WEST SUFFOLK CHILDREN'S EYE SURGERY TEAM VISIT BANGLADESH
In April 2006, three members of the Paediatric Ophthalmology Team from the Eye Treatment Centre at West Suffolk Hospital visited a new Childrens Eye Centre at the Bangladesh Society for the Blind (BNSB) Eye Hospital in Moulvibazar, Bangladesh. The trip was sponsored by ORBIS a charity dedicated to the eradication of blindness in the developing world. Dr Tony Vivian (paediatric ophthalmologist), Stuart McGill (orthoptist) and Rachel Andrews (paediatric nurse and theatre sister) headed out to this remote part of north-eastern Bangladesh to provide training to the local doctors, orthoptists and nurses in the treatment of children with poor vision due to eye disease.
The start of the program was darkened by the sad death of Dr Islaam who was the founder of the BNSB Eye Hospital at Moulvibazar. He died on the morning of the day we were to arrive. Our first function was to represent Orbis at the funeral and viewing of the body at the hospital. He was buried later that day. The hospital managers and doctors were deeply saddened by the death of a great man who had made such an impact on the provision of eye treatment in the region over the last 30 years. After discussion with the family, it was decided that he would have insisted that the program continued and so no changes were made to the plans that he had carefully crafted prior to our arrival.
Orbis have been instrumental in developing paediatric ophthalmology in the region. They have helped develop a wonderful Paediatric Eye Centre and contributed to training two of the BNSB surgeons in children's eye problems, who have had the opportunity to travel to Pakistan and India to observe children’s eye surgery. The purpose of our visit was to enable the surgeons at Moulvibazar to start putting their training into practice with onsite teaching of surgical strategies for strabismus (squint), ptosis (droopy eyelids) and paediatric cataract.
THE CLINIC
Dr Kafayet was the senior surgeon who was very interested in starting surgery for strabismus and ptosis. Our training started in the outpatient department where an amazing array of patients were waiting for us. There is still great respect for the British and British doctors in Bangladesh and patients had come from all over the north-east of Bangladesh and even as far as Dhaka. Stuart, Rachel and I work as members of a team and we were keen to promote the team approach.
We were delighted to find that all the eye care professionals at the hospital embraced the concept of the team approach and before long the clinic was in full swing. The patients were seen first by Stuart and the local orthoptists and optometrists. The techniques that we use in Bury St Edmunds to examine patients and document findings were demonstrated. The equipment in the outpatient dept was good and we also bought some of our own instruments which we have left for them to use when we have gone.
We shared our knowledge and made treatment strategies for the patients. We were all particularly keen to promote the sharing of information with the parents of the children, which was not common practice in Bangladesh.
Having sensitivity for the feelings and the experience of the child is something that all the participants commented upon as a strong point in our team approach. It is so fundamental to the way we deliver care to our children in Bury St Edmunds but it is not part of the medical culture in Bangladesh where the parents are not involved in the decision making.
By the end of the first day we had already admitted 12 patients for surgery which was far more than we could manage in a whole day of operating. The range of conditions included congenital cataracts, squints and ptosis.
This girl has a large convergent squint.
A left ptosis caused by a nerve palsy from birth.
A lovely girl, blinded by congenital cataracts, her mother was anxious that we may not be able to operate on her daughter.
There were many patients who had conditions that we could not treat. Inherited syndromes, corneal opacities due to infections such as measles and rubella and vitamin A deficiency, previous eye injuries and retinal conditions due to various causes.
This girl has a condition known as Goldenhar Syndrome.
A traumatic injury to the right eye.
OPERATING THEATRES
The operating theatre had a team of four paramedics. Their training consisted of a three month theatre course which they then developed through practical experience. They had little background medical knowledge but their ophthalmic and anaesthetic understanding was good and they were exceptionally keen to learn more. Training them for ptosis and strabismus surgery was done in study sessions and during operating sessions.
While working along side them we also taught the nurses and doctors the closed technique of glove donning, maintenance of the sterile field, the safe disposal of sharps and the risks of needle-stick injuries.
The other area of interest in the operating theatres was the childs’ experience of the patient journey. Instead of whisking the child from the parents in the ward to lie on a trolley by itself in the anaesthetic room, we encouraged them to allow the parents into the anaesthetic room during induction of the anaesthetic. The children were much happier and the theatre staff were pleased with the improvement in the pathway. Many of the changes we encouraged did not involve much cost. There were some obvious needs in the theatres which would benefit from investment. There was no operating light which makes squint surgery difficult. There was only one bipolar cautery lead which meant there was no opportunity to sterilize it. The vitrectomy machine was non-functional making the job of paediatric cataract removal less effective.
We continue to keep in touch with the nurses and doctors in the paediatric clinic and theatres in Moulvibazar. We are encouraged by the feedback that they are continuing to develop paediatric ophthalmology. We hope to return to help Moulvibazar develop further their expertise in strabismus and ptosis surgery.
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