Dr Sundaram Natarajan, globally renowned vitreo-retina surgeon, visits Kashmir every month. He was in Srinagar for the third time lately for the treatment of pellet hit victims on voluntarily basis. In a free-wheeling chat with Saima Bhat, the doctor depicts the medical situation in valley
KL: So doctor, how do you see the situation in Kashmir?
Dr S Nataranjan (SN): It is quite terrible and unfortunate — especially the calamity of eye injuries. Frankly speaking, the condition of injured is complicated as pellets have ripped their retinas. Fixing them require multiple surgeries. But given the nature of the injury, these patients now need psychologists, who can keep them in a right frame of mind. These patients keep coming, questioning: why aren’t they able to see, or why they developed same problem again. Though I assure them that their sight will get restored sooner or later, but then their desperation is understandable. You see, this is a long term treatment, spanning over months.
KL:But as of now, I mean after surgery, how are these patients doing?
SN: Many patients are doing well after surgery. You know, we retina surgeons keep facing this dilemma from patients — whether or not, their sight get restored. In our line, sight is not directly proportional to immediate treatment. It takes time. Lately, I along with other two doctors operated pellet-hit patients from morning till midnight. Around 20 of them can’t see immediately. That’s why I believe in 5P’s: perseverance, persistence, prayer, patients and precision. Moreover, as a surgeon, we can be sympathetic not empathic.
KL: Alright. So, how many surgeries do these patients require precisely?
SN: Some may need one; but some more than one. But see, since we are tackling mostly young patients here, we are encountering with a different kind of problem. These are all young people, theyhave got blood in their eyes. We call it vitreous hemorrhage. The vitreous is attached to the retina like a gum on silk. So, problem is, we have to remove that blood clot with highest efficiency. We have to make sure not to tear retina. But the problem is, pellets tears retina. For that, we use laser treatment. Once that is done, then we have to treat cell of an eye — retinal pigment cells, which nourishes retina. It comes into the vitreous and then it migrates. In the process of natural healing, it develops scar.
KL:In that case, doctor, are we staring at retinal crisis over here?
SN: Indeed. But please understand, retina helps us see the colour, vision, 3D — so no part should wrinkle. To keep that in position, we have to struggle. We call it proliferative vitreo-retinopathy and it is a challenging injury for surgeons. Unfortunately, 80 percent of the injured patients here have one eye injury. I remember, whosoever we operated, are surgically successful. It is a psychological trauma, we have to boost their morale.
KL: In view of this “trauma”, what are the possible impairments they are likely to face?
SN: They can do any work except flying. They can take a job, which doesn’t require two eyes. You see, in USA, they have car driving license for one-eyed person, but in India such laws don’t exist. I am sure you must have heard about cricketer Nawab Pataudi. He had lost his one eye in accident. But still, he played cricket. I remember, he once said in his interview, when he hit a six, he didn’t see the ball “but bowler’s action”. By judgment, he could hit a six.
KL: But, do you thing, faking normalcy will help these kids?
SN: I know they have lost their one eye, but they should not lose hope. It is not possible that a patient will regain sight overnight. As I said, it is going to take some time.
KL:Alright. So, how is the mood inside the Operation Theatre these days?
SN: It is like a war-field. You see, when I do surgery, inside an eye it is like driving in a snow storm, where we can’t see anything. So, we have to first clear the blood drenched area and then operate. It is big challenge for a surgeon. Here we have to talk a lot to a patient after performing surgery. But usually I prefer to talk before surgery. After surgery, patient has to wait for natural healing. Both dawa and dua are needed here.
KL: Indeed. But do you have adequate facilities in hospital?
SN: I am happy the department is well-equipped in SMHS. I met chief minister Mehbooba Mufti and asked her to equip other two operation theatres — so that, we can have three fully equipped functional OTs. We have been promised trauma centre, too. But we sincerely hope the pellet injuries somehow stop now.
KL: Since you just mentioned pellet — so, can you elaborate on the impact of pellet on eye?
SN: An eye is like a tomato. And when a high velocity pellet hits it, it produces tear in the cornea and injures retina, thus triggers hemorrhage in the back of an eye. The impact either tears retina or detaches it. Some develop late retinal detachment. It goes to the centre of retina called macula. Unfortunately, we don’t have any treatment to transplant or regenerate macula or optic nerve. These two areas we can repair but we can’t make cells to regenerate.
KL: What about the embedded pellet? Are you able to remove it?
SN: Pellet that pierces eye comes out in most of the cases. It mostly embeds into orbit. We remove it through incision.
KL: Okay, but how much chances are there that these patients can regain sight?
SN: That is what we are waiting for. Any retina surgery needs 6 weeks to heal. I think many patients are happy but scientifically we have to analyse first. But some has recurrent retina problems. We are operating those patients again. I think we have to analyse them in 3 to 6 months. Many patients have regained just 5 percent sight, but few, even 70 percent.
KL: How many patients you operated upon so far?
SN: Till Sept 22, of 800 eye injury patients at SMHS, the department treated 750 for wound repair. Of them, 360 received vitreous surgeries. These surgeries were done by all four surgeons of SMHS and some visiting surgeons. I did 124 surgeries myself.
KL: Did any of them visit you in Mumbai as well?
SN: Yes, two patients. One was injured on August 31 and he is doing extremely well. He had got the first wound repair here in Kashmir. He had a cornea wound, which is going to take some time to heal. The second patient was Insha. A lot of people wrote to me to operate her. I was hesitant operating her. There was no light perception. She had brain injury and then meningitis, brain infection. I was hesitant. But many requested including doctors from US, England, who wanted to sponsor her treatment of retinal transplant—artificial retina—costing around Rs 2 crore. But this treatment is not eligible for any injury patient.
KL:Are you saying, no medical treatment can restore Insha’s sight now?
SN: Insha’s retina is in a very bad condition. Besides, she suffers from other eye complexities like vitreous hemorrhage, hemorrhage behind her retina and choroid detachment. In such kind of patients, we take consent from patients because the chances are very low. She agreed to treatment. Her surgery has gone well. But pellet has sliced part of her retina. One third of her retina is missing. So whatever was there, we cleared the blood and put the retina back. Let’s hope for the best.
KL: Earlier you termed it a “war-like situation” in Kashmir. How is the situation now?
SN: I am here for the third time. My friends ask me, how is the situation and security in valley? I tell them only ambulance is a security for me. I believe on the ‘secret’ book by Rhonda Byrne, where author writes: people think about what they don’t want and attract more of same. So I am imagining there is peace prevailing and peace is happening. I want same Kashmir, the one I visited during 80s.
KL: That indeed sounds like a wishful thinking, doctor! But do you get to treat such patients from any part of India as well?
SN: I have treated bullet and grenade injured in Chennai, but not pellet. It is for the first time that I am treating pellet injuries.
KL: Aren’t some doctors saying that pellets leak out eye fluid, then, how successful are these surgeries?
SN: See, eye is gel and tissues, so it doesn’t collapse fully. We stretch it and it gets again filled with fluids. Then we do rest of the surgeries.
KL: Any particular case that is hard to forget?
SN: Almost all. ButI did this recurrent retina surgery on a 5-year-old child. It went good, and I hope there are chances of improvement. See the problem in retinal surgery is recurrent retinal detachment. One day we have to inject oil; and then next day, remove that oil, scar in tissue and again re-injected oil. It looks like a mechanic repairing car. We have to struggle because in the natural healing of eye, it produces scar and then, scar produces retinal detachment which makes retina thicker. That is why we have to give time between two surgeries. It should neither be too early nor too late.
KL:By attending an unabated rush, how do you keep yourself going?
SN: It is frustrating. I keep motivating myself. I keep telling my patients that if they get even 1 or 20 percent, they should give us blessings as 100 percent normal vision is impossible.
KL: Last of all, what is the status of eye care facility treatment in valley?
SN: Actually I want to encourage everybody to be operated here in Kashmir. They go outside as they see the other side green. We have best facility here. And my dream is Kashmir’s trauma centre to be known as the best in world.
