Dr. Suzette Luke’s experiences as a Wills Eye Global Fellow in Rwanda and India
By Suzette Luke M.D.
Experience a typical day at LVPEI: 10/20/18
There’s a steady flow of brilliant minds swarming the halls of LVPEI every day. The day begins at 7 am …sharp. As I walk over from the apartment to LVPEI, there’s a certain point after entering the main gate, where my path merges with the rush of residents and fellows heading into the building. Everyone silently speeds walks down the hall and up six flights of stairs to the lecture hall, squeezing through the doorway at 6:59 am as the staff have one hand on the doorknob, ready to shut and lock it right at 7 am. Phew, obstacle #1 overcome: made it to lecture on time. Obstacle #2: finding a seat. All of the attendings, trainees, and optometrists attend these lectures, so sometimes there are absolutely no seats remaining and you are directed to the overflow room to watch the lecture. It’s quite incredible actually, that everyone makes it a priority to come to the lecture this early in the morning – it’s a testament to the dedication of these clinicians. After this, trainees will either head to the canteen for breakfast or to their respective clinics to see post-ops before heading to their assigned locations for the day. There are about 2000 patients who come through the Institute on a daily basis, so you can imagine that the days are long and busy. The institute is set up so that every step of the patient experience (from registration to ancillary testing to counseling before check out) is addressed in an efficient manner, which is evident in how many patients they are able to see per day. It’s remarkable. The institution is fully equipped with every subspecialty, including low vision and rehabilitation, ocular oncology and even an innovation lab. I spent most of my time outside of MSICS training with Dr. Sirisha in the glaucoma clinic. She is a very revered glaucoma specialist who is loved by her patients and trainees. She efficiently moves through the wave of patients with empathy, a positive attitude and manages to find time to teach along the way. It takes a few days to really get adjusted to the pace and the magnitude of all that goes on at LVPEI, but once you get a hold of it and see how much it has to offer, you can’t help but dive in and try to learn as much as possible.
MSICS Training: 11/3/18
MSICS training is well underway at this point, primarily under the guidance of Dr. Revathy. She spends most of her days with the residents and fellows in the training OR, teaching Phaco and MSICS. I couldn’t have asked for a better instructor. She is so patient and always gives constructive feedback to help you improve with your next case. It’s been nice having other trainees around as well, as we watch each other’s cases – learning from the challenges, celebrating victories and critiquing mistakes – to help each other grow. As with any type of surgery, after doing a couple, you start to understand how vital each step is to the success and ease of the case. Of course with MSICS there are several critical steps that make a huge difference, such as the integrity of the scleral tunnel and delivery of the nucleus, but it’s the seemingly less obvious precautions – such as the appropriate bend of the shaft and tip of the cystitome, quality of cauterization, length of the ACM port, amount of viscoelastic used – that has surprised me more as key components of a successful surgery. Many challenging cases later, and thanks to Dr. Revathy and team, I now feel comfortable with the MSICS technique and am excited about improving these skills and treating more patients both abroad and at home in the US with this surgery.
An OR day with Dr. Sirisha, myself and 2 other trainees observing glaucoma in the OR. Unfortunately, Dr. Revathy is not in any of the pictures
Myself and Dr. SIrisha on the last day of the rotation. A brilliant glaucoma specialist who I truly enjoyed working with.
A picture of the LVPEI main campus
I spent one week at Aravind Eye Hospital in Madurai, trying my best to learn what makes this hospital system so great. Dr. Balaji, a consultant at Aravind, was in charge of setting up my schedule for the week and he couldn’t have done a better job. I had meetings set up with the director of the vision centers, residency program director, LIACO (an initiative to improve eye care in other countries), aurolab (lab producing intraocular lens, sutures, eyedrops, etc) and many more. I also was lucky enough to visit a vision center and a cataract campaign. Every consultant I met was so dedicated to the mission and philosophy of the founder Dr. V, which has really penetrated through the entire hospital system. There are two areas that I want to highlight:
Vision Centers: These are very small, usually around 500 sq. ft, offices that are primary eye centers in small towns. The towns usually have a population of about 15,000 and no other major eye center is within a reasonable distance. In each vision center, there are 2 sisters (technicians), one is the administrator and the other is the provider for that center. Prior to their placement in the centers, these sisters are recruited (usually from the same village that they will then work in) and go through a few years training process at Aravind. They learn everything from retinoscopy and applanation to performing fundus exams and photos. Patients can walk in to be seen and the sister will do a complete exam and discuss every case (including showing slit lamp and fundus findings/photos) to a resident or fellow at the main hospital via video conference, who will then decide the management for that patient. They keep track of productivity each year, analyze the data and work on areas that need improvement. Each new consultant at the base hospital is assigned certain vision centers to manage, and luckily during my week, it was Dr. Balaji’s turn to check in on his centers. He observes the sisters while they are seeing a patient and presenting to the consultant over video call and grades their work. He discusses with them their strengths, weaknesses, and areas that need improvement. In this way, these centers are sustainable and continuously improving. This system has allowed Aravind hospital to reach populations who would be unable to seek eye care otherwise.
Cataract campaign: Aravind provides many different types of camps – cataract, refraction, diabetic, etc. I was fortunate enough to observe a cataract campaign during my week. A team is rallied and sent out to a village – 2 residents, technicians, counselors, refractionists, and so on. This particular camp was about 2 hours outside of Madurai. Between the two residents and the rest of the team, nearly 300 patients were screened in just a few hours! At the end of the camp, patients who were thought to have visually significant cataracts requiring surgery were provided transportation to the base hospital the same day, for surgeries to be performed the next day. Everything is covered during their stay in Madurai – boarding, nutrition, surgery, post-op medications. What struck me the most about this particular camp, is pictured in the image below. Boxes of various powered spherical and spherocylindrical lenses are brought along to the camp. Patients are refracted and given a prescription. Another sister takes this prescription, finds the appropriate lenses, then chips and grinds the lenses for the patient….right then and there to be fitted into their frames, SAME DAY. I was completely blown away by this. Hand ground lenses. This sister must have chipped and ground 50+ lenses that day, almost non-stop from morning until early afternoon. Now, this is outreach at its finest – giving sight in every way possible and as soon as possible.
Dr. Balaji and his team at one of the vision centers. The two sisters in blue are the sisters who run that vision center, doing a fantastic job for their patients.
A sister hand grinding lenses to be fitted same-day into a patient’s existing frames
Rwanda International Institute of Ophthalmology (RIIO): 12/20/18
Last stop for this travel block: RIIO, Rwanda International Institute of Ophthalmology. This is the first and only ophthalmology residency program in Rwanda, under the guidance of Dr. Ciku and Dr. John. The program currently has 4 first-year residents who are actively preparing for the first part of their ICO exam in April. My time here was spent focusing on lectures and refining clinical and surgical skills with the residents. They had an amazing opportunity to take an MSICS training course in Cape Town and returned at the start of my visit. With these skills fresh in their minds, we practiced suturing and scleral tunnels in the wet-lab, in addition to applanation, retinoscopy and gonioscopy in the clinic. Of special importance to me on this trip, was the opportunity to participate in my first surgical outreach camp of the fellowship year. I accompanied Dr. Francis, a local ophthalmologist in Kigali, and team members from the Fred Hollows Foundation, to a village about 2 hours away called Kiziguro. We arrived at the outreach site on Friday evening where we assessed patients for cataract surgery and then the next two days were operating days. What stood out to me was the number of patients with bilateral, dense cataracts. I’m talking bilateral count fingers to light perception vision…for years. These patients were traveling from hours away and needed the help of at least 1-2 family members for their every single move. It’s a feeling comparable to no other when you see a patient who was needing assistance and tactile guidance to get to the operating table before surgery, the very next day after surgery walking unaided with a huge smile on their face. One patient expressed in Kinyarwanda “if the surgery in my other eye will allow me to see like this one, I will jump up and touch the sky!” This surgery that takes little time and is of low cost, gave this gift to these patients and their gratitude is unmeasurable. This was an experience engraved in my mind. It’s a perfect reminder of what this fellowship is all about – improving eye care around the world and training ophthalmologists to go out and serve these deserving patients of their country. The more we transfer skills and knowledge to trainees and community ophthalmologists, the more sight we improve and preserve.
Dr. Francis and the team at the Kiziguro hospital along with members from the Fred Hollows Foundation. Supplies for this outreach was provided by the foundation.
2 pictures of bilateral dense cataracts in patients encountered during the outreach. There were many patients who had similar findings
RIIO first-year residents standing in front of their educational department
Dr. John and Dr. Ciku working hard in the OR on my last day in Kigali