Delivering ophthalmology in Cambodia with the Khmer Sight Foundation

In 2017, 120 ophthalmologists and other eye care professionals voluntarily visited Cambodia at close-to-weekly intervals in an initiative that was facilitated by the Khmer Sight Foundation. Most were from the United Kingdom but there were also volunteers from Germany, Austria, Italy, Singapore and India.

The goal was to screen 20,000 Cambodians in need of eye care and perform up to 10,000 cataract and pterygium surgeries. This year, the need is still pressing, and the Khmer Sight Foundation continues to welcome new volunteers.

Ophthalmologists shortage

Where ophthalmology is concerned, there is a significant unmet need in Cambodia. In a country that was ravaged by a tragic past during the Khmer Rogue era and only now slowly recovering, there are only 38 ophthalmologists available to serve a nation of 15 million.

Close to 28,000 Cambodians go blind every year and, sadly, 90% of blindness is avoidable. The scale of the issue is possibly underestimated due to incomplete epidemiological data but the logic is irrefutable; socioeconomic deprivation and having a disability creates a vicious cycle of poverty.

As clinicians in Europe, we often take for granted what goes on behind the running of a successful eye service. We walk into our clean workspace in the morning, prepared by the invisible cleaning fairy, and sit in our well-equipped office, where the magical equipment elf has been stocking the cupboards overnight with lenses, devices and all sorts of drugs.

In your usual theatre, The Magical Force delivers what you need – biometries, IOLs, microscopes, clean instruments, and a working phacoemulsification machine. You do not challenge The Magical Force.

Overseas challenges

The truth is, a lot goes into providing a high-quality and high-volume service. To start it from almost scratch with limited resources, for a population that may not have had eye health as their priority, is truly not a walk in the proverbial park. It is more like a marathon. Whilst wearing flip-flops.

We need to deliver good quality care – but within practical means. Everything has a cost to it, either in terms of time, man-power or equipment. Ophthalmology is an equipment-heavy specialty and our clinics and theatres use up a lot of consumables.

Stock is expensive and donated from various charitable sources, so the supply is limited. Working in Cambodia makes one realise how much we truly waste when we are back home!

Another challenges is that often, despite the best intentions of the treating doctor and the translator, it can still be difficult to obtain the patient’s full history. This could be due to the patient’s understanding of their condition, their knowledge, the chronicity of their untreated disease, or a combination of these factors.

General medical practice can be quite paternalistic, and patients often prefer it that way (“just make the decision for me, doctor”). I observed, however, that we western-trained doctors naturally try to reach for patient-centred decisions (“what would you like to have done?”). This does not work all the time; in Cambodia, we became adept at making quick decisions in patients’ best interests.

Theatre is another challenge, owing to sterilisation techniques, the sharing of equipment (for example, one phaco cassette for four to five patients), a mixed variety of IOLs, the lack of specialist equipment (limited anterior vitrectomy kits), inexperienced staff, and most importantly, dense and difficult cataracts. 

Funnily enough, despite being on the other side of the world, one patient group remains consistent. The patient with chronic dry eyes. At least in Cambodia, they seem to be actually slightly pleased after you prescribe some eye drops.

 The main challenges that Cambodia face are lack of expertise (they have one of the lowest number of ophthalmologists per capita in the world) and lack of access (many destitute patients live in rural areas with poor access to healthcare).

For a Cambodian villager to go from screening to clinic to eye doctor to surgery is a real mammoth task in terms of organisation and logistics. Fortunately, every villager owns a mobile phone or at least knows someone who does.

I am sure I echo the sentiments of all the volunteers who visited when I say that it was a refreshing and humbling experience – and we would like to take this opportunity to thank KSF, Sean Ngu and the people of Cambodia for welcoming us.

Cambodia is re-building itself. The deep scars of her past will always be palpable but the resilience of her youthful generation stands out. The new generation of Cambodians will be her greatest resource, and education, training and self-sufficiency the most worthwhile investments.

Disclosures:

Dr Damien Yeo, MBBS FRCOPHTH
E: Damien.yeo@nhs.net
Dr Yeo currently works at the Clinical and Academic Department of Ophthalmology (CADO), Great Ormond Street Hospital for Children NHS Foundation Trust, UK, as a clinical fellow in paediatric ophthalmology and strabismus. Dr Yeo did not indicate any financial interests in the subject matter.

Professor Sunil Shah, FRCS(Ed) FRCOphth FBCLA
E: profsunilshah@gmail.com
Prof. Shah is a consultant at the Birmingham and Midland Eye Centre, UK, where he runs a cornea and cataract service. Prof. Shah did not indicate any financial interests in the subject matter.