Treatable and preventable blindness has been identified by the World Health Organization (WHO) as a major global health problem.1 The World Health Organization proclaimed "Foresight Prevents Blindness" on World Health Day, April 7, 1976. There has been much international interest since then in the problem of treatable and preventable blindness, and governments of many developing nations have become aware of the socioeconomic loss they sustain because of high blindness prevalence rates.2
The prevalence of blindness is as much as 10to40times higher in areas of certain developing countries as compared to the more technologically advanced western nations.1 Cataract, trachoma, onchocerciasis, and xerophthalmia are the major causes of blindness worldwide. We know from WHO data that there are 28 million people with visual acuity iess than 1 0/200 (3/60) in the better eye. There are presently believed to be 42 million people with visual acuity of less than 20/200 (6/60) in the better eye.4 Cataract accounts for 1 7 million of all individuals with a visual acuity less than 10/200 (3/60).4 Millions are blind from corneal complications of trachoma. Precise data on blindness from trachoma are unavailable.
Cataract represents the largest category of potentially surgically curable blindness. Additionally, lid surgery to correct entropion with trichiasissecondarytotrachoma can prevent progression of corneal scarring and subsequent blindness.
Resources available for ocular surgery in developing nations are limited. Appropriate technology in health care can extend health resources in the Third World.5 Surgical delivery in ophthalmology can be cost-effective and inexpensive. For example, a single cataract extraction can be performed for as little as U.S. $10."
MATERIALS AND METHODS
The following modifications to ocular surgery have been integrated into the central and rural eye services of the Kenya Rural Blindness Prevention Project.
Sterilization for some surgical instruments may be accomplished by boiling over a portable gas (butane) stove. Scissors, knives, and delicate instuments can be sterilized chemically, in methyl alcohol. Figure 1 illustrates the portable camping gas stove and stainless steel container, together with two trays of surgical instruments and case which may be carried to rural health facilities for eye surgery.
An operating room light may be created from the halogen headlight. This light is portable and can be powered by a 1 2volt battery positioned in a light truck or van. Figure 2 demonstrates the leads of the headlight being attached to the terminals of the battery which remains under the hood of the vehicle parked outside the operating room. This portable light also serves as a back-up light source in the event of power outages at static hospitals. Figure 3 illustrates ophthal mie clinical officers performing entropion surgery using this operating light.
A surgical headrest may be created from foam sheet packing material. An 8" X 8" section of this material is contoured to accommodate the patient's head. It is used in the operating room to provide comfort a nd partial immobilization during surgery (Figure 4),
FIGURE 7: Surgical set with butane gas stove for sterilization.
FIGURE 2: Affixing the leads of the operating room light to a 12-vo/t automobile battery.
The blade breaker provides a means for creating inexpensive cataract blades. The blade is chemically sterilized. One blade may provide six cataract knives (Figure 5).
The erisiphake has virtually disappeared from the ophthalmic surgical instrumentation in developed countries. It remains valuable in developing nations where high ophthalmic technology is unavailable. It is virtually failsafe, and it does not rely on electrical power. An erisiphake and an extracted Morgagnian cataract are illustrated in Figure 6. Capsule forceps may also be used for cataract extraction. For those surgeons who prefer cryoextraction, an inexpensive and efficient system of cryoextraction may be manufactured locally.7
FIGURE 3: Ophthalmic clinical officer performing surgery (operating light from a 12 -volt battery).
FIGURE 4: Surgical head rest styled from packing crate material.
FIGURE 5: Blade breaker and locally-manufactured razor blades.
FIGURE 6: Erisiphake and Morgagnian cataract.
FIGURE 7: Making an eye shield from discarded x-ray film
FIGURE 8: Mobile eye unit and ophthalmic clinical officers.
Protection of the postoperative eye may be provided by an eye shield manufactured from discarded x-ray film. A 2-1/2" diameter circle is cut from the film with scissors, and one radial incision is made to the center. It is then folded into a shallow cone, and the edges are affixed in position with a staple or tape (Figure 7).
Mobile services may be taken to the field in four-wheel drive vehicles. Such a unit is pictured in Figure 8. These units are self-contained with diagnostic and surgical instruments, expendable supplies, teaching curricula for training other health workers, and water, if necessary. Medical assistants and ophthalmologists staff these units. Moble eye units greatly expand rural eye services in many African countries.8
The overburden of curable and preventably blind individuals will continue to grow unless logical and functional strategies are devised to meet this health problem. We must strive to develop inexpensive and resourceful health care and eye care delivery systems. A variety of efficient and inexpensive modifications to ocular surgery in rural Africa has been presented.
The authors would welcome suggestions and further ideas from ocular surgeons who work in developing countries.
The authors gratefully acknowledge the teaching and example of their colleague Dr. Geoffrey G. Bisley, presently Warden and Chief Surgeon of St. John Ophthalmic Hospital in Jerusalem. Dr. Bisley pioneered ophthalmic services in independent Kenya.
1. WHO Chronicle. World Health Organization. 1980; 34:332335.
2. Mahler H: Foresight prevents blindness. World Health 1 976, p 3.
3. Guidelines for Programmes for the Prevention of Blindness. Geneva, World Health Organization, 1979, ? 9.
4. World Blindness and Its Prevention. Oxford, International Agency for the Prevention of Blindness, 1980, pp 7, 75.
5. Parker A, NeweJ) KW, et al: Appropriate tools for health care. WHO Chronicle 1 977; 3 1 : 1 31 -1 37.
6. Prevention of Blindness Report of the Advising Meeting on Program Development. Geneva, World Health Organization, 1978. p 9.
7. Christy NE: A new effective, efficient and economical system of cryoextraction. Ophthalmic Surg 1981; 1 2(9):666-668.
8. Bisley GG: Handbook of Ophthalmology for Developing Countries, ed 2. Oxford, Oxford University Press, 1980, pp 130-139.