Eyeworld

EW MEETING REPORTER 63 APAO Sydney 2011's scientific program continued March 22, including two of the Congress's six named lectures: the 2011 Susruta Lecture and the 2011 ICO Golden Apple Lecture. These lectures, embedded in symposiums on cataract and IOL surgery techniques, focused on the problem of delivering cataract surgery to those who need it most—but are unable to avail of it—in the Asia-Pacific region. April 2011 APAO reaches out Often in international ophthalmol- ogy meetings such as this Congress, the brunt of discussion revolves around the astonishing technologi- cal advances being made in the field. Yet there are parts of the world where the ancient practice of couch- ing—a procedure in which a needle is used to dislodge a cataract, push it out of the lens capsule and into the vitreous cavity, perhaps the oldest form of cataract surgery—is still being performed. Typical of underdeveloped na- tions in the Asia-Pacific region, Pakistan is bursting with population growth. This population is also rap- idly aging; Pakistan has one of the lowest GDPs and per capita income in the world; the country regularly contends with regional conflicts, politics, and religious extremism. This bleak portrait of Pakistan was painted by Nadeem Hassif Butt, M.D., professor of ophthal- mology, Lahore, Pakistan, and this year's Susruta Lecturer. It was and is against this dark background that he and his countrymen fought and continue to fight against cataract blindness. Not too far away, in China, a country with a population of 1.8 bil- lion, a similar battle is being fought. The WHO projects an estimated 6.7 million new cataracts a year; in China, less than one million cataract surgeries are performed annually. The problem in China, accord- ing to Dennis Lam, M.D., secretary general of APAO, and this Congress's ICO Golden Apple Lecturer, is basi- cally one of geography; in China, he said, there is a city-village barrier. Most technological resources and services—including cataract sur- gery—are localized in the urban cen- ters of the country. Yet more than 60% (more than 800 million) of the country's population lives in vil- lages, well out of reach of these serv- ices. Despite these sobering facts, the underlying message of both Dr. Butt's Susruta Lecture and Dr. Lam's Golden Apple Lecture was one of hope. Conquest of cataract surgery in the 21st century: The Pakistan model Cataract surgery, said Dr. Butt, poses more challenges to surgeons in un- derdeveloped countries. Owing to the unequal distribution of the world's resources, patients in under- developed nations tend to arrive at ophthalmology clinics with eyes al- ready riddled with complications— assuming, of course, that they get there at all and that there is even a clinic for these patients to get to. But even with limited resources, he said, they were able to control the menace of cataract blindness. Working mainly out of the Pak- istan Institute of Community Oph- thalmology (PICO) and the Punjabi Institute of Preventive Ophthalmol- ogy (PIPO), together with govern- ment and non-government organizations (NGOs) such as the Layton Rahmatullah Benevolent Trust (LRBT), Dr. Butt and his col- leagues used public health strategies to increase awareness, while increas- ing the residency uptake and cataract surgery volume of partici- pating hospitals. Executing the program through district comprehensive eyecare pro- grams, the national prevalence of cataract blindness in Pakistan has been reduced to 0.9%. Teaching men to fish Meanwhile, Dr. Lam and his col- leagues in China launched Project Vision, with the aim of raising the cataract surgery rate to 1,000,000 cataract surgeries a year. To do this, they brought cataract surgery train- ing out of the urban centers and into county hospitals, training pas- sionate volunteers to perform cataract surgery. The choice of cataract surgery technique is a key part of Project Vi- sion; Dr. Lam developed a standard- APAO continued from page 62 ized technique they call manual su- tureless medium-incision cataract surgery (MS-MICS), in which cataracts are extracted through an 8- mm wide incision with a 4-mm long sclera-corneal tunnel. By completely standardizing the technique, Dr. Lam and his col- leagues are able to ensure good out- comes, despite having non-surgeons perform the procedure. Project Vision has already set up 20 centers in five provinces and has trained 60 independent MS-MICS surgeons, 15 of whom have become trainers; the goal of the project is to establish 100 charity eye centers, train 1,000 of these "rural doctors," and perform at least 1,000,000 cataract surgeries a year. The model, said Dr. Lam, has matured to the point that he is con- fident enough to apply it beyond China; Indonesia is now expecting to launch a similar program later this year. Editors' note: None of the doctors men- tioned have financial interests related to the content of this article. Glaucoma, beyond the eye The Arthur Lim Award recognizes ophthalmologists who have exhib- ited exemplary leadership in oph- thalmology, leading to substantial improvements in ophthalmic teach- ing and training in their region and beyond. This year, the honor of deliver- ing the Arthur Lim Lecture went to Ningli Wang, M.D., director and professor of ophthalmology, Beijing Tongren Eye Center; vice president, Beijing Tongren Hospital; and direc- tor of ophthalmology and visual sci- ence laboratory, Capital Medical University, Beijing. In his lecture, Dr. Wang encour- aged attendees to look at glaucoma as a condition with dimensions "be- yond the eye," a perspective that makes all the more sense in light of the problematic identification of an increasing number of patients with normal tension glaucoma (NTG). NTG has long defied satisfactory explanation. Part of the difficulty lies in the neatness of increased in- traocular pressure as an integral part of glaucoma pathology. Dr. Wang described studies that found optic nerve and optic nerve sheath changes in cases of NTG be- ginning only some distance from the orbit—about 9 mm behind the eyeball, in the subarachnoid space. He encouraged his audience to think of glaucoma not only as an eye disease, but also a systemic or brain disease. We don't yet have the answer, he said, but it definitely lies ahead. Dr. Wang and his colleagues have already published much on the subject of NTG and will continue to conduct research until the questions are exhausted, the answers found. Editors' note: Dr. Wang declared no fi- nancial interests related to his com- ments.

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