Pediatric surgery: the best and worst surgeries to do

One of the absolute most fun things I get to do is take pictures with kids after surgery. Usually this means that their surgery went well, so family and child are happy to oblige. The actual performing of the surgery on a child, I don't like so much, and every time in the middle of surgery I ask myself why I endure the mental anguish.  For anybody who has done pediatric cataract surgery you understand. The following photos and stories are the reason. We have done close to 100 pediatric cataract surgeries this year alone and I wanted to take a moment to share a few great stories from surgeries I did this week.

 

First, I'll share about this family of three boys. I was touched deeply since the kids were nearly identical in age to my 3 boys. The oldest Dionisio, middle Evaristo, and youngest Nelson were all born with congenital lens opacities. Their family lives about 16 hours away by car, and a 2-3 day bus journey. Unfortunately they had never had surgery before, so they all had nystagmus  (the eyes moved all the time signifying poor vision potential, amblyopia). BUT.... I just can't leave them that way when I think there might be a chance, so we did surgery on them all the same day and this photo is after the second eyes were done. Fortunately they all cooperated for local anesthesia.

 

Despite the nystagmus, the vision was definitely improved and all lenses were in the posterior chamber nicely secure. We will continue to observe them and I'm optimistic that vision will improve with time.  I'm so grateful we got to help these awesome family.

 

Below is Zeferina. She got hit in the right eye by a rock and was left with a large, white cataract. I am always cautious with traumatic cataracts as they can present challenges unique from standard cases. Upon completion of the rhexis, I noticed a forward pressure coming from the soft lens nucleus, a little hydrodissection confirmed the presence of vitreous as there was an almost perfectly oval defect in the posterior capsule with fibrosed margins. A complete anterior vitrectomy to remove cortical remains and a lens was placed in the capsular bag. Vision today was 20/80 uncorrected. Doesn't she look adorable? Ok, Ok I get it Angolans as a rule don't like to smile for pictures (if this is your first time reading the blog, it's a recurring theme).

Ernesto is 9 years old. He was born with congenital cataracts that grew over the last several years. He did not have nystagmus, and I was very optimistic about his vision chances. He however, did not agree with the local anesthesia as whenever he felt something ( drop of water on this eyelid, movement around his face from my hands, etc...) He flinched his head from side to side. Very difficult to work like that when you have sharp instruments inside the eye. Unfortunately, I only learned about his reaction after the eye was already opened, in fact during the capsulorhexis, which was not completed successfully; not a coincidence.  Gratefully, I had enough intact capsule to place a lens optic in the bag with haptics in the sulcus. His vision was 20/60 today and I only had to joke around with him a little bit to get this half smile. I love the tuxedo shirt.

Please keep Angola and the rest of the developing world in your prayers as there are thousands of needlessly blind children just like these waiting for their miracle. What can you do to be apart of the cure?

Ladies Retreat 2013

 

 

Ladies Retreat Again! Two nights, lot's of singing, dancing and eating.

I'm dreaming of the day that a group of American women come over for a womens retreat. How fun would that be!! You are all invited.

We went out to this little village to visit a new church plant. Besides making lot's of joyfull noises we also went out to each house to meet the community and invite them to come meet the new pastor.

Thanks for watching,

 

From Angola with Love,

Lori

 

This is No Sacrifice

When John and I got married, we played a song called "This is no sacrifice, here's my life." And I loved those words but never really understood them until now.
There are some who have praised us for our "selfless" acts of selling our things to serve the blind in Angola. If I could convey our understanding of God and His Kingdom, and the amazing encounters we have had because we left our comfortable world; you would realize that we have sacrificed nothing. Instead, we have traded up in life. I have the privelege of being reminded  daily of our many blessings. Daily, we get to feel the reward of helping others in need without looking for them. Our children see, everyday, other kids who don't have it so good (although, they don't always sit content with the same "old" toys). I'm not bombarded with commercials for the latest and greatest gadgets telling me what I should be wasting my hard earned money on.
I've seen my children's prayers get answered. I've seen my husband grow in the Fruits of the Spirit. I've seen the Lord actively working in my life. Even when I thought I didn't have the kind of Spiritual Gifts that God needed in a Missionary, but I get to see Him use me! I can't hide behind all the "truely qualified" ministry people. I get to be that person. My life is so full! So blessed, so unified with my family.
I have made no sacrifice of true meaning, but I have traded up in the Kingdom of God; and want to hear no more of how amazing we are. If we were so amazing, God would have been able to teach us and use us in these ways right there in the U.S. But instead he had to send us way over here to get our attention. .
When I hear someone thanking me for coming here, I feel so humbled. It's like someone thanking me for eating a piece of chocolate cake. I just love my life.




From Angola With Love,
Lori

Note: The wording I used today, "traded up" was taken from the book "Love Does" by Bob Goff.

Proud to be an American

Happy 4th of July from Angola. It's the coldest time of year here, which means low 80s, brrrrrr. I'm loving it! I wore long sleeves all day today and didn't get hot, this is the life!
Anyway, our blog today will be a reflection on why we are proud to be Americans. I can honestly say, that before moving here, I was quite indifferent. Like many youngsters, I just didn't know how good I had it. But after living away from our precious land of Liberty for almost two years, the American pride is welling up inside me.
Let's start with road rules. You may not agree, but we are so very organized on the road in the U.S. and the people actually obey the rules, and cops only stop you when you break a rule, and not just when he is hungry. Thank you also for reliable street lights.
Customer service, when I walk into a store and I have to greet the staff first, I don't feel wanted, then they will be bothered that I had the audacity to bring in my children. My friend actually was asked to send her son outside to wait for her! And forget about exact change, if they owe me anything under 50 cents its totally acceptable to make up for it in candy. (My sons love that)
Thank you also America for paved roads! As we are driving back home from visiting a friend or a church outside of downtown, we all take an automatic sigh of relief as soon as we hit the pavement and the car goes silent and our ab muscles relax! Aaahh.
Thanks America for having enough teachers that our kids can all go to school at the same time in the mornings. Here, The even grades go in the morning, the odd grades go after lunch and many high schoolers go in the evenings. They have to share the buildings and the teachers. This goes for public and private schools.
Thank you America for having four seasons.
Thank you America for selling ground beef.
Thank you America for cleaning our tap water, thank you for tap water.
Thank you for vaccine options for our children.
Thank you for wonderful education options.
Thank you for Wal-Mart and coffee shops, and movie theaters.
Thank you for votes that count.
Thank you for water heaters!
Thank you for not having Malaria mosquitoes.
Thank you that we all have the option of electricity.
Oliver says, "Thank you for cartoons in English"
Zekie says, "Thank you for toys that don't break"
Romie says, "America?? Eu não quero ir no avião." (I don't want to go on the airplane.")
John misses green grass, baseball games, and steady electricity.

But living in Africa does have some perks. . .

like two wheeled school buses.

and walking boutiques.

massive termite mounds

nursing mommy's photo op

hunting exotic game

elephants

kudu

and giraffe

and of course my precious boys.

 

Happy Independence Day America, we miss you!

 

From Angola with Love,
Lori

He still cares for individuals

I find it easy to get caught up in the big picture of trying to fix all of Angola's eye problems, train future ophthalmologists, and lead the Boa Vista project, instead of appreciating the individuals that we treat. However, from time to time God sends patients with stories so memorable that I cannot help but thank God for allowing me to be a part of this good work.
Today I will share two stories from surgeries that were done yesterday at Boa Vista that touched my heart deeply. This work would not be possible without the generous support of readers like you. So read, reflect and give thanks to God because He is still in the business of performing miracles and transforming lives of individuals.

1. Joaquina is 45 years old and lives in Luanda. She is blind in both eyes from cataracts and she has severe leg deformities from the polio she suffered as a child.

 In the neighborhood she lives in there are no side walks or roads that a wheelchair could access. She crawls on her hand and knees using flip flop sandals as "shoes" for her hands. She entered the consultation room with some difficulty, feeling her way across the room using her hands to guide her blind eyes. Her eyes had a type of cataract called posterior subcapsular cataract. Previous to my arrival at Boa Vista this type of cataract surgery was not being done, because it is more difficult to perform than a "normal" white cataract. She would have been told to return in 6 months when the cataracts were "ripe".
However, thanks to a generous donation of a modern cataract surgery machine (thank you Chris and Steve) I said yes we can help!
I performed a perfect phacoemulsification surgery on her right eye yesterday and this is the sight I was greeted with today as I entered Boa Vista.

One very happy patient and one very grateful doctor who can't believe how good God has been. We were able to restore her sight and help her navigate through her world. I can only imagine the troubles she had navigating blindly on her hands and knees through the dirty streets of Luanda (which is a third world version of New York). Now, if only I had a friend who did orthopedic surgery....

We are now running a successful phacoemulsification program in addition to our manual cataract surgery. Effectively expanding our capacity to help the greatest numbers of people and blessing me with the ability to stay current in cataract surgery technology. When I left for Angola there was no modern cataract surgery being done here and I was worried that I would forget how to do the surgery and be unable to return to the United States because of my diminished surgical skills. Those worries proved (as most are) to be lies. Through the generous provision of donated equipment and materials my surgical skills have multiplied and I am a far better surgeon and capable of performing a wide variety of surgeries well.

2. Our next patient is Lorenzo,  a 31-year-old man, who was led into the clinic by his brother. For the last 16 years he has been blind. Imagine that. A young healthy man unable to work, study, play soccer because of blindness. They said his eyes always looked a little funny since birth; but only after the "white spots" came was he completely blind.

 

 

For the non-eye doctor I will briefly describe the pictures. First his iris (the brown part) has a congenital abnormality, the pupil is not in the center of the iris but rater displaced up and out. Actually this is as big as the pupil would get as it refused to dilate with eye drops. There is the white spot, or cataract as I like to call them. The pupils slightly reacted to light, but he could point to the direction from where my light was coming from so I thought he could see if only we could do a cataract surgery. I performed an ultrasound of the eye and discovered that it was a very small eye only 18 mm in diameter (normal is 22-24mm). He would also need a lens implant that was very high in power (33 diopters), which I discovered we actually had here!. I did surgery on friday. It was one of the most challenging surgeries I have done in a long time. The orbit/eye is very small and had difficult access surgically. The anterior chamber was extremely shallow. The pupil was indeed only this big after multiple rounds of eye drops. I was saved by another donation of flexible iris hooks (Thank you Chris) which allowed me to mechanically retract the iris and open a pupil to give me access to the cataract. When I opened the iris for the first time I saw a perfectly white nucleus surrounded by darkness, I was worried that the lens would be dislocated. However, after proceeding it was only the very clear cortex I was seeing and the lens was actually not dislocated. The case went well.

Pupil is round, still displaced after surgery, but minimally traumatized.

 His vision was 6/24 today 1 day after surgery. I expect that to improve in the next few days. But today we had a good time shaking hands and hugging as the man who was blind, now sees.









There are so many stories like these at Boa Vista. I admit with some shame that at times I forget about these precious individual lives and their stories as I strive to change an entire country's eye health care system (and become jaded in the process). Thank you God for sending me gentle reminders about your love and care for individuals and for using a selfish creature like me to bless others.
-John

Calling All Adventurers and Ministry Teams

Many have asked if we could use a ministry team, or missions group. The answer is YES! I will tell you what is going on, and if anything strikes a chord with you, then please come.

OPTHALMOLOGISTS
If you are willing to come do surgery for a couple weeks that's great, if you want to stay for a month or even a year. You are welcome and wanted. Opthalmology nurses and techs would be very useful too.

READING
Teaching how to read. It would probably help if you knew Portuguese, but I'm no teacher, if there are ways of teaching how to read without knowing the language, I"m not aware of it. But the language is much more phonetic than English is.

ENGLISH
Teaching English, anyone who wants to come do an English class as an Evangelical tool, that would be so great. You would teach in the church, and we would advertise in the community, so all are welcome, then we would have our members come and be your helpers, that way they can meet the "prechristians" and show them the love and acceptance of the Lord.

CONSTRUCTION
There are always opportunities for construction, but the construction here is mainly brick making, brick laying and then pouring concrete. Actually if you could teach people this trade, that would be even better. People do it here without worrying about being really flat or perfectly done. The art of precision is lost.

PREACHING AND TEACHING THE WORD OF GOD
Again it would be best if one spoke Portuguese in this area, but we can and will find translators.

INVENTORY ORGANIZATION
Organizing our inventory is a new thing to me, and I could use all the help that I can get.

PHOTO AND VIDEO JOURNALISM
Someone who come and document the work that is being done here in a professional manner.

BLIND ASSOCIATION
The Lord has place me in a wonderful and intimidating position. Working with a blind association, with a building that is way too small and not enough resources to feed everyone on the list. For now, we can only feed half, and the half cannot fit into our "building" more like an office. The government has promised to build a bigger location, they have been waiting for a couple years. After the building is built, then what? We have ideas of Braille classes, training the blind in a trade or a craft, and opening a store front to sell the crafts. Big dreams right? But I'm not equipped to teach Braille, nor do I have a trade to teach, or a craft. Ha, I write! So I'm doing what I know how to do best. I'm writing to implore all of you out there that know anything about blind associations.

Thanks for reading, I can't wait to hear from you all, we will plan on receiving you all as soon as you are ready!!

From Angola With Love,
Lori

Church

 

After almost two years of living here, I've finally jumped into church leadership. yikes! So far, we have been attending regularly and helping with the teaching, but I was so afraid of changing their culture into my American standards that I needed to just observe. And because the people are so reserved and stand offish, I'm still learning cultural things even now.

But I'm attending a church, where as far as I'm aware, the pastor and one young woman, John, Oliver and me are the only ones that read!!! I went to the Wednesday night worship meeting and the poor young man of 25 year was preaching and using text that had nothing to do with his topics. He would have one of us read and then talk about it, but when the words didn't match up he just kept right on like they did. And our people are all just listening and I have no idea why they are coming back, but they are! So I started a womens bible study, we met at 5:30pm, and it starts getting dark at 6pm and I didn't even think about this. I'm reading the Bible with the light of my cell phone! The women were receptive, but I still have so much to learn.

But taking the American out of me has been harder than I ever thought. I'm sooo thankful that I've was lucky enough to be born an such an amazing country, I have a new and profound kind of American pride that I didn't know I could.  Just the ideas that I had and the concept that people know how how to read and study the Bible at home on their own. I'm totally back in the Bible days, where people need to gather at the church to hear the word of God. And I don't mean my opinion of the Word, I mean just to have someone sit in the church and read, people will come and listen!

And to want to have a Bible study after work doesn't work unless the church can afford a generator, but then you have the obnoxious sound of a generator. Then when we gather, the older women want to hear the Bible in Umbundu, and the younger generation want Portuguese, so in this culture, even when there are not foreigners, there needs to be translations.

 

 Oh, and bathrooms, just remember not to drink to much coffee on days you go to church, because the "bathroom" is a tent that is only a 3 quarter enclosure. Not even a hole! They do have a giant hole waiting for the finaces to build a batheroom around it, or I should just say walls around it, but so far, it's not happened. Very few of our members have jobs, and when I say jobs, I mean buying and selling vegitables. Or getting picked up for the day to help lay concrete or something. Nothing regular or secure.
The picture below, is the landmark that I remember, so I know where to turn to find our church. The walls of the "building" are made of patched together t-shirts, a very common way to have shelter from the sun.

I love my church, but there is so much work to do. I am now teaching reading once a week in the mornings. The pastor teaches everday, and I help in on Mondays. He teaches 6 am women, 8am children, 10 youth. None go to school, just our church for education. Then I lead Sunday school and Wednesday night ladies Bible study. I'm praying that I start noticing leaders within the group to start training and helping this church be sustainable without me, but we have a long way to go. I mean it will go with or without me, but I do think the Lord has placed me at this church in this new neighborhood for a reason. And I'm very excited and overwhelmed by the responcability.

So this is what's is happening for now. Thanks for reading.

From Angola With Love,
Lori

Sending out Dr. Sebastiao!

What an exciting day for the Clements family!!! We came to Angola for John to train doctors in Ophthalmology, and today we had the graduation of his first prodigy! Dr. Sabastiao Mavatiti has gone through John's fast cataract surgery course, he has completed 100 cataract surgeries with good results and this evening we commissioned him to one of the northern provinces of Angola. Angolans caring for Angolans, it is so wonderful.

We are so proud of  Dr. Sebastiao, he has shown himself to be a compassionate, careful, and a compitent doctor.  May the Lord continue to flood our doors with people like Dr. Sebastiao, who have a heart to learn and help others.

                                                       Dr Sebastiao and His beautiful family

 Then, pictured below,  the tear jerking part of the ceremony, when John had one of Sabastiao's patients stand up. And he said that before sugery he couldn't see, now because of doctor Sabatiao, he can see. Wow! So beautiful.

                                           The Boa Vista team makes it all happen!

The rugrats, that interrupt ceremonies.

Congratulations Dr. Sebastiao Mavatiti!!!

We are so proud of you.

Fun with trauma repair

Fun with traumatic repair

Ok, so it's been a while since I (John) posted some cool ophthalmology cases. For those that don't like eye ball pictures, I promise these aren't too bad....

1. A 24-year-old male reported decreased vision in the right eye for 2 years. After some questioning he admited that the eye had been struck by a soccer ball, and that is when the decrease in vision began. His vision was found to be hand motions olny. The pupil was irregular, and appeared to have a traumatic iris coloboma. There was no afferent pupillary defect and a sonagraphy (B-Scan) was done showing a normal appearing retina and optic nerve. IOP was normal. *Disclaimer, this photo is not my actual patient but, you get the idea

 

I was very concerned about potential zonular pathology in the area of iris defect, but agreed to attempt a surgical correction. I spent more time than usual pre-operatively explaining that the vision result of surgery may not be good.

At the start of surgery I was pleasantly surprised to find the lens stable and no obvious zonular loss. I was able to complete a linear capsulotomy ( was worried about CCC causing troubles here and still worried about long term zonular stability for in the bag placement of IOL).

For the lens implant I placed a 1 piece PMMA lens with haptics in sulcus and optic beneath linear flaps of capsule.

I then turned attention to the iris coloboma. It had been a few years since I performed iris suturing, but figured this was a great case to get some practice. I only had one error, the first pass I attempted with the long CIF-4 needle was completely wrong, and had to redo it. However, the second pass was much better, and I tied it with a McCannell knot. Couldn't quite remember the siepser slip knot. The result is shown below at 1 week. The vision result was a pleasant surprise, 20/40 un-corrected, resulting in happy patient and even happier doctor. 

 

2. A 32-year-old man had been involved in a motorcycle accident one day before coming to the clinic. The only injury he suffered was to the left eye. Vision was perception of light, no APD. He had a corneal laceration and traumatic cataract, (This picture is actually from a different patient, but very similar presentation)

I performed urgent surgical repair. During surgery it became apparent that the posterior capsule had been violated from the perforation. I performed a lensectomy, vitrectomy and sutured the corneal wound. I left him aphakic. Fortunately, the eye did well post repair, as shown. 

 

With a +10.00 lens he was seeing 6/36 in our clinic. The problem was his other eye is a perfect 6/5 and the imbalance prevented glasses correction. You eye people out there may be wondering about contact lens correction, but frankly it doesn't exist in Angola. So my options were leave him afakic (he declined this), anterior chamber lens (surgeon was hesitant for this because ascan showed a 22D lens would be best and I only have 19D ACIOL) or iris sutured lens. All of these options have pluses and minuses. I elected to place an iris sutured IOL. I think it was a good enough option for him and plus I was really wanting a case to practice this technique on. Surgery went well, only had a little trouble positioning the lens with haptics behind iris with optic capture anteriorly. I used a monarch injector to place a 3 piece MA60-AC acrylic lens (which I now have with our phaco supplies).

Here is his appearance at one week. Vision has improved to 20/60, which I am pleasantly surprised with, given the cornea scar and astigmatism. 

 

Please, for any anterior segment surgeons who may be reading, send me your comments, tips or other feedback.

Acknowledgments: Thank you for showing me the technique Dr Pineda and a big thanks to Dr Croasdale for supplies.

John