VOSH/Southeast established a standing committee at its Board meeting on August 6, 2011 to oversee further work in Haiti. This committee was established as a result of a very successful VOSH/SE supported vision clinic in the Cite Soleil section of Port-Au-Prince in July, 2011. This
week long clinic utilized low-tech refraction methods andspherical spectacles. Dr. Bob Barr and other experienced lay members of VOSH/SE spent a few hours training non-professional Haitian volunteers in establishing visual acuities, operating the I-Test basic refractor and dispensing spectacles. The Haitian volunteers were able to accomplish most of the clinic’s work after this training. The success of this approach indicates a methodology which can succeed in providing vision care to a huge percentage of the Haitian population which has no other access to better sight. Read the full report on the procedures and success of this recent clinic.
Summary of Haiti Mission – Eye Program
WinterPark Presbyterian Church/VOSH SE
July 9-16, 2011
Purpose of Program:
The Eye Program portion of the mission to Haiti was intended to investigate the potential for non-medical trained mission workers to perform the following tasks:
- Perform a basic refractive screening using the I-Test or similar device to determine a satisfactory spherical equivalent refraction.
- To provide a functional pair of eyeglasses for distance vision and/or near vision based on the spherical equivalent refraction results.
- Screen for significant eye disease, trauma, or neurological problems using simple external eye examination techniques and an Eye Triage Atlas.
- Investigate the possible establishment of a formal health referral network utilizing existing health care providers and facilities in the area.
The Eye Program was conducted in cooperation with Haiti Outreach Ministries (HOM) in Port Au Prince, Haiti. The mission compounds in Cite Soleil and Blanchard were utilized for two days each. The setup was the same at each site. The patients proceeded through stations in the following order:
- Visual Acuities – The patient was asked to read a distance wall chart with each eye. A brief history was taken at this station.
- Refraction – The patient was next sent to this station where they were given a distance spherical equivalent refraction on each eye using the I-Test device. Local volunteers from the mission were trained to perform this test. We had three I-Test devices available for this station.
- Dispensing – The patients were sent to this station to receive the glasses based on the I-Test results. The near Add was determined using an age table. A range of powers were shown as necessary to achieve the best vision at distance and near. The best glasses determined were dispensed as single vision distance or near. A limited number of bifocals were available. The available lens powers ranged from +4D to -4D.
- Health Screening – Patients that could not respond to properly to the I-Test or who were found to have a significant eye or vision problem were sent to this station. An optometrist performed Retinoscopy, lens rack refraction, external eye health screening, and direct ophthalmoscopy as needed. There was a very limited supply of medications and artificial tears available, as this was primarily a refractive training mission.
Observations and Outcomes:
- Types of Refractive Errors Observed
- There were about 120-140 patients examined each day.
- The vast majority had hyperopic prescriptions, including the children screened.
- Astigmatism was found to be typically less than -1D when present based on retinoscopy findings .
- There were three myopes found ranging from -12D to -18D.
- There were a small number of pseudophakes , but no aphakes.
- Performance of Mission Volunteers on Refraction and Dispensing
- We had 4 young volunteers to perform the refraction screening using the I-Test device.
- Written instructions were provided in both English and French.
- The volunteers were asked to read through the instructions and practice on each other before beginning the clinic. They had no more than 30 minutes to review and practice.
- All volunteers were found to be highly capable of performing the required steps and achieving a useable result on most patients seen.
- Final visual acuities were not reliable, but this was a problem regardless of who was performing the tests.
- A high percentage (~80%) of patients screened were provided with a prescription using the I-Test.
- Dispensing of prescriptions also went well with the volunteers. They proved capable of demonstrating the eyeglasses using the I-test as the initial prescription. They were also able to determine the reading glasses using the I-Test results combined with the Age Table for Adds.
- Ocular Disease and the Value of the Eye Triage Atlas
- The second goal of the Eye Program was to determine if non-medical volunteers could screen for potentially vision threatening eye conditions.
- On the first day, 6 of the 16 conditions illustrated in the Atlas were seen in the clinic.
- The volunteers were soon able to recognize conditions such as pterygia and cataracts and match them to the images in the atlas.
- With more exposure to a variety of conditions, the non-medical volunteers would have been capable of identifying most of the conditions presented in the Atlas.
- Assessment of Clinical Screening Devices , Techniques, and Patient Responses
- The I-Test proved to be an easily useable tool for rapid screening of eyeglass prescriptions by non-medical volunteers.
- The eyeglass dispensing techniques were quickly mastered by the non-medical volunteers.
- The Eye Triage Atlas proved highly effective in assisting with screening of vision threatening eye conditions by non-medical volunteers.
- The Blumenator illuminated hand magnifiers were useful for examining the cornea for fluorescein staining due to infection or injury. The white light version was useful for visualizing cataracts. These instruments would better serve trained observers and would be of minimal benefit to the non-medical volunteers.
- The instructions and techniques described in the handouts for the use of the I-Test were very effective. The determination of near Add using the Age Table increased the efficiency o f the I-Test screening.
- The attempt to use the pinhole to determine if significant astigmatism was interfering with the final spherical equivalent acuity proved a failure due to communication issues. There were also very few patients with significant astigmatism in the population screened.
- Communication was a major problem. Visual acuities were very unreliable due to a combination of a lack of understanding and a desire on the patient’s part to intentionally read poorly in order to get a pair of glasses.
- Creole is a descriptive language and does not lend itself to easy translation when asking yes/no or better/worse questions. A conversation typically ensues, often confounding our interpreters in figuring out what is being said.
- There also appeared to a significant level of dementia in the older population, making coherent responses difficult to obtain. These patients could only be satisfied using a tedious trial and error approach in presenting eyeglasses.
- There was an almost complete lack of referral sources for urgent and emergency eye care needs. There were some potential resources available, but there was no established network to be able to obtain medical care. The potential to establish these networks definitely exists, but it will take a concerted effort to make this a reality.
All goals set out in this program were achieved to some degree. The potential to have non-medical volunteers provide basic refractive screenings, eye health screenings, and dispense satisfactory eyeglasses was proven as highly possible. Professional contacts were made and fact-gathering proved encouraging towards the development of a formal health care referral network within the communities served in this mission.
This results of this program demonstrated the potential to provide at least minimal eye care to this greatly underserved population utilizing local personnel and resources to the greatest extent.
Submitted by: Robert D. Barr, OD, FAAO August 6, 2011