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.
OCULOPLASTICS: Trauma and Lacrimal Obstruction
Dr. Suzanne Freitag and Dr. Victoria Starks, the 2016-2018 Oculoplastics fellow, followed up on Dr. Freitag’s April 2016 Oculoplastics academic module, delivering a weeklong course focusing on lacrimal duct defects and ocular trauma as requested by MURHEC’s residents, featuring didactics, surgical skills instruction, and clinical and surgical teaching. Dr. Freitag gave lectures on “Congenital Lacrimal Obstruction” and “Acquired Lacrimal Obstruction”, while Dr. Starks prepared an afternoon course for the final day on “Trauma and Suturing” that included a lecture, Jeopardy-style quiz game based on pre-trip distributed materials (lacrimal systems, anatomy, and trauma), and a 90-minute hands-on Soft Tissue Suture Course, focusing on suture techniques for canalicular laceration repair.
Professor Amos Twinamasiko, MD, who has a particular interest in developing Oculoplastics at MURHEC, once again partnered with Dr. Freitag for the week as the primary faculty partner and co-coordinated the module. During the week, Dr. Twinamasiko observed and performed bicanalicular lacrimal intubation, burn management, and dermis fat grafts for anophthalmic sockets. Thanks to a generous donation from Mass Eye and Ear and the MEEI Longwood Central Processing Department, assembled by Marti Cunningham, Dr. Freitag was able to present Dr. Twinamasiko and MURHEC with instrument sets for lid, orbit, and lacrimal surgery. These instrument sets will enable Dr. Twinamasiko and MURHEC to continue to develop expertise and capacity in Oculoplastics and Ocular Trauma.
In the United States, ocular trauma is a common feature of emergency departments and is second only to cataracts as the most common cause of visual impairment. Key to treating any case of ocular trauma, including eyelid and corneal lacerations and damage to the orbit, is timely treatment. In Mbarara, not unexpectedly, an elevated risk for ocular trauma is linked to poor enforcement of helmet laws for motorcycle taxi (“boda boda”) drivers and passengers. Unfortunately, at this time, there is no Ocular Trauma Score system in place at the Mbarara Regional Referral Hospital (MRRH) Emergency Department and no protocols to guide treatment and referrals to MURHEC, its affiliated eye hospital. For lid lacerations and damage to the lacrimal duct systems, which if left untreated will cause patients continued discomfort and potential vision loss, treatment must occur within 48 hours before scar tissue has formed. Once scar tissue forms, it is difficult and sometimes impossible to restore proper eyelid and/or lacrimal duct function. Fortunately, several patients suffering from “fresh” eyelid lacerations presented at MURHEC and Ruharo, allowing Drs. Freitag and Starks to demonstrate the efficacy of timely treatment and setting the stage for a conversation driven by Dr. Twinamasiko regarding improving communication with the MRRH Emergency Department. With a new Emergency Residency starting at MUST in October 2017, there is a great opportunity to incorporate lectures by the MUST Ophthalmology to improve referrals. Dr. Freitag was also able to donate two Wills Eye Hospital Emergency manuals that are targeted to residents on-call in the Emergency Department for rapid response, triage, and referral.
On Monday, Dr. Freitag, Dr. Amos Twinamasiko (MURHEC) and Dr. Keith Waddell (Ruharo Eye Hospital, MURHEC) screened patients at both institutions, reviewing surgical decision-making protocols with the residents. During the week, in coordination with Dr. Amos Twinamasiko and a rotating team of residents, Dr. Freitag and Dr. Starks performed, assisted, and observed a bilateral levator ptosis repair (1), bilateral frontalis suspension ptosis repair (1), eyelid scar revision with tarsal graft (2), eyelid scar revision with skin graft (1), excision of vascular malformation upper eyelid (1), extensive burn reconstruction to 3 eyelids with skin grafting (1), anophthalmic socket reconstruction with dermis fat graft (2), repair of entropion/trichiasis both lids (2 patients), lash extirpation (2), bilateral canalicular trephine and intubation (1), excision of small eyelid lesion (2), acute lid and facial trauma reconstruction (2) for a total of 18 patients. These surgeries represented an informative subsection of the oculoplastic disease burden felt by MURHEC and Ruharo Eye Centre. The number of cases allowed for a high level of participation by not only third-year residents like Dr. Arlene Bobb-Semple and Dr. Patrick Budengeri but also from second and first-year residents, including Dr. Rachel Kabunga. All surgical procedures utilized only MURHEC supplies and instruments, and Drs. Arlene Bobb-Semple and Lucy Namakula are coordinating patient follow-up.
In addition to operating at MURHEC, Drs. Freitag and Starks also operated at Ruharo Eye Hospital, the mission-based eye hospital that serves as a formal training partner and resident rotation host for MURHEC. There, working with Dr. Keith Waddell and MURHEC residents, the team performed a bilateral bicanalicular intubation (1), acute trauma eyelid reconstruction (1), and scar revision with skin graft (1) for a total of 3 patients. Through coordination with Nelson Chwa, orthoptist and Ruharo administrator, Dr. Freitag was also able to see two patients seen during her previous April trip, who needed additional procedures, including a two-year-old girl who underwent blepharoplasty to expand her eye openings. Seven months later and a needed ptosis surgery done by Dr. Waddell, and the little girl has dramatically gained range of vision, no longer needing to constantly move her head to objects in her periphery. Unfortunately, due to a family medical emergency, Dr. Freitag was unable to stay for the second planned week at Ruharo to continue developing Oculoplastics capacity focused on anophthalmic sockets for improved cosmesis and prosthetic fits, but was able to donate 30 pediatric/small prostheses, implants, and sutures as well as requested textbook donations to Ruharo’s new resource center. Dr. Keith Waddell and Ruharo Eye Hospital are the primary referral center for retinoblastoma in Uganda, seeing over a hundred new patients in 2016. Dr. Freitag is planning on returning in 2017 to continue and further develop this partnership.