| Chapter 58 Appropriate Methods and Resources for Third World Ophthalmology JOSEPH TAYLOR Table Of Contents |
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APPROPRIATE MANPOWER APPROPRIATE DRUGS APPROPRIATE OPTICAL SERVICES STANDARD APPROPRIATE EQUIPMENT REFERENCES |
| It could be argued that all that has to be done is to transfer the well-proved
methods and instrumentation from the West to all the areas of
the world and all problems would be solved! Even if such a transfer were
possible, nothing would be further from the truth. For example, no
matter how many ophthalmic lasers were to be made available, this would
not solve the problem of glaucoma. The machines would break down and, since
most sufferers from glaucoma are not accessible, nothing would
be gained. The laser is completely “nonappropriate” to tackle
the problem of glaucoma in a Third World setting. There is an increasing
demand for eye services in the Third World, due to the vastly
improved communications and the increasing awareness that something can
be done. When the task is examined, it is obvious that, because of the striking differences in the causes of blindness, because of the forbidding geographical barriers, and because of the overriding poverty of resources, appropriate methods specifically geared and designed to the nature and to the extent of the problem must be applied. For methods applied to Third World ophthalmic problems to be appropriate, they must be economical in all parameters, that is, cost effective, time effective, and sight effective. |
| APPROPRIATE MANPOWER | ||||||||||||||||||||||||||||||||||||||||||
| Whereas in the Western World context services are delivered entirely by
highly trained, specialized staff working in fully equipped centers, this
is quite inappropriate for the Third Word where there is a great
paucity of highly trained staff, and the eye service has to be given to
a widely and often sparsely scattered population, so that a very large
staff is required. Since much of the work is simple, only a small number
of highly specialized staff, but a much larger number of auxiliary
staff, are required; the latter are specially trained on a “job
oriented” basis to cover the many rural centers where eye services
need to be delivered. Full use also must be made of other available
medical personnel. To provide the numbers of staff needed, the following groups should be included: (1) full-time eye workers, (2) integrated eye workers, and (3) voluntary eye workers. FULL-TIME EYE WORKERS FULLY TRAINED OPHTHALMOLOGISTS. Experience has shown that the best and most appropriate results are obtained if the ophthalmologist has received at least part of his basic training in the Third World. (When an adequate number of supporting staff are available, one ophthalmologist per 500,000 people is a suitable initial target for which to aim.) MEDICAL EYE AUXILIARIES. Auxiliaries should be drawn from paramedical workers (and in some cases specially trained registered nurses), who have already worked for some years in a general medical service and have then received specialist eye training for varying periods (from 3 to 18 months). These workers should be doing routine eye care, including subjective refractions, routine lid surgery, and in some situations (when they have received additional special training), cataract surgery. EYE NURSES. Eye nurses must have had full general training and have then had a special postgraduate course in eye care. This may be composed of in-service, short-term intensive courses, or a more formal course leading to recognition as an ophthalmic nurse. These nurses work mainly on a district level, doing routine eye clinics (including school clinics), and also work in close association with others in the district team, especially those in the maternal and child welfare services. They are also the direct link between the eye services and the community services at the village level. OPTICAL TECHNICIANS. These technicians make up a special technical staff whose sole job it is to produce large quantities of cheap and easily available standard spectacles. (See details in section on optical services.) INTEGRATED EYE WORKERS In contradistinction to the eye services in the West, where eye care is almost entirely in the hands of full-time specialized eye staff, in the Third World all health workers, of any type, must be involved to integrate eye services and eye care as part of their day-to-day, normal activity. These integrated eye workers, ranging from the general practitioner to the maternity and child welfare aides, should all be given, both at the training stage and as part of further in-service training, some knowledge of eye diseases and eye care in its widest sense. Only when every medical and health worker can include eye care in their day-to-day activities will eye services become available to the whole population. GENERAL PRACTITIONER OPHTHALMOLOGIST. There are many general practitioners working at the district or regional level who have a surgical bent or interest. Advantage should be taken of this to train these general medical graduates specifically in basic ophthalmic surgery, especially cataract surgery. Special training and organization are needed, but only if these general practitioner ophthalmologists (cataract surgeons) are recruited and included in the eye team will it be possible to meet the large burden, including the backlog, of those who need to have cataract extractions. It should be realized that cataract is the largest single cause of treatable blindness worldwide and in the Third World accounts for between 30% and 50% of the total number of blind in practically all areas. ALL PHYSICIANS, PARAMEDICAL STAFF, NURSES, AND MIDWIVES. These professionals should receive more training in eye care during their undergraduate course so that they can participate in eye care delivery. VOLUNTARY EYE WORKERS. There are many persons who, in the course of their normal work, have close contact with the community, especially at the village level. These persons, by use of appropriate knowledge, could be instrumental in the prevention of blindness. For example, the primary school teacher, the environmental sanitation worker, the adult literacy teacher, the church teacher, and others have great potential if they are integrated into the whole system of preventive eye care and should be invited to attend eye seminars and simple instruction courses organized at the district and village level. It is also important to emphasize that all types of eye staff need to have the stimulus of continuing education and eye seminars to provide the necessary incentive and encouragement in what is often a difficult field and to provide updating of their knowledge and skills. In this way, not only will the worker get continual education and encouragement but the leaders in the eye field also will be made aware of difficulties as they arise. The effectiveness of having already-experienced medical and paramedical staff trained as eye auxiliaries and providing appropriate eye services is amply exemplified by the experience of Tanzania, Kenya, and Malawi. Experienced medical assistants were given short in-service training in ophthalmology, varying from intensive 3-month courses to more formal courses of 1 year to 18 months. In these countries the introduction and implementation of these training schemes has completely revolutionized delivery of eye services over the past 10 years, from a service limited to the capital city to a countrywide basic eye program. (See Table 1 for details of the Tanzanian organization and experience.)
TABLE 1. Utilization of Eye Manpower in Ophthalmic Services--Tanzania, 1983
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| APPROPRIATE DRUGS | ||||||||||||||||||||||||||||||||
The lead given by the World Health Organization (WHO)1,2 in providing a list of essential drugs is a step in the right direction
but must be taken a stage further to provide a small number of standard, inexpensive
drugs for eye treatment. This is essential to providing
what is needed to cover the more common problems on a wide basis. Commercially
prepared drugs are extremely expensive, being sold at about
ten times the basic cost, and also do not overcome the geographic problem
of having drugs available at remote places when and where they are
needed. To overcome this basic problem, it is necessary to produce
basic eye preparations locally on a noncommercial basis. Details of this
method of production are given in a simple publication.3 The basis of this approach is that empty, standard, otherwise wasted vials
are used as the containers (commercially, the container accounts
for half the cost of eye preparations), and a few basic chemicals are
all that is needed to make the standard eye drops required. These basic
drops include the following:
Although it is good to have a supply of fresh distilled water, facilities for bacterial filtration, and autoclaving, even if these facilities are not available the preparation of eye drops is quite safe using cleanly collected rain water or demineralized water, filtered with ordinary filter paper and funnel and sterilized in a simple water bath or domestic pressure cooker. Both disposable and reusable droppers are cheaply available for use with standard vials. If a hospital pharmacy should be available, so much the better. These and other drops can be made easily, simply, and cheaply at a cost that is almost negligible in the total eye budget. It is not easy, or economical, to prepare eye ointments on a small scale, but nonbranded preparations (ordered in bulk and prepacked for distribution to the main centers of eye care) are very cheap. Experience in Tanzania has shown that for ointments procured in this way, the price was less than 50% of the cheapest available commercial product. If the standard eye drops are locally produced, only two standard eye ointments are required:
In practice, one tube of atropine for every ten tubes of tetracycline will cover requirements in most situations. Of course, if atropine eye drops 1% are freely available, the atropine eye ointment can be omitted entirely. These few standard eye preparations cover more than 90% of common eye conditions. Certain other drugs are needed in those centers staffed by an ophthalmologist:
Other corticosteroids and antiviral agents are not in the standard lists but are included in the Local Production of Eye Drops3 as the cheapest preparations required in the more specialized centers. Pilocarpine, timolol, and other glaucoma preparations have been deliberately omitted. Experience has shown that the only appropriate method for the management of primary glaucoma in the Third World is surgery at the earliest stage and opportunity (Table 2).
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| APPROPRIATE OPTICAL SERVICES |
| As is the case with eye drugs, the cost of even a simple pair of reading
glasses produced in the normal commercial manner is completely beyond
the resources of the average person in the Third World. Even the simplest
type of standard spectacle purchased through the average city optician
costs the equivalent of I or 2 months' wages, which is quite unacceptable. An
alternative means of supplying this essential need, at
a maximum cost of 1 week's wage, has to be found. INEXPENSIVE STANDARD GLASSES In general, the following types of spectacles are required: Simple reading glasses: 80% to 85% Simple spherical corrections are all that is required to cover more than 90% of the optical needs. For astigmatic corrections, satisfactory substitutes, in terms of a spherical equivalent, can also cover the needs of many of the remaining patients, without serious loss in corrected acuity. If there are any patients who require spherocylinders, these spectacles can be obtained from a “central bank” of lenses available in most countries. Simple manuals describing methods for edging and standard spherical lenses have been developed to produce effective and acceptable spectacles at one tenth of the minimum monthly wage, which is about $5 per pair of glasses.4 OPTICAL WORKSHOPS In various countries of Africa (e.g., Botswana, Malawi, Tanzania, Kenya, the Cameroons, Sierra Leone), simple optical workshops have been established for producing standard spectacles, using a hand-edger with a diamond-impregnated stone and powered by a standard 1/4-HP electric motor. An identical hand-edging machine can also be operated by a pedal-powered method. Standard plastic spectacle frames are being made entirely by hand, although production could be much increased if already existing plastic extrusion machinery were used, with a suitable mold. The spectacle parts thus produced are assembled by hand. At present, standard finished spectacle lenses are bought in bulk, but the overall costs can be reduced by the development of a simple manual method of surfacing (grinding) and polishing of standard spherical lenses. The cost of the rough blank is only 20% of the finished lens. With the further development of the pedal-powered alternative to the electric motor, practical production of spectacles at rural, even village, level is within sight. |
| STANDARD APPROPRIATE EQUIPMENT |
| Valuable resources of trained staff have often been wasted, or at best
poorly used, because they have not been given even the basic equipment
to carry out their work; even though the equipment is often cheap and
simple. The following is a basic minimum equipment list needed to carry
on a standard eye clinic. With it, more than 80% of the common eye
problems can be dealt with. BASIC DIAGNOSTIC EQUIPMENT
STANDARD SURGICAL EQUIPMENT Most clinics and operating rooms are overequipped and oversophisticated. Furthermore, standardization and simplification have been proved to increase efficiency and output and simplify maintenance. STERILIZATION. Sharp instruments are most simply sterilized by immersion in an efficient antiseptic solution such as 2% Savlon (a mixture of hibitane and cetrimide) together with an antirust agent such as sodium nitrite. This method is simple, cheap, and kind to the delicate sharp instruments used in eye work and does not depend on electricity or the integrity of a sterilizer. It also means that the sharp instruments are continually sterile and available for use. All other nonsharp surgical instruments are sterilized simply by boiling (protecting the points by a rubber or silicone tube [2-ram] sheath). When protected in this way, the use of trays and racks is unnecessary. In all cases soft or rain water must be used for boiling to prevent damaging the instruments with deposits from hard water. Again, this method is simple and cheap, and almost universally applicable, even in very simple and rural situations. LIGHTING. Good light is of great importance in intraocular surgery, and every effort should be made to supply lighting with minimal shadow effect. There are many ways of achieving this. A two-bulb system is good and effective and prevents being plunged into darkness if one bulb burns out. Simple car headlights can be adapted and hand held, but where regular intraocular surgery is done some more permanent arrangement should be made. There are numerous models available and a mediocre light can be much improved if the room is dimmed. MAGNIFICATION. Operating microscopes are not recommended as a standard for Third World ophthalmology. Good magnification can be obtained by using one of the many binocular telescopic loupes with a magnification from 3x to 6x. A magnification of 4x is a good compromise between magnification and size of field. If desired, a headlamp can be combined with the binocular loupe. For a combination of excellence and economy the INAMI Binocular 4x Loupe is fully recommended. ANESTHESIA. There is no doubt that local anesthesia is most effective and economical, and experience in many areas has also confirmed that premedication is quite unnecessary. When the occasion arises in which general anesthesia is preferable (e.g., intraocular surgery for children and in some penetrating eye injuries), then the simple “EMO System” using a controlled mixture of ether and air with intubation following a short-acting relaxant is effective, safe, and cheap and is becoming more widely available. If necessary, eye medical auxiliaries should be given a special course in general anesthesia for eye surgery. There is also the alternative of ketamine with a local block for eye surgery in small children. CRYOPROBES. The cryoprobe has greatly simplified cataract extraction and improved the results. On the other hand, the use of sophisticated and expensive cryosurgical machines is to be discouraged when there are no technicians to maintain them. There are simple, manual so-called disposable cryoprobes using freon as the refrigerant that are both cheap and effective, especially when the cryoprobe is constructed of plastic, which also acts as an efficient insulator. The Dual II curved, plastic cryoprobe is the best and most economical system yet available and, when purchased centrally and in bulk, costs only 20 cents per cataract extraction. SURGICAL INSTRUMENT SETS. A wide variety of instruments are available, and personal preferences are involved. However, standardization of sets and the regular use of a few good instruments have proved more efficient than a wide diversity of choice. It is also much easier to ensure that a few instruments are maintained in good condition at all times rather than a large and complicated set. The details that follow are the result of long experience of working in varied, sometimes almost primitive, conditions, but at the same time maintaining the highest standards and achieving consistently good results. There are two sets (Tables 3 and 4): A minor surgical eye set costs $200 to $300 and is suitable for the following:
TABLE 3. Minor Surgical Eye Set* 1 plain dissecting forceps 1 fixation forceps * Approximate cost $200 (1983).
TABLE 4. Basic Major (Intraocular) Surgical Eye Set 1 plain dissecting forceps 1 fixation forceps
A basic major (intraocular) eye set costs $2000 and is suitable for the following:
No single operative technique is the best, and some variation with the operator and with the circumstances is inevitable. However, simplicity is of paramount importance, since only simple methods are applicable in varying circumstances and they are always easier both to teach and to learn. With the great difficulties of communication and follow-up existing in Third World situations, it is best to do a “once for all” rather than a staged procedure. For the same reasons it may be right to do a more comprehensive procedure rather than trying a method that may need to be repeated. In intraocular work, infection is catastrophic and almost invariably leads to loss of the eye. No effort should be spared to prevent infection. Despite the fact that simplicity and standardization are strongly urged, they should in no way mean any lowering of standards that can and should be maintained even in the simplest and most remote situations found in the Third World setting. |