A New Sky for My Eye!

By Geoff Tabin, M.D.
Fall 1997

In Nepal and Tibet, cataracts are responsible for nearly 70 percent of all blindness. In Nepal, 10 percent of all people over 60 are blind in both eyes from cataracts, according to a WHO survey. The figure is thought to be much higher in Tibet. The cause of these high rates-genetic predilection, high-altitude sunlight, poor nutrition, or other factors-is not clear. During "cataract camps," above, Drs. Ruit and Tabin can perform up to 100 cataract surgeries per day. They do one eye and then supervise the local staff as they do the second eye.

Intro

Medrokongga County, three hours north of Lhasa, is one of the poorest counties in Tibet, one of the poorest countries in the world. The main highway, a rutted dirt and gravel road snakes along the mighty Tsong Po River. On both sides the arid Tibetan Plateau rises steeply into jagged foothills of the Himalayas.

A few scattered settlements of bare wood and mud hovels cling to the flat bed of land along the river. White Buddhist prayer flags flap in the wind on top of each box-like dwelling. Yaks and goats graze on the sparse grass in the brown remnants of barley fields.

At this altitude of 13,000 feet. the temperature dips below freezing every night in mid-September. There is no electricity or even firewood to be found in this region. Cooking is done over open fires of dried yak dung.

Life is harsh here, particularly if you are blind. And Medrokongga County has one of the highest rates of cataract blindness in the world. Hospital workers have prescreened patients and tell us that there are more than 200 people in the county of about 400 households who are blind from cataracts in both eyes.

Our bus bounces to a halt in front of the Medrokongga County hospital. Our cataract team includes my partner Dr. Sanduk Ruit, a Nepalese ophthalmologist, two nurses and two technicians from our hospital in Kathmandu, plus three Tibetan doctors, three Tibetan nurses, and three Tibetan technicians whom we have been training.

I first met Dr. Ruit in 1994 during a fellowship year studying corneal diseases and surgery in Australia. I spent a month with him in Nepal at a cataract camp in the mountains. Following my fellowship year, he asked me to help run an eye hospital in southern Nepal and to teach cataract surgery, which 1 did for six months.

My interest in international ophthalmology grew out of my contact with Tibetans and Nepalese during my climbs in the Himalayas during the early 1980s. (See sidebar on "Blind Corners".) I was struck then that ophthalmology could have an enormous and immediate impact by preventing or treating nearly all blindness.

Dr. Ruit, who trained in India and Australia, is an absolute master surgeon who has perfected the inexpensive delivery of surgery in remote regions. We have worked together in Nepal and Tibet and formed the Himalayan Cataract Project in 1995 to train doctors in microsurgery and lens implants.

The People Need Us

Rumors of this cataract camp began circulating in the county nearly a year ago and hundreds of elderly Tibetans and their families have gathered at the county hospital. They have been waiting for months. Their gazes combine a mixture of hope and doubt.

No one has ever been cured of blindness here before.

The hospital has the sickly smell of many such Third World facilities, a mixture of the acrid odor of stale urine with the rich scents of excrement and antiseptic. The halls and tables are dusty. A welcoming committee of flies buzzes in every room. There is no heat and no power.

As the portable microscope, generator, and other supplies are unloaded, Dr. Ruit looks across the barren dirt courtyard of the hospital and gives me a broad smile.

Pointing at the blind crowd, he excitedly exclaims that every thing is perfect. "This is where the people need us."

Twelve hours per day for the next three days, Dr. Ruit and I operate side by side in a makeshift operating room without any high-tech equipment beyond a microscope. When the generator fails, we continue working through the microscope on eyes that are illuminated by assistants holding flashlights.

Technicians, trained by Dr. Ruit and myself, inject local anesthetics to the eyes and prepare the patients for surgery. When a surgery is finished, the patient is rolled off one side of the table as the next one is rolled on. The face is painted with antiseptic and surgery continues. The turnover time between patients is less than a minute.

Dr. Ruit has no trouble sustaining a rate of seven perfect surgeries per hour for a 12-hour operating day. For a cost of about $20 our patients get approximately the same surgery that was done in the United States about 10 years ago. While patients need six weeks to recover and glasses to see 20/20, they go from seeing only shadows to ambulatory vision, roughly 20/80, in the first day. State-of-the-art surgery here would cost about $6,000 with patients usually having 20/20 vision without glasses in three days.

The Hell of Darkness

" There is a new sky for my eye! I am free from the hell of darkness!" exclaims Sonam Dechen, moments after the white gauze patch has been removed from her left eye. Tears of joy stream down her bronzed cheeks. Yesterday the 63-year-old widow was unable to see the shadow of a hand moving in front of her face. Today she can see well.

With no living sons, she had no one to take care of her, often going days without eating and falling into ditches. Sonam was certain she would soon die. "Now," she proudly exclaims, "I will be able to take care of myself."

In three days. Dr. Ruit and I performed nearly 200 "miracles" in Medrokongga County. The cataract team then moves on to Nyimu County, an equally poverty-stricken area south of Lhasa, and finishes at Lhasa City Hospital. In 10 days, 506 totally blind Tibetans have their sight restored.

There are no surgical complications and no infections. Such a success rate has not been achieved in this setting before. Two College of Medicine students, Beth Macomber'OO and Sean McKeon'OO are gathering data this summer in Nepal on the complication rate and visual outcomes from Dr. Ruit's cataract technique. We plan to publish the results in peer review literature next year.

More importantly, the surgery is observed by three Tibetan ophthalmologists. Two of them spent three months in Kathmandu under Dr. Ruit's tutelage learning how to perform microsurgery and insert lens implants after cataract removal. The next week three Tibetan surgeons perform 91 more procedures under our supervision with the microscope, surgical instruments, and intraocular lenses the team has donated to the hospital.

That September 1996 trip was the Himalayan Cataract Project's third venture to teach eye care in Tibet. We have now established an eye center in Lhasa that is actively restoring sight to Tibetans. In the past year we trained three more Tibetan surgeons and will have a cataract camp and establish a surgical center in the densely populated Kham Region of eastern Tibet.

Our work is just a start. Tibet has a backlog of 30,000 people who need cataract surgery, according to Chinese estimates. This year Tibetan surgeons will perform about 1,000 operations. but this will not keep pace with the 2,000 additional people who will become blind. We hope as we train more local doctors and donate more equipment that we can eliminate the backlog in about 10 years.

Low-Budget, All-Volunteer Program

The year-old University of Vermont Himalayan Cataract Project is a low-budget, all-volunteer program that builds on the efforts and humanistic concerns of many. Most notable has been the work of the late Fred Hollows, a renowned New Zealand ophthalmologist who brought Dr. Ruit to Australia in 1990 for a year to train in extracapsular cataract surgery with intraocular lens placement. Until this training, Dr. Ruit like all Nepalese ophthalmologists at that time removed the entire lens during cataract surgery. The patient then had to wear thick coke-bottle-like glasses.

Unfortunately, there were few facilities for accurate refraction in Nepal, and patients who lost, scratched, or broke their glasses were as blind as they were before surgery. In fact, the second leading cause of blindness is lack of glasses after surgery.

Dr. Hollows went further by starting the Fred Hollows Foundation which helped establish the Tilganga Eye Centre in Kath mandu and a factory to produce low-cost high-quality intraocular lenses in Kathmandu.

Dr. Ruit and I have carried on his work through the Himalayan Cataract Project. The total cost of one project—bringing a team to Nepal for training, buying a microscope and all surgical equipment, conducting a cataract camp, and leaving lens and equipment for local doctors to do an additional 200 cases—is about $10,000 plus transportation costs.

Ophthalmologic companies have provided free lenses and surgical supplies and two friends have donated $20,000 in addition to the $25,000 that I have contributed.

In 1996, I came to the College of Medicine and Fletcher Alien Health Care to be the region's specialist in corneal transplantation and external eye diseases. With the support of the University of Vermont, the cataract project now has a tax deductible, charitable status and is officially known as the University of Vermont Himalayan Cataract Project.

We are recycling throwaway supplies from the operating rooms of Fletcher Alien and are collecting equipment and supplies from other hospitals in the Northeast. We are now developing a budget and are seeking foundation and private support. I welcome the help of Western ophthalmologists, but the time commitment—a minimum of one month teaching—eliminates most volunteers.

Program Extends to Pakistan

This August with the support of the Hoerni Foundation, I will be going to Pakistan to assess their needs and to perform the first intraocular lens surgery in the Baltoro Region in the Himalayas. We would like to create a teaching eye center in Lhasa, Tibet, and expand into Bhutan and Sikkim.

Our goals are ambitious but I think doable. We want to train technicians, scrub nurses, and at least three doctors per year to perform their own cataract surgery. We will continue to train people in Nepal but hope to bring international fellows to the College of Medicine for advanced clinical training.

We hope to make the local programs self-sustaining by charging those who can afford to pay while providing free care for those who can't.

This will not happen overnight, but I believe that we and other international groups, working with community health care workers, can eliminate all treatable and preventable blindness in the Himalayan Region in our lifetime.