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.
.
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 in Geta, 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 teams were 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 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 TOTAL
OPD 65 5654 7758 6788 7418 11052 10591 12463 14179 14382 17734 20848 19812 21316 26086 26561 24750 21878 22697 25233 31484 35000 39959 37386 39899 44324 49024 58246 67423 76227 86946 88318 3
Witho PCIOL ut IOL 0 0 52 0 388 0 431 0 396 0 731 0 834 0 1463 0 2461 0 2963 0 2395 19 2713 2 2306 0 3403 12 3541 3 3626 116 3802 306 3920 635 3211 1326 2116 3720 1626 5239 987 7566 476 9523 326 9401 194 11230 154 13161 115 15125 134 17363 117 21745 171 25654 252 28583 45304 17072 9
AC IOL
TOTAL
0 0 0 0 0 0 0 0 0 0 0 69 14 22 97 40 27 38 49 143 202 254 307 178 171 149 180 193 244 163 249 2789
0 52 388 431 396 731 834 1463 2461 2963 2414 2784 2320 3437 3641 3782 4135 4593 4586 5979 7067 8807 10306 9905 11595 13464 15420 17690 22106 25988 29084 218822
OTHER TOTAL TOTAL IOS EOS SURGERY 0 2 2 0 217 269 0 285 673 0 104 535 0 200 596 0 277 1008 0 182 1016 0 147 1610 0 207 2668 0 386 3349 177 319 2910 192 436 3412 79 294 2693 431 396 4264 678 457 4776 499 468 4749 534 427 5096 420 525 5538 443 496 5525 590 536 7105 524 627 8218 536 765 10108 765 626 11697 779 672 11356 512 948 13055 273 956 14693 308 1161 16889 358 1123 19171 437 1376 23919 486 1332 27806 1671 1436 32191 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 .