Surgical eye missions on a shoestring budget

1. J. ALBERTO MARTINEZ, MD
VISIONARY FOUNDATION
Surgical Eye Missions on
a Shoestring Budget

2. Description/Objectives
The course will detail the organization, funding
and implementation of surgical eye missions to
impoverished areas of the world
Objectives:
 How a mission that provides eye care to the
needy is done
• How anybody can do it
• Are we really helping?
 To motivate by sharing personal experiences

3. Outline
 Why eye surgical missions?
 Does one have to be a wealthy
philanthropist?
 How I first got involved
 Choosing a location
 Choosing an organization
 Logistics
 Our trips to Africa, south and Central America
 Creating your own foundation

4. WHY?
According to the World Health Organization (WHO)
2010:
 285 million people are visually impaired (45 million
blind)
 80% of visual impairment can be avoided or cured
 90% in developing countries

6. Prevalence of Blindness
 Population is projected to increase from 6
billion to 8 billion by 2020
 From 1 billion people over 45 to 2 billion
over 45 by 2020
 the number of blind will increase by 2
million per year (unless something is
done)

7. Can you imagine being blind in a
Developing country?
When someone becomes blind in
the developing world:
 90% of these individuals can no
longer work
 Life expectancy drops down 1/3
that of a peer, in age and health
 50% of the blind report a loss of
social standing and decision-
making authority
 80% of all women note loss of
authority with their family

8. What are the leading cause of
blindness? (according to WHO)
Cataract: 47.9%
Glaucoma: 12.3%
ARMD: 8.7%
Corneal opacities: 5.1%
Diabetic retinopathy: 4.8%
Childhood blindness: 3.9%
Trachoma: 3.6%
Onchocerciasis: 0.8%

9. Global Priorities (WHO)
 Cataract
 Trachoma
 Onchocerchiasis
 Childhood blindness
 Refractive errors

10. Onchocerchiasis
River blindness affects 37 million people, mostly
living in poor, rural African communities
River blindness affects 37 million people, mostly
living in poor, rural African communities

11. Trends in global blindness
 The burden of blindness from infectious
diseases has decreased dramatically over
the past 20 years
 However, other causes such as cataract,
ARMD and glaucoma are INCREASING
because of the growing and increased
AGING of the population.

12. LOASIS
 Organism-Loa loa
 Vector - Chrysops spp. (deerfly)
 Microfilariae: Blood-borne
 Adult worms: subcutaneous
 Prevalence - ?3-13 million
 Geographic Distribution - West and
Central Africa

13. Clinical manifestation
 Asymptomatic
 Non-specific
o urticaria, pruritus,
myalgias
 Calabar swellings
 Eyeworm
 Complications
o Endomyocardial
fibrosis, renal
disease,
encephalopathy,
entrapment

14. Progress in Reducing World
Blindness
 Significant progress in preventing and curing visual
impairment in many countries over the last 20 years
 International partnerships have achieved reduction in
onchocerciasis-related blindness

15.  Ghana and Morocco both have reported
elimination of trachoma (2010 and 2007
respectively).
 Over the last decade, Brazil has been
providing eye care services through the
national social security system.
 service provision for the poorest at district
level.

18. Effective Help
Given the causes
of Blindness, it is
most cost effective
to concentrate in
two areas:
 Refractive errors
 Cataracts

19. Refractive errors
 This is perhaps the area where one can have
the most impact with the least resources:
Need :
• Knowledge of refraction
• A phoropter or
• Loose lenses
• Eyeglasses to dispense

20. Refractive errors
 Fortunately, eyeglasses are plentiful and relatively easy
to obtain.
 One can buy very cheap (a couple of dollars) readers
for presbyopes
 The Lions Club has an eyeglass recycling system that
processes thousands of second hand glasses
o One can request from them Boxes of glasses
o The boxes come labeled by the power and cylinder

21. Refractive errors
 After the refraction the nearest match is
dispensed.
 I have seen villagers walk for days with
complains of poor near vision, only to see the
incredible joy in their faces when you give
them a simple pair of readers!

22. Cataract Surgery
 CE is ideally suited for
surgical missions because:
 Relatively easy to perform
 Relatively easily obtained
equipment
 Relatively easy to obtain
supplies
 Minimal follow-up needed
 Impact is profound and
permanent

23. Cataract surgery
 The most crucial
need is to have a
LOCAL
ophthalmologist to
partner with
 He/she will:
o Identify the cases
o Perform Axial eye
length and IOL
calc.
o Follow up the
patients
 A bonus if they

24. Cataract surgery
 Need an
operating room
with:
 Microscope
 Phaco machine
 Surgical
instruments
 Intraocular lenses
 Consumables

25. Glaucoma
 Glaucoma remains a daunting problem, particularly in
Africa.
 Drops are not accessible to most
 Trabeculectomy is difficult on a short mission trip
(follow up)
 Lasers (ALT, SLT) are helpful but still temporary
solution
 NEW, implantable micro devices Istents!

26. Biggest problem: lack of trained
MDs
 The lack of trained ophthalmologists as a
major factor limiting the diagnosis and care of
people with glaucoma in developing
countries.
o In Europe, there is one ophthalmologist for every
10 000 people
o In India, there is one for every 400 000 people
o In Africa, one or less for every million.
 Incidentally, the US there are approximately
1 ophthalmologist per 20,000 people. That
ratio is much higher in Maryland , particularly
in Montgomery county

27. Practicing MDs Vs. Blindness

28. Mission 1:
Kenya, Africa
 Trip to Laikipia Rhino reserve in Kenya.
 Sponsored by the Paul Chester Foundation. 5 MD’s
(ENT, GYN, IM, 2 Ophth)
 Partially a scouting/evaluation
 No cataract surgery was performed (no infraestructure).
Only trachoma (eyelid) surgery.
 More than two hundred patients evaluated, “treated” for
glaucoma, other minor things
 Very frustrating

29. Mission 1: Kenya, Africa
 Began
construction
of an OR next
to the
reservation.
 Realized that
the problems
was really
cataracts
 Screened
patients for
cataract
 Promised to
return

30. Mission 2: Malindi, Africa
 This trip was to Malindi, a
small port city one hour
north of Mombasa, East
Coast of Kenya
 A local eye health care
worker (a nurse with eye
training) , screened the
patients for cataract
surgery.
 Also operated on
congenital glaucoma and
pterygia
 No axial eye length
obtained. Everyone got a

31. Mission 2: Malindi, Africa
 A phaco machine was Borrowed through
Alcon, shipped to Kenia
 A local, multilingual, scrub tech was flown
from Nairobi. Invaluable
 Cases were performed under topical
anesthesia (except for bilateral
trabeculectomies in an 8 month old with
buphthalmos)
 Anesthesiologists were used for more severe
problems (i.e. hyppopotamus bites)

32. Mission 2: Malindi, Africa
 All consumables for
the OR were provided
by Alcon,
 drops by various drug
companies (allergan,
B&L, Ista etc)
 OR was
disassembled after
surgery.

33. Mission 2: Malindi, Africa
Approximately 45 cataract surgeries were
performed in 4 surgical days
Also 30 pterygia, 2 trabeculectomies
8 boxes of Lions club-processed eyeglasses
given to the eye dept of the hospital
One day follow-up of all patients accomplished

34. Mission 3:
Tumaco, Colombia
Tumaco is a town of 100,000 in the pacific cost
of Colombia, close to Ecuador
 Inhabitants are mostly Afro-Colombians
 Poverty is severe. Average income is $2/day
 A convergence of Guerrilla and Narcotics
warfare has affected the city.
 Fortunately a secure area of the city was
provided by the local marines

35. Mission 3: Tumaco, Colombia
 The first trip was a fact finding mission
 Connection was made with a local
Ophthalmologist that visits Tumaco
twice/month
 This Ophthalmologist agreed to pre-screen
the patients, get AEL, take care of the follow-
up

36. Mission 4: Tumaco, Colombia
 The second Trip
Included An ENT,
Anesthesiologist, Plastic
Surgeon, 3
ophthalmologists
 A very successful, trip in
terms of surgeries
accomplished:
 55 Cataract surgeries,
80 pterygiectomies, 30
ALTs, 60

37. Mission 4: Tumaco, Colombia
 Success created by excellent local support
 We were able to procure a microscope
which stayed behind.
 Another microscope was borrowed (and
returned) form Bogotá
 An anterior segment fellow from Bogota, the
capital joined us. Most of the time 2 eye
surgeons operating simultaneously
 A phaco machine and scrub tech were
obtained from Bogota.

38. Flying Solo
 Previous surgical missions with a foundation
providing all types of care, not just
ophthalmology
 Eyes are very specific, high volume surgery,
very different logistics
 Was unhappy with the focus on fundraising,
publicity, too many hangers-on
 Thus, decided to start my own foundation

39. Alcon Missions
 There are fantastic resources available
 Most notably Alcon Missions.
 On a website, you fill out a form with the
required information and they will send you
essentially all you need to perform eye
surgery: from blades to viscoelastic, IOL,s
drapes etc
 They ship it to your office, you repackage and
away you go!

40. Creating your own foundation
Getting started
 Opening a foundation
 After you determine the work you will do and
that it meets a real need, you must developing
these essential ingredients of a successful
nonprofit:
 A mission
 High-quality, responsive, and unduplicated
programs and services
 Reliable and diverse revenue streams
 Clear lines of accountability
 Adequate facilities

41. Creating your own foundation
Starting a nonprofit generally also
requires these steps to formalize your
organization:
 File articles of incorporation with the
Secretary of State or other appropriate state
agency.
 Apply for exempt status with the Internal
Revenue Service (IRS). Please note that it
can take 3-12 months for the IRS to return its
decision.
 Register with the state(s) where you plan to

42. First Trip With our
Own Foundation
 P
a
r
t
n
e
r
e
d
w
i
t
h
D
r
.
B
e
r
n
i
e
K
r
e
u
t
z
,
.

43. San Pedro Sula, Honduras
 Initially, a fact finding trip
 Made a connection with a local
ophthalmologist
 He is in Private practice, but also runs a
charity clinic
 Has a functional eye OR with phaco machine
and microscope

44. San Pedro Sula
Why Honduras?
 It is one of the poorest countries in Latin
America
 Spanish native language
 Same time zone, four hour flight
The need is clear:
According to local statistics, there are about
42,000 diagnosed cataracts in Honduras.
However, only approximately 5,175 cataract
surgeries are performed in Honduras yearly.
Thus there are tens of thousands of people in
need of cataract surgery.

45. San Pedro Sula, Honduras
Part of the problem is that there are only 64
Ophthalmologists in the entire country.
Honduras has a population of 8,200.000 million
people, approximately one ophthalmologist
per 128,125 people.
In comparison to the US, there is one
ophthalmologist per 20,000 people.
Essentially, TEN times more ophthalmologists
per person in the US.

46. Another interesting finding while visiting San
Pedro Sula, I was informed that there was only
one cornea specialist in the entire country,
located in Tegucigalpa, Honduras'capital, about
6 hours away from San Pedro Sula driving.
The need for corneal transplant is unknown, but it
is estimated that there are thousands of people
blind for lack of a corneal transplant.
There are no eye banks in Honduras as of now.
We are discussing starting one.

47. Most MD's are concentrated in two cities:
Tegucigalpa and San Pedro Sula. This leaves the
population of rural areas severely underserved.
Most people may never see an eye doctor.
In addition, there is a large burden in un-operated
pterygiae. The number of people suffering from
this disease is unknown, but is estimated to be
tens of thousands.
Other prevalent diseases are:
 Glaucoma and diabetic
 Retinopathy.

48. San Pedro Sula, Honduras 2012
 First surgical mission was conducted in San
Pedro Sula, Honduras, from October 27th
to
November 2nd
2012
 Surgical equipment, logistics, and travel
Organized by the foundation secretary: Anna
Pigotti and Dr Kreutz team
 Performed 7 corneal transplants
 35 Cataract surgeries

49. A careful analysis by Dr.
Fajardo and Dr. Martinez
concluded that surgical
mission was an
excellent success.
Dr. Fajardo gracefully
invited us to other
missions in the future

50. San Pedro Sula/transplants 2012
 Follow-up accomplished locally by
well trained surgeon
 Patients have done well, guidance
on suture removal accomplished via
e-mail (photos, topography,
refraction)
 Future missions will again include
PK’s

51. San Pedro Sula: CE 2012
 35 CE, most of them
phaco a few extracaps
 AEL and IOL powers had
been calculated in
advance
 IOL’s were donated by
Alcon
 Consumables by Alcon
and others
 Patients did well. No cases
of dropped nuclei or

52. San Pedro Sula/CE 2012
 We planned to make this a yearly event.
 We plan to strengthen our local ties. A lecture
was given to local ophthalmologists. We were
invited to lecture at their National Annual
meeting in Tegucigalpa

53. Honduras Surgical Eye Mission
February 15-21, 2014
A total of 48 eye surgeries surgeries were
performed:
o 1 Trabeculectomy
o 3 Intra-operative Avastin injections to
manage diabetic retinopathy
o 4 Istent placements
o 6 corneal transplants (3 DSAEK, 3
Penetrating)
o 34 cataract surgeries (28 phaco, 6
extra-cap. One combined penetrating
keratoplasty with CE and IOL, one
Phacotrabeculectomy )

54. Honduras Surgical Eye Mission
February 15-21, 2014
Post-ops were seen the following day after
surgery, and all medications needed for
post-op care were provided.

55. Honduras Surgical Eye Mission
February 15-21, 2014
Complications:
 3 capsular tear with vitreous loss required and
anterior vitrectomy. One of them resulted on a
sulcus placement of an IOL. The other 2 cases
required anterior chamber IOLs.
 2 patients had postoperative pressure spikes
managed by paracentesis and pressure lowering
meds
 These complicated cases were seen one day
post-op and found to be stable. Except for
significant cornea edema.
 These cases were followed closely by Dr.
Fajardo. They all had good outcomes

56. Honduras Surgical
Eye Mission
April 22-17, 2015
A total of 33 eye
surgeries were
performed:
 4 Istent implantations
 12 corneal transplants
(4 DSAEK, 8 PK)
 17 cataract surgeries (1
phaco+ Istent,
1phaco+DSAEK, 3

57. Honduras Surgical
Eye Mission
April 22-17, 2015
 Post-ops were seen the following
day after surgery, and all
medications needed for post-op
care were provided.
Complications:
 One of the DSAEK had a partial flat
chamber.
Through the use of “Whatsapp” Dr.
Fajardo and Dr. Barahona have
shared photos of the post-operative
follow ops. We plan to return the
first week of April 2016 this time
with 2 surgeons to have a bigger
surgical impact.

61. Equipment Donation
 Through our 501c3
foundation status we can
obtain donations that are
tax deductible.
 Phaco machine,
examining chairs, slit
lamps, instruments
 Etc.

62. Training: Dr. Marvin Barahona

63. Are we really helping?
 Unite for sight (UFS): International
organization focused on providing eye care.
 UFS has a module titled: The significant
harm of worst practices in eye care
 They are CRITICAL of certain “worst
practices” by optometric missions and
“Medical safaris”

64. UFS:Optometric and Medical
Missions : Are we REALLY
helping?
 Providing optometric care solely in the form
of presbyopic or refractive correction is
thought to be counterproductive and can
prevent patients from seeking eye care for
other ophthalmic conditions

65. Are we really helping?
 Handing out glasses by non eye-care
professionals: Shorts circuits the eye
care process

66. Are we really helping?
Worst Practices: “referrals” to local eye
doctors without facilitating access

67. Are we really helping?
 Medical “safaris” or “medical tourism”
“volunteer vacations”
 Sometimes focused on OUTPUT not
OUTCOMES
 Poor follow up. No local coordination
 Untrained physicians.
 Leave a burden for local practicioners

68. Tips: what to know before you go
on an optometric mission
 Eyeglass Distribution By Non-Eye Care
Professionals: bad practice in global health
 “Referrals” to Local Eye Doctors:
“Referring” without reducing barriers to care
will not enable a patient to access locally
available resources
 The Dangers of Short-Term “Surgical
Safaris”: Post-surgical monitoring and follow-
up care is necessary to prevent infection and
to ensure the success of an operation

69.  We feel blessed and honored to have
had a chance to improve the lives of
some Hondureños.
 In return for that help we bring back
with us a feeling of satisfaction that is
unparalleled in depth and never
ending

70. “Para-Mission activities. Local girls
Orphanage

72.  Juan. Living in
“bordo” slums by
the river. Teased
about his eye. Went
to his parents,
requested
permission. Found
and paid an
anesthesiologist,
removed his
dermoid. Looks
much better (photo
next year)

74. For more information contact:
apigotti@voeyedr.com