March 2008

 

CATARACT/ IOL

 

Robert M. Sinskey Clinic in Ethiopia continues to grow


by I. Howard Fine, M.D., with Vanessa Caceres

 

Approximately five years ago, the ASCRS Foundation, with a great deal of enthusiasm, ambition, and naiveté embarked on a mission to create eye surgery facilities within the developing world focused on pediatric cataracts. Over the last four years, we have had an important measure of success, have learned a great deal, and are closing in on being able to reach our goals in our initial endeavor, which is the ASCRS Foundation Robert M. Sinskey Clinic in Addis Ababa, Ethiopia.

We have a highly motivated, altruistic, humanistic, and patriotic staff and surgeon in the full-time employ of our clinic there. Little by little, we are bringing that clinic up to the standard of care that we hope to provide, which is equivalent to what is obtainable in the fully-developed world. The training that we are able to provide is coming from the enormous support of individuals who have actually traveled to the clinic to spend time in teaching surgical technique, as well as the training of technicians and support staff, and administrative work. Thus far, we have been lucky to have the enormous help of Abhay Vasavada, M.D., from Ahmedabad, India, Haripriya Aravind, M.D., and her family from the Aravind System of clinics in India, Pranav Amin, M.D., from Yuba City, California, who is actually the director of our clinic system, and Geoffrey Tabin, M.D., and Alan Crandall, M.D., from the University of Utah. We are anticipating that Susan Senft, M.D., from Kona, Hawaii, will be traveling to the clinic, shortly to help in surgical training.

David Robinson, M.D., volunteered his services and recently spent approximately ten days working at the clinic, with the ancillary and administrative staff as well. He has accomplished a lot in further defining ongoing needs, anticipating future growth, and especially organizing the administrative matters that will allow the clinic to not only run more smoothly, but to grow. Not surprisingly, he found this to be an extremely rewarding experience, which has added satisfaction to his own practice at home in Delaware. I think all of our readers will enjoy reading about the clinic in Addis Ababa and many may consider wanting to participate in what goes on there.

I. Howard Fine, MD, Column Editor

 

Physician recounts his recent visit

Kefyalew Regassa Gobena, M.D., and David Robinson, M.D., at the Robert M. Sinskey Pediatric Eyecare Clinic in Addis Ababa, Ethiopia

Ethiopian man on the street Source: David Robinson, M.D.

As the ASCRS Foundation’s Robert M. Sinskey Eyecare Clinic in Addis Ababa, Ethiopia has become more established in the past two years, three U.S. physicians have had the incredible opportunity to work directly with the clinic staff to help it run more smoothly. The latest visitor was David Robinson, M.D., Rehoboth Beach, Del., who visited for a week in January. Dr. Robinson worked closely with clinic’s ophthalmologist Kefyalew Regassa Gobena, M.D. (or Dr. Kefyalew as he’s called), helping to set up new equipment and train staff. Dr. Robinson wanted to tout his “amazing experience” at the clinic and share with our readers how the clinic has grown and progressed—and where it could still use your help. Here are some highlights from a recent interview with Dr. Robinson:

How did you initially get involved with the clinic and the ASCRS Foundation?

Dr. Robinson: The wife of my old tennis coach called me saying she has a friend from Ethiopia. When she asked her friend what she wanted for Christmas, she replied, “I want my brother to be able to see.” The Ethiopian woman said her 31-year-old brother had only one good eye and at age 9 had suffered a trauma to that eye and then traumatic cataract surgery which was unsuccessful. Since that time he has been essentially blind in that eye and had gone through school using Braille. I can only imagine what that must have been like; in Ethiopia, there are no ADA [Americans with Disabilities Act] requirements. Despite the challenges, he had put himself through school, college, and law school with honors and had became a district attorney. He was moving through the ranks but his vision had become so poor that he could not perform the duties of the next level job. His other eye was supposedly blind since birth.

I was asked if I could help him. I did some researching and came across an article about the ASCRS Foundation’s Sinskey Clinic. I reached Dr. Sinskey and explained the situation. He told me that one of his fellows, Dr. Pranav Amin, M.D., [Yuba City, Calif.], planned to visit the clinic shortly on a training mission. I then spoke with both Dr. Amin and Dr. Kefyalew in Ethiopia about this patient.

When Dr. Amin visited Ethiopia in June, 2007, he examined the patient using the limited equipment the clinic had at the time. Dr. Amin said, “I think you can help him, but I’m not sure.” On that information alone the patient flew to the U.S. to visit his family in North Carolina, and then traveled seven hours north to see me in Delaware. I initially had to write to the U. S. Embassy to say I was providing medical care for him for free.

I examined his left eye and after two hours determined there was nothing I could do to help him. I was very disappointed. But because he had traveled so far I asked him to return the next day. I kept thinking about the other eye which they said had been blind since birth. When he returned the next day we measured the length of his eye and found he was a –28 myope. I gave him a near card to read; he held it at 10, 8, 6, 4, and 3 inches—still nothing. Finally, he put it between his eyebrow and cheek and pushed it against his face. I shone a light in close and he read the third line from the bottom. I said, “This eye actually has vision!” We calculated him for a –8 implant. The next day I did surgery and he saw 20/50 uncorrected. It was absolutely the most amazing experience for me and my staff. We help people to see everyday, but here was a man who faced a life of blindness in a country with no way of helping him. To watch his face and his family’s attitude change in just five minutes was amazing.

I was so inspired by that experience that I decided to the visit the Foundation’s clinic in Ethiopia myself. What excited me was the foundation’s work to train a local doctor to help build a self-sustaining clinic that can provide ongoing care to people in their community, while also teaching and instructing the local medical staff.

When you first arrived, what were the things that surprised you the most?

Dr. Robinson: First, they had no running water! The clinic has water only two days a week, but they never know which two days. Dr. Kefyalew and his staff have been very inventive when it comes to finding ways to overcome the water limits. They saturate cotton balls with alcohol in jars and pull them out to clean their hands. They actually clean their hands very well this way. When I first arrived, there was no autorefractor, no phoropter, no indirect ophthalmoscope, and no applanation tonometer. Important equipment sent by the foundation was held up in Ethiopian customs. They didn’t have a lot of the simple equipment that ophthalmologists normally use. Fortunately, the customs problem was resolved and all the equipment arrived a day or so into my visit. So, there were big changes during that week. I introduced all the new pieces of equipment to the staff, including the autorefractor, indirect ophthalmoscope, and the applanation tonometer.

The other thing that surprised me was how well-run the clinic is and how they’ve adopted an almost Western-style approach to daily operations. They register patients as we do, they have a medical chart, and the nurses do some of the vision screening and check the IOP. After that, patients see Dr. Kefyalew. Pranav Amin and Geoff Tabin, M.D. [Salt Lake City, Utah], who had visited the clinic before me, had instituted a very efficient way of seeing patients.

Another significant challenge is that there are no patient appointments. Most people don’t have cars and arrive on foot. The clinic is situated in one of the poorer parts of an already poor city, and it’s basically first-come, first-served. From day-to-day they never know if they’ll be treating 20 patients or 50 patients. The clinic staff does everything they can to take care of everyone, and in the week I was there I never saw a patient turned away.

How does the first-come, first-served system work for surgery?

Dr. Robinson: Patients having surgery are usually told to come back later that day or the next day. They’re operated on very soon after they’re diagnosed. There were a number of patients who had traveled hundreds of miles by bus just for the chance to be seen by Dr. Kefyalew. It’s a challenge for them to get there because there are no street signs or proper addresses in the city. You basically have to ask someone, and they’ll tell you it’s near this church or that church, or that school. That’s why they try and do surgery soon after the patient arrives.

At this point, it’s not a high-volume cataract surgery clinic, although it is very busy. It is more of a comprehensive ophthalmology practice. Along with a heavy population of acute and chronic trachoma patients and their associated upper and lower lid surgical eyelid disease, Dr. Kefyalew treats patients with glaucoma, uveitis, diabetic retinopathy, cataracts, Bell’s palsy, accommodative esotropia with amblyopia, dry eyes, presbyopia, and refractive errors. He also performs trabeculectomies, cataract surgeries, and lid procedures as indicated. The clinic is providing service not just for cataract patients but for an array of disease and problems.

Is there anywhere else in the country to get similar services as are offered in the clinic?

Dr. Robinson: The city has the Menelik Hospital which is government-run. It’s almost a free clinic for people and it’s incredibly overrun. Before the Sinskey Clinic opened, Menelik was the only available option for many Ethiopians. There is also some private practice ophthalmology, but it is beyond the realm of affordability for nearly everyone both inside and outside of the city. It’s hard to describe the level of poverty—just mile upon mile without running water and people living in mud shacks with corrugated steel roofs. Most people could never afford private practice. The Foundation’s Sinskey clinic charges significantly less—about the equivalent of $1.60 for an exam. The clinic now provides a very important middle ground between Menelik and private practice.

What needs do you think the clinic has in the next six months to a year?

Dr. Robinson: What’s happened at the clinic during the past several months is that the patient volume has started to dramatically increase, to 40-55 patients a day. The clinic already saw over 5,000 patients last year, and at the current rate they’ll start to approach 10,000 patients a year in the next 12-24 months. They’ll need more money and more support for supplies, and they need more equipment. All of the equipment has been donated, and like the equipment in our offices we have to assume that someday it will break or need repair. There is really nowhere in the country to fix such things. An ongoing program to maintain the equipment would be extremely helpful.

It also would be invaluable to get administrative help through ASCRS, either permanently or for an extended period of time, to help the clinic staff move forward with their plan for self-sustainability. They have made great strides on their own, but will need our help to make it a reality.

What lessons did you take from your experience there?

Dr. Robinson: The most important thing is just the joy of being a physician again and realizing what an incredible opportunity we have through the ASCRS Foundation to help people. The Ethiopian patients are so appreciative. In ophthalmology, we get so bogged down with administrative issues that we sometimes forget that we are doctors. Since returning, I’ve enjoyed my patients more than ever and enjoy what I’m able to do for them. Every physician who has an opportunity to help a program like this should do it. The ASCRS Foundation has an ambitious humanitarian mission through its Robert Sinskey Eyecare Clinic in Ethiopia, and your help is needed. Contributions to the ASCRS Foundation are tax-deductible and 100% of the donation is used to benefit the clinic. Please contact Don Bell at dbell@ascrs.org for more information.

Contact Information

Robinson: 302-645-2300, drobinson@delawareeye.com

Robert M. Sinskey Clinic in Ethiopia continues to grow Robert M. Sinskey Clinic in Ethiopia continues to grow
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