surgical eye missions on a shoestring budget
TRANSCRIPT
J. ALBERTO MARTINEZ, MD
VISIONARY FOUNDATION
Surgical Eye Missions on a Shoestring
Budget
Description/Objectives
The course will detail the organization, funding and implementation of surgical eye missions to impoverished areas of the world
Objectives: How a mission that provides eye care to
the needy is done• How anybody can do it• Are we really helping? To motivate by sharing personal
experiences
Outline
Why eye surgical missions? Does one have to be a wealthy
philanthropist? How I first got involved Choosing a location Choosing an organization Logistics Our trips to Africa, south and Central America Creating your own foundation
WHY?
According to the World Health Organization (WHO) 2010: 285 million people are visually impaired (45
million blind) 80% of visual impairment can be avoided or cured 90% in developing countries
Prevalence of Blindness
Population is projected to increase from 6 billion to 8 billion by 2020
From 1 billion people over 45 to 2 billion over 45 by 2020
the number of blind will increase by 2 million per year (unless something is done)
Can you imagine being blind in a Developing country?
When someone becomes blind in the developing world:
90% of these individuals can no longer work
Life expectancy drops down 1/3 that of a peer, in age and health
50% of the blind report a loss of social standing and decision-making authority
80% of all women note loss of authority with their family
What are the leading cause of blindness? (according to WHO)
Cataract: 47.9%Glaucoma: 12.3%
ARMD: 8.7%
Corneal opacities: 5.1%Diabetic retinopathy: 4.8%
Childhood blindness: 3.9%Trachoma: 3.6%
Onchocerciasis: 0.8%
Global Priorities (WHO)
Cataract Trachoma Onchocerchiasis Childhood blindness Refractive errors
Onchocerchiasis
River blindness affects 37 million people, mostly living in poor, rural African
communities
River blindness affects 37 million people, mostly living in poor, rural African
communities
Trends in global blindness
The burden of blindness from infectious diseases has decreased dramatically over the past 20 years
However, other causes such as cataract, ARMD and glaucoma are INCREASING because of the growing and increased AGING of the population.
LOASIS
Organism-Loa loa Vector - Chrysops spp. (deerfly) Microfilariae: Blood-borne Adult worms: subcutaneous Prevalence - ?3-13 million Geographic Distribution - West and Central Africa
Clinical manifestation Asymptomatic Non-specific
o urticaria, pruritus, myalgias
Calabar swellings Eyeworm Complications
o Endomyocardial fibrosis, renal disease, encephalopathy, entrapment
Progress in Reducing World Blindness
Significant progress in preventing and curing visual impairment in many countries over the last 20 years
International partnerships have achieved reduction in onchocerciasis-related blindness
Ghana and Morocco both have reported elimination of trachoma (2010 and 2007 respectively).
Over the last decade, Brazil has been providing eye care services through the national social security system.
service provision for the poorest at district level.
Effective Help
Given the causes of Blindness, it is most cost effective to concentrate in two areas:
Refractive errors Cataracts
Refractive errors
This is perhaps the area where one can have the most impact with the least resources:
Need :• Knowledge of refraction• A phoropter or• Loose lenses• Eyeglasses to dispense
Refractive errors
Fortunately, eyeglasses are plentiful and relatively easy to obtain.
One can buy very cheap (a couple of dollars) readers for presbyopes
The Lions Club has an eyeglass recycling system that processes thousands of second hand glasseso One can request from them Boxes of glasseso The boxes come labeled by the power and
cylinder
Refractive errors After the refraction the nearest match is
dispensed. I have seen villagers walk for days with
complains of poor near vision, only to see the incredible joy in their faces when you give them a simple pair of readers!
Cataract Surgery
CE is ideally suited for surgical missions because:
Relatively easy to perform Relatively easily obtained
equipment Relatively easy to obtain
supplies Minimal follow-up needed Impact is profound and
permanent
Cataract surgery
The most crucial need is to have a LOCAL ophthalmologist to partner with
He/she will:o Identify the caseso Perform Axial eye
length and IOL calc.o Follow up the
patients A bonus if they have
infraestructure (a working eye OR)
Cataract surgery
Need an operating room with:
Microscope Phaco machine Surgical
instruments Intraocular lenses Consumables
Glaucoma
Glaucoma remains a daunting problem, particularly in Africa.
Drops are not accessible to most Trabeculectomy is difficult on a short mission
trip (follow up) Lasers (ALT, SLT) are helpful but still temporary
solution NEW, implantable micro devices Istents!
Biggest problem: lack of trained MDs
The lack of trained ophthalmologists as a major factor limiting the diagnosis and care of people with glaucoma in developing countries. o In Europe, there is one ophthalmologist for
every 10 000 peopleo In India, there is one for every 400 000 people o In Africa, one or less for every million.
Incidentally, the US there are approximately 1 ophthalmologist per 20,000 people. That ratio is much higher in Maryland , particularly in Montgomery county
Practicing MDs Vs. Blindness
Mission 1: Kenya, Africa
Trip to Laikipia Rhino reserve in Kenya. Sponsored by the Paul Chester Foundation. 5 MD’s
(ENT, GYN, IM, 2 Ophth) Partially a scouting/evaluation No cataract surgery was performed (no
infraestructure). Only trachoma (eyelid) surgery. More than two hundred patients evaluated,
“treated” for glaucoma, other minor things Very frustrating
Mission 1: Kenya, Africa
Began construction of an OR next to the reservation.
Realized that the problems was really cataracts
Screened patients for cataract
Promised to return
Mission 2: Malindi, Africa
This trip was to Malindi, a small port city one hour north of Mombasa, East Coast of Kenya
A local eye health care worker (a nurse with eye training) , screened the patients for cataract surgery.
Also operated on congenital glaucoma and pterygia
No axial eye length obtained. Everyone got a 22D IOL
Mission 2: Malindi, Africa
A phaco machine was Borrowed through Alcon, shipped to Kenia
A local, multilingual, scrub tech was flown from Nairobi. Invaluable
Cases were performed under topical anesthesia (except for bilateral trabeculectomies in an 8 month old with buphthalmos)
Anesthesiologists were used for more severe problems (i.e. hyppopotamus bites)
Mission 2: Malindi, Africa
All consumables for the OR were provided by Alcon,
drops by various drug companies (allergan, B&L, Ista etc)
OR was disassembled after surgery.
Mission 2: Malindi, Africa
Approximately 45 cataract surgeries were performed in 4 surgical days
Also 30 pterygia, 2 trabeculectomies8 boxes of Lions club-processed
eyeglasses given to the eye dept of the hospital
One day follow-up of all patients accomplished
Mission 3: Tumaco, Colombia
Tumaco is a town of 100,000 in the pacific cost of Colombia, close to Ecuador
Inhabitants are mostly Afro-Colombians Poverty is severe. Average income is
$2/day A convergence of Guerrilla and Narcotics
warfare has affected the city. Fortunately a secure area of the city was
provided by the local marines
Mission 3: Tumaco, Colombia
The first trip was a fact finding mission Connection was made with a local
Ophthalmologist that visits Tumaco twice/month
This Ophthalmologist agreed to pre-screen the patients, get AEL, take care of the follow-up
Mission 4: Tumaco, Colombia
The second Trip Included An ENT, Anesthesiologist, Plastic Surgeon, 3 ophthalmologists
A very successful, trip in terms of surgeries accomplished:
55 Cataract surgeries, 80 pterygiectomies, 30 ALTs, 60 refractions/glasses
Mission 4: Tumaco, Colombia
Success created by excellent local support
We were able to procure a microscope which stayed behind.
Another microscope was borrowed (and returned) form Bogotá
An anterior segment fellow from Bogota, the capital joined us. Most of the time 2 eye surgeons operating simultaneously
A phaco machine and scrub tech were obtained from Bogota.
Flying Solo
Previous surgical missions with a foundation providing all types of care, not just ophthalmology
Eyes are very specific, high volume surgery, very different logistics
Was unhappy with the focus on fundraising, publicity, too many hangers-on
Thus, decided to start my own foundation
Alcon Missions
There are fantastic resources available Most notably Alcon Missions. On a website, you fill out a form with the
required information and they will send you essentially all you need to perform eye surgery: from blades to viscoelastic, IOL,s drapes etc
They ship it to your office, you repackage and away you go!
Creating your own foundation
Getting started Opening a foundation After you determine the work you will do
and that it meets a real need, you must developing these essential ingredients of a successful nonprofit: A mission High-quality, responsive, and unduplicated
programs and services Reliable and diverse revenue streams Clear lines of accountability Adequate facilities
Creating your own foundationStarting a nonprofit generally also
requires these steps to formalize your organization:
File articles of incorporation with the Secretary of State or other appropriate state agency.
Apply for exempt status with the Internal Revenue Service (IRS). Please note that it can take 3-12 months for the IRS to return its decision.
Register with the state(s) where you plan to do fundraising activities.
First Trip With our Own Foundation
Partnered with Dr. Bernie Kreutz,.
San Pedro Sula, Honduras
Initially, a fact finding trip Made a connection with a local
ophthalmologist He is in Private practice, but also runs a
charity clinic Has a functional eye OR with phaco machine
and microscope
San Pedro Sula
Why Honduras? It is one of the poorest countries in Latin
America Spanish native language Same time zone, four hour flightThe need is clear:
According to local statistics, there are about 42,000 diagnosed cataracts in Honduras. However, only approximately 5,175 cataract surgeries are performed in Honduras yearly. Thus there are tens of thousands of people in need of cataract surgery.
San Pedro Sula, Honduras
Part of the problem is that there are only 64 Ophthalmologists in the entire country.
Honduras has a population of 8,200.000 million people, approximately one ophthalmologist per 128,125 people.
In comparison to the US, there is one ophthalmologist per 20,000 people. Essentially, TEN times more ophthalmologists per person in the US.
Another interesting finding while visiting San Pedro Sula, I was informed that there was only one cornea specialist in the entire country, located in Tegucigalpa, Honduras'capital, about 6 hours away from San Pedro Sula driving.
The need for corneal transplant is unknown, but it is estimated that there are thousands of people blind for lack of a corneal transplant.
There are no eye banks in Honduras as of now. We are discussing starting one.
Most MD's are concentrated in two cities: Tegucigalpa and San Pedro Sula. This leaves the population of rural areas severely underserved. Most people may never see an eye doctor.
In addition, there is a large burden in un-operated pterygiae. The number of people suffering from this disease is unknown, but is estimated to be tens of thousands.
Other prevalent diseases are: Glaucoma and diabetic Retinopathy.
San Pedro Sula, Honduras 2012
First surgical mission was conducted in San Pedro Sula, Honduras, from October 27th to November 2nd 2012
Surgical equipment, logistics, and travel Organized by the foundation secretary: Anna Pigotti and Dr Kreutz team
Performed 7 corneal transplants 35 Cataract surgeries
A careful analysis by Dr. Fajardo and Dr. Martinez concluded that surgical mission was an excellent success. Dr. Fajardo gracefully invited us to other missions in the future
San Pedro Sula/transplants 2012
Follow-up accomplished locally by well trained surgeon
Patients have done well, guidance on suture removal accomplished via e-mail (photos, topography, refraction)
Future missions will again include PK’s
San Pedro Sula: CE 2012
35 CE, most of them phaco a few extracaps
AEL and IOL powers had been calculated in advance
IOL’s were donated by Alcon
Consumables by Alcon and others
Patients did well. No cases of dropped nuclei or corneal de-compensation
San Pedro Sula/CE 2012
We planned to make this a yearly event. We plan to strengthen our local ties. A
lecture was given to local ophthalmologists. We were invited to lecture at their National Annual meeting in Tegucigalpa
Honduras Surgical Eye Mission February 15-21, 2014
A total of 48 eye surgeries surgeries were performed:o 1 Trabeculectomyo 3 Intra-operative Avastin injections
to manage diabetic retinopathy o 4 Istent placementso 6 corneal transplants (3 DSAEK, 3
Penetrating) o 34 cataract surgeries (28 phaco, 6
extra-cap. One combined penetrating keratoplasty with CE and IOL, one Phacotrabeculectomy )
Honduras Surgical Eye Mission February 15-21, 2014
Post-ops were seen the following day after surgery, and all medications needed for post-op care were provided.
Honduras Surgical Eye Mission February 15-21, 2014
Complications: 3 capsular tear with vitreous loss required and
anterior vitrectomy. One of them resulted on a sulcus placement of an IOL. The other 2 cases required anterior chamber IOLs.
2 patients had postoperative pressure spikes managed by paracentesis and pressure lowering meds
These complicated cases were seen one day post-op and found to be stable. Except for significant cornea edema.
These cases were followed closely by Dr. Fajardo. They all had good outcomes
Honduras Surgical Eye Mission April 22-17, 2015
A total of 33 eye surgeries were performed:
4 Istent implantations 12 corneal transplants
(4 DSAEK, 8 PK) 17 cataract surgeries
(1 phaco+ Istent, 1phaco+DSAEK, 3 extra capsular)
Honduras Surgical Eye Mission April 22-17, 2015 Post-ops were seen the
following day after surgery, and all medications needed for post-op care were provided.
Complications: One of the DSAEK had a partial
flat chamber.Through the use of “Whatsapp” Dr. Fajardo and Dr. Barahona have shared photos of the post-operative follow ops. We plan to return the first week of April 2016 this time with 2 surgeons to have a bigger surgical impact.
Equipment Donation
Through our 501c3 foundation status we can obtain donations that are tax deductible.
Phaco machine, examining chairs, slit lamps, instruments
Etc.
Training: Dr. Marvin Barahona
Are we really helping?
Unite for sight (UFS): International organization focused on providing eye care.
UFS has a module titled: The significant harm of worst practices in eye care
They are CRITICAL of certain “worst practices” by optometric missions and “Medical safaris”
UFS:Optometric and Medical Missions : Are we REALLY helping? Providing optometric care solely in the form of
presbyopic or refractive correction is thought to be counterproductive and can prevent patients from seeking eye care for other ophthalmic conditions
Are we really helping? Handing out glasses by non eye-
care professionals: Shorts circuits the eye care process
Are we really helping?
Worst Practices: “referrals” to local eye doctors without facilitating access
Are we really helping?
Medical “safaris” or “medical tourism” “volunteer vacations”
Sometimes focused on OUTPUT not OUTCOMES
Poor follow up. No local coordination Untrained physicians. Leave a burden for local practicioners
Tips: what to know before you go on an optometric mission
Eyeglass Distribution By Non-Eye Care Professionals: bad practice in global health
“Referrals” to Local Eye Doctors: “Referring” without reducing barriers to care will not enable a patient to access locally available resources
The Dangers of Short-Term “Surgical Safaris”: Post-surgical monitoring and follow-up care is necessary to prevent infection and to ensure the success of an operation
We feel blessed and honored to have had a chance to improve the lives of some Hondureños.
In return for that help we bring back with us a feeling of satisfaction that is unparalleled in depth and never ending
“Para-Mission activities. Local girls Orphanage
Juan. Living in “bordo” slums by the river. Teased about his eye. Went to his parents, requested permission. Found and paid an anesthesiologist, removed his dermoid. Looks much better (photo next year)
For more information contact:[email protected]
