From lances to lasers – inspirational progress at St … lances to lasers – inspirational progress at St John Eye Hospital Symposium 12 th May, 2015 Nick Astbury, Medical Advisor
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From lances to lasers – inspirational progress at St John Eye Hospital Symposium 12 th May, 2015 Nick Astbury, Medical Advisor
From lances to lasers –inspirational progress at St John
Eye Hospital Symposium12th May, 2015
Nick Astbury, Medical Advisor
VISION 2020 LINKS
In Hezekiah’s Tunnel, 1998
Clinic in Jenin, 1998
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Jenin
2006
2009
From lances to lasers…
1097 2015
Argon laserCataract knife
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Siege of antioch http://burnpit.us/2011/07/siege-jerusalem-ends-goal-first-crusade-achieved 1097 to 2015 918 years
• History• Blindness in the OPT• Eye diseases explained• Inspirational progress
First Hospice
“an enormous multitude of sick people, both men and women, who are attended and restored to health daily at very great expense”
(John of Wurzberg)Circa 1099
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The history of healing and St John is an ancient one. Even then the service was overwhelmed. John of Wurtzburg, a German priest wrote a pilgrim’s guide book. Up to 2000 people. Up to 50 carried out dead daily with new ones arriving Scourge of trachoma was endemic in Palestine during the Crusades. Crusaders and pilgrims to the Holy Land may have returned infected with trachoma which they then introduced Italy and elsewhere into Europe in the 13th C. St Francis of Assisi (1182-1226) visited Palestine on at least two occasions between 1218-1221. By 1223 he had severe trachoma and trichiasis. He was blind when he died in 1226
Napoleonic Wars (1798-1815)
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Napoleonic Wars (1798-1815) Artist: Gerome, Jean-Leon 1873 Under Napoleon, French troops were devastated by infections. In one battalion, 125 out of 350 men had ophthalmia, …many cases were self limiting, but others persisted for months An expedition to upper Egypt had to be aborted in 1798, when 1400 developed ophthalmia out of a force of 3000 men. “there were more blind men than healthy” In this fascinating study of Napoleon's ten-week incursion two hundred years ago into the Holy Land and Syria, Nathan Schur brings to life the key events between February and May 1799. Using numerous eyewitness accounts, he examines the response to the invading French armies and French attitudes to the people and land they were attempting to subjugate. In early 1799 Napoleon launched an offensive from his base in Egypt and pushed his available forces northwards into Palestine, capturing Gaza and storming Jaffa, accompanied by great loss of life and a massacre of the defenders. His troops, elated by victory, were halted by the determined resistance of Ottoman and British forces at Acre, 'the key to Palestine', and a protracted and bloody siege resulted. Napoleon, despite defeating Turkish forces sent to relieve Acre, was frustrated with the slow progress of the siege and eventually called the expedition off and withdrew into Egypt with a French army decimated by bubonic plague. With details of the savage fighting, the progress of the campaign from the perspective of such diverse figures as French generals, British marines, Ottoman officials and inhabitants of the region, and a masterly insight into the thoughts and actions of the leading participants - including Napoleon, Berthier, Sidney Smith and Djezzar-Pasha - this is the full story of an inglorious but colourful episode in the wars of Napoleon.
“Ineradicable filth, squalor and indolence pervades the whole population of the Levant” William Bowman
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Epilation forceps known from 2600BC British Egyptian Campaigns (1801-1915) Infectious and contagious nature of ophthalmia was noted. In one battalion 606 of 700 soldiers affected. 90 became blind. Strict hygiene measures introduced.
“Nowhere are there are such beautiful eyes so eaten up with dirt anddisease, without hope or remedy, as in Syria.
A good English Oculist would be God’s own blessing out there, the whole country would swarm to him.”
Isabel Burton, author of “The Inner Life of Syria, Palestine and the Holy Land” 1875
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Isabel Burton, author of “The Inner Life of Syria, Palestine and the Holy Land” (1875) 1881
Sir Edmund Lechmere’s visit to Jerusalem in 1880
“…looking to the extensive prevalence of affections of the eye, it would be impossible to find an object the value of which would be more immediately felt and appreciated than a dispensary for ophthalmic cases.”
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On the case with his wife took for a site for an eye hospital “…a memorandum (was) presented by Sir Edmund Lechmere Bart., MP, in December 1876…respecting the acquisition of a site for an English Hospital in the City of Jerusalem, (which) was communicated to the Porte…” (Records of the Order 1879) Secretary to the Order of St John President of Freemasons Cofounder of the British Red Cross Bought back St. John’s Gate for the Order in 1874
The original Eye Hospital on the Bethlehem Road - 1882
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A brief intro to put into historical perspective – this is the original hospital on the Bethlehem Rd as founded in 1882 before any alterations When Sir Edmund Lechmere and his wife visited they found the site. Dr Waddell conducted the negotiations with much skill and circumspection Price £1050 Internal alterations £300 paid for by a concert given by a successful concert and a donation by the Duke of Westminster
“One of the greatest difficulties which had to be overcome was how to keep the patients in order: naturally unruly, turbulent, and unaccustomed to discipline, the entrance of a crowd such as this was found to be merely a question of physical force –the weakest going to the wall”
Eyewitness 1883
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1883 He provided a valuable description of the way the Hospital worked: “Next morning…at 8 o‟clock, we appear, making our way to the gate through a dense and motley crowd of all nations and classes – Christians, Jews from all parts of the world, Moslems, Bedouins, and Fellaheen…One of the greatest difficulties which has had to be overcome was how to keep the patients in order: naturally unruly, turbulent, and unaccustomed to anything like discipline, the entrance of a crowd such as this was found to be merely a question of physical force – the weakest going to the wall.” Men and women were sorted by cards, into groups of five each, and were admitted to the doctor in turn. “This arrangement is found to work extremely well, and perfect order is maintained without difficulty, as any turbulence, noise or disobedience, is punished by the Doctor himself, who deprives the offender of his turn, and places him among the last to be seen.”
Dr Waddell1883…11,000 pts£100 pa
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Dr Waddell from Shrewsbury Plainly moved by the plight of the people he treated Protestants 26; Greek, Armenian Christians 1114; Jews 989. Mohammedans 725 Religious mix of patients, 1885
St John Eye Hospital
1960
The Need is as great as ever
• Blindness rate is 10x higher than here• Cataract still the leading cause• Diabetes growing problem• Many have poor access• Poor health education,
hygiene, diet and consanguinity
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Diabetes 12-15% prev. people 25 time more likely to develop blindness
Prevalence of blindness in oPt
4.9%Pop 1.8m
2.5%Pop 2.5m
UK – 0.2%
Women 4.3%Men 2.2%
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Population growth rate 3.5 UK Women (4.3%) more than men (2.2%)
RAAB in Palestinian Territories
Ref: PLoS One. 2010 Jul 29;5(7):e118542010
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JULY 2010 This gave rise to an estimate of blindness for the total population of 0.4%, which was half of that previously estimated for the EMR-B (0.8%) [1]. The prevalence of blindness was higher in Gaza (4.9%, 95% CI: 3.7–6.1%) than in the West Bank (2.5%, 95% CI: 1.9–3.1%) and among women (4.3%,95% CI: 3.3–5.2%) compared to men (2.2%,95% CI:1.5–2.9%). Avoidable causes (i.e. cataract, refractive error, aphakia, surgical complications, corneal scarring and phthysis) accounted for 80.0% of bilateral blindness and cataract was the main cause of blindness (55.0%). In conclusion, our study shows that despite the lower than predicted level of blindness, most blindness in the Occupied Palestinian Territories is avoidable. Raising health awareness, gender equity, better outcomes of cataract surgery and improving accessibility should be targeted. The implementation of strategic and sustainable interventions in the delivery of eye services must be made a high priority. CONCLUSIONS: The prevalence of blindness suggests that significant numbers of people in the Occupied Palestinian Territories exist who do not access eye care - predominantly women and those residing in Gaza. Programmes need to focus on maximizing the use of current services by these excluded groups.
Causes of blindness in the OPT
55%
14%
8%
6%
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Diabetes 12-15% prev. people 25 time more likely to develop blindness Cataract 55% Corneal scarring 14% Diabetic retinopathy 8% Glaucoma 6% Prevalence of Blindness – West Bank 2.5%, Gaza 4.9% among women (4.3%, compared to men (2.2%)
Cataract
Causes
• Age• Risk factors
– Smoking– Ultraviolet light– Diabetes
• Trauma• Congenital
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Age 85%, Smoking 17% risk, U/V 10%
Old and new methods
EXTRACAPSULAR
PHACOEMULSIFICATIONSMALL INCISION
INTRACAPSULAR
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Albrecht Hennig fishook Nepal
Harold Ridley and the first intraocularLens in 1949
Cataract in children
Abdullah, West Bank, bilateral congenital cataracts, 2012
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Three month old Abdullah from the West Bank was suffering from congenital cataract in both eyes when his parents Ahmad and Nema brought him to us in Jerusalem at the beginning of September. In the United Kingdom, only around 200 children are born with congenital cataract every year (RNIB, 2012). Yet in the oPt, it is quite common for us to treat babies and infants for cataracts. The risk is greater in the oPt because of the local practise of consanguineous marriage, which of itself gives rise to many congenital diseases. Abdullah’s parents are second cousins and Ahmad, his father, also suffered from cataract as a child. Today Ahmad suffers from nystagmus – uncontrolled movement of the eyes – and, in his left eye, glaucoma. He and the rest of the family are well known to staff at our Jerusalem Hospital. Abdullah has three older brothers and two older sisters – all under 12 years old. Two of his brothers, eleven year old Awad and five year old Mohamad, also suffered from cataracts as babies. It is vitally important that cataracts in babies be treated early as their visual system is still so new. This system continues to develop up to the age of seven and, throughout, the eye must generate a clear image otherwise it will not fully mature and the eyes will become ‘lazy’ – or develop amblyopia in one eye, or both eyes. Later complications such as glaucoma can also develop and both of Abdullah’s brothers who suffered from cataracts – as well as his father – also suffer from glaucoma. Treatment for congenital cataract in babies is similar to that provided to adults and – if surgery is required – this takes the form of a Lensectomy. During a Lensectomy, a small opening is made in the side of the cornea at the front of the eye through which the cloudy lens is removed. In adults, once the cataract lens has been removed, it is then replaced by an artificial intraocular lens. In babies under three, however, it is the practice of SJEHG – as well as hospitals in Israel – not to implant an artificial lens. A lens is implanted later if it is needed; otherwise, contact lenses and glasses are used to correct refractive error. On 5 September, at our Jerusalem Hospital, young Abdullah underwent his first Lensectomy. The surgery went well and there were no complications. The vision in Abdullah’s left eye is already improving and soon he will undergo surgery on his right. Nema Faqieh, who accompanied her son on his journey to Jerusalem, was thankful to all at the hospital for the good care Abdullah received and for the kindness that was shown them both. Numbers: In UK 200/60m born with cc each year. Prev in oPt about X5. Therefore expect 75/4.3m children/year born in oPt with cc (60m pop in UK 14 times higher than 4.3 pop in oPt)
Glaucoma
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Glaucoma is the leading cause of global irreversible blindness 64m worldwide, increasing to 76.0 million in 2020 and 111.8 million in 2040 Prev of blindness in Gaza is 5% of which 6% have glaucoma. Therefore= 5,400 blind from glaucoma in Gaza (pop 1.8m)
Diabetic Retinopathy
Diabetes 15% prevalence10% will have sight threatening retinopathySo about 70,000 in oPt
Diabetic Retinopathy
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In general, it can be assumed that approximately one third of those with diabetes will have diabetic retinopathy, and approximately one third of those––or about 10%––will have sight-threatening diabetic retinopathy that requires treatment.
Laser treatment
Corneal disease
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Student teacher in Gaza (acanthamoeba)
Keratoconus
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crier/guard at Al Aqsa Mosque (keratoconus)
Keratoconus
Corneal graft Corneal ‘crosslinking’
Children
2014 - 37,500 children seen at SJEH (30% of total)
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In 2014 37,500 children seen at SJEH (30% of total of 124,000) 2 million children (making up 47% of the Palestinian population)
2m children in oPt 1/3 under 10 Gaza 75% under 25
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Gaza - 75% under the age of 25 Average age 18 Pop 1.8m 30% under 10 in oPt
Childhood blindness in the West Bank and Gaza strip: Eye (1993) 7, 580–583; doi: 10.1038/eye.1993.126
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52% marriages between relatives A study of all the schools for the blind in the West Bank and Gaza Strip was undertaken during 1993-2. Two hundred and five children had a complete ophthalmic examination. This represented 94% of all children aged 5-15 years attending schools for the blind. According to WHO categories of visual loss, 63% were blind and 21% had severe visual impairment. The main causes of blindness and severe visual loss were retinal (52%), optic atrophy (12%), glaucoma (9%) and cataract (7%). Common retinal diseases included degenerative myopia, Leber's congenital amaurosis, cone dystrophy and retinitis pigmentosa. Depending on the locality, 44-85% of these children were the product of a consanguineous marriage and a positive family history was present in 57%. The minimum prevalence of childhood blindness was estimated to be 0.32/1000 children. A reduction in the prevalence of blindness requires a reduction in consanguineous marriages, genetic counselling for affected families and public health measures to ensure early referral for management of cataract and glaucoma.
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For example…
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Poor diet and intermarriage means high rate of congenital diseases (cataract, glaucoma, retinal disease, eye malformations)
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Dr Humam
Congenital retinal disease
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Lebers corneal electrodes and Midazolam sedation Muyasser Ghanem
Progress in the last decade
Now 19 ophthalmic specialists in St John Group
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The number of medical staff have increased by 10% 19 specialists in Group 4 residents
All imporftant Refractions Contact Lens fitting Low visual aids
Chrisjan Dees
Ted Burton
Tony Tyers
Hirut von Lamy
Wendy Franks
Numbers
• All outpatients seen in group per annum:2009 = 93,000 2014 = 124,000
• All major ops done in group per annum:2009 = 3500 2014 = 5200
Teaching and training
• 5 Residents at SJEH
• Medical students– Jordan, Australia, UK– Al Quds University
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AlQuds 32 students in 6 batches from 2014
Teaching and training
• Orthoptic assistants• Optometrists• Technicians
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POST GRADUATE Short term Advanced Glaucoma Training Ophthalmologist from Gaza Four Year Ophthalmic Residency Five residents in training UNDERGRADUATE International Elective Medical Students Jordan, Australia and UK (Duke Elder Prize Winner) Al Quds University Medical Students From January 2014 - 32 Students in 6 batches ORTHOPTICS Israeli Diploma Qualification SJEH orthoptic assistants trained and prepared for exam Clinical Orthoptic training provided for other units (3 Israeli Orthoptists) OPTOMETRISTS Training in special contact lens fitting Two SJEH optometrists with Hadassah College DIAGNOSTICS Biometry Optometrist signed off to do biometry in Anabta Optical Coherence Tomography (OCT) SJEH Nurse practitioner signed off to do OCT test
Community partnerships
• Screening babies for retinopathy of prematurity• Vision screening schoolchildren• Screening adults for diabetic retinopathy
26,000 screened so far
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Screening Neonates for Retinopathy of Prematurity (ROP) East Jerusalem Hospitals (EJH) – 28 Caritas Baby Hospital - 34 Holy Family Hospital - 39 (since August 2014 bimonthly) Screening children Screening of EJH children referred for diagnosis - 155 Screening at Caritas Baby Hospital & Holy Family Hospital - 78 Screening vision school children – trial run for preschool, further collaboration with MoH and MoEd sought for success Screening adults for diabetes Screening for diabetic retinopathy ongoing (UNRWA) Screening pregnant women with gestational diabetes (in future with Holy Family Hospital)
Training partnerships
• Hadassah University– Residency and fellowships for SJEH doctors– Research in the future
• Hadassah Academic College of Jerusalem– Special contact lenses/workshops
• Tel Aviv University– Three orthoptic students trained at St John– SJEH enable to take Israeli exam
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Hadassah University Hospital Joint Teaching Uveitis Fellowship (August 2012 – January 2013) Cornea Fellowship (September 2012 – September 2013) 3 year Ophthalmic Residency - Diploma (January 2011- February 2014) Future – possible fellowships in Genetics and Retina with research opportunities Hadassah Academic College of Jerusalem - Optometry Special Contact Lens Clinic bimonthly – 5th year Optometry students Fitting of special contact lenses for St John patients Training St John optometrists in fitting special lenses Workshops / seminars on corneal problems / contact lenses at St John Tel Aviv University Training of Orthoptic students at St John (three trained) Orthoptic assistants enabled to take the orthoptic exam
Centre for reconciliation – Christian patient (actually I made that up), Jewish Prof Saul Merin (died Aug 2012) , Palestinian consultant – there could be a lot to say about this slide
Memorandum of Understanding
April 2014
Palestinian MOH
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Wednesday, 23 April 2014 On 24th March in the Palestinian Minister of Health’s office in Ramallah, Dr. Jawad Awad signed a Memorandum of Understanding with St John of Jerusalem Eye Hospital Group in the presence of Brigadier Tom Ogilvie-Graham, Chief Executive of the Eye Hospital Group. The agreement covers various matters relating to mutual cooperation in the provision of ophthalmology in the occupied Palestinian territories. The Eye Hospital Group will now examine and treat diabetic patients in Ministry of Health (MoH) clinics and will provide free surgical services for some patients who are referred from the MoH. The Eye Hospital Group will also train MoH medical personnel, in order to increase the efficiency of surgical specialties in ophthalmic surgery. Surgeries will also be performed in public hospitals by St John Eye Hospital surgeons.
New buildings and facilities
• Anabta
New buildings and facilities
• Hebron
New buildings and facilities
• Jerusalem
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2 new floors
New buildings and facilities
• Gaza
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2 new floors
New buildings and facilities
• Gaza
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2 new floors
New buildings and facilities
• Gaza
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2 new floors
New equipment explained
• ‘Phaco’ machine
New equipment
• Ultrasound
New equipment
• Fluorescein angiography
New equipment
• Corneal topography
New equipment
• Corneal Collagen Crosslinking
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Corneal collagen cross-linking is a technique which uses UV light and a photosensitizer to strengthen chemical bonds in the cornea. The goal of the treatment is to halt progressive and irregular changes in corneal shape known as ectasia. These ectatic changes are typically marked by corneal thinning and an increase in the anterior and/or posterior curvatures of the cornea, and often lead to high levels of myopia and astigmatism. The most common form of ectasia is keratoconus and less often ectasia is seen after laser vision correction such as LASIK.
New equipment
• Optical Coherence Tomography (OCT)normal
Diabetic macular oedema
and after treatment
New equipment
• Valon ‘pattern’ laser
Clinical Governance
“Duty to provide the best care to patients”
– Reporting clinical incidents and learning from mistakes– Audit of clinical outcomes ie cataract surgery– Staff appraisal– Risk register– Complaints– Member of World Association
of Eye Hospitals– JCI accreditation
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World Association of Eye Hospitals (WAEH) As a member of WAEH we can avail of and exchange indicators for quality. We have already participated with other WAEH members in three WAEH Structure, Process and Trends indicators: ‘A Study of Current Care Management Practices in Cataract Surgery’ with The Royal Victoria Eye and Ear Hospital, Melbourne. And been part of Performance Monitor Indicator on ‘New Patients Against Old’ with other WAEH members spearheaded by the Rotterdam Eye Hospital We have also submitted some information on another WAEH - Procedure: To ensure the correct intraocular lens is inserted in cataract surgery with Moorfields Eye Hospital It has been difficult to get all the information to them, without electronic medical records. We are working on collecting this manually where possible, for the next cycle. JOINT COMMISSION INTERNATIONAL
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
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The country but not the politics!
What I will miss
• The staff• The hospital and clinics• The patients• The hospitality• The food• The country• The board
Inspirational progress!
Please support my 100 mile bike ride for St John – on Aug 2nd
