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My first day I was greeted by Dr. Sanjay, the hospital director and head of the cornea service. To say that Dr. Sanjay is a legaend in Nepal would be an understatement. He played a key role in the growth of Lahan Eye Hospital, and was the head of the project that opened BEH. Dr. Sanjay has operated on over 250,000 eyes, performing everything from high-quality small incision cataracts surgery (SICS) to pterygium excisions, pediatric cataracts, and corneal lamellar surgery. At a pace of one SICS every 2-3 minutes, he flies through 15-20 surgeries an hour performing consistently perfect techniques. Dr. Sanjay taught me on my first day how to create a DSEK graft with manual dissection, when modern keratomes or eye banks aren’t available to do it for you. As one of the senior surgeons commented, he has “beautiful hands” meaning that every movement is perfect and precise, without an extra move out of place, exactly as intended. There are few surgeons in the world who can boast such surgical volume and it’s only in places such as BEH or Lahan that a surgeon can reach such high numbers thanks to a well constructed system.

BEH has multiple training programs including a residency in it’s third year, anterior segment fellowship, cornea fellowship, and retina fellowship. The anterior segment fellowship is a 2 year surgical training program for those who graduated from residency in Nepal or India, and provides an unbelievable volume of surgery for young physicians. As a point of reference, the average resident in America may perform 100 – 250 cataract surgeries. The two year fellows will graduate with between 10,000 and 15,000 cataract surgeries under their belt, and a number of other procedures including pterygium excisions and dacryocystorhinostomy. While the training program is geared towards high-volume cataract surgery, the fellows are still able to gain competency in modern phacoemulsification techniques, often performing over 1,000 cases in their second year.

For those who have not visited a high volume cataract center such as BEH, these numbers can seem impossible – how can one surgeon do so many surgeries in such a short period of time? What it comes down to is efficiency. Every step of ever surgery, every material used, every team member, and every hospital employee has been focused in making the hospital a finely tuned machine. The operating rooms have two beds per surgeon with a microscope that swivels in-between. An outstanding scrub nurse is in charge of each table – making sure the patients arrive when necessary, are properly prepped and draped, all the surgical tools are laid out and ready to go, and are the maintainers of sterility throughout the process. In this way, the doctor will only spend a few seconds moving from one case to the next, in contrast with an American operating theater where turnover between cases can take anywhere from 5 to 30 minutes depending on the protocol of the surgical center. In coming posts, we will discuss further in detail how these feats are accomplished and what efficiency and community health look like in Nepal.

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The healthcare systems in countries like Rwanda take time and constant effort to affect change, but it is thanks to those passionate individuals like Dr. Ciku and Dr. John that real progress is made. The coming years in Rwanda will be exciting, and I look forward to the continued partnership with our friends overseas.

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As part of the introduction course, we had the first Journal Club for the RIIO. The residents discussed a pair of papers including the first Rapid Assessment of Avoidable Blindness (RAAB) conducted in Rwanda. RAABs are an important tool for evaluating the disease burden of a region, and describes a specific technique to minimize bias or error while collecting data from a rural population. They have been used throughout Africa, Asia, South America and beyond to identify areas of preventable blindness. The primary goals of a RAAB are to:

– Estimate the prevalence and causes of avoidable blindness and visual impairment in people aged 50 and above

– Assess cataract surgical coverage

– Identify the main barriers to the uptake of cataract surgery

– Measure outcome after cataract surgery.

More information can be found on the website located here:

http://iceh.lshtm.ac.uk/rapid-assessment-of-avoidable-blindness/

The original RAAB performed in Rwanda was completed by Dr. Mathenge in 2006 which found approximately a 2% rate of blindness, largely preventable, throughout the western province. A subsequent RAAB was repeated by Dr. Mathenge and the first Wills CAGO fellow (and current fellowship co-director), Alessandra Intili.

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