OHSU ophthalmologist helps save eyesight in Bangladesh

An estimated 650,000 adults in Bangladesh suffer from blindness, according to researchers.

At the end of November, Oregon Health & Science University ophthalmologist Beth Edmunds traveled to the country to teach local doctors a minimally invasive operation for adults and children with glaucoma.

She joins us to share what she took away from her time volunteering and what it was like operating in the world’s only flying teaching hospital.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We end today with Beth Edmunds. She’s an ophthalmologist from Oregon Health & Science University’s Casey Eye Institute. At the end of November, she traveled to Bangladesh to teach local doctors and their teams how to perform specific surgeries for childhood glaucoma. She conducted that training at a unique venue – a repurposed passenger plane with its own classroom, operating room and recovery room. It’s called the Flying Eye Hospital and it’s run by the nonprofit, Orbis International. Beth Edmunds, welcome to “Think Out Loud.”

Beth Edmunds: Thank you. It’s lovely to be here.

Miller: You focus on childhood glaucoma as well as glaucoma in adults. Can you give us a sense for how this disease develops and the prognosis, especially if it’s untreated?

Edmunds: Often, the first thing I hear a parent or even an adult patient say when they hear that there’s a child in the clinic is, “Oh, I thought this was a condition that only happened to older people.”

Miller: That’s what I thought.

Edmunds: This is where it’s doubly tough, when you have young parents with their first child, grappling with the difficulties of just looking after a baby, to then say, “Well, your child has got this condition called glaucoma,” and have to do the very slow explanation of what this means.

And for children – in particular, those that are born with it or in whom it develops very soon after birth – untreated, the prognosis is not good. The likelihood of a fully sighted lifetime is very low. Many children will have some sight into adulthood, but on the whole, if untreated, this is a pretty devastating condition. But we do know that if it’s caught early, before the damage occurs, there are treatments that can really make a difference. And sometimes we can actually, we don’t ever like to say “cure,” but sometimes one can even cure it.

Miller: But, unlike with cataracts, am I right that if vision has been damaged significantly by glaucoma and then there’s treatment, you can’t bring back sight?

Edmunds: Yes, correct. And that is why this is a very time pressured thing. One wants to catch it early. Of course, any disease in its early stages can be subtle, and then one wants to intervene early. Getting the awareness and the message out there that yes, children and babies can have glaucoma, too, and also getting the training out there so that people know what to do with these cases and don’t just regard them as a smaller version of adult glaucoma – which they’re not – it’s difficult. It is a pretty rare condition, but, yes, at any point when one intervenes, the goal is then to try and slow the condition down, so that at least you’re stopping things from progressing at the pace that they were.

Miller: Why did you want to go to Bangladesh?

Edmunds: Well, I wanted to do something with Orbis. Orbis was going to Bangladesh, so I was open to wherever they wished to go for that particular trip. Orbis visits countries all over the world, and the timing of their trip to a particular place has to coordinate or be possible within the time that a volunteer faculty is able to join them. So it was very fortunate that I received an invitation, and indeed, was able to join them.

And the reason for Orbis going to Bangladesh and me, therefore, was because … The aerial went to Chittagong in Bangladesh, which has a very low number of ophthalmologists per capita, only about six out of a million. Whereas, in the United States, we have 52 per million people. And even with those ophthalmologists, of course, access to care for the people is difficult. These are undeveloped countries, low resourced, but there are hospital systems and medical systems there. And Orbis identifies places where there is a structure that they can pair with, so that they can help develop the people and the things that are already there to the next level.

So what they’ll do is identify young doctors in the departments who are already fully-trained as an ophthalmologist, but who recognize that they’d like more skills in pediatric glaucoma, specifically. And then we go out with that in mind. The idea is to train that surgeon and the team, which includes nurses, optometrists, mechanics, recovery staff, anesthesiologists – because all of those pieces are needed to be able to deliver safe surgical care to children. Hence, Bangladesh was one of those areas that could benefit from this kind of project.

Miller: Can you describe the plane where this training took place?

Edmunds: Yes, I’d heard about it. I think it’s one of those things still in life … It’s quite nice, as an older adult, to be really excited about doing something. And stepping on that plane was every bit as exciting as I’d hoped it would be. Because you approach a plane that looks like any other plane sitting on the tarmac, except of course it’s got Orbis International written along the side of it. And you walk up the gangplank. When it’s parked, I suppose at a more remote part of the airport where there’s just sort of brush and scrub around the sides, it feels a little bit like the 1960’s, when you saw people boarding these glamorous planes up a wider gangplank.

Miller: Cigarettes in hand and martini waiting for them …

Edmunds: It had that feel, but those things weren’t there. Coffee cup in hand, the modern equivalent …

Miller: That sounds better for a surgeon, especially.

Edmunds: Yes, yes, decaf.

As you go through the door, is when you get the surprise, because instead of being rows and rows of seats, you walk into a small little alleyway. And straight opposite you is where the actual operating room is, which is a contained room. Of course, it needs to be equipped, ventilated and kept clean to the same spec as any operating room would. So it’s a self-contained unit.

Next to it is a recovery suite, where the patients who have had their surgeries are recovered by the nurses. And in fact, on the first day I was there, they were doing a mock recess drill. So it was really interesting to see everybody doing the kind of drill that I would recognize from a hospital here.

Towards the front of the plane, there’s a simulation lab where they’ve got state-of-the-art simulation equipment, so the trainees can be taught by simulation some of these surgical techniques.

And then at the front of the plane, some of the original seats are still laid out, so that feels more familiar. But there’s a very big audiovisual system connected and stationed behind the cockpit, where all the videos are played and where we were giving lectures with our PowerPoints. And in fact, it’s connected to the operating room. So I had the added requirement of not only performing the surgery, but also talking about it in real time and answering questions from the audience.

Miller: My understanding of this Orbis model is that this is the epitome of the “Teach a person to fish,” idea, as opposed to, “We’ll fly somewhere and while we’re there, we will help as many people as possible, then we’ll fly to the next place.”

But it seems that training in any given procedure, it’s necessary but not sufficient. It’s not sufficient if the equipment and facilities, if the physical infrastructure in a place is not robust enough. Can the doctors and nurses, the teams that you trained, do versions of the interventions that you train them on, after you leave?

Edmunds: You raise such an important point. There is the importance of it, indeed, being a truly viable training, intervention or surgery that that you’re teaching, that this is indeed sustainable and do-able locally. Now, sometimes one’s also supplementing what one’s doing, in terms of training the technique. In some cases, one is supplying instruments, teaching people how to fix those instruments should they break. But yes, there is no point teaching a surgery that can’t then be continued when the support is no longer there.

I think this is also where Orbis is very thoughtful and careful to choose a site where they know that this is possible, where there is already an existing infrastructure, where there is already a relationship. Orbis has gone to Bangladesh every five or six years or so, so they know the team on the ground and the team knows that they’re coming back. But then there is also this continued contact with the team afterwards.

For example, I got to meet my participant trainees, established that relationship beforehand, obviously met them and trained them in person. But now, [I] still continue to mentor them, have maintained that relationship, so that every few weeks I get an email or a call saying, “Professor, what do we do now?” And then we discuss the case and what might be a good option with their environment in mind.

But yes, I think you also are alluding to the actual surgeries themselves, and one of these surgeries that we taught, we tend to do a more modern version here that uses a very lovely microcatheter hand piece with a blinking light, which helps you to see where you are. That adds about $1,500 to the cost of the operation. There is another version, however, that I was able to do with them in Bangladesh, where one just uses a blunted suture filament that is firm enough to be threaded into the canal, just the same way as the microcatheter is. It’s a little bit more tricky that you don’t have this lovely blinking light to follow. But it’s eminently performable. So to be able to teach them that operation, known as GATT – and I can give you the long name if you like [and] we reckoned was probably the first time ever being performed in Bangladesh – which a well proven, highly successful surgery for childhood glaucoma, was a very special thing to be able to do.

Miller: Beth Edmunds, thank you very much. That’s Beth Edmunds. She is a professor of ophthalmology at the Casey Eye Institute at Oregon Health & Science University. In November, she went to Bangladesh to teach ophthalmologists there how to treat glaucoma in children.

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