OPTIN Ophthalmology Visit Notes Nov 30 th Dec 10 th Oliver Backhouse & Pat Wallis

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1 OPTIN Ophthalmology Visit Notes Nov 30 th Dec 10 th 2008 Oliver Backhouse & Pat Wallis A successful trip which allowed us to meet all parties involved in delivering the Vision 2020 national eye programme for Madagascar. These involved Prof Prisca (HJRA / Government); Jose Bronfman (Lions Sight First Madagascar); Vicky Hopley (CBM / Government Refraction school); Dr Robinson Andrianivina (Dept Health); Ely Rabemiarana (SALFA Community work - Antsirabe); Dr Philippe Rakotondrajoa (SALFA Ophthalmologist Antsirabe). In 2007 the new Vision 2020 National Eye Health plan was launched and Antsirabe is a pilot area as well as Antananarivo and Tamatave. With the help of David Johnson and his brother, Medisoft was installed at HJRA Antananarivo and at Andranmadio Antsirabe. Three days of teaching / demonstration / troubleshooting was undertaken at either hospital to the Ophthalmologists / DUCOE present as well as Ophthalmic nurses at Andranmadio. Talks on Biometry were given and demonstrated and some retrospective data was entered into Medisoft to demonstrate the need and power of audit. All were reminded that the main causes of borderline / poor vision in other countries were: lack of postop spectacles; poor surgery and poor cases selection. All realised the need for reflection on ones practice to be able to deliver a better quality of service which in turn would lead to a reduction in the barriers to eye care. The main finding from each unit were: 1] Prof Prisca HJRA. Antananarivo. 5 people doing biometry. Stressed audit of whose results are best as some technicians, however willing, may not be accurate. New biometry machine urgently needed as no current image of scan quality given. Very variable readings. Pat to send old SJUH one asap. 3/10 retrospective case notes revealed odd findings later explained to us as results being made up to please the Prof! Prisca wants to keep the 2 DUCOE she has this may go against original DUCOE plan of having them out in regional areas but there is concern that there is no government money to employ them. This may be about to change. Lots of equipment but much damaged Argon aiming beam; FFA camera (but even if repaired unlikely any patient could afford the treatment) so many patients go private. Prisca has fully working and equipped private office. Autorefractor condemned. Saw 7 post-op graft patients form visiting Canadian ophthalmologist 1/52 prior. Sutures not turned in most patients / high risk cases apart from 2 keratoconics who had deep lamella grafts. Expression of was this the right thing to do / quality of surgery. Ongoing discussion. Prof Violette to move to the private Adventist clinic. Dr Lalena currently favoured to take over Prof post. Moderate English. Health ministry stopped move to Phaco as deemed too expensive.

2 Patients who need argon laser sent to Adventist clinic. Corneal graft go to Reunion. No vitrector but Prisca just got a new B&L Phaco machine. Likely will be for private use. 2] Jose Bronfman Lions Sight First Madagascar. See Lions summary of cataract outcomes. I question the accuracy of the cataract outcome figures. Some friction with the new CBM / Government refraction school based in HJRA as Lions have had and do a good refraction service there already. It appears that CBM have changed direction in that they are now working with the government directly. We are unsure why a separate unit, nearby the Lions refraction programme, has been created although it probably revolves around the fact that the new refraction school is a government scheme and not an NGO owned one. This can t be the whole story as 2 of the Lions refraction trainees are at the government refraction school which is in its infancy. Concern that the DUCOE are not being exposed to enough surgery and that some are unemployed and setting up privately and doing refraction. Says doing only 50 cataract cases in 2 years. No DUCOE training in SALFA units now. 3] Vicky Hopley HJRA new CBM / Government refraction school Vicky due to come home end of March 2009 Currently 10 students all are in jobs already but have chosen and been chosen to become refractionists. Two are midwives and this has caused friction with Lions as they do not understand why they are being trained. Hopefully all will have new refractionist jobs in towns around Madagascar but they will go back to their old jobs if there is no government money to employ them. Lions do not believe there will be any money for this or the further training of DUCOEs and it is this which is causing deep frustration as they now feel they have lost control of the previous tight agenda to deliver Vision 2020 Ophthalmology in Madagascar which they started and still support (there are no government cataract operations done in Madagascar without the funding support of Lions) Told us of John Pugh who has been trying to develop a nursing programme in Mandritsara but has not been successful. We need to speak to him. pughsnews@hotmail.com 4] Dr Robinson Andrianivina (Dept Health) Only 2 weeks in post when we met him. Taken over the job of Dr Lucie. Explained the Leeds Link in the four priority areas. Asked how he can help us: To make sure all parties that deliver eye care in Madagascar are coordinated under the Vision 2020 programme. Names were given to him of the various key players and he will arrange a meeting to see them together. He explained that ophthalmology does not take such a high priority as TB, Malaria, AIDS (although there is still little in Madagascar thankfully).

3 5] Ely Rabemiarana (SALFA Community work - Antsirabe) She gave a superb talk on her Community eye work in the field of screening for refractive errors. See her talk. Two community workers Richard and Christian help her with her work. Their area around Antsirabe is called Vakinankararatra. This has an area of 18,931 Km2; Population of 2 million; Split into 7 districts with 89 communes. Each commune has village groups (Fokontany). The president of Madagascar has stated that change in health care is only possible if the village leaders are understanding of the problems and so last year 30,000 Fokontany leaders were all given management training. Ely s programme revolved around: comprehensive eye care (basic medical, cataract identification, glasses); school screening; childhood blindness; training programme; Teaching re Vision 2020, eye disease and available treatment; Identification of patients; referral pathways; counselling, transportation to the eye unit and World Sight Day. 9% of those who came forward for screening needed Cataract surgery 44% of glasses prescribed were for Presbyopia Glasses given to children if Myopia < -0.5 or Hypermetropia > 2.5 (unless with headaches at a lower refraction) 29% of teachers screened needed glasses 0.2% of children screened got glasses (136 / 67,321 of these 3,432 saw an eye doctor many due to ocular irritation). Out of 1711 schools screened 1,480 / 293,270 got glasses. With Fiana project as well over 400,000 children have now been screened. Barriers to eye care: Transport cost, Lack of awareness, Cost, Distance, Quality of service. Must have capacity and deliver quality. Too many staff away can make Andranmadio devoid of Eye doctors occasionally. If 1 person not happy it can make 25 not bother to come. Management structure needed. Childhood blindness screening started in Sept Regions of Betafo and Mandritsara. 98 children identified. 1 cataract case. Future cataract searchers to link with AIDS / Vaccination groups. 6] Dr Philippe Rakotondrajoa (SALFA Ophthalmologist Antsirabe) Gave us a presentation on the units output and cataract service. Similar to HJRA cataract operated on only when vision is 6/60 or worse. Pathway: If from far away they come the day before; have biometry; surgery the following day (sutureless small incision ECCE); stay that night; home the next day. Reviewed 1/52, 2/52 and 1/12 post op. Glasses then given. John First Ophthalmic trained nurse in Madagascar. Two others to get Ophthalmic training at new school when Dr Henry gets it going. Interesting concept of timed appointments are paid for by the patient otherwise patients just turn up and wait. Outpatient peak in Reducing due to lack of staff at the hospital occasionally? Make own eye drops: Pred 1%, Gentamycin, Betadine 5%, Cyclopentolate, Atropine, Timoptol.

4 More Trabeculectomies done now. 3,000Ar for a bottle of Timoptol ( 1= 2,700Ar) 75% Malagasy live on < $ 2/day Ready made reading specs from China. Make others including cylinders. Current CSR 450 (7 ops each for the 3 surgeons). Aim for Hence 30 each a week needed. Realistically they could do this as capacity is there but are numbers? 32% self pay (44,000Ar per eye). 68% Lions supported (3,000Ar per eye) Outcomes: 71% good; 24% borderline; 5% poor. PC rupture 3-7%. Follow-up < 50%. Should planning be on a prevelance of 1% cataract in the population. Need population study as they strongly believe this figure of 1% is too high and so the CSR aim should be lower. Biometry / Medisoft findings: o Ks always being recorded at 90 and 180 degrees o A constant not being changed for differing IOLs o No printout of A scan or ACD so difficult to pinpoint causes of biometry error. o Myopic surprise 2 in many retrospective data entered pressing on eye, not in bag IOL, viscoelastic behind IOL, inaccurate post-op refraction (unlikely as they have a refractionist. Suggested prospective data collection, auto Ks, one IOL type, printout scan and ACD and compare refraction with autorefractor). 7] Paediatric Ophthalmology in Madagascar: WHO suggest 1 Paediatric Ophthalmologist for every 10 million of population. This means that there should be 2 in Madagascar. Currently there are none with this subspeciality training. See excellent article by Andrew B attached. Refraction being addressed as is lack of Vitamin A. Priority areas are in refraction; cataract surgery and corneal scarring. Most of corneal scarring is secondary to keratomalacia or trauma. Leeds input to be mainly on the appropriate management of congenital cataract. Prof Prisca and Dr Henry do this surgery more than others in Madagascar. Paediatric anaesthesia is available and a service for refraction and some patching as well meaning that for the first time this type of surgery is possible in a reasonably safe environment. Concept of amblyopia / patching and close follow-up need addressing. Of the 54 childhood cataracts done in Andranmadio since % were traumatic and 82% of unknown congenital origin. 21% were under the age of 5years. Outcomes? Henry writing this up. Dr Henry has been in communication with Paul Cartwright (Pead Ophthalmologist) and his wife Susan Llelywn in KCMC Tanzania. 8] Research Projects agreed: Medisoft SALFA School Screening SALFA Tsara Maso eye game SALFA Ophthalmic Nursing in Madagascar SALFA

5 Student refractionists: Autofreraction / Subjective refraction; Refraction / DUCOE Refraction; Cause of Extreme myopia Cause of poor cataract service uptake (see Astrid Fletcher paper) - Lions 9] Miscellaneous: Possibly an Orthoptist would be better to visit in March 08 squint / patching / binocular vision / how to asses a child with visual problem Optometrist to help Vicky with Refraction teaching programme. Richard Hide New UK Consulate in part of German Embassy in Antananarivo.