1. Developing an Eye Care Program in an Underserved Community
Sam Powdrill
University of Kentucky
Previously served at Tenwek Eye Unit

2. Objectives
1.     Consider the setting, demographics and facilities available for eye care and surgery in underserved rural Africa
2.     Identify the challenges and barriers to eye health and the development of a program of blindness prevention
3.     Discuss  appropriate and low cost options to providing eye care and cataract surgery to underserved populations

3. Pokot
Kipsigis
kisii
Tenwek Hospital
Maasai

4. Community Assessment

5. Causes of World Blindness
285 million visually impaired globally
39 million blind million low vision
Cause %
Trend
Cataract 40
decreasing
Glaucoma 10
increasing
AMD and other diseases
Corneal 5
Diabetic retinopathy
Refractive errors
Trachoma / infective scar
Onchocerciasis
Vitamin A deficiency 1

6. 80% of developing world blindness is avoidable
60% Treatable
20 % Preventable

7. Eye Care Advances in the past 30 years
1990s Ivermectin – for Onchocerciasis
Good quality Low cost IOLs introduced in the early 1990s
MSICS use since the early 1990s
Availability Low cost glasses with injection molded lenses
Introduction of SAFE for combating Trachoma 1996

8. Many in Rural Africa are Blind
Out of 100 people
1 is blind in both eyes
3 more have significant loss of vision
2 of these could see again with surgery
Why is there so much blindness?

9. INCIDENCE BACKLOG PREVALENCE BLIND PEOPLE OPERABLE EYES CSR
RECEIVED SURGERY
MORTALITY

10. Eye Care Comparison United States Africa
1 in 100 blind another 1% severely visually impaired
1 in 1000 blind
1 eye doctor for 1million people
1 eye doctor for 20,000 people
300 cataracts done per 1 million people
5800 cataracts done per 1 million people

11. Profile of Blindness in Western Kenya

12. Estimated Profile of Blindness in Maasai and Pokot areas
Corneal causes are increased by trachoma

13. What is the challenge?
Immediate catchment of approximately 1,000,000 people
1% blind
1% severely visually impaired
Half of these are from cataract
Estimated 2000 new cases for cataract surgery annually
One eye surgeon

14. Large numbers of people are blind from cataract
Many do not come for surgery because of:
A – availability
B – bad outcomes
C – cost
D – distance
E – escort
F – fear

15. Build Trust

16. Mission Medicine can do something about this with:
Excellent Hospitals
Excellent local training programs
Community rapport
Spiritual care
Dedicated clinicians and staff

17. Start with good communication
What does the community think the greatest needs are?
How do they hope to meet these needs?
How can we partner with them
Only enter a community on their invitation

18. Poor access to care

19. Children learn how to wash their face with minimal water
Community eye health

20. Effective community Eye health
Available
Acceptable
Appropriate
Affordable
Alma Atta – health for all by 2000

21. Community clinics

22. Advertising Where to advertise Use simple flyers or radio
Local leaders
Health workers
Village or town centers
Public transport
Schools
Churches
Use simple flyers or radio
Make personal contacts
Three weeks ahead of the screening day

23. Mobile clinics and surgery
Mobile clinics can keep the patient volume high
Many patients do not come voluntarily for surgery
Operable cataract patients should be at least 10% of any clinic to make the clinic viable.
If the patient numbers at a clinic decline then it is time to move on
Mobile surgery increases surgical compliance
Mobile surgery is time consuming and expensive
It is better to transport the patients to where the surgeon is if possible

24. She walked for six days through the harsh african bush to be able to see again

26. Start with a basic service then build

27. Focus on the common easily treatable problems
Have a small variety of effective low cost eye drops
Just keep common lowcost meds
Buy locally whenever possible
Eye drops can be made in your unit if not readily available
Have a supply of common glasses with spherical lenses – especially reading glasses
Have basic eye instruments
Refer complicated cases to the larger eye hospital

28. Focus on screening and reducing cataract
blindness

29. Cataract priorities
Screening
Selection
Surgery
Spectacles

31. Manual Small Incision Cataract Surgery (MSICS)
Safe
Good results
Quick
Low cost
Available resources and equipment
Can be done in rural areas with limited facilities
The easiest cataract surgery method to teach in the developing world

32. Don’t spend a lot of time chasing and managing glaucoma
Screening can be done in the clinic, but having dedicated screening programs for glaucoma can hurt your cataract screening
Glaucoma in the developing world is best treated surgically because drops are expensive and compliance low
Glaucoma treatment rarely improves the vision and the disease continues to progress

34. Treat itching eye conservatively
Like the poor , they are always with us
Encourage cold eye compresses and rinses
Use moistening drops
Avoid using steroid drops

35. Trachoma

37. Tarsal plate rotation surgery
Training a local nurse to do the surgery in rural areas

38. Continually train staff and the community

41. Staff training Consistantly train in the clinic and in surgery
Schedule dedicated training away from the work setting
Cross train the staff for maximum coverage
Incorporate spiritual mentoring and character building through example and teaching
Encourage them to take initiative.
Praise them when they do.

43. Train in the community Go to communities that invite you.
Health helper - visits the families and is responsible to the committee
Village committee – chooses the committee and manage the health
Combine the eye training with regular health training
Keep things simple and clear
Immunizations, hygiene, healthy diet, visual acuity and cataract.
Minimize the emphasis on glaucoma

44. Equipment and supplies
Sometimes hard to get – buy locally when possible
Expensive
Needs to be maintained – have a mechanism and budget for repair
Train staff to use instruments and maintain them

45. Basic repair kit light brass hammer bending tool 3. cotton wool
4. 600grit diamond
file
5 .small Arkansas stone
6. assorted fine files
7. mild abrasive (tooth paste)

46. Innovation We need equipment that is: high quality designs Portable
Low maintenance
low cost
replaceable

49. Managing the finances
If possible produce glasses and eye drops locally
Support the operation of the clinic on glasses production and sales
Subsidize cataracts with the glasses and private patient fees
Build the volume with cataract surgery, low cost and high volume
Consider transporting the patients to the hospital to maximize surgeon time
Most rural surgery programs will need at least some outside funding

51. Price
About $100 per surgery – varies by patient volume and salaries / training level of surgeons
Advertising
Negotiation with the community
Support from luxury glasses and higher paying patients at the hospital
Don’t make your service middle / upper class
Local production of eye drops and glasses
Consider transporting the patient to the hospital.

52. Surgical conditions are rarely optimum
Procedure
Keep the surgical procedures simple
Over pack slightly – nothing worse than running out of supplies away from home.
Surgical conditions are rarely optimum
The surgical cases are often the most difficult with the least equipment and highest risk of complications

55. Integrating Spiritual care with eye care
Plan for spiritual training with other training times
The patients don’t feel sick so they are alert and have time to listen
Many blind people are depressed and discouraged
Restored sight is physically transforming – it can be spiritually transforming, as well
Take the time to enjoy the moments when the bandages come off. Many patients will share this joy publically if given an opportunity

70. What Does all this mean for the eye surgeon who wants to go short term?
Return to the same place multiple times
Take appropriate supplies and instruments
Train someone local to do what you do
Use well tried procedures
Try to keep complications to a minimum