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World Patient Safety Day: Avoid putting anything in the eyes without consultation

Interview with Dr Shalinder Sabherwal, Dr Shroff's Charity Eye Hospital

shalinder Dr Shalinder Sabherwal

What does world patient safety day mean and how seriously is it taken in our context?

Patient safety is critical and is taken very seriously by organisations such as ours that do a high volume of work. For eye care and healthcare in general, there are various processes involved in delivering the right treatment to the patients, including the right environment to provide patients advanced treatment facilities with assistive technologies. Most of our work in eye care is surgical, and any infection in the eye during surgery can be very serious, leading to the loss of the eye.

What are some examples of processes involved in eye care?

At Dr Shroff’s Charity Eye Hospital, when we come across a patient who requires surgery, there are protocols we follow regarding the kind of investigations they should undergo to determine how to have a safe surgery. Right now, most of the surgeries happens under local anaesthesia or even topical without injection but some surgeries require general anaesthesia.

Prior to any surgery, proper care is given to the patient. Adequate time is given to be mentally and physically prepared, for the surgery. During any eye surgery, we take care that the surgery is performed at a facility with required facilities to perform the surgery, and that equipment is properly sterilized.

Besides that, there are protocols to deal with latent infections that may happen in the environment and cause problems. Bodies like National Accreditation Board for Hospitals (NABH) define these protocols.

We also take care of infections, complications and postoperative follow-up rates. Shroff’s charity eye hospital tries to maintain a follow-up rate of 80-85% final follow-up. However, 50% of our patients come from primary-level and remote places, therefore, sometimes it becomes difficult for us to encourage patient from these geographies to come for follow-ups. Patients follow up treatment as soon as they start to experience better vision which happens after just one day of treatment. However, our focus is to accelerate follow ups with as many patients as possible to ensure patient safety and provide best eye care facilities.

How do you follow up with people coming from remote areas? Is it done telephonically?

Our organization follows two models, which help us to better cater to such areas: the cross-subsidy model and the hub-spoke model. These models are designed to ensure that those who do not have access to quality and affordable eye care are provided the same at minimal or no cost. They have designed to ensure access to people from the remotest of regions.

While the cross-subsidy model works on economies of scale by ensuring large number of surgeries for people from high income groups, the hospital is able to ensure that 50% of its surgical work is reserved for people with minimal or no access to quality eye care.

The hub and spoke model on the other hand, consists of doctors engaging in door-to-door screening at a village level which helps us identify ailments quickly and refer patients to primary eye care centres also called vision centres. And in case, if the condition cannot be treated at a vision centre level, they are referred to a secondary centre. While the Daryaganj (New Delhi) hospital is the hub and the base unit where all the super specialists are present, the spokes (the secondary centres and clinics) are distributed across various district headquarters in the states of Rajasthan, Haryana, and Uttar Pradesh. These centres are well equipped with the latest technologies. Only in the rarest of cases are patients still referred to the main hospital in Delhi.

We have a network of these private care centres near remote areas, as well as block headquarters. For example, after day one, a follow-up with the surgeon is required, followed by the optometrist and technician at the vision centre, and these centres are linked to the main centre via teleophthalmology. Only after that is a decision made by the doctor as to whether the patient should travel. I would estimate that 70 to 80% of follow-ups after day one take place at these centres located closer to the patients.

What are the most common eye ailments that afflict Indians, especially those in rural India? Does our genetic makeup predispose us to some specific kind of ailments?

The condition which mainly causes blindness, loss of vision, or visual impairment is cataract. We aren't so sure about the genetic makeup, but Indians are more prone to early cataracts as compared to those in. the West. It could be hereditary too. There are some cataracts that are age related but then Indians are also prone to getting them as early as 40 years. Since 60-70% of our population is rural, a lot of agricultural injuries happen which cause corneal opacity, which is also the second most common cause of blindness in India, according to the National Family Health Survey.

Our environment also plays a role and effects our eyes. For example, our regions remain considerably hot and humid most of the times. These conditions are congenial for infection causing organisms to grow.

Other conditions are like the rest of the world. Myopia is a worldwide phenomenon that is also occurring in India because of all these near vision activities (eg. screen time). Diabetes is much more common in the Indian population due to genetic susceptibility. There are many cases of diabetic retinopathy, particularly in South India. The cases are fewer in the north, but it is an emerging condition, and not much can be said about it for now.

For age-related cataracts, other than family genetics, are there other contributing factors?

Some of the responsible factors are:

a)   People spend a lot of time outdoors and are affected by the ultraviolet rays as the country is sunnier

b)   India is known to be a diabetes capital of the world. Co-morbidities like diabetes can lead to early cataracts and early maturity of the cataracts. Cataract in a non-diabetic patient, takes more time to get to a surgical stage than a person with diabetes or uncontrolled diabetes. Statistics show that 50% of our diabetes is undetected, and among the detected ones, only a few patients go for regular treatment.

Besides diabetes, what other co-morbidities affect the eyes?

Something that we see often are conditions related to blood pressure. Blood pressure does not cause any symptoms and is often detected late during a routine check-up. However, we have started observing some associated retinal ailments that are sometimes not very serious but can be vision threatening because of uncontrolled blood pressure. Hyperthyroidism can also cause serious complications in the eye at all levels, from the lid to the cornea, and may even infect the optic nerve present deeper inside the eye.

Is there a change in ailments over the years that you see in the Indian demographic?

It is difficult to say, but I believe that as we get older, we see more glaucoma and age-related macular degeneration. Myopia is becoming more common in people of all ages; previously, it was mostly seen in teenagers. Conditions such as dry eyes may have become more serious over time. It is attributed to the pollution level in which we live in as well as the amount of screen time we are exposed to. Dryness, which was never a problem for children, is now affecting young children and adults.

Are dry eyes reversible?                                   

The condition can be improved to some extent through lifestyle changes. Fortunately, there are numerous lubricants available to help you get through the symptomatic period. These (lubricants) in general, have few side effects and can have a positive impact as well. However, it is always advised to consult an ophthalmologist if the condition stays for a while and causes disruption in daily activities. Normally dryness caused by prolonged screen activity is reversible. It may be irreversible if there are other eye diseases or systemic diseases like autoimmune disorders.


How does diet impact the health of our eyes?

For children, vitamin A deficiency, has both direct and indirect impact. Such situations can sometimes not only be eye-threatening but also fatal. Eating good and fulfilling foods such as fruits and green, healthy vegetables makes a big difference. If you are eating a balanced diet, there is no need for supplements.

Is it safe to use over-the-counter drops to enhance vision without a doctor’s prescription?

We need to know how much, if any, benefit they offer or are just placebos. There is a cost involved and these can also cause inconvenience to the patient. Regarding, homeopathic or allopathic drops, I strongly advise that any such drugs be used only after consulting a doctor because some of them contain potentially harmful ingredients. For instance, giving steroid drops for a minor ailment can have side effects and may worsen the condition.

Many problems arise when people stop going to the doctor but continue to use the drops, or when a chemist prescribes high-concentration medicines for minor ailments, which can lead to glaucoma and actual vision loss. Besides, some of these drops frequently contain chemicals that may not be directly harmful, but their preservatives can cause a lot of corneal surface irritation, which would eventually be harmful in the long run, causing toxic corneal conditions. So, if you're thinking about putting drops in your eyes for both long- and short-term purposes, I'd recommend getting a consultation.

Is there also a marked gender differential in those who seek care for eye related problems?  

According to global statistics, women account for 55% of all eye problems and impairment. One factor is that women have higher longevity than men. Most eye disorders, such as glaucoma, cataracts, and other diseases, worsen with age. We conducted a multicentric study based on access to cataract services and discovered that women had cataracts for a longer period and had poorer vision. Women also tend to wait until the condition turns very bad before seeking treatment for a simple one-time intervention surgery like a cataract.

Previously, primary eyecare was provided in camps where we saw a higher concentration of men because it was for a set period. Because of their ease of access and availability throughout the day, the eye care and vision centres, I mentioned earlier, have demonstrated greater gender equality.

Our focus is community-based projects and outreach camps.  We're also focusing on door-to-door screening, eye screening, and awareness raising in villages.

Have you witnessed a regional divide in how women access healthcare in terms of the north and the south?

I haven't worked in the south or seen any studies comparing the north and the south, but generally primary healthcare is very developed in most southern states. That takes care of a lot of conditions including eye care. Big players from the NGO sector have been traditionally built, which may have caused some behaviour change over time, which could be why women there (in the South) have better access.


Screen time is a big challenge and we have come to the stage where perhaps it is futile to tell anyone to limit their it. With that given, what is the best that we can do for our eyes?                                                                                                                                                                                                                                                                          

The first piece of advice is to turn off the devices when they are not needed. Follow the 20-20-20 rule, which means for every 20 minutes of staring at a screen, you should take a twenty-second break and look at something at least 20 feet away. It benefits both the eye strain and the muscles. It works out and relaxes the muscles. We advise professionals who must look at a screen to be aware of their blinking because you tend to blink less when looking at a screen.

They can also use supplementary aids such as anti-glare coating on their glasses and keep the brightness of these appliances as low as possible. They may occasionally require lubricants, which may be prescribed on an ongoing basis. Some of these lubricants are preservative-free and thus pose little risk. Not only should children limit their screen time, but they should also spend time outside to slow the progression of myopia.

Glasses are now being sold, touted as having special qualities to protect eyes from the screen. Are there any specific glasses one must invest in or can any O (zero) power glasses be used to protect your eyes from the screen?

You don't need very expensive glasses. But, if you're going to wear glasses, I think it's a good idea to have these anti-reflective coatings. It does provide glare protection. It will not protect you from muscle strain because you will still be focusing nearby, but it will protect you from the glare's dryness and irritation.

One of the components of the program that the Dr Shroff Charity Eye Hospital is training young women to provide ophthalmic care. How many of these women are able to continue in that role after marriage and/or childbirth?

There are no easy answers to that. We take them (girls) right after school for training. They are young and can devote more time to the job. Another thing we discovered during an impact study is that before taking the course, the average age they would consider good to marry is around 20-21, but after taking the course, the age had shifted to 25. The course prepares them to be self-sufficient, financially independent, to have a say in what happens around them, and to have more years on the job.

We are now seeing a trend in our organisation where we are recruiting women from local geographies. So, if you're working in, say, Saharanpur, we'll take them from Saharanpur as well as the blocks or villages where they'll eventually be stationed. We have noticed a trend where some of them are returning to work after their weddings. 

It's difficult to return to work immediately after childbirth because it's a physically demanding job. We have flexibility in our screening programmes when it comes to training women. They do take a break (eg. for childbirth), and then return because these jobs are flexible enough that they can work 2-3 hours in the morning and 2-3 hours in the afternoon. However, in the hospital setting, this is generally not possible. Some of them (women) will leave you for a few years, but we always hope that once they are more stable in their household circumstances, they will return to eye care and help the eye care in general.

What are your five top tips to keep our eyes in good shape all our lives?

One is a regular checkup, which should be done before a condition develops, for both children and also for people over the age of 40. The second step is to take care of your way of life. The third factor is taking care of the co-morbidities that we discussed. If you have diabetes and a hypertensive thyroid, you should consult your doctor and get an eye exam as soon as they recommend it. And, if possible, avoid taking things over the counter while waiting for the right prescription.

In UP, have you been able to develop a road map of how to collaborate with and strengthen the government system? The ASHAs (Accredited Social Health Activists) for instance are the biggest resource for early identification and surveillance.

We are working in UP with a large organisation that works for government health structure strengthening, so we are indirectly involved in training at all levels, including that of ASHAs. We also includes paramedics, such as optometrists, who come to our hospital in UP to receive training and credentials.

There are surgeons coming from government institutes for training in some specific conditions other than cataract.

There is a consortium called Vision 2020 India, which is made up of approximately 150 to 200 non-profit hospitals and organisations in India. We are working on developing a strategy for integrating eyecare into primary care. What is currently lacking is trained manpower in the government at the primary level, so the eyes are sometimes overlooked by the health system.

Do eye exercises, such as those in yoga for instance, play a preventive and possibly reversible role in eye ailments?

They have been shown to help in computer vision syndrome- eye strain with computer usage.

We Indians love using home nuskhas (remedies) such as splashing our eyes with rose water. What are your thoughts on that?

People use it for comfort or because of the misconception that it may help to delay cataracts. Cataracts usually take years to develop in people who already have them. It is unproven if these drops can actually help delay cataracts. So, putting something in the eye which could have risky ingredients and paying for that is not the safest option. In the case of using rose water, I think it is best to avoid it if the purity of the product is unclear. Splashing of water is only recommended in case something falls in your eye and there is no immediate access to a doctor. On the eye surface, there is a tear-filled layer present that is meant to protect the eye and increase comfort. Regular splashing of eyes with water (the purity of which you are unsure of) which has minerals or using drops with potentially harmful ingredients can damage the tear-filled layer in the eye. Avoid doing anything regularly with the eye unless advised by the ophthalmologist.

Kajal is very popularly used in our country both as tradition and make up. How safe is it?

We have seen a lot of young kids with heavy amounts of Kajal in the eye, Kajal in itself is not harmful if applied in moderation and outside the eye. Sometimes is applied to children in such great quantity that it tends to go in and not only cause allergies and irritation but can also restrict the drainage of tears. Continued use of kajal can cause inflammation and can cause the problem of watering.  So, it has to be applied in moderation and by making sure that it is not touching the inside of the lid or the eyeball.

People who use contact lenses and eye makeup should take extra care about using it in moderation. Also, make sure that the lenses are worn before applying any makeup and not after. Improper use of contact lenses over long periods of time will cause allergies. Some people become so intolerant that they cannot wear contact lenses in the future. Using everything in moderation and not putting it inside the eye is best.

What is the safest way to wipe off kajal?

Oil is not required to remove it, just water will be enough and if it is applied in moderation then there will be no issue.

(Dr Shalinder Sabherwal is the Head of Community Ophthalmology and Associate Medical Director, Dr Shroff's Charity Eye Hospital, which is India’s oldest eye and ENT care hospital. 

The hospital performs 15,000 free cataract surgeries every year and 50% of its work is done at highly subsidised rates. In 2022, through its outreach programme the hospital covered 3000 villages and screened 30,00,000 people through door to door checking.)

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