Fighting preventable blindness in the Dominican Republic

Dr. Kosoko-Lasaki tackles glaucoma and vitamin A deficiency

Doctors at Creighton University's ILAC medical facility perform surgeries on Dominican villagers from rural areas Source: Creighton University

Dr. Kosoko-Lasaki screens a patient for glaucoma in the D.R. Source: Creighton University
Dr. Kosoko-Lasaki examines a young girl for VAD, the leading cause of preventable blindness in children Source: Creighton University
The ILAC medical facility Source: Creighton University

For the entirety of her career, Sade Kosoko-Lasaki, M.D., has centered her research around the prevention of blindness. Over the past decade, Dr. Kosoko-Lasaki, professor of ophthalmology surgery and glaucoma specialist, Creighton University, Omaha, Neb., has traveled to the Dominican Republic (D.R.) to further that quest by addressing vitamin A deficiency (VAD) and glaucoma, two major areas of public health concern in the developing Caribbean country. Creighton University has a medical mission program based in both Omaha and the D.R. called ILAC, or the Institute for Latin American Concern, which began in 1973. "ILAC has a medical facility [in the D.R.] where we schedule surgeries with various groups for poor people in the rural areas," said Radalme Pena, executive director, ILAC. Surgical services ILAC provides include hernia, orthopedic, ophthalmologic, and ear, nose, and throat, among others. Doctors travel to the D.R. from around the world and donate their time as part of a volunteer health program.
The medical facility has three ORs, each with two beds. ILAC trains volunteer public health workers called cooperadores who travel to 162 Dominican villages and examine people for VAD and other diseases. If there's a problem, the cooperadores round up the patients and bring them to ILAC for treatment. Creighton medical students also travel to the D.R. ILAC facility as part of an exchange mission program. When one Creighton student came back from the country telling Dr. Kosoko-Lasaki of villagers with night blindness, an early sign of VAD, she knew she had to act. With the help of numerous organizations including ILAC, the World Health Organization, and a non-profit humanitarian association called Sight and Life, Dr. Kosoko-Lasaki traveled to the D.R. in the early 2000s for her first vitamin A intervention. VAD is the leading cause of preventable blindness in children, mostly affecting lower income countries like the Dominican where, according to the CIA World Factbook, 42.2% of the population lives below the poverty line. VAD also causes a host of additional health issues such as anemia, increased risk of infection, and early mortality. WHO classifies the D.R. as having a mild VAD public health crisis, affecting an estimated 2-10% of its population, according to a 2009 report. "Vitamin A is primarily found in animal products like eggs or milk," said Klaus Kraemer, Ph.D., executive director, Sight and Life, Basel, Switzerland. "In many countries, it's just a matter of affordability and knowledge. Animal foods are very difficult for the poor to buy." During VAD interventions, Dr. Kosoko-Lasaki administers vitamin A megadoses, donated by Sight and Life, to children between the ages of 3 and 10, as well as lactating mothers and pregnant women in the second and third trimester. In recent years, Dr. Kosoko-Lasaki expanded her charity work in the Dominican to encompass glaucoma screening and surgery as well. Sebastian Guzman, M.D., an ophthalmologist based in the D.R, approached her during one of her VAD trips and asked if she'd be interested in glaucoma collaboration. Dr. Kosoko-Lasaki would see glaucoma patients in addition to doing vitamin A dosing, and Dr. Guzman would follow-up with her patients for free if necessary. "I asked her if she would come next year to do some glaucoma work," said Dr. Guzman. "That's how it started. The next year she came and saw patients."
"In order to go into any country and do glaucoma surgery, we need to have collaborators to follow-up on patients," Dr. Kosoko-Lasaki said. "It's not a one-time deal. Most ophthalmologists shy away from glaucoma surgery because it's not gratifying. The patients don't see better; sometimes they see worse. Glaucoma blindness in the D.R. is pretty high. The patients I see have severe glaucoma with pressures in the 30s."
Dr. Kosoko-Lasaki's last trip to the Dominican was in March 2011 for 6 days, four of which were dedicated to glaucoma surgery. She brought with her Rebecca Batt, a certified ophthalmic assistant, who took patient pressures and performed reading exams, and Brett Briggs, a Creighton student, who coordinated the glaucoma screening process, visual field, and visual acuity. "We saw upward of 250 people," said Mr. Briggs. "People hear there's an American doctor coming and they travel from far and wide. The D.R. is very underserved. People just don't have the money to see an ophthalmologist. A lot of these patients are risking losing their jobs by taking off work to see a doctor." Dr. Kosoko-Lasaki and her team were able to cover a tremendous amount of ground in under a week. She performed 120 adult eye exams and found 41 existing cases of glaucoma, seven new cases of glaucoma, and 13 instances of other ocular diseases. She administrated vitamin A megadoses to 117 children, educated 30 cooperadores on vitamin A and ocular health, and performed 12 laser glaucoma surgeries and one trabeculectomy. The patients' average pressure drop was 46%. "Surgery [in the D.R.] isn't a challenge because I do it in Dr. Guzman's surgical center," Dr. Kosoko-Lasaki explained. "It's not as challenging as it would be if I didn't have that collaboration with Dr. Guzman. He donates the use of his staff, and when I go down, I take some of the essentials. I take my own instruments and a lot of samples of medication that I leave for him. It's like a little exchange." She also makes sure the cooperadores get a full eye exam. "My belief is if they're on my staff, it would be a shame if they were doing everything they could to help others and had glaucoma and didn't know it," she said. "So I examine all the cooperadores. I instruct them on glaucoma, and the word gets out that they can trust me." The patients are immensely thankful and gracious to Dr. Kosoko-Lasaki and her staff, and bring her, for example, wild flowers as a thank you. "They say to me, 'What do you want, Doctor? Food?' and I say, 'No, no food. I want you to do what you can for guests,'" she said. "They sing and clap. They are very happy."
"Patients are extremely thankful," said Mr. Briggs. "They say 'thank you' probably 100 times. Some are a little bewildered as to what's going on because they don't really understand. But we try to explain. Some don't fully understand why they take [glaucoma] medicine, but they trust so much in the doctor that they'll do it regardless of their understanding." Dr. Kosoko-Lasaki plans on continuing to donate her time in the D.R. and says she's seen improvements in the country's glaucoma care over the years. "Patients are aware, and the clinic is very busy," she said. "Awareness is what is needed for glaucoma. When people are aware, they want to be treated."
She would like to see doctors focus more of their volunteering on glaucoma, however, noting it's the second most common cause of blindness in the world. "Attention hasn't been directed to that area because of the difficulty of managing the disease," Dr. Kosoko-Lasaki said. "The medications are expensive. Patients in the D.R. have access to medications, but if someone gives it out for free one or two times—a medication that patients are supposed to take for the rest of their life—at what point do they stop giving it for free? That's the challenge."

Contact information

Briggs: BrettBriggs@creighton.edu
Guzman: sebastianguzman@hotmail.com
Kosoko-Lasaki: SadeKosoko-Lasaki@creighton.edu
Kraemer: Klaus.Kraemer@dsm.com
Peña: radalme@hotmail.com