According to the World Health Organization (WHO), there are more than 2.2 billion people worldwide suffering from vision impairment or blindness. In at least 1 billion of these cases, vision impairment could have been prevented or has yet to be addressed. Despite effective and relatively low-cost interventions, millions of people living in low-income or middle-income countries (LMICs) experience vision impairment due to treatable or preventable conditions such as refractive error and cataracts.
As a [recent article] in The Ophthalmic ASC notes, a growing community of ocular surgeons in the United States have taken meaningful steps to help alleviate some of these eye-health issues around the world. One of them is Cathleen McCabe, MD, chief medical officer of Eye Health America and medical director of The Eye Associates, both in Sarasota, Florida. During our conversation, which has been edited for length and clarity, Dr. McCabe discussed her recent experiences providing eye care in Africa and the Caribbean, and encouraged other surgeons to consider becoming involved in international charitable care.
Question: So, tell us about the trip you recently took to Kenya!
Cathleen McCabe, MD: The trip we just took was with an organization called Kenya Relief. It is a trip that has been largely organized by Tim Page in Michigan. We see patients in the clinic and we perform surgery. This time, I think we did over 100 surgeries and saw about 600 patients in clinic.
The scope of problems that we see in Kenya is pretty advanced. We’ve seen really advanced traumas, advanced melanomas of the conjunctiva, even advanced tumors, and all the cataracts are blinding cataracts—dense, no view white cataracts in little tiny orbits that are very challenging.
One of the issues is that a lot of people can’t get to the doctor. Kenya Relief’s clinic is in Migori, a city in western Kenya, and I think 80% or more of the households have firewood as their primary energy source. We do some home visits when we’re there. These give us some insight into the home circumstances of some of the people in the area, and the challenges they’ll face when they go back to their homes. They’re largely mud brick structures, very simple structures, and a very different lifestyle than here in the United States.
It’s a challenging experience as a surgeon because it tests your flexibility and ingenuity. You don’t always have all the tricks and special equipment that we have in the US to deal with these cases, so you really must think about what is needed to help the patient, how you can do it safely, and how the patient is going to be able to care for themselves afterward. That’s a challenge.
Q. So what is the facility like? And did you bring any of your own equipment, or were you solely reliant on what they had in the clinic to perform cataract surgery or other procedures?
Dr. McCabe: Kenya Relief was started by a nurse anesthetist from the United States, in response to his college-age daughter Brittney dying unexpectedly in 2001. Since high school, Brittney had been sponsoring a child from Africa, and when she passed away her dad wanted to find this child that she had been passionate about sponsoring. He ended up going to Africa and finding the child, and he became passionate about helping not just this child but also his family and then people in the area in Brittney’s memory. There was a need and opportunity to make a meaningful impact there, so the facility is an orphanage and a school, and children live there full time. They’re not always technically an orphan the way we would think about it, they’re not always without a family or parents, but the circumstance of their family is such that they can’t really send them to school. Kenya Relief will go to families who are in those circumstances and arrange so one of the children can potentially attend the school, live at the facility, and be educated. They also created a clinic across the street from the school and housing, and throughout the year they host different medical teams, all with different specialties.
The first time I went to this location was in 2016. At the time, they didn’t have a dedicated wing for surgery, but they had a large room where we could do surgical procedures. By the next time I came, which was in 2021, they had created this surgical wing where they now have two operating rooms. In one of the ORs, we have three beds and microscopes, so three surgeons can work on three patients in parallel. The other operating room is used for special procedures that need general anesthesia, so procedures on children would happen over there, as well as some of the oculoplastics procedures. They’re working on building an overnight facility for maternal health, for obstetrics, so that’s in process.
Q. What sort of equipment do they have in their clinic facility? Do you have access to phacoemulsification machines and other equipment that you would use in the United States?
Dr. McCabe: We don’t generally do phaco—we do extracapsular cataract extraction, the less technology-intensive form of cataract surgery. This year, one of the team members, Dr. Eric Purdy from Indiana, brought a small phaco machine (CataRhex 3; Oertli) that you can carry on the plane. It works well, so I was able to do some phaco this time as well, so that was fun.
In general, we do bring everything. We bring all the lenses, we bring all the viscoelastic, we bring disposables that are needed. Since teams have been coming for years, there are some materials left over from previous years that can help, but we generally don’t rely on that. You may not know until you get there what they have on hand, so we bring everything we think we might need, including the preoperative and postoperative drops.
Q. How many people went with you, and for how long? Does Kenya Relief have a dormitory or campus where you can stay, or were there other arrangements?
Dr. McCabe: We had around 28 people in our group this time, and we were there for a week. We fly into Nairobi and stay overnight, because we usually arrive late and it takes a few hours to get through customs. Then it’s a pretty long van ride the next day, six hours or so, to get to Migori, and we spend a day setting up the clinic and setting up the operating room, getting everything unpacked, and organizing all the different supplies that everybody’s brought. Lately, we’ve been also seeing patients that first day—I think we probably saw 60 patients that afternoon. For another three days we see clinic patients and do surgery. Then we end up going on a small safari at the end.
In the orphanage itself they do have a dormitory-like building that has multiple rooms, and the rooms have bunk beds in them and two different shared bathrooms, one for women and one for men. We had a big team this time, so we also used another building that was behind it, where missionaries have stayed before. There are three bedrooms in there that we were able to use.
The living areas can vary from trip to trip. On some mission trips, local families will host you and your team members. On other trips you could be staying at a local hotel. I’ve been leading another mission in Saint Vincent and the Grenadines for over 20 years now, and we stay in a hotel resort that has little cabins that team members share. That’s nice, because at the end of the day we get to go back to that retreat, and we have a group dinner together and group breakfast together in the morning before we set out. There’s more opportunity to get to know the other members of your team and have some fellowship time with them.
Q. Please tell me more about your work in Saint Vincent and the Grenadines.
Dr. McCabe: Eric Purdy, MD, is my friend who I invited to come to Kenya [in the fall of 2023]. Back in 2003, he originally invited me to come with him to Saint Vincent. So we’ve been going on that trip together for many years. His whole family has gone, our whole family has gone, and we’ve invited many other people to come along as well. That mission was originally started by another doctor about 35 years ago, and so Eric and I have been doing it a little over 20 years.
The mission to Saint Vincent and the Grenadines is something that we’ve kind of poured our hearts and souls into, and it’s grown. In 2020 we bought a building on the island that had previously been owned by a general surgeon named Dr. Cecil Cyrus, who was Vincentian. He had brought western medicine and surgical practices from England, where he trained, back to Saint Vincent and spent his whole life treating just about everything and created a great practice. He retired and turned this building into a museum of his medical career, but previously it was a clinic with operating rooms. We purchased the building because we wanted to have a place that we could have more permanent equipment for our cataract mission. We didn’t want to disrupt the local indigent hospital, where we had been doing our clinic, and thought this would enable us to visit more times during the year and maybe even do some training there.
So we purchased the building in January 2020, and had all kinds of plans to go down and renovate—unaware, of course, that the world was going to change with the COVID pandemic. So that got delayed. Then there was a volcano on Saint Vincent that erupted in 2021, so we were delayed in going back until 2022. [Editor’s note: the eruption displaced nearly 18% of the island’s population, roughly 20,000 people.] So over the past few years we’ve been working really hard with the doctor’s son, Paul Cyrus, who has helped us to renovate the building. We were able to dedicate the building to Dr. Cyrus before he passed away in his 90s last April. We expect to be ready to do surgery there by the time we do our next mission, which will be Memorial Day week of 2024.
Q: What it’s like when you go to Saint Vincent—talk me through a typical week that you spend helping others there?
Dr. McCabe: It’s a different structure [than the Kenya Relief trips]. We usually get there on Friday or Saturday. It used to be a big adventure to get down there, as there weren’t any direct flights from the United States. We had to fly into either Barbados or Trinidad and Tobago, and then take a small plane to the islands, which has lots of weight restrictions and they’re less reliable. In 2017 an international airport was built on Saint Vincent, so now they have direct flights from Miami and New York. That has simplified the travel a lot. So we get there, as I mentioned, on Friday or Saturday. The next day we will set up the clinic. We do a parallel clinic—that’s an optometric clinic and an eye clinic. In the past it’s been held in a cricket stadium, where there’s good, covered seating for the patients who are waiting and enough space inside for all the things that will be done with testing. We will see about 1,000 patients during the week, from Monday through Friday, and we distribute glasses during that time, usually about 600 or 700 pairs of glasses.
When we first started, there were no ophthalmologists in Saint Vincent taking care of indigent patients. Now there are four ophthalmologists that we work with. Three of them are general ophthalmology and one is a retina specialist. They identify patients throughout the year that will come, so they’re all preidentified, and we screen all the patients, get all their preoperative measurements, do all the calculations for their implants, and schedule everybody for the entire week during that Sunday screening. Typically, we have somewhere around 250 patients show up. We can really schedule a little over 100, so there’s a lot of patients that we’ll either turn away or have them follow up with one of the local ophthalmologists. Or we’ll see them and triage the urgency of what they need. So, Sunday’s a busy day. Then the rest of the week is surgery for the surgical team. We have two beds in the same room that we operate on, and in the indigent hospital where they have two ORs they shut down elective surgeries while we’re there so that’s why it’s a little disruptive to what goes on there. We do surgery all week and the clinic sees patients and distributes glasses all week.
Q. How are you able to give away 600 or 700 pairs of glasses? Do you get donations of frames? Are they from local people, or do you have to ship the glasses down there?
Dr. McCabe: When we started the clinic, we worked with the Lions Club locally in Saint Vincent. [Editor’s note: Lions International has a program called Recycle for Sight, in which they collect used eyeglasses in good condition and donate them to people living in low- and middle-income countries. The Lions determine the prescriptions of the glasses and enter them into a computer system.] When we measure the patients’ refraction at the clinic in Saint Vincent, we would enter that into the computer system, and it would pick out the three closest pairs of glasses. Then my kids and other volunteers would help find the boxes with the right glasses, and we’d have the patients try them. You have to do a little salesmanship, telling them, “They may not look the best, but you see the best with these,” so you learn a lot about psychology.
We continue to provide those glasses from the Lions, but the frames are generally older and dated-looking, so it can be hard to find a pair of glasses that patients would choose for themselves. No matter how blind you are, if you’re a big guy and the only thing that fits you is little purple or pink glasses, you may not want to wear those. So six or seven years ago, we started trying to find a better way of providing glasses that patients would be more willing to wear. We work with a company that offers kits where you can choose one or two frame styles, maybe a couple of different colors, and they’ll have spherical lenses that we can pop into those frames to make something that’s close to what the patient needs. A limitation is we can’t treat astigmatism with those systems, so we’re always looking for something better, but we’ve been bringing those pop-in glasses systems for quite some time. The companies don’t donate them often—although sometimes we do get donations of readers and things like that. Usually, we must buy the kits, which we pay for with charitable donations.
Q. Can you share some stories about notable patients that you’ve seen over the years?
Dr. McCabe: I like to tell the story of this lady I saw in Saint Vincent who was bilaterally blind and was not able to ambulate or do any of her activities of daily living. She came in with her daughter, who was really caring for her mom, and we took out her cataract. When the daughter came back another time with her mom to have the other eye done, she was so grateful. She said, “you don’t know how my life has changed. Before, I had to get up really early, I had to make sure my mom was OK for the day, take care of my toddler make sure she was going to be okay, drop her off at daycare, work, come home, take care of my mom, and take care of my daughter. Now, my mom takes care of herself, and she can help me with my daughter. My life is completely changed.”
It brought the perspective that what we do is not always just for the patient, it’s often meaningful for the family. It could be meaningful for the entire community, enabling them to contribute instead of being someone that people worry about or need to help. So, what we do has a ripple effect. I tell that story a lot.
In Kenya the last two years we had some really sad stories of kids. The last patient I saw two years ago was a little boy. They said, “before you finish clinic, can you see this little boy? He’s 4 and he got poked in the eye with a stick and he’s crying.” I’m thinking it’s a corneal scratch. Well, he got poked in the eye with a stick a month earlier and he had a huge scleral perforation. His entire globe was filled with infection, which could have extended intracranially through his optic nerve, and he needed to be enucleated. But that was probably a life-saving treatment for him, because where was he going to go to get that treatment? And how accessible was it going to be when they waited a month for him to see us? Can you imagine the pain he was in for that entire month?
Just having to make those kinds of decisions is hard. We know sometimes that there’s a tumor—we don’t know the extent of the tumor, we don’t know the nature of how aggressive it is, and we have to ask a patient, “Can we take your eye out?” And they have to decide right then.
In Saint Vincent last year, we had a patient come in with his mom, who couldn’t walk and was a bilateral mature cataract patient. He was just there to bring his mom—but he had this big tumor across his entire eye, and we were like, “You need treatment. We’re really concerned about you.” He wasn’t sure he wanted anything done, but in the end, he did let us do surgery.
Q. Do you ever have patients that you’ve seen who return for follow-up the next time you come to the clinic?
Dr. McCabe: Oh yeah, lots of patients like that. A lot of those patients that are utterly blind, we’ll do one eye surgery and they’ll come back for their other eye the next time we’re there, in a year or two. I don’t always remember all my patients there, but there was one lady who had really cool hair. She had this corkscrew-like purple hair and I remembered her hair when she came back to have her other eye done. I was pretty sure I had taken a picture of her the first visit, so I looked through my pictures and was able to show her, “Look, this is you last time.” It was fun because I could remember that I’d seen her.
Q. Are there legal differences that you need to be aware of when providing medical care in another country? Are there differences in practice patterns from the US?
Dr. McCabe: It’s interesting sometimes to see what a country focuses on for their regulatory things. A lot of times if we’re doing exactly what we would do in the US, that’s great. Sometimes we have restrictions on reuse of things in the US that don’t really make sense—they’re not based on science, and we could reuse those instruments and they’re still very functional and are safe to reuse but because of labeling restrictions in the US we cannot reuse them. We obviously don’t have those restrictions in Africa or in Saint Vincent, so we are able to be more sustainable in our attitude toward disposables in other countries. It’s nice, because we don’t always have unlimited access to all the things that we need, so being able to reuse items until they’re not functional makes a lot of sense.
One interesting thing is that sometimes these countries have rules that are more restrictive than in the United States. For instance, in Saint Vincent they really want you to wear sterilized scrubs. You cannot walk over the red line with your scrubs on; if you do, you need to change them. They are very, very strict about it, where we wouldn’t necessarily be so strict about that in the US. Every place has its little differences.
Q. If a surgeon wants to get involved in doing the sort of international care that you’re doing how would they do it? What would you recommend is the easiest way to get started, or what are some steps that they can follow?
Dr. McCabe: The biggest thing I can say is, “Don’t try to invent the wheel on your own.” If you’re new to missions, start by joining an established mission. They’ve already done all the logistics—they know there’s going to be good follow-up care for the patients, they know how the patients are going to be identified, and where you’re going to be working, and what the local needs are. That way you’ll get to work with a surgeon who’s experienced in that location, so you can learn the things that make for a successful mission—how you can impact the local community in a positive way without competing with local doctors. There are so many things to understand that you don’t think of immediately. If you just think, “I’m going to go do surgery and do good,” you must really plan those things out. Go a few times—go with some different missions to see different approaches.
There’s are a lot of different organizations that that arrange these trips, including Medical Ministry International, HCP Cureblindness, and Hawaiian Eye Foundation. A group called Americares Medical Outreach, which donates medicines and medical products to mission groups, includes a list of organizations on its website. Other organizations are not difficult to find on Google.
If you’re interested in going to a country where the surgical resources are limited, find a way to either watch somebody do extracapsular cataract surgery or take a course in it. Try to gain those skills ahead of time. What you don’t want to do is go to a location and think that you’re going to learn complicated skills for complex patients in a remote location, where you don’t have the best lighting, the most reliable electricity, the best microscope, or the kinds of backup you would have for complications in the US. Learn those skills before you go—don’t try to learn them on the fly.
I highly encourage people to go. It will make you a better surgeon. You’ll be more flexible and inventive in your thinking. I’ve brought back so many different tips that I use in my daily clinic based on things I had to think about differently and different tools I had to use on a mission because I didn’t have everything available to me. It will benefit you in ways that you can’t imagine now, and your patients also will benefit from it. OASC
