1. Sam Powdrill University of Kentucky Previously at Tenwek Hospital, Kenya Eye care in the Tropics for Non- ophthalmologists

2. Tenwek Hospital

3. Objectives 1.Define blindness from a community perspective 2.Understand the burden of avoidable blindness in our world 3.Exposure to the most common causes of visual impairment and World blindness 4.Gain an understanding of current prevention of blindness efforts and methods

4. 50 million blind in our world 600 people go blind every hour Half of these are blind from cataract 90% live in the developing world

5. 80% of developing world blindness is avoidable 60% Treatable 20 % Preventable

6. Many in Kenya 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

7. So, How can you make a difference?

8. Start with a community assessment. How big is the problem?

9. Causes of World Blindess In millions Cataract 25 Trachoma 7 Glaucoma 5 Refractive errors 5 Diabetes 2.5 Vit A def 1 Macular deg. 1 Oncho 0.5 Injuries 0.5 Leprosy 0.25 Retinal 5 Trachoma

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

11. Size of the problem in the local community 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

12. Profile of Blindness in Western Kenya

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

14. Pokot Kipsigis Maasai kisii Tenwek Hospital

15. The main eye care provider for 1 million rural people  9, 000 cataract operations needing to be done now  800 new cataract cases per year  Only one eye surgeon on staff

16. Patient Profile Culture –Language – always pre- arrange reliable translators. Education – illiterate doesn’t mean stupid! Perception and expectations – How does the patient perceive the problem Local co-morbid considerations and risks Financial priorities of the family – is cataract surgery more important than school fees Follow up – is follow up likely or possible Seasonal considerations – planting, harvesting, rains

18. Screening for cataract surgery at an outlying center

19. Here the gift of sight is a privilege that many do not have

22. Portable Scanoptics microscope

24. Most cataracts are very dense and phaco is both difficult and costly on these lenses.

25. Frown incision allows for a suture-less extracapsular procedure to to remove the nucleus through a wide tunnel

26. Linear capsulotomy with 26 ga needle. Continuous capsulorhexis if adequate visibility

27. Nucleus delivered by hydrodissection

28. Lens in place after completion of capsulorhexis wound closed and tight without suture

29. Anterior Chamber Lens implant  Aphakia  Posterior capsule complications

30. old glasses

31. new glasses

32. Optical workshop

33. Anterior lens placed under visco-elastic through a clear corneal temporal incision The patient had previous intracapsular surgery without an intraocular lens

34. Large numbers of people are blind from cataract Many do not come because of: Availability Bad outcomes Cost Distance Escort Fear

35. Service to Patient Available Acceptable Appropriate Affordable Alma Atta – health for all by 2000

36. Mobile Surgery Taking eye surgery to a community that does not have a functioning static service within reach of the local people

37. Considerations in Mobile surgery Patient Profile Personnel Physical factors Procedure Price

38. Personnel A local person health provider doing screening ahead of time Translators Patient attendants Mid level eye care provider - screening Equipment person / circulator Scrub technician Surgeon

39. Physical challenges Transport – patients and surgery team Local Facility – cleanliness, water, food, power source Instrument maintenance and care

41. tonometry on a church bench

50. LOKORI

54. Loupes are used for cataract surgery to reduce equipment weight

56. This man has just had his bandage removed and is seeing his hand clearly after being blind for several years

57. Thrilled to see again and dancing This blind lady walked for five days through the bush to get cataract surgery

59. Which is better ? One or two

60. Trachoma

62. Trachoma folicles with inflammation

63. Trachoma inflammation and scar

64. Blind eye from entopion and corneal scarring

65. Epidemiological assessment of Trachoma (EAT)  20% of children 1 – 5 years old have either trachoma TF or TI  1 adult in 100 has trachoma trichiasis If either of these is true then the community has endemic trachoma

66. Community 1  TF or TI 45% of 1-5 year old children  Examined 200 adults and found one with TT Community with endemic trachoma which is new to the area.

67. Community 2  TF or TI 5% of 1-5 year old children  Examined 100 adults and found 4 with TT Community with endemic trachoma which is diminishing.

68. Community 3  TF or TI 45% of 1-5 year old children  Examined 100 adults and found three with TT Community with endemic trachoma which is unchecked and longstanding.

69. Treatment  Active disease - tetracycline eye ointment b.I.d X 6 weeks OR  Azithromycin one tablet stat  Trichiasis – tarsal plate rotation surgery

70. Prevention Daily face washing No livestock in or near the living area Improved pit latrines Efficient use of water Smaller familes with less crowding Education

71. Eye Lid surgery

72. screening

73. Upper eyelid entropion surgery for trachoma

76. Eye lid incision

79. Undermining and advancement of tarsus

80. 6-0 vicryl rotating sutures

81. Post op review Bleeding Under correction Over correction Corneal damage

82. S A F E S – surgery A – antibiotics F – face washing E - environment

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

84. Follow up Do things right the first time many patients never return for follow up. Promote cataract and trachoma surgery Don’t build a program on glaucoma control

85. Refractive errors Nearsighted – myopia Farsighted – hyperopia Astigmatism Presbyopia

86. Glaucoma Acute angle closure Chronic open angle Other glaucomas

87. Chronic glaucoma Intraocular pressure Cup disc ratio Visual field

88. Cup disc ratio slides

89. Normal retina

90. measurement 0.5 0.7

91. 0.8 0.9 0.7

92. 0.8 0.3 0.6

93. Comparison of ACG and Uveitis

94. Aqueous flow in the eye & filtering mechanism

95. Iris position in angle closure glaucoma

96. Angle closure glaucoma

97. Glaucoma Acute angle closure Sudden onset Painful Sudden loss of vision Red eye Very high pressure Closed angle Fair complexion Chronic Open Angle Gradual onset Painless Gradual visual loss Eye not red Medium pressure rise Open angle Dark complexion

98. Angle Closure Glaucoma Note: irregular light reflex, mid-sized pupil

99. Glaucoma Acute Angle Closure Glaucoma – This is the only common type of glaucoma with a significant red eye – Unilateral pain, redness, decreased vision, “halos” around lights before the peak of signs and symptoms – Cloudy cornea (scattered light reflex); fixed, mid- dilated pupil; red eye with ciliary flush, shallow anterior chamber with iris shadow. Treatment – Lower Intraocular pressure (pilocarpine drops and acetazolamide orally) and referral for laser or surgical peripheral iridotomy if medical treatment fails

102. Chronic glaucoma treatment Prevent with early screening at age 40 and older Timolol and / or Xalatan eye drops For high pressures – acetazolamide orally If pressures remain high on treatment – then surgical intervention is needed.

103. Macular Degeneration age related gradual loss of central vision Loss of vision is permanent but peripheral vision remains intact. No treatment – need to encourage use of visual aids

105. Red Eye: overview Allergic Conjunctivitis Infectious Conjunctivitis Infectious Keratitis Orbital cellulitis Measles Vitamin A deficiency Inflammatory causes Tumors Traumatic causes Glaucoma Contact Lens complications Eyelid Margin disease infectious inflammatory nutritional neoplastic mechanical allergic

106. blinding or non-blinding If both eyes are red treat them If one eye is red and painful refer

107. Use extreme caution with steroids in a red eye You should probably consult an Ophthalmologist first

108. Never use a topical anesthetic to treat pain in an eye cyclopentolate drops topically give relief for a painful eye if necessary anesthetic drops can be used when examining the eye

109. Allergic Conjunctivitis Atopic – Associated with asthma & eczema Allergic – Associated with sinus congestion & pain, runny nose, and itching Drug allergy – Atropine, neomycin, and also lotions, and contact allergies – History will help with the diagnosis

110. Allergic conjunctivitis Note: whitish papillae are seen on the upper lid conjunctiva

111. Allergic conjunctivitis Limbal irritationCobblestone papillae and shield ulcer

112. Cold water rinse Cold compresses Zinc sulphate drops or artificial tears NSAID drops or Mast cell inhibitor drops or anti-histamines Severe disease with papillae need aggressive treatment with steroid drops and short courses of oral steroids. Allergic conjunctivitis treatment

113. Pterygium This is a growth of fibrovascular tissue onto the conjunctiva and cornea Associated with sun, wind, and dust exposure Treatment – Usually unnecessary – If inflamed, topical NSAIDs or steroids – If obscuring the visual axis, refer for surgical removal

114. Pterygium Note: triangular shape of pterygium, with parallel vessels