Dr Namperumalsamy: A Legend and a Legacy in Indian Ophthalmology

‘To find your mission in life is to discover the intersection between your heart’s deep gladness and the world’s deep hunger’. Frederick Buechner Dr Namperumalsamy, or Dr Nam, for his students and admirers globally, is an iconic figure in Indian Ophthalmology and his life and legacy could well be an inspiration to generations of ophthalmologists. With humble beginnings from a farmer’s family raised, in rural Theni district of Western Tamil Nadu, his life saw a meteoric rise, not just as one of the pioneering Vitreo retinal surgeons of India, but also in leading one of the largest eye care organizations in India to excellence in patient care, training and research. His overbearing passion, however, was even more towards a fundamental need in Community Ophthalmology to be able to bridge the last mile in eye care coverage and bring the best of eye care to those who cannot easily access it. It is not very common in the field of Medicine, to see a highly accomplished professional in an area as super specialized as Retina and Vitreous, to leverage the advances in technology and exploit it to reach the common man through tele-consultations, mobile screening and technology enable primary vision care centres. All with a passion to see every common man, in even the remotest of geography, gets affordable eye care. FROM AMBASAMUDRAM TO AMERICA - THE MAKING OF A VITREO RETINAL SURGEON Born into a humble agrarian family in Ambasamudram, a village in the Theni District of West Tamil Nadu, Dr Nam’s parents [Figure 1] had a significant influence in ensuring good education for him and his siblings. With meagre agricultural incomes and several siblings to support, Dr Nam had to depend upon government scholarships to fund his higher education and completed post-graduation in ophthalmology at the prestigious Madurai Medical College in 1966. He was married to Dr G Natchiar, a colleague in the department of ophthalmology and sister of Dr G Venkataswamy, who also was his mentor, which was a significant event in his life that paved way for much of his professional accomplishments in the next five decades [Figure 2]. Close association with Dr G Venkataswamy, who later founded the Aravind Eye hospitals, was a major influence in his personal as well as professional life for the next four decades. He taught, mentored, and guided Dr Nam and in the initial decade of their association, Dr Nam had travelled to every corner of Tamil Nadu attending eye camps, learning nuances of large volume cataract surgery, mastering eye care management and importance of community ophthalmology and its role in eliminating avoidable blindness in poor-resource settings.Figure 1: Parents of Dr Nam, who had inspired him to take up medicine as his professionFigure 2: Dr Nam with Dr G Venkataswamy (Right), who was his greatest inspiration and Mentor, and Dr G Natchiar (left), who had supported him throughout in his professional and personal lifeThe Government Erskine (Now Rajaji) Hospital in Madurai Department of Ophthalmology was led by Dr G Venkataswamy, attracted many visitors from abroad. Impressed by the interest evinced by Dr Nam in posterior segment diseases, Dr Morton F Goldberg, from the University of Illinois offered a 2-year fellowship training in Vitreo retinal diseases [Figure 3]. Dr Nam was trained by Dr Gholam Peyman in Medical retina and was also part of the multi centric clinical study on diabetic retinopathy (DRS) conducted by the National Eye Institute, USA. This laid the seeds of his interest in retinal diseases, and in particular, diabetic retinopathy that preceded his trail blazing contribution to management of this disease later in India.Figure 3: Dr Nam and Dr Natchiar with Dr Morton Goldberg in the University of Illinois, where he received training in Medical Retina and Diabetic Retinopathy which inspired his crusade against Diabetic Retinopathy in IndiaYet another major landmark event was the opportunity to be trained under Dr Charles Schepens, the father of Retina Surgery and the inventor of Binocular Indirect Ophthalmoscope, in the Surgical Retina Speciality at the Retina Associates, Harvard Medical University in Boston. Observing Dr Nam’s interest in posterior segment diseases, Dr Schepens offered the opportunity to be trained as his fellow when he visited Government Rajaji Hospital [Figure 4]. This led to establishment of the Department of Vitreo Retinal diseases, the first of its kind in the country. When Dr Nam joined Aravind eye hospital in 1977, the department was established under his leadership and fellowship program was also started that led to training of hundreds of ophthalmologists in the country, many of whom continue to be leading vitreo retinal surgeons [Figure 5].Figure 4: Drs Nam and Natchiar with Dr Charles Schepens, who was instrumental in training in Retina and Vitreous Surgery in the USFigure 5: Dr Nam with a few Vitreo Retina Fellows trained by himA LIFE TIME OF CRUSADE ON DIABETIC RETINOPATHY Dr Nam considered prevention of blindness due to diabetic retinopathy as his life’s mission and pioneered several initiatives towards this objective. With institutional support from the public (Technology Information Forecasting and Assessment Council [TIFAC], Government of India), international NGOs (Lions International), World Diabetes Federation, and other public–private partnerships, Dr. Nam launched an ambitious Aravind Diabetic Retinopathy Project in 2000 to address various aspects of care for diabetic retinopathy [Figure 6]. These included an inclusive diabetic eye screening model, defining the care pathway from community to tertiary level; developing retinal lasers, ophthalmoscopes, software for automatic grading and reading fundus images; and translating many bench-to-bedside and bench-to-community research ideas. The software for grading diabetic retinopathy was one of the first attempts in India to evolve machine learning for automated diagnosis of diabetic retinopathy. He facilitated collaborations with diabetes hospitals and physicians and Diabetic retinopathy screening in the communities continues to evaluate thousands of diabetics every year to detect and treat all forms of diabetic eye disease. In the last year, 25,795 diabetics were screened for diabetic retinopathy. He had set up mobile vans with tele-communications technology equipped with fundus cameras that could transmit high-quality fundus images to remotely based ophthalmologists that could enable screening across distance barriers, addressing the issue of accessibility of eye care services in rural communities. He pioneered public-private partnerships by collaborating with primary health centres, equipping them with fundus cameras and screening diabetics who attended for their periodical monitoring of glycaemic status and obtaining their monthly oral anti diabetic agents.Figure 6: Dr Nam with Dr APJ Kalam, a former President of India, whose association with Dr Nam for nearly three decades inspired his efforts to leverage technology in DR screening, research and primary eye carePROMOTING CENTRES OF EXCELLENCE IN EYE CARE Though combating diabetic retinopathy and consequent vision impairment from diabetes was his overarching passion, he was equally persuasive to ensure preventable blindness of any cause is to be proactively detected and appropriately managed before visual impairment sets in. Dr Venkataswamy had strived to evolve an equitable, sustainable eye care delivery model that addressed the cataract blindness in adequate measure. Building on the legacy of his mentor, Dr Nam focused on promoting centres of excellence that would evolve affordable models to tackle age related macular degeneration, glaucoma, retinopathy of prematurity, retinoblastoma. He encouraged and actively facilitated his ophthalmologists to proactively evolve models of screening for diseases like ROP (Preterm neonatal screening), refractive errors (Mobile ophthalmic screening with on-the-spot spectacle delivery), school health screening initiative and screening family members of persons with glaucoma. Since Retinoblastoma affected children mostly in lower socio-economic strata, he facilitated setting up Endowment funds (Ring of Hope) to support the treatment of these children, including their systemic management. ENABLING LAST MILE COVERAGE IN EYE CARE – LEVERAGING TECHNOLOGY TO ACHIEVE UNIVERSAL EYE COVERAGE Even two decades prior to the global surge in telemedicine platforms in healthcare to transcend the distance barrier divide, Dr Nam had helped set up healthcare access technologies such as telemedicine-based consultations by establishing IT-enabled primary vision centres in rural areas where eye care was not available. These were staffed by trained vision technicians who could perform essential eye examinations and facilitate tele consultations with ophthalmologists from tertiary centres. Influenced by both Dr. Venkataswamy and Dr. A. P. J. Abdul Kalam, the former President of India, he leveraged primary vision centres to ensure that eye care was available at the doorstep of the common man with a deep knowledge that less than 7% of those in need of eye care ever utilized the community outreach camps. Thanks to his efforts, Aravind Eye Hospital now operates 118 vision care centres, ensuring a wide coverage in most rural districts of Tamil Nadu. In his native Theni district, none need to travel more than 10 km to access eye care. In the two decades since their inception, these primary eye care centres have been able to meet the eye care needs of the entire populations they each serve within 5 years of their commencing services, helping achieve universal eye care in their communities. With a total outpatient visit of 1,019,806 in the past one year, the vision centres recently breached the 1 million barrier new outpatients since their inception. BUILDING THE NEXTGEN OPHTHALMIC WORKFORCE Dr. Nam, a Dr. B. C. Roy awardee, has been an excellent teacher and mentor to hundreds of ophthalmologists at Aravind Eye Hospital and its partnering hospitals. He has served as a clinical teacher and research guide for over two decades. He played a seminal role in evolving Aravind’s residency and fellowship training programs, one of the country’s most sought-after programs. An academician par excellence, he facilitated learning opportunities, inculcating surgical skills, and organizing journal clubs and grand round discussions with leading universities like Harvard and Johns Hopkins through teleconferencing facilities much earlier than the contemporary webinars and virtual clinical discussions. He continues to be a role model to many ophthalmologists around the country in blending professionalism, evidence-based and patient-centric care, and ethical clinical practice. Building the requisite human resource capabilities and skills to take on the challenge of combating blindness has ever remained his priority. PRIORITIZING RESEARCH AS A TOOL TO PROMOTE EYE HEALTH Dr Nam was not complacent with promoting primary eye care and tertiary, curative medicine alone to address the humongous problem of vision impairment. He believed one must find the root cause of the disease and ensure how it can even be prevented. This, he believed, could only be achieved by investing one’s efforts in fundamental and clinical research. Dr. Nam was largely responsible for inculcating a culture of research and fostered the practice of peer-reviewed publications by ophthalmologists at Aravind Eye Hospital. He assiduously built international collaborative efforts with many institutions and universities of repute, particularly in the USA, including the National Eye Institute (NEI), focusing on building and augmenting Aravind’s internal capabilities and talents. He established the Dr. G. Venkataswamy Eye Research Institute that fosters research in basic ophthalmic and applied clinical sciences. Aravind Eye Hospital’s research faculty and clinician-scientists have close to 1544 research publications in the indexed peer reviewed literature in the last decade. Dr. Nam has emerged from the shadows of his more illustrious mentor Dr. Venkataswamy (popularly known as Dr. V). It was never an easy task to succeed Dr. V. But standing on the standards laid down by his more illustrious predecessor, Dr. Nam made giant leaps in inclusive patient care, ophthalmic education, and translational research. While Dr. Venkataswamy focused on cost-effective quality care for cataract blindness, Dr. Nam extended similar affordable and accessible care to several other preventable eye diseases, including glaucoma, diabetic retinopathy, and retinopathy of prematurity. The focus of Aravind Eye Hospital on basic and clinical research in the understanding of infective keratitis, retinoblastoma, ocular stem cell biology, and genetics is largely due to his untiring efforts. His legacy is bound to have a far-reaching impact not only in preventing incurable blindness but also in placing translational ophthalmic research on a firm footing with a potential to probe pathophysiologic mechanisms and possible therapeutic targets for at least some of these blinding diseases. For his many path-breaking contributions to effecting accessible and affordable eye care for millions in India and elsewhere, he was decorated with the Padma Award in 2007 by the Government of India [Figure 7], and the globally acclaimed TIME magazine had chosen him as one of the most influential leaders in the year 2010 [Figure 8]. To the thousands of students mentored and inspired by him, he will ever remain a beacon who had guided their path towards a meaningful life of caring, giving and sharing their skills and knowledge to make their world a better place.Figure 7: Dr Nam was Awarded the Padmashree and Dr BC Roy Award by the Presidents of India (above) and AAO honored Dr. Nam with the Humanitarian Award (below)Figure 8: The TIME Magazine had featured Dr Nam as one of the 100 most influential leaders