Ophthalmologists serve important purpose after natural disasters

Through care or supplies, volunteering ophthalmologists can fill a crucial need for communities, residents and patients affected by natural disasters.

Ophthalmologists can provide important medical support to patients in the wake of a natural disaster and should consider volunteering their services either at home or abroad, Richard K. Lee, MD, PhD, of Bascom Palmer Eye Institute, said.

“People often think, ‘Well, I’m an ophthalmologist, and here’s a situation where I can’t help.’ Everyone can help. In any disaster, as physicians, we really have an opportunity to help in more ways than one and in ways we might not think about. We are all focused on our daily lives, to pound out those patients in our clinics, but you will find it very satisfying to do something very important and you will realize that at the end of the day you are a doctor and you can help,” he said.

Source: Richard K. Lee, MD, PhD

Meeting refractive needs

Lee and colleagues at Bascom Palmer Eye Institute traveled to the Florida Keys after Hurricane Irma in 2017 with the institute’s Vision Van, a mobile ophthalmology office. The volunteers offered medical services, support and much-needed medications to the remaining residents and the first responders in the disaster area.

In addition to his volunteer work in the United States, Lee traveled to Japan after the 2011 earthquake and tsunami and to Haiti after the 2010 earthquake. He has also made multiple trips to the Galapagos Islands to donate his services to this isolated population.

Refractive needs and medications are usually the most sought-after services from ophthalmologists after a natural disaster, Lee said.

“From the tsunami in Japan to Hurricane Katrina to the earthquake in Haiti, all these places where we have been, refractive help is by far the greatest need,” he said. People lose their distance and reading glasses or forget them in their rush to pack and leave.

Source: Nandini Venkateswaran, MD, and Richard K. Lee, MD, PhD

Lee and colleagues typically bring about 1,000 pairs of glasses to natural disaster areas or developing countries during volunteer trips, in addition to sunglasses. The high number of glasses is necessary to run the “combinatorial series,” he said, to provide used spherical equivalent eyeglasses. Volunteers refract each patient with either an autorefractor or a hand-held refractor that requires no external power. In some cases, donated spherical lenses are provided.

This allows the volunteers to provide patients with glasses that have customization for each eye.

“It is not perfect, not what you would get at an optical shop, but better than only straight-up readers. Eyeglasses will protect people from stepping on nails, falling or hurting themselves in unfamiliar environments after a disaster. Eyeglasses will allow them to read labels so they do not take the wrong medications. That is one of the big dangers; people do things they normally would not do because they cannot read or see where they are going. In Haiti, for instance, most of the injuries we saw in regard to the eye were in people who stepped where they should not have stepped or walked into things because they could not see. It is the consequences thereafter a disaster we often have to deal with,” he said.

Variety of needs

Thomas E. Johnson, MD, of Bascom Palmer Eye Institute, also volunteered in Port-au-Prince, Haiti, after the 2010 earthquake. Johnson and colleagues set up a mobile eye clinic at the disaster area and supplied residents with glasses, medications and medical services, he said.

“Many patients in Haiti lost their glasses and eye medications during the earthquake. We set up a mobile eye clinic and brought an autorefractor to enable us to refract patients and determine their prescriptions. Additionally, we supplied a glasses library. We brought many pairs of glasses so we could give most patients glasses that were at least close to their prescription. They may not have been perfect, but patients could at least see with them. We also brought eye drops donated from our pharmacy at Bascom Palmer, particularly glaucoma medications, as many people lost their medications in the earthquake,” he said.

Maintaining a flexible attitude while volunteering in a disaster area is crucial, Johnson said. Much of his volunteer mission in Haiti involved performing non-ophthalmic duties for residents affected by the earthquake. He helped to set up an operating room using picnic tables and assisted on multiple amputation surgeries.

“Be flexible and be willing to help out however you can. You are not always going to be doing just ophthalmology. There are life-threatening conditions that may also require your assistance. While we were working in the field hospital, for example, we found that we had some severely sick and injured patients. One patient was about to deliver a child, one had neurosurgical trauma — conditions that were out of the scope of the ability to treat at our field hospital. We transported those patients to an Israeli hospital across town in another area of Port-au-Prince. No ambulance was available, so we gently placed those patients on stretchers and duct taped the stretchers to the tops of the seats on a Coaster bus. In all we transported five patients to the Israeli field hospital and dropped them off with the Israeli doctors, who had a much more sophisticated setup than we did, with obstetrics coverage and an ICU,” Johnson said.

Volunteering domestically

After a natural disaster, the needs of residents in a developing country and the needs of those in the United States are different. For example, the No. 1 ophthalmic need for those affected by recent California wildfires was extra glasses or extra contact lenses, Charles W. Flowers Jr., MD, of USC Roski Eye Institute, Keck Medicine of USC, said.

“One of the things we encourage people to do, particularly if they wear contact lenses or glasses, is to have a reserve pair of corrective lenses on hand. You do not just want to have one pair of contacts available,” Flowers said. “You cannot run from a fire if you cannot see. We try to encourage people to have backup spares. You need a backup pair of glasses because if there is no water you cannot clean your hands or lenses, and glasses can provide a protective barrier from embers and ash.”

Due to their proximity to the California wildfires, satellite clinics of Keck School of Medicine experienced nearly 20% more patient visits to address smoke exposure, Flowers said.

With wildfires, clinics see a significant increase in cases of ocular irritation or ocular allergies. The natural tear flushing system only has a certain capacity before becoming overwhelmed. If the eyes begin to retain an increased amount of foreign matter, such as ash, smoke particulates or embers, the risk of conjunctivitis and eye irritation significantly increases, Flowers said.

Ophthalmologists should make sure they have a large supply of over-the-counter tear drops on hand to help patients and first responders who are in an area affected by a wildfire, he said.

Fewer samples available

Additionally, patient access to ocular drugs can be challenging during a natural disaster. In the past, clinics could provide patients with surplus samples provided by pharmaceutical companies. In the current environment, however, pharmaceutical companies provide fewer samples so there is less medication available for emergencies, Flowers said.

Fifteen years ago, if patients did not have access to their pharmacies, “offices would have a stock of samples to give them during difficult times. We could give them samples, get them over the hump,” he said. The situation now is “problematic” because these samples are no longer available, he said.

Flowers said that physicians should reach out to the pharmaceutical industry and request companies set aside inventory for such situations and to “release these drugs gratis so we can take care of the people in the short term.”

Portable examinations

Access to drugs is especially difficult in a developing country after natural disasters. The No. 1 need in most of these areas is medication. Ophthalmologists should try to bring as many ocular drugs and antibiotics as possible when volunteering, Lee said.

When going into the field, Lee brings a backpack filled with medications, such as eye drops and glaucoma medications, and portable technology that can be used to conduct impromptu ocular examinations in a nonclinical setting.

“In my backpack I have a small hand-held digital camera that’s a fundus camera for non-dilated photography. I have a portable phoropter that I bought through a Kickstarter-founded company developed by an MIT professor (EyeNetra). I have a Tono-Pen (Reichert) to check eye pressure. I have a direct ophthalmoscope, and we just developed this virtual reality goggle-based field screener so I can do a pretty complete eye exam with items that fill less than half my backpack. The rest of what I bring is medications and glasses,” he said.

Technology is key

Advances in technology have made treating patients outside of the clinic and those in disaster areas much easier, OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS, said.

Hovanesian volunteered his services in Armenia in 1999 after an earthquake. The country had been ravaged by the earthquake and an ongoing war, he said, and faced a complete economic collapse in the wake of the fall of the Soviet Union.

When conditions are not optimal for ocular care, finding innovative solutions may be necessary.

Ophthalmologists cannot take a femtosecond laser into the field on a mission trip, but they can take innovative technology such as the miLOOP (Iantech), a small device used to break up large and dense cataracts for easier removal, he said.

“[The miLOOP] has great implications for working in the developing world. It makes small incisions for extracapsular surgery. It will facilitate that very nicely and allow us to segment those into smaller pieces in a controlled environment of the eye and to take a large and dense cataract to fragment it for easier removal. That’s a lovely technology that applies very nicely. There have been a number of things like that that have come along that make things easier for us,” Hovanesian said.

Corneal damage was common among many of the patients he saw, either from trauma or advanced infection that had not been treated. For trauma patients, corneal transplants were usually necessary, and volunteers used corneas brought to Armenia donated by American eye tissue banks, such as Tissue Banks International, SightLife and Vision Share, he said.

Volunteering in the developing world

Many victims in disaster-ravaged areas view surgery as a cure-all that will help them gain sight, Hovanesian said, but this is often not the case.

Source: Richard K. Lee, MD, PhD

“In desperate situations, people seem to see surgery as a miraculous cure for their blindness. Surgeons know this is not always the case. The same people who suffer those natural disasters often do not have good access to care afterward, so how do we future-proof our procedures so noncompliant, or patients without access to care, can still manage? These are some of the challenges that we face,” he said.

Diseases may exist in these countries because patients have poor access to care, and many have advanced retinal diseases. In the U.S., it is not common to see diabetic tractional retinal detachment, but in a developing country, the condition is much more common because patients have little access to care and no control for diabetes, he said.

In addition to devices and advanced technology, the best resource ophthalmologists can have in a natural disaster is their “mental resource,” Hovanesian said.

“Your mental resources are very valuable. You need to step aside from your normal way of operating and thinking and to look at other ways of working. Can you operate without gloves? Yes, you can. Can you operate without a microscope? Yes, you can. I recall one surgeon in a remote area of Armenia who had an old Soviet microscope, and in the earthquake the bulbs had been damaged. He fashioned a way to use a headlight from his car in the microscope to operate by,” he said.

Challenges in Puerto Rico

The poor infrastructure of many areas can make volunteer and aid efforts particularly challenging. As of Dec. 15, 2017, 3 months after Hurricane Maria struck Puerto Rico, it had only 64% of its power restored, and nine of its 78 municipalities remained entirely without power, according to an Associated Press report.

Source: Richard K. Lee, MD, PhD

Medtronic, a medical device company headquartered in Dublin, Ireland, employs more than 4,000 workers and 1,000 contractors at facilities in Puerto Rico, Medtronic CEO Omar Ishrak said at OCTANe’s annual Medical Technology Innovation Forum. Including the families of the Medtronic employees, about 10,000 people affiliated with the company live there.

About 25% of Medtronic’s global production is in Puerto Rico, so getting the factories up and running again, with or without governmental help, was crucial, he said.

“Without them, we would have no devices,” Ishrak said.

Medtronic brought operations up to about 100% through temporary power supplies, such as generators, and new IT systems to bring the factories back online. Supplies were flown into Puerto Rico from Miami daily, not just for the factory, but also for all of the Medtronic employees, he said.

Employees were supplied with food, medicine, water and generators to bring home for their families, Ishrak said.

“We created child care facilities so people can bring in their children. We installed about 100 laundry machines in our four facilities so they can wash their clothes. We gave them temporary housing, and we made cash available to them because in Puerto Rico nothing else was accepted. This was necessary because it was the right thing to do. We felt that while work was important, you have to put your family first and get that right, and then work will follow. True enough, those were the basic principles they followed, and we’ve come up in our operations relatively quickly based on our own temporary capabilities,” he said.

Creating well-rounded surgeons

Volunteering in a disaster area or a third-world country can help make surgeons more versatile and capable as they quickly gain crucial experience, Hovanesian said.

He urged young ophthalmologists to consider going on a volunteer trip and noted that most employers are willing to let associates volunteer without docking their vacation time because it improves their surgical skills.

Hovanesian urged interested volunteers to find an existing volunteer organization or to travel with a colleague who has made prior trips. Joining an established group or colleague is much easier and less intimidating than venturing out solo.

“It is an intimidating prospect. It is better to join a group like the Armenian EyeCare Project or the Himalayan Cataract Project. There are dozens of smaller organizations that do meaningful aid work and make regular trips with physicians along. You gain tremendous surgical experience. It is an incredibly uplifting part of your career to do volunteer work. You are proud of yourself for doing it, your colleagues are proud of you, your patients are proud of you, and it is the right thing to do with the skills we have all learned,” he said. – by Robert Linnehan

• References:
• Anger grows as Puerto Rico misses power restoration deadline. www.nbcphiladelphia.com/news/national-international/Anger-Grows-as-Puerto-Rico-Misses-Power-Restoration-Deadline-464458783.html. Published Dec. 15, 2017.
• Ishrak O. Keynote: Value based healthcare. Presented at OCTANe’s Medical Technology Innovation Forum annual meeting; Oct. 30-31, 2017; Newport Beach, California.
• Yuki K, et al. Clin Ophthalmol. 2014;doi:10.2147/OPTH.S58887.

• For more information:
• Charles W. Flowers Jr., MD, can be reached at USC Roski Eye Institute, Keck Medicine of USC, 1450 San Pablo St., 4th Floor, Los Angeles, CA 90033; email: charles.flowers@med.usc.edu.
• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Laguna Hills, CA 92653; email: drhovanesian@harvardeye.com.
• Thomas E. Johnson, MD, can be reached at Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; email: tjohnson@med.miami.edu.
• Richard K. Lee, MD, PhD, can be reached at Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; email: rlee@med.miami.edu.

Disclosures: Hovanesian reports he is a small equity holder in Iantech. Flowers, Johnson and Lee report no relevant financial disclosures.

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