Global Health Implementation & Vision 2020 Links. Global Health Implementation & Vision 2020 Links. University of St Andrews & NHS Fife/Lothian

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1 ARCLIGHT - MALAWI Global Health Implementation & Vision 2020 Links University of St Andrews & NHS Fife/Lothian Global Health Implementation & Vision 2020 Links University of St Andrews & NHS Fife/Lothian 2015 In June 2014, x150 Solar LED ophthalmoscope-loupeotoscope instruments, called Arclight, were gifted by the Fred Hollows Foundation, Australia to a range of eye care and other medical professionals in Malawi during a Vision 2020 Links visit by teams from NHS Fife/Lothian and the University of St Andrews. In response to the positive feedback a proposal to distribute a further x1000 units in a more comprehensive initiative has been developed in Dr Blaikie Consultant Ophthalmologist & Honorary Senior Lecturer University of St Andrews & NHS Fife, Scotland, UK. collaboration with the Global Health Implementation Program of the University of St Andrews and the Fred Hollows Foundation.

2 ARCLIGHT INTRODUCTION Traditional diagnostic instruments such as direct ophthalmoscopes or otoscopes are expensive, complex, heavy, and are not widely available in developing countries. In recent years several simpler, easy-to-use, pocket-sized models have been developed. The Arclight is an ultra low-cost instrument - which is an ophthalmoscope, magnifying loupe, and otoscope. The loupe is a magnifying lens - which is used to get a close-up view of the front of the eye. It can be used with daylight white light, or bluish light. The white light is used for a general view of the lids and lashes, conjunctiva, cornea, and anterior chamber. The blue light is ideal to look for corneal damage or ulcers after staining the eye with fluorescein. The ophthalmoscope has a sighthole, corrective lenses for refractive errors, and a switch to change between low or high light settings. It is used in the same way as the traditional ophthalmoscope. The accompanying How to use video (with full captions) is available to download at >> 2

3 Ophthalmoscope Loupe Otoscope 3

4 1 FIRST, LOOK AT THE RED REFLEX. To start: select the 0 no-lens setting. Hold the Arclight at arms-length from the eye - from this distance look at the red reflex in both eyes - this will allow you to compare the two sides. Next, select the +4 lens, and hold about a hand-span distance from the eye, this will give a magnified view of the red reflex, and will show in more detail any cataracts or other opacities. It may also show small abnormalities such as keratic precipitates, which are small deposits on the back surface of the cornea. 4

5 If you are examining the patient's right eye - hold in your right hand and look with your right eye. If you are examining the left eye use your left hand and left eye. 5

6 2 ONCE YOU HAVE ASSESSED THE RED REFLEX LOOK AT THE OPTIC DISC AND RETINA. To do this: select the 0 no-lens setting and ask the patient to look straight ahead and NOT into the light. Move closer to the eye. As with all ophthalmoscopes you'll get a far better view if you DIM the lighting in the room. Dilate the pupil and come very close to the patient. The white light is used to look at the optic disc and the surrounding retina. If the patient has a very small pupil or if they are light sensitive the low beam setting should be used, otherwise the high beam will usually give a better view. If you cannot see the retina clearly this may be because of a refractive error. Use the corrective lenses to get a better view - try the minus lenses for short-sighted or myopic patients, or try the plus lens for long-sighted or hyperopic patients. If you or the patient wear glasses or contact lenses the best image may result from keeping them on for the examination. 6

7 If the pupils are small or the view is hazy actively move your head and the Arclight UP, DOWN, IN and OUT as needed to get the best view. Once you can see the retina, find one of the retinal blood vessels; again you may need to alter the focus with the corrective lenses until the blood vessel is clearly in focus. Retinal blood vessels branch out from the optic disc follow the blood vessel back until you reach the disc. Once you have examined the optic disc move the ophthalmoscope to look at the rest of the retina. If you have dilated the pupil you should be able to get a view of the macula by asking the patient to look at the light. You can get a better view the retinal blood vessels and any haemorrhages or tiny new vessels by selecting the green filter. 7

8 Optic Disc Dilated View Macula 8

9 REMEMBER: MATCH the eyes - use your right eye to view the patient's right eye and left for left. Get CLOSE to the patient's eye and make sure that your eye is close to the sight hole. Examine the patient with the room lights as LOW as practically possible. Make sure the patient looks straight ahead and NOT into the light. DILATE the pupils if it is safe to do so as this will give you a far better view of the lens and fundus The Arclight has a handy ruler to allow easy measurement of abnormalities; there is also a gauge to estimate pupil size; a near vision chart; a line target for measuring the near point of convergence; white and red targets for testing the visual field and the optic nerve function; a colour strip to allow basic testing for colour defects; and a scale to help assess the cup disc ratio. 9

10 3 FOR HEALTH WORKERS WHO ALSO HAVE TO EXAMINE THE EARS, THE ARCLIGHT CAN BE USED IN A SIMILAR WAY TO A TRADITIONAL OTOSCOPE. The Arclight is supplied with two push-fit attachments called speculums. The large speculum is used for bigger children and adults, and the small speculum for infants. These fit over the magnifying loupe. TILT the patient's head to the side. To straighten the ear canal - pull the pinna backwards and upwards, in young children - pull the pinna straight backwards. Gently insert the speculum along the canal pointing the speculum towards the angle of the jaw on the opposite side. Hold the Arclight like a pencil. To reduce sudden movements, parents should cradle their child's head. In the ear canal - you may see wax or foreign bodies, the wall of the canal may be inflamed or infected. 10

11 Move the speculum gently along the canal just past the canal hairs until the tympanic membrane comes into view. Look at the pars tensa and pars flaccida, and note any signs of infection, perforations or other defects. Hold the device in the right hand to examine the right ear and left hand for left ear. Examine the GOOD ear first to avoid infection spread. Just past Hairs 11

12 The Arclight can also be used to examine the throat - with the tongue depressor, and can also be used as a magnifier to examine the skin. With the blue light - certain skin infections that fluoresce under the blue light will show up more clearly. The Arclight has a built-in solar panel - so that it can be easily charged in places with no ready electricity supply. It can also be easily and quickly charged in about 20 minutes from a computer using its USB socket. 12

13 Who will get them? Mid-level ophthalmic health workers (nurses, clinical officers, assistants), optometrists and ophthalmologists already skilled in direct ophthalmoscopy will find the instrument the most beneficial. Other health care workers used to performing ear examination will also gain most from the device. With patience students of all types (medical and optometry) will find it an ideal learning tool. After discussion with lead clinicians in Malawi and the Ministry of Health we plan to target: Ophthalmic Clinical Officers/Cataract Surgeons. Nurses with eye or ear experience. Ophthalmologists. Optometrists. Physicians treating non-communicable diseases. Paediatricians. Medical Students Clinical Officers in Training Where will they go? The main sites of distribution will include: Kamuzu Central Hospital, Lilongwe Lions Eye Hospital, Blantyre Queen Elizabeth Central Hospital, Blantyre School of Optometry, Lilongwe School of Optometry, Mzuzu College of Medicine, Blantyre College of Medicine, Lilongwe District Hospitals where NCD clinics are set up 13

14 Dr Andrew Blaikie Consultant Ophthalmologist & Honorary Senior Lecturer University of St Andrews, Global Health Implementation & NHS Fife/Lothian March

15 The Fred Hollows Foundation The Fred Hollows Foundation is a not-for-profit, non-government, international development agency focused on eliminating avoidable blindness. The Foundation has supported the production of the world s first low-cost ophthalmoscope-loupe-otoscope for developing countries. It recognises that these solutions could have a genuinely global and transformative reach and address a crying need. Working throughout the world and within the indigenous Australian community, it concentrates on the comprehensive treatment of cataract blindness, but also other causes of blindness, including trachoma, diabetic retinopathy, and refractive error. The Fred Hollows Foundation was established to continue the work of the late Professor Fred Hollows ( ). Fred was a philanthropist and ophthalmologist who became known for restoring sight to thousands of people in developing countries and his passionate fight to improve the health of indigenous Australians living in remote communities. 15