Category: African Scetches

How my MSICS began

Senanga town, Western Province of Zambia. April 2014.

Senanga, April 2014


Here is how it all happened that day. My future wife was with me on my first day in the operating room and was able to take these photos. It was incredibly unusual, my heart was bursting with a thirst for new experiences, surrounded by new people, new impressions every working day. In April, my boss and later a good friend David finally agreed to teach me manual small incision cataract surgery (MSICS). Before that, I had the honor of observing his art for several months non-stop. The burning call of fearless youth… Even now, as I study phaco, it’s not as sharp or exciting as it used to be that days.
Mistakes were surely made. My teacher had to correct my sclerocorneal tunnels more than once.
Pay attention to the instrument table. That is exactly how much you need to effectively remove cataracts without a phaco machine and sutures.

And after the operating days, we sat together on the banks of the Zambezi River and enjoyed the sunset, not knowing that those were some of the best days of our lives.

Zambezi River, Zambia
Senanga, September 2015

Later, when I grew up and my teacher left me, I started doing independent outreach trips. This next photo is from the same town of Senanga, but already from September 2015.

Behind me are cataract patients operated on in one day. Yes, the amount of good that can be done using that limited set of instruments from the previous photos is global in both direct and figurative senses. Global ophthalmology rocks.

How does cornea by onchocerciasis look like?

“The characteristic facial expression of the onchocerciasis patients is also based on the interstitial keratitis, which prefers a horizontal axis and creates a vertical positioned ovular bow in the ribbon shaped degeneration of the cornea”. (c) Dr. Guido Kluxen’s excellent reasearch book “Dr. Jean Hissette’s Research Expeditions to Elucidate River Blindness”, 2011

I think I had never seen onchocerciasis patients in Zambia. Although onchocerciasis is not endemic there, one sees daily unclear corneal opacities as a result of various keratitides or uveitides. Some patients travel from Angola, Namibia and Congo. The latter should still be endemic… So I decided to google these corneas, as the description is not too descriptive.

Keratitis semilunaris, sclerosing keratitis by onchocerciasis, (c) https://www.researchgate.net/figure/Keratitis-semilunaris-a-form-of-the-band-shaped-keratopathy-by-courtesy-of-HjTrojan_fig4_224830713

Cataract surgery outreach, Congo, 1930s

Dr. Jean Hissette’s cataract surgery in Kasai in the Belgian Congo, 1930

Photo from Dr. Guido Kluxen’s excellent reasearch book “Dr. Jean Hissette’s Research Expeditions to Elucidate River Blindness”, 2011

Interestingly, Dr. Hissette performed his cataract OPs using large conjunctival peritomies and additionally – iridectomies. Many surgeries were complicated with synechias, which were typicall for onchocerciasis induced uveitis.

I found interesting as well, how the doctor treated assistance during these OPs: “I did the surgeries without assistance, as I believe that if you do not have adequate assistance, it is better to operate without any”. May be often the case in the tropical setup.

Dr. Jean Hissette’s cataract surgery in Kasai in the Belgian Congo, 1930 (Photo from Dr. Guido Kluxen’s excellent reasearch book “Dr. Jean Hissette’s Research Expeditions to Elucidate River Blindness”, 2011)

Not every fornix-OSSN is to be exenterated

In our Setup in Zambia one rule which we used to have was: as soon as OSSN involves a caruncle or conjunctival fornices, the eye (no matter how good it could see) should be planned to exenteration or at least extended enucleation). I used to not to question this practice in the abscence of MRI at hand.

However, fellows from Duisburg (Germany) proved that an excision of forniceal OSSN can still be good compensated with buccal or amniotic mucous membrames. And recurrencies of ~30%. Which is actually not bad considering the mutilating alternative. A food for thought. https://pubmed.ncbi.nlm.nih.gov/35940212/