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
The proposition of becoming a doctor was “like an electric shock,”
|Daljit Singh, MBBS, MS, continues to
spend his career adapting and innovating surgical techniques and technology.
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,”
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
“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
“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
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
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.”
|Daljit Singh Eye Hospital, Surgery
Center, now has a staff of more than 60 people. |
Singh learned how to create his own surgical equipment, a lesson he has passed
on to other ophthalmologists.
Images: Singh D
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
This led Dr. Singh to operate on what looked to be a lost case of corneal
“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.
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
“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
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,”
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: email@example.com; 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.