Toughest Case: Mr Ken Nischal, head of clinical and academic ophthalmology, Great Ormond Street Hospital

I'm an ophthalmologist specially trained in paediatrics at Great Ormond Street Hospital. The eye is separated into components and I'm an anterior segment specialist, which is basically the front of the eye.

When I returned from my specialist training in Toronto Hospital for Sick Children in 1998, I began to develop a service based at Great Ormond Street for very young children born with problems in their corneas.

Some children are born with corneas that are opaque, meaning they can't see. I was interested in these rare conditions and to try and help these children.

A three-month-old boy was referred to me because one eye had total opacity of the cornea, so you couldn't see any of the coloured part of the eye, and the other eye was similar, but a little bit bigger because he also had glaucoma.

In children under the age of four, if the pressure in the eye goes up higher than it should be – greater than 21mm of mercury – then the eye expands like a balloon, so his right eye was a little bigger than his left eye and we didn't know what was going on behind the opacity.

The first thing we did was a normal ultrasound and we found that the left eye had a total retinal detachment, which means that the retina had not formed properly and was completely off, so there was no chance of any vision in that eye. There's nothing that can be done when a baby's born with that sort of condition.

So I had a three-month-old baby who had only one eye with which he could potentially see. At the time, he would react to light but that was all, and the cornea was opaque. If I operated and did a corneal transplant, which is a high-risk procedure, and he lost the eye from an infection, or the cornea was rejected, there was a chance that this child would lose the vision that he had, but if we did nothing, there was a chance that he would lose that vision anyway.

It was a tough decision. We decided with the parents that we would go ahead and operate, and the next problem was that there was a real shortage of corneal transplant material. It was just after it was discovered that Liverpool pathologists had been saving body parts and organs from the post mortems of children. There was a huge public outcry and, as a consequence, organ donor rates had radically dropped throughout the UK.

When you operate on an infant, you need corneal material that is under the age of 21, so you need someone to have passed away under this age and for their family to have agreed to donate the eyes. Due to the shortage, we did a bit of PR work with our hospital to try and raise awareness that there were babies that needed these corneal transplants.

Luckily for this young boy, we managed to get material from a three-year-old child who had sadly passed away. The parents had read the piece in one of the newspapers and had come forward and said that they'd like to donate one eye specifically for this child.

So we did the corneal transplant and he's five years old now and he can see with one eye. He still comes to see me for check ups. He actually has some developmental issues which are due to his brain not being quite normal, so giving him sight has been hugely beneficial. If you give a child enough vision to be able to recognise objects, their global development is much better.



www.eyedoc.org.uk

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