Ophthalmology in Paradise?
Dr Peter Hadden, an Auckland ophthalmologist, visits Samoa annually. He reports on his experiences there on his last trip.
I have been fortunate to be able to travel to Samoa annually for the past four years, and recently have been back again; visiting the Eye Department at “Tupua Tamasese Meaole Hospital” (“TTM Hospital”) in Apia, to work with and help the eye care professionals there.
The two most commonly encountered conditions causing visual loss there are, as one would expect, cataracts and diabetes mellitus; most of my job is to help them improve their management of both of these conditions. I am also shown various unusual cases that they have not been able to diagnose, including not only retinal and lens-related conditions but also pathology well outside my usual area of interest, such as squints and orbital conditions, which is rather challenging and certainly keeps me on my toes! Luckily for me I have access to the internet and can text colleagues back home, which I did with a challenging case of thyroid eye disease which Richard Hart had previously been looking after.
However, the vast majority of the pathology that I saw was cataract and diabetic retinopathy. The cataract population in Samoa is different from that in most of New Zealand – they are almost universally very advanced, hard cataracts. Phacoemulsification, the main method of cataract extraction used in New Zealand, has only just become available there, thanks in the main I believe to Mike Mair from Timaru, but for such dense cataracts as they have the Legacy, the machine they have, is not always suitable as significant amounts of power may be required. It’s certainly difficult having been spoilt with the Phaco Ozil that we have at Eye Institute and then be forced to use a much older machine. On top of this, the ophthalmologist in Apia also does not have much experience in phacoemulsfication, so his usual technique is a modified form of extracapsular cataract extraction called “Small incision cataract surgery” – SICS for short, which is sutureless, does not require retrobulbar or subtenon’s anaesthesia, and does provide pretty rapid visual recovery. I have been quite impressed by some of the results that I was shown with this technique.
However, for those patients suitable for phacoemulsification of course they would like to be able use this technique, as the results are superior, so I spent two days demonstrating modern phacoemulsification cataract surgery and trying to teach it to the ophthalmologist there. The patients of course are very satisfied as the visual acuity on the first post operative day is inevitably better than with SICS or the even older extracapsular technique that is also used in Samoa. I’m not sure, however, given the training required and the amount of disposable (and therefore expensive) equipment needed for phacoemulsification, whether for Samoa it is truly the best solution, especially given the pretty reasonable results of SICS in their hands; I certainly wouldn’t like to see phacoemulsification complications such as dropped nucleus having to come my way when they do SICS well. Even with the best surgical technique, however, the visual results are still not going to be as good as those we can achieve at Eye Institute in Auckland, mostly because of the use we make of advanced technology such as the IOL Master, computerised corneal topography, limbal relaxing incisions and toric intraocular lenses which enable a much more accurate refractive outcome and which are simply unavailable in Samoa.
The other scourge is diabetic retinopathy, and the Samoan population has one of the highest rates of diabetes in the world, which continues to increase. This is partially due to genetics and partially due to changes in diet. Moreover, the complications of diabetes are increasing as the population ages and each individual has had diabetes for longer.
Proliferative diabetic retinopathy and diabetic maculopathy are the most important ocular complications of diabetes, and both can potentially result in severe visual loss. Laser photocoagulation, the mainstay of treatment, is ideally performed before the patient experiences visual loss, as it more easily prevents visual loss than cures vision already lost. TTM Hospital has an ophthalmologist who is well versed in laser treatment, and they have a good quality laser, but the real problem is finding the patients who need the laser treatment in the community before they develop problems. I also performed what I believe is the first intravitreal injection to treat diabetic maculopathy done there, so perhaps I have introduced something new to them that might be helpful for more of their patients. They are therefore trying to educate nurses and other doctors such as diabetic physicians and general practitioners to be able to check people’s vision and perform a cursory but relevant ocular examination for diabetic retinopathy. In New Zealand, the most common form of screening is by retinal photography, and they do hope to be able to do this in the future although it requires outlay in the form of fundus cameras and a screening programme to be put in place. Of course, sometimes vitrectomy surgery is required for severe diabetic retinopathy and part of my role was also to determine when this might be required; as it is not possible for me to do this in Samoa I have taken a few patients to New Zealand for vitreoretinal surgery.
Training and continuing medical education is also of major importance. I hope that they found my visit helpful in that regard, as they are isolated both because they do not get all the educational material that we get and because of their geographic isolation; hopefully by including them more in events such as the RANZCO Congress and with several of us helping them (to my knowledge, as well as myself Keith Gross from Rotorua and Mike Mair from Timaru also go, as does a Dr Smiles from Australia).
In summary, although they don’t have as much equipment, resources and teaching programmes in place as we have in New Zealand, all the staff there involved in eye care are very dedicated and enthusiastic, and with help I hope that the quality of eye care possible in Samoa will continue to improve. They are also some of the most friendly and interesting people to work with, and I look forward to my next trip.
I am very grateful for the support given to myself and TTM Hospital, both to enable my visit and for free donations of equipment, from the Counties Manukau District Health Board, Alcon Laboratories and OIC, the Ophthalmic Instrument Company.
Peter Hadden is an Auckland ophthalmologist, working at Eye Institute Remuera and New Lynn, Greenlane Clinical Centre and Retina Specialists. His areas of interest are cataract and retinal surgery and ocular oncology.
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