Over the next several blogs, I would like to review/summarize the booklet produced by John Cheatham, MD Reaching The Blind Poor about ten years ago. John passed away unexpectedly in 2009 with an MI. His obituary ( A Life Without Furniture ) can be found at the Mission Eyes Network website. For over ten years, John visited and helped financially many eye clinics in Latin America, subSaharan Africa, and Asia. His family foundation continues to support an eye clinic in Antigua, Guatemala, and clinics elsewhere.
Excerpts from Reaching The Blind Poor by John Cheatham MD
- Patient selection means everything. Operating cataract patients, for example, with advanced glaucoma or posterior uveitis usually brings disappointment and frustration. The effect of this is to harm the name of the hospital and of the doctor, thereby discouraging operable cataract patients from seeking treatment.
- I repeatedly see hopeless cases ” referred ” somewhere else. This places an enormous emotional — and economic — burden on the poor.
- We must accept that many blinding conditions that may be treatable in our society are untreated in most of the developing world. Vague promises of future corneal transplants and of posterior segment procedures lead to disappointment in almost all cases. If there is no treatment possibility, e.g., absolute glaucoma, the doctor should make this clear to the patient and family, thereby hopefully avoiding future treatment costs and disappointments.
- Glasses should not be provided in most cases for minor refractive errors. Just as in the example of unneeded drops ( chronic environmental eye irritation ), this creates the belief that vision will be harmed if their use is not continued. It is also enormously time-consuming and can divert us from attempting to treat the blind. I am disappointed that many eye programs exert considerable effort toward providing unnecessary medications and unneeded glasses. Reading glasses, on the other hand, are both useful and easy to distribute.
- Poor world ( low-income ) ophthalmology is like dentistry — what works is essentially surgical.
- Ophthalmic assistants should not be trained unless there is a specific need for them. They should work under the supervision of experienced doctors. The unsupervised assistant can do more harm than good.
- If biometry is not available, try to choose an IOL power unlikely to leave the patient hyperopic. Almost everyone is happy with mild to moderate myopia.
- The safest, easiest anesthesia is peribulbar without a facial block. We use 2% xylocaine with epinephrine and then have the patient lower IOP using the heel of their hand to press gently on the globe. We have discontinued the use of hyaluronidase.
- Safe eye surgery can be done almost anywhere without the elaborate OR procedures required in other surgical specialties. What matters is proper hygienic preparation and meticulous instrument sterilization.
- BSS is sometimes not used but rather Ringer’s Lactate or even normal saline solution. Adding 0.5 ml adrenalin ( 1:1,000 preservative-free ) to 500 ml of the irrigating solution is tremendously helpful in maintaining the pupil dilation of heavily pigmented irises.
- 2% methylcellulose is an excellent and safe viscoelastic. Aurolab manufactures a 3 ml vial which costs about three US dollars. This is also available in Mexico and elsewhere in India ( other vendors ).
- Pterygium surgery can and does lead to many complications. Do not operate on early pterygiums. This is often overdone by visiting ophthalmologists due to a lack of other surgical cases. When it is required, we should try to use intraoperative antimetabolites and/or a good conjunctival flap.
- Corneal transplants without adequate follow-up possibilities should not be done on patients with good vision in the other eye.
- Avoid expensive testing for “academic” purposes. Testing is warranted only when the results can significantly help to improve the patient’s condition. I often see patients sent for costly CT scans when no treatment will be available to them.
- Be extremely careful in areas of poor follow-up in choosing to operate patients with only one seeing eye. We once operated a man who had enough vision to travel unassisted to our clinic. Vitreous loss led to a retinal detachment, and he is today totally blind.
- The poor neither demand, expect nor usually need the precise visual results available in our society. What they seek is the safe, basic, readily available, inexpensive surgery that will allow them to again participate in their world and to cease being burdens on their already overburdened families.
In the near future, I will continue with more excerpts from Dr. Cheatham’s booklet ( Reaching The Blind Poor ) as his observations/suggestions are still pertinent today.
Peace,
Baxter