion, but there was an increasing interest in what I was doing,” he said.
The president of India, Giani Zail Singh, was one of those interested in lens implantation. Despite advice from other surgeons to obtain his surgery in the United States, the president came to Dr. Singh for his advice and pursued the operation with him.
“The surgery took hardly 6 to 7 minutes. I also attempted to correct his pre-existing astigmatism by applying a slighter tighter suture,” Dr. Singh said.
The president had “a perfect recovery,” with a final vision of 6/6, he said.
In 1979, Dr. Singh had also started doing extracapsular surgery for high myopia.
“I earned severe reprimand from the noted retina surgeons that I was endangering the eyes for retinal detachment. My answer was that the surgery was done only after making sure about the integrity of the retina,” he said. “The condemnation continued till 1993, when the first positive report of such an operation came from the U.S.”
In 1986, Dr. Singh started doing extracapsular cataract extraction with a higher-power IOL to treat high hypermetropia, and 1 year later, he started lens implantation in phakic hyperopes.
“I started running courses on extracapsular surgery and lens implantation, free of charge, of course. From 1980 until 1992, almost 600 ophthalmologists from all parts of India came,” he said. “Thus were planted small seeds of lens implantation technology — simple and suitable for the Third World situation all over the country — that soon blossomed and provided lens implantation facilities to [all] of India.”
In addition, Dr. Singh said, “The spread of my patients all over the country broke the taboo on intraocular lenses.”
Pediatric IOL implantation
A taboo that was fought by Dr. Singh was the implantation of IOLs in pediatric patients, a procedure he started in 1980.
“We have done more than 10,000 lens implants in children. When the world abhorred the very idea of lens implantation in children, we were implanting iris-claw lenses in children as young as 2 months,” he said. “Two months is an important landmark since amblyopia starts setting after this age. The problem is how to decide about the power of the IOL in a growing eye.”
Dr. Singh said if a lens is implanted in an amblyopic child, three things can happen: the patient remains hyperopic because of undercorrection; the patient becomes emmetropic; or the patient becomes myopic.
“Many of these amblyopic children, with or without nystagmus, shall have a chance of seeing near objects and reading without glasses. An amblyopic child with myopia of -10 D can easily pursue studies without a handicap,” he said.
Dr. Singh said he also performs extracapsular cataract extraction with an IOL when a child develops very high myopia with early changes at the posterior pole. — by Katrina Altersitz
- Daljit Singh, MBBS, MS, can be reached at Dr. Daljit Singh Eye Hospital,1-Radha Soami Road, Amritsar 143001, India; +91-9815000207; fax: +91-183- 2549700; e-mail: firstname.lastname@example.org; Web site: http://www.daljiteye.com/. Dr. Singh has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.