Divine Intervention

Many of you know that we have been praying for the arrival of our shipment of supplies for some time now. I was trusting in the Lord that it would come in December, January.... But as our supplies dwindled, and finally had to stop surgery yesterday I got really worried.. I scheduled an 8 yr old boy for surgery for this coming monday. I promised his mother that we would do surgery on Monday. But as the days progressed and it looked like I would have to cancel surgery for this little blind child, and the dozens of other blind that we would have to turn away.

So this morning in our weekly devotion at Boa Vista, we spent a special time in intercessory prayer. We all lifted our voices in prayer and asked for the shipment to be released from the customs officials today so we could continue to do the Lord's work with the blind.

  We got notice a few hours later that the shipment had been released. WOW! This is no small matter, the customs officials here are notorious for delaying and at times losing shipments all together. So we were all really excited to unload the container tonight.

Here is a picture of our administrator, David, helping unload the container this evening. He did so much work to get to this point, but I had to remind him that we had hired guys to unload this and he should let his back have a rest.
I'm so grateful to God for his faithfulness to me and to the work here in Angola. One of the privledges and challenges here is having to rely on God's power for so many things. We don't have control for the importation of supplies, our equipment is technologically challenged, the surgeries are difficult and the patients are inumberable. I have to rely on God's power here and it is teaching me that I can trust Him.
-John

I miss Grand Rounds

Everyday I'm surrounded by all of these really interesting cases. I try to explain how interesting these cases are to my nursing staff, but it's just every day problems for them. I think it loses something in my portuguese...
So once again I'll share some interesting cases from the last week.


1. Meet Isabel. She is 16 and has had to stop school because she can no longer see to read her books or the chalkboard.

 

These type of congenital cataracts are becoming commonplace for me. After I looked at her, I felt confident that I could help with surgery. But I'm never sure how much. Fortunately, I have some divine help here! She could see 20/40 the first day after surgery uncorrected. She will have the second eye operated on next week, then return to finish school in Luanda.

2.

7 yr old Eva can't see well out of her left eye. On closer inspection her facial symmetry is abnormal as well.

If you look closely at her left ear you will see an abnormality. Also the large growth on her cornea.

 She has Goldenhar's Syndrome. A congenital malformation of the left side of her face. I gave her glasses to try and treat the astigmatism while I wait for her mother to get a general medical evaluation of Eva. These children can have other internal organ malformations. If this corneal limbal dermoid continues to grow or her vision worsens I will excise it.

3.  19 yr old Maria has double vision when she tries to look to the right.

4 months previously she had some type of surgery by somebody in the capital. It sounds like it was either a pterygium or pingueguela. Something very small and likely un-needed surgery. Now she has pain and double vision. I'm calling this a psuedo-pterygium, an inflammatory growth following surgery. There is a large adhesion of the bulbar/palpebral conjunctiva and restriction of movement of the globe.

I took her to the operating room and did a modified ptyergium surgery with an autograft, and takedown of the adhesions. I placed a large contact lens to prevent recurrence of the adhesions. Post op week 1 she looks good, double vision is gone, she is happy (mostly) eye is still pretty red.

4. 23 yr old man has a red painful eye for the last 6 months. No previous medical history. Vision is Counting fingers. The anterior chamber is deep, but has near 360 degree cornea peripheral thinning, with heavy vascularization.

Those of you who read this blog regularly will recognize this as Mooren's ulcer. I did a systemic work up here, which was negative for every test I can run here. I'm treating him with systemic steroids/topical ointment and close observation. I'm hoping he doesn't perf, I really don't want to touch this with surgery.

5. 62 yr old man had cataract surgery a couple of weeks ago elsewhere. His cornea is swollen. What is not pictured here is the complete Descemet's detachment into the anterior chamber.

I attempted to place an air bubble into the anterior chamber,and even used vent incisions to try and get the fluid to come out, but it just wouldn't. This is actually post op photo.

I'm debating trying some full thickness cornea sutures in an attempt to force DM to get closer to the posterior stroma. What I'm not sure of, is whether he has epithelium growing on descemets preventing attachement.

6. 35 yr old woman with bilateral eyelid lesions (Kaposi's?). These looked very atypical, so I got an HIV test. It was positive. I'm always very suspicous of any atypical anything here for HIV. We are getting her treatment with HAART.  HIV is actually not as prevalent here as I thought it would be. But, I do make the diagnosis with frequency here.

7. Subluxated, Dislocated, Luxated.... Call it what you will, but the picture is just beautiful. This type of cataract surgery here is actually somewhat easy, crude, but effective. Some of my happiest patients had Intracapsular cataract surgery with SICS, and an ACIOL placed. I have an automated vitrectomy machine, so that helps.

These are just some of the interesting things that I was able to take pictures of this week. Thanks for reading.

John

Blind Assotiation

So I get to spend time with the Blind Assotiation every Thursday morning. This is when their weekly food supply is distributed as well as a small Bible study and social time. This population is very often forgotten in this culture and to get together weekly and talk about life is a treat. I enjoy it too, although it can be tiresome because there are so many needs and they are always asking for things, like last Thurday, a young women asked me to buy her some expensive hair. This was one of the many requests that I decided to say "no" to, but sometimes there are legitamate requests that need to be heard.

 Worship

 Receiving their corn flour in bags

 Outside

 This gentlemen received his bag of food, plus for two other blind and has hailed a taxi to take him home.

This Assotiation has enough funding to feed 81 blind. (with a waiting list) That means they get just enough corn flour to survive, no vegetables or fruit or nutrition. But they do recieve a portion of corn four which they cook with hot water and it turns into a sort of grits type food, but make no mistake, it has no flavor like our grits, but they seem to like it that way, when possible they serve it with greens and that is where the flavor comes. Anyway, they receive the corn flour and two small peices of bread for the week. This is down because they lost funding for three peices a week like they got last year. Which is a matter of $10 a week. $10 buys 100 peices of bread. This week I will buy the extra bread, but I'm putting the request out there for you to consider a donation to the blind assotiation.

Everytime I want to give I hear people saying it's not good to give, you are only creating dependancy, but let's remember that the blind are dependant in a culture like this, and the Bible says in Matthew 31-46 when it is talking about the end and Jesus is evaluating if we did or did not feed the hungry and cloth the naked, it says, "And the King will say, 'I tell you the truth, when you did it to one of the least of these my brothers and sisters, you were doing it to me."

Besides the bread issue, this week the president (also blind) came to me with another valid request. They are asking for folding walking sticks. I have looked into it and they are nowhere to be found here in Angola. I mean, the president does have one, but it was brought in from Europe some time ago. So I realize that as a reader of our blog we have lot's of disturbing images, and lot's of requests. I really don't want to lose anyone as a reader, so please if you do not feel the Spirit leading you to help with any of our request, just read and move on with your life. Or you can commit to pray for the needs. We appreciate you reading, I don't want to weigh anyone down. But if you are moved by the Spirit to contrubute, then listen and follow through.  

I know nothing about folding walking sticks, except what I've googled, so I'm searching for those who know more, and if you feel like sending over a box or two of folding walking sticks I know at least 81 poeple, whose lives will be changes for the better. I've watched many of you collect hundreds of glasses for our ministry! We are amazed, how sending out one blog can change the lives of Angolan. So thank you and continue with me in our grand pursuit of emulating the heart of God.

On a lighter note, Oliver has started school here at a private Portuguese speaking school. He is still really struggling with the Language, so please pray for him.

 Roman playing with Brother Justinho (our guard)

And finally Zekie, with his buzz cut because he got gum in his hair last week.

From Angola with Love,

Lori

Fun Day in the OR

Wanted to give a taste of my average surgical day here right now. These pictures are my surgeries from Friday morning. I'm doing about 10 surgeries every morning. Hoping to increase that number soon. If I only did straightforward white cataracts i could probably do 15 in a half day right now. But, right now I'm getting lots of experience with complex African cataracts.  There are guys in India who do this surgery in 3 minutes!!! Maybe after I've been doing this for 10 years I can do that to, but I doubt it. I don't have it in me to operate that fast, I'm too cautious.

1. I try to start the day with a straight forward mature cataract. This one was over in about 10 minutes.

2. These mature whites are my favorite to take out these days. Lots of them here, and the patients are always happy the next day.

3. Another mature white cataract. I'm concerned about the capsule in all of these cases, but with a can opener rhexis I have yet to see the argentinian flag sign. Did see that when I tried a CCC on one of these

 4. As the population here in Angola gets more "well nourished" due to increasing ease of food supply after the long war, the prevelance of diabetes and PSC cataracts grows as well. I get a good number of these now. I'm staying in practice for CCC with these. I have trypan blue which helps with the poor optics of my microscope.

 5. Now my day really begins. This young woman has a retinal detachment in this eye, and will not see well after surgery. However, she was desparate for some cure this "white eye" . She is 27 and suffers the social stigma of an abnormal eye. I don't have cosmetic contact lenses or corneal tatooing (sorry Dr Pineda). So we decided to take out the cataract. I was concerned about losing vitreous here and having retinal spill out of my wound, so I made a 6.5mm tunnel, but only entered with my keratome. From there I performed a canopener (would like to use CCC for all of these, but unfotunately my visco elastic is not very good. These compressed bags filled with liquid cortex shoot out to the periphery when punctured) I aspirated the cortex with simcoe cannula, polished the bag with the same and inserted a lens in the sulcus. No vitreous!

 6. Old trauma here in a young patient. No real nucleus, only fibrotic capsule. These are tough. Sometimes there is a hole in the posterior capsule before surgery begins. I found a space where the anterior and posterior capsules weren't fused together, cut it with cystotome and injected visco. From there I cut the fibrotic anterior capsule with scissors, washed the capsule only to find a perfectly round hole in the capsule. No vitreous came forward so I placed the lens in the sulcus, did a happy dance and got out of the eye. I had to leave some adherent material on the posterior capsule, but "the enemy of good is better" so I happily took my prize and called it good. I have tried to clean the bag completely in other cases only to have to remove a large amount of vitreous after I broke the bag.

7. Same story, second verse. Young patient, 24, had trauma as a child now has this cataract. When I arrived here I refused to do these surgeries. But now, I know a little more how important image is to the Angolan people. Having this stigma of an unusual appearing eye is not good. This patient was happy the following day becase the eye looked normal, his vision was only counting fingers. The doctor was happy too because I didn't break capsule.

 8. 13 year old boy with traumatic cataract causing cornea edema and inflammation, Cornea was punctured with some type of needle, it also punctured anterior capsule spilling lens contents into the anterior chamber, but managed to stop short of the posterior capsule. This injury happend several weeks ago, I'm not sure if he will see again, but surgery went well. I made a tunnel, entered only with keratome. Used simcoe to remove cortex. Enlarged wound, placed a lens with optic in bag, haptics in sulcus. The capsule had split like the Argentinian flag from trauma, so I was unable to place completely in bag.

 9. This is a not uncommon case. This lens spontaneously dislocated into the AC. This was actually pretty easy, I gave pilocarpine before surgery. Made a tunnel, removed lens with lens loop. Looked for vitreous, but there was none to the wound. Placed ACIOL, made iridotomy. placed a suture and called it good.

 10. Now that I look at this pre-op photo, not sure if this was a wise move to take off the pterygium here. 70 year old man, he had 5 diopters of cyl which corresponded to ptyergium. We will see how it turns out. I do all of these with conjunctival autografts, I use 10-0 nylon 4 sutures (1 at each corner) and they have been looking really good at 1 months time.

Watching My Husband

The rare opportunity opened for me to see John in action. While we were out on John's first Bush surgeries, in a province called Catala, the kids and I were free to come in and out of the operating room. The above picture was taken by our 6-year-old son, Oliver.
As I watched John change into his scrubs right in front of the nurse (male) and patient on the bed, there was a light-hearted feeling in the room, but as soon as he took his seat and the nurses scurried about to prepare for the surgery, he seemed so important and powerful sitting there doing what God created him to do.

There he is about to change a mans future by giving him sight. A heaviness came over me, not once have I heard John take credit for his abilities. He humbly depends on the Lord in hard times and praises Him for the good times. I think of all the conveniences he has given up in reguards to surgery and I'm so proud of him. He carries a great burden being one a very few ophthalmologists in Angola.

I realized that I've been taking my role as his help-meet too lightly. Instead, I thought I was put in his life to make sure his head didn't get too big. Today I realized how much God is using me as I serve my husband and family. As I keep the house in peaceful order and make nutritious and yummy meals. I can free some his worries by not having chaos in the home.

I'm praying today for strength to go on. For me and especially for John. I pray that John doesn't burn out. And that God bring Angolan doctors to us that want training in ophalmology.

On a happy note, my mom just got here and we are having a wonderful time with here, here are some pictures from yesterday.

From Angola With Love,

Lori

Life Changing Surgery For less than your next Dinner out

This it Tete. She is 18 years old and blind in both eyes. Her brother says that she has not seen anything for the last 3 years. She lives in Uige province, a remote province without access to healthcare. She spends her days doing hard labor; her family guides her by the hand to her work station and she grinds grain with what looks like a large mortar and pestal for hours on end without ever seeing the faces of her loved ones. She can't see the beauty of the African sunrise, the Baobab trees in blossom or the tall green grass waiving in the breeze. She has cataracts in both eyes and had the misfortune of being born in Angola.

   There are many of these young people here that were born with cataracts and now there is nothing that can be done. I have operated on cataracts like this and after the surgery the vision is the same because the eyes never learned how to talk to the brain properly (amblyopia).  Furthermore, she had the look of a syndromic child. An odd body type, possibly from an intrauterine infection or genetic disorder.

However, her brother insisted that 3 years ago she could see something. I could sense God urging me to do this surgery despite my doubts about her being able to see after surgery.

    Her surgery was difficult. I'm going to explain it a bit for my opthalmology friends out there. She did not have a nucleus to speak of, only liquified cortex and capsular fibrosis. I made a quick linear incision in the anterior capsule with my cystotome at 12 oclock, and expressed the liquified cortex. These are tricky because if you use too much force with your needle you puncture the posterior capsule quickly as there is no nucleus to guard it. I filled the bag with viscoelastic and used scissors to open the rest of the bag, I placed a 1 piece PMMA Auralab lens in the sulcus and cleaned up the AC and called it a day. Surgery cost is less than $50 USD.

The next day when I went to see my post ops I was greeted by her brother who was all smiles. I found Tete in the ward looking at everything. Judging by the way she was inspecting every detail in the room , the surgery had returned her vision. There is a very uniform blank stare/expression on the faces of the blind. It is terrible to see. But when it is wiped away by a successful surgery, it is very gratifying.

We did surgery on both eyes in the span of 5 days. She is now 20/30 at distance and J3 near in both eyes uncorrected.

Thank you to everyone who is supporting us here both financially and with your prayers. You helped bring back sight to this young woman.

                                John with Tete (center) and her brother (blue)

My First Surgery in the Bush

We only had to travel 3 hours to get to Catala, but the conditions were much different. One could only get there with 4 wheel drive. So now I finally understand what all the hype is about in "going muddin' " in a 4x4. Yes! That was fun.
Here sits the crowd that awaited me at the mission hospital. Many were blind from glaucoma and other problems that I could not fix in the bush, so we narrowed them down to 5 patients with operable cataracts.

 This woman had surgery with another group and did not have a lens implant during the surgery. I had the pleasure of fitting here with +12.00 glasses. She was happy, don't let the serious face fool you. Thanks to the donor of these glasses, whoever you may be!

Wow, this was my operating room.  Wind and flies blowing through the windows, not the last time I will swat flies in my operating room I'm sure. We brought a portable generator to power the light in my microscope and instrument sterilizer.

The conditions are difficult here. Our mobil microscope is not very good, I'm hoping for a new one.  My first surgery actually did not go as well as i would like as I had vitreous loss. The cataract was actually the most difficult of the day. The normal lens capsule is easily torn, but this one was so dense I had to use scissors to cut it, as my needle wouldn't cut it do to fibrosis. I think the posterior capsule was also fibrotic and scarred onto the lens as when I removed the lens there was a large hole in the posterior capsule and vitreous coming to the wound. The rest of the surgeries went very well, but I was really worried about that first case all night. However, God took that which I thought was not good and turned it into something beautiful. This woman was so happy; smiling, singing and dancing after I removed the patch. Actually she was the most happy of all the patients all day, and her eye actually looked very good.

I actually really enjoy checking people for glasses now, especially underneath the Baobab tree! I despised glasses exams in my residency training, but now I'm very happy that I learned this skill. Many people here just need glasses. Now I just need more glasses to give out during these site visits. Thanks to all of you who have donated glasses to our project, we are eagerly awaiting there arrival in Angola!

Lori has found that bubbles are a great icebreaker for the kids.

These trips are not all hard work. We also got to go hiking as well.

Lori really wants to put one of these huts in our backyard as a play house for the boys.

Angola is surprising us as we get to explore new areas. The terrain varies from arid desert, to tropical forest, and mountain plains. While the mountains aren't snow capped and the highest is somewhere around 7,000 ft above sea level, they are still great to climb. Pictured is the summit of a small peak with views of one of the highest mountains in the background. That is our next challenge.

On this trip we also took a stop in another place called Kalukembe to attend a memorial service of another missionary that will be greatly missed, JPB's (our mission director) mother.  She was nearly 100 years old, and served as a nurse in Kalukembe for decades. It was a moving service, as Angolans shared how Anny Brechet had impacted their lives and brought the gospel to their country.

While we were there, we also got to visit an interesting hopsital.

This hospital was one of the first missionary hospitals in Angola, and has had many great missionary doctors call it home for a time. If you ever get a chance to read "The sword and the scalpel" a book about Robert Foster, MD, it describes his time at this hospital. However, it has been without a doctor for decades. The work was disrupted by the war here, and even though there has been peace since 2002, no doctor has been resident here since the mid 1990's. Good news however, we had the priviledge of meeting Dr Batacou, who had come only 1 week previously as the first full time doctor.

 I hope to come back to this hospital someday soon to do cataract surgery in this operation room.

 Look at this smile! Zeke used this bathroom even with spiders and frogs watching him do his business. Also the bucket on the floor is the flush, you need to fill the bucket with water first, and then pour it down for the flush. This is a common means of personal hygiene here.

While there has not been any full time doctor here, the nurses here are very experienced and even do surgeries (as shown Above).

This is the pediatrics ward. The conditions are very crowded. The staff to patient ratio is not very good. Many patients have terrible diseases/injuries from which they will not recover. But despite the sometimes dire conditions, the gospel is preached to the patients and there is a genuine sense of hope throughout the hospital.

Thanks for reading,

John