MBARARA SEPTEMBER 2015 OPHTHALMOLOGY FACULTY VISIT

MURHEC-RUHARO-OGSH | CORNEA AND PEDIATRICS MODULE (September 28 – October 2, 2015)

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Dr. Ankoor Shah lectures to MURHEC ophthalmology residents on performing comprehensive eye exams.

The third Mass Eye and Ear|Office of Global Surgery and Health (OGSH) Ophthalmology faculty visit to Mbarara University and Referral Hospital Eye Centre (MURHEC) continued on the same specialty topic areas as the March 2015 trip, focusing primarily on the treatment of keratoconus through cornea transplantation and the surgical treatment of pediatric strabismus, both common in the local patient population. Roberto Pineda, MD (Mass Eye and Ear) and Ankoor Shah, MD (Boston Children’s Hospital) returned as co-faculty for the academic module, working with the residents and faculty at MURHEC and Ruharo Eye Hospital.

The academic schedule for the week allowed first-year residents (6) to rotate between cornea and pediatrics, with second- (4) and third-year (1) residents focusing on one topic area for clinical and surgical teaching. Didactics took the form of daily joint lectures on cornea and pediatric topics, resident case presentations, and resident-led journal club discussions. On Friday, Drs. Pineda and Shah also gathered a large audience of Ruharo staff, MURHEC/Ruharo faculty, and residents, to discuss proper follow-up care and protocols. In addition to surgical techniques and interpreting outcome studies, Drs. Pineda and Shah emphasized the fundamentals of comprehensive vision assessment, physician-patient communication, and surgical safety, including time outs and the WHO Surgical Safety Checklist.

Monday was screening day for surgery and included follow-up for corneal transplant and strabismus patients seen on previous OGSH faculty visits, who have been followed by select residents as part of an ongoing clinical research project. On Tuesday, Wednesday and Thursday, residents and faculty attended lectures or other didactics followed by teaching in clinic and in operating theatre. Friday was dedicated to patient follow-up, administration of the International Council of Ophthalmology (ICO) example exam, and a wrap-up meeting to discuss the week.

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Dr. Roberto Pineda and Dr. Sam Ruvuma perform a cornea transplantation.

As part of the cornea module, Dr. Pineda, Dr. Sam Ruvuma (MURHEC), and attending residents performed 2 BB-DALK procedures, 4 PKP procedures, and one corneoscleral annular tectonic graft at the operating theaters at Ruharo and MURHEC. The graft was done in response to a Mooren’s ulcer case and greatly excited the MURHEC faculty, for whom the rare condition is more common and had not yet had a successful treatment. Dr. Pineda, Dr. John Onyango (Head of Department for Ophthalmology at MURHEC), and Dr. Ruvuma are preparing to write a protocol for managing Mooren’s Ulcer patients. This was Dr. Pineda’s third faculty trip (November 2014, March 2015) to MURHEC and Ruharo.

It is the small things that make a difference. Dr. Tambula May (3rd-year resident)

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Dr. Freddy Bwetsia examines a patient after strabismus surgery.

The pediatric module led by Dr. Shah concentrated on pediatric strabismus, using a short-tag noose adjustable suture technique, following up on his faculty visit in earlier this year. Strabismus surgery is a good candidate for surgical teaching since it is possible to “watch and repeat”, with the proctor doing one eye muscle and the trainee the other. This repeated module allowed Dr. Freddy Mbumba Bwetsia (MURHEC affiliate faculty, Ruharo staff) to become sufficiently facile in the technique that he felt confident proctoring residents through procedures performed at the end of the week. Excellent patient outcomes, both from the previous module and the current week, encouraged residents, including Dr. Tambula May, a third-year resident, whose interest in pediatrics is in part due to Dr. Shah’s visit in March. While during the last pediatric module, she merely watched the strabismus surgeries, this week, under Dr. Bwetsia’s guidance, she took a more active role, performing the procedure herself.

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Dr. Shah discusses strabismus follow-up protocols with Ruharo staff, faculty, and residents.

The week was seen by all parties as the most successful in the first year of the academic partnership between the OGSH and MURHEC/Ruharo. Learning from issues in previous faculty visits including availability of residents and faculty, MURHEC and Ruharo worked to ensure that residents were freed from other academic commitments. For OGSH faculty, greater attention was spent devising more interactive didactic sessions and addressing recognized knowledge and skill gaps. The increased clarity in the relationship between MURHEC and Ruharo also added to the success of the week. It allowed for more constructive discussions on how to further improve the program during onsite visits by international collaborators (OGSH and University of Bristol) as well as during rest of the academic year.

This program was much more cohesive and structured than those previous. I believe this will set the tone for future Ophthalmology programs at MUST. Dr. Roberto Pineda

MURHEC and Ruharo Eye Hospital, a mission-based hospital with an extensive regional community outreach program, have recently signed an MOU to formalize their relationship and combine their strengths. Ruharo, whose ophthalmologists are affiliate faculty at MURHEC, hosts MURHEC resident rotations, with first-years rotating between the institutions every two weeks and second- and third-year residents rotating every 4 weeks. An established locus for eye health care delivery in the region for the past 30 years, Ruharo provides stable access to a large patient population, inpatient postoperative care, and a vehicle for effective follow-up. As a public training hospital, MURHEC continues to be the only option for vision care for patients who cannot pay the small for-service fees at Ruharo as well as linking Ruharo to the Ophthalmology Residency Program and thus steady access to additional faculty and residents to provide patient care.

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Dr. John Onyango (MURHEC), Dr. Freddy Bwetsia (MURHEC and Ruharo), and Mr. Richard Womugasho (Ruharo) discuss resident rotations at Ruharo.

During a meeting with Dr. John Onyango, Dr. Freddy Mbumba Bwetsia, Mr. Richard Womugasho (Administrative Director, Ruharo), and Dr. Keith Waddell (MURHEC affiliate faculty, Ruharo staff), they reconfirmed their institutions’ commitment to resident education and emphasized the importance of structuring resident rotations at Ruharo and have dedicated ophthalmology staff to directly oversee training. While Ruharo’s mission is the provision of ophthalmic care for a large subset of the population, Dr. Waddell, a South African-born ophthalmologist who has served the East Africa region from Ruharo for over thirty years, stressed the critical role of training in addressing the continuously growing disease burden and patient population. The Residency Program at MURHEC not only trains Ugandan ophthalmologists, but also hosts residents from Burundi, South Sudan, the Congo, and even Guyana. There are a limited number of ophthalmology training programs in low- and middle-income countries throughout the world, with some countries having no local training opportunities and single-digit numbers of ophthalmologists who are surgically active. Discussions like this one, linking public training hospitals to NGO-run facilities, have become more common and represent a fortunate turn in the relations such institutions.

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