Dispatch From the Field: Terry Cooper Reports on Second Half of Uganda Mission

Pediatric Consults with Pictor Plus

On our third day at the Mulago Referral Hospital, we moved on to the pediatric ward. Consultant ophthalmologist, Geoffrey Woodruff joined the team to provide mentoring and training to the local pediatric ophthalmology team.

The pediatric team carried out 14 intra-ocular operations on children. Geoff Woodruff concentrated on training in the surgery of pediatric cataract, to allow better provision by the team there.

From there, it was on to the Ruharo Eye Centre to visit ophthalmologist Keith Waddell, and see the work he is doing to diagnose and treat childhood eye cancer, retinoblastoma (Rb). The remote clinic is located in Mbarara in the south west of Uganda, near the border with Rwanda. Since Keith established the clinic in 1984, it has grown to become the retinoblastoma referral center for South West Uganda, as well as taking patients from Rwanda, Congo and Tanzania.

Meeting Keith was inspiring. He trained and qualified as a physician in the UK, initially specializing in oncology before training as an ophthalmologist. He settled in Uganda as a medical missionary and built the eye center in a field adjacent to the hospital. At 80 years old, Keith works full-time for two weeks a month in the clinic, and the rest of the month on the road visiting hospitals and clinics throughout the region.

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Childhood cancer, retinoblastoma (Rb), is a rare disease–incident in 1:15,000-20,000 live births. In the UK, 50-60 cases are diagnosed each year. With Uganda’s significantly higher birth rate, the number of cases is therefore much higher. Around the time of my visit, over 40 cases were seen at the Ruharo Eye Centre in a single week. The caseload is so high that many Rb specialists from abroad visit Ruharo to improve their experience and skills.

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The survival rates of Rb vary by geography. In the UK, 98% of children survive. In Africa it is much lower. Mortality was 100% in Uganda until Keith Waddell and his team began work to reduce it to less than 70%. Successful treatment of Rb depends on early diagnosis of the disease. It has been heartbreaking to see many children that will not survive as it was not spotted early enough. In these cases, Keith concentrates on cosmetic treatment, paying attention to how the eyes and face look, and on palliative care.

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I can see how Pictor Plus could be an important tool to increase early diagnosis. It could be used for initial screening of patients by paramedical staff in remote areas, with the resulting images sent by email to a specialist like Keith for diagnosis and referral for treatment. Pictor Plus has many advantages for this type of telemedicine application. It’s extremely lightweight and portable. I was able to work for two days without using local mains power, which is of poor quality and unreliable. Instead, I carried the Pictor Plus in a backpack equipped with solar panels which power a removable battery. This setup could easily travel on visits to local clinics in remote villages where there may be no power.

In the hospital, we used Pictor Plus for examinations under anesthetic (EUA), carried out routinely by Keith on all patients being treated for Rb. Once Rb has been diagnosed, the treatment pathway is usually enucleation of the affected eye followed by a course of chemotherapy. The EUA is an important part of the pathway as it allows a thorough examination. Using Pictor Plus complements the typical BIO examination. Because of its small size and portability, it has been relatively easy to take fundus images of children ranging in age from two months to 12 years old.

Though I’m home now, I’ve not forgotten all that I’ve seen. To improve Rb mortality rates, there is a desperate need to for an education program targeted at parents to alert them to the signs that could indicate Rb. I am working with health correspondents of the two main daily newspapers in Uganda, the Daily Monitor and New Vision, to develop Rb educational articles for forthcoming issues.

“The entire trip was extremely humbling and rewarding. I was able to see firsthand the impact that technology, which we have come to take for granted, has in these impoverished nations. It also felt good working as part of a multi-disciplinary team all playing our part in delivering a service of real value and impact on other’s lives.”