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Phacoemulsification Surgery in Eye Camps at High Altitude Dr 74th AIOC 2016, Kolkata This paper was judged as the BEST PAPER of COMMUNITY/ SOCIAL OPHTHALMOLOGY-I Session Phacoemulsification Surgery in Eye Camps at High Altitude Dr. (Maj General) J K S Parihar, Dr. Piyush Kumar Chaturvedi, Dr. Sanjay Kumar Mishra, Dr. Jaya Kaushik he Indian Himalayas cover approximately 591,000 km2 or 18% of TIndia’s land surface and spread over six Himalayan States. District Leh (Ladakh, J&K) form the northern tip of the Indian sub continent with an area of 45110 km2 which probably makes it largest district in the country in terms of area, is one of the coldest and most elevated inhabited region of the world having 113 inhabited villages and one uninhabited village with an altitude ranging from 2900 to 5900 meters. The whole of the district is mountainous region with three parallel ranges of the Himalayas. Between these ranges the Shayok, Indus and Zanskar rivers flow and most of the population lives in the valleys of these rivers. The density of population is 3 person which stands lowest among the inhabited parts of the earth. Approximately 23.30% population is semi urban and remaining 76.17% is rural.1 Surrounded by valleys, barren snow capped mountains, the sparse population which inhabit this region preserving their rare culture are living in inhospitable and inaccessible areas where the wind of modernization never blows. Being a high altitude area it is adorned with surrounding difficult geographic features which compounds the problems of accessibility, transport and communication. The issue of health and health care has always found a back seat in this terrain where survival itself has been a challenge. Based upon the experiences and facts cited above, this unique module of three tier comprehensive eye care has been thoughtfully designed and focused at restoring sight by providing the ultimate comprehensive and modern surgical technology on the anvil, aimed at the population residing in the far reaches of Eastern Ladakh. This programme was further have been knitted with other activities of social engineering pertaining to health care, national integration and environmental protection as well. Methodology and Execution It being a maiden effort of such a kind a thorough pre launch plan was drafted with special emphasis and due attention to following facts: (a) Prevailing weather conditions Other Best Free Papers (b) Geography: Selection of suitable nodal points located centrally and well connected with roads or treks as well. (c) Road transport facilities: Available Road heads to transport amenities, equipment and manpower. (d) Manpower: Ophthalmologist, Anaesthesiologist, Nursing staff, Operating room Assistants as well as Engineers for technical assistance for electro-medical equipments. During the planning of manpower and equipment for the surgical eye camp (Tier III) following points were premeditated (i) Back up phacoemulsification machine (ii) Stand by or backup surgeon (iii) Uninterrupted Electricity supply (iv) Availability of Anesthetist during the Surgical camp (v) Well trained staff for pre-op counseling and medication (vi) Well expertise for immediate and late follow-up (vi) Availability of expertise to handle emergency (ocular as well as non ocular) (e) Dissemination of Information: The prior information of the medical screening, per-operative assessment and surgical camps was disseminated well in advance so that the information could travel to the farthest areas which are not so well connected. First Tier included numerous small medical camps held in the periphery by the non medical personnel in coordination with the medical staff at places as distant as 200–350 Kms from basic and forward surgical setup in the most inhospitable terrain and in extremely adverse weather conditions. These diagnostic camps were equipped with all essential facilities like Mobile lab, ECG and other medical examination. In addition to provide treatment for common medical problems these medical camps helped to identify potential cases for the eye treatment and subsequent surgeries if required. In this phase of the module, about 25 initial screening camps were organized in 2011 and 2012 over a period of three months in very remote and discrete villages adjoining Tangtse, Chushul, Demchok, Fukche and Nyoma of Eastern Ladakh, where more than 3213 patients were examined and treated for various common medical ailments as well as screened for eye surgery. 1021 patients were detected with ocular illness requiring further evaluation and management by an Ophthalmologist. The second tier of comprehensive eye care was comprised of detailed ocular evaluation by Ophthalmologist at Leh, Chushul, Fukche, Tangtse 74th AIOC 2016, Kolkata and Nyoma wherein specialized eye examination equipment such as the Keratometer and A Scan biometry were made available at Secondary level diagnostic eye camps during the month of Sep 2011 and May –Jun 2012 respectively. This exercise was focused at treating cases requiring specialized ocular evaluation and screening of cases requiring surgical intervention. 196 patients were detected with visually significant cataract. It included 102 males and 94 females. They underwent counseling for cataract surgery and underwent Keratometry, B scan, tonometry and IOL calculation as a part of pre-op evaluation. During the final and third phase total 157 patients (82 males and 75 females) turned out for surgery. At the camp during pre anesthetic check-up 19 (8 males and 11 females) patients were found unfit for surgery due to medical conditions. 12 new patients turned out for surgery. They underwent pre-op evaluation and pre anesthetic workup during ongoing surgical camp. Total 150 patients have been operated for cataract by Phacoemulsification and foldable PCIOL implantation. In addition two patients underwent phaco with trabeculectomy and 01 AGV implantation. ResultS Phacosurgery was performed on 110 eyes at Leh (11203 feet altitude) where as 50 eyes were operated upon at Tangtse (14106 feet height). This unique and unparalleled endeavor has been a successful effort of enterprising the idea of medical outreach to the people. It has promulgated our belief and concern for the populace which inhabits one of the most harsh terrains at the far flung frontiers of our country, outlying for away from the urbanized economically developed centers. In this whole well orchestrated exercise more than 3213 inhabitants of eastern Ladakh were benefitted during the various medical camps and out of which 150 diagnosed cases of cataract were successfully treated surgically by phacoemulsification and foldable IOL implantation. A total of 80.1% cases (80.3% males and 79.8% females) of cataract detected during Tier II camp has turned out for surgical treatment, though 9.9%(7.8% males and 14.7% females) were found unfit to undergo immediate surgery due to medical conditions detected during pre anesthetic check-up, finally 72.1% of the cases (73.8% males and 70.1% females) were benefitted from this Tier III surgical camp. Discussion Since the eye camps drew patients from a wide area of Eastern Ladakh and patients had to be transported by the Indian Army for the same. The extensive logistics arrangements to organize such activities were a herculean task. To motivate patients to undergo a surgical procedure and as well for them to also travel almost 200 to 350 Kms was a huge challenge Other Best Free Papers in itself. To convert a forward surgical centre into a standard eye operation theatre equipped with latest surgical equipments required great efforts. In addition to activating the operation theatre, the post operative ward, other logistic facilities were also extended to the patients and their attendants. The latest ophthalmic surgical microscope and Phacoemulsifier machines along with other sophisticated eye equipments were brought in from Delhi and Leh respectively. This medical event was planned and executed keeping many parallel contingencies when approaching a terrain with least predictable terrain, weather conditions and a widely dispersed population has eventuated into remedying 150 patients from cataract which still stands as commonest cause of preventable blindness in our country.4 Almost 80% turnout of the patients detected with cataract in a place where density of population is most meager in the world1 draws our attention to the overwhelming response to effort of medical outreach, if done with thought and vision to attain the prior set goal. The successful virgin effort of providing complete visual rehabilitation at such hostile geographic terrain, with a challenge of finding unexpected meteorologically different variables while performing phaco surgery in high altitude area has been a maiden event in itself. All the surgeries were culminated with implantation of high end single piece foldable acrylic PC IOL has opened a new avenue for comprehensive community outreach efforts.3,5 An equal turnout response from both the genders (80.3% males and 79.8% females at tier III) at all Tiers of camps is a glorifying outcome which points to low gender bias and almost equal acceptability of surgical procedure between both genders in spite of the fact that majority of the population targeted was tribal which is quiet contrary to similar efforts among tribal population in other parts of the country6,7 as well as the neighboring country with similar but less hostile terrain.8 This initiative camp has probably prepared a ground for further such programs which may deliver further dividends as experienced in other parts of country. 9 ConCluSion A large part of our country has hilly terrains viz the Himalayan region. These areas due to its peculiar environmental, geographical and demographical factors entails more enthusiastic and outreach approach for modern medical facilities with perseverance and prior goals as spine. The eye surgery camps were a endeavor which successfully achieved its purpose of extending modern medical facilities to the untouched areas requiring attention. It gave a new direction to the avenue of outreach of facilities and expertise. 74th AIOC 2016, Kolkata REferences 1. Blockwise Amenity Directory. District Statistical Agencies of Directorate of Economics and Statistics, J&K.
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