Volume FIVE, Issue ONE Quarter ONE, 2010
electronic bulletin
Eye screenings for children in Yerevan
IN THIS ISSUE One day on the Mobile Eye Hospital
Data analysis & research in the region of lori According to the AECP doctors’ approximation, 10-15% of screened children in Yerevan are registered with eye problems. At the same time, the AECP statistical estimate for the country is 8.7%.
Narek has started wearing eyeglasses only recently. At the beginning it was unusual, sometimes, even distressing. The boy felt embarrassed, since was afraid that his kindergarten friends would make fun of him. He was pleasantly surprised when his peers accepted him absolutely normally. In fact, it was comforting to discover that there was nothing scary in wearing eyeglasses at all. As Narek’s nurse, Mrs. Hrush, told us, the boy has started only recently to communicate with his peers at a full scope. He was timid and shy, and the reason for that was the low vision, as discovered later on. Narek’s mother, Ani, said that it was difficult for her to understand why her child watched television from a close distance and frequently demonstrated unstable coordination in movements. All this
was misleadingly ascribed to Narek’s character. Things started to change when the ophthalmologists of the Armenian EyeCare Project (AECP) visited Narek’s kindergarten. The screening identified refraction problems with the boy. The AECP doctors prescribed and prepared free-of-charge eye glasses for him. After wearing them for a while, the staff of the kindergarten and Narek’s parents noticed substantial positive advances in his behavior. According to the approximation of the AECP doctors, 10-15% of children screened in Yerevan are registered as having eye problems. At the same time, the AECP statistical estimate for the entire country of Armenia is 8.7%. All children attending schools and
kindergartens undergo a number of officially established medical checkups against different diseases and infections. Schools and kindergartens usually have health points with nurses functioning locally. According to the state norms in Armenia, every 400 children should be attended by a nurse or a medical representative, who has to assure adequate health and safety conditions and direct communication with correspondent health bodies when required. Eye care is classified under the category when only general examination and advisory are possible, as admitted by the local medical personnel. Perhaps, this is the reason why the percentage of children identified with eye problems for the first time is in the range
THE AECP LAUNCHES A NEW PROGRAM on Retinopathy of Prematurity in Armenia The gift of sight
notes from the field
continued on page 2 >>>
bringing
sight
to armenian eyes the armenian eyecare project aygestan 5, house 7 yerevan, armenia phone (374 10) 55 90 68 fax (374 10) 57 76 94 aecp@cornet.am
p.o. box 5630 newport beach, ca 92662 phone 949.675.5767 fax 949 673.2356 aecp@eyecareproject.com
Founded in 1992, in the United States by an American-Armenian ophthalmologist Roger Ohanesian, M.D., the Armenian EyeCare Project (AECP) is a California based nonprofit corporation dedicated to the elimination of preventable blindness in Armenia. In 2003, the AECP established an office in Yerevan and launched its program “Bringing Sight to Armenian Eyes.” The Initiative has five comprehensive, integrated components developed to eliminate preventable blindness. They include direct patient care, medical education and training, public education, research and capacity building. More than 240,000 people have been screened and over 10,000 sight-saving surgeries and laser trea ments have been performed in the Mobile Eye Hospital. The AECP has been a USAID partner since 2004.
www.eyecareproject.com This publication was made possible with the support of the American People through the U.S. Agency for International Development (USAID) and the Armenian EyeCare Project (AECP). The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views of USAID or the U.S. Government.
2 AECP ELECTRONIC BULLETIN – VOLUME FIVE/ISSUE ONE
<<< started on page 1 of 40-60%. These kids (along with their parents and teachers) learn about their eye problems only after specific professional eye screenings. With the Mobile Eye Hospital garaged for the winter following its travels throughout the regions, the AECP medical teams traditionally provide services in Yerevan. This winter the AECP worked in the administrative districts of Davitashen and Erebuni, in close cooperation with the Yerevan City Hall and
beneficiaries of the Mission Armenia received local administrations. 113 eyeglasses, and 35 eyeglasses went to the The AECP medielderly in Davitashen. The eye screenings for cal groups visited the elderly in Erebuni took place in the Nursfive kindergaring Home tens and six sec#1, the Repulican ondary schools Center of in Davitashen. Veterans Altogether, the and the AECP experts examined about councils of 2,300 children, perished redirected 69 kids for double check-ups to the soldiers Malayan Ophthalmologic Center (MOC), and preand veterscribed 12 eyeglasses. ans. Out of In Erebuni the AECP groups carried out eye more than 300 examscreenings in 15 kindergartens and 26 schools. Out of more than 7,000 children examined, 752 were ined, 162 were provided with eyeglasses and about registered with eye problems and 328 kids were 80 people were referred to the Mobile Eye Hospital redirected for double check-ups to the MOC. for laser treatment and surgeries. In addition to children’s eye screenings, the AECP organized examinations for the elderly, too. Eye screenings took place in the Town of Hope of the Diaconia Charitable Organization and in social service centers of the Mission Armenia, NGO. The
One day on the Mobile Eye Hospital
The Armenian EyeCare Project (AECP) and its Mobile Eye Hospital (MEH) within the program “Bringing Sight to Armenian Eyes” currently carries out the fourth tour in the regions of Armenia. On April 6-10, the MEH was stationed in the premises of the nursing home #1 in the village Haghanak in the proximity of Yerevan.
After eye screenings conducted in Davitashen and Erebuni administrative districts of Yerevan, 40 beneficiaries from the Mission Armenia, NGO, 16 elderly individuals from the nursing home #1, four veterans form the Republican Center of Veterans and eight people from the councils of perished soldiers and veterans were referred to the MEH for surgeries and laser treatment. Dr. Asatur Hovsepyan has been coordinating the work of the MEH since the start of the program “Bringing Sight to Armenian Eyes” in 2003. Asatur’s colleagues joke that he is the extension of the MEH. Apart from being a very talented eye surgeon, Dr. Hovsepyan is a very good engineer and can fix anything and everything on the MEH. He is a person of many talents which is critical for a mobile hospital that works independently in the regions. Asatur is famous for his professionalism, dedication, sincere and considerate attitude to the MEH patients and staff. The work on the MEH is organized on a nonstop basis. Two examination rooms furnished with latest medical equipment allow providing several services at the same time. The day starts with check-ups of referred patients and laser procedures if needed. In the meantime, the operated patients of the previous day start arriving for a post-op checkup. This is when the eye bandage is removed. It is the favorite part for the MEH staff because they love to witness the happiness of their patients when those see the light again. Countless blessings are voiced in the MEH every day to the medical crew, the organizers and the benefactors of the ‘’Bringing Sight to Armenian Eye’’. ‘’This newly operated eye sees better than the other one’’ exclaimed Janna, when the nurse took off her eye patch. The surgery that lasted less than an hour opened the sight for a practically blind eye, and Janna’s amazement was a natural reaction after years of darkness. As most of the MEH patients, Janna had not even thought of
having surgery for many years due to the extreme poverty that she and her family lives in. This was a unique opportunity for her to get a free of charge high quality medical service on the MEH. Zhora (George), 85 is a second World War veteran. He is still strong and energetic. To prove that he told me - “Give me your hand! See!!! There is still enough vigor in me!!!” Dr. Hovsepyan removed the cataract in his single eye some years ago. The other eye was lost back in the war long ago. This visit to MEH was not related to Zhora’s eye problems. He was accompanying his sister-in-law, who lives with them, because there is nobody to take care of her. She was referred to MEH for a cataract surgery. Zhora is sure that everything will be fine with Manik, since Dr. Hovsepian is in
to visit a benevolent soup kitchen. “The existence of the MEH is an immeasurable happiness, since it helped me, and many others to get rid of this blurriness in the eyes” Seda said. Hamlet, a former police officer, has been confined to a wheel-chair for already ten years. He was injured at service and lives in the nursing home since then. Despite serious conditions, Hamlet remains a positive person with charming humor. Most probably, his optimistic and positive nature helped him endure the efforts of an entire team lifting him up to the MEH for an eye surgery. Hamlet let perform the surgery easily, and the MEH medical staff accomplished this challenging task with honor. Armine Gylugyulyan, the representative of the Mission Armenia NGO told us that doctors on the MEH are equally considerate towards all patients. “Our job is to raise the issues of the single elderly people. Their eye problems are of primary priority for our organization. In most of the cases, they fall down because of low vision. They fall and hurt themselves, causing major injuries that lead to complicated health problems in the future. Most of the elderly people are unable to resolve their charge. problems on their own. Often their relatives do Normally, not care at all, and we are the only ones who take them to a hospital - to the MEH in our case. I have surger ies accompanied 14 people for surgeries to the MEH. start on the All of them were performed perfectly.” second half of the day. On average from seven to ten surgeries Donara Gharibyan, the senior nurse of the Nursing are performed daily on the MEH. For the majority home #1 added in her turn: “It’s already five years of cases these are surgeries of the frontal side of that the MEH is visiting us. We are very pleased and the eye: including, cataract removal and implanta- satisfied. Thanks to you, many of our senior citizens tion of new lenses, glaucoma restrain, pterigium regain their vision and see the light. The medical removal, etc. staff of the MEH is very professional and attentive. Numerous patients come to the MEH - each with We highly appreciate the opportunity of receiving particular pain, complain, problem, and destiny. high quality eye care and treatment in the backyard Seda is a single woman. She has no children and of our nursing home. This is indeed a salvation for there is nobody to look after her. Because of the many people especially that it is extremely hard to miserable pension, this woman spends most of arrange surgeries in other hospitals.” the day in the city market, selling greens and vegetables. The money she gets from this “business” is hardly enough to survive, hence Seda is obliged
AECP ELECTRONIC BULLETIN â&#x20AC;&#x201C; VOLUME FIVE/ISSUE ONEâ&#x20AC;&#x192; 3
DATA ANALYSIS & RESEACRH
The Results of the AECP Mission in Lori Region in 2005-2009 The Armenian Eye Care Project (AECP) accomplished three missions in urban and rural communities of the Lori region (marz) in Armenia in the period of 2005-2009. During these visits, cumulatively, the AECP ophthalmologists screened 18,569 residents, 68% out of which were adults and 32% - children. Nearly half of the screened population was from rural communities, where eye care services are less accessible. On the Mobile Eye Hospital (MEH) the AECP doctors provided detailed examination to 2,815 people and performed surgeries and laser treatments for 1,165 adults. In addition, the AECP provided eye glasses to 3,987 people, belonging to socially vulnerable groups. Parallel to eye screenings, the AECP created a database of its patients in Lori. The analysis of the accumulated data allows calculating main indicators for eye problems and vision impairment of the population in the region. According to the AECP estimates, 0.6% of the population in Lori is blind, and 5% has low vision. Thus, in total, 5.6% of the population in Lori is visually impaired. The prevalence of visual impairment in Lori is higher than the national average by 1.8 percentage points. Cataract is the main reason for being visually impaired in the region - 45%
of diagnosed cases were caused by unilateral or bilateral cataract. It is also important to estimate the prevalence of eye diseases causing blindness, such as glaucoma, cataract, corneal diseases, diabetic retinopathy and macular degeneration. It should be mentioned, that more than half of diagnosed cases of eye diseases causing blindness were revealed by the AECP doctors for the first time. It means that the AECP gave an opportunity to the first time diagnosed persons to prevent their possible blindness in due course of time. Thus, the AECP activities are essential for blindness prevention both in the given region and in the country as a whole. In accordance with the AECP estimates, 11.7% of the adult population in Lori has at least one eye disease causing blindness, and the prevalence of cataract is the highest among these diseases 6.9%. The blindness caused by cataract is possible to prevent by timely surgical treatment. Nevertheless, according to the AECP data, only 21% of adults having unilateral or bilateral cataract in Lori have had a cataract surgery in one or two eyes. It is noteworthy that this percentage is much higher (63% in India, 44% in Pakistan) even in many developing countries.
Eye disorders and diseases
Prevalence among the total number of the population in Lori region - %
External diseases, including:
28.2
Corneal disorders
2.0
Cataract
6.9
Non-glaucomatic disorders of the optic nerve
1.3
Glaucoma
1.2
Fundus disorders, including:
7.1
Diabetic retinopathy
1.1
Hypertonic retinopathy
1.7
Macular degeneration
1.9
Total % of people having at least 11.7 one eye disease causing blindness
THE AECP LAUNCHES A NEW PROGRAM
The AECP Launches a Screening and Treatment Program for Retinopathy of Prematurity in Armenia An international conference dedicated to issues of Retinopathy of Prematurity will take place in Yerevan on June 28-29. In this regard a representative medical mission from the United States will arrive in Armenia. All over the world the number of surviving babies born prematurely and with low birth weight is rising due to advances in neonatal care. These newborns however have many health risks in their future lives such as retinopathy of prematurity (ROP). ROP is a condition in which abnormal retinal neovascularization occurs at the intersection of mature and premature retina leading to changes in the retina including macular traction and retinal detachment which result in childhood blindness. The risk group for ROP is defined as infants born with a birth weight of less than 1500 g or with a gestational age of 30 weeks or less and infants with a birth weight between 1500 and 2000 g or gestational age of more than 30 weeks with an unstable clinical course and who are believed by their attending neonatologist to be at risk . According to international data, more than 50% of newborns having a birth-weight of less than 1250 grams have some degree of ROP. The probability of ROP is inversely proportional to birth-weight; the lower the birth-weight of the child, the higher the probability that he or she will develop ROP. ROP screening is carried out about 4 weeks after birth. The screening is a retinal examination using an indirect ophthalmoscope. If ROP is detected, the ophthalmologist will carry out follow-up examinations. Depending on the course of the disease the ophthalmologist may recommend laser procedure which effectively prevents the risk of blindness later in life. The problem of ROP is emerging in Armenia, as evidenced by practicing neonatologists and ophthalmologists who encounter more and more of such cases. According to some estimates, about 500-600 children are born annually who belong to the risk group. In Armenia the ROP screening, early detection and treatment are not available. As a result, the vision problems of these children are being revealed when it is already too late, making treatment less effective. Aside from that, children with ROP have no option but to go to St. Petersburg to receive treatment. As a result very few children receive such treatment, and if it is not carried out the children become blind. It is known that
sight is the most important sense of children, and they receive 80% of their knowledge and world perception from it. It is for this reason that the development of childhood blindness makes it difficult to integrate children into education and society. Being entrusted by the Ministry of Health of Armenia, the AECP considers the introduction of retinopathy of prematurity screening, diagnostics and treatment program as crucial for the prevention of disease, early detection, and treatment in Armenia. The project is planned to implement at two Neonatal Intensive Care Units (NICUs) at University Clinic #1 and at the Republican Center of Perinatology and Obstetrics. Subsequently, the project will be introduced into other NICUs. All the aspects of the program will be discussed at the international conference which will take place on June 28-29 inYerevan. In this regard a representative medical mission with leading specialists in the sphere from the United States will arrive in Armenia. In order to train the Armenian specialists the American experts will perform eye screenings and laser treatment, launching the main stage of the ROP program in Armenia. It is noteworthy that the AECP has already purchased some part of the necessary equipment and transported it to Armenia. Training and public awareness materials are being prepared at this stage. More information about the ROP program will be placed in the next issue of this electronic bulletin.
THE GIFT OF SIGHT
4 AECP ELECTRONIC BULLETIN – VOLUME FIVE/ISSUE ONE
Thank You for My Son’s Future Fellows of the Armenian EyeCare Project (AECP) save the sight of one more Armenian child.
Six-year-old Manvelik is almost a family member for the medical staff of the Malayan Eye Center (MOC) in Yerevan. He has been coming to MOC from the village of Akunk (Kotayk marz) for already three years and has been treated by at least five doctors. On the whole, Manvelik has been seeing eye doctors since two when he had burnt his eyes with a laundry bleach liquid. Lilit, Manvelik ’s mother, will never forget that October day: “We were prepared to leave the house when I noticed my younger son missing. Shortly, I heard a horrifying clamor from the bathroom. There I saw Manvelik screaming, with his hands on his face.” Manvelik had taken the open container with bleach liquid and tried to drink from it, thinking it was juice. The liquid was splashed all over his face and hands. “When I washed his face with water and he managed to open his eyelids at last, I saw that his eyes were completely white”, Lilit told us. Emotions have been overwhelming Lilit since then – ranging from self-condemnation, guilt, helplessness to fear for her son’s future. Before coming to MOC, Lilit had taken Manvelik to many doctors. Her fear grew when doctors told her that
they would be unable to save his right eye. Thanks God the other eye preserved some vision at that moment, even though it was burned as well. Manvelik suffered - he could not open the eyelid, he did not see anything with his right eye, and in addition, felt very insecure and isolated, since children in the yard made fun of him. From her emotional experience Lilit remembered the sufferings and the fear that her son would never see properly in the future. “It is impossible to express what we have experienced. My husband works as seasonal worker and hardly manages to help both ends meet. There were moments when I could not imagine where to get means for my son’s treatment” said Lilit. Manvelik, his parents and two siblings are an ordinary poor family. Their income constitutes a state pension of 20,000 drams (50 $) and 11,000 drams (28$) for Manvelik. This situation lasted for almost four years until a miracle happened to Manvelik. After a series of surgeries performed at the Malayan Eye Center, Manvelik was able to see with his right eye again. The AECP has its role in the “miracle”. Manvelik now carries a keratoprosthesis provided by the AECP. All three doctors who are treating Manevelik, did an AECP fellowship in the US. According to Manvelik’s doctor, Dr. Anna Hovakimyan: “The
major success is in the combined hard work performed by the MOC medical staff towards restoring the eyesight of this kid. It is very noteworthy that all doctors who cured Manvelik are AECP fellows trained in the United States. Plastic surgeon Dr. Armine Gharakeshishyan has opened the damaged eyelid, I have implanted the keratoprosthesis. Besides, some signs of glaucoma have been identified, and our glaucoma specialist, Dr. Lilit Voskanyan is working with the kid as well. This is really a great investment and contribution from the AECP.” Dr. Anna Hovakimyan said that their American mentors and colleagues may be proud of them, because Armenian ophthalmologists successfully practice innovative techniques and knowledge provided by the AECP physicians travelling regularly to Armenia. It should be mentioned that 32 medical missions to Armenia have been organized by the AECP from the U.S. More than 50 American eye specialists have visited Armenia on their own expenses to train local ophthalmologists at the Malayan Eye Center and heal patients. In Dr. Anna Hovakimyan’s words, the fact that Armenian doctors grow and become more safe-reliant is the most desirable outcome for their American colleagues. The family yet has a long way to go - Manvelik will undergo more procedures and laser treatment. However, this does not break the will of his mother. Lilit feels that things change when people really care for her loving son. “Thank you for my son’s future” she concluded.
Notes from the Field
Fragments from the story by Dana Hornbeak about an internship with the Armenian EyeCare Project at the Malayan Ophthalmologic Center in Yerevan. Dana is a medical student at the Duke University. She needed an internship to qualify for further academic residency at the University of Pennsylvania/Scheie Eye Institute.
Malayan Ophthalmologic Center: Yerevan, Armenia, February 2010. I see Grigor’s calloused, weathered hands before his eyes: farmer’s hands, as stoic and tough as he is. His eyes are a bewitching clear hazel: a cross between Middle Eastern and European, manifesting the hundreds of years of cultural mixing that typify this crossroads. Smiling through missing teeth and wrinkled dimples, he hands a small white paper to the ophthalmologist and sits down for a refraction reading. I glance at the slip: the label “Armenian EyeCare Project” (AECP) stands out amidst the Armenian characters. I learn that Grigor is from a rural village several hours north of Yerevan, and was seen by one of the AECP’s regional eye screenings. Diagnosed with a dense cataract, he came to the Malayan Ophthalmologic Center (MOC) for surgery – all arranged by the Armenian EyeCare Project. He now returns for a post-operative checkup – excellent outcome, no complications – and will return to his farm tomorrow. For Grigor, as for countless other patients, his “Armenian brothers in America” are restoring his vision. Restored vision in turn means restored livelihood, as all farm, factory, and household activities rely on adequate eyesight. There are very few safety nets here. For many patients, the Armenian-American diaspora and organizations like the Armenian EyeCare Project are their primary opportunities to receive health care. Due to poverty, isolation of countryside villages,
or both, patients often present to AECP screenings or to the Malayan Ophthalmologic Center with advanced disease. My first day in the admitting and triage clinic, for example, included a fulminant case of preseptal cellulitis, a fifteen-year-old boy with untreated low vision since a penetrating eye injury at age six, and a cataract visible from across the room - the most severe cataract I have ever seen. As Dr. Ohanesian says, “In the U.S. there are cataracts, but here there are cataracts.” These patients come to the Malayan Ophthalmologic Center because it is considered the leader in ophthalmologic care in the country – a rank largely due to the partnership with the Armenian EyeCare Project, including donated equipment and professional collaboration. In rural regions, it is much more difficult to obtain eye care. Most families usually do not have access to medical care, much less ophthalmologic care. Even if they have money for an eye checkup, there are usually no ophthalmologic specialists in their region, and only rudimentary surgical facilities. The AECP’s Mobile Eye Hospital comes here: to the most remote, under-resourced areas, and to the individuals who would otherwise have no recourse for lost eyesight. My 1.5 months in Yerevan are both clinically and organizationally interesting. Clinically, as a fourth-year Duke medical student soon to start my ophthalmology residency at the University of Pennsylvania, it is a fantastic educational opportunity: learning from experienced Armenian oph-
thalmologists, seeing complex ocular pathologies, and practicing examination skills. Organizationally, it has been a case-study of the Armenian EyeCare Project, drawing on my background of a Master of Public Health (MPH) and undergraduate Honors Thesis. For my undergraduate thesis, I analyzed the organizational structure of a health care-related NGO in the Peruvian Amazon. Despite the cultural differences and 10,000+ miles separating them, many of the markers of the Amazon NGO’s success are visible in the AECP. These include strong collaboration with local professionals, a committed core leadership group, positive relations with the local community, sustainable education programs, responsiveness to changing health needs, and provision of necessary equipment. To these, the Project has added research, which promotes long-term academic involvement with the local medical university. The Armenian EyeCare Project is well-known by the local community, both in Yerevan and in rural Armenia. “Even in rural regions,” notes an MOC ophthalmologist, “every ophthalmologist in Armenia knows about the Project.” Unlike many American or European NGOs elsewhere which have engendered competition among local partners, the Armenian EyeCare Project works alongside - completely integrated with local physicians, nurses, and health leaders. As a result, its catchment area extends throughout the country, something that few healthrelated networks have been able to accomplish.