We have a set schedule every week that we follow. Dr. Tim kindly outlined it for me the first day I arrived.
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| Weekly schedule |
Wednesdays, we have clinic here in Siteki at Good Shepherd.
Dr. Tim and I made it into clinic about 9:15 this morning to
an entire waiting room full of patients. We immediately set to work. Again, it
was a very interesting day, but there is always some frustration. The visions
that are checked by the technicians seem to be an “estimated” vision. In fact,
I had one patient whose vision had miraculously improved in the right eye from
longstanding “hand motions” to nearly 6/15 (equivalent of 20/50 in the U.S.)!
Amazing. And then, when I looked at her, it was clear there was NO WAY she
could see much out of the eye. The pupil was completely blocked with “scar
tissue” from old anterior uveitis secondary to syphilis. At any rate, I
rechecked her vision, asking her to cover her left eye, and it was clear she
was peeking. So I covered the eye myself and realized her vision was “NLP” (no
light perception). I love the technicians, but clearly things like this slow me
down.
And today, I finally understood how useful it is to check
for an RAPD. I had many patients who had been previously diagnosed (by whom, I
have no idea) as needing a cataract extraction. But upon exam, the cataract did
not seem to correspond to the vision (i.e. vision was much worse than could be
explained by cataract alone), so I did a quick pupil check and determined that
there was an enormous RAPD. Upon dilation, it was clear it was NOT a cataract,
but rather end stage glaucoma with a completely cupped nerve that was
responsible for the visual decrease. It makes quite a difference: for a
cataract we would operate, for end stage glaucoma, we put the patient on drops
to try to preserve what tiny amount of vision he or she has remaining.
Other interesting things seen today:
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Interstitial keratitis from syphilis
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Bilateral chronic angle closure glaucoma with
mid-dilated pupils, decreased vision, and intraocular pressures in the 30s.
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Many patients with end-stage glaucoma
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A patient with very mild cataract, who didn’t
want to buy glasses until we “took her lenses out and cleaned them” (she wanted
cataract surgery when all she really needs is glasses).
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Pseudoexfoliation glaucoma
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Tractional retinal detachment secondary to
long-standing proliferative diabetic retinopathy
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| Clinic at Good Shepherd Hospital. Dr Tim's/Dr. Pons' slit lamp on the left, my slit lamp on the right of the photo |
A quick note about patient privacy. Many of the patients we
see in clinic are HIV positive. When we examine the patients, it in one large
room, with both myself and Dr. Tim sitting at one end. There are two long
benches in front of our slit-lamps, and the patients just scoot down the bench
until they reach us. At that point it is their turn to be examined. Obviously,
given this set-up, privacy is NON-EXISTENT. And oddly, everyone is okay with
this. Dr. Tim told me my first day is was perfectly acceptable and even
considered appropriate to ask the patient in front of everyone else if they are
on “ARVs” (anti-retrovirals). The patients don’t even bat an eye and will share
this personal information. I can’t even imagine this in the United
States—asking patients this extremely personal information in a room full of
other patients. But, I guess it probably has something to do with how
incredibly prevalent HIV is in this population; it isn’t considered abnormal to
have HIV—it is just a fact of life that 1 in 4 deal with here in Swaziland. And
I am sure we would give them more privacy if we had the ability. The clinic is
literally four rooms: the examination room, waiting room, office, and a
bathroom.
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| Swaziland from above |
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