Before travelling to Kathmandu on a volunteer trip last May, Sunnybrook operating room nurse Sabrina Rafaeli and Chief of Ophthalmology Dr. Peter Kertes expected to find a hospital “60 or 70 years behind the developed world,” admits Rafaeli.
To their surprise, when they arrived at Tilganga Institute of Ophthalmology in Nepal, they actually found a hospital that was well-equipped. But there was a catch.
“They have all the equipment … they needed help improving and expanding their surgical techniques,” says Dr. Kertes.
He specializes in the diagnosis and treatment of diseases of the retina, and has a particular interest in the realm of pediatric retinal diseases such as retinopathy of prematurity. Dr. Kertes has volunteered his time all over the developing world.
Over the course of the week, Dr. Kertes trained two Nepalese ophthalmologists while Rafaeli worked with three nurses on the operations of 12 children. They were on a volunteer trip to train medical staff in specialized eye health care that was sponsored by ORBIS, an NGO dedicated to treating blindness and saving sight worldwide.
Dr. Peter Kertes sees pediatric patients at Tilganga Institute of Ophthalmology in Kathmandu last May.
“The truth is that there are sources, often charitable organizations like ORBIS, that give hospitals such as Tilganga access to the latest and greatest equipment,” Dr. Kertes explains, “but the equipment sometimes comes without the necessary training to teach them how to use it.”
For example, surgeons in the west frequently make use of a BiOM, a device that is attached to the microscope that provides a three-dimensional view of the retina to its very periphery.
“They had one of these at Tilganga,” recalls Dr. Kertes, “but no one there had any experience with it and didn't really know how to use it. I was able to show them how to attach it to the microscope and how to use it. The looks on their faces when they were able to visualize the retina the way we do routinely was priceless.”
Sometimes it’s not even that complicated. The operating room in Tilganga had two beds side by side. Having fewer resources in Nepal, surgeons would share surgical instruments between patients.
“They wouldn’t change gloves or gowns between patients,” explains Rafaeli. ”There was inadequate sterilization between patients. I was overwhelmed by that.” So, Rafaeli explained sterilization methods to Nepalese operating-room nurses. “Sterility is not so front-of-mind with them,” adds Dr. Kertes. “Here in Canada, we can afford to throw things away and, yes, it’s very wasteful, but there are some basic standards that should be maintained.” Dr. Kertes says the staff at Tilganga would lay out all the surgical tools, even the highly specialized ones that would not be needed for the particular surgery performed that day. “One of the things we talked about was making packages of specific instruments for specific kinds of surgeries,” notes Dr. Kertes. “That way you can be more efficient and conscious about sterilization.”
Dr. Kertes says he would encourage the Nepalese surgeons to think about their goals, then modify the surgery based on those goals. “We talked about doing what was necessary, and not just following a set template for surgery.”
“The looks on their faces when they were able to visualize the retina the way we do routinely was priceless.”
Compared to working in Canada, surgeons in Nepal would see far more trauma-related issues in children who, for example, get foreign bodies in their eyes from hammering metal.
“So, as an ophthalmologist who sees that kind of trauma,” says Dr. Kertes, “your role is to encourage public health advocacy like wearing safety glasses. Hopefully we conveyed that message as well. I really have to commend the doctors in Nepal for being forward-looking and wanting to be prepared for the future,” he adds.
Both Dr. Kertes and Rafaeli say they still keep in touch with the surgeons and nurses back in Nepal. “We still talk to them on Facebook and exchange e-mails,” Rafaeli says.
“Ophthalmology is so visual,” adds Dr. Kertes. “Unlike our colleagues we can directly see what is wrong without having to rely on other tests like X-rays or CT scans. This lends itself well to consultations through e-mail or over the Internet.”
Rafaeli and Dr. Kertes also highly encourage other health-care professionals to volunteer abroad. “If you ever get the opportunity to do something like this, take it,” urges Rafaeli. “The contribution it makes to your soul is well worth the experience.”
CLOSER TO HOME
One of Dr. Peter Kertes’ major projects is working with Sunnybrook’s Women & Babies Neonatal Intensive Care Unit (NICU) to prevent the onset of retinopathy of prematurity, a disease that is one of the most common causes of blindness in premature children.
He screens the infants at the NICU at least once a week and also works closely with patients at The Hospital for Sick Children in Toronto. “The exam usually takes 10 minutes, but it can be harrowing for parents,” Dr. Kertes says.
“They’ve had so much bad news and this disease appears always toward the end,” he adds. “It takes time to develop and then you have to break the news to them that their child might become blind.”
In the last few weeks of pregnancy, blood vessels grow from the central part of the retina outward. But in premature babies, the process is incomplete. If the blood vessels grow normally, the disease will not take root. However, if there is scarring and the blood vessels grow abnormally, the infant will develop retinopathy of prematurity.
“Sunnybrook has the largest level 3 nursery in Toronto, which means they see the sickest and smallest babies,” Dr. Kertes notes.
The treatment is fairly straightforward with a high rate of success and can be treated with laser or an injection directly to the eye.