Mar
16
2015

 JanieYoo Zambia

My heart sank. Hand Motions (HM) vision. Hypopyon.  Not a good sign when my 60-year-old patient’s vision in that left eye was Counting Fingers at 3 meters just the day before.  The day before had started out as a routine operating theatre day at Lusaka Eye Hospital in the Southern African country of Zambia...

My nurses had prepared the theatre in readiness for the day’s surgeries.  On the schedule, the line-up consisted of a routine intravitreal Avastin injection, a few cataract extractions, and an emergency glycerol-preserved corneal transplant. 

When it came time to do E.M.’s cataract, a softer, posterior subcapsular type – with the manual small incision extracapsular cataract surgery method – all started well.  As is my routine, I offered up a quick prayer, asking a blessing upon the eye and the surgery that was to take place.  A conjunctival peritomy was made superiorly, a superior scleral wound and nasal paracentesis port were created, a capsulorrhexis was completed, and hydrodissection was performed.  The lens was sticky and soft, but it came forward easily into the anterior chamber.  I urged it out with a lens loop.  But as I began to aspirate the cortex with my Simcoe cannula, I immediately felt that something was not right.  The resistance that my thumb felt against the syringe indicated that vitreous was present.  I noted an oval-shaped posterior capsular tear.  No big deal.  I have encountered more than my share of vitreous during my time in Africa, so I calmly asked the nurses to set up our vitrector.  Stepping on the pedal produced no more than a splash of water through the AC maintainer.  No cutter.  My nurses dutifully switched out the vitrectomy tip, thinking that it was defective.  Still no cutter.  A third tip was screwed on carefully.  The machine was turned on and off.  It was re-primed.  The cords were removed and replaced.  Troubleshooting continued for 30 minutes.  The maintenance manager trained in servicing ophthalmic equipment was quickly called to assist.  We had no functioning alternate vitrector. 

As the clock was ticking, and my patient – very much awake – was waiting for me to proceed, I began to seek alternate solutions.  Manual anterior vitrectomy was done to remove vitreous grossly from the wound.  Viscoelastic filled the anterior chamber, and a cannula on an empty syringe allowed me to remove the majority of the cortex without engaging the vitreous.  Patience.  Perseverence.  Painstakingly, I managed to push the vitreous back with viscoelastic and position a PMMA lens carefully into the sulcus.  The wounds were sutured, and I sighed a sigh of relief.  The entire case took about an hour, 4 or 5 times longer than any normal case should.  It turns out the metal connection for the vitrectomy handpiece was defective, with one of its 6 metal prongs completely missing.  But despite a nonfunctioning vitrector, the case had been salvaged.  Yet I won’t deny that it was days like this when I would ask myself, “What am I doing here in Africa?” 

My assessment on postop day 1:  Postoperative endophthalmitis.  Every ophthalmic surgeon’s nightmare.  I quickly took the patient back to the theatre for a “tap and inject” of intravitreal antibiotics.  When I returned to my office, I fell to my knees crying out with a short plea to the Lord, “God, please, help E.M.’s eye.”  I felt even more alone and helpless and discouraged. 

The first few days, I followed him closely.  The patient’s vision remained HM, but the hypopyon and fibrin resolved.  On day 4, his vision started to improve.  By day 8, his vision in the left eye was CF@ 2.5 meters, and I began to rejoice and realize that God had answered my prayer.  My patient’s eye would be saved. 

Although my patient’s eye is still far from perfect, with vitreous cell and debris still clouding the media in the back of the eye, I have the faith that God is going to take care of it.  And likewise, I know He will take care of me.  Each time I encounter situations when I don’t know what to do, His hands guide mine.  He gives me words when I don’t have them.  He gives me wisdom when I least know what to do.  The Lord has likely saved me from hundreds of cases of endophthalmitis without my knowledge.  And He has probably put his thumb on potential cases of suprachoroidal hemorrhage before I even had a chance to experience this frightening complication.  What a wonderful Lord we serve; what a great Physician He is.  It is when I reflect on how much He has done to help me – as I work as His hands in the healing ministry – that I realize that there is nothing I would rather be doing that serving Him in the mission field.  Although I get discouraged with the lack of so many things – lack of sharp or precise surgical microinstruments, lack of properly functioning eye equipment, or even lack of properly trained staff – I gain my strength knowing that He is my all.  He will carry me through.  He will sustain me.  And He will help me.  I am simply to do the best that I can with what I have.  And God will take care of the rest. 

-- Janie Yoo, Zambia

 
Written by Janie Yoo
 
 
     

MSICS Training for Surgeons

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There is tremendous need for a very good cataract procedure where phacoemulsification technology is either not available or too expensive to provide to the masses that need surgery. Manual Small Incision Cataract Surgery (MSICS) is the perfect surgery for much of the world: it is inexpensive, effective, produces minimal astigmatism, sutureless, safe, relatively quick to perform and is relatively simple to learn with good instruction. If you have an interest in doing medical missions in the future, strongly consider MSICS training. Our friends at Global Sight Alliance and Vision Outreach International would love to assist you! Click on the links below to learn more.

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