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