SUBSPECIALTIES: CORNEA & RETINA
On January 12, 2016, the city of Port-au-Prince took a breath and then proceeded with business as usual. Six years after the earthquake that devastated the capital city of Haiti, the steel scaffolding of the planned expansion and replacement of the primary public training hospital (Hôpital de l’Université d’Etat d’Haiti – HUEH) can finally be seen, rising over the repurposed, still-standing, and temporary clinic spaces that have served as placeholders in the interim. In the ophthalmology block, theatre nurses accept that today will not be declared a national holiday, and turn to help the residents and visiting faculty Roberto Pineda, MD, prepare for the day’s surgical teaching cases.
For the second Ophthalmology faculty visit to Haiti under the auspices of Global Surgery and Health at Massachusetts Eye and Ear Infirmary (Mass Eye and Ear), Roberto Pineda, MD, and Shizuo Mukai, MD, continued to develop the partnership with the HUEH Residency Program. Responding to findings and discussions from the initial faculty visit in June, Drs. Pineda and Mukai focused their visit on resident education, dovetailing ophthalmology fundamentals with modern innovation. Whether shoulder-to-shoulder in the operating room, working through patient histories in clinic, or discussing cases in small group sessions, Drs. Mukai and Pineda prioritized interactive learning and relevant skills transfer. Modern ophthalmology is increasing technology-focused, challenging resource-limited programs (especially those that are part of the public healthcare system) to provide both modern education and high-level patient care. Drs. Pineda and Mukai’s message to the residents was often that more does not always equate with better.
Following up on his previous faculty trip topic on cornea and anterior segment, Dr. Pineda expanded the dialogue with the residents to include penetrating keratoplasty and DALK techniques and management. Through the generosity of the Lions Eye Institute (Tampa), Dr. Pineda was able to bring donated cornea tissue, allowing residents the opportunity to learn how to identify good candidates for transplantation, practice and observe different grafting techniques, and ensure proper follow-up care and effective communication with the patient. Residents presented surgical candidates, whose conditions ranged from keratoconus and trauma to complications from cataract surgery. Dr. Judlande Cinalien, a recent graduate of the residency program, returned to HUEH to work with Dr. Pineda, assisting him in the operating theatre along with residents Drs. Jean Eddy Charitte and Renold Delijacques, while numerous residents rotated in to observe.
Although Haiti does not currently have an eye bank, many of its citizens are able to access corneal transplants either outside the country or by visiting ophthalmologists on humanitarian missions. Unfortunately, this leads to occasional graft failure due to a lack of patient education and follow-up, thus reinforcing the importance of transplant management as part of the residents’ education. Proper follow-up and management protocols along with patient education are vital to improving ophthalmic surgical outcomes and are often underemphasized in humanitarian interventions.
Based upon the prevalence of diabetic retinopathy and other retinal conditions, Dr. Mukai introduced residents to smartphone-based retinal photography. Fundus photography generally requires a $200,000 USD investment in equipment, which has been a major incentive for identifying disruptive technology solutions, such as the adaptation of smartphones. As a clinician, Dr. Mukai’s approach to this problem is to keep things simple, with minimal equipment demands. Following a lecture and brief demonstration, Dr. Mukai had residents practicing taking retinal images with just a smartphone and a 20 mm optic lens. Since the smartphone, a device already in the pocket of every ophthalmology resident, has the necessary resolution, functionality, and image-sharing capabilities, it is a perfect tool for research and improving patient care. Not to mention the myriad of uses and apps tailored for use in clinic, for patient education, office management, and access to educational references. The benefits of such a tool were obvious to Dr. Jennie Dalvius, a recent residency graduate who is working on a research project on the treatment of diabetic retinopathy complications in Haiti and will start utilizing the technique for her database. The simplicity of the method also opens up the possibility of outreach programs, allowing the reliable diagnosis of a number of major retinal conditions. Dr. Mukai also challenged the residents to make full use of the equipment they had, powering indirect ophthalmoscopes with penlights, and how to help avoid frustration caused by the frequent power outages.
The faculty team was also fortunate enough to collaborate with CBM, an NGO which supports a broad range of advocacy, patient service, and education initiatives aimed at improving the quality of life for those with disabilities, and the Comité National de prévention de la Cécité (CNPC-Haiti), the Haitian Vision 2020 committee comprised of Haitian ophthalmologists who serve as an advisory committee and advocacy group on eye health for the Ministry of Health. In Haiti, CBM has been an active partner for the Ophthalmology Department, investing in infrastructure and equipment as well as supporting education opportunities for residents.
In a discussion with representatives from both groups, several major themes arose. First, residents graduating from training program at HUEH, the only source for ophthalmology training in the country, do not feel fully prepared to enter into practice, especially one providing modern surgical interventions. There is great interest among the two groups to provide short-term fellowship opportunities for recent graduate to gain competencies in core areas, utilizing private ophthalmology clinics for mentorship and facilities. Second, there is great concern over the market distortion caused by the high number of ophthalmology surgical mission trips to Haiti. Ophthalmologists entering the market place find it difficult to set up practices due to high equipment costs and a lack of patients able or willing to pay for services, creating a major obstacle to building local capacity.
- PENETRATING KERATOPLASTY TECHNIQUES AND MANAGEMENT
- CONDUCTING A RETINA EXAM IN THE DARK (TECHNIQUES FOR RETINA ASSESSMENT DURING POWER OUTAGES)
- RETINA CASE-BASED DISCUSSIONS pt. 1, pt. 2, pt. 3
- SMARTPHONES IN OPHTHALMOLOGY
- DESIGNING INEXPENSIVE RETINAL IMAGING TECHNIQUES FOR THE CLINIC AND THE OR
- MANAGEMENT OF PENETRATING KERATOPLASTY AND DALK
- POSTERIOR SEGMENT CAUSES OF LEUKOCORIA
- SURVIVAL GUIDE TO COMMON CORNEAL AND EXTERNAL DISEASE PROBLEMS
Our thanks to attending faculty Dr. Francois Romain (HUEH HOD) and Dr. Vladimir Pierre, current residents, and the recently graduated residents who joined us. Thanks also to Marie Joseph, Betsy Sherwood, and the CBM team for providing guidance and partnership