The Cardinal Role of Family Physicians
In
Enhancement of Eye Donation
And
Effective Eye Banking

ASSESSMENT OF THE PROBLEM OF CORNEAL BLINDNESS IN INDIA

India has the dubious distinction of having the highest number (Approx. 10 million) 0f blind people in the world. (Approx. 40 million).

25% of the total blind persons in India are due to the diseases of cornea (approx. 2.5 million) and 60% of them are below the age of 12 years. Every year the number of Corneally blind person increases by 20-25 thousand.

The corneally blinds often can be helped to regain useful vision and take up to their occupation by a simple operation of Cornea grafting or Keratoplasty, only if, there is access to good quality donor corneas.

Every year approx. 10 million people die in India, but however, only 12-15 thousand persons donate eyes.

In spite of preventive and curative measures undertaken by authorities and social service organizations the net figure of Corneally blind people in India is increasing by leaps and bounds. At the prevalent rate of 20-25 thousand per year, the estimated figure of Corneally blind in 2015 will be 3 million.

The magnitude of corneal blindness prevalent, particularly in young people jeopardizes their future. The immensity of loss to the society and the Nation can be imagined.

Family Physicians are vital links between motivation of people for eye donation, procurement of large number of good quality donor eyes and successful functioning of Eye Banks.

MANAGEMENT OF THE PROBLEM

Theoretically, the problem of tackling corneal blindness with cornea grafting surgery seems very simple. There should be 20 million corneas available in India, if 10 million potential donors who die every year donate their eyes. But in practice very few people donate eyes.

50% of 25-30 thousand corneas harvested are from Gujarat and city of Mumbai. It is imperative to motivate people all over India for more eye donations on a war footing.

REASONS FOR FEW DONOR EYES

A survey was carried out amongst 127 doctors from different parts of Mumbai and Ahmedabad, to elicit the reasons for, “Why family was unwilling to donate eyes of deceased?”

The reasons elicited:

(1) Lack of awareness and knowledge:

Some people are not aware that the eyes of a deceased can be donated and utilized for giving sight to corneally blind person. Some families who are aware do not have knowledge about the procedure of Eye Donation.


(2) Misconceptions:

(a) Some people believe that, “If eyes are donated the donor will be born as a blind in the next birth.”
(b) If eyes are donated and the final rites are performed on incomplete body then the donor will not achieve “Moksha” (salvation).
(c) Not only illiterate people but also few doctors have the misconception that, “Eyes are to be donated just prior to death, and if, by any chance, the donor survives he has to lead a dark life through out the rest of life”.

(3) Emotional:

After the death of a person the bereaved family is under tremendous emotional stress and may forget about eye donation.

Few consoling words and proper request for eye donation by a doctor at this stage will positively motivate the family to donate eyes.



(4) Religion:

Bereaved family members believe that their religion may be against eye and other organ donations.

In fact, no religion is against such donations. On the contrary, Hindu religious scripture Mahabharata has positive mention of eye and bone donation. There are Fatwas issued by Maulavies in Islam. Similarly there is mention of such donations in Bible of Christians and Talmud of Jews

EYE BANKS

The statistics from Eye Bank Association of India (EBAI) reveals out of few hundred eye banks in India, only 20 collect even the bare minimum of 50 (Fifty) donor eyes in a year.

To procure large number of good quality donor eyes following measures are vital:

(a) Continuous motivation of people through mass media and any
other Innovative way.
(b) Upgrading existing eye banks.

(c) Establishing new effective eye banks.

Family Physicians are vital links between motivation of people, procurement of large number of good quality donor eyes and successful functioning of an Eye Bank.

It would be interesting to assess a well functioning eye bank.



PROFILE OF A SUCCESSFUL EYE BANK
(ARPAN EYE BANK)

Arpan eye bank at Ghatkopar, in Mumbai, was inaugurated on 26th April 1987. It is managed by a public charitable trust. Its area of operation is only Ghatkopar, one of the suburbs in Mumbai.

10 trained family Physicians available within the local area attend eye calls in rotation. Up to 03/09/2007 Arpan Eye bank has collected and distributed more than 8527 donor eyes.

On an average, each eye call was received 1 hour after death, was attended within 30-45 minutes of intimation and eyes were retrieved within 2 hours of death, ensuring good quality donor eyes

Success of Arpan Eye Bank confirms that Family Physicians are ideal personnel to work for an eye bank.

FAMILY PHYSICIANS IDEAL FOR MOTIVATION

Family Physicians are ideal persons to educate and motivate people because, he/she:

(1) Is usually present at the time of death.
(2) Is first one to declare and certify death.
(3) Has very good rapport with the family.
(4) His/Her word is a Gospel truth.

FAMILY PHYSICIANS IDEAL FOR EYE BANKING

Family Physicians working for an Eye Bank are ideal because, he/she:

(1) Is available round the clock at all places.
(2) Can master the Enucleation technique and other medical aspects of eye banking very easily.
(3) Eyes can be retrieved very early after death and in turn better quality of donor cornea is ensured.
(4) Is like a family member of bereaved family. Enucleation done by him/her is more acceptable to the family then the call attended by eye bank technicians or Ophthalmologists.
(5) It is not much taxing on their professional practice or family life. The fear of compromising with their practice and family life, very often, is misplaced.







CORRECTIVE MEASURES

Doctors should be exposed to the problem of Corneal Blindness, Eye Bank and it’s working from their student days in medical colleges.

If, Doctors get necessary training in Eye Banking, at this stage, then they will be definitely interested in motivating general public for eye donation during their professional careers. The will also extend co-operation to eye banks all over India, thus helping the National cause of “Removal Of Blindness”.

For government agencies this is very easy. If following suggested measures are implemented now, the problem of corneal blindness will be adequately tackled in near future.

(1) Eye Banking should be included in the subject of Preventive and Social Medicine (PSM).
(2) Performing a few Enucleations should mandatory. At present the medical students have to conduct few deliveries during Obstetrics term and also have to attend post mortem cases during pathology term. Similarly affixed number of Enucleations, also, should be a part of medical education. This can be easily implemented during anatomy term, when students dissect human body. Enucleation can be practiced on postmortem cases too.
(3) One to two weeks of practical training in Eye Bank should be a part of Internship. Performing Enucleations at donors’ residence will expose them to emotional atmosphere prevalent in bereaved family.
(4) This requisite will provide functioning eye bank in all medical colleges augmenting number of eye banks in India.
(5) Private charitable trust hospitals should be encouraged to set up new eye banks with the help of local doctors and social workers.
(6) Trained family physicians should be given a chance to take active part in eye banking by teaching others with lectures, training them with audio-visual aids and practical demonstrations.
(7) Facilities for training in eye banking should be made available to family physicians, who are interested in serving eye banks.
(8) Government authorities and Social service organizations should spare more energy and funds to tackle problem of corneal blindness, in view of affliction of young people.
(9) Mass media should take up the cause, give regular publicity and create awareness for Eye Donation as is done for blood donation and AIDS awareness.

RECOMMENDATIONS

(1) Training in Eye Banking should be a mandatory part of the Medical Curriculum.
(2) Trained Family Physicians should be given a chance to take active part in teaching.
(3) The training course in Eye banking should be made available for private practitioners.
(4) Private charitable trust hospitals and similar organizations should be encouraged to set up new eye banks. Its working should be totally transparent. An Ophthalmologist should be the Medical Director, looking after the quality aspect and other medial technicalities only. Day to day administration and other working should not be looked after by an Ophthalmologist.
(5) Government Authorities and Social Service Organizations should spare more funds and energy.
(6) Mass media should take up the cause, publicize it regularly and educate people.

BACKGROUND AND AIM: Recent studies suggest the development of a procoagulant state with hemodilution. We conducted this study to investigate the effect of hemodilution, by the priming solution in a cardiopulmonary bypass (CPB) circuit, on "point of care" coagulation assays (activated clotting time [ACT] and thromboelastography [TEG]). METHODS: Twenty patients undergoing cardiac surgery with crystalloid priming of CPB circuit were evaluated. Confounding variables arising from contact activation were eliminated by minor modifications. Ten milliliter per kilogram body weight of priming solution (lactated Ringer's) was infused via the aortic cannula. ACT and TEG were performed, both prior to and immediately after hemodilution. In case of latter, four variables, reaction time (r), coagulation time (k), maximum amplitude (MA), and clot formation rate (angle alpha), were estimated and considered for the results. To see if these results are duplicated "in vitro," prebypass blood samples from eight heparinized patients, diluted (4:1) with priming solution from the venous reservoir, were also analyzed. RESULTS: Falls in ACT, from a mean of 659.7 (+/-260.6) seconds to 251.5 (+/-103.2) seconds (p < 0.01), r time (678.1 [+/-318.1] sec to 468.7 [+/-152.7] sec) (p < 0.01), and k time (211.7 [+/-161.7] sec to 123.8 [+/-32.1] sec) (p < 0.05) on TEG were noted upon hemodilution. Angle alpha and MA increased, but were not statistically significant. Results from the in vitro study closely matched the results from our in vivo analysis. CONCLUSION: The study suggests that hemodilution by crystalloid priming solution may impair the efficacy of anticoagulation during CPB. The mechanism for this phenomenon remains to be elucidated.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether mitral valve repair at the time of coronary artery bypass grafting (CABG) in patients with coronary artery disease and mild to moderate mitral insufficiency improves short and long-term outcome. Altogether 465 papers were found using the reported search, of which 16 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is good evidence to suggest that moderate mitral regurgitation in patients undergoing isolated CABG adversely affects survival and mitral regurgitation does not reliably improve after CABG alone. Unfortunately, the evidence to support mitral valve repair at the time of CABG to improve long-term survival is still weak. On balance, patients with moderate ischaemic mitral regurgitation having CABG should have mitral repair at the same time, although the evidence to support this is weaker than one might like.

OBJECTIVE: Ambulatory surgery, where the processes of admission, surgery and discharge are completed within 24h, is an increasingly important part of many surgical specialties. The aim of this study was to evaluate suitability of ambulatory approach for low-risk open-heart procedures. METHODS: A retrospective analysis of 48 patients who had undergone atrial septal defect (ASD) closure at our centre (from October 2005 through November 2006) suggested that this open-heart procedure was optimally suited for treatment with ambulatory approach. Based on this, 15 patients with ostium secundum ASD underwent surgical closure as ambulatory patients, with targeted discharge within 24h of admission. Twenty patients receiving conventional surgery in the other two units of the department served as the control group. RESULTS: Fourteen of the 15 patients were successfully discharged within 24h of admission. One patient remained in the hospital for excess incision site pain and was discharged on the 2nd postoperative day. Mean hospital stay for the entire cohort of 15 patients was 1583+/-669 min, whereas the mean hospital stay in the control group was 9.8 days. Follow-up was 100% complete at 30 days. There were no in-hospital or out-of-hospital complications in either group. No patient was readmitted at our centre or elsewhere for any complication arising from the procedure. CONCLUSIONS: This study suggests that sufficient advancement in cardiac surgery has occurred to permit low-risk open-heart procedures (with an expected uneventful postoperative course) to be performed on an ambulatory basis. Once such a practice is firmly established, expanding its horizon may provide considerable improvement in patient satisfaction, more patient turnover per bed, and significant financial savings.

WORLD ALZHEIMER’S DAY ; 21St SEPTEMBER

21st September is recognized as “World Alzheimer’s day”. It is wrong to say that this day is celebrated as “World Alzheimer’s day” because celebrations are associated for fun or good memories. In case of Alzheimer’s disease, there are sufferings hidden in the disease process. This article may help to find a ray of hope to all Alzheimer sufferers. Today we are completing 103 years to discover the Alzheimer’s disease but still there are lots of gray areas in the field in terms of understanding the cause, diagnosing it and getting proper treatment to find the solution.
What is Alzheimer’s disease?
Alzheimer’s disease is a type of mental disorder which affects the process of memory related functions of the brain. As on date, it is considered as incurable disease. The progress of Alzheimer’s disease is very slow but affects permanently which wipes out the process of thinking, judgmental skills and finally an affected person becomes incompetent to carry on day-to-day activities for his own survival. Most of the cases are over the age of 60 but the pathology of this disease starts 10-15 years before the symptoms are noticed. At the beginning, the symptoms are taken very casually where the seriousness is hardly known to anybody. Gradually the disease spreads in other parts of the brain which interferes with all the physiological functions of the brain.
Medically, it is recognized as gradual degeneration of the brain tissue. The disease is named based on the observations done by German psychiatrist and neuropathologist Alois Alzheimer in 1906. He was the first to correlate the symptoms of memory loss and the structural changes in the brain of a lady after she died. He found that the brain of the lady had tangles and a plaque made from protein fragments and the entire structure was drastically changed. It is now over 103 years after the disease is known to the medical fraternity but there is no remedy to cure it.
What is the cause?
The short answer to this question is “Not known”. There are some imaginary theories based on epidemiological data as follows:
1) Depressed individuals are more prone to Alzheimer’s disease.
2) Statins (the drugs given for cholesterol lowering) increase the incidence Alzheimer’s disease. Recent research from Prof. Yeon-Kyun Shin, Iowa State University has recently published a report on his exhaustive work on this subject.
3) It is likely that the causes include genetic, environmental, and lifestyle factors. A gene located on chromosome 19 is associated with late onset Alzheimer's disease.
4) Other risk factors for Alzheimer's disease include high blood pressure (hypertension), coronary artery disease, diabetes, and possibly elevated blood cholesterol.
5) Some studies have found that women have more risk for Alzheimer's disease than men.
6) Few studies have proven that Alzheimer’s disease is more prevalent in cases of previous head injuries.
7) It is also studied that Estrogen therapy after menopause triggers Alzheimer’s disease.
But these causes are completely hypothetical. There is no concrete data available to understand the real cause. Hence it is extremely difficult to adopt any precautionary measure to prevent or treat Alzheimer’s disease.
Since medical fraternity has hardly anything to offer for Alzheimer’s disease, caregiver plays a major role in management of such cases. Common suggestions are given to the sufferers like regular exercise, good diet, peace of mind, hygienic surroundings, pleasant atmosphere with cheerful communication etc. Practically all these recommendations are good for any individual for overall health and wellbeing. There is nothing specific attributed to Alzheimer’s disease.
What is the treatment of Alzheimer’s disease?
The shortest answer to this question is “No treatment”. According to modern medicine, when the cause is not clearly understood, how can there be a solution? Most of the diseases of infectious origin, the causative organism is detected and hence it becomes easy to find a recipe to overcome the infection. In the diseases of systemic origin, the pathophsiology is understood properly and the treatment becomes easy. In Alzheimer’s, the picture is different. The disease mechanism is unknown and hence “No treatment”. There is one drug, Donepezil which is used to treat symptoms of Alzheimer's disease in individuals with mild to moderate illness. The drug may cause small improvements in dementia for a short period of time, but donepezil does not stop the progression of Alzheimer's disease. Donepezil helps prevent the breakdown of acetylcholine in the brain, thus temporarily increasing its concentration. In doing so, it improves the thinking process by facilitating nerve impulse transmission within the brain. Diarrhea, nausea, and vomiting occur more often with the 10-mg dose than the 5-mg dosage. Other side effects are abnormal dreams, depression, drowsiness, fainting, loss of appetite, weight loss, frequent urination, arthritis, easy bruising, difficulty in sleeping, dizziness, nausea, muscle cramps, headache, or other pains. Donepezil is not safe as it also has interaction with many other medicines which alter its effects. Since there is no other option left, Donepezil is prescribed for Alzheimer’s. The medical field should have open doors to welcome newer ideas and safe drugs to treat this dreadful condition.
What other alternative?
Considering the patho-physiology of the disease, it is rational to think whether Ayurveda can offer something in Alzheimer’s? It is true that the disease was not mentioned in Ayurveda by this name but there many recipes mentioned to treat various kinds of mental, psychological and emotional disorders. While studying the subject, many hidden things came out which are of immense importance in managing Alzheimer’s disease. Few important references are given below to scientific thinkers.
1) Nasal medication has immediate access to the brain as it bypasses the blood brain barrier. Hence the nasal route would be the best route to treat Alzheimer’s disease. Ayurveda has mentioned very clearly that nose is the gateway to brain and diseases attributed to Central Nervous System can be successfully treated only with nasal medication. American Association of Pharmaceutical Scientists (AAPS) has published a research paper on this concept and the conclusion is “In summary, the advantages of intranasal delivery are considerable. It is both rapid and non-invasive. It bypasses the BBB and targets the CNS, reducing systemic exposure and thus systemic side effects. Even for drugs that can cross the BBB, it can reduce systemic side effects by reducing the need for the drug to enter the systemic circulation. It does not require any modification of the therapeutic agent being delivered and should work for a wide range of drugs. Intranasal delivery may facilitate the treatment and prevention of many different neurologic and psychiatric disorders”.
S Talegaonkar, PR Mishra; Indian J Pharmacol June 2004 Vol 36 Issue 3; 140-147
2) Human brain is made of approximately 70% fat and 30% protein. Therefore it has a natural affinity towards lipids for its normal functioning. Considering references from Ayurvedic texts, cow ghee is the best available lipid and has 3 different actions on the nervous system. Acquisition, storage and recall are the 3 basic functions of the brain and cow ghee possess the properties to enhance these three fold brain functions. It is as simple to understand that water is not easily soluble to oil but another oil or ghee can easily be absorbed. Therefore water-soluble or water based drugs do not penetrate the brain easily. This concept also goes very scientifically with the research on new drug in Europe for Huntington’s disease. Huntington’s disease ("HD") is a genetic neurodegenerative disease characterized by movement disorder, dementia and psychiatric disturbance. Early symptoms might affect cognitive ability or mobility and include depression, mood swings, forgetfulness, clumsiness, involuntary twitching and lack of coordination. Later, concentration and short-tem memory diminish, and involuntary movements of the head, trunk and limbs increase. Eventually, the person is unable to care for himself or herself. Death follows from complications including choking, infection or heart failure. The drug developed for treating this is basically an Omega 3 based fatty acid, given orally and has proved quite effective. The drug is in the process of launching world-wide in a short span of time. Ayurveda has given emphasis on Cow Ghee which is also a fat, easily available and has been an household item of Indian kitchen.
3) A brain wave ‘p300’ is linked to memory and learning. The faster the rate of transmission, the brain functions more efficiently. Researchers took 26 volunteers hooked them with electrodes and checked their p300 rate. Immediately after taking the test, they were given DHA (derivative of Omega-3). Two hours later, their brain waves were measured, and this time the p300 rate was significantly faster in the group. This supports importance of lipids in the neurotransmission as well. What Ayurveda has recommended also goes very much hand in hand with this research. Therefore in Indian tradition, it is customary to put few drops of oil (the purpose is to introduce a fatty substance) during massage given since infancy period.
Myanaga, K., K. Yonemura, and K. Yazawa.
International Conference on Highly Unsaturated Fatty Acids in Nutrition and Disease Prevention. 1996 Barcelona, Spain.
4. The nasal route is studied for the administration of systemically active drugs because delivery is convenient, reliable and rapid. A drug developed was administered through Nasal route and the florescent imaging showed that the absorption is 100 ± 30 % just within 1.5 minutes
Ref: Maria Dahlin and Erik Björk; Department of Pharmacy, Division of Pharmaceutics, Uppsala University, Biomedical Center, SE-751 23 Uppsala, Sweden
5. Another research from VA Medical center, San Francisco, USA which is published in the journal “Future Neurology” in 2008 says that ‘The nose may help the brain; intranasal drug delivery for treating neurological diseases.
There are end number of research papers published which give us a guideline to treat neurological diseases and which could be a breakthrough in treating Alzheimer’s disease. Not only Ayurveda but even modern research also supports the concept of treating the brain diseases through nasal route. Importance of Lipids in neurological diseases is also established by modern medicine which is evident in Ayurvedic classics. Indian traditional way of life supports the theory of using unctuous substances for lubricating the sense organs which are the sensory paths to access the central nervous system. In spite of that why do we still pursue the issue of Alzheimer’s disease?
When should one start Nasal treatment?
The symptoms of Alzheimer’s disease start appearing after 10 to 15 years later after the actual pathology starts in the brain. Therefore it is extremely important to start the treatment at the age of 50.
There are many herbs proven to have phenomenal improvement in the brain at the cellular level. The well known are Brahmi (Bacopa monnieri), Ashwagandha (Withania somnifera), Shankhapushpi (Evolvulus alsinoides), Vacha (Acorus calamus), Saffron (Crocus sativus), Tulsi (Ocimum sanctum) etc. Oral medicines find difficulty in reaching the brain as there is a physiological mechanism called Blood Brain Barrier which prohibits the absorption. Therefore it is practical to use these herbs in the form of nasal medication and also should be processed by special method called “Sneha - Paka - Widhi” described in Ayurveda. This will bypass the Blood Brain Barrier and allow the active herbal constituents to reach the central nervous system and arrest the progress of Alzheimer’s eventually. Besides this, the nasal medication also helps to improve vision, arrest hair fall, prevent graying of hair, improve hearing and many other diseases attributed to ENT and supra-clavicular disorders. Like synthetic drugs have side effects, Ayurvedic drugs have side benefits. Unknowingly these formulations impart some added benefits and contribute to positive health achievements.
As on date, there is no technique available to detect or forecast the Alzheimer’s disease in advance. Therefore it is safe to start such nasal medication at the age of 50 and keep fingers crossed and think positive for gaining élan health in older age. Ayurveda recommends this nasal treatment should be done daily, 4 to 6 drops in both the nostrils, preferably in the morning or evening. It is good to take a sip of warm water after introducing the drops if there is a feeling of the contents coming in the throat. Since the base is ghee, the bottle should be made warm to liquefy the contents in case it is not properly flowing.
Considering the research in modern era and viewing the verses in Ayurveda it becomes evident that Ancient science has enormous hidden potential. It is rather a golden treasury for human beings but needs to be explored and understood properly. Many times it seems that Ayurveda has given short verse with big meaning which is equivalent to one doctorate in that field. It is just like a question asked and the answer given in Ayurveda, modern research helps to find the various steps involved in getting the answer.

Dr. Santosh Jalukar

№ 9969106404