WHO/NEP/PBL and Geta Eye Hospital

Albert Kolstad

Oslo, May 2012

Nepali ophthalmologist Ram Prasad Pokhrel in 1978 took part in a meeting arranged by WHO and IAPB in Delhi. He gave a speech on the dismal situation of blindness in Nepal and asked for help.

French/Swiss doctor Nicole Grasset, previous director of WHO Smallpox Program, took interest in the problem and utilized her old network to raise funds and recruit essential personnel.

With assistance from Ministry of Health and WHO she had established an office in Patan, Kathmandu by September 1980.

To decide the size and cause of blindness in Nepal a survey was needed. 116 sites were selected, each a small village or same size community.

Five teams, each consisting of one ophthalmologist, one medical officer and ten enumerators traveled to the survey sites by car, by helicopter or on foot. Here each team spent one week. All houses were registered, each inhabitant given an examination card.

Eye examination was done by the ophthalmologist in a dark room, using a torch, a head loupe and an ophthalmoscope. The findings were entered on the card with tick marks in 80 groups of boxes, divided into function, lids, media and fundus, concluding with a diagnosis.

The cards were first processed by computer in Kathmandu, then in Michigan, USA, and resulted in the book The Epidemiology of Blindness in Nepal published by Seva Foundation in 1988, containing 474 pages.

The survey showed that 0.84 % of the population were blind in both eyes, not counting fingers at 3 meters.

Avoidable blindness (preventable and curable) was 80% of all blindness. Of these most important was cataract (84%) and trachoma (3%).

Cataract is a clouding of the lens, situated behind the pupil. It is more common in the aged population, and seen earlier in the tropics than in temperate countries.

Cataract was found more than twice as often in Terai than in the Hills and Mountains.

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If sunlight is a cause of cataract, it should be found less in the hills where mountains are obstructing the sun. We measured the angle to the mountain tops along the horizon and found a strong relationship between calculated average sun hours and cataract.

Cataract is only treated by surgery and best done in a hospital with adequate facilities. Since the highest prevalence of blindness was found in the Far Western Region it was decided that an eye hospital should be constructed inGeta, near Dhanghadi. A 6 bighas plot of forest land was provided by Nepal government summer 1981.

Indian mistris and local labour using sal wood, burned brick and mud started construction, while I was living in the tent seen in the background.

Five buildings were constructed: outpatients department (OPD), waiting hall, operating theatre (OT), patient ward and office.

The OPD for examining patients was also used for training of staff, here seen from the waiting hall.

The OT had one prep room with five tables and two surgery rooms, each with 2 tables. It later had the roof covered with corrugated iron sheets since the tiles placed in mud started leaking.

Office building for admin functions under construction.

Water is obtained by pushing a water filled iron pipe into the ground, then fixing a hand pump on the pipe.

Sterilizing instruments, cotton materials and rubber gloves is by pressure cooker or autoclave on a kerosene burner.

Autoclave being cleaned

Electricity needed for illuminating the surgical field is provided by a diesel engine driving a 12 v dc dynamo. The engine is cooled by circulating water into an oil drum. The brick house came later and so did the 240 v ac generator.

The operating microscope has a 0.5 additional front lens providing proper magnification and working distance. A 12 volt halogen lamp gives a small spot illumination. An ex-butane gas cannister with Freon-12 refrigerant is remotely controlled by a solenoid valve and will provide brief bursts of gas to a spaghetti cryoprobe.

The instrument set needed for cataract surgery contains: blade breaker, iris repositor (2), colibri forceps with tying platform, corneal scissors (2, R&L), needle holder, tying forceps (2, angled & straight) and pointed Vannas scissors. These micro instruments are made by Speedway-Delhi, copied from Moria originals.

Chinese carbon steel razorblade, 10-0 monofilament nylon on eyed spatula needle. Spongo cellulose sponge cut to pointed triangles for drying blood and aqueous.

OAs preparing patients for surgery, here giving retrobulbar blocks

OA Bidya Pant using the cryo system for a cataract extraction, assisted by illiterate girl from Geti village.

A close-up showing intracapsular cryo extraction with spaghetti probe.

Tying the 10-0 nylon suture.

The wards have wooden beds with straw for matress.

The patients eat in the open, cooking over a small fire.

The wards have increased in number as more patients come from India.

The optical workshop prepares blanks to fit into spectacle frames.

Patients operated for cataract need optical correction, usually power +10.

Trachoma is ranked as number two cause of blindness in Nepal. A chronic bacterial infection of the inner surface of the lids, leading to scar formation turning the lid margins in. We call this entropion.

Trachoma is found most frequently among the Tharu ethnic group.

Trachoma is more common in the Western Regions, which have less precipitation than the rest of the country.

The Tharus live in villages close to their animals. Flies and dust are two likely causes spreading trachoma.

The house flies find food in the face of children.

The flies carry the trachoma infection from child to the elderly female caretakers.

Entropion is corrected by bilamellar tarsal rotation.(BLTR). The lid is split in two and several matress sutures tied to evert the lid margin.

The operation can be done by trained OAs, if necessary based in a tent. During the construction of Geta Eye Hospital two mobile trachoma teamswere active in the field.

The sutures are removed after 2-3 week

I lived in Doctors House for more than 10 years, which were my best.

These two played important parts in the early history of Geta: Nicole and Mukti.

Malla, another Ghurka.

Sissel

18. ANNUAL CLINICAL ACTIVITIES (1981-2011)

GETA EYE HOSPIT

YEAR OPD Without IOL

PCIOL AC IOL

TOTAL OTHER IOS

TOTAL EOS

TOTAL SURGERY

1981 65 0 0 0 0 0 2 21982 5654 52 0 0 52 0 217 2691983 7758 388 0 0 388 0 285 6731984 6788 431 0 0 431 0 104 5351985 7418 396 0 0 396 0 200 5961986 11052 731 0 0 731 0 277 10081987 10591 834 0 0 834 0 182 10161988 12463 1463 0 0 1463 0 147 16101989 14179 2461 0 0 2461 0 207 26681990 14382 2963 0 0 2963 0 386 33491991 17734 2395 19 0 2414 177 319 29101992 20848 2713 2 69 2784 192 436 34121993 19812 2306 0 14 2320 79 294 26931994 21316 3403 12 22 3437 431 396 42641995 26086 3541 3 97 3641 678 457 47761996 26561 3626 116 40 3782 499 468 47491997 24750 3802 306 27 4135 534 427 50961998 21878 3920 635 38 4593 420 525 55381999 22697 3211 1326 49 4586 443 496 55252000 25233 2116 3720 143 5979 590 536 71052001 31484 1626 5239 202 7067 524 627 82182002 35000 987 7566 254 8807 536 765 101082003 39959 476 9523 307 10306 765 626 116972004 37386 326 9401 178 9905 779 672 113562005 39899 194 11230 171 11595 512 948 130552006 44324 154 13161 149 13464 273 956 146932007 49024 115 15125 180 15420 308 1161 16889

2008 58246 134 17363 193 17690 358 1123 191712009 67423 117 21745 244 22106 437 1376 239192010 76227 171 25654 163 25988 486 1332 278062011 86946 252 28583 249 29084 1671 1436 32191

TOTAL 883183

45304 170729

2789 218822 10692 17383 246897

Time has passed, in 2009 we are back inNepal. H.S.Bista takes good care of us, here in Kathmandu Guesthouse. But our main destination is Geta.

Among the many new buildings in Geta I recogniced the old OT where the activity once started.

The new buildings may be according to Nepali taste, but the old ones were more charming.

We stayed in Doctors House. Holi celebration had unfortunately stopped routine work, which we had wanted to observe.

Asha Rana was the first person recruited to the hospital. She is today head scrub nurse and has been toAfrica assisting Bidya.

Construrtion of new OT in full swing.

Bidya and JSP with hospital mascot. Sissel had Holi decoration.

Celebration in Geti village

Back in Kathmandu we visited Dr.R.P.Pokhrel and were invited for dinner with NNJS board in Everest Hotel.

There we received a precious gift: A miniature model of the holy temple Pashupathinath, from where Tilganga gets donor material.

Tharu Babu Ram had a fungal ulcer on his last eye and was lucky that Bidya now had been trained to do keratoplasty.

Donor material by air from Tilganga to Geta, where Bidya fixed the corneal button with 16 interrupted sutures.

Babu Ram now has a new eye

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