The little girl is brilliant in orange, her headscarf framing an inquisitive face tilting back in an attempt to look around the clinic room. The two-year-old was born with blepharophimosis, a condition that affects development of the eyelids, resulting in narrow eye openings and severely reduced vision range. Somali refugees, she and her mother are two of the many who seek asylum in Uganda, filling refugee camps and communities throughout the country. In another clinic room, a group of children of varying ages share a common challenge, empty eye sockets following successful enucleations due to retinoblastoma that saved their lives but left sockets unable to hold prostheses. Oculoplastics, an ophthalmology specialty that includes surgical procedures that involve the orbit, eyelids, tear ducts, and the face, is not often considered part of the global health package.
During the initial site visit and meetings with the Ophthalmology faculty at Mbarara University and Referral Hospital Eye Centre (MURHEC) in February 2013, Dr. Amos Twinamasiko told representatives from Massachusetts Eye and Ear’s Office of Global Surgery that a priority area for their program was Oculoplastics. While cataract and glaucoma are recognized as critical components of an Ophthalmology Residency program, oculoplastics is often an overlooked specialty when it comes to global health educational interventions in resource-constrained settings. Due to a lack of specialized ophthalmology care available in the region, MURHEC is a first and often last stop for most seeking treatment for eyelid trauma, ptosis, lacrimal duct obstruction, and non-orbital congenital anomalies that distort vision.
In summary, a fantastic week. We found needs and were able to fill them, with skills transfer that will continue in our absence. Dr. Suzanne Freitag
In April 2016, Suzanne Freitag, MD and Juan Carlos Jimenez-Perez, MD, a faculty and fellow team from Mass Eye and Ear, visited MURHEC and its training partner, Ruharo Eye Centre, to work with the faculty and residents on establishing the building blocks of an oculoplastics program. Dr. Freitag focused on Dr. Twinamasiko, a member of the Ophthalmology faculty with a special interest in oculoplastics, who observed and then performed ptosis surgery, including frontalis suspension. During the week, the Dr. Freitag and Dr. Jimenez-Perez involved rotating residents and faculty members in performing frontalis suspension repairs, canalicular recanalization, trauma lid and canalicular reconstruction, dacryocystectomy, reconstruction RUL congenital anomaly with mucous membrane and skin graft, and dermis fat grafts to anophthalmic sockets. They also gave a series of didactic lectures tailored to the patients presented on topics including blepharoptosis, blepharophimosis, clinical case presentations, and periocular trauma. At the end of the week, the residents participated in a Soft Tissue Suture Course that delineated essential surgical skills in a way that was accessible to residents (and faculty members) of all levels. Utilizing pig ears to simulate eyelid cartilage, residents of all years, alongside a game Dr. Twinamasiko, practiced a variety of basic suturing techniques for dealing with eyelid and canalicular lacerations, including cutaneous, subcutaneous, and vertical mattress.
I believe that the suturing lab was crucial in the improvement of their abilities as surgeons. Dr. Juan Carlos Jimenez-Perez
For the past decade Ruharo Eye Centre has been the main referral center for retinoblastoma in Uganda. In 2015, Dr. Keith Waddell and his team saw 90 new retinoblastoma patients (89 of whom were from Uganda), performed 84 enucleations, and gave 388 courses of chemotherapy. Dr. Waddell, an affiliate professor at MURHEC, had recently penned a report to their funding partners describing their need for improved cosmesis in outcomes of enucleated children when he learned of Dr. Freitag’s visit. Dr. Waddell was eager to become proficient in the use of dermis fat grafts for anophthalmic sockets to allow for better prosthesis fits. Children operated on and treated at Ruharo have good odds for retaining their second eye, an outcome to which Dr. Waddell and his team are fiercely devoted. But while saving a child’s life and then vision are the primary goals, it becomes one step short of the finish line when that child no longer wants to go to school or be in social settings because an empty eye socket that will not hold a prosthesis. After working with Dr. Freitag and Dr. Jimenez-Perez, Dr. Waddell now has a new tool in dermis fat grafts to improve cosmesis.
For next steps, Dr. Freitag would eventually like to offer a cadaver orbital dissection course following the establishment of more basic fundamentals in oculoplastics, structured around reported local patient pathology. In the meantime, discussions with the MURHEC faculty indicate a natural progression to addressing repair of canalicular and eyelid trauma for the next oculoplastics module. At Ruharo, patients have a need for improved prosthesis quality. The current prosthetic offerings, while fulfilling baseline requirements, fall short of offering the quality of life that these children should be enjoying. The next Oculoplastics module is scheduled for December 2016.