Interview with Prof. Humberto de Castro Lima

Pioneering in ophthalmology

With over 50 years in the profession, ophthalmologist Humberto de Castro Lima recounts his trajectory in the specialty and outlines an overview of current Brazilian ophthalmology.
Almeida Marina

In 1948, the young Bahian Humberto de Castro Lima graduated from the Faculty of Medicine of Bahia, the first medical school in Brazil created by Dom João VI. At that time, I still did not know that he would become one of the great names in Brazilian ophthalmology, thanks to his pioneering spirit and enthusiasm for the specialty. 

It was this same pioneering spirit that propelled him to venture into the USA, in days when scientific exchange between countries – especially between rich and poor nations – was not as easy as it is today. Lima packed his bags soon after graduating to deepen his knowledge in New York, USA. There, he studied hard, met great professionals and witnessed discoveries and procedures that would become landmarks for his specialty on the world stage.

When he returned to Brazil, he was already, without knowing it, at the forefront of Brazilian ophthalmology. He specialized in glaucoma, without ever leaving aside the other subspecialties. Became part of the team of top professionals. It did not take long for his name to become a reference in the North and Northeast of the country and his opinion came to be respected and consulted by ophthalmologists throughout Brazil.

Today, at 82 years of age and with more than 50 years of career, Lima is still active. He still talks about ophthalmology with the same passion as at the beginning of his career and analyzes the current situation of the specialty in the country with the same lucidity and critical spirit that permeated all his career decisions. Below are some of the main excerpts from the interview he gave to Universo Visual.

Visual Universe – What was your first contact with ophthalmology?
Humberto de Castro Lima - The beginning of my specialization in ophthalmology happened when I was in the third year of medical school, at the invitation of Professor Orlando de Castro Lima, my brother and first master in ophthalmology and otolaryngology. He called me to work in clinics for needy patients and in his private practice, a very common practice at the time. Later, between the fifth and sixth years of college, I was accepted for a three-month specialization course in ophthalmology, taught by the eminent professor Moacyr Álvaro, who was the one who brought me very close to ophthalmology in São Paulo.

UV – And after graduating in ophthalmology, what did you do?
Lima - Right after graduation I already had a good number of patients and I practiced for six months in Salvador, when the opportunity arose for a scholarship from the Bahia Association of Medicine to be an intern at Passaic General Hospital, in New Jersey, USA. In August 1949, I flew to the US and did an 11-month rotational internship in general medicine. Despite not having university characteristics, the hospital had a very reasonable standard, with anatomo-clinical sessions and other stimulating activities, which gave me the basis for general practice and surgery, but offered nothing of significance in ophthalmology. Therefore, during this period, I attended numerous courses in the specialty. These were short courses, especially at the New York Eye and Ear Infirmary, in New York, where I was lucky to meet Conrad Berens, the great American master who definitely changed my professional life.

Conrad Berens had a Pan-American vision and sought to help everyone who came from South American countries. He was a man of unusual personality and taught me, by example, intelligent and ethical behaviors and processes. Before joining the New York Eye and Ear Infirmary, affiliated at the time to New York University, I already had great admiration for other great masters of American ophthalmology such as Wendell Hughes, H. Romaine and Milton Berliner. But it was dr. Berens, because of his prestige and influence, who managed to get me a “special resident” internship for almost two months.

This period paved the way for a complete medical residency in ophthalmology and, during those two months, I think I was the resident who worked the most, as I was elated and willing to take advantage of every opportunity. I fulfilled my duties and also covered the shifts of most other residents. However, I would return to Brazil with an extremely superficial view of advanced American ophthalmology, as in that period it was not possible to go deeper.

But a fluke changed my fate when, no longer hoping to continue, my dear roommate and fellow Henry Sloane was called into the Korean War. With their support and the favorable vote of the Board of Surgeons, I took the seat and completed my journey in the US as a true resident for another two years.

UV – How was this period?
Lima - A wonderful experience. It was a time when I had the opportunity to participate in the “Lancaster Lectures in Ophthalmology” course, conducted by the Boston Council of Ophthalmology, where I met, among others, Peter Kronfeld, a great glaucomatologist, and the insurmountable and unforgettable master of retinology Charles Schensee. During this short time, we stayed in the city of Maine, taking classes in the morning, afternoon, and evening. This intensive basic course corresponded to what was regularly given in American universities or accredited hospitals.

At that time I lived with great masters of American and world ophthalmology, such as Brittain Payne, Bernard Samuels and European refugees from Nazi persecution, such as former head professor from Vienna, Adalbert Fucs and former professor Klefeld, head of Brussels. The meetings, the seminars, the clinical sessions, the meetings of the Society of Ophthalmology of New York were like true monthly congresses, placed at my disposal, in the feverish scientific and cultural activity of what Charles Schepens called “the foyer of international culture”.

The two years of residency at the New York Eye and Ear Infirmary earned me the title of junior and senior resident and house surgeon. At the end of my residency, I stayed for another six months in the hospital and was appointed to work as a clinical assistant. At the same time, I decided to take the American Board of Ophthalmology, a kind of specialist title. After four years away from Bahia, I returned with the recognition of the aptitude of an American specialist.

UV - And how was your return to Brazil?
Lima - When I arrived from the residency, my education was very broad and generic, but I still had great enthusiasm and success in strabology, a specialty that was still in its infancy in Bahia. I performed a huge number of functional and aesthetic surgeries, innovating in indications and methods and changing the regional panorama. I have also performed numerous cataract and glaucoma surgeries. Glaucomatology was, in fact, the specialty to which I dedicated most of my life, as I had been infected by the enthusiasm of the great glaucomatologist Peter Kron, from Chicago, USA.

UV – Besides Professor Moacyr Álvaro, who has influenced you the most in your career?
Lima - When I was a student I had a very constructive relationship with the ophthalmologist Ciro de Rezende, which extended after my training. In São Paulo I also lived with Jorge Alberto Caldeira, Renato Toledo, Rubens Belfort Matos and, more recently, with Remo Susanna, Newton Kara José, Paulo Augusto de Arruda Melo and Rubens Belfort Júnior. In Rio Grande do Sul, I also had great partners such as Italo Marcon and Ivo Corrêa Meyer. In Paraná, dear Carlos and Saly Moreira. I mention these people because they were a great learning experience for my specialization.

UV – How do you see the current need for specialization of ophthalmologists?
Lima - The trend in ophthalmology is for more and more specialists focused on a sector or segment. It is a repetition of what happens in medicine in general. As it is an extremely technical, rational specialty with such rich instrumentation, ophthalmology is conducive to this specialization. However, I think that over-specialization is an exaggeration when it starts very early, but it is an improvement, at a certain point in life. I don't see it as inconvenient.

I was never an extreme expert. I was a well-informed glaucomatologist, concerned with working in all segments of ophthalmology, including after my arrival in Bahia, when I underwent retinal surgery for eight years. In 1962, as president of the round table, at the opening of the Belo Horizonte Congress, under the aegis of Hilton Rocha, I presented a careful work, whose theme was “Glaucoma: Medico-Social Problem”.

UV – What differences do you see between the residences of that time and the current ones?
Lima - In fact, I would say that with my residency I anticipated the history of Bahian ophthalmology. I did a complete residency, with characteristics very similar to the current Brazilian medical residency. Brazil today is very advanced, and Brazilian residences are as good as any outside the country.

The New York Eye and Ear Infirmary residency was a practical learning experience, with a huge volume of diagnoses and treatments, giving a broad view of eye problems. Furthermore, in New York, my learning was complemented by the large number of lectures, conferences and symposiums available, as is the case today in São Paulo and in the great capitals. In fact, I don't see much difference in my case. I do see a huge difference between the Brazil of 1950 and the Brazil of today, which is evolving fantastically. Those who graduated in Brazil in the 50s did not have medical residencies available, which only developed from the 70s onwards. The Brazilian training system has evolved in an extraordinary way, with the Brazilian Council of Ophthalmology at its head.

UV – Do you think that being an ophthalmologist today is more difficult?
Lima - I cannot opine in the collective sense. My situation was always surrounded by very particular circumstances: when I actually started my career, after four years in residency, my clinic was in a province, as the city of Salvador didn't even have 500 thousand inhabitants.

As I mentioned, before traveling I trained with my brother and, at the time, ophthalmology and otolaryngology were practiced together. But when I returned from the residency, he decided to dedicate himself exclusively to otolaryngology. As a result, my office was filled with patients and my name almost became synonymous with ophthalmology. I became a reference in ophthalmology in the North and Northeast.

A very happy event in my career was the development of glaucomatology in the country, led by Roberto Sampaolesi, Celso de Carvalho and Nassim Calixto. The great personalities of ophthalmology at the time guided me and kept in constant contact with me. Therefore, my career cannot be taken as an example, as I was privileged. Despite having many valuable colleagues in the city, I was the owner of the land and, at that moment, I cannot say that I had difficulties.

In addition to the great concern with the complications of all eye surgeries and establishing the best for the patients' happiness, I am pleased to have treated rich and poor with equal deference, with the best I could give.

UV – How have technological advances and new drugs benefited ophthalmology?
Lima - The evolution of ophthalmology has been fantastic and patients are the biggest beneficiaries. When I returned from the residence, a patient operated on for the retina was lying down for 15 to 30 days, sometimes with two sand pillows, one on each side. There were two sand bricks to keep your head from moving and running risks of, for example, detachment – ​​techniques that later proved to be absolutely ineffective.

The surgical evolution was enormous. I did a lot of “Arruga surgery” early in my career. It was necessary to cauterize large extensions of the posterior segment. Now, retinal surgery is smooth, beautiful, elegant, and, you might even say, artistic. In cataract surgery, small holes allow a suitable bed to be placed for an artificial lens, providing more comfort to the patient and avoiding immobility and suffering due to complications. Today, surgeries are highly safe and effective.

When I arrived from the US we were still using injections of attenuated typhus microbes to trigger fever and produce cortisol. Today, with the evolution of drugs, we have steroids. Another example: eye strain was previously treated exclusively with pilocarpine and eserine. Currently, beta-blockers give patients a better quality of life.

The area of ​​electronics and optics has also evolved a lot. At the time I started, there were only bifocal lenses. Trifocals soon appeared and only much later did the multifocals, such as Varilux, which were improved. The implants didn't exist. I participated in the first implant of an intraocular lens in the USA, performed by Joaquim Barraquer, with whom I had a very fruitful relationship for all these years. Step by step, we come to today's intraocular lenses, contact lenses, refractive surgeries.

These changes must be seen from two aspects. First, the advancement of technology, which has reached exceptional levels in all fields of life. The Internet revolution, for example, with its immense possibilities for dissemination and exchange of knowledge, has led us, among other things, to be able to hold conferences and courses at a distance, using video-conferences. This is a new world, which I'm even a little afraid to participate in, as I'm not used to it. But, there is a second aspect, as or more important than the other: that of the ingenuity of the great ophthalmologists throughout the ages. I am from the time of the Schiotz tonometer, which was unreliable due to scleral rigidity. Then, in the second half of the last century, the marvel that is the Goldmann tonometer emerged, inspired by an experiment carried out long before, by the Russian Maklakov.

This continuous development of techniques, including by Brazilian ophthalmologists, makes us think that, alongside technological development, there was a permanent improvement of the human being, a search for virtuosity and super-specialization that led doctors to become great restorers of the economy of the eyeball, to the point where it can restore an individual's vision.

UV - How do you see Brazilian ophthalmology today on the world stage?
Lima - The Brazilian ophthalmology, without a doubt, has grown a lot from all points of view in these almost 60 years. In the number of specialists, surgical capacity, knowledge production, organization and professional recognition, inside and outside the country. The training offered to young people, through the residencies, thanks also to the requirements of the CBO, promotes a qualification based on solid foundations, combining theoretical knowledge with great practical experience, very different from my time. Residents of the Brazilian Institute of Ophthalmology and Prevention of Blindness, founded by me on October 10, 1959, for example, perform 300 to 400 cataract surgeries during their residency period under ideal technical conditions. I have my doubts if, anywhere else in the world, a young ophthalmologist in training has access to this volume of surgical training.

UV – What tips would you give to those who are starting this career?
Lima - What can you say to young people? Does what Ruy Barbosa said in the last century still make sense? It was more or less like this: to learn to command you must know how to obey, to understand it is important to know how to listen, one must not be delirious with one's own triumph. In order not to give up, it is good to think that you can come to know everything, but in order not to become presumptuous, it is good to imagine that, no matter how much you have learned, very little will have come to know.

Always remembering that life is a permanent learning process, I believe that being disciplined, studious, curious and getting closer to the competent ones, drawing from them what comes from experience, are some basic rules for being a good doctor. But to be a great ophthalmologist, more is needed. It is also necessary to be a human doctor, concerned with listening, welcoming and caring for people. I have noticed, in most young ophthalmologists, an enormous desire to learn.