Category Archives: Surgery
Glaucoma is the second leading cause of blindness worldwide, after cataract. But unlike cataract, the blindness caused by glaucoma is irreversible. That’s why identifying the condition early and treating it effectively is vital to save sight.
In this blog, the second in our series showcasing how CBM is helping achieve the Vision 2020 targets towards eliminating avoidable blindness, CBM glaucoma specialist Heiko Philippin, who is based in Tanzania, East Africa, talks about his work treating glaucoma in Africa.
I started working at KCMC in Tanzania in December 2009. Each year, we carry out around 2,500 glaucoma examinations, some of the patients come repeatedly – so 1000-1500 patients with glaucoma each year. Around 100 or less would be children with paediatric glaucoma.
The main challenges are that patients present late – there are numerous different reasons for this – and that treatment options can be limited.
CBM is supporting the management and treatment of glaucoma at a number of different levels. Treating glaucoma is challenging – the condition requires life-long treatment and follow up. In large parts of Africa, we do not have all of the treatment options available as in Europe for example, though at KCMC we have a reasonable amount of treatment options, especially now also with the new laser treatment.
The appropriate treatment option depends on the age group, the stage of glaucoma and the amount of eye pressure reduction which is necessary. We usually start with eye drops or laser, if these are not feasible or not enough then surgical options come into place, mainly a procedure called trabeculectomy. Shunts, which reduce the pressure, are usually only used in desperate cases.
The choice of eye drops is limited in Africa compared to in Europe. In a lot of areas in this region, we only have one type of drop available, while in Europe there are 6 different groups of eye drops available. Over the years things have definitely improved in larger urban centres, though. At KCMC we can offer 4 different types of eyedrops, but this is not common.
The second group of treatment is laser – this is also limited – and the last treatment option is surgery. The most common is trabeculectomy; we can offer our services at similar standards as in any other country.
The next improvement is that we are planning to offer tubes (shunts) which reduce the eye pressure. Aravind in India has now developed a low cost shunt. Often the patient will have tried eye drops and laser before this option
CBM has helped with the procurement of eye drops, which are often not part of standard procurement, and has helped finance larger equipment, which would not be possible otherwise.
CBM has also supported training – I have received specialist training and now offer fellowships in Glaucoma to doctors in Sub Saharan Africa. CBM also offers training to ophthalmologists including the treatment of glaucoma.
I am currently running a trial for a treatment called Selective Laser Trabeculoplasty (SLT), thanks to a joint grant from Standard Chartered’s Seeing is Believing programme and CBM. SLT has been in use in the UK and elsewhere for several years, but this is the first time it is being trialled in Sub-Saharan Africa. We want to find out if the laser treatment is equal or better than the standard treatment which is currently available here. If it is equal or better, then the laser treatment will offer pressure reduction for one or probably more years without the need for the patient to come back every few months for eye drops. Patients are often not able to take the eye drops for different reasons, so we are hoping that the overall treatment of glaucoma will improve.
Of the patients I see, 100 or less are children. They often have a different type of glaucoma, they can have congenital glaucoma or secondary glaucoma due to other eye problems, both are challenging to treat.
I see a lot of patients who are blind according to the WHO definition – visual acuity of less than 3/60 – roughly they could count fingers up at a distance of 3 meters. If you use this definition then a lot of my patients I see are legally blind.
Glaucoma patients who have low vision or even have no visual function left, who cannot differentiate between light and darkness we refer to the low vision department, where we advise on low-vision devices so that they are able to do daily activities better. We can also assist for example in using a cane so they can move around more safely, and we refer them to CBM partners, Tanzanian Society for the Blind.
Next stop was Antsirabe, 3 hours drive south of Antananarivo at CRMM (Centre du Reeducation Mortrice de Madagascar) – a dedicated orthopaedic disability hospital. Here we are running a ponseti training course for 26 practitioners, and operating on neglected clubfoot surgical cases.
CRMM here, and CAM in Antananarivo are “pilot centres” for the Madagascar Clubfoot Project. With the support of CBM, we will make further visits over the next 12 months and then we’ll select a local faculty of clubfoot trainers who will be able to instruct clubfoot practitioners throughout Madagascar.
The vision is to create a national network of clubfoot treatment centres – ensuring that every child born with clubfoot in Madagascar will have access to treatment and that the disability of clubfoot will be prevented. CBM desperately needs ongoing funding in able to achieve this goal.
Tikale had a traumatic cataract in his right eye. He was trying to get through some bushes to cross a road, when one snapped back and caught him strongly in the eye. Within a week his vision clouded over, and by the time a month later when he made it to the hospital he was blind in that eye.
It was Strinnar Duncan’s wedding day yesterday. 9am Church, followed by photos around Nkhoma, then a big lunch (chicken and goat); and then lots and lots of dancing (Pelikani-pelikani; the tradition of different groups of guests dancing at different times, throwing money in the air as you go).
We have just passed the end of June, and the cool and dryness of winter is here. Most of the people in central Malawi have harvested good crops this year, and are free to head to the market, spend time with their families and enjoy this time of prosperity.
In fact this is our busiest time of year. We are sending our ambulances out to the south lakeshore. A 4 hour 300 kilometre drive to do Wednesday and Saturday mobile clinics. There is a great number of blind and severely visually impaired people in this area.
Glaucoma is the second main cause of global blindness, after cataract. It is a condition that slowly affects the optic nerve at the back of the eye, and is often associated with high pressure in the eye. Untreated, the high pressure destroys vision causing tunnel vision, and perhaps eventual blindness. People here in Africa tend to be affected by a more aggressive form of the potentially blinding condition than say for example in USA or Europe. Sadly though, because it is so slow to progress, people often become blind before they seek help here. At Nkhoma last year I looked at all the glaucoma operations we did, and two-thirds of patients who we operated on were already blind in the other eye. We are trying to start a screening program to detect glaucoma in the early stages, when we can treat it and stop the loss of vision.
One of the greatest aspects of working here at Nkhoma is the team at the Eye Hospital. I have the pleasure of working with a team of nearly 40 dedicated nurses, patient attendants, drivers, administrative staff; and one clinical officer, Mr Ephraim Kambewa.
I mention Mr Kambewa especially, as he has returned after 18 months training in Tanzania last year, and has graduated now as a qualified Senior ophthalmic clinical officer Cataract Surgeon! It was thanks to cbm that his training was possible.