Sight For All

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  Dr. James Muecke Director Vision Myanmar Program Chairman Sight For All S.A. Institute of Ophthalmology Adelaide 5000,  South Australia Australia Fax 0011 – 61 – 8 – 8222 2741.
Dr James Muecke is a visiting Consultant Eye Surgeon of Royal Adelaide  Hospital and Adelaide Women's and Children's Hospital in South Australia.  He graduated from Adelaide  University school of Medicine in 1988. James is the organizer of Vision Myanmar in Australia  Professor Than Aung is the former Head of the Department of Ophthalmology at the Yangon Eye Hospital. He graduated from the Rangoon University School of Medicine in 1961. Than Aung has been Instrumental in the continued success of the Vision Myanmar Programme.  
Year 2016
Congratulations to Sight For All Chairman Dr James Muecke on receiving an Eye Health Hero Award! James' hard work and passion for Sight For All has made a huge positive impact to eye health globally, well done James!
About the programme- Recognition for eye care practitioners and front line staff
The Eye Health Heroes programme is an initiative of the International Agency for the Prevention of Blindness (IAPB) in partnership with L’OCCITANE Foundation designed to celebrate eye care practitioners and front line staff whose everyday efforts behind the scenes are making a real difference towards Universal Eye Health. Nominations are expected to come in from 154 IAPB member organisations from around the world, including virtually every major international eye health NGO, global apex bodies for both ophthalmology and optometry, disabled persons’ organisations, academic institutions and concerned corporations, all working together to eliminate avoidable blindness and visual impairment worldwide. See Eye Health Heroes 2012 at 9GA. Also see Eye Health Leaders 20132014 and 2015 The nominated Heroes will be honoured at the 10GA Celebration Ceremony


In July this year ( 2016), Sight For All welcomed Beth Rackham to the position of Marketing and Events Coordinator. Beth's first role was in finalising all of the plans for The Very Slow Long Lunch, our fantastic event held recently that raised over $95,000 for our in-country projects. Welcome to the team Beth!  


Sight For All has four key strategies in our fight against blindness. Research is one of these key strategies. Since 2004, we have conducted international studies in 7 countries including Myanmar, Sri Lanka, Lao, Bhutan and Cambodia. We hope to continue this research to better equip ourselves with the knowledge needed to fight preventable blindness  


Year 2017

February 2017
The Sight For All circle closes! Visionaries Dr Steve McGovern and Alan Hoare are pictured above with
Paediatric Ophthalmologist Dr Tin Mg Thant who is loaning back Sight For All donated equipment required
to conduct the Meiktila Blindness study. After the first research survey, sub-specialty training, equipment
donations and the study that has just commenced, the full circle is complete. Feb 2017


Sight For All Visionary, Dr Megan Wood recently completed her residency in ophthalmology at the Royal Adelaide Hospital and returned back home to the UK last week. It won't be long until we see Megan again as she is volunteering to be part of two research teams that will be conducting surveys in Myanmar and Lao over the next two months. Both surveys will provide some extremely important data that we look forward to sharing with you in the future! Thank you Dr Wood for being part of our research team.  
January 2017
From the 9th to 13th of January Sight For All Visionary Dr Sumu Simon delivered a week of neuro-ophthalmology teaching in Myanmar to three of our Fellows. This was the sixth visit for the Fellowship, which is continuing on from 2016 and is set to finish in October this year. Our Fellows are gaining more knowledge and skills after each teaching visit and told us that Dr Sumu Simon's lectures were excellent! Thank you Dr Simon for sharing your knowledge and skills.      
January 2017
Our Vitreoretinal Pioneer of Myanmar, Prof. Henry Newland, Consultant Vitreoretinal Surgeon and Head of Department of Ophthalmology, Royal Adelaide Hospital, Australia and our Myanmar VR Team ( Prof. Henry Newland ------> Prof. Mya Aung ------> Prof. San Myint -------> San Hlaing Min, Thazin Shwe, Chaw Wai Lwin, Myo Aung Kyaw, Ei Kay Thwe Han, Wah Wah Lwin, Ma Ma Yin Minn Pann, Aye Win Myint Phyo)      

Year 2016

  Dr Htet is completing a Corneal Fellowship, spending one year in Adelaide, Australia before she will return home to Myanmar with specific knowledge, skills and experience to treat patients with corneal conditions. Dr Htet comes from a small town called Monywa in the North of Myanmar. Growing up, Dr Htet knew she wanted to become a doctor and in particular it was her sister, who is permanently blind, that inspired her to become an Ophthalmologist. Although Dr Htet has had to overcome many challenges to get here - including learning another language - she is excited for the future and hopes to make a large impact on her country's health care system. Dr Htet told us that the best part of her job is seeing someone get their vision back, "It makes me proud of what I do!". You will be hearing more about this inspirational doctor over the coming months as we follow her Sight For All Fellowship journey    
23 September 2016
Sight For All - A Shared Vision Today is World Retina Day - an important occasion to raise awareness of retinal diseases which are amongst the most common causes of vision loss, especially diabetic retinopathy, now one of the fastest growing causes of blindness in the developing world. Sight For All has implemented Retinal Fellowship Projects in Lao, Myanmar, Sri Lanka and Vietnam, helping to reduce blindness due to diseases of the retina. #worldretinaday2016 #sightforall    


  Glaucoma is a leading cause of blindness if it is left untreated. Sight For All aims to eliminate this blinding disease through the training of specialist ophthalmologists. To date, Sight For All has trained Glaucoma specialists in the countries of Bhutan, Cambodia, Lao and Myanmar to equip them with the skills to treat this blinding yet preventable disease well into the future. The result is a sustainable approach to eliminating avoidable blindness caused by glaucoma.



Year 2015

James Pumped to be at the EY Entrepreneur Of The Year last night to see James Muecke win the National Social category for the amazing work he does with Sight For All. An extremely deserved  winner. — with Mena Muecke and James Muecke.

 Fund Raising

Thank you to everybody who made Sight For All's Very Slow Long Lunch such a magical memorable day. Our Events team and staff created the fundraiser of the year. Our  sponsors, catering teams, artists, stylists, photographer, auctioneer, volunteers and guests all came together to generate an incredible atmosphere of fun, goodwill and positive energy. South Australia should be very proud! Last night, our chairman Dr James Muecke (pictured here with family) was awarded the Ernst & Young Social Entrepreneur of the Year 2015 award at the Central Region award night by Martin Haese - Lord Mayor of Adelaide. Congratulations Dr Muecke! ---------------------------------------------------------------------------------- Sight fo All   - A shared Vision Education is one of Sight For All's four key strategies. Sight For All focuses on providing sub-specialty workshops and fellowships here in Australia, as well as in-country fellowships conducted in our partner countries. So far we have trained doctors in various sub-specialties from countries including Lao, Myanmar, Nepal, Vietnam, Sri Lanka, Bhutan, Cambodia and India. Sight For All's sustainable approach to teaching ensures the fight against blindness in our neigbour countries continues well into the future.  


Training Programmes

Dr May Ko Ko Thet is one of Sight For All's Fellows trained in Australia. Sight For All has trained a total of 27 fellows in Australia, with over 1/4 of whom have been female ophthalmologists. As the first glaucoma specialist in Yangon, Myanmar, Dr Thet is empowering women within the ophthalmic community in Myanmar. She will soon be training her own fellow and as such Sight For All's sustainable education program continues.


Dr San Hlaing Min from Myanmar (shown here with Sight For All - A Shared Vision's Judy Bickmore) has just completed a year long Vitreo-retina fellowship at the Royal Adelaide Hospital. Dr San Hlaing Min is heading back home to Yangon this weekend to work as a Vitreo-retina specialist at the Yangon Eye Hospital. It has been a pleasure having Dr SanHlaing Min here in Adelaide over the past year. Best wishes and safe travels! With JudyBickmore in Royal Adelaide Hospital.  


Executive Officer Judy Bickmore recently travelled to Myanmar to experience Sight For All's sight-saving work in-country for the first time. The trip provided Judy with the opportunity to meet fellows previously trained in Adelaide, experience the clinical setting & operating theatre and meet patients whose lives have been saved because of Sight For All's sustainable education program. Reflecting on the opportunity, Judy said "My Sight For All trip to Myanmar was an unforgettable experience that has touched me forever. To everyone who supports Sight For All, I say thank you. Because of your support the sight-saving, inspirational work being conducted in Sight For All's 8 partner countries can continue". #SightForAll#asharedvision
Our wonderful Sight For All ophthalmic fellow's based in Yangon Myanmar - between them they cover four different areas of sub specialty, bringing much needed eye health skills to Myanmar. — withSan Hlaing MinThan Htun Aung and May Ko Ko Thet.
Sight For All trained Myanmar's first paediatric ophthalmologist Dr Than Htun Aung. Our sustainable education strategy is aiming to improve children's eye care and reduce the frequency of childhood blindness. Dr Aung now treats up to 20 000 children a year!
Gavin O'Callaghan is one of Sight For All's ophthalmic health care professional Board Directors. "As an optometrist and Board Director, not only he help Sight For All deliver positive outcomes in Australia, he is proud and privileged to use his skills to teach our colleagues in-country." said Gavin after a recent trip to Myanmar where he taught our partner colleagues clinical optometry skills.


Dr Tin Maung Thant has successfully completed his fellowship training in Paediatric Ophthalmology at YEH through the arrangement and the support of Sight For All Foundation (Australia) and Yangon Eye Hospital. During his 12 months training, he has been actively participating and involved in all Paed Ophth activities including very busy Paed OPD, dealing a lot of children with eye problems, Paed Eye Surgeries especially Strabismus surgeries and Paed Cataract surgeries, ROP screening program, Retinoblastoma clinics. Although he is now on his way back to Sagaing where he was posted before, he is going to start Paediatric Eye Care works in Mandalay at MEENTH soon and all necessary equipments will be donated by Sight For All Foundation (Australia). It is going to be the 2nd Paediatric Eye Care centre for the country.  Paediatric Ophth


Congratulations Dr May Ko Ko Thet on completing your 12 month Glaucoma Fellowship with Sight For All. It’s been a pleasure having you here for the past 12 months. Best of luck as you return home to Myanmar. Sight for all 2Sight for all Sight For All has supported over 30 SECs in Myanmar with equipment, training and health awareness over the past few years, and would like to continue this support. There may be a number of new centres in need of support, namely Thahtone and Myaung Ma, and throughout 2014 there were no ophthalmologists in attendance at these centres. Need to check if the situation has changed.  

 Year 2014

james-muecke1   Brisbane 2014 RANZCO national congress, James Muecke.


  INTRODUCTION The association between MOH and Royal Adelaide Hospital ( RAH) dates back to 1990 when Dr. Henry Newland, Director of Ophthalmology of RAH visited Myanmar as a WHO Consultant to conduct training in Yag laser iridotomy for treatment and prevention of Angle closure glaucoma. Between this and 1998 he made 3 more visits to Myanmar as WHO consultant to conduct training in corneal grafting, vitreo- retinal surgery and phaesoemulsification. Subsequently, specialist teams from RAH led by Dr. James Muecke made teaching visits to Yangon Eye Hospital and Mandalay Eye ENT Hospital, in 2000 and 2001. Discussion and drafting of Sisterhood affiliation between MOH and RAH began following these visits.   Efforts made by the two parties, resulted in the final draft and approval by the authorities concerned.

Year 2013

Sight For All, Vision Myanmar Program Teaching Workshop

14 to 24 February 2013

Dr. John Glastonbury,  Member Vision Myanmar Program conducted a 2 week Teaching Workshop for ophthalmology trainees at the Yangon Eye Hospital 14 to 24 February 2013.  


 Year 2012

“Sight For All Vision Myanmar” team to visit Myanmar
From 14 to 22 December 2012.
The team members are: 1. Dr James Muecke, ophthalmologist 2. Dr Paul Athanasiov, ophthalmologist 3. Steve Nygaard, technical assistant 4. Robert Hicks, technical assistant 5. Kerry Heysen, technical assistant, 6. Jethro Heysen-Hicks, technical assistant 7. Ms Siew Kim Teo, registered nurse,
Activities During the period of visit (Fri 14th Dec to Sat 22nd Dec 2012), the team will visit and assess cataract surgery capacity at two Secondary Eye Centres (SECs) – Hakha and Falam in Chin State.
  • Observe the local ophthalmologists performing cataract surgery after installing the appropriate ophthalmic equipment that is needed, ie. operating microscopes (OM), slit lamps (SL), A-scanners (AS), and keratometers (KM) (see the list of equipment below). Teaching in the use of biometry equipment (A-scanners and keratometers) will be undertaken.
  • Provide assistance to the nursing staff involved with eye surgery at these centres. Sister Teo, the Clinical Nurse Consultant from Eye Operating Theatre at Royal Adelaide Hospital, will assist the local nursing staff, in particular to address issues of sterilisation and handling of microsurgical equipment.
  • Finally, undertake a local eye health promotion seminar at each of the centres. An understanding of cataracts, cataract surgery, the barriers to cataract surgery in rural populations and ways of overcoming these barriers will be addressed to local health care workers and nursing staff (midwives), so that cataract surgery awareness can be raised amongst the local population with the ultimate aim of improving cataract surgery rates.
  • A Myanmar ophthalmologist is requested to assist the team for this week and all necessary optical and surgical equipment for the upgrade will be sent prior to arrival. Sterilisers, air conditioners, and electricity generators will be purchased locally for a particular centre if needed.
The team would also like free time to visit the tourist attractions near Mandalay and the town of Pyin U Lwin during the week. Proposed SECs: Hakha
  •   SL x1
  •   AS x1
  •   KM x1
  • SL x1
  • AS x1
  • KM x1
Operating microscopes (OM), Slit lamps (SL), A-scanners (AS), and keratometers (KM) Proposed itinerary
  • On arrival in Yangon, take flight from Yangon to Mandalay, Night stop at Mandalay Hill Resort Take flight from Mandalay to Kalaymyo, night stop in Kalaymyo Drive to Falam (5-7hrs) night stop in Falam All day at Falam Secondary Eye Centre (SEC), night stop in Falam Drive to Hakha in am (4hrs), arrive Hakha SEC and night stop in Hakka Drive back to Kalaymyo (9-11hrs) night stop in Kalaymyo. Take flight from Kalay to Mandalay , visit sites and night stop at Mandalay Hill Resort Drive to Pyin U Lwin (Maymyo). visit sites in PUL, night in PUL at Candacraig Hotel Drive to Mandalay Airport, take flight from Mandalay to Yangon, - Singapore - Adelaide.
1. OBJECTIVE To conduct an impact assessment of equipment and training provided by Sight For All to eye centres in Yangon and the surrounding districts, Myanmar. 2. BACKGROUND Sight For All (SFA) is an Australian-based, non-denominational, charitable organisation committed to fighting avoidable blindness, particularly in the Asia-Pacific region. It is supported by the Australian Government, corporate sponsorship, and private philanthropists. SFA has worked closely with the people of Myanmar following a landmark ophthalmic survey in 2005 that revealed the highest prevalence of habitual blindness ever reported.1 Funded by a one-million-dollar grant from the Australian Government through AusAID, SFA is currently undertaking a systematic upgrade of ophthalmic equipment and facility in three Tertiary Eye Centres (TECs) and 32 Secondary Eye Centres (SECs) in the country. These centres have received equipment, which include operating microscopes, slit lamps, keratometers, axial-length scanners, microsurgical instruments, lasers, visual field analysers, air conditioners, autoclaves and electricity generators. Equipment has been strategically distributed to ensure that all SECs are capable of performing high quality and efficient cataract surgery using targeted intraocular lens implants (IOLs), and that all TECs are capable of managing more complicated cases of ophthalmic disease such vitreo-retinal and paediatric diseases. In addition to the resource upgrade, SFA has been focusing on building capacity amongst the Myanmar ophthalmic health professionals. The organisation has been training local ophthalmologists and ophthalmic nurses in the correct use of the donated equipment, has been holding cataract awareness workshops for health care workers in regional areas, and is also conducting a series of subspecialty educational workshops at Yangon and Mandalay Eye Hospitals. SFA has also sponsored several Myanmar ophthalmologists to undertake subspecialty training fellowships in Australia, including vitreo-retinal, oculoplastics and paediatric ophthalmology. The Meiktila Eye Study was a population-based, cross-sectional ophthalmic survey of the inhabitants of rural villages in central Myanmar conducted in 2005. It revealed a blindness prevalence rate of 8.1%; the highest rate ever reported.1 Cataract was the most common cause of visual impairment in this population, accounting for 64% of unilateral blindness and 53% of bilateral blindness.2 Consequently, increased cataract surgical rate and improved cataract surgical outcomes were the primary goals of SFA’s initiative in Myanmar. Prior to SFA’s involvement, ophthalmologists working in the SECs used the same strength of IOL (or a best guess estimate) for all cataract cases as they did not have biometry equipment to measure the eye and calculate the most appropriate IOL. Now, the vast majority of eye centres in Myanmar have the resources and training to perform high quality and efficient cataract surgery using IOLs appropriate for each patient. Pilot data for this proposed study was obtained by Dr Nick Andrew during a seven day visit to Yangon in May 2012. Structured interviews were undertaken with local Senior Consultant Ophthalmologists, and the Myanmar Ministry of Health voluntarily provided data on the cataract surgical rate at SECs around Yangon. Table 1 lists the centres assessed and the type of data obtained. SFA has fostered a strong relationship of collaboration with the Myanmar ophthalmic community, and this was readily apparent during the interviews in May. Whilst this study is dependent upon that rapport, we hope that it will also strengthen our relationship by facilitating on-going interaction with the people of Myanmar. Much has been learned regarding the delivery of ophthalmic care around Yangon and information that has helped to shape this study is outlined under the subheadings below. The Structure of the Ophthalmic Health Care System in Myanmar The Ministry of Health is the predominate provider of public health care, including ophthalmic care, to the population of Myanmar. The remaining portion of care is provided by NGOs and private hospitals. The Ministry of Health delivers ophthalmic care through a three-tiered system. At the base of the pyramid are Primary Eye Centres (PECs), which are rural health centres staffed by nurses and health assistants. Their role is to perform vision assessment, provide eye health education, detect common eye diseases and to refer to SECs or initiate treatment as appropriate. SECs are eye units based near a district hospital that are staffed by nurses and one or more ophthalmologists. The SECs form the backbone of ophthalmic care in Myanmar and perform both medical and surgical management of patients. Surgical procedures performed by SECs include cataract extractions, trabeculectomies, pterygium excisions, and minor oculoplastic procedures. The Tertiary Eye Centres are teaching eye hospitals associated with medical universities, staffed by subspecialists, and equipped with more sophisticated diagnostic and therapeutic equipment. Their role is to provide higher-level diagnostic services and to manage difficult cases. All ophthalmologists that are trained in Myanmar are required to work in the public health care system during office hours (0830-1600, Mon-Fri) until age 60. In addition to the public health system, there are 70 eye hospitals in Myanmar that are either privately operated or sponsored by NGOs. The private hospitals are staffed by senior ophthalmology registrars and ophthalmology consultants and are open after normal office hours. Private clinics offer advanced diagnostic techniques and the option of phacoemulsification cataract surgery. They also allow patients the ability to select their surgeon. The NGO-sponsored hospitals are funded by the Buddhist Missionary Society (majority), or other NGOs (minority). They are staffed by volunteer ophthalmologists, and provide either free or heavily subsidised ophthalmic care. NGOs also provide assistance to Secondary Eye Centres intermittently by donating consumables or sponsoring surgical outreach trips. Although the exact value of donations made by other NGOs is not known, all of the ophthalmologists interviewed in May stated that SFA has made the greatest contribution to ophthalmic care in Myanmar. Further, SFA is the only NGO to have provided training to Myanmar ophthalmologists and ophthalmic nurses. Cataract Surgery: Technical Details Ophthalmologists perform extra-capsular cataract extraction (ECCE) with IOL insertion in the public health care system of Myanmar. Most ophthalmologists use a 6mm to 6.5mm scleral incision and scleral tunnel, although one interviewed ophthalmologist operated via a 4mm two-step limbal incision. A continuous curvilinear capsulorrhexis is performed in the majority of patients, with only one interviewed ophthalmologist routinely using the ‘can-opener’ technique. The wound is closed using one to three 10-0 nylon sutures. The cheapest and most commonly used lens is a single-piece PMMA lens made by Aurolab, an Indian manufacturer. This lens has round-edged optics and is not heparin-coated. All interviewed ophthalmologists used a quinolone or macrolide antibiotic drop commencing one day prior to surgery in conjunction with a topical steroid post-op. The Yangon Eye Hospital routinely adds a five-day course of oral cephalexin 500mg twice daily in addition to topical therapy. Cost of Cataract Surgery The ophthalmologist(s) are entirely responsible for the financial management of their Secondary Eye Centre. This includes ordering consumables, setting the service fee, and collecting payment. The service fee includes the cost of the IOL and consumables, operating theatre expenses, and the price of medications. They are entitled to set a service fee that yields a small profit for their centre, however prices are monitored by the Ministry of Health. The profits generated are predominately used to subsidise the cost of surgery for patients who could not otherwise afford it. These severely disadvantaged patients are required to bring a letter written by the head of their village verifying their need for subsidised care. To a small extent, the profits generated from surgical cases may also be shared by the ophthalmologists and nursing staff of the centre. This additional income is one of the only incentives for increased surgical output in the public system. The minimum cost of cataract surgery ranged from 20,000 Kyat (~24 USD) to 35,000 Kyat (~42 USD). The Indian-made Aurolab IOL is the cheapest available IOL and costs about 5 USD, whereas an Alcon IOL costs about 20 USD. For comparison, the cost of cataract surgery in a private hospital in Yangon ranges from 150-200 USD depending on the surgeon, the operative technique (ECCE vs. phacoemulsification), and the type of IOL used. To put these numbers into perspective, the income of a Myanmar soldier, city worker, or moderately successful farmer is about 170 USD per month. (In contrast, Athanasiouv 2008: “20 USD is approximately 3 weeks average income for a village farmer”) Barriers to Cataract Surgery In the Meiktila Eye Study, 76.3% of patients with cataract-induced low vision or blindness refused referral for surgery. The most commonly recorded reasons were cost, lack of time, lack of family support, and fear of surgery and potential complications.3 In the structured interviews, all ophthalmologists identified cost and patient fear as the two main barriers to cataract surgery in and around Yangon. Although extremely poor patients are entitled to subsidised or even free cataract surgery, there are other direct and indirect costs of undergoing the procedure. For instance, there are costs associated with travelling to the hospital, costs associated with the time away from work, and costs incurred by the chaperone when they accompany the patient to hospital and provide for them during their stay (usually 1-2 nights). Patients without strong family support may find it difficult to manage these costs and are less likely to present for surgery. Patient fear of surgery is still felt to have an impact on cataract surgical rates, particularly in the rural population surrounding Yangon, but its impact is becoming much less significant. Whilst many patients have reservations about surgery and some require extensive reassurance before they will proceed, the percentage of patients refusing cataract surgery was estimated as being only 1-5%. In comparison, 76.3% of patients refused surgery in the Meiktila Eye Study. The ophthalmologists felt that the fear of surgery, once a major barrier for surgical coverage, was being overcome by positive feedback from post-operative patients. This positive feedback is a real compliment for the Secondary Eye Centres, and is indirect evidence that SFA’s work in the region has improved the visual outcome of patients. Identified barriers to the efficient delivery of cataract surgery included malfunctioning equipment, insufficient surgical instrument kits, slow sterilisation facilities, the wet season impeding patient access to the centres, and inadequate community awareness of the SECs. None of the interviewed ophthalmologists were aware of any posters or flyers advertising their centre to the local community, and one ophthalmologist suspected that patients in his district were travelling to Yangon Eye Hospital for their surgery as they were unaware of his SEC. Improved advertising for eye centres is a goal targeted by the Ministry of Health as part of their initiative announced in January 2012, Vision 2020 The Right to Sight. It is thus hoped that a structured advertising campaign will begin in the near future, helping to improve resource utilisation. The most significant determinant of eye centre workload was the density of the surrounding population, with centres on the outskirts of Yangon notably quieter than those in densely populated areas. 2. HYPOTHESIS First hypothesis (H1): Equipment and training provided by Sight For All to SECs around Yangon has been associated with an increase in the cataract surgical rate in those centres. Aim 1: To collect pre-intervention and post-intervention data on the rate of cataract surgery performed at eye centres around Yangon. Second hypothesis (H2): The visual acuities and post-operative refractive error achieved in eye centres around Yangon is now consistent with world standards of ophthalmic care for ECCE. Aim 2: To collect data on pre and post-operative visual acuity, and post-operative refractive error, for cataract surgery performed at eye centres around Yangon. Third Hypothesis (H3): Successful cataract surgery is associated with a significant improvement in the patient’s quality of life and their ability to contribute to their community. Aim 3: To conduct a quality of life (QOL) survey of patient’s undergoing cataract surgery in eye centres around Yangon. 3. METHODS The proposed eye centers to be included in this study are listed in Table 1. Aim 1: To collect pre-intervention and post-intervention data on the rate of cataract surgery performed at eye centres around Yangon. Methods 1: The information is kept on file by the Ministry of Health and is easily retrieved. The Ministry has already voluntarily provided SFA with data for eight SECs (Table 2), and has kindly offered to provide data for additional centers upon request. Aim 2: To collect data on pre-operative visual acuity, and post-operative visual acuity and refractive error, for cataract surgery performed at eye centres around Yangon. Methods 2: Myanmar ophthalmic nurses will be asked to record this information on data collection sheets sent to each eye centre. Data collected will include pre-operative and post-operative visual acuities, and the results of refraction testing at the last scheduled post-operative appointment (usually day 30). The ophthalmic nurses normally record this information in the patient’s medical records; transcribing it onto the data collection sheet will be an insignificant addition to the staff workload. A copy of the data collection sheet appears in Appendix 1. Aim 3: To conduct a QOL survey of patient’s undergoing cataract surgery in eye centres around Yangon Methods 3: A Myanmar-language, modified version of the Visual Function Assessment will be sent to eye centres around Yangon. Patients will be asked to complete the survey at their last scheduled follow-up appointment (usually day 30). The survey takes less than 5 minutes to complete, is easy to understand, and will provide validated results. An English-language version of the survey is included in Appendix 2. The instrument will be translated (from English to Myanmar) and back-translated (from Myanmar to English) by two independent qualified translators. This is consistent with the guidelines outlined by Guillemin et al. regarding the cross-cultural adaptation of health-related QOL measures.4 The rationale for the modified questionnaire is described below. VF-14: Overview Visual acuity and contrast sensitivity testing are inadequate measures of a patient’s visual capability.5, 6 The Visual Functioning Index (VF)-14 was constructed in 1994 as an English-language visual assessment tool, and has since been validated in a large number of population-based studies.7 Using Rasch analysis, the VF-14 has been optimised into short-form versions that have excellent psychometric properties.8 VF-14: Cross-Cultural Studies in Asian Populations The VF-14 has been shown to have excellent psychometric properties when translated into a Chinese-language or Korean-language form.5, 9 Dam et al. surveyed Chinese immigrants living in Canada with the VF-14 and found that the Chinese-language version had excellent internal consistency, reproducibility, and reliability. All items in the VF-14 were felt to be applicable to the Chinese cohort living in Vancouver, except driving. Importantly, removing the four least-answered questions from the VF-14 did not significantly alter the reliability or utility of the instrument. Modifications to the VF tool for the Myanmar population Questions excluded and rationale: 1. “Taking part in sports, such as bowling, handball, tennis, golf”. This item is excluded from both the VF-11 and the VF-8 without detriment to the instrument’s psychometric properties on Rasch analysis.8 This item has also been excluded from our VF tool as we do not feel that it will have relevance to the cohort of Myanmar patients undergoing cataract surgery. 2. “Driving during the day”. This item is excluded in both the VF-11 and VF-8.8 It was found to be irrelevant for Chinese immigrants living in Canada, and could be removed from the Visual Function Index in that cohort without altering the results of the instrument.5 This item has been excluded from our VF tool as it will not have relevance to the vast majority of Myanmar patients undergoing cataract surgery in the public system. 3. “Driving at night”. As for point 2. 4. “Watching television”. To the authors’ knowledge, this item has not been excluded from any VF tool, however we feel it will not have relevance to the vast majority of Myanmar patients undergoing cataract surgery in the public system. Questions added in addition to the VF tool Questions included: 1. “How has cataract surgery affected your ability to work?” 2. “Since cataract surgery are you earning more income or less income?” 3. “What factors made it difficult for you to have cataract surgery?” 4. STUDY SCHEDULE AND ESTIMATED PATIENT NUMBERS Table 2 lists the number of cataract surgical procedures performed in 2011 at eight eye centres around Yangon. We estimate that a complete data set (visual acuities, refractive error, visual function assessment) will be collected for only 50% of cataract cases during the study period. The eight eye centres listed in Table 2 will be included in this study, and the proposed duration of data collection is six months. This is estimated to yield a data set of approximately 1100 cases. 5. REFERENCES: 1. Casson RJ, Newland HS, Muecke J, et al. Prevalence and causes of visual impairment in rural myanmar: the Meiktila Eye Study. Ophthalmology 2007; 114(12):2302-8. 2. Athanasiov PA, Casson RJ, Sullivan T, et al. Cataract in rural Myanmar: prevalence and risk factors from the Meiktila Eye Study. Br J Ophthalmol 2008; 92(9):1169-74. 3. Athanasiov PA, Casson RJ, Newland HS, et al. Cataract surgical coverage and self-reported barriers to cataract surgery in a rural Myanmar population. Clin Experiment Ophthalmol 2008; 36(6):521-5. 4. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol 1993; 46(12):1417-32. 5. Dam OM, Sibley LM, Law FC, et al. Reliability and reproducibility of a Chinese-language visual function assessment. Ophthalmic Epidemiol 2001; 8(5):327-37. 6. Elliott DB, Hurst MA, Weatherill J. Comparing clinical tests of visual function in cataract with the patient’s perceived visual disability. Eye (Lond) 1990; 4 ( Pt 5):712-7. 7. Lundstrom M, Wendel E. Assessment of vision-related quality of life measures in ophthalmic conditions. Expert Rev Pharmacoecon Outcomes Res 2006; 6(6):691-724. 8. Gothwal VK, Wright TA, Lamoureux EL, Pesudovs K. Measuring outcomes of cataract surgery using the Visual Function Index-14. J Cataract Refract Surg 2010; 36(7):1181-8. 9. Lee JE, Fos PJ, Zuniga MA, Kastl PR, Sung JH. Health-related quality of life of cataract patients: cross-cultural comparisons of utility and psychometric measures. Ophthalmic Epidemiol 2003; 10(3):177-91. Table 1. Eye Centres Assessed No. Centre Classification Data Obtained Name of Ophthalmologist Interviewed 1 Yangon Eye Hospital TEC Quantitative & Qualitative Dr San Myint 2 Insein General Hospital SEC Quantitative & Qualitative Dr Ohmmar Myint 3 Thingungyun Eye Department SEC Quantitative & Qualitative Dr Yee Yee Aunh 4 East Yangon Hospital SEC Quantitative & Qualitative Dr Kyaw Soe 5 Pyay General Hospital SEC Quantitative NA 6 Bago General Hospital, Bago Division SEC Quantitative NA 7 Hinthada General Hospital, Ayeyarawaddy Region SEC Quantitative NA 8 Pyapon District Hospital SEC Quantitative NA TEC, Tertiary Eye Centre; SEC, Secondary Eye Centre Table 2: Number of Cataract Cases Performed at Eye Centres around Yangon in 2011 Centre Number of Cataract Cases, 2011 Thingungyun Eye Department 1265 Bago General Hospital 353 Insein General Hospital 281 East Yangon Hospital 163 Yangon Eye Hospital 864 Hinthada General Hospital 91 Pyay General Hospital 513 Pyapon District Hospital 850 TOTAL 4,380 Data courtesy of the Burmese Ministry of Health, 2012 Appendix 1: Data Collection Sheet (example) No. Name DOB Pre-op VA D1 VA D7 VA M1 VA Post-op refraction (spherical equivalent) 1. 2. 3. 4. Appendix 2: Self-Assessment Questionnaire to be used in the Burmese Population Item Item Description Response and Score Frame question: “Do you have any difficulty, even with glasses?” 1 Reading small print, such as labels on medicine bottles, a telephone book, food labels No (4); A little (3); A moderate amount (2); A great deal (1); Unable to do the activity (0) 2 Reading a newspaper or a book As for item 1 3 Reading a large-print book or large-print newspaper or numbers on a telephone As for item 1 4 Recognising people when they are close to you As for item 1 5 Seeing steps, stairs, or curbs As for item 1 6 Reading traffic signs, street signs, or store signs As for item 1 7 Doing fine handwork, such as sewing, knitting, crocheting, carpentry As for item 1 8 Participating in religious activities As for item 1 9 Playing games, such as bingo, dominos, card games, mah-jong As for item 1 10 Cooking As for item 1 Additional Questions: Item Item Description Response and Score 1 How has cataract surgery affected your ability to work? Greatly increased my ability to work (5); Moderately increased my ability to work (4); Not affected my ability to work (3); Moderately decreased my ability to work (2); Greatly decreased my ability to work (1) I did not work before my cataract operation and I am not working now (0) 2 Since cataract surgery are you earning more income or less income? Greatly more income (5); Moderately more income (4); The same income (3); Moderately less income (2); Greatly less income (1); I did not work before my cataract operation and I am not working now (0) 3 What factors made it difficult for you to have cataract surgery? (select all that are appropriate) Cost Lack of time Lack of family support Fear of surgery or complications Transport to hospital Lack of awareness about where to go for help Other, ______________


July 2012
 “Sight For All Vision Myanmar” small incision cataract surgery team to visit Myanmar for a one-week period in July 2012.
The team members’ details are:
  1. Dr Francis Nathan, ophthalmologist, passport number: M6770343 (Australia)
  2. Mrs Merlin Nathan, passport number: M6581077 (Australia)
  3. Dr Callistus Reginald Seimon, ophthalmologist, passport number: N2241503 (Sri Lanka)
  4. Mrs Indira Lourdes Seimon, passport number: N1851504 (Sri Lanka)
The team will arrive in Yangon on Sunday 8th July and depart Yangon on Saturday 14th July 2012. Drs F Nathan and CR Seimon will be undertaking clinical and surgical teaching at Mandalay Eye and ENT Hospital during this period.

Ophthalmology Notes

Vitreoretinal Surgery in Myanmar

Dr Henry Newland

South Australian Institute of Ophthalmology

The indications for vitreoretinal surgery include diabetic retinopathy, spontaneous posterior vitreous detachment, trauma and intra-ocular foreign bodies. Others include retinal detachment, vitrectomy for diagnostic purposes and vitrectomy associated with epiretinal membrane peeling and macular hole surgery. The prevalence of diabetes is normally estimated to be 3% of the population but may well be higher in Myanmar. Of those diabetics some 40% can expect to develop diabetic retinopathy, higher if there is poor control or late presentation. Diabetic retinopathy is the leading cause of blindness in those aged over 60 years and has a devastating socio-economic effect. The critical changes leading to diabetic retinopathy involve loss of pericytes and a breakdown of the junctions between pericytes allowing leakage from capillaries. Diabetic retinopathy can be classified as background or proliferative.
  • Background diabetic retinopathy consists of micro-aneurysms, exudates, haemorrhage, vascular beading and intra-retina microvascular abnormalities. Background  diabetic retinopathy then progresses to moderate and later severe. At this state macular grid laser and pan retinal laser photocoagulation are indicated to prevent blindness.
  • Proliferative diabetic retinopathy may develop with new blood vessels on the disc or elsewhere and these blood vessels are at risk of bleeding leading to vitreous haemorrhage – the single most important risk factor for blindness in a diabetic. Haemorrhage is the leading indication for surgery in diabetics.
Macular oedema is another common cause of visual loss in diabetics and treatment consists of grid laser in the first instance although intravitreal anti-VEGF injections may be required prior to laser to reduce the oedema, allowing laser to be effective. The management of diabetics from an ophthalmic perspective involves screening, diagnosis and close monitoring in the mild background diabetic retinopathy patient. This is the cheapest and most effective option. Later when the retinopathy has progressed, laser and anti-VEGF injections and vitreoretinal surgery are all more expensive options. Vitreoretinal surgery is:
  • Mostly day surgery under local anaesthetic
  • Disposable (packs and consumables)
  • USD 100 per case
  • May require multiple surgeries
A Vitreoretinal unit is required for each 3 million of population (as recommended in Sri Lanka), therefore 2 units would be recommended for Yangon and 1 unit for Mandalay in the first instance. Later other units could be considered on a state or division basis depending on logistics. Each unit costs in the vicinity of USD 250,000, of which a microscope is of the order of USD 100,000. Vitreoretinal diagnosis is outpatient based requiring pupil dilation and additional screening tools including fluorescein angiography, optical coherence tomography and digital retinal screening which is now used in several centres worldwide. Subspecialty vitreoretinal training is required and the options are overseas training, usually requiring an IELTS score of 7.0 or in-country. To date 3 surgeons are being trained in the UK two have been trained in Australia and several observerships have been arranged in Europe and in India. An Adelaide based non-government organisation Sight For All, collaborates with the local VR specialists in Yangon to provide hands on training in usually 2-3 weeks long visits. Selected Myanmar ophthalmologists are trained in Yangon with 1:1 sessions which have been especially useful in establishing the VR units but also in providing training for those unlikely to be able to achieve English language proficiency. Sight For All hopes the Ministry of Health will give vitreoretinal surgery priority for a large number of surgeries predicted in the future.


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