Surgical Eye Expeditions International – Visit to India (Cataract Study)

By Joe Kennan FRCSEd FRCOphth (Consultant Ophthalmic Surgeon)

I travelled to India again on Saturday January 31st 2009 in order to work for a further week under the auspices of SEE ( Surgical Eye Expeditions) International at the Tarabai Desai Eye Hospital in Jodhpur, in the state of Rajasthan.  This year I was accompanied by a team which included Mr Martin Owen, Operating Department Practitioner, Mrs Linda Gill, Theatre Sister and Outpatient  Ophthalmic Nurse, and Dr Nigel Payne, and Ophthalmic and General Anaesthetist. We took with us supplies provided by SEE International in order to undertake the cataract surgeries.

The scene was different this year in that there had been outbreaks of ocular infections, more than would be expected or were acceptable, in eye camps undertaken by other organisations in the region.  The government had placed a cessation order on the continued provision of these external camps until action had been taken to determine the source of the infection and how best to decrease the risk for future camps.  During this year in India I began to understand the term camp better. I always imagined it as working under canvas out in the villages. The term is used however to mean an accessibility and provision of free eye surgery to the local population who could not afford to pay for it.  These may well be patients who are seen during the year and who are diagnosed as having cataract and who wait for a camp to occur. The camps can occur in different forms.  The form that they undertook this year was that surgery was provided free for any patient who could not afford to pay for it at the base hospital in Jodhpur. There were some external camps where the eye team left a hospital to do outpatient clinics in the villages, and the patients were then brought back to the base hospital for their surgeries, and this came under the term of in-reach camps. Out-reach camps are where the team travel to the villages and undertake surgery in the villages, and this form of provision of services was not available this year due to the infection problem.

The typical pattern of work this year was that Linda and I undertook clinic and outpatient assessments in the morning from approximately nine o’ clock to three o’clock pm.  We identified patients requiring cataract surgeries and they were admitted to the hospital for preparation that afternoon and surgery in the evening.  We also encountered a range of non-cataract conditions which required treatment such as corneal infections which were particularly severe in the sheep workers and hill farmers. Part of the reason for the severity of these lesions may be the late presentation of the conditions.

There was an incidence  of glaucoma and the question was whether the patients would then take their medication for life. The patients had to pay for their outpatients visit (30 rupees for a one month ticket; 70 rupees equals one pound) and also have to pay for their medications. These are in the main made locally and brought either at the hospital pharmacy or in the city pharmacy. Glaucoma has the term of black water in India and it is this fear of blackness coming across the vision that drives the patients to continue to take their medication.

Cataract was of course prevalent and as usual many of the patients did not want surgery until the cataracts were far progressed. There was however a slightly younger group of patients who had a type of cataract which interfered with working lives for whom we were able to provide the modern type of cataract surgery with small incisions and foldable intraocular lenses free of charge. We in addition saw and treated children with squints, watery eyes, and allergic eye disease. Patients also presented with corneal foreign bodies, severe conjunctivitis, diabetic eye disease, and vitreoretinal disorders, all of which required assessment and treatment. The afternoon was a rest time at our local hostel, or perhaps a quick trip to the market, and we returned to the hospital at approximately five thirty pm for the evening surgeries.

The evening surgeries were lower in number than previously due to the ban on the external camps, although there were still a considerable number of patients who presented in the mornings and were operated that evening for free cataract surgery. The cataracts were very challenging. We used a mixture of methods from modern phacoemulsification with small incision cataract surgery and foldable lenses, to a sutureless cataract surgery with extraction of the cataract lens through a long self-sealing tunnel, using a method termed as SICS (Small Incision Cataract Surgery). The local anaesthetics for the cataract surgeries were provided by either the theatre assistants who traditionally undertake this procedure, or by Dr Nigel Payne.  The advantages and methods of delivery of the different types of local anaesthetic were discussed between the theatre assistants and Dr Payne.  Linda assisted me with my surgeries, initially with the help of the local team in setting up the machines, and subsequently more independently on her own, which freed the theatre assistants to allow them more time to set up and keep the other operating tables working. Martin helped assess the flow of the theatre, and the placement of the microscopes in relation to the operating tables, which enabled us to use the better microscopes for the more detailed modern surgery.

Linda brought suitcases of glasses donated by the people of Surrey to Jodhpur. Linda had measured these glasses and labelled them for their different strengths. The patients with refractive problems in the eye clinic were measured for glasses, and if we were able to fit them with an appropriate pair these were provided free of charge. This project was a great success with the local population and even the hospital driver benefitted from the glasses provision!.

Dr Payne and I spoke at the annual meeting of the Jodhpur Ophthalmic Society which was held at the Tarabai Desai Eye Institute during our stay. I presented a paper on the eye conditions related to HIV infection. Dr Payne presented a paper on modern ophthalmic anaesthesia which engendered great discussion.  We also discussed as a group the methods best suited to tackle the more challenging cataracts in the local population.

Later in the week we had a team meeting to discuss whether we might be able to make any improvements to reduce the risk of infection in the operating theatres taking into consideration the difficulties being experienced in the external camps. We decided that we could pay better attention to disposal of our sharp instruments, and that we could provide larger, bright yellow coloured containers for disposal of all sharp instruments. We also  further discussed the issues of  packs, which describes the packaging of the instruments needed for cataract surgery, with the hope that a new pack could be opened for each case. This was in order to address the issues of sterility while maintaining a rapid throughput in theatre in order to treat the numbers of patients requiring surgery.  This was an interesting discussion and developed into whether we should be considering providing cataract surgical sets which would be sterilisable and reusable.  These could be provided locally. A team going out to the villages could then take a large number of sets with them in the hospital bus and these sets would then return with the team for cleaning and resterilisation at the base hospital so that they could be reused.

We decided to explore the cost of permanent cataract sets which could be obtained from local manufacturers, and also the cost of the other equipment needed for SICS surgery and phaco-emulsification surgery.  We could then provide a price for sponsorship of a cataract surgery of either type, and we could ask for sponsorship for these surgeries. In this way we could build up our number of sets, look after and replace instruments as necessary, and use any extra funding that would become available to upgrade the microscopes and the phaco-emulsification machines, as it was becoming more evident that we were now using an increased mixture of the both methods. We decided to proceed with our previous ideas of requesting sponsorship for one or more of the different types of surgeries over a five year period as this will help in provision planning and providing a more predictable charitable income for the hospital.

The Tarabai Desai Eye Institute is building a new wing which will include a new operating theatre and the provision of other outpatient space which may provide the basis for the early development of more specialised clinics.

We also learnt a little more about Jodhpur during our stay.  Jodhpur was founded byRao Jodha in 1459 AD who named the city after his own name.  Jodhpur is also known as the Blue City as many of the dwellings are painted in a rich light blue colour. The city is overlooked by the imposing structure of the Mehrangarh Fort. One of the other structures of historic interest is the Umaid Bhawan Palace which was built under a famine relief project that gave employment to the local population during a time of famine.  This remains the residence of the former rulers with other parts running as a hotel and a museum. The local markets provide a fascinating riot of colour and activity including sari and spice buying, vegetable stalls, and multiple small stalls providing a multitude of local enterprises.

In summary the work continues on how best to continue to provide free cataract surgery to the needful local population, how to fund this, how to provide it in as safe a manner as possible, and how to organise and equip the teams bringing the surgery to the local village populations. External funding will be required and this will be explored once the cost of the sterlisable and reusable cataract sets has been determined.

It was a great joy and privilege for me to return to Jodhpur to work again, and I am very grateful to the team that accompanied me this year for their expertise and help.  This allowed us to engage with the local team and discuss the issues concerning surgery in all departments from which we all learnt.

Joseph Keenan FRCSEd FRCOphth.,

Consultant Ophthalmic Surgeon

Posted by Joseph Keenan - September 28, 2009
Category: Cataract


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