Sam Powdrill University of Kentucky Previously served at Tenwek Eye Unit

1. Developing an Eye Care Program in an Underserved Community Sam Powdrill University of Kentucky Previously served at Tenwek Eye Unit

2. Objectives • 1.     Consider the setting, demographics and facilities available for eye care and surgery in underserved rural Africa • 2.     Identify the challenges and barriers to eye health and the development of a program of blindness prevention • 3.     Discuss  appropriate and low cost options to providing eye care and cataract surgery to underserved populations

3. Pokot Kipsigis kisii Tenwek Hospital Maasai

4. Community Assessment

5. Causes of World Blindness 285 million visually impaired globally 39 million blind - 246 million low vision

6. 80% of developing world blindness is avoidable • 60% Treatable • 20 % Preventable

7. Eye Care Advances in the past 30 years • 1990s Ivermectin 1987 – for Onchocerciasis • Good quality Low cost IOLs introduced in the early 1990s • MSICS use since the early 1990s • Availability Low cost glasses with injection molded lenses • Introduction of SAFE for combating Trachoma 1996

8. Many in Rural Africa 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 Why is there so much blindness?

9. INCIDENCE BACKLOG PREVALENCE OPERABLE EYES BLIND PEOPLE CSR RECEIVED SURGERY MORTALITY

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

11. Profile of Blindness in Western Kenya

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

13. What is the challenge? • 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

14. Large numbers of people are blind from cataract Many do not come for surgery because of: A – availability B – bad outcomes C – cost D – distance E – escort F – fear

15. Build Trust

16. Mission Medicine can do something about this with: • Excellent Hospitals • Excellent local training programs • Community rapport • Spiritual care • Dedicated clinicians and staff

17. Start with good communication • What does the community think the greatest needs are? • How do they hope to meet these needs? • How can we partner with them • Only enter a community on their invitation

18. Poor access to care

19. Community eye health Children learn how to wash their face with minimal water

20. Effective community Eye health • Available • Acceptable • Appropriate • Affordable Alma Atta – health for all by 2000

21. Community clinics

22. Advertising • Where to advertise • Local leaders • Health workers • Village or town centers • Public transport • Schools • Churches • Use simple flyers or radio • Make personal contacts • Three weeks ahead of the screening day

23. Mobile clinics and surgery • Mobile clinics can keep the patient volume high • Many patients do not come voluntarily for surgery • Operable cataract patients should be at least 10% of any clinic to make the clinic viable. • If the patient numbers at a clinic decline then it is time to move on • Mobile surgery increases surgical compliance • Mobile surgery is time consuming and expensive • It is better to transport the patients to where the surgeon is if possible

24. She walked for six days through the harsh african bush to be able to see again

26. Start with a basic service then build

27. Focus on the common easily treatable problems • Have a small variety of effective low cost eye drops • Just keep common lowcost meds • Buy locally whenever possible • Eye drops can be made in your unit if not readily available • Have a supply of common glasses with spherical lenses – especially reading glasses • Have basic eye instruments • Refer complicated cases to the larger eye hospital

28. Focus on screening and reducing cataract blindness

29. Cataract priorities • Screening • Selection • Surgery • Spectacles

31. Manual Small Incision Cataract Surgery (MSICS) • Safe • Good results • Quick • Low cost • Available resources and equipment • Can be done in rural areas with limited facilities • The easiest cataract surgery method to teach in the developing world

32. Don’t spend a lot of time chasing and managing glaucoma • Screening can be done in the clinic, but having dedicated screening programs for glaucoma can hurt your cataract screening • Glaucoma in the developing world is best treated surgically because drops are expensive and compliance low • Glaucoma treatment rarely improves the vision and the disease continues to progress

34. Treat itching eye conservatively Like the poor , they are always with us • Encourage cold eye compresses and rinses • Use moistening drops • Avoid using steroid drops

35. Trachoma

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

38. Continually train staff and the community

41. Staff training • Consistantly train in the clinic and in surgery • Schedule dedicated training away from the work setting • Cross train the staff for maximum coverage • Incorporate spiritual mentoring and character building through example and teaching • Encourage them to take initiative. • Praise them when they do.

43. Train in the community • Go to communities that invite you. • Health helper - visits the families and is responsible to the committee • Village committee – chooses the committee and manage the health • Combine the eye training with regular health training • Keep things simple and clear • Immunizations, hygiene, healthy diet, visual acuity and cataract. • Minimize the emphasis on glaucoma

44. Equipment and supplies • Sometimes hard to get – buy locally when possible • Expensive • Needs to be maintained – have a mechanism and budget for repair • Train staff to use instruments and maintain them

45. light brass hammer • bending tool • 3. cotton wool • 4. 600grit diamond • file • 5 .small Arkansas stone • 6. assorted fine files • 7. mild abrasive (tooth paste) Basic repair kit

46. Innovation We need equipment that is: • high quality designs • Portable • Low maintenance • low cost • replaceable

49. Managing the finances • If possible produce glasses and eye drops locally • Support the operation of the clinic on glasses production and sales • Subsidize cataracts with the glasses and private patient fees • Build the volume with cataract surgery, low cost and high volume • Consider transporting the patients to the hospital to maximize surgeon time • Most rural surgery programs will need at least some outside funding