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Large communal wards provide safe housing for those traveling long distances for surgery. Without the inclusion of inpatient units, infection rates would jump and patient compliance would drop. An overnight bed can cost a patient as little as 40 cents, while the cataract surgery may be obtained for $12 USD.

Biratnagar Eye Hospital

The next stop on the fellow schedule for the year is Biratnagar, Nepal, at the Biratnagar Eye Hospital (BEH). BEH is part of the Eastern Regional Eye Care Program (EREC-P), a non-profit group that is part of a 33 year collaboration between Nepal Netra Jyoti Sangh (NNJS), the Social Welfare Council of Nepal, and Christian Blind Mission (CBM). The first hospital in this system to open was the Sagarmatha Choudhary Eye Hospital (SCEH) in Lahan, Nepal, and BEH was later opened in 2006 due to the overflowing volume of patients in SCEH. BEH serves the southeastern region of Nepal as well as northern states of India, and even Bangladesh. Over a thousand patients arrive every day in their busy season, with up to 450 of them receiving same-day or next-day cataract surgery. A full spectrum of subspecialty clinics makes sure that no disease goes unmanaged.

My first day I was greeted by Dr. Sanjay, the hospital director and head of the cornea service. To say that Dr. Sanjay is a legend in Nepal would be an understatement. He played a key role in the growth of Lahan Eye Hospital, and was the head of the project that opened BEH. Dr. Sanjay has operated on over 250,000 eyes, performing everything from high-quality small incision cataracts surgery (SICS) to pterygium excisions, pediatric cataracts, and corneal lamellar surgery. At a pace of one SICS every 2-3 minutes, he flies through 15-20 surgeries an hour performing consistently perfect techniques. Dr. Sanjay taught me on my first day how to create a DSEK graft with manual dissection, when modern keratomes or eye banks aren’t available to do it for you. As one of the senior surgeons commented, he has “beautiful hands” meaning that every movement is perfect and precise, without an extra move out of place, exactly as intended. There are few surgeons in the world who can boast such surgical volume and it’s only in places such as BEH or Lahan that a surgeon can reach such high numbers thanks to a well constructed system.

BEH has multiple training programs including a residency in it’s third year, anterior segment fellowship, cornea fellowship, and retina fellowship. The anterior segment fellowship is a 2 year surgical training program for those who graduated from residency in Nepal or India, and provides an unbelievable volume of surgery for young physicians. As a point of reference, the average resident in America may perform 100 - 250 cataract surgeries. The two year fellows will graduate with between 10,000 and 15,000 cataract surgeries under their belt, and a number of other procedures including pterygium excisions and dacryocystorhinostomy. While the training program is geared towards high-volume cataract surgery, the fellows are still able to gain competency in modern phacoemulsification techniques, often performing over 1,000 cases in their second year.

For those who have not visited a high volume cataract center such as BEH, these numbers can seem impossible - how can one surgeon do so many surgeries in such a short period of time? What it comes down to is efficiency. Every step of ever surgery, every material used, every team member, and every hospital employee has been focused in making the hospital a finely tuned machine. The operating rooms have two beds per surgeon with a microscope that swivels in-between. An outstanding scrub nurse is in charge of each table - making sure the patients arrive when necessary, are properly prepped and draped, all the surgical tools are laid out and ready to go, and are the maintainers of sterility throughout the process. In this way, the doctor will only spend a few seconds moving from one case to the next, in contrast with an American operating theater where turnover between cases can take anywhere from 5 to 30 minutes depending on the protocol of the surgical center. In coming posts, we will discuss further in detail how these feats are accomplished and what efficiency and community health look like in Nepal.

Wrapping up in Rwanda

It has been the greatest pleasure, seeing the hard work that Drs. Ciku and John have put in with the residency finally coming to fruition. Years in the making, they overcame an unbelievable number number of challenges in order to make this dream a reality. Though much of the hard work is still to come with curriculum development, resident clinic construction, surgical education and international rotations to plan, we at the CAGO are honored to provide support throughout the process. Our hope for the coming months is to have a delegation from Wills Eye and the CAGO visit the Kigali site and further contribute to project planning. In the next academic year we will have two CAGO fellows spend a month each working in various capacities with the residents, who by that time will have nearly a year of clinical experience under their belts.

The healthcare systems in countries like Rwanda take time and constant effort to affect change, but it is thanks to those passionate individuals like Dr. Ciku and Dr. John that real progress is made. The coming years in Rwanda will be exciting, and I look forward to the continued partnership with our friends overseas.

Dr. John, right

Dr. Ciku, far right

Happy patients enjoying their restored the day after cataract surgery. A great Sunday morning at the Kubungo district hospital.

Dr. Egide reviews instructions with patients for during the procedure as well as post-operative care. Patient education is a key part of positive outcomes after cataract surgery, and can be a challenge in regions with low health literacy rates. The time and commitment by physicians like Dr. Egide make all the difference.

Patients quietly await surgery outside the block room. A moment of peace and introspection before being anesthetized and taken to the theater where a 10 minute surgery will return the vision they’ve been living without for years.

Outreach

Over the weekend we joined Dr. Egide Gisagara on a government sponsored outreach to the district hospital. The majority of Rwanda’s limited ophthalmic force is based in the Capital, Kigali, though the majority of the population is dispersed in smaller cities and villages throughout the countryside. This issue is addressed by setting up district hospitals in each of the country’s 30 districts. Ophthalmic clinics are staffed by ophthalmic nurses or optometric technicians who will do basic screenings and in some cases even prescribe glasses. Any patient with a surgical disease who cannot travel to Kigali for private treatment is then called back to the district hospital on an outreach weekend, when a surgeon will come for several days for a high-volume surgical camp.

Rwanda has had a developing healthcare system over the past two decades, and operates on a universal healthcare model known as Mutuelles de Santé. Premiums are based on a sliding scale model with the very poor paying little to no money for their insurance while the upper tiers cover the majority of the country’s healthcare costs. In the setting of outreach camps described above, the government will pay ophthalmologists to spend their weekends providing care in these underserved regions. While this is moving things in a positive direction, the severe understaffing of ophthalmologists means that some hospitals may only perform surgery one or two weekends out of the entire year.

On our outreach weekend, we arrived Friday night to a large group of patients being screened at the health center. They had signed up 80 patients for surgery and were busy getting their pre-op measurements and intraocular lens choices prepared. Saturday morning we reached the hospital early to begin setting up the OR for a long day of cases. Though the district hospital had operating facilities available, there were no surgical instruments, materials, or operating microscopes available, so all equipment had to be brought from Kigali and set up for the weekend. With two tables and two microscopes in one OR, Dr. Egide and I set out performing SICS as quickly as the slow sterilization processes would allow us. Those patients that were not completed Saturday stayed overnight and had their surgery Sunday.

An added educational bonus of the outreach camp was that Drs. Fidel and Moise were able to join us and learn some of the fundamental skills of running an ophthalmic OR. One resident performed anesthetic blocks while the other worked with the technicians acquiring the patients’ biometrics and preparing them for surgery. It was an excellent demonstration of the wealth of experience that awaits our residents over the coming years.

RIIO Residents (left to right): Jean Pierre Byukusenge, Emmanuel Nsengiyumva, Moses Habineza, Fidele Amani Mugisha; Wills Fellow: Brenton Finklea

Kigali

Week two at the RIIO residency proved to be a very productive week with the new residents. The years working as General Practitioners set the group up with good clinical skills, from which we have tackled the ophthalmologic exam and evaluation. Many of the Wills Eye faculty were kind enough to provide lectures for me to present as part of our introduction course for which I’m extremely grateful. With their assistance, we have been able to spend several hours per day going over the major subspecialty systems in ophthalmology so that the residents will enter clinics with a broad overview of what they may encounter.

As part of the introduction course, we had the first Journal Club for the RIIO. The residents discussed a pair of papers including the first Rapid Assessment of Avoidable Blindness (RAAB) conducted in Rwanda. RAABs are an important tool for evaluating the disease burden of a region, and describes a specific technique to minimize bias or error while collecting data from a rural population. They have been used throughout Africa, Asia, South America and beyond to identify areas of preventable blindness. The primary goals of a RAAB are to:

- Estimate the prevalence and causes of avoidable blindness and visual impairment in people aged 50 and above

- Assess cataract surgical coverage

- Identify the main barriers to the uptake of cataract surgery

- Measure outcome after cataract surgery.

More information can be found on the website located here:

http://iceh.lshtm.ac.uk/rapid-assessment-of-avoidable-blindness/

The original RAAB performed in Rwanda was completed by Dr. Mathenge in 2006 which found approximately a 2% rate of blindness, largely preventable, throughout the western province. A subsequent RAAB was repeated by Dr. Mathenge and the first Wills CAGO fellow (and current fellowship co-director), Alessandra Intili.

The RIIO partnered with the Agarwal hospital system when it first opened in Kigali. By combining forces, Drs. John and Ciku have been able to deliver top notch care in a low resource setting. Now with the RIIO School Of Ophthalmology open, they plan to have a small resident-run clinic that is independent and will be supervised by local and visiting doctors. When the resident clinic opens in the next few months, they will be able to learn in a controlled setting while providing eye care to the underserved of Kigali.

Dr. Fidel practices his microsuturing techniques in the RIIO wetlab while Dr. Emmanuel watches on.

The Rwanda International Institute of Ophthalmology

For the past several years, the Rwanda International Institute of Ophthalmology has been growing the specialty throughtout the country under the guidance of Ciku Mathenge and her husband John. A long time goal, the RIIO opened it’s doors to the first class of Rwandan ophthalmology residents in January of this year. The CAGO at Wills Eye has been working closely with the RIIO over the past several years to support Ciku in John in realize this mission. Now that the first step has been completed, gaining government and NGO financial support to start the residency, we are returning to Rwanda to begin the real work – training the residency’s inaugural class.

I arrived on Sunday April 6th to a quiet Kigali on the first day of their mourning week in remembrance of the recent genocide. During this week all businesses close at 3 pm and from 3 – 5 pm everyone has town meetings to discuss the events that happened and try to find a common peace between all citizens. Despite these happenings, we began our introduction to residency crash course this week in full force. We started the week with an intensive review of all examination skills and basic ophthalmic charting. Over the following days we have explored refraction, retinoscopy, and a full spectrum of diagnostic testing. The residents have been doing great!

The four residents selected for the class all graduated from medical school in the one medical school in Rwanda and have spent the past 2-4 years working as general practitioners in the area. Their medical knowledge is robust and clinical experience very good, so we have been progressing quickly through our courses. Thanks goes as well to the American Academy of Ophthalmology who donated four copies of “Practical Ophthalmology” textbooks, a full set of the Basic and Clinical Science Course, and a variety of other relevant materials for the starting ophthalmologist. Over the coming weeks we will highlight each of the residents who will be leading the way forward in Rwandan ophthalmology.

We closed out the week with an ocular dissection course, reviewing eye anatomy and basic surgical approaches to the globe. During their time as general practitioners each doctor excelled at suturing skills, now we are beginning to bring it all down to a microscopic level. This has all been a great start to what will be a promising future at the RIIO.

***The following several entries are from my January - February 2018 trip to Sierra Leone and Liberia. Due to a paucity of internet access (and electricity) at the time these are being presented on my return to the USA***

This week I arrived in Serabu, Sierra Leone with Dr. Cathy Schanzer and her husband Tom Lewis. The pair of Missionaries have spent the past 30 years working in Africa, and the past 12 years developing one of the strongest surgical programs for comprehensive ophthalmology and treatable cataract blindness in Sierra Leone. The small town of Serabu consists of only about 5,000 residents living life in the post-war region without electricity or water service. Since Tom and Cathy have been working in Serabu, they have not only built a medical center but also invested heavily in the community. Several years ago they brought a team who drilled 7 wells throughout the town, providing the first clean and readily available water source for the people of Serabu. These water sources have proved invaluable, cutting down childhood mortality, presence of water-bourne diseases and overall ease of obtaining a basic necessity. Their employees and volunteers have taught sanitation lessons to the villagers over the past several years as well. Many have attributed these efforts to the success Serabu saw in avoiding the Ebola epidemic, having no reported deaths from Ebola during this two year crisis.

The couple have observed excellent global health principles in establishing this clinic, employing and training many locals from the town and recruiting anesthesia and nursing staff from Freetown to support the clinic during surgical periods. The clinic now has year-round staffing for all clinical and surgical needs, while twice a year the complete surgical team comes to provide high-volume cataract surgical care and to provide consultation for complex cases. The team is looking further into partnering with the limited local ophthalmology force, which is currently made up of 4 Sierra Leonean doctors, one of which now is mostly administrative for the health department. We met with Dr. Vandy (the leader of ophthalmology in the Sierra Leone) on our first day in the country in order to discuss the clinic and how it will fit into the growing landscape of the country. We hope that Dr. Vandy and one of the young ophthalmologists from Freetown will join us in Serabu later this week to continue developing this relationship, and to provide some training in phacoemulsification surgery to the young physician.

CAGO in Port au Prince

While in Haiti, the CAGO team attended the Haitian Society of Ophthalmology meeting in Port au Prince where we were able to hear some teaching provided by local ophthalmologists. Several non-Haitian ophthalmologists were also invited to provide insight into new and interesting topics in the field of eye care including our very own Brad Feldman and Dan Alter, a retina specialist from Illinois.

Left to right: Anshu Chandra, OD; Regine Edouard, MD; Dan Alter, MD; Brad Feldman, MD; Brent Finklea, MD

Cap-Haitien, Haiti

This week I was fortunate to be joined in Cap-Haitien by one of our outstanding third year residents, Ayan Chatterjee. Dr. Chatterjee was able to bring a number of surgical supplies with him provided by SEE International which enable the clinic to keep providing affordable care to those in greatest need. Ayan joined us as part of the WIRE program (Wills International Resident Experience) which gives residents the opportunity to take part in global initiatives in partnership with CAGO. We spent the week seeing patients in clinic alongside our Haitian and Cuban counterparts intermixed with time in the OR. One of the goals of this particular WIRE site is to allow residents to learn a new procedure: MSICS (Manual Small Incision Cataract Surgery). The procedure is a variation on standard extracapsular cataract surgery and is performed throughout the developing world due to it’s simplicity, safety, and significant affordability in comparison to phacoemulsification cataract surgery. It was a pleasure to make the shift from student to educator and work with Ayan on a number of cases over the course of the week.

A quick word on my own experiences with the WIRE program – I was fortunate enough to spend two weeks as a third year resident with Dr. Ben Roberts in Tenwek, Kenya. The Tenwek Mission Hospital has been a primary care providing institution in the region for several decades and it is thanks to Dr. Roberts that the ophthalmology department has become such a vibrant source of education for Nairobi resident and international students. Working with Dr. Roberts was incredibly influential in my development as a surgeon and as global health professional for which I am exceptionally grateful.

Fond-Des-Blancs, Haiti

The St. Boniface hospital in Fond-des-blancs, Haiti has been developing an eye clinic over the past 4 years under the sole guidance of Anshu Chandra. Dr. Chandra is an optometrist from New York who began working in FDB about 5 years ago through her organization, the Global Eye Project. At that time, the Haitian central plateau did not have any accessible eye care to speak of. A long and arduous journey to Port Au Prince, most of the rural community could not make such a tiresome and expensive trip even in time of emergency. After several trips to establish a clinic at St. Boniface Hospital, Dr. Chandra decided that it was necessary to move permanently to Haiti in order to ensure the success of the clinic and to provide continuous care to the local population. Very quickly after establishing the full time clinic with only a few examination stations in a 500 square foot space, she realized that much more was necessary to provide the level of care needed by the community. Since then she has made incredible advances including the addition of many more examination lanes total 11 stations as well as diagnostic equipment such as a visual field machine and a spectral-domain OCT (optical coherence tomographer). Though the clinic was small in surface area, the density of equipment gave opportunity for assistance – though with no medical training facilities in sight, Dr. Chandra had to get creative. Beginning two years ago she started training assistants to tech patients for her so that she could successfully get through an enormous clinical volume without sacrificing quality of patient care. These locals often times had very limited formal education so for two hours prior to clinic every morning Dr. Chandra teaches basic and clinical ophthalmic sciences, all in the local Creole dialect. From there the team dives right into long clinic hours which can last until 10 o’clock at night or later depending on the volume of patients that show up that day.

The clinic is currently undergoing its next step in advancing the comprehensive nature of local ophthalmic care delivery – the institution of a full surgical program. During my short visit to the clinic, they received a shipment of a quality surgical microscope donated through the Global Eye Project. We spent our time assembling the microscope and taking stock of the surgical equipment currently available at the hospital so that the operating rooms can be fully loaded in anticipation of upcoming surgical teams. The first surgeons expected early in 2018 are American ophthalmologists assisting Dr. Chandra with the huge backlog of cataracts waiting to be removed. Very quickly however, Dr. Chandra plans to transition to Haitian ophthalmologists who will be coming regularly to fill in the surgical schedule. All in all it is phenomenal effort on the part of Dr. Chandra which began with an empty room and a vision, and has developed into the only location for quality, comprehensive eye care in the region.

We would like to welcome Brenton Finklea, MD as our fellow in the Center for Academic Global Ophthalmology for the 2017- 2018 academic year. Brent is a recent graduate of the Wills Eye Hospital residency program and has already spent time working with our department on a number of projects. A native of Florida, Brent received an undergraduate degree in Engineering from the University of Florida before undertaking medical school at the University of Virginia.

Over the coming 12 months Brent will be working on collaborations between Wills and and institutions around the globe. On his first departure from the USA, he will be spending time at the LV Prasad Eye institute in Hyderabad, India and the Aravind Eye Hospital in Madurai, India. At these renowned institutions, Indian and foreign residents and fellows receive top-notch clinical and surgical training while delivering quality eye care to all levels of society. Through this series of discussions we invite you to follow the accounts and experiences of the Wills Eye Global Ophthalmology Fellow.

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