Hindsight is 20/20

Are you surprised that I started my first CASI blog post of 2017 with an ophthalmology pun? Probably not, if you’ve read my previous posts.

To quote my last post from August 2015: “It’s unclear as to when I’ll return to India, but I’m confident that it’ll happen someday.” Fast forward to May 2017, and today is that day!

I’ll begin with a quick re-introduction. I’m a Biological Basis of Behavior Major/South Asian Studies Minor at Penn entering my senior year. I was a CASI Intern for 10 weeks in the summer of 2015 at Aravind Eye Hospital in Madurai, India. Immediately after my first Aravind internship, I transitioned into clinical research lead by Dr. Virginia Stallings at the Children’s Hospital of Philadelphia in the Department of Gastroenterology, Hepatology, and Nutrition. Through this job, I have had the wonderful opportunity of working on an intersectional project in ophthalmology, where we are investigating the connections between night blindness and vitamin A deficiency in pediatric sickle cell disease patients. Beginning last August, I became the Student Programs Assistant for CASI, allowing me to work with the lovely Aparna Wilder and CASI staff.

As any of the previous interns can tell you, working at Aravind leaves an indelible impact, particularly if you are hoping to become a physician. For me, it was witnessing not only the compassion shown to each patient, but also the intense discipline with which Aravind employees approach their work. When I left India in 2015, I had a sneaking suspicion that I would eventually return. I don’t think I necessarily anticipated hauling myself halfway across the world two years later, but as time went on my desire to come back to Aravind continually increased. Because I was encouraged to explore ophthalmology through my project at CHOP, my interests in eye health were furthered from both clinical and research standpoints.

Thanks to the generous support of CASI travel funds for research, the International Gelfman Fund, and the Rosemary D. Mazzatenta Scholars Award (as well as the study team at CHOP for letting me leave for the summer), I will spend the next two months conducting research at Aravind’s Pondicherry branch.

To remind you of the astounding scale of Aravind’s services, today alone there are nearly 2000 patients undergoing procedures or receiving consults. Around 400 of those patients, traveling to Aravind from rural eye camps, had cataract surgeries that were free of cost. Cataract surgeries are beautiful to observe due to the sophisticated technical abilities of the surgeons here, each procedure taking merely a few minutes. So far, I’ve realized that the initial feeling of awe one experiences in response to the day to day operations of Aravind are not diminished the second time around. If anything, I am more amazed because I better understand the careful orchestration and logistical planning that goes into ensuring all aspects of the delivery of care run smoothly.

I have been here for a week and a half, and I couldn’t possibly be happier. Upon entering the hospital on a pleasant 108°F day, I was flooded with memories of my first summer in the Tamil Nadu heat. While many aspects of this trip are similar to the first, this experience differs in that I am entering with concrete plans of how I intend to further Aravind’s mission of ending needless blindness.

The backbone of Aravind’s workforce is comprised of Mid Level Ophthalmic Personnel (MLOPs), young women who are trained for specialized duties within the hospital, including Inpatient and Outpatient services, Medical Records, Surgical Theatre, and more.  One such speciality is counseling, and MLOPs in this vital role ensure that patients and their families are fully informed on the details of consults and procedures. In addition to the paying patient group, Aravind is accessible to a diverse patient population due to rural camp outreach and subsidized or free surgeries for low income individuals. In particular, cataract surgeries dominate the majority of Aravind’s procedural workload. In 2015-2016 alone, 262,752 cataract surgeries were performed across Aravind’s branch hospitals. Patient education is essential in producing positive patient outcomes following cataract surgery. As a result, post-operative instructions must be dispensed to patients in a manner that alleviates concerns about recovery and  encourages compliance in applying eye drops and maintaining proper eye hygiene.

MLOP counseling is essential in facilitating a smooth recovery, but one-on-one counseling tends to be inefficient and lacks consistency. This time-consuming protocol also detracts from the clinical efforts of the MLOPs in providing attentive patient care. In order to optimize the counseling process to benefit both the MLOPs and the patients, Aravind recently proposed a group counseling approach to present post-operative instructions to patients. The expected benefits of this model are an increase in efficiency and consistency of instruction, with the added benefit of increased patient morale through the creation of a supportive group environment. The new framework involves a multimedia presentation with audio, images, and text in order to reach patients of high and low health literacies. The MLOPs will also moderate a time in which patients can ask questions and learn from each other’s concerns and prior experiences. We are planning to evaluate the effectiveness of group counseling through an initial questionnaire-based study in which patients will be asked to provide feedback on outcomes, communication, and emotions following counseling. These results will be compared to data collected following the traditional one-on-one counseling procedure. The next phase of this project involves an analysis of counseling efficacy based on a patient’s initial health literacy.

My second project seems to be fueled by a healthy dose of serendipity. My project at CHOP revolves around a visual exam called Full-Field Stimulus Threshold Testing, or FST. This test offers a psychophysical method of measuring an individual’s dark adaptation abilities. FST is an alternative to Electroretinography (ERG), a test that involves the placement of an electrode on the eye to quantify photoreceptor function (which is sometimes not well tolerated by children, as you might imagine). As we have found, FST is uncommon in regular clinical practice, making it hard to compare data with other studies. The science is as interesting as it is complex, and FST has shown great potential as a tool to investigate the effects of clinical treatments for deficits in retinal function.

Much to my delight, Aravind-Pondicherry recently acquired what is allegedly the only FST apparatus in India. It’s hard enough to find groups using FST in the U.S., and I could hardly contain myself when I wandered into the retina clinic and saw the equipment. The ophthalmologists here are having a difficult time getting the test to work, understandably so because the literature is relatively limited. Because I have bothered so many people in the U.S. to ask questions about the test, I have a basic understanding of the procedure and data produced by it. My plan over the next two months is to get the machine up and running for clinical use, practice it with low vision patients, and create a mini-CME course for the retina specialists on the theory and methods of using FST.

I’m so excited to be back at Aravind, and I look forward to sharing updates with you over the next two months!

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About oliviamhess

I interned at Aravind Eye Hospital-Madurai as a CASI Student Programs Intern in 2015, and I am returning to Aravind in Pondicherry to conduct research using CASI Summer Travel Funds, the Association of Alumnae Rosemary D. Mazzatenta Scholars Award, and the Gelfman International Summer Fund.