Pakistan Trip Report

Report of the Himalayan Cataract Project
Hoerni Foundation
Central Asia Institute

Mission to Northern Pakistan

August/September 1997
by Geoff Tabin, M.D.

The purpose of this trip was to explore the state of ophthalmology in northern Pakistan, perform sight-restoring cataract surgery and other procedures, and begin teaching cataract surgery with microsurgical instrumentation and intraocular lenses in northern Pakistan.

In northern Pakistan there is a great need for ophthalmic care. There is a government ophthalmologist as well as a Christian eye hospital that are working in Gilgit at the mouth of the Hunza Valley. The Christian doctors, one from England and one from the United States, are working hard to create a high quality hospital. They are doing microsurgery for all of their cataract patients and using intraocular lenses for visual rehabilitation. The Pakistani government ophthalmologist operates in a worse environment and performs cataract surgery without a microscope. North of Gilgit there is only one eye doctor for a population of approximately 400,000 people in northern Pakistan. This area is predominantly Shiite Muslim as opposed to Sunni Muslim for the majority of Pakistan. As a result this doctor gets very little teaching or help from the rest of his country. The doctor, Niaz Ali, is also one of only four doctors in the region with a full medical degree. He thus is also forced to perform general medical care as well as being an ophthalmologist. Prior to our recent trip, he was only performing cataract surgery without a microscope and had never placed an intraocular lens. He has an enormous cataract problem with a huge backlog of bilaterally blind patients. There is also a very large number of patients, particularly children, who have strabismus and also a large volume of patients with blocked tear ducts. There is an operating microscope that is available for his use in the government hospital. However, it is of rather poor quality and it is difficult for Dr. Ali to obtain operating room time and support at his hospital. Finally, the hospital has an operating room in very poor hygenic conditions (live rats running in the operating room and dirt everywhere).

Our recent trip was organized by Greg Mortenson who is working hard on several projects to benefit the people of northern Pakistan. His representatives met myself and my assistant, Neal Beidleman, at the Rawalpindi/Islamabad airport. Because flights were being canceled by inclement weather it was decided we should drive immediately from Islamabad to Gilgit. We did briefly have the opportunity to visit the main teaching eye hospital in Rawalpindi which is a good hospital, very clean with seemingly well-trained ophthalmologists. They are developing a training program for a full four year residency in ophthalmology. I discussed with them the possibility of developing a shorter cataract-training course. The head of their training program, Dr. Aswan, was interested in this idea but felt that is was not something he would be able to implement for some time.

The next morning Neal and I departed in a Jeep for Gilgit where Dr. Mitch Ryan at the Gilgit Eye Hospital had pre-screened several patients and where Dr. Niaz Ali from Skardu was waiting for us. Unfortunately, torrential rains washed out the Karakorum Highway between Chilas and Gilgit and we were halted overnight by a large landslide. We waited from 4 in the morning until dawn in our Jeep. At this time is was evident that the mudslide was impossible to pass at that juncture. Unfortunately, the road also slid behind us and we were caught between two mudslides. It was two days before we were able to walk across the further mudslide carrying our equipment and meet a Jeep that had been sent to pick us up from Gilgit. We thus abandoned our first vehicle and continued on, reaching Gilgit after 3 days. In Gilgit, Dr. Ali used a microscope for the first time. The American doctor, Mitch Ryan, is doing very high-quality cataract surgery with lens implants and I had the pleasure of seeing several of his post-operative patients. Dr. Ali observed my technique for cataract surgery and had his first experience operating under a microscope. The road continued to be washed out in all directions from Gilgit, making our onward journey to Skardu impossible and also making it impossible for additional patients to come to the hospital. Greg Mortenson arrived at the Gilgit hospital and as a gesture of good will, the 15 patients who received cataract surgery under our project at the Gilgit eye hospital were all given a bound copy of the Holy Koran. This public relations gesture, we hope, will go a long way to encourage patients to receive care from a Christian hospital and still continue their devotion to the Islam faith.

After five days the road to Skardu was cleared enough for passage by a four-wheel drive Jeep and we proceeded on the 12 hour drive to Skardu. Our team in Skardu consisted of myself, Dr. Ali, Neal Beidleman, an engineer who was absolutely essential in fixing and maintaining our equipment in general and the operating microscope in specific, and Mr. Jahved, who is the chief scrub assistant for the Gilgit eye hospital. Mr. Jahved was indispensable as the state of the operating theater in Skardu was horrendous and Mr. Jahved took responsibility for fully cleaning and steilizing the operating room in Skardu as well as sterilizing and maintaining all of our surgical equipment.

We arrived in Skardu to find that Pakistani State Radio had been broadcasting our imminent arrival throughout northern Pakistan and large banner posters regarding our eye camp had been placed in the streets of Skardu as well as in front of the hospital. We thus faced a crush of hundreds of patients who had been waiting for several days for our arrival. We screened approximately 200 patients per day, giving free medications to those who needed them, free reading glasses to presbyopic patients, and scheduling surgery on patients who were bilaterally blind from cataracts. There was a huge number of children with strabismus and also a huge number of children with congentitally blocked tear ducts that leads to chronic tearing as adults. Unfortunately, due to time contraints, we were only able to operate on 55 patients who were bilaterally blind from senile cataracts, 4 pediatric patients who were blind from traumatic cataracts, and one demonstration strabismus surgery on a woman with extropia and one demonstration dacryocystorhinostomy on a woman with chronic epiphora.

All of the surgery was performend at the government hospital in Skardu. The conditions of the hospital was very poor with dirt everywhere. Thanks to the the great effort of Mr.Jahved and Neal Beidleman, we were able to create a semi-sterile environment. There were also problems with the electrical supply but fortunately Neal was able to help us with a generator and in keeping the operating microscope functioning and focused. All operative cataract patients had their faces washed and eyelashes cut prior to surgery and underwent a full surgical prep and had antibiotic drops placed in their eye. They underwent a second full prep and installation of antibiotics at the time of the retrofulbar and facial anesthetic for eye surgery. The patients all had a final prep prior to surgery. Every cataract patient received a successful surgery with intraocular lens. After surgery all of the patients were given steriod antibiotics and instructions on how to use them. We had only a three-day follow up on our surgical patients. However, there were no major complications. There were two cases of posterior capsule rupture with vitreous loss. There were no post-operative infections. All of the cataract patients went from best vision, Hand Motions or less pre-operatively, to at least ambulatory vision post-operatively. The strabismus and DCR cases also went very well.

A major focus of the trip was to teach Dr. Ali and his assistants how to prepare patients for surgery and perform microsurgical cataract extraction with intraocular lens placement. Dr. Ali did portions of half of the cases and was able to complete 6 full cases of catatract extraction with posterior chamber lens implantation. He improved consistently throughout the trip. He did have one case of capsular rupture during lens expression and one during intraocular lens placement. Both patients underwent a limited vitrectomy with anterior lens placement and both were seeing well post-operatively. By the end of our trip Dr. Ali was much more at ease under the microscope. He was still not fully competent to continue cataract surgery with lens implantation on his own. However, we will be sending Dr. Ali to the Tilganga Eye Centre for further training under Dr. Sanduk Ruit. At the conclusion of this, I expect he will be capable of sight-restoring cataract surgery once he returns from Kathmandu.

Our overall plan will be to return to northern Pakistan next summer to further Dr. Ali's cataract surgery training and to help him perform a high volume cataract camp in a remote valley. In addition to obtaining further training for Dr. Ali, I feel it is necessary for us to provide him with a new operating microscope that will be more durable and also portable for remote eye camps. We also should supply him with two new sets of cataract surgery instruments. The total cost for all of this equipment will be approximately $5,000 US dollars. Finally, we must work with Dr. Ali to help him find a better environment in which to operate. It would be helpful for one of his assistants to go to Kathmandu to learn sterile techniques. We will attempt to arrange this as well. I have also heard that one of Pakistan's most dedicated philanthropists, Mr. Suleman Habib, has an interest in improving eye care in northern Pakistan. I will approach Mr. Habib regarding the possibility of his also helping Dr. Ali.

With great thanks for the generous support from the John Hoerni Foundation, the Central Asia Institute, Storz Ophthalmics, Coulson Ophthalmics, Visitec, Ethicon, Allergan, Alcon, KLS Martin, Vermont Lions Charity, Jim and Laura McCarthy, Marion Berg, and Juli Larson, M.D.