Giving Back Sight
AYAD Robert Dashwood worked as a Research Officer at the Tilganga Eye Centre, Kathmandu, Nepal. Through the support of The Fred Hollows Foundation, Australia, the Tilganga Eye Centre are performing fantastic work, giving people back their sight and reducing the economic burdens blindness places on everyday Nepali families…
The first time I saw surgery I was almost physically ill - the skin peeled back, a chisel pulled out and some bone chipped away. I’ve seen videos of cataract and other eye surgeries being performed as part of my AYAD assignment that I would liken to a game of billiards. But in Banepa, a small trading town on the road to Tibet, in a makeshift operating theatre inside a school classroom, Dr Sanduk Ruit made cataract surgery look like an art form – 67 times.
On one weekend in February, I was in Banepa in the Kavre district 50km east of Kathmandu on an Outreach Microsurgical Eye Clinic (OMEC) being conducted by my host organization Tilganga Eye Centre.
Leaving at 7am on Saturday, we had all the equipment to set up a remote operating theatre, rice and potatoes included - the staple of the Nepali diet. On arrival, we unloaded the equipment and it was time for breakfast. I love Nepali breakfast, curried soy beans and oily deep fried bread and tea with 4 or 5 tonnes of sugar dropped in it. From there we spilt up to go to our respective screening camp locations. The team that adopted me were bound for Dolalghat, about 50 kilometres north of Banepa.
With Nepali roads and traffic rules it took us some time to get there. On arrival, we set up our equipment, observed the numbers of patients already waiting for registration and then promptly left for morning tea. Starting to wonder when the work would be done, I looked out from the school we were based at to the river below where many Kathmandu families come on weekends to get out of the ‘Du.
Our team consisted of two trained ophthalmic assistants (OAs), two students, an army of willing volunteers and the brother of one of the guys who had come along because he felt like it. On more detailed screening camps, the OAs will also give prescriptions for corrective lenses but on this particular camp we were looking for cataracts. Cataract patients would receive surgery the following day in Banepa – for free.
After finishing morning tea, the boys got straight into it. Every patient needs to have their visual acuity measured, get screened for disease and those with cataracts need to go to 'counselling' before they are carted off to Banepa for surgery the next day.
Being my second ever screening camp, I was about as useful as a canoe in a drought but was put in the counselling room to collect patient details. It was Luson’s (the brother) and my job to explain to the patients that required surgery what was going to happen and collect their details.
Remember your last visit to the optometrist? At a minimum it probably took you 20 minutes. He had lots of lines and colours and gadgets, he could flick a switch and turn off all the lights, directing your attention to the eye chart lit up on the wall. The walls would be adorned with his children's pre-school art and you would casually banter about the weather that week.
Inside the space of 5 hours, the Tilganga crew had been through more than 300 patients with a few stragglers to go (that’s about 1 patient per minute). Not having lunch until everything was finished at about 3 o'clock, I finally understood why we had stopped for so much to eat and drink in the morning. They had not stopped talking, explaining and running around after patients since they started. After lunch, 5 exhausted boys and our driver traded jokes and used my tall, white ‘bideshi-ness’ to get the attention of the girls buying fruit across the road at the local market. For them, this was just any old average week.
Twenty-two patients had been lined up for 'eye cleaning'. Most of our patients are 60+ and lack a formal education. Mentioning the word surgery conjures up myths of evil doctors with twirlable moustaches removing the patient’s eyes, rubbing them on a dirty towel and then putting the eye back in. ‘Cleaning eyes’ is the best way the staff have found to explain the procedure that doesn’t end in the patient running for the hills.
Returning to Banepa the work was not over. The patients, having been given some time to collect their things, had been delivered (on the back of a ute) and were waiting to have their biometry tests done. A cataract is a pathological opacification of the eye’s natural lens and occurs in all kinds of people as they get older. Cataract surgery involves replacing that lens with a man-made one. Biometry tells us what kind of lens the patient will need during their surgery. When the day was finally done, the patients were setup in a neighbouring hall and we retired to our guesthouse for food prepared by the multitalented sherpa, Nigma.
Surgical cataract removal can be done in a few different ways. What I watched Dr Ruit do was the method of phacoemulsification. Through small incisions in the patient's eye, the opacified lens is broken up into tiny pieces that are then sucked out through a tool rather like a very expensive vacuum cleaner.
As I was watching Dr Ruit work, the power cut out and the entire operating theatre was enveloped in darkness. He just put down his scalpel and waited patiently with his hands resting on the table while Pemba-daai ran around madly trying to get the power going again. Currently, Nepal is plagued by power cuts, usually for more than 16 hours per day, every day. This is a result of no rain for the hydro power plants, politics, 12 years of civil conflict and, ironically, flooding late last year.
The Tilganga staff do work under circumstances that I believe many western healthcare professionals would refuse to accept. No running water, school desks as operating tables, bits of cardboard covering the windows, patients waiting calmly in stairwells for hours and surgical timeframes making the 5 minute Trapdoor episodes I watched as a kid look like epic movies. By the end of the day they had done more than 70 surgeries. It's hardly your average run of the mill week for me.
Monday was a shorter surgical day, but also involved post-op checkups on our patients from Sunday’s surgery. This is the time where you take off the patient’s eye patch and wave your hands in front of their face. As I watched on, I could isolate the exact moment of recognition that they were no longer blind. Some people had not had functional use of their eyes for years.
We had one patient, bilaterally blind and mute, Chandraman Tamang. He was a very sorry looking gentleman in a yellow jacket. It was all he could do to identify his shoes and put them on. His son had to help with almost everything. He could not communicate his thoughts but was obviously anxious about spending so much time waiting. Kept calm by the amazingly stoic patients waiting alongside, he eventually got through his surgery, but coming out of the OT he was still as blind as he was the day before. Then Monday happened. His eye-patch was removed and Khem-daai pointed up the stairs where his son was waving and holding up 2 fingers. Mr Tamang was beside himself with excitement and smiled for the first time.
I don’t know that there are many points in life where you feel the way I did in that single moment. I could not help but giggle as a wave of welcome happiness rushed through my entire body. All the patients around him started to hold up their fingers for him to count and he started to copy them. Khem, the manager of the Outreach department has been on tens of eye camps and still obviously felt the excitement of that moment.
Throughout Monday the surgeries continued, along with more screening of new patients and post-op follow up. Tuesday, as our last day, saw everything packed up and loaded back on the bus. The patients had their post-op visual acuity measured, and I have to admit to being slightly jealous that some could see better than me.
My work in the Research Department keeps me detached from actual patient care in the day-to-day. However the chance to experience an OMEC for the first time reminds me how important the work both my host organisation and my partner organisation (The Fred Hollows Foundations) really is.