Return to Samaro

A few weekends after returning to Dembi Dollo from the Gambella eye camp, I journeyed with the girls who live with the Daughters of Charity back to Samaro.  The four girls who were there for the summer- Anane, Senna, Ayantu, and Letu- had all either lost their parents or left homes where their parents either neglected or abused them.  We ventured first to the district of Anka, which Sister Evelyn had dubbed "the end of the world," since it contained a wide, elevated plateau from which one could see Samaro, Addo (location of the podo clinic), and other towns even further out.  From there, we headed down the steep drop-off past the plateau, down to the road which led to Samaro.

Alex, the Irish permaculturist, had long since left the million dollar fields, but Sister Kaffa still oversaw the kindergarten, animal life, and plant life in Samaro.  We stopped by the chicken coop and picked some mangoes, but sadly missed out on visiting the young calf, which had recently died due to lack of milk.  At the day's end, we slowly trudged our way back up the mountain to the sisters' compound despite six year old Letu's worries that we might not have enough energy to make it.  We returned rejuvenated and revitalized from the agrarian paradise we had had the opportunity to enjoy.

Letu with her "umbrella"

Sight

"When you restore sight, you restore hope."

-Dr. Samuel

What is it like to become blind?  Over the week of the Gambella eye camp, I had ample opportunity to ruminate on this question.  I can only imagine the gradual loss of vision which occurs with the more common causes of blindness, and the hopelessness that ensues as the darkness slowly creeps in.  With glaucoma, one loses vision from the outside in, first being unable to see out of the corners of the eye until eventually one can no longer see anything at all.  When a nuclear cataract first develops, one's reading vision actually improves to the point where some people no longer need to use reading glasses.  This joy quickly turns into worry, however, as the nuclear cataract matures and gradually blocks out all sight.

I tried to grapple with the emotions which the blind experience- the depression from realizing that you will never be able to see the faces of your children again, the loss of self-worth from being unable to work or do any meaningful activity, the complete and utter dependency of being reliant on someone else to help you perform even the most basic functions.  We even heard stories about some blind people who would cry out at the top of their lungs for help because they desperately needed to use the toilet but had no way of finding it and no one to help them do so.

One morning, a young man wearing a UCLA t-shirt pulled me aside.  His ten-year old brother, he told me, needed to be seen by Dr. Samuel.  His brother had been born blind in one eye, and had recently become blind in the other and desperately needed help.  As Dr. Samuel came down the line screening patients for operable cataracts, he reached the young boy and gave his verdict- the boy had extensive corneal scarring from trachoma which could not be reversed with cataract surgery, or any surgery available in Ethiopia.

In desperation, the young man grabbed me again.  "Have him recheck!" he burst, unable to believe there was nothing to be done for his brother.  I calmly re-explained Dr. Samuel's diagnosis, trying to avoid my own conflicted feelings about the boy's case.

As the young man and his little brother dejectedly collapsed on the benches along the hallway, I sat down with them.  A wave of hopelessness washed over me as I felt the despair and anguish of the brothers sitting next to me.

"We tried to get him an appointment in Juba, we tried to get him an appointment in Khartoum," the man wailed [Juba is the capital of South Sudan, Khartoum is the capital of Sudan].

The tragedy of this boy's blindness was compounded by the fact that even though they had sought medical care earlier in three different countries, there simply were not enough doctors available to treat everyone who needed care.  The young boy's life had been irrevocably altered because of this simple fact, and he was relegated to a lifetime of blindness.

Yet there was still hope amidst the tragedy.  Anne-Berit brought up Shashamane school for the blind, which Larry, Sean, Joey, and I had visited near the beginning of the trip.  I strongly urged the young man to visit the school with his brother and family- they had the resources to help his brother get an education and could help him live his life to the fullest, despite his visual limitations.

The disappointment of being unable to aid many of the patients was outweighed by the joy of witnessing patients from the previous day regain their sight.  As we arrived at the hospital each morning, forty to fifty patients who had undergone cataract surgery the day prior sat in the courtyard just outside the operating room.  We would slowly make our way down the line, removing the patches covering the healing eyes and distributing post-op medications, while Dr. Samuel checked the eyes for any complications and, most importantly, for restored vision.

Dr. Samuel checking visual acuity

Patients typically didn't react immediately once the eye patches were removed, but as they began to look around and as the realization that their sight had returned crept in, smiles erupted on faces all over the courtyard.  Some patients would point at their grandchildren, finally seeing their faces again, and a few even belted out worship songs and shouted prayers of thankfulness to God.  Mario and Sean followed one elderly patient named Gideon back to his house, where his pastor presided over a ceremony and his church choir offered up songs of praise for the transformation in Gideon's life.

One woman who had had her sight restored grabbed my hand and gestured toward the sky, saying something I couldn't understand.  "She is saying, 'I thank God for you,'" my friend Jango explained.  "I didn't even do anything!" I laughed.  I suppose I should be thankful none of the patients licked my hand, which was an experience that befell Sean when an overjoyed woman wanted to express her gratitude.

a post-op patient

 family and friends gather excitedly around a man who has regained his sight

At the end of each day, despite being drenched in sweat, despite being covered in mosquito bites, despite having to eat meals covered with flies, despite the fatigue of 12-hour days, despite the frustration with argumentative patients or the inefficiencies of Ethiopian healthcare, I felt this unshakeable sense that somehow- somehow -it was all worth it.

Manual Small-incision Cataract Surgery

Cataract surgeries performed at the Gambella eye camp:  276
Highest number of surgeries performed in one day of the camp:  49
Cost of each cataract surgery:  $50 US dollars (cost to patient is free)
Average duration of a single cataract surgery at the eye camp:  < 15 minutes

 Dr. Samuel's notes explaining manual small-incision cataract surgery

The manual small incision cataract surgery (MSICS) procedure which Dr. Samuel regularly uses reflects the incredible resilience of the human body.  To perform the operation, the surgeon essentially cuts open the eyeball, replaces the lens, and patches the eye- without sewing or suturing the cut in the eyeball!  After one day, the eye actually heals itself and the patient has his or her vision restored.

Of course, the details of the procedure add additional layers of complexity.  A step-by-step guide to MSICS-

Prep- Dilation, Sterilization, and Anesthesia

Before the operation can begin, the patient's pupil must be dilated in order to give the eye surgeon the largest possible area in which to work.  Because the lens lies behind the iris, the further the pupil is dilated, the less the iris will obstruct the exit of the lens.  We used a mixture of tropicamide, cyclopentolate, and phenylephrine to achieve dilation.

As with any other surgery, the surgical field must be sterilized prior to operation- at the eye camps, Dr. Samuel uses a povidone-iodine mixture.

Finally, the eye must be numbed and rendered immobile.  This was accomplished with a lidocaine-adrenaline injection.  The adrenaline works by delaying the absorption of lidocaine, the anesthetic, into the body so that the numbing effect can continue throughout the duration of the surgery.

Step 1- Conjunctival Dissection

eye as seen from the side

Once the patient is lying on the operating table, under the eye of the ophthalmologist's microscope, the real fun begins.  The ophthalmologist grabs hold of the outer layer of the white of the eye (the conjunctiva) and makes a careful horizontal cut a few millimeters above the iris.  Though this step is referred to as the conjunctival dissection, it is technically a dissection of two layers- the conjunctiva and the layer of the eye below it, called Tenon's capsule.  In dark-skinned people, such as those in Gambella, Tenon's capsule is much thicker, and sometimes the ophthalmologist must make a second cut to dissect Tenon's capsule instead of taking the two layers out with one blow.

After pulling away an area of the conjunctiva and Tenon's capsule, the surgeon then seals (or "cauterizes") the blood vessels he or she has exposed.

Step 2- Linear Incision

eye seen face on

Next, the ophthalmologist makes a careful horizontal cut in the sclera, the layer underneath the conjunctiva and Tenon's capsule.  Some surgeons prefer the "smiley face" cut or the "frowning face" cut, but Dr. Samuel's incision of choice was linear.

Step 3- Scleral Tunnel

eye facing up as seen from the side

Thirdly, the eye surgeon creates an upward sloping tunnel from the incision he has just created all the way to the area in front of the iris (the anterior chamber).

Step 4- Capsulorrhexis

Now that the ophthalmologist can reach the lens, he can peel off a circular area of the front part of the "bag" (or capsule) holding the lens.  In other methods of MSICS, doctors peel off the front of the bag in other ways, such as in a "V" shape.

Step 5- Hydrodissection

 eye as seen from above

Once the front of the capsule is removed and the nucleus (or center) of the lens is exposed, the ophthalmologist shoots a stream of water at the nucleus, rotating it about 180 degrees to completely detach it from the rest of the lens.  


Step 6- Nuclear Extraction

 eye as seen from above- pulling the nucleus through the scleral tunnel

Next, the surgeon can reach into the capsule and pull out the nucleus of the lens.  Dr. Samuel's preferred technique was to use a fishhook, which he created by reforming the needle of a syringe into a hook shape.  Not all nuclei are created equal, and there was a huge amount of variability in the consistency of lens nuclei at the eye camp.  Dr. Samuel deemed the fairly mature cataracts "delicious," as they were solid, hard, and dense, and relatively easy to extract.  Hypermature cataracts, on the other hand, have progressed further than mature cataracts and are also known as Morgagnian.  In Morgagnian cataracts, the outer part of the lens (the cortex) actually turns from solid to liquid though the inner part of the lens (the nucleus) remains solid.

According to Dr. Samuel, the nuclear extraction step is the hardest part of the operation, as the lens is in danger of falling further back into the eye.  To me, this seemed like the most exciting part of the surgery, as the removal of the lens from the eyeball was almost like the delivery of a baby (albeit a tiny baby that you throw away immediately after the surgery).


Step 7- Aspiration

Since the lens is composed of both the center portion (nucleus) and the outer portion (cortex), even after the nucleus has been extracted, the less rigid peripheral portion of the lens remains.  Typically, the surgeon aspirates or suctions out the cortex using a device called a Simcoe cannula, essentially vacuuming behind the iris to pull out the strands of lens remaining.  Sometimes, fragments of cortex remain behind the iris on the same side of the eye that the incision was made.  In this case, it is impossible to reach the last pieces of cortex, so an additional incision must be made about 120 degrees counter-clockwise from the initial incision.  From there, the ophthalmologist has the perfect angle from which to suction out the last of the lens.


Step 8- Inject Viscoelastic

Normally, the space behind the cornea (the anterior chamber) contains a water-like liquid called aqueous humor which, among other things, helps to maintain a sort of pressure equilibrium in the eye.  During MSICS, this equilibrium is disrupted and thus the ophthalmologist injects a similar (but synthetic) material called viscoelastic to help restore the appropriate pressures.  The surgeon can choose between dispersive and cohesive viscoelastic.

Cohesive viscoelastic, as its name suggests, tends to clump together, making it easier to remove.

Molecules of dispersive viscoelastic, on the other hand, separate from each other making removal more difficult.  The benefit of dispersive viscoelastic is that it coats the inside of the cornea (endothelium), providing a nice protective coat.


Step 9- Lens Implantation

 inserting the new lens through the tunnel and under the iris

Finally, the ophthalmologist inserts the new lens into the spot where the old lens used to sit- behind the iris and within the "bag" (capsule).  Two curved prongs on either side of the new lens called haptics ensure that the lens hooks snugly into the capsule.  To my understanding, the viscoelastic helps create the right pressure in the front of the eye so that the surgeon has an easier time placing the new lens.

artifical lens with hooks (or "haptics") on either side

Step 10- Removal of Viscoelastic


When the surgeon removes the viscoelastic using the vacuum-like tool called a Simcoe cannula, he can also use the opportunity to "polish" the newly inserted lens along the patient's visual axis.  This helps to lessen any blurriness the patient might otherwise experience.


Step 11- Closing the Wound

applying water pressure to the incision to seal it

Finally, the ophthalmologist fills the space behind the cornea with water to restore the pressure lost after the removal of viscoelastic, then shoots water along the linear incision he made in Step 2.  If all has gone according to plan, when the surgeon lightly taps the patient's cornea, no water leaks out of the incision because a flap of eye is holding it shut.

Throughout the surgery, the ophthalmologist must make numerous decisions as he goes.  If the surgeon senses the patient is tense, he will typically make his initial dissections further from the intersection of the white of the eye and the cornea (the limbus), thereby creating a longer scleral tunnel.  Tense patients are at greater risk of their irises leaking out through the incision, so creating a longer tunnel helps prevent this.  Patients who have a condition called pseudoexfoliation, in which protein deposits appear in the iris and/or lens present as riskier surgical cases because the strands encircling the lens and holding it in place (zonule fibers) are more fragile.  Thus, the ophthalmologist must be especially delicate in his surgical actions.


After drying the eye and injecting an antibiotic mixed with a medication to reduce inflammation, the patient's eye is patched up and he or she is sent home to rest until the next morning, when- if all has gone well- the patient will regain sight.