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SURGICALEYECAMPREPORT
AndOrientationManual
24th–28thAUGUST2017PHNOMPENH,CAMBODIA
EyeCareinCambodia
CurrentSituation
•Over180,000Cambodianareblind.10,000Cambodianssufferavoidableblindnesseachyear.
•90%ofblindnessisavoidable.79%iscurableand11%ispreventable.
•Three-quartersofblindnessisduetocataracts,andtherestisduetouncorrectedvision,glaucoma,cornealscarringandpterygium.
•Only38ophthalmologistsserviceapopulationofover15,000,000–oneofthelowestnumberofophthalmologistspercapitaintheworld.
InCambodia,10percentofthepopulationlivesbelowthepovertyline;over40percentearnsonly$2perday.Mostofthepoorliveinruralareaswherethereiseithernoorlimitedaccesstoeyecare.Womenaremorethantwiceaslikelyasmentosufferfromcataractblindness.Cataractbacklogisover300,000
ObjectiveoftheEyeCamp:
• Toscreenpatientsforcataract• Toprovidesurgicaleyeserviceforcataractandotherconditions• Toshareourexpertisewithlocalresidentdoctors
IntroductiontoKhmer–SovietFriendshipHospital
Khmer-SovietFriendshipHospitalisa500bedpublichospitalinPhnomPenh.ThehospitalismanagedbytheMinistryofHeath
IntroductiontoKhmerSightFoundation
KhmerSightfoundedbySeanNguandthelateDrKimFrumarfromSydneyin2015tounifyophthalmologyandeyecareinCambodia.Ouraimistobuildlocalcapacitythroughtraininglocaldoctorsandhealthworkers,buildingnewfacilities,andintroducingthelatesttechnologyandequipment.Wearehelpingcreateaself-sustaininglocalcentreofexcellenceforeyecaretrainingandservicedeliveryinCambodia’scapitalPhnomPenh.Thiswillenableustocreateaone-stopcentreforeyescreeningandoperations.Wehelptrainophthalmologistssotherewillbeagenerationoflocalspecialistsreadytotakeonthechallengeoferadicatingavoidableblindness.Ourvolunteerhealthworkersprovideavitallinkbetweenpatientsandeyehealthservices.Theyvisitremoteruralcommunitiestoconducteyescreeningsandprovidebasicinstructionsoneyehygiene.In2017KSFhasselectedatleastoneCambodiandoctortocompleteaninternationalfellowshipinsub-specialtieslackinginCambodia.Developmentsarealsounderwayforpatientswithcornealandretinalissuestobetreatedinthefuture,aswellaspaediatricissues.Bydevelopingsurgicalanddiagnosticskillsandprovidingscholarshipsabroadtotraininsub-specialities,thelocaleyespecialistscanhelptheirowncountrybecomeself-reliant.
Volunteers(needtoputpicsofeachmember)
Medicalteam
DrRupeshAgrawal(Rotarian),Singapore
DrRekhaKhandelwal(Rotarian),India
DrShivaniSule(Rotarian),India
DrCijinJose,India
DrRoy Tan,Singapore
DrJanikaShah,Singapore
DrZeenathisa,Singapore
Rotaryteam–RotaryClubofSingapore
RtnTapanRao,
RtnDeeptiLalchandani
RtnJimmyOoi
ProfessorSunilShahInternational Medical Chairperson KSF
SeanNguCo-founder–BoardmemberKSF
Overview
KhmerSovietFriendshipHospitalontheYothapolKhemarakPhouminBoulevard,PhnomPenhisapublichospitalmanagedbytheMinistryofHealth,GovernmentofCambodia.ProfNgyMengservesastheDirectorofthehospital,inadditiontobeingtheDirectoroftheNationalProgramforEyeHealth.DrNYTharath,whoisaGlaucomafellow,servesastheHeadofDepartmentforOphthalmology.Besideshim,DrSalyThearith,aRetinafellow,isanotherconsultant.Apartfromtheconsultants,thereare3fellowsundergoingtheirsubspecialtytraining.TheKhmerSoviethas11residents,1inthethirdyear,4inthesecondyearand6inthefirstyearofresidency.Theresidentsplayavitalrole,bothintheOPDsandintheOT.Therefore,getintroducedtotheresidentsatthestartofthemissionsoyouknowwhotheyarefromtheoutset.
ScreeningtakesplacebymedicalstudentvolunteersoftheKhmerSightinthevillages,oftentheweekendbeforetheforthcomingmission.Duringscreening,peoplecometoanominatedfacilityinthevillageandare“processed”.TheyhaveaBPdoneandareseenbyaGP.TheyarethenassessedtoseeiftheyhavecataractorpterygiumandaVAisdone.Ideally,onlythosewithvisuallythreateningpterygiumoraVAlessthanorequalto6/36intheWORSEeyeareencouragedtogetonthebuswhichtransportsthepatienttothehospital,butpleaseappreciatethatfamilymemberswithnosignificantvisualproblemsmayaccompanythepatient.Pleasedoappreciatethatnotallpatientswillfulfillthecriteriaforsurgeryeventhoughtheyhavebeenscreened.
Ifyouhaveachancetoattendascreeningclinic,pleaseteachthemedicalstudentvolunteershowtoassessforvisuallythreateningpterygiumandcataractandchecktheyaremeasuringvisioncorrectly;iftheyarenotpleasecorrectthem.Moreover,domakethempayattentiontoAfferentPupillarydefectsandNasolacrimalDuctobstructions.SinceresourcessuchasslitlampsandOphthalmoscopesarenotavailableatscreeningcentres,carryingahand-heldslitlamporanindirectophthalmoscope(andafewvialsofTropicamide)wouldbeextremelybeneficial.
EachpersonwhoisdeemedforfurthertreatmentisgivenanA5pieceofpaperwiththeirBPandVAwrittenonit.ThisistheirtickettogetonthebusbutitisalsoevidencethattheyarefromapoorperipheralvillageandnotsomeonewhocanaffordprivatetreatmentwhohaswalkedinoffthestreetsofPhnomPenh.
Patientsarrivebusloadbybusload.TheygotothegroundfloorintheNewOPDforOphthalmologyandENTintheKhmerSovietFriendshipHospital.
Medicalstudentvolunteersactastranslatorsforyou.Askthemtoregisterallpatientsandmeasurethevisioninbotheyesfirst.Atregistrationaskthemtostaplethe“busticket“formtotheregistrationform.
Itisadvisabletoputseniorophthalmologistsinthewaitingroomtovalidatetheneedforsurgery:onlythosewithsightthreateningpterygiumandonlythosewithVAlesstoorequalto6/36intheworseeye.Skinmarksruboffintheheat–sostickapieceoftapeintheirfrontsmarkedwith:
A)Pterygium
B)Cataract
Assess:
Thesearepatientsthatneedfurtherexaminationataslitlampiftheyclearlyhavesomethingelsethatneedsattention
Allpatientswithtapeontheirfrontswaitinthequeueforaslitlampexamination(ontheGroundfloorintheKhmerSovietFriendshipHospital).SincethescreeningprocesshasnotyetbecomesmoothattheKhmerSoviet,MANYofthepatientsgetclearedforsurgeryWITHOUTIOPmeasurement,FundusevaluationandPupillaryLightReflexevaluation.Makesureeverypatientgettingclearanceforcataractorpterygiumsurgeryhascompletedthefollowingmandatorychecks:
1)Visualacuity,withpinholeinbotheyes2)PresenceorabsenceofanAfferentPupillaryDefect.DonotoperateifthereisanAPD.3)SlitLampexamination4)MeasurementoftheIntraOcularPressure(ResidentsgenerallydotheNon-Contactmethod)5)Fundusevaluation
Then:
Sendallpatientsthatneedcataractsurgeryforbiometry.TheygototheSmallSurgeryroomintheGroundflooroftheKhmerSovietHospitalwiththeirnotesforbiometryandcalculationoftheIOLpowers.
SendallpatientswithpterygiumneedingsurgerytotheSmallSurgeryroomintheGroundflooroftheKhmerSovietHospitalwiththeirnotes.
Sendpatientswithouttape,home.
Onthefirstday,prioritisethosewithcataractandpterygiumfirstandthenseethe“assess”patientssotheatrecangetgoing.
Onthesecondandsubsequentdays,thereislessrushaspatientswillbereadyfortheatreprocessedfromthedaybefore.
Hospital-Location,LayoutandFacilities
TheNewOPDGroundFloor.Thefollowingprocedurestakeplacehere:
• Preoperativevisionassessment• Preoperativeexamination(Slitlamp,IOPandFundus)• Biometry(intheSmallSurgeryroom,detailedbelow)• Registrationforsurgery• Postoperativeexamination• Postoperativerefractionandprescriptionofglasses
TheSmallSurgeryroomhas:
1. Biometry(IOLMaster)2. AscanUltrasound3. BscanUltrasound4. AutoRefraction
The3rdFlooroftheNewOPDBlockhas:
1. Laserroom(PI,SLT,LaserforDiabeticRetinopathy)2. Perimetry3. OCTscan4. Funduscamera(dilated)
OperationTheatre,3rdFloor,OldBlock,KhmerSovietFriendshipHospital
Surgery
Keepyournotesmakingsuretheyareasgoodasinyourhomecountry.
1. Fillinthetheatrebookwithpatientname,operationandsideand*ifitiscomplicated.2. Makesureyouwriteanoperatingnoteandwriteyournameclearlydetailinganycomplications3. Ifsurgeryiscomplicated,makesurethereareclearplansforfollowupandcommunicatethisto
amedicalstudentandtothepatient.
AstheKhmerSoviethasashortageofsurgicalscrubs,bringingyourownscrubwillputlessstrainonthelimitedresources.
YourscrubnursewillbeamedicalstudentvolunteerwhomaynotspeakmuchEnglish.Therefore,itisbettertoarrangemultiplesurgicaltraysbeforestartingproceduresfortheday.Aseveryinstrumentyouarefamiliarwithmaynotbeavailable,itisprudenttobringyourownsetofinstruments.Bringingthefollowingwillmakeyoursurgeryeasier:
• Limsforceps• Capsulorhexisforceps• Chopper• Sinskeyhook(s)• Wirevectis• Lenshook
IfyouchoosetooperateunderLocalAnaesthesia,pleasenotethatinjectingthePeribulbarblockwillhavetobedoneontheoperatingtableitselfduetotheunavailabilityofbedswherepatientscanbeblockedpreoperatively.
Knowhowtosetupandprimeaphacomachineandknowyoursettings
Note:Atpresent,theKhmerSovietOperationTheatrehas2tables,2operatingmicroscopes(Zeiss)and1Phacomachine(NidekCV7000).
Knowhowtosetupavitrectomyandknowyoursettings
Youmustpre-emptmorethanyoudoinyourhomecountry
AdrenalineneedsaddingtotheRingersLactatesolution.Nominatesomeonetodothisoraddityourselfandmarkthebag
Chooseyourlensandgetit
SetupaComplicationtrolleyatthebeginningofthedaywith:
Miochol;Intracameralphenylephrine;Capsuletensionring;Irishooks;Visionblue;Suturematerial:10/0vicryland10/0nylon;Tyingforceps
Andensureitemsarereplacediftheyareused
KeepaneyeonyourRingersLactatesolutionsoitdoesnotrunout
Gownsareusedonepersessionandglovesarechangedforeachcase
Theknivesarere-used.Askforanotherifyoursisblunt
Thekeratomesarewiderthanweareusedto.Onlygoinhalfthewidth;thenthewoundwillnotleakwhenusingthesimcoI/A
Thewoundneedstobeenlargedwhenusinganon-foldableIOLandthensuturesareneeded.Wefoundithelpfultousea6-7mmscleraltunnelandputa6mmPMMAlensinthesulcus.Thiswoundwillre-sealwithouttheneedforsutures.
Youcanuseahandhelddiathermytocauterisescleralvesselsbutitgetsveryhot.OryoucanheataninstrumentinaBunsenburnertocauterisethescleralvessels
Bringyourownspecificinstrumentsformorespecialistsurgeryegpaedglaucoma/paedcataract
Pleasenotethesurgicalenvironmentisnotthesameasathome!
Beclearaboutwhoshouldbelistedforsurgery.Onlyoperateonthosewithavisionof6/36orworseinthebettereye,becausetheresultpostopneedstobebetterthanpreop!DonotoperateifthereisanAPD
Instrumentswhichareveryusefulandwhicharenotreadilyavailable:
90Dlens
28/30Dlens
Handheldslit-lamp
Icaretonometer
Batterychargedindirectophthalmoscope(andcorrectplug)
Goodhalogenlightforcheckingpupils
Non-permanentmarkerpens
Whitestickytape
Theatregreens
Retinoscope
Aboxoftriallenses:reallyhelpfulifyouareexpectingtoseepaedcases
PatientScreening
Surgery
Postop:
TeachingLocalResidentdoctors:
Lastdayofthecamp:
ReportoftheEyecamp:
SurgeriesperformedPhaco-4,SICS12(oneextendedtoECCE),1ECCE,8pterygiums,3SICStotrainee,2pterygiumstotrainee.Complications–Nil
Challengesfaced
• Technicalfactors–o Lackofcoordinationbetweenthelocalteam&Volunteeringteamwithregardstoroles
&responsibilitiesduringthecampleadinglossvaluabletimeatstartofeachdayofthecamp
o Unfamiliaritytoenvironment&instrumentso Lackofadequateinstruments&medicine(eg.Mannitol)
• TeamFactors:o Languagebarrierwithscrubteam
• AnestheticsFactorso Majorityoftheperi-bulbarblockswerenoteffective
Insightsfromthecamp:
Followingaresomekeyinsightsfromthecampandareaoffocusforfuturecamps.
Phase Currentscenario/Lacunae Possiblesolution1 Pre-
operative• Pre-operativework-up,startingantibiotic
dropsandNSAIDSnotacommonpractice• Roleofpre-opantibioticsandpovidonemay
bestressedbynextbatchofdoctors• UseofPovidoneIodinenotcommonly
followed• PresenceofMeibomitis • Veryimportanttoscreenitandstartmedicines
beforesurgery• ManypatientshadPseudoexfoliation(PXS) • Importanceofpre-opSlitlampexamination
andplanningsurgeryaccordinglytoavoidintra-opcomplicationsshouldbetaught.
• RoleofIOPcheckandasymmetricPXSwithPXGinsameeyearefewofthetopicswhichshouldbediscussedwithresidents
2 Operative SuperiorLimbalScarring:• Almostallcaseshadsuperiorlimbal
scarringandalsosomewerevascularized,becauseofwhichmakingtunnelwasdifficultwiththeavailablecrescentblades.
• Thisscaringmaybefromtheiryoungageatthetimewhentrachoma(??)wasprevalentinCambodia
• ResidentsperformedSICSbytaking7-8mmstraighttunnelwhichmayinducelotof
• Residentsshouldbetaughtaboutastigmatismfreezoneandfrownincision
• Withhighnumberofpatientswithsuperiorscarredlimbus,aresearchstudytoevaluateastigmatismpre-operativeandpost-operativewithdifferentsectiontypesandmanagingintra-operativelyshouldbeconsidered.
astigmatismDenseArcus:• Almostallthepatienthaddensearcus.• Presenceofdensearcusmayleadto
visibilityissuesifclearcorneaphacoisperformed
• HenceresidentsmustbetaughtaboutECCEandSICSasbasicprocedures
Pterygium:• Manyyoungpatientshadbigpterygiums• Thispossiblymaybeduetolocationof
Cambodiabeingnearertoequator
• Residentsshouldbemadeawarethatcombining
largepterygiumwithcataractisnotagoodoptionasitmayleadtoastigmatismandvisibilityissuesandhowever,ifsuchneedarise,residentsshouldbetaughthowtoproceedforsuchcases.
• BasedonstudiesfromTaiwan,researchstudiesevaluatingassociationofhighriskofskincancersinpatientswithpterygiumandroleofimpressioncytologyinexcisedareatoseeforrecurrencemaybeconsidered
TypeofCataracts:• Morepatientspresentedwithnuclear
cataractcomparedtocorticalcataract.• ThismaybepossiblyduetohighUV
radiation,lowersocioeconomicstatus
• Insuchscenarioofmoreptspresentingwithnuclearcataract,it’sveryimportantforresidentstolearnagoodECCEforlargeanddensenuclearcataractandalsomustusevectistechniquetopreventintra-operativecomplications.Thismaybenextbatchcanfocusmoreonthis.
• PerformingagoodECCEwithpre-placedsuturesandendocapsulartechnique,onecanpreventintra-opcomplicationsisthinPC,zonularweaknessamongothers.
• Phacoshouldonlybedoneinselectedcasesaspatientsfromrural/peripherytownmaynotaffordfoldablelensandincreasingphacoincisionsizefornon-foldablelenswilldefeatthepurpose.
• Focusingonthesetopics(ECCEandsafepracticesincataractsurgeries)canbeoneofobjectiveofthenextcamp.
• Mannitolwasnotavailable • Itsavailabilityshouldbemademandatory• Itsuseintraoperatively,pre-operativelyisvery
importantforresidentstoknow.• Lateralcanthotomy • Lateralcanthotomyindicationsontableandhow
todoitshouldbetaughttoresidents