Gurinder Singh1,2, Jin Ye Yeo3
1Department of Ophthalmology, The University of Kansas Medical Center, Kansas City, KS, USA; 2The University of Missouri - Kansas City Medical Center, Kansas City, MO, USA; 3ATM Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. ATM Editorial Office, AME Publishing Company. Email: editor@atmjournal.org
This interview can be cited as: Singh G, Yeo JY. Meeting the Editorial Board Member of ATM: Prof. Gurinder Singh. Ann Transl Med. 2024. Available from: https://atm.amegroups.org/post/view/meeting-the-editorial-board-member-of-atm-prof-gurinder-singh.
Expert introduction
Prof. Gurinder Singh (Figure 1) is an accomplished Ophthalmologist in the United States. He is board-certified by the American Board of Ophthalmology and has been in clinical practice for the last 40+ years. He holds the title of Clinical Professor of Ophthalmology at the University of Kansas Medical Center, Kansas City, Kansas, and the University of Missouri – Kansas City Medical Center, Kansas City, Missouri.
From the humble beginnings of getting his basic medical training at Government Medical College, Patiala, Punjab, India, to being an Invited Guest Doctor at the Department of Ophthalmology, Hamburg University, Germany, Prof. Singh also had the honor of being a Clinical Fellow in Cornea, Uveitis and Immunology at Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA. He was part of the team that developed the presently used culture medium for Corneal Preservation at room temperature. His interest in Corneal Endothelium and Epithelium has been well-documented in peer-reviewed international journals and textbooks. He has been involved in basic as well as clinical research and introduced the use of mitomycin-C topically to prevent pterygium recurrence in the West.
Prof. Singh had been a scientific reviewer for renowned journals, such as Archives of Ophthalmology, Ophthalmology, American Journal of Ophthalmology, and Cornea, to name a few, before joining the Editorial Board of the Annals of Translational Medicine (ATM) and Journal of Ophthalmology. He has been awarded the Achievement Award by the American Academy of Ophthalmology and The University of Kansas Eye Department, and has been Invited Guest Speaker in Bulgaria, Pakistan, and Belarus. He has been a regular speaker at German Ophthalmological Society meetings and presented his work at American Academy of Ophthalmology meetings.
Figure 1 Prof. Gurinder Singh
Interview
ATM: What motivated you to pursue a career in Ophthalmology?
Prof. Singh: Ophthalmology is one of the unique specialties in medicine where medicine and surgery are bundled together. On one hand, Ophthalmologists treat patients with medicines and drugs for conditions or diseases such as conjunctivitis, glaucoma, episcleritis, and scleritis, to name a few. On the other hand, we perform surgeries on patients for cataracts, uncontrolled glaucoma, retinal detachment, pterygium, etc., and laser procedures for diabetic retinopathy, retinal holes, uncontrolled glaucoma, etc. With the advances in refractive surgery, we offer corrective procedures such as LASIK and photo-refractive keratectomy (PRK) to patients whose glasses and/or contact lenses fail to offer the best corrective vision.
My professor, the late Dr. Dhanwant Singh, MBBS, FRCS (London), motivated and convinced me to adopt the specialty of Ophthalmology as a career within the medical field. Dr. Dhanwant Singh was performing pterygium surgery on the eye of my grandfather, whom he knew well; my father (S. Dalip Singh) and Dr. Dhanwant Singh were classmates in high school. I was watching the surgery as an intern at that time. My grandfather and Dr. Dhanwant Singh decided for me that I would be an Ophthalmologist. Over the years, I have appreciated that decision because he gave me so much clinical and surgical work, along with building my confidence as a clinician and surgeon, that what I have achieved in the field of Ophthalmology has been the outcome of that decision. It was such a rewarding experience to restore vision in the blind that I could not think of any other specialty as an option for my career.
What a gratification to see a smile on the face of a patient when he/she could see with the eye that was blind before I removed the cataract. These were instant results, rewards, and gratification for the work that kept me motivated to pursue a career in Ophthalmology. Bringing back sight to the blind, relieving pain caused by severe glaucoma, restoring vision after retinal detachment surgeries, etc., are so rewarding that I continued to pursue a career in Ophthalmology and never looked back. I had operated on more than 600 cataractous eyes during my training and over 3,000 surgeries over the next three years in Free Eye Operation Camps in India before I was offered an opportunity to learn Ophthalmic Microsurgery by Prof. Draeger in Hamburg, Germany. Treating and operating on the eyes of elderly patients from villages/countryside in their backyards (Free Eye Operation Camps), who could not travel to the hospital for their treatment, was the most gratifying and rewarding experience I had during those three years.
An invitation from Hamburg University Eppendorf, Germany, as a Guest Doctor, intensified my passion for Ophthalmology. It was the time when Microsurgery was being introduced in the field of Ophthalmology. While learning ophthalmic microsurgery, I grabbed an opportunity to get involved in basic research on ‘corneal preservation, corneal endothelial cell damage, corneal epithelial regeneration in non-healing corneal ulcers,’ etc. I take pride in being one of the team members who developed the presently used ‘corneal culture medium at room temperature’ for corneal transplantation. This work was appreciated by Prof. C Stephen Foster, who offered me a clinical fellowship at the most prestigious institution, Massachusetts Eye and Ear Infirmary (MEEI), Harvard Medical School, Boston, USA. From humble beginnings in Medical College, Patiala, India to ‘Mecca of Ophthalmology (MEEI)’ solidified my passion for Ophthalmology and continued my motivation to serve humanity as an Ophthalmologist.
Though I was motivated by my first mentor to be an ophthalmologist, I feel that was the best first step forward in this most rewarding professional journey in Ophthalmology. Once again, I feel that the blend of medical and surgical aspects in the field of Ophthalmology and instant results are unique to this specialty of medicine.
It may not be out of place to mention here some names of my colleagues, friends, and guides who have kept me motivated in clinical and basic ophthalmic research and publications. Prof Dhanwant Singh paved my way in Ophthalmology. Vijay Sharma, PhD, Prabodh Sehajpal, PhD, and Amarjit S Bhanwar, PhD motivated me to start publishing and share my clinical and research experiences with the ophthalmic community. Prof. Joerg Draeger offered me the opportunity to learn ophthalmic microsurgery. During my stay at Hamburg University, Prof. Rolf Guthoff and Prof. Matthias Boehnke initiated me into basic ophthalmic research. Prof. Richard Lindstrom at the University of Minnesota offered me a research fellowship that, later on, was very helpful in getting my foot into the door of American Ophthalmology. Besides being my mentors at MEEI, Harvard Medical School, Prof. Kenneth Kenyon and Prof. C Stephen Foster secured me a position as Resident-in-training in Ophthalmology in the United States; without that training, I would not be a Board-Certified Ophthalmologist in the United States. Prof. M Roy Wilson was gracious enough to accept me as a Resident in Ophthalmology in Los Angeles; in those days, to be accepted into Ophthalmology Residency Training for a Foreign Medical Graduate was unimaginable. There were numerous other incidents in my career that kept me motivated and solidified my professional ophthalmic career. I have the honor of shaking hands with some ‘Pillars of Modern Ophthalmology.’ Prof. Peter Choice, Prof. Fyodorov, Prof. Barraquer, Prof. Charles Schepens, Prof. George Spaeth, and Prof. Claes Dohlman are some names to mention here, besides Prof Kenyon, Prof Foster, Prof Wilson and Prof Lindstrom. These ‘Giants of Ophthalmology’ kept me motivated to help humanity and the blind and continue my pursuit in Ophthalmology.
ATM: With over 40 years of clinical practice, what changes have you witnessed in the field of Ophthalmology?
Prof. Singh: As with other fields of medicine, the specialty of Ophthalmology has widened its scope exponentially over these 40+ years of my professional career. I was trained at Medical College, Patiala, India, to operate on the eyes with the naked eye or with the use of Loupe Glasses, the magnifiers also used by jewellers. We would wait for the eyes to go blind with ‘mature cataract’ before operating on the eyes because of the risks of high rate of infections and complications of basic surgery. As mentioned previously, I trained to use a microscope in ophthalmic surgery at Hamburg. That is the time microsurgery was being introduced in the field of Ophthalmology. Introduction of Intra-Ocular Lens (IOL) Implantation, started in 1948, was gaining popularity in the late 1970-80s worldwide. Otherwise, thick glasses to correct vision with Aphakic Lenses were the only option available. The evolution of IOL is another story in itself. Anterior chamber IOL, pupil-fixated IOL, Iris suture-fixated IOL, Posterior chamber IOL, Sulcus Supported IOL, and ‘in-the-bag IOL,’ etc., are some examples of changes I have witnessed over these 40+ years of clinical practice. Cataract surgery evolved from Intra-capsular to Extra-capsular to Phacoemulsification procedure.
When I started my career in Ophthalmology, the only available option for corneal transplantation was using the cornea removed from the cadaver eyes within two to three days. These eyes were stored in the refrigerator only for 2-3 days. As mentioned previously, I was part of the team in Hamburg, and in collaboration with a team in Aarhus, Denmark, that developed a culture medium for corneal preservation at room temperature for up to 30 days. It is the same culture medium used these days for easy preservation and transportation around the world at room temperature. While talking about corneal transplantation, it is befitting to mention that I have witnessed penetrating keratoplasty being replaced by just corneal endothelial transplantation in selected corneal pathologies. These procedures are called “Descemet stripping endothelial keratoplasty (DSEK)” and “Descemet membrane endothelial keratoplasty (DMEK).”
Similarly, we had only pilocarpine drops to treat glaucoma at one stage. Now, there are multiple options of anti-glaucoma eye drops, with different classes (families) of drops available. Trabeculectomy and/or Scheie’s procedures have been replaced by numerous procedures based on trabecular meshwork, Schlemm’s Canal, Minimally Invasive Glaucoma Surgery (MIGS) procedures, etc., to name a few. I happened to introduce the role of Mitomycin-C in reducing the recurrence rate of pterygium to the Western world in 1988, though it was introduced in Japan in the 1960s. It took off in glaucoma filtration procedures as well.
Another significant change I have witnessed is in the field of Refractive Surgery. We have used spectacles/glasses to correct myopia, hyperopia, and presbyopia for ages. Corrective contact lenses replaced the need for glasses for many, though these have risks of complications of corneal infections, giant papillary conjunctivitis, etc. Introduced by Prof. Fyodorov of Moscow, the procedure of Radial Keratotomy (RK) took off around the world to correct myopia. I happened to analyze the long-term results of RK at Minneapolis while I was a research fellow with Dr. Lindstrom. It was published as a multi-center study under the title of PERK (Prospective Evaluation of Radial Keratotomy) study, and it documented that the initial successful results regressed over 5-10 years. There, I worked with Corneal Inlays in rabbit eyes as well. During these 40+ years, I have witnessed PRK (Photo-Refractive Keratectomy) and LASIK (Laser-Assisted In-Situ Keratomileusis) replacing RK.
Retinal surgery and the use of anti-VEGF (Vascular Endothelial Growth Factor) are other advances or changes I have witnessed in the field of Ophthalmology. With the use of a laser we treat retinal holes before those would lead to retinal detachment. Diabetic retinopathy and similar retinopathies are treated with laser photocoagulation. It was an accidental finding that patients treated with Avastin (anti-cancer medication) for colorectal cancer were getting better with their comorbidity of macular degeneration and macular swelling. That has evolved into intra-vitreal injection of anti-VEGF agents to control macular swelling of wet-type macular degeneration and diabetic macular edema. It is a temporary treatment (at least for me) because we do not treat the basic etiopathology of VEGF released by anoxic, starving retinal cells. I prefer doing focal laser photocoagulation, if possible, in maculopathy and pan-retinal photocoagulation in proliferative diabetic retinopathy.
ATM: Could you provide a brief overview of the advancements in cataract surgery? How have these advancements impacted the field and your practice?
Prof. Singh: From the naked eye to the use of a microscope, from intra-capsular removal of Mature Cataracts causing blindness to Extra-Capsular and Phacoemulsification, from von-Graefe’s corneo-scleral incision of 1800 and three to five 5/0 silk sutures wound closure to small incision suture less procedures, from patients bed-ridden for a week post-operatively to patients walking out of Ambulatory Surgery Centers minutes after cataract surgery, etc., are some advances in cataract surgery that have revolutionized the procedure. The indications for cataract surgery from a blind eye with mature cataracts have changed to cataracts causing an inability to drive safely and pass the driver eye test, and vision disturbing the lifestyle, etc. The post-operative infection rates have dropped to being negligible with better sterilization techniques and the use of prophylactic intra-operative antibiotics, while infections were a big deterrent in performing cataract surgery in the past. During the early days of my professional career, facial retrobulbar anesthesia was the standard of care to perform cataract surgery. At present, I believe, globally, we use topical lidocaine gel anesthetic in most cases. That prevents the risks of retrobulbar hemorrhage, globe perforation, and damage to the optic nerve and other nerves supplying the eye-movement muscles. Still, despite all these advancements, accidents do happen intra-operatively and post-operatively, with infections damaging the eyes. My colleagues use Toric and Multifocal intra-ocular lens implants, but I admit, I am traditional and have not jumped onto this bandwagon. In the United States, these Toric and Multifocal IOLs are not covered by most health insurances, and patients have to pay from their pockets to have these lenses implanted. I do not implant these IOLs because these are not fool-proof, patients complain of night vision glare, and still need corrective glasses. Similarly, accommodative IOLs are being developed at this time but not successfully yet.
ATM: What emerging technologies or treatments in other aspects of Ophthalmology excite you the most right now?
Prof. Singh: Glaucoma is one of the many ocular conditions that has defied its understanding and management. Researchers and clinicians have made big strides to better understand and manage it appropriately, but still, we fail in our efforts a lot. Normal-Tension Glaucoma, Low-Tension Glaucoma, Ocular Hypertension, Glaucoma Suspect, etc., are the terms encountered every day because ‘one size does not fit everyone.’ Similarly, numerous drugs and their combinations have been developed to customize treatment for each patient. I am hoping these new techniques of working on the trabecular meshwork and Schlemm’s Canal level may bear fruit one day. Retinal macular surgeries, cameras, chips, and similar devices to be implanted in the macular area to make the blind eye able to see are under investigation.
ATM: As a clinical professor in Ophthalmology, what do you believe is the most important when training the next generation of ophthalmologists?
Prof. Singh: I have been a Clinical Professor of Ophthalmology at the two local University Medical Centers. I used to have didactic lectures and supervise Residents in training in the clinics and in surgery, but not lately. Now, Residents and medical students shadow me in my clinic/office setting. Foremost, I tell the residents to ‘look for Horses and Donkeys first, because Zebras are very rare.’ By this, I mean to look for common conditions and diseases first before jumping onto rare conditions and syndromes. Big fancy names and syndromes do not impress me if one is missing the common conditions. Yes, those rare cases are around, but not in big numbers. During my fellowship at MEEI and Harvard Med School, I saw very rare cases because those were referred to the tertiary care center from around the world. So, one should keep the eyes and mind open to look for these rarities while seeing day-to-day common problems.
Another thing that bothers me is when residents and medical students pull out their cell phones to look for the answers on ‘online search’ to my questions. If these online searches were the way to learn, then why come to my lectures or clinic? Textbooks and peer-reviewed Medical Journals cannot be replaced by online searches. Hands-on training and learning cannot be substituted by throw-away magazines.
I learned from and was trained by experienced mentors and professors. Now, I feel I must transfer the knowledge to the next generation of ophthalmologists. The foundations of Ophthalmology were laid by pioneers such as von-Graefe, Donders, von Helmholtz, Duke-Elders, Ridley, Choice, Schepens, and Binkhorst, etc. on which we have made these advancements in Ophthalmology. That basic knowledge has been transferred from generation to generation so that we are where we are today. To advance this knowledge to the next generation is my responsibility along with others.
ATM: What global trend in Ophthalmology do you find most interesting or concerning?
Prof. Singh: I will address the global trends in Ophthalmology that concern me first. Not only in the field of Ophthalmology, but medicine in general, we are jumping onto the application of Artificial Intelligence (AI) in decision-making to diagnose and treat medical conditions and diseases. The algorithms generated by the computers and AI are based on ‘generalization’ and not ‘customized’ for each individual patient. For example, a patient walking into the emergency room with complaints of headache, blurry vision, and pain behind the eyeballs is subjected to be ruled out from acute glaucoma, to optic neuritis, to pseudotumor cerebri, to intracranial mass and ends up with CT scans and MRIs because of the algorithms developed by AI. If that patient, and other similar cases, was listened to properly by an astute clinician with a customized approach, that patient would be recommended to first get an ocular examination and refraction done for corrective glasses that probably would take care of headaches, blurry vision, and ocular pain.
Online search engines are replacing the need for didactic lectures and teachings by experienced clinicians and surgeons. Present-day learning is based on throw-away journals and magazines and not textbooks and peer-reviewed journals. Simulated computer-generated surgeries cannot substitute the old-style hands-on operations and teaching. Similarly, so much misinformation is thrown at the public by television and computers that the public at large believes it more than the medical professionals. Pin-hole spectacle glasses, blue light protective glasses, and one set of glasses to correct presbyopia for everyone are some examples that my patients have questioned me about.
Most concerning for me as a clinician and a researcher is the falsification of data in scientific publications. During the early days of my professional career, I was shocked to hear the phrase ‘Publish or Perish.’ To advance their professional careers, researchers and clinicians started stealing and falsifying data; the results we are witnessing today when research papers and publications are retracted in hundreds, even from prestigious institutions and Nobel laureates. Plagiarism has infested the medical field globally. I have turned down some manuscripts for reviewing because I could not verify their authenticity and the data.
Yes, we are working hard to find treatments and cures for many ocular conditions, giving hope to patients going blind because of severe glaucoma, macular degeneration, diabetic retinopathy etc. Goniotomy, trabeculotomy, trabeculoplasty, MIGs procedures, etc. for glaucoma, Intra-vitreal injections of anti-VEGF agents, intra-ocular drug delivery implants, and lately, gene therapy etc. for macular pathologies are some of those examples, but nothing has been perfected yet.
ATM: How has your experience been as an Editorial Board Member of ATM?
Prof. Singh: I wish to thank the ATM journal and its Board for giving me this opportunity to be a member of the Editorial Board. The journal has been very fair in selecting the manuscripts for publication after going through a careful peer review process. The editorial staff has been prompt and efficient in handling the manuscripts.
ATM: As an Editorial Board Member, what are your aspirations for the future of ATM?
Prof. Singh: I wish the ATM journal to be a well-reputed and respected journal internationally, publishing high-quality research work in a timely fashion, not worrying about quantity. It should encourage its staff to be honest, fair, and hard-working to draw international recognition. I wish the best for the ATM journal, its Editorial Board, and the Staff.