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Inside Eyetube.net | Jun 2011

Eye Care Beyond Mandalay

A 30-minute drive from the historic city of Mandalay, in the heartland of Myanmar, lies the seat of an ancient Myanmar dynasty, Sagaing. It is now a dusty provincial city with only beautiful pagodas reminiscent of its past glory. On the outskirts of this sleepy city, nestled at the foot of the Sagaing Hills that separate it from the mighty Irrawaddy River, is the Sitagu Ayudana Hospital (Figure 1). Today, the Sitagu Ayudana Hospital is the center of the largest nongovernmental sight-saving project in Myanmar.


Thirty years ago, in London, I met the venerable Ashin Nyanissara, PhD, D.Litt, an eminent Buddhist leader and teacher who was traveling to the West for the first time. He was the patron and founder of the Sitagu Association, which established many humanitarian projects including the Sagaing Hills Water Supply Project. Already a renowned public speaker with a remarkable ability to raise funds for his projects, Dr. Nyanissara was planning to build a hospital that focused on treating eye diseases.

Having spent many years involved with the Trachoma Control and Prevention of Blindness Project in Central Myanmar under the auspices of the World Health Organization (WHO), I arrived in the United Kingdom to pursue my postgraduate training in ophthalmology. My experience as an epidemiology team leader in the Trachoma Control Project made me acutely aware of the extent of the problem of preventable and treatable blindness in Myanmar. In those days, there were about 40 ophthalmologists in Myanmar for a country of 45 million people. Most of the ophthalmologists were based in the major cities of Yangon and Mandalay, where the only two eye hospitals in the country were located. Only a few smaller cities had dedicated eye care facilities. Seventy-five percent of the population distribution was rural, and the transportation infrastructure had barely changed since the end of World War II. Progress was being made in controlling endemic trachoma, but cataracts had become the leading cause of treatable blindness.

Under the auspices of and due to the untiring efforts of the venerable Dr. Nyanissara, the Sitagu Ayudana Hospital was built and inaugurated in 1989. (Ayudana means life-giving.) At the invitation of Dr. Nyanissara, and having completed my postgraduate qualifications, I joined San Aye, MD, a fellow expatriate ophthalmologist from San Francisco, to establish the Eye Unit at Sitagu Ayudana Hospital. We donated the first slit lamp and operating microscope, along with surgical instruments and other supplies to the hospital. For the first time in Myanmar, extracapsular cataract extractions (ECCE) with IOL implants were performed. Thanks to generous local and international support and donations, Sitagu Ayudana Hospital became the best equipped eye hospital in the country.


In 1994, Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth, then a newly appointed Consultant Ophthalmologist at the Queen Victoria Hospital in East Grinstead, and Hillary Welling of Alcon UK (Hertfordshire), a qualified ophthalmic nurse, accompanied me to Sagaing (Figure 2). Using a portable machine, we performed the first phacoemulsification with IOL implantation in Myanmar. We soon found out that most of the cataracts we encountered were too dense for that early generation portable machine to emulsify. Since then, both Dr. Aye and I have visited this hospital every year. We go during the dry season at the end of the monsoon rains when travel becomes easier, and patients from distant rural areas can attend and seek sight-saving cataract surgery.

Our work in Myanmar sparked interest among my fellow ophthalmologists in the United Kingdom, and several consultant eye surgeons, many of whom had extensive experience working in poor countries, have offered their services. Most notably, David Moss, MD, FRCOphth; John Sandford-Smith, MBE, FRCOphth; Sal Rassam, MB, BCh, BAO, LRCSI, LRCPI, DO, MD, FRCOphth; Mike Eckstein, FRCOphth; and Mike Falcon, FRCS, FRCOphth, joined the network of regular contributors to Sitagu Ayudana Hospital. The teams led by these eye surgeons have included many other fellow consultants, senior and specialist registrars, and nurses. Others who have joined the network of volunteers include surgeons trained in the United Kingdom who are now based in Singapore and Malaysia.


Although participants from the United Kingdom and other countries have been mainly responsible for the introduction and dissemination of new technology and methods in Myanmar, local ophthalmologists led by Mya Aung, MBBS, DO, Dr. Med. Sc(Ophth), have been the main providers of the large volume of cataract surgeries performed in the Sitagu outreach clinics. Myanmar ophthalmologists, most of whom are locally trained, are keen learners and adopters of new techniques once they have overcome the substantial hurdle of acquiring equipment and instrumentation. They are capable of maintaining the sustained output of work needed to meet the demands of the population.


The Sitagu Ayudana Hospital was the first medical institution in Myanmar to introduce IOL implantation after ECCE. Many training sessions were conducted to educate the local ophthalmologists on the technique until it became a widely adopted procedure. Newer and more advanced phaco machines were acquired, which enabled many cataracts of moderate to higher density to be removed, leading to reduced morbidity and quicker visual recovery. The procedure was demonstrated at training sessions. Now, phaco machines are more widely available in Myanmar, and the procedure is fairly common in private practices outside of the Sitagu Eye Centers.

Mr. Sandford-Smith, an expert in small-incision sutureless ECCE, has been performing this technique and teaching local eye surgeons in Myanmar. To date, the country has only two trained vitreoretinal surgeons, both based in Yangon. As a result, vitreoretinal surgery and medical retina are not available outside of Yangon. There are no pediatric ophthalmologists.

Mr. Rassam, a vitreoretinal surgeon who also has an interest in pediatric ophthalmology, has been performing vitreoretinal surgery at the Ayudana Hospital in Sagaing on patients who would otherwise have had no hope for regaining their sight (Figure 3). Additionally, with the help of David R. Uncles, MD, an anesthesia consultant, he has performed numerous pediatric cataract operations.


From its start in a single hospital in Sagaing, the Sitagu Eye Care Project has significantly expanded. At least one center is to be located in each of the 14 states and divisions of Myanmar (Table 1). Mobile eye teams from Sagaing and local Myanmar ophthalmologists and international ophthalmologists volunteer their services at these eye units throughout the year.

Tens of thousands of sight-saving cataract and other procedures have been performed since the inception of the Sitagu Eye Care Projects. According to 2001 figures published by the WHO, the blindness prevalence rate in Myanmar was 0.9%, which was among the highest in the region. Thailand had a blindness prevalence rate of 0.3%, and India of 0.7%. Sustained efforts on the part of government and nongovernmental organizations, as well as international support, are still needed to meet the WHO’s Vision 2020 target set in 2006 of 819 cataract operations per million population per year.


The Sitagu Eye Care Project owes its success to the compassionate leadership of the venerable Dr. Nyanissara; the goodwill of the ophthalmologists, local and from abroad; optometrist Khin Htwe, B.Optom; and many British nurses, especially Lesley Carter, RGN and Anne Smith, RGN, who have contributed their time and expertise for many years and who have self-financed their volunteer trips to Myanmar. Many others have helped who are not named here. In many cases, material aid in the form of new and used equipment has been offered. Our success would not have been possible without the generous donations of many people from Myanmar and the United Kingdom to build and equip the hospitals and supply essential items such as IOLs, sutures, and medications for these sight-saving procedures. Much of this important work was made possible because of the valuable ophthalmic supplies donated by Alcon UK and anesthetic agents from Abbott Laboratories (Abbott Park, Illinois).

Wilbert K-C Hoe, MBBS, DP&TM, FRCSEd, FRCOphth, DO, is a laser refractive surgeon at Optimax Laser Eye Clinics, London. Dr. Hoe states that he has no financial interest in the material presented in this article. He may be reached at e-mail: hoewilbert@blueyonder.co.uk.