MACHO 1

Eye Department KCMC Newsletter

Issue 1 Volume 1 Serial 1                                                                      30^th September 2011

A note of Introduction                                                                                       W. Makupa

After attending the annual scientific conference of OSEA in Dar es Salaam it became evident that eye care cadres in Tanzania will need to have a forum of their own. This would mean an annual meeting and also a newsletter for sharing information. It was in this spirit that “MACHO” developed as an idea on 12^th September 2010. It is only now that this is coming to fruition. For a while it was thought that it may be possible to have it strictly as internet group mailing list, but most of primary eye care cadres and some of mid level eye care cadres do not have regular access to the internet. This means that we will have to produce a few hard copies for those who do not have access to the internet.

The aim of this newsletter is to share information on best practices, eye care updates and eye care services rendered at the Eye Department KCMC.

White Pupil                                                                                                           I. Makupa

The normal appearance of the pupil of the human eye is black. In flash photographs the pupil may appear red, called the "red eye/red reflex", and is entirely normal. The appearance of a white pupil is never a normal condition and requires immediate evaluation by specialists trained in ophthalmology. Pre-referral treatment is not recommended for abnormal red reflex or white pupil. White pupil in an infant or child may occur in a number of eye diseases. Most commonly occurs in congenital cataract and retinoblastoma (Rb- a malignancy of the retina). It can also be caused by other rare eye conditions. Both Congenital Cataract and Retinoblastoma are eye diseases with grave consequences on the child’s vision or even life (Rb). Early presentation and immediate referral to an eye care professional are essential for good outcomes.

Awareness & Education: public and healthcare professionals

Increased awareness and education about the white pupil (leukocoria), may lead to earlier diagnosis, and consequently, a higher likelihood of cure and better vision potential for affected eyes.

Parents, rather than healthcare professionals, are usually the first to notice the white pupil. It is very important to inform and empower parents by public education about white pupil. As the time frame available for observation is much greater for parents, focusing on educating parents rather than increasing professional screening may be the most effective way to increase early detection of leukocoria. Educating the public on white pupil could also empower parents to persuade a reluctant primary healthcare professional to refer to a specialist.

Educational resources for parents:

• Internet resources
• Public awareness campaigns                                                                      Awareness materials include:  posters and flyers, television and radio advertisements.

Education for healthcare professionals

Once parents notice the white pupil, their healthcare practitioners must know to respond with prompt referral. Children with white pupil need immediate referral to an ophthalmologist. This is essential for timely diagnosis and good treatment outcomes. The referral lag has serious consequences both in congenital cataract and retinoblastoma. To increase awareness of leukocoria among healthcare professionals, posters and educational leaflets (e.g. describing the correct method for how and when to administer the red reflex test) can be provided to healthcare professionals throughout Tanzania.

Public & healthcare awareness & education: recommendations

We recommend that:

• Information on white pupil be included in public healthcare packages given to new parents.
• Major pediatric and vision screening provide information on white pupil in their print and online public information materials.
• Information on leukocoria, information about the proper performance of the red reflex test be provided to healthcare professionals who see young children and pregnant women in their clinics.
• White pupil education be included in the healthcare curricula.

Eye Health Care Services available at KCMC are:

1. Optical services, complete with refraction, prescription and making of eye glasses for both adults and children
2. Complete ophthalmolgical consult, with paraclinical diagnostic tools such as: autorefractor, ophthalmic ultrasound, automated perimetry, fundus flourescein angiography and optical coherence tomography.
3. Comprehensive ocular surgical services, biometry is performed in each cataract patient to calculate the power of intraocular lens to be implanted with the aim of achieving best possible outcome.
4. Ocular pharmacy stocked to cater for basic and necessary ocular therapeutics
5. Rehabilitative services for the visually impaired are available with a range of low vision devices.
6. The Eye Department in collaboration with its partners (KCCO and EACO), conducts Day Eye Diseases Screening Outreaches (Direct Referral Site) within Kilimanjaro Region twice every week to screen the population for sight threatening conditions and transports to hospital all those who need intervention. Also Week Eye Surgery Outreaches are conducted to places too far from KCMC but the need for care exists.                                                           

Editor: W. Makupa, Eye Department KCMC, P.O.Box 3010 Moshi – Tanzania

Tel: +255 27 275 4890 Fax: +255 27 275 4381 Email: makupauw@yahoo.com

MACHO 2

Eye Department KCMC Newsletter

Issue 2 Volume 1 Serial 2                                                                       30^th December2011

Improving Eye Care in KCMC                                                                        W. Makupa

Kilimanjaro Christian Medical Centre opened its doors for the first time on 6^th March 1971, and the Eye Department was one of the initial constituent departments of clinical specialty. At that time there was one ophthalmologist, the late Joseph Taylor, who was also the Medical Superintendent of the hospital. From 1976 the Eye Department was housed in its own building, thanks to Christoffel Blindenmission (CBM). With a dedicated clinical space, ward and theatre, eye care at KCMC is not affected by periodic problems of overcrowding, as is the case in the rest of the hospital.

For years, the department was the one of the two centres in the country providing tertiary eye health care services. In 1997, the Lutheran Church founded the Kilimanjaro Christian Medical College, a year later postgraduate training in ophthalmology commenced. Up to this moment, 20 ophthalmologists have graduated. The department is also the only training centre in the country for AMO Ophthalmology and Advanced Diploma in Ophthalmic Nursing (both programmes are under Ministry of Health - Allied Health Sciences Schools).

From the year 2000 onwards, the department experienced improvement in ocular diagnostics; with the acquisition of ophthalmic sonography, autorefractor/keratometer, fundus flourescein angiography, automated visual field analyzer and optical coherence tomography. Our decision making has been revolutionized by these machines.

The availability of ophthalmic diode lasers have given a second chance at sight to most of the 574 patients undergoing laser treatment for diabetic retinopathy, not to mention the irreplaceable role of lasers in vitreo-retina surgery.

Although eye diseases screening outreach and eye surgical outreach have been an integral part of departmental services from the very inception, it is the focusing and consolidation of these activities in the recent years that has started to bear fruit. The number of people seeking and requiring cataract surgery has been decreasing annually from a peak in 2004. This has allowed us to be able to focus on other blinding eye diseases, such as glaucoma and diabetic retinopathy.

A dedicated paediatric ophthalmology service has made it possible to provide timely and quality eye care for children. A child friendly clinical room makes the young patients feel at ease, while proper devices for evaluating minor’s vision complements the service provision. Ample theatre time allocated for childhood ocular surgery positively segregates in their favour.

Besides paediatric ophthalmology, the department also provides sub-speciality care in vitreo-retina surgery and ocular oncology. And, there are plans to develop oculoplastic surgery, glaucoma and cornea.

The department together with regional ophthalmic public health organizations is able to produce quality research; that is the basis of planning, monitoring and evaluation of our services.

All these improvements have been possible only because of the nurturing environment created by the GSF-KCMC administration and their strong support.

Cataract Surgery at the Eye Operating Theatre KCMC.

Eye Health Care Services available at KCMC are:

1. Optical services, complete with refraction, prescription and making of eye glasses for both adults and children
2. Complete ophthalmolgical consult, with paraclinical diagnostic tools such as: autorefractor, ophthalmic ultrasound, automated perimetry, fundus flourescein angiography and optical coherence tomography.
3. Comprehensive ocular surgical services, biometry is performed in each cataract patient to calculate the power of intraocular lens to be implanted with the aim of achieving best possible outcome.
4. Ocular pharmacy stocked to cater for basic and necessary ocular therapeutics
5. Rehabilitative services for the visually impaired are available with a range of low vision devices.
6. The Eye Department in collaboration with its partners conducts Day Eye Diseases Screening Outreaches (Direct Referral Site) within Kilimanjaro Region twice every week to screen the population for sight threatening conditions and transports to hospital all those who need intervention. Also Week-long Eye Surgical Outreaches (Surgical Outreach or Surgical Safari) are conducted to places too far from KCMC but where the need for eye health care exists.          

                                                 

Editor: W. Makupa, Eye Department KCMC, P.O.Box 3010 Moshi – Tanzania

Tel: +255 784 332 667 Fax: +255 27 275 4381 Email: makupauw@yahoo.com

MACHO 3

Eye Department KCMC Newsletter

Issue 1 Volume 2 Serial 3                                                                          30^th March 2012

The Role of Visual Field Analysis in Glaucoma                                     William Makupa

Primary Open Angle Glaucoma is defined as optic neuropathy with visual field defects whereby increased intra-ocular pressure is the main risk factor. Therefore by definition it is a disease of the optic nerve, where gradually the axons connecting the eyeball to the brain get destroyed by increased pressure of the aqueous humour. Loss of axons, seen clinically as excavation (cupping) of the optic disc results in visual field defects, this is because the areas represented by the destroyed axons are not transmitting impulses to the brain anymore.

The cause of increased intra-ocular pressure is a complex one, has to do with deficient drainage of the trabecular meshwork. There is a strong genetical component to developing Primary Open Angle Glaucoma. In case of Secondary Open Angle Glaucoma the causes for clogging up of the trabecular meshwork are usually obvious clinically, be it exfoliation, pigment, red blood cells (usually related to injury) or lens proteins.

Clinically a glaucoma patient might have difficulty in expressing the symptoms, some of the patients will vaguely describe the advanced visual field loss as visual disturbance. It is very important for the eye healthcare cadre to understand that glaucoma is an asymptomatic eye disease. The first tell tale sign is either increased intra-ocular pressure or cupped disc, depending on the skills and knowledge of the examiner. Intra-ocular pressure is not measured routinely in set ups relying on Schiøtz tonometer. Disc assessment using a direct ophthalmoscope needs skill and versatility and should be a routine examination by all eye healthcare cadres. The severity of glaucoma in our setting is graded by the extent of disc excavation, 0.3 cupping is considered healthy and 0.9 cupping is considered severe. Optic disc cupping evaluation is a subjective matter at best of times, hence the role of visual field analysis.

Since February 2009, the Eye Department KCMC had a Carl Zeiss Humphrey Visual Field Analyser Model 740i. This equipment is an automated visual field analyser, which is easy to administer and gives accurate perimetric readings. Before acquiring it we were relying on a manual Goldman perimeter that had broken down, it took a long time to administer, relied on optometrists who were always busy with other tasks and could not accurately plot scotomata.

After the excitement of this new equipment had died down, we got to the task of training one of our medical attendants to be the Visual Field Technician, this was done successfully. Within three months Howard Kitonka was administering the perimetric test as well as any other perimetrist. To make it accessible the test cost only Sh 10,000/= and there is a waiver for those too poor to pay.  Ideally every glaucoma patient should have the test done once a year, to determine whether the disease has been arrested by the treatment offered or it is progressing nevertheless. Also it enables the clinicians to decide whether the glaucoma damage is too advanced to risk filtration surgery so as to opt for other kinds of treatment. Lastly it is an essential tool for neurologists to locate central nervous system lesions.

Going back to the definition of glaucoma, visual field defects are the most accurate clinical signs of the disease, their progression correlates with diseases progression and finally in cases of normal tension glaucoma, visual field defects may be the only clinical sign confirming the diagnosis.  

Visual Field Assessment at KCMC.

          Eye Health Care Services available at KCMC are:

1. Optical services, complete with refraction, prescription and making of eye glasses for both adults and children
2. Complete ophthalmolgical consult, with paraclinical diagnostic tools such as: automated refraction, keratometry, pachymetry, cornea topography,  ophthalmic ultrasound, automated perimetry, fundus colour photography, fundus flourescein angiography and optical coherence tomography.
3. Comprehensive ocular surgical services, biometry is performed in each cataract patient to calculate the power of intraocular lens to be implanted with the aim of achieving best possible outcome.
4. Ocular pharmacy stocked to cater for basic and necessary ocular therapeutics
5. Rehabilitative services for the visually impaired are available with a range of low vision devices.
6. The Eye Department in collaboration with its partners (CBM and EACO), conducts Day Eye Diseases Screening Outreaches within Kilimanjaro Region  every week to screen the population for sight threatening conditions and transports to hospital all those who need intervention. Also Week-Long Eye Surgical Outreaches (Surgical Outreach or Surgical Safari) are conducted to places too far from KCMC but the need for care exists.     

Editor: W. Makupa, Eye Department KCMC, P.O.Box 3010 Moshi – Tanzania

Tel: +255 784 332 667 Fax: +255 27 275 4381 Email: makupauw@yahoo.com