The Final Eye Screening

Posted by Mercy Ships staff on Dec 28, 2011 at 11:03 am

When the Mercy Ships Eye Team arrives at Kissy U.M.C. Eye Hospital in Freetown, Sierra Leone, they are met by over 300 people waiting outside the gates. These people have come from all over the country and beyond, hoping to receive treatment for various eye conditions. Many of them have slept outside the previous night to keep their place in line.

It is 7:30 a.m. on the morning of the final eye screening for the 2011 Sierra Leone Field Service. “You never know what the atmosphere is going to be when you arrive,” says Barbara Quesenberry, Off-ship Security Officer for the Africa Mercy. At last week’s screening, a fight broke out at the gate. Occasionally Mercy Ships screenings have been shut down because crowds got out of control, but today the atmosphere is relatively calm.

“Expectations go up at the end of a field service,” says Woody Hopper, Program Administrator for the eye team on the Africa Mercy. “The patients sense that we aren’t going to be here much longer, and there is a feeling of ‘This is it. This is my last chance.’”

Barbara explains to the crowd that today the eye team is only screening for bilateral cataracts, and anyone with other medical issues should leave the line – but no one does. The Mercy Ships team is used to large crowds, but with only nine surgical spaces left to fill before the ship sails to Ghana, they know that they have an especially difficult task ahead of them today. From the more than 300 people waiting in line, they plan to make a maximum of ten appointments for cataract surgery.

Patients are brought through the gates by the security team in groups of 30, and a team member pre-screens each person to determine who will go inside the clinic for further examination. With so many people to assess, decisions must be made quickly, but saying “no” is not easy. “Mentally it’s anguish having to say ‘no’ so much,” says Woody. “But you get used to it enough where you can do it. We don’t want to say ‘no’ to anyone, of course, but you have to know the limits of what you can do.”

Dr. Guy Chevalley from Switzerland is the last ophthalmic surgeon available for this field service, and he will be onboard for seven surgical days. Dr. Guy averages 12-15 cataract surgeries per day using the MSICS (manual small incision cataract surgery) technique. This innovative procedure allows Mercy Ships surgeons to remove cataracts at maximum capacity but with much less expensive instrumentation and equipment than they would have at home. But with a schedule that is already nearly full from previous screenings, Dr. Guy can’t possibly meet the demand the eye team is witnessing today.

During this final screening, patients who are not selected for further screening are given eye health education, eye drops and vitamin A tablets, and then they are led out of the compound. “I’m glad that we don’t just have to say ‘no’ and that’s it,” says Woody. “We have the benefit of some small things we can provide when we screen and the patient isn’t appropriate for treatment.”

Patients who are selected for further screening form a group to one side. Members of the eye team collect patients’ information before proceeding inside the hospital for a visual acuity test. The Tumbling E Chart, which consists of capital E’s facing various directions, allows the team to assess the vision of patients who are not able to read. Patients simply indicate with a wave of the hand which way the letter is facing.

Patients with vision in the 6/24 to 6/36 range (20/80-20/120) are sent to day-worker Innocent Kogbeyo, who fits them with reading glasses or prescription glasses. Those with 6/18 (20/60) vision or better in one eye are sent home with sunglasses, eye drops and – if they are children – vitamin A tablets. “A few weeks ago we would have referred a person with 6/18 vision for more testing,” says Woody. “But, as it is [at the end of the field service], their vision just isn’t bad enough.”

Patients with 6/60 (20/200) vision or worse in both eyes are taken to see the ophthalmic technicians, who do further assessment with an opthalmascope. As a result of the limited spaces remaining in the schedule, today the team will have to apply their criteria for surgical candidacy even more rigidly than usual. Only patients who have fully mature bilateral cataracts, 6/60 vision or worse, and no other obvious health problems will be sent to day-worker Martha Abu to receive an appointment for the secondary screening, which will take place tomorrow. Patients whose cataracts are not fully mature are given appointments for autorefraction so that they can be fitted with prescription glasses. Patients with mature cataracts in only one eye are referred for surgery to Kissy U.M.C. Eye Hospital.

“We’re making surgeries more accessible by offering free surgeries and building capacity by training local surgeons,” says Woody. “When we come into an area and there is a local health system there, we don’t want to provide services that overwhelm what is already available – but the need is so great that we don’t have much of a problem with that.”

By 10:30 a.m., Martha has scheduled 8 people for the secondary cataract screening, and the line of patients waiting outside is still long. Salimatu, a 16-year-old with what appears to be dense cataracts in both eyes, has just completed her visual acuity test, which revealed that she can see hand movement at three meters with her left eye and count fingers at three meters with her right. A member of the eye team leads her by the hand to a chair in the adjoining room, where she is examined by Morna Whitlock, an ophthalmic technician from the UK.  

After assessing Salimatu’s eyes, Morna writes “Nil to do – would require corneal transplant” on her chart. “It’s too far gone,” Morna explains. “If we were in Europe or the States, she could get a transplant and probably have a good result – but, as it is, there is nothing we can do.”

Glory Lamin, a pastor and day-worker on the eye team, explains this to Salimatu and then leads the weeping girl out of the room. “I told her she doesn’t need to give up,” Glory explains later. “There is a creator who is the greatest physician. Men have limits, but God has no limits. She was encouraged by that,” he says.

“The lens is dying from the moment you are born,” Morna explains. Poor diet, poor hygiene, injury and exposure to dust and UV light can all contribute to the development of cataracts. This year, the eye team traveled around Kono District, providing free eye testing, health education, vitamin A tablets and prescription glasses/sunglasses to schoolchildren – with the aim of preventing the types of problems that may have caused Salimatu to lose her sight.

By 11:30 a.m., Innocent has given out 22 pairs of readers, and Martha has scheduled 21 patients for secondary cataract screening.

Abdullah and his father, Ibrahim, have been waiting outside since 2 a.m., and now it is Ibrahim’s turn to be seen by South African optometrist Tseli Khalatha. In the chair next to Ibrahim, Theresa, a 19-year-old commerce student, is being assessed by Morna. Both Theresa and Ibrahim have bilateral cataracts, and Theresa’s are very dense. “She will be blind in a year or so if they aren’t removed,” Morna says. Both patients are sent to Martha to get appointment cards for the secondary screening, bringing the number of candidates for the nine available spaces up to 24.

As the screening starts to wrap up, things become more tense. Some people who have been refused surgery demand second opinions. Others cry and are comforted by members of the team. “The younger people especially will hug you and cry until you feel like crying, too,” says Martha. “It’s very hard.”

 “All we can do is pray for them and let them go,” says Isaac Lincoln, an eye team day-worker. “It’s so difficult to do. Sometimes you look at Woody’s face, and you see the sadness.”

By the time the screening ends at 12 p.m., nearly 200 of the over 300 people outside the gate have been assessed by an optometrist or ophthalmic technician, and 25 have been scheduled for the secondary cataract screening. As they close the screening site, the team knows that they have more difficult decisions ahead of them the following morning.

At 7 a.m. on Tuesday morning, the team is once again assembled – this time inside the white house, a three-room building on the dock next to the Africa Mercy. The 25 patients who were given appointment cards the previous day are waiting outside.

Eye Team Coordinator John Harwood leads the team in prayer before they begin their day. “Dear Heavenly Father, we know we don’t live in a perfect world,” John says. “And we really have a hard time understanding that sometimes. Please help us to remember that there is more to life than we can see or understand.”

Once the team is ready, patients are brought into the building in groups of five and seated on a bench in the middle room, where Tseli and Morna are set up with a slit lamp and autorefraction machine. Tseli begins by assessing each patient’s eyes with the slit lamp to determine if the cataract density matches the patient’s vision. This is the last diagnostic step prior to scheduling the patient for cataract surgery. Woody explains that if something doesn’t make sense, they must keep looking.

If the cataract is dense, the patient moves to the next station for biometry, where the corneal curvature and axial length are measured to determine the power of the lens implant to be inserted after the cataract is removed. If the cataract does not appear dense, Morna measures the patient’s prescription with the autorefractor and sends them to Innocent to see if their vision improves with glasses.

After they have been assessed, patients who are being fitted with glasses move to the adjoining room to see Innocent, who fits them with prescription glasses. Meanwhile, patients who are considered candidates for surgery wait in the hallway for further instructions. Typically, surgical candidates are immediately given appointment cards and sent home. Today is different – because there are only nine slots left, Woody is waiting until everyone has been screened to decide what to do.

Ibrahim is one of the first patients to come through the line. He has 6/60 vision in one eye and no light perception in the other. Tseli sends him for autorefraction, and Innocent fits him with glasses that bring his vision up to 6/18, which in Sierra Leone is good enough to drive a car and walk unaided. “That’s great!” says Ibrahim when he tries on the glasses. “I’m happy.”

It doesn’t take long before there are more surgical candidates waiting in the hallway than there are slots available. “We’ve had at least three people who were not put into the surgery row because they got glasses,” says Woody. “That makes it easier, but we’re still going to end up with more than nine people.”

A patient enters with her baby, and Morna immediately recognizes the child who had bilateral cataract surgery on the Africa Mercy one month earlier. Delighted, she takes a toy out of her pocket and holds it in front of the little boy, waving it from side to side. The baby follows the toy with his eyes. “Nice tracking,” she says. He grabs the toy with both hands. “That’s what we like to see!” Morna says. She turns to the mother. “When he [eventually] goes to school, he must sit near the teacher all his life,” she says as the baby toddles off down the line of patients. “A blind child doesn’t develop,” Morna explains. “A month ago, he would have just sat there – now he wants to explore. That’s sight! It’s just wonderful.”

Theresa, the young woman with bilateral cataracts, takes her place in front of Tseli’s slit lamp, another diagnostic tool used to determine cataract density. Examining Theresa today, Tseli discovers that she has vernalkeratoconjunctivitis in both eyes and that the left cornea is beyond repair. Before he makes his final decision, Tseli asks Woody’s opinion.

“I think the left eye gives us the answer for what we can expect for the right,” Woody says. “It’s probably not a good situation.” In any case, the team cannot operate while Theresa’s eyes are inflamed, and it will take weeks for the inflammation to clear. Tseli gives her treatment for her condition and a referral slip to have her eyes reassessed at Kissy U.M.C. Eye Hospital once it clears. Isaac counsels her before she leaves. “I tell them it’s not the end of your life,” he says. “I have seen people here who are blind who have families, go to university, work. I tell the patients that. I say, ‘You eat, I eat. You feel, I feel.’ The only difference is that they can’t see.”

Isaac, who is trained as an accountant, applied for a job as a day-worker on the Africa Mercy when Mercy Ships came to Sierra Leone. He was assigned to the eye team, and now he has decided that he would like to build on what he has learned from Mercy Ships by going back to school to become an optometrist. “Look at what Mercy Ships has done for Sierra Leone,” Isaac says. “They are really helping people. As an accountant, I was just helping myself, but as an optometrist I could help others,” he explains.

After everyone has been assessed, there are 17 patients who are considered ideal candidates for surgery. Woody calls Peri-operative Coordinator Shannon Hickey, and together they decide to bump up the number of surgeries on each remaining surgical day from 15 to17 so that they can fit everyone in. “Dr. Guy did great with 12 surgeries yesterday, so in a couple of days he’ll be able to do 15, 16, 17. That way we don’t have to say ‘no’ anymore,” Woody says.

When the final eye screening of the 2011 Sierra Leone Field Service is over, 17 patients have been written into the schedule and given the orange appointment cards that they will bring with them on the day of their surgery.

Since arriving in Sierra Leone in February, 2011, the eye team has performed over 1,000 cataract surgeries, nearly 200 pterygium surgeries, 8,794 eye evaluations and treatments, 1,084 YAG Laser capsulotomies and 3,308 basic eye exams. In the same period, they have also distributed 2,261 pairs of sunglasses, 2,962 pairs of reading glasses and 1,254 pairs of prescription glasses.

Six weeks after cataract surgery, patients return to the ship for their final post-op appointments, and Dr. Guy performs YAG Laser capsulotomies on each of them to prevent the formation of secondary cataracts. Then patients are given reading glasses or distance glasses, as needed.

A special celebration follows this final step. The gift of sight is celebrated with singing and drumming. Patients are invited to offer testimonies of how the treatment they received from Mercy Ships has changed their lives.

On Friday of their final screening week, the eye team gathers on the dock outside of the White House for the weekly Celebration of Sight. Rugiatu is quick to raise her hand and come to the front of the crowd. She tells her listeners that she was a nurse, but when she developed bilateral cataracts, she lost her job because she couldn’t read the patient charts. Now, after her surgery, she can go back to work. “Thank you Mercy Ships, and thank God, because He directed me here,” she says.

Hearing stories like Rugiatu’s – stories about lives transformed by the services that Mercy Ships provides – helps the eye team to cope with the challenges that they face in their work. “It makes my day so sweet to see someone who was blind who now can see,” says Isaac. “It makes a huge difference in their life – and in my life, too.”

Story by Catherine Cooper
Edited by Nancy Predaina
Photos by Liz Cantu and David Peterson

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