In continuation of the partnership linking Mbarara University and Referral Hospital Eye Centre (MURHEC), Ruharo Eye Hospital, Mbarara University of Science and Technology (MUST), and Mass Eye and Ear’s Office of Global Surgery, Suzanne Freitag, MD and Roberto Pineda, MD led back-to-back academic modules on Oculoplastics and Corneal Disease November 28th through December 9th, 2016. Both Mass Eye and Ear Ophthalmologists returned for their respective second and fourth trips working with the Ophthalmology faculty and residents at MURHEC in Mbarara, Uganda. MURHEC currently hosts 13 Ophthalmology residents, only four of whom are Ugandan. The remaining residents will return to their home countries of Guyana, Burundi, Congo, Sierra Leone, and South Sudan after graduating, dramatically increasing the number of ophthalmologists in each country, which currently ranges from 1 to 14.
CORNEA: Management of Cataract Complications, Keratoconus, Mooren’s Ulcer
For the second week, Dr. Roberto Pineda continued his ongoing work with MURHEC and Ruharo faculty and residents on management of cataract complications and clinical and surgical management of Keratoconus and Mooren’s ulcer. Mbarara Regional Referral Hospital, and thus MURHEC, serves a catchment area of over four million people (6 districts) and over ten million for specialty care, including patients from districts outside its catchment area in Uganda and neighboring countries such as Rwanda and Tanzania. Currently, MURHEC and Ruharo perform 2,000 cataract procedures annually. While there is an acute need for more cataract surgery, there is a parallel and imperative need for quality cataract surgery. Dr. Pineda was asked to lecture on avoiding and managing cataract complications, including posterior capsule tears, due to poor patient selection by less experienced residents or more complicated cases that involve small pupils or steep corneas. According to Dr. John Onyango, Head of the MUST Ophthalmology Department, Uganda recently adopted a new national protocol on cataract surgery. He is interested in coordinating with Dr. Pineda to develop a study proposal on patients with and without antibiotic drops, which are not yet readily available in the amounts needed at MURHEC. While the use antibiotic drops post-op is common practice in most places, there is limited literature on the actual improved efficacy of their use. Due to universal issues with adherence, demonstrating that outcomes are similar whether drops are used or not, would be of great benefit not only to Uganda.
Keratoconus and Mooren’s ulcer are corneal conditions that occur with heightened frequency and severity in Sub-Saharan Africa, including Uganda, and are priorities for both institutions. Keratoconus is a degenerative condition impacting young adults in which the cornea progressively thins, allowing it to bulge into a cone-shape that distorts vision. For advanced cases, a corneal transplant is required to restore vision. Unlike Mooren’s ulcer found in the United States, which is rare, unilateral, and presents predominately in elderly Caucasian men, Mooren’s ulcer in sub-Saharan Africa is far more common, bilateral, and is typically seen in young adult men. Mooren’s ulcer as seen in Uganda is particularly aggressive, the corneal ulceration causing limbal inflammation and eventually leading to a “melting” of the cornea, destroying the stromal tissue and leaving the patient blind. Initial treatment options for Moooren’s ulcer are topical steroids, followed by oral steroids, and if necessary, immunosuppressants. If none of these therapies are effective, a conjunctival resection can be performed, excising a small ring of limbal conjunctiva. Additionally, in less severe cases, a corneal patch graft may be applied to stabilize the cornea.
Due to its infrequent presentation in the United States in Europe, there has been very little literature describing and advising treatment for Mooren’s ulcer. The greater prevalence of the disease in Uganda provides MURHEC the opportunity to develop an evidence-based protocol for treatment and management of the disease that currently does not exist in medical literature. Dr. Denise Kuvuma, a second year resident, is interested in focusing on Mooren’s ulcer for her resident research dissertation. With Dr. Pineda’s support and guidance, she plans to develop a group database to record detailed patient response to different therapies and medications. Formulating a protocol and timetable for disease management of this disease would provide much needed guidance for improving patient outcomes.
Based upon faculty and resident request, Dr. Pineda gave lectures on “Managing the Small Pupil” (avoiding cataract surgery complications), “Suture Management”, “Anterior Vitrectomy”, and “Mooren’s Ulcer”. Additionally, in response to a patient with possible Marfan’s and a displaced lens, Dr. Pineda showed and discussed a video on Lens Replacement Surgery, a procedure that will need to be scheduled for his next visit due to the need for intraocular devices. MURHEC is currently in plans for the acquisition of a phacoemulsification machine to increase their Cataract Surgical Rate. In anticipation of the need for developing this new skillset, Dr. Pineda gave a talk on “10 Things I Wish I Knew When Starting Phacoemulsification”, which offered advice ranging from proper posture and microscope techniques to how to practice techniques and improve dexterity to watching for the most common mistakes.
On Monday, Dr. Pineda worked with third year residents, Drs. Lucy Namakula, Arlene Bobb-Semple, and Patrick Budengeri and a rotating group of first and second years to follow-up with previous cornea transplant recipients and screen new patients. Nelson Chwa coordinated patients seen originally at Ruharo Eye Hospital, including both past recipients and new patients. Over Dr. Pineda’s three previous visits, he and the MURHEC faculty and residents have performed 20 cornea transplants on patients between the ages of 13 and 28 suffering from keratoconus. A number of faculty and residents, including Dr. Sam Ruvuma, Dr. Simon Arunga, Dr. Lloyd Williams (graduated 2015, Sierra Leone), and Dr. Patrick Budengeri (graduates 2017, Burundi) have taken lead on building a research database to follow outcomes of these and future cornea transplant patients and have presented their data at regional Ophthalmology meetings.
During this visit, Dr. Pineda operated on 10 patients and followed up with eleven patients, including several from the original transplant cohort operated on in November 2014 as well as from March and September of 2015. To this point, all transplants have survived and are continuing to be seen for follow-up at Ruharo Eye Hospital, organized by Nelson Chwa. Continued follow-up is critical for the maintenance of good surgical outcomes for corneal transplants due to the continued risk of rejection and the gradual removal of corneal sutures, which occurs over years. An issue for several patients was the failure to regularly take steroid drops, which are necessary for transplant survival and help prevent corneal ulcers. Through patient interviews, cost was determined not to be an issue, but instead the need for continued patient education on the importance of the medication and the role it plays in continued eye health. While there is still no eye bank in Uganda, the opening of Dr. Agarwal’s Eye Hospital, which brings in corneal tissue from India, has enabled more corneal transplantations to be preformed in-country and the necessity for protocols in how to manage follow-up.
Patient selection criteria for transplants include age (patients below the age of 12 tend to not have good outcomes), bilateral disease (patients with severe vision loss in both eyes are prioritized over unilateral vision loss), and effective management of preexisting conditions. Several screened patients were not good candidates for corneal transplants due to the high likelihood of rejection linked to conditions such as vernal keratoconjunctivitis (VKC) and Stephen-Johnson syndrome. Several patients suffered from VKC that had not been fully managed with oral and topical antihistamines. Until the VKC is properly managed, transplants would most likely be rejected and continued damage to stem cells would lead to blindness. This was the basis for an important discussion with Dr. Lucy Namakula, who is interested in changing the current VKC treatment protocol at MURHEC to include a more aggressive full-body approach, treating it as a chronic condition rather than as isolated symptoms. Oral steroids, which are more commonly prescribed in Uganda than in the United States, were discouraged in favor of more frequent and continued use of topical steroids and oral antihistamines with frequent monitoring for the need for increased dosages. Patients with Stephen-Johnson syndrome will need an alternative procedure such as the use of an artificial cornea, which has a much lower rejection rate than traditional tissue transplant but necessitates rigorous follow-up and maintenance. Mass Eye and Ear has been a pioneer in the development of the artificial cornea (Boston Keratoprosthesis), and Dr. Pineda has spent the last decade working with programs in Ethiopia, Sudan, and other countries to pioneer the use of the device in regions with need.
During the week, Dr. Pineda worked with Dr. Lucy Namakula, Dr. Byamungu Sakano, Dr. Arlene Bobb-Semple, Dr. Seraphine Ntizahuvye, Dr. Denise Kavuma, Dr. Guy Kintoki, and Dr. Emmanuel Agwella in the operating room, performing five keratoplasties (including 1 BB DALK, 1 DALK, 1 DALK converted to PK, 1 manual DALK, and 1 PK), two corneal patch grafts for treatment of Mooren’s ulcer, one conjunctival resection for treatment of Mooren’s Ulcer, one superficial keratectomy with amniotic membrane, and a removal of a white cataract for a cornea transplant recipient. Bandage contacts were necessary for two of the procedures (conjunctival resection and superficial keratectomy) and were provided by Ruharo Eye Hospital.
At the end of the week, Dr. Pineda, Dr. Onyango, and the rest of the MURHEC faculty and residents met to discuss potential research projects and plans for upcoming modules. Three main research projects that are currently in planning include (1) continued follow-up of transplant patients, (2) data collection and protocol development for Mooren’s ulcer, and (3) study of the efficacy of dropless cataract surgery. Dr. Pineda and the team from MEEI have agreed to provide help with research study design and data analysis. In response to requests from graduating residents who will be returning to very limited ophthalmology departments, Dr. Pineda will also be developing a list detailing equipment priorities for an ophthalmology department with recommendations on devices that have minimal disposables, reasonable price points, and a high survivability rate in environments with limited biomedical tech support and power issues. For upcoming trips, the MURHEC team would like to focus on the steps necessary to prepare them for adopting phacoemulsification as another method for cataract surgery, including practical instruction on capsulorhexis, and on improving their understanding of ocular biometry.