The following is written by our President & CEO, Dr Raj Agrawal.
Since this is our first visit to the country, I traveled to Burundi alone. Flying into Bujumbura, the capital city, on the night of Sunday Mar 15, John Cropsey picked me up at the airport. Kibuye, where John works, is up in the mountains, and hence we stayed at the Hope Africa University's guest house in Bujumbura for the night. I met Dr Randall Bond, the Dean of the Medical School, and his wife Carolyn, who live in a beautiful house here, part of which is the guest house.
Mar 16 - Day 1 - Drive to Kibuye & Eye Clinic:
The next morning, Monday March 16th, John and I, along with some of his nursing staff who had come to Bujumbura for the weekend, left for Kibuye in his hospital car. Though the distance is not much, the mountainous roads and the traffic, as well as police check points along the way, make for some interesting experience on the road!
One of the interesting sights on this road is of young men on bikes that are loaded with either bananas or tobacco leaves, with the riders barely keeping themselves upright as the bikes race crazily down the steep mountain roads! It looks dangerous, but surprisingly did not see any major accidents related to them. But I was told that some of these young men die in pursuit of their occupation. They apparently make 4-5 trips in a day, with one downhill distance of about 20 miles or so. Even worse in how they go back up the mountains. They latch onto trucks and other vehicles that are driving up these mountains - the sight of 4-5 men on their bikes hanging on for dear life behind the vehicles as the trucks drive up the mountains is downright scary!
On reaching Kibuye, knowing there were over a 100 patients waiting for us, we went straight to the clinic and started work in earnest.
Patients had come not only from surrounding areas, they has also come from far off places, some of them on foot, since they have no money to pay for their transport. Some of the patients had also come from adjoining country of Congo, which does not have any retinal specialists or facilities there.
A majority of these patients had diabetic retinopathy, from a few patients exhibiting high-risk characteristics. Others had macular holes, ERMs, retinal detachment, and ocular trauma related retinal complications. After a day's work of examining these patients, we ended the day late in the evening with a decision to operate patients the next day.
We had three medical students who were in the first clinical ophthalmology rotation. During my time in the clinic and the OR, we conducted impromptu teaching sessions, as well as had them scrub in for cases to experience ophthalmic surgical management. I was impressed by their understanding of eye anatomy and bit of ocular disease, even at their medical school level. I was hoping one of them at least wanted to be a retinal specialist, which proved true, with one student who was from Cameroon mentioning she was keen on a career in ophthalmology, though she was not yet sure if she would take up retina specialty.
March 17 - Day 2 - First surgical day:
- A young child with a traumatic cataract with a suspected retinal detachment for surgery. Considering that the B-scan ultrasound was not functional, we evaluated the patient clinically that gave us reason to believe (faulty perception of light and low intraocular pressure) that the patient had an associated retinal detachment as well. We set up the patient for 23 gauge pars plana vitrectomy (PPV)using Alcon® trocar-cannula system fixed to Synergetics® Versavit® vitrectomy machine, and removed the cataract. Once inside, we realized that the patient had low hypotony retinopathy, which allowed us to clean vitreous bulk and close the case. This patient will be taken up for secondary IOL once the retina is back to normal.
- Case had retinal detachment with early PVR, with a horse-show tear and a dialysis in the periphery. Considering the relative mobility of retina, I thought a buckle can be attempted. We did a sutureless buckle on this gentleman, placing the buckle in scleral pockets (sutures increase the chances of infection, specially in difficult environments) and draining subretinal fluid to make the retinal breaks flat on the buckle.
Late afternoon, we performed lasers using Iridex® Oculight laser, including grid lasers and an indirect laser to patients with peripheral retinal degeneration.
March 18 - Day 3- Second surgical day:
We scheduled two routine macular holes, along with one traumatic macular hole. All three underwent 23-gauge PPV, followed by internal limiting membrane (ILM) peeling, which was successfully performed in all cases.
Following the cases, we went to an outreach center where the eye clinic staff sees patients locally who may need additional treatment at the eye clinic. Patients with cataract and other surgical ailments are given an appointment to come to the clinic.
March 19 - Day 4 - Third surgical day:
- Case of an epiretinal membrane, which was removed with 23-gauge forceps after a PPV. No ILM peel was attempted since the macular folds were clearly seen.
- Traumatic cataract with retinal detachment with PVR like features seen hazily through the cataract. John removed the cataract in this old gentleman using SICS technique. During vitrectomy, a giant retinal tear (GRT) was noticed in the superior quadrant, with a nuclear chunk that has floated subretinal. This chunk was removed using modified flute needle, and expressed out of the anterior segment via the SIMS incision using the handshake technique. Retina was stiff, as noticed after injecting a bit of PFCL, and hence massage was performed using the flute needle. Once retina appeared mobile, PFCL was injected unto the edge of the GRT (anterior edge was cut), followed by laser to the posterior edge, and 360 barrage was also performed. Good anterior vitrectomy allowed for avoiding the use of a 360 encircling band. Once laser was completed, following an inferior PI, PFCL-silicone oil exchange was performed. The intraocular pressure appeared ok at the end of the procedure.
- Case of cataract with altered vitreous hemorrhage (suspected BRVO related bleed preop). Following preplacement of 23-guage PPV ports, cataract was removed via SICS technique by John. Once the altered blood was carefully removed with vitrectomy, there was no evidence of a BRVO. Peripheral retina was carefully examined using indirect ophthalmoscope, but no retinal break was seen. It was thought that the blood could have been due to PVD induction causing an avulsion of a small vessel. With no evidence of any leak, no laser was done. An IOL was inserted from the SICS wound after PPV was completed.
Mar 20 - Day 5 - Postop day:
I had been examining the patients operated earlier as they came back after their surgery, and saw all the operated patients on this day, this being the last day before my departure from Kibuye. Most cases were seen to be doing well, except for a bit of fibrin reaction in the anterior segment in the patient with GRT, for which increased topical steroids was advised. Two of the macular holes operated showed more fibrinous reaction in the anterior segment, which was not considered infective from the history (patient noted reduction in pain since surgery) and examination (eye was not significantly congested). Considering they had not applied steroid eyedrops after surgery, they were asked to stay back in the hospital, with frequent steroid eye drops being applied.
After handshakes with the eye clinic staff and a few pictures with patients (who kept their heads in prone position after macular hole surgery!), John took me around the hospital as well as part of the village of Kibuye, which skirts the hospital land.
After lunch, I was driven back to Bujumbura. I met Dr Levi Kandeke in his offices, who is a Geneva-trained ophthalmologist specializing in pediatric cataract surgery. He is also responsible for the National Eye Care program in Burundi. We discussed the current scenario for retinal surgery in Burundi, as well as the possibility of Retina Global working with him and the Government of Burundi, to help make a lasting impact on those Burundians afflicted with retinal diseases. After sharing our experiences in training and in career, he was kind enough to drop me off at the airport.
In all, the visit was very fruitful. With 8 surgical cases over 3 operating days in a scenario where the support staff are not trained for retinal surgery, is, in my opinion, a big accomplishment. A lot of credit goes to John for managing the systems well, including figuring out the connections and instruments, while helping me in the cases. He also managed to get patients to come for the clinic, with some of them coming from as far as Congo.
I plan to visit Burundi again in September, as a follow-up to this visit. John and I will likely see more patients, and operate on those requiring retinal surgery. We also plan to work towards getting the clinic the required instrumentation that will make our work much less stressful.
Levi and I discussed about identifying a young ophthalmologist (he mentioned two are likely to finish residency by August) who can be offered a retina fellowship training in a suitable place. My visit may give us a chance to evaluate this person before offering the fellowship. We also plan to consider starting a telemedicine program between his center and Retina Global, which will allow us to provide image-based reporting of patients in Burundi. He also said he will discuss with the Ministry of Health to consider creating a task-force for retinal disease management for the country.
What are the needs there?
Levi currently only has a set-up for medical retina. He requires a full vitreo-retinal setup. We are looking for donations of equipment to Retina Global, or donations to us for us to buy equipment for his center.
John has a reasonable set-up for vitreo-retinal surgery, but he has to reuse disposable instruments such as trocare-cannula systems, probes, etc. It would be good if we could have industry support us by donating such equipment to help manage difficult cases. That being said, we may also need to buy some other equipment, for which we need donations. Please consider supporting Retina Global, which is a 501(c)(3) approved nonprofit organization ; your donation gets utilized for the purposes it is meant for, and you get a nice tax deduction.