The List

She was a 29-year-old female who did not speak a word of English (but only her local tribal tongue).  She was reserved, shy, and barely uttered a word during the whole clinic visit.  Slightly overweight and with a moon-shaped face, she was not the most attractive young woman.  Her vision was counting fingers at 1 meter in the right eye and counting fingers at 6 inches in the left eye.  Her “sister,” who spoke perfect English, was much more self-confident and served as the patient’s spokesperson.  

The story unfolded.  They were both orphans.  Since the age of two, the patient had started to have difficulty with vision.  In grade school, she could not see the chalkboard at the front of the class.  Even over the last few years, the vision had declined.  Last year, the patient got married.  However, “because of the issue of the vision, she was chased by her husband,” recalled the sister.  Three years ago, the patient came to Lusaka Eye Hospital for an examination.  She was told that she needed to go to South Africa to find glasses that fit her prescription (likely because of high astigmatism).  She had no money for the glasses, so she remained as she was – living life in a blur, without any semblance of clarity.  When I examined her, the eyes were completely normal except for her corneas – steep cone-like protrusions with apical scarring typical of severe keratoconus.  The sister begged me to help the patient.  All I could offer was some advice (no eye rubbing), and placement of the patient name on the Corneal Transplant List.  Options are limited here.  Hopefully I can find a way to obtain corneal tissue in the near future.  

Another patient, a 5-month-old infant, was brought in by his parents.  He had apparently had corneal opacities in both eyes from birth.  The white opacities had gotten more and more dense over the last few months.  Surprisingly, the patient did not have nystagmus, but the intraocular pressure seemed high by palpation.  Peripherally only in the left eye, one could observe a formed anterior chamber and flat iris.  Like a knee-jerk reflex, my mind categorized all the possible causes of white corneas in infants (STUMPED: sclerocornea, tears in Descemet’s, ulcers, metabolic/mucopolysaccharidosis, Peter’s anomaly, edema from glaucoma or CHED, dermoid).  The cornea didn’t look characteristic of the corneal edema from congenital glaucoma that is so common in Zambia.  It seemed to be more of a congenital metabolic process.  I scheduled him for an exam under anesthesia.  After that, he may need to be placed on the ever-growing List.  

As the only full time practicing corneal specialist in the entire country of Zambia – a country with 13 million people and only 22 ophthalmologists – I’m quickly realizing that I need corneal donor tissue, and I need it fast. 

Cornea Cornea

Warning: this entry geared for medical personnel.  Read at your own risk.

It’s great to be in the OR again.  Errr…”theatre” as they call it here.  Yesterday I did my first 2 cases.  Two corneal transplants, in fact. 

The first patient was a 32-year-old female who had suffered from blindness in her left eye since she was 10 years old.  She had a cataract surgery in 1990, then a subsequent surgery in 1991 and was left aphakic.  Since then, she has had a dense corneal scar, leaving her barely able to see hand movements but nothing more out of the left eye.  To top everything off, she has had intermittent pain in the left eye due to uncontrolled eye pressures (on my first encounter with her, the IOP was 47 mm Hg). Fortunately, her right eye remains healthy.  

She understood that perhaps it might be too late to regain vision, but she wanted to give it a try.  She had waited this long, without hope, without anywhere to turn, for the last 20 years, and here was her one chance to regain sight.  I gave her my usual speech about the risks, complications, and visual potential (very guarded, in her case), but she still wanted to proceed.

I reviewed the corneal tissues I had received from Dr. Buxton and Colquhoun, and I chose the best possible candidate: the donor was a 47-year-old who had died after probable obstruction aspiration after suffering from quadriplegia due to a traumatic brain injury in 2008. 

In the operating theatre, I offered up a quick prayer aloud, asking for guidance and divine assistance.  The surgery was uneventful, except for the unwelcome gobs of voluminous vitreous that seemed to take on a volcanic nature as I opened up the unicameral aphakic eye.  Fortunately, vitreous was the only object streaming out of the eye.  I prayed that the other intraocular contents remain back where they belonged.  Quickly, I partially sutured the graft into place, then cleaned up the vitreous as well as I could from the front of the eye.  At the end of the case, the cornea looked stable, but still disconcertingly hazy.

For non-medical people: Don't mind the green eye, it's just fluorescein dye.  =)

The second patient was a 36-year-old patient with HIV/AIDS.  She had suffered from Stevens-Johnson’s Syndrome due to a sulfa-based antibiotic since October 2010.  She became blind in the left eye due to the corneal scarring.  Symblephara (conjunctival adhesions) limited ocular motility bilaterally.  However, about 2 months ago she developed a corneal ulcer in the right eye, her only seeing eye (which was previously seeing 6/9, equivalent to 20/30).  After treatment with many different antibiotics, she lost her vision.  By the time I examined her yesterday, her corneal tissue was extremely thinned.  Uvea was prolapsing forward, and I’m sure she had had a recent corneal perforation at some point.  I asked silently, “God, what could be done for this awful looking eye?” 

I decided to proceed with a therapeutic corneal transplant, to at least provide some sort of stability to the ocular surface.  Thankfully, the surgery was again uneventful, except for the fact that the iris was completely adherent to the cornea due to the prior inflammation.  There was copious bleeding as I cut out the iris.  At one point intraoperatively a glimmer of hope arose in my heart as I realized that the lens was intact and I could gain a semblance of a red reflex.  If the cornea clears, or if a future transplant were performed, I realized that this woman might be able to see again.

Now it is a waiting game. Those readers who believe in prayer, please pray hard!

Thorn in my flesh

Pain worse than a toothache, ten times worse than a leg muscle cramp. Saturday morning I felt a twinge in my back lasting a fraction of a second.  Immediately, my heart sank; I knew this back pain all too well.  On Sunday I was virtually bedridden.  Attempting to roll out of bed without precipitating the back spasms that knock my breath away was my biggest chore of the day.  These spasms left me at the mercies of gravity; my fear of falling straight to the floor kept me hanging on so violently to any piece of furniture that each muscle fiber in my body quivered.  One episode early Sunday morning was so painful that I started to faint (the ringing in the ears, the grayish TV-static-like visual phenomenon that slowly closes in until the whole world turns black), and if it hadn’t been for my husband’s heroic rescue from bathroom to bed I very well may have lost consciousness.  I have been walking like an invalid as each step takes every ounce of my concentration.  But, by God’s grace, I am slowly improving.

This physical ailment comes at an opportune time, a time in which I can reflect on my mortality, my humanity, and the precious frailty of life and health.  What is life if there is no health?  What use would I be if I had traveled all the way to Africa and then had some health issue abruptly put an end to all my plans and dreams? 

Many of us take our health for granted, especially when we are young and without major physical maladies.  I would always take pride in reporting to my primary doctor, “I have no past medical history, no surgeries, no hospitalizations, no known drug allergies, no history of tobacco/alcohol/drug use, no medications….” As if I would forever be sheltered from common ailments that plague mankind.  But this episode has been a poignant reminder that we must not take our health lightly.  It is not enough to claim a certain lifestyle (vegetarian, vegan, or what have you).  We must live each day committed to following all the principles that we know are good: NEW START (Nutrition, exercise, water, sunshine, temperance, air, rest, trust in God). 

Just as the apostle Paul had a thorn in his flesh, may this pain in my back be a reminder to me of my impotence and of His ultimate power

Zimba & Livingston

On Monday, Mr. Jere (our driver), Dr. Mumba (the Zambian ophthalmologist), and I started off on the nearly 400 km trek to Zimba, in the Southern Province.  There we met Drs. Jeffrey Colquhoun and Douglas Buxton, two American ophthalmologists who were in Zambia on their yearly short-term mission trip through International Vision Volunteers, screening and operating on patients at the Zimba Eye Centre. 

Swarms of people patiently awaited their turn to be evaluated.  Prepared to stay several days, many of them brought their belongings in a sack (most importantly a blanket and a pot), and at night they camped out under the stars after cooking a meal on a small self-started fire just around the clinic. 

It was refreshing to see this American team selflessly giving of their time, money, and talent to help provide eye care to this destitute population.  We had a nice chat with the doctors and began to make plans on how to collaborate.  I agreed to follow up any patients who lived closer to Lusaka, especially those who had recently undergone corneal transplantation.  They generously offered to donate any excess supplies that were not used during their trips.  All in all, I enjoyed meeting this group and look forward to working with them in the future. 

Because we were so close to Livingston (only 80 km from Zimba), I begged my driver to let me see Victoria Falls before we headed back to Lusaka.   

We spent a good two hours enjoying the beauty of the Falls, then on Wednesday we journeyed back to Lusaka. Now that I have seen the Falls during the dry season, I can't wait to see its waters brimming over after the rainy season.  I will definitely be back.