November 2007




Robert M. Sinskey Clinic in Ethiopia

by Vanessa Caceres EyeWorld Contributing Editor



Dr. Kefyalew, the clinic’s staff ophthalmologist, performed all surgeries

Pressure applied with a tennis ball and long socks Source: Pranav Amin, M.D.

Dr. Amin worked as a surgeon at the clinic and helped improve patient management

The ophthalmic nurse learned how to drape and prep Source: Pranav Amin, M.D.

Clinic advances, serves local population

In Ethiopia, a country of 76 million people and only 95 ophthalmologists, raising the standard of eye care can be a challenge. However, the ASCRS Foundation’s Robert M. Sinskey Pediatric Eyecare Clinic in Addis Ababa, Ethiopia, aims to improve local ophthalmic offerings for a traditional underserved segment of the population.

The Sinskey Clinic currently sees about 350 patients per month, and a U.S.-based ophthalmologist recently had the chance to work hands-on and observe how the staff members are helping local residents.

He had a soup-to-nuts role at the clinic during his visit.

“In Addis Ababa, I was not only a surgeon,” said Pranav Amin, M.D., Yuba City, Calif., who visited the clinic for one week in June 2007. “I worked to fix the microscope, set phaco as a technician, adjusted tables and equipment, helped the circulating nurse, worked as scrub tech, and set up protocol for pre-op and recovery in our clinic.”

The clinic, a standalone single-story building, was opened in 2005 by the ASCRS Foundation. It is located in a poorer community and is adjacent to the Free Methodist Health Center, which provides healthcare for women and children. Keeping with the foundation goal to offer humanitarian eye care, patients pay $1 per eye exam and $35 per eye for cataract surgery, paid in the local currency called Birr. Those charges compare with an average cost of $100 to $200 per eye at a university hospital or with a private ophthalmologist, Dr. Amin said. The per capita income in Ethiopia is only $100 a year.

Dr. Amin’s plan was to observe the clinic’s staff ophthalmologist, Kefyalew Regassa Gobena, M.D., help fine-tune phacoemulsification procedures, check equipment functioning, and offer suggestions to improve the clinic. However, he did much more than he had originally planned.

“We changed the operating room arrangement to create more room for the surgeon and supplies,” he said. “We also set up the entire OR [operating room] differently to [perform] more efficient eye surgeries and produce consistently good outcomes.”

Improving patient management

One round of changes Dr. Amin helped oversee were those made to patient flow.

Before, patients scheduled for surgery on any given day arrived at the same time, around 8 a.m., Dr. Amin said. For example, “the last case we started at 4:30 p.m., and that patient had arrived with all the others at 8 in the morning,” he said. To curtail waiting, Dr. Amin recommended that patients arrive in the order of their expected OR time. Sometimes patients would move during the middle of the surgery, leading to shouting of “Ahan kasa kasu,” “Do not move,” in the local Amharic language. This was often because they had to use the bathroom. So, Dr. Amin suggested a mandate that patients use the restroom before surgery.

On some days, half of the patients scheduled for surgery did not show, Dr. Amin said. To help avoid this, Dr. Amin advised that the clinic collect 50 Birr—about 15% of the surgery fee—in advance. “This deposit would be nonrefundable if the patient did not show,” Dr. Amin said. Of course, it would also be applied toward the fee if the patient was there on the day of surgery, he added. Dr. Amin said this system allowed the clinic to utilize the limited OR time to the full advantage of local patients.

Smoother surgical procedures

Dr. Amin also suggested some ways that Dr. Kefyalew and staff could perform surgery more smoothly.

One change was improving the insertion of dilating drops in the eye upon a patient’s arrival. Dr. Amin taught the receptionist who inserts the drops how to check if dilation is complete and know when to add further drops. Another change was improving pre-op education and the attainment of surgery-related medication. Most patients do not have money readily available to pay for medicines; other times, travel back and forth to the clinic hinders easy access to prescriptions or medications, Dr. Amin said. To remedy this, patients now receive prescriptions for steroids and antibiotic eyedrops before surgery so there is time to obtain necessary funds and fill the prescriptions, instead of receiving these prescriptions post-op, which often leads to a delay in starting or not using the medications. During surgery itself, Dr. Amin reviewed prepping and draping procedures with the ophthalmic nurse to help cut down on blepharitis. The nurse now completes prepping and draping with the patient while the surgeon prepares the phaco equipment.

Even small changes to the OR itself should make surgery at the clinic easier to perform, Dr. Amin said.

“Since the OR seemed a little cramped, we changed the orientation,” he said. “I recommended eliminating things from the OR that are not being used,” such as anesthesia supplies and equipment. Another small but productive change was repositioning the patient in the OR, so Dr. Kefyalew has a clearer view of the eye.

“I made the change in patient position suitable to [Dr. Kefyalew’s] temporal surgical position by tilting the head of the patient slightly to the side of surgeon … This appears to have helped improve his comfort during the case,” Dr. Amin said.

Dr. Amin also helped Dr. Kefyalew lower the phaco machine and service the microscope—a task Dr. Amin learned how to do while in Ethiopia via e-mail help from representatives of Advanced Medical Optics (AMO, Santa Ana, Calif.) and Carl Zeiss Meditec (Dublin, Calif./Jena, Germany); both moves give Dr. Kefyalew a better surgical view and have helped create more stable fluidics in the patients’ anterior chambers.

Another minor but important change to the OR was placement of tape to indicate where the bed should be moved for right eye to left eye surgery.

“It would take a long time to change between a right eye to a left eye surgery, as there needed to be movement of the bed and microscope,” Dr. Amin said. “We started simple tape placement on the floor to tell the staff where the wheels of the bed should be placed each time. It worked well and prevented too much time and effort in adjusting for the ideal position of the bed.”

Growing the clinic

With a dedicated surgeon and hard-working staff, the Robert M. Sinskey Clinic is serving a traditional underserved portion of the Ethiopian population. Going forward, the clinic can flourish with more necessary equipment and supplies, more staff training, and strong customer service that is not typical in that area, Dr. Amin said.

“Consistently good visual outcomes with good customer service would create happy patients and spread the word of mouth, increasing the volume of patients and revenue, making the clinic self-sustaining,” Dr. Amin said.

Contact Information

Amin: 530-749-3510,

The Robert M. Sinskey Pediatric Eyecare Clinic has a constant need for surgical supplies to serve its Ethiopian patients. Items such as foldable intraocular lens, reusable surgical knives/instruments, and antibiotic/steroid/anti-inflammatory/glaucoma eye drops are unavailable in Ethiopia and must be purchased and shipped from overseas. Individuals interested in donating such equipment should contact Donald Bell at 703-591-2220.

Robert M. Sinskey Clinic in Ethiopia Robert M. Sinskey Clinic in Ethiopia
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