C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY

Letter to the editor

The St John Ophthalmic Hospital, Jerusalem

EDITOR There are few cities for which the present century has been as turbulent as Jerusalem, and few places where the legacies of a turbulent past are felt more palpably to the present day. A little over 100 years ago Jerusalem was a forgotten city, a windswept backwater of the decay- ing Ottoman Empire known to few West- erners. The modern era began in 1917 when Jerusalem fell to Allenby and be- came the capital of the British Empire in the Middle East. In 1948 the city was again torn with strife and was divided with the birth of Israel. Reunification came with the Israeli conquest of the Jordanian sec- tor and the West Bank in 1967. Today the ancient struggle for the control of Jerusa- lem continues as it has since the begin- ning of recorded hi~tory. ' ,~ ,~

Throughout all the tribulation and tragedy of the past century, St John has stood firm in its commitment to the wel- fare of all the peoples of the Middle East. The order has operated its Ophthalmic Hospital in Jerusalem since 1882 and has maintained its presence despite war and the ongoing upheaval of the Palestinian Intifada.'

It is this dogged determination to main- tain its presence in the Middle East and the parallel determination to provide the highest standards of care and excellence in the rapidly developing medical speci- ality of ophthalmology that form the ba- sis of the international reputation of the St John Ophthalmic Hospital. The latest and the best in medical technology are

provided to the poor, the disenfranchised and the refugee.

In 1882 the pattern of blindness was much as it was in Biblical times, trachoma and cataract blinded many. Arabs, Bedouin and Druse would cross mountains and desert and travel from neighbouring countries to bring their relatives to StJohn in the hope of what often must have seemed to be a miraculous cure for pain- ful and blinding disease.'

Thanks to the care and education brought by St John staff, the ancient scourge of trachoma has largely been eliminated from the Holy Land.

Today, the barriers are political as well. The Order struggles to provide ophthal- mic care in an often savagely divided land. St John has set up a permanent clinic on the Gaza strip. Here, the refugees live in squalor in vast camps and outnumber the indigenous population. St John cares for a people that the world seems to wish to forget. Vital operations are performed in a specially designed mobile operating thea- tre. The mobile theatre is a concession to the volatile political situation and seems, paradoxically, to provide a sense of stabil- ity and progress in a perilously disordered and often brutal environment. Often, St John staff take considerable personal risks to provide care for their patients. There are plans for a special clinic in Jericho and Outreach, St John's mobile clinic travels the West Bank, Gaza and Israel as far as the Golan Heights, bringing modern thera- pies to ancient places and to the needy.

One cannot forget the sights and sen- sations of Outreach. The long journeys through the mountains and olive groves of Palestine. Shepherds tending their flocks. The winding road leading to moun- tain villages. Hundreds of children greet the StJohn van, their curiosity aroused by the uniformed St John nurses and the complicated and delicate equipment be- ing carefully unpacked. To the elderly vil- lagers the white cross of St John is already familiar. There is a dark vibrancy of the villagers waiting for the doctor and their gaily coloured costumes. Life has changed little here for centuries.

The StJohn Ophthalmic Hospital is an impressive building designed in the mod- ern crusader style and built of the famous Jerusalem sandstone. It stands amidst well- kept lawns, olive and citrus trees in the Sheikh Jarrah district about one kilome- tre from the old city of Jerusalem The gardens are a quiet haven from the sur- rounding bustle and strife, the well wa- tered lawns a respite from the blinding heat of the sun.

The hospital is of 88 beds, two of which have been endowed recently by the Priory of Australia. The day begins at 7.30 am when hundreds of patients gather outside the gates for treatment, just as they have for over 100 years. Each year over 60,000 patients are treated and over 6,000 opera- tions performed. The modern and very well-equipped outpatient clinic is possibly the busiest ophthalmic outpatient service in the world.

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Letter to the editor

Modern ophthalmic laser therapy is available. There is a specialised diabetic service and an argon laser which is used to treat diabetes. Often the advanced dia- betes causes painful glaucoma and retinal detachment. Diabetes is now endemic in many developing communities of the world and threatens the sight of many. St John also has portable lasers for use in Gaza or on Outreach. In addition, mod- ern medical imaging devices, such as ul- trasound, are available to the physicians as is a YAG laser.

There are specialised departments within the hospital; these include a pros- thetic department, which fits artificial eyes and provides a high level of care for chil- dren suffering from congenital malforma- tions and malignant tumours of the eye. Cosmesis is important so that a youngster can take his or her place in society with- out the stigma of deforming disease.

The hospital has a high commitment to medical education and its nursing stu- dents, trained to the highest standards, are sought by hospitals all over the world. Recently, the hospital has undertaken the training of young ophthalmic surgeons.

The operating theatres undertake the most complicated of microsurgical proce- dures. However, the commonest operation performed is cataract extraction. There is nothing so gratifylng as seeing some eld- erly refugee regaining her sight thanks to St John. What a joy to see the grandchil- dren again. In many developing commu- nities, there is a high ophthalmic morbid- ity due to cataract, in part caused by environmental factors. Forty million peo- ple are estimated to be blind ~orldwide.~

St John regularly undertakes compli- cated surgery for retinal disease, child- hood glaucoma, malformations and retinoblastoma. Sometimes, the theatres become involved in the events of the day as when the Australian Priory Fellows were among those who treated the wounded from the massacres at Hebron and the Al’Aqsa mosques. Corneal graft material is flown from all over the world by StJohn for its patients.

The hospital, like all other large insti- tutions, has it famous ‘characters’, like Hassan, the theatre technician, who reck-

ons that he has given 100,000 local anaes- thetics in his over 40 years at St John; Abdullah Qatary, who works in outpatients and has a similar length of service must be known to every child on the West Bank. Dr Khalid Tuck Tuck and Dr Ziad Jaouni are also well respected for their many years at St John. Rasmeeyah, the housekeeper, is known for her kindness to the families of the visiting medical officers.

The Australian Priory of St John and StJohn Ambulance Australia have recently sent Mr Neil Shuey, a Melbourne optom- etrist, to St. John and he is performing valuable work. He has been teaching and is currently upgrading the optometric department of the hospital.

Optometric imput is particularly im- portant at St John. Several surveys from Saudi Arabia indicate refractive error is still the commonest cause of blindness and personal experience would indicate the situation is the same among Palestin- i a n ~ . ~ , ~

The treatment of amblyopia with accu- rate prescription and occlusion is of para- mount importance to the many paediat- ric patients. One striking feature of the clinical work here is the high paediatric component: 47 per cent of the population of the Gaza Strip is aged under 16 years. There is a vastly higher proportion of com- plicated paediatric eye problems than one would see in the UK or Australia. These include eye trauma, infection and heredi- tary eye conditions of the anterior and posterior segments. In the former group are congenital cataract, congenital glau- coma and the mesodermal dysgenesis syn- dromes. In the latter are the flecked retina syndromes, the hereditary telangiectasias and retinitis pigmentosa. Complicated motility problems are also common. The phakomatoses are seen regularly, particu- larly the variants of neurofibromatosis.

The Palestinian custom of consanguin- eous marriage accounts for the high preva- lence of autosomal recessive disease. The rate of consanguinity is the highest in the world due to first cousin marriage (62 per cent of West Bank marriages).

In addition, the teaching of aspects of optometry is urgent as normal spectacle prescriptions and many post-operative

prescriptions are inaccurate, resulting in protracted or poor visual rehabilitation. The prescription of low vision aids and helping patients cope with poor acuity are addi- tional important roles for an optometrist.

Preventive ophthalmology and re- search, such as delineating those factors responsible for the high prevalence of endemic eye disease and instituting means of correction, are further areas in which an optometrist can contribute.

Mr Shuey has been involved with diag- nostic screening and on the Outreach mo- bile clinic. In letters and faxes to the priory, Mr Shuey indicates he is finding his time in Jerusalem interesting and worthwhile.

Perhaps, because of its distinguished past, the St John Ophthalmic Hospital seems so ready to face the future. In the Middle East the future has many uncer- tainties. The firm commitment of St John is not only to stay but to grow in the face of adversity and to help those in distress with a quiet confidence born of a century of tradition and care.

REFERENCES 1 . King E, Luke H. The knights of St John in

the British realm. London: St John’s Gate, 1967: 163-176. Hunter F A. The Palestinian Uprising, A War by Other Means. London: I B Tauris &

Melman Y, Raviv D. Behind the Uprising, Israelis, Jordanians and Palestinians. Westport Connecticut: Greenwood Press,

4. West SK, Valmadrid CT. Epidemiology of risk factors for age related cataract. Sum Oph- thalmoll995; 39: 323-334.

5. Tabbara K, Robs-Degnan D. Blindness in Saudi Arabia. J A M 1986; 255 : 3378-3384.

6. Al Farran M, Visual outcome and complica- tions after cataract extraction in Saudi Ara- bia. BritJOphthalmoll990; 74 : 141-143.

2.

CO., 1991: 1-119, 142-145. 3.

1989: 1-15.

John O’Shea MD FRCSEd. St John Australian Priory Fellow 1994

Correspondence and enquiries to: Ms Christine Slater Volunteer Services Supervisor St John Ambulance Australia 98 York St, South Melbourne VIC 3205, AUSTRALIA Facsimile 03 9696 0578

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