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MAGAZINE

January 2021
Volume One

OSWI Times

Celebrating Our Milestones

Arindel Maharaj MD, PhD. Assistant
Professor, Bascom Palmer Eye
Institute, University of Miami, USA.

Since I left Trinidad in 1995 to pursue medical training in the USA
I have felt a sense of patriotism and obligation to serve the Caribbe-
an population. Bascom Palmer Eye Institute has provided me the
avenue to fulfil this dream. As an Assistant Professor in Clinical Ophthalmology (Glaucoma
and Cataracts) since 2014, a large percentage of my patients are Caribbean born, or fly direct-
ly from the Caribbean. I feel especially proud to take care of this group of patients, and I sense
a mutual feeling of respect and pride from these patients that they are being cared for by a
doctor of Caribbean heritage.

OSWI however has allowed me to have a very significant role in Caribbean
Ophthalmology. I first became involved in OSWI in my very first day as a faculty at BPEI,
when Dr. Eduardo Alfonso – Chair BPEI, educated me about the organization. In Jamaica
2014, I was immediately welcomed by a warm, hospitable Caribbean group of Ophthalmolo-
gists, with whom I’ve now fostered friendships, mentorships and collaborations. The alliance
between BPEI and OSWI took off when under the guidance of Dr. Nigel Barker and Dr. Eduar-
do Alfonso, I spearheaded the first BPEI symposium at OSWI Guyana 2017, with 4 distin-
guished faculty from BPEI who all volunteered to travel to Guyana and deliver multiple work-
shops and lectures at OSWI. They too felt the warmth and hospitability of the Caribbean Oph-
thalmologists, and have continued to maintain close collaborations. Since that meeting, we
have had 2 more symposia – Jamaica 2018, Trinidad 2019; now over 10 BPEI faculty have
attended OSWI in the last 4 years with the unfortunate cancellation of OSWI 2020 due to
COVID-19 was promising to bring a new collaboration to OSWI with the presence of Duke
University along with BPEI at OSWI.

Through collaboration with OSWI, I’ve also become boarded in Medicine in Trinidad and
Tobago. With help from Trinidadian colleagues, I have been able to now see patients in Trini-
dad and deliver surgical and clinical care in Trinidad, while educating local ophthalmologists
in both the clinic and surgical suite in glaucoma; I hope to expand this collaboration to other
Caribbean countries as well. Many ophthalmologists and trainees have also visited BPEI for
clinical observerships, CURSO meetings, and have consulted and collaborated with BPEI
specialists with complex eye diseases either by email/phone consultations or sending patients
directly to BPEI and in some cases us sending patients to the Caribbean.

As we enter a paradigm shift in virtual education we will find even more powerful ways to con-
tinue the collaboration – during the COVID lockdown, several subspecialty virtual OSWI sym-
posia were delivered with participants from both OSWI and BPEI; these were well received
and further allowed OSWI members to share stories about the pandemic and “lime” with each
other.

While I may no longer physically live in the Caribbean, I cannot feel any more sense of pride
and fulfilment with my faculty position at BPEI and my involvement and collaboration with the
OSWI family.

A Young Ophthalmologist in America

By Carla I Bourne MD

At eighteen, going abroad to Ophthalmic Consultants of setbacks. Learning a new
study on a scholarship Boston. culture, dealing with preju-
seemed like the grandest dices as a foreigner, a
adventure of them all. At After medical school I female, and of African
that age you feel invincible, moved a few hours south to descent while navigating
and that time has no limits. Norfolk, Virginia for an Inter- the politics of different work
My acceptance into the nal Medicine internship at environments are challeng-
competitive BS/MD pro- Eastern Virginia Medical es faced but not often men-
gram at Howard University School (EVMS) and after- tioned. However, good men-
shortened the usual wards returned to Howard torship and lessons learnt
eight-year American medi- University Hospital for Oph- as a Caribbean child keep
cal school track to six years. thalmology Residency. I had you grounded and prepared
At that time I was, ‘living my left home knowing that I for any battle. You must
best CARICOM life,’ by wanted to be an ophthal- remain prepared to push
attending the Mecca of His- mologist. My experiences past boundaries and always
torically Black Colleges and shadowing mentors, both in be open to opportunities.
Universities (HBCU) with a Barbados and the USA,
student population from confirmed my interest. How- Despite the hurdles of prac-
throughout the Caribbean ever, it was watching the tising in the current medical
and the Diaspora. Studying impact of glaucoma on my climate I am still in love with
in Washington DC, one of grandfather and the realiza- the field of ophthalmology.
the most metropolitan cities tion of the debilitating nature There are few specialties as
in the USA, meant that even of the disease for communi- fascinating. Where else can
on a student budget, new ties of African descent that you look inside the body
experiences and opportuni- inspired me to pursue without a scalpel? There are
ties abounded. At the same sub-specialization in Glau- few specialties where tiny
time, at eighteen, few stop coma at Tufts New England incisions can make such a
to consider the years Eye Center and Ophthalmic profound improvement on
required to become a Consultants of Boston. quality of life. It has been
fellowship trained Ophthal- fulfilling to finally be able to
mologist. Meanwhile the Life evolves and just as we give back and I especially
years pass you by imper- have gone from couching to
ceptibly. femto-assisted cataract sur- Enjoy the op-
gery, so has my career in portunity to
After medical school I the USA. I had planned to teach didactics
moved a few hours south to return home to Barbados and wet labs at
Norfolk, Virginia for an Inter- after training but personal OSWI and
nal Medicine internship at reasons and an offer to join meetings at
Eastern Virginia Medical the faculty of the University home in Barba-
School (EVMS) and after- of South Florida in Tampa, dos
wards returned to Howard took me down an alternate
University Hospital for Oph- career path. Becoming a
thalmology Residency. I had clinical academician afford-
left home knowing that I ed me the chance to enjoy
wanted to be an ophthal- teaching and mentoring stu-
mologist. My experiences dents, residents, fellows
shadowing mentors, both in and my peers. When I shift-
Barbados and the USA, ed my practice to the Veter-
confirmed my interest. How- ans’ Hospital a few years
ever, it was watching the ago, it also allowed me to
impact of glaucoma on my extend care to another
grandfather and the realiza- demographic while continu-
tion of the debilitating nature ing to teach.
of the disease for communi-
ties of African descent that On the surface, it is some-
inspired me to pursue what easy to assume that
sub-specialization in Glau- accomplishments occur
coma at Tufts New England without struggles and
Eye Center and

MESSAGE FROM
PRESIDENT BERNIE

CHANG

Professor Bernie Chang
President The Royal College of Ophthalmologists

It is a pleasure to have been invited by OSWI to contribute to its first online

publication. My congratulations as well on reaching your 30 year milestone.

Some of you at OSWI will know that I have a strong link with the Caribbean, being married to
a Trini and having had the privilege to have trained with, and also latterly trained, very talent-
ed ophthalmologists from Trinidad especially. A good few have remained close friends to this
day.
It was thanks to Dr Nigel Barker, your past President that I became more involved with OSWI
as we both share a passion for improving the quality of training.

The Covid-19 pandemic in the UK has had significant impact on delivery of more routine eye
care services as well as reducing training opportunities. The Royal College of Ophthalmolo-
gists led on the work to ensure patients with urgent eye conditions were still being seen while
advising on the infection control policies such as PPE to keep both patients and staff as safe
as possible. As I write this, we are working on how to restore services and increase our
capacity to manage increased demand. Our guidance and recommendations on these issues
are published on our website and may be useful to ophthalmologists in the Caribbean. It is
evident that in order to ensure as many patients are seen in a timely manner, a multi-discipli-
nary approach, such as with our optometry colleagues and better integration of primary and
community eye care with secondary care is needed. This is certainly something to be consid-
ered, if like in the UK, capacity is struggling to keep up with demand.

Despite the pandemic, I see many opportunities for OSWI and the RCOphth to develop a
closer relationship.

1 The RCOphth could actively support surgical skills and simulation-based train-
ing in the Caribbean.

2 Collaboration between the OSWI and RCOphth at their annual annual con-
gress.

3 The RCOphth can look to offer FRCOphth examinations and exams support in
the Caribbean.

4 Using the current dual sponsorship scheme/Medical Training Initiative to facili-
tate overseas training.

We could be explore overseas fellowships for senior residents in the Caribbean wishing to
study in the UK and our ophthalmic specialist trainees from the UK can benefit from opportu-
nities working in the Caribbean where disease like glaucoma and diabetes can be more chal-
lenging to manage.

The pandemic has led to new thinking about how to reach members and others working in
the ophthalmic sector, whilst in lockdown and where social distancing measures mean limited
physical access to surgical skills courses and equipment. We are investing in high quality
webinars to reach ophthalmologists across the globe, as well as looking to reinstate our edu-
cational seminars, lectures and training courses such as Training the Trainers.

Other areas of activity that the Royal College is very committed to is the VISION2020 LINKS
programme and recently held a successful full day webinar with training sessions and lots of
interactivity and discussion with COESCA. Also, through the Commonwealth Eye Health
Consortium, VISION2020 LINKS has collaboratively tackled diabetic retinopathy through the
Diabetic Retinopathy Network: DR-NET.

There is no doubt that this global pandemic has changed the way we live and work and not
just in delivering health care. Nevertheless, everyone working in ophthalmology have adapt-
ed our services to ensure that patient care is maintained and many of us have been deployed
across other areas of health care. Nevertheless, we have to work more collaboratively and
effectively to ensure the most high-risk patients are not lost in the system due to the demand
on the service and that the entire workforce is adequately protected.

Finally, during these unprecedented times, I would like to wish you all good health and hope
everyone stays safe. I wish OSWI every success for the future and look forward to when we
can all meet up virtually or in person.

The Commonwealth Consortium Members reviewing abstracts at Train the Trainers course at
visit to the Royal College’s the Annual Congress, 2018 Annual Congress, 2019
surgical skills centre, 2019

MY ELECTIVE ABROAD

DR. SHARI CADOGAN
YEAR 6 RESIDENT, DM OPHTHALMOLOGY

The University of the West Indies The firm academic foundation of

Doctor of Medicine (DM) Ophthalmolo- University of Toronto DOVS, comple-
gy is a six-year program consisting of 3 mented the clinic setting. The ophthal-
parts – part 1 covers the basic sciences mology program is highly resident cen-
over a two-year period, part 2 covers tred with weekly grand rounds and dedi-
optics and refraction over a one-year cated block teaching one half day per
period while part 3 during the last week. Usually two residents and occa-
three-years are the clinical teaching sionally fellows present on these rounds
years. During the final clinical years, we and I too was also rostered in for the
set off on our electives. The elective medical retina round. The morale
period is customarily done outside of the amongst the residents seems
Caribbean, at a hospital and specialty unmatched and is evidenced by their
area in ophthalmology of our choosing. I keen attitudes. While on elective I was
choose to undertake my elective at privileged be part of their university
through the University of Toronto De- funded resident’s retreat to Prince
partment of Ophthalmology and Visual Edward County, which provides an
Sciences (DOVS). opportunity for the new residents to
bond with the existing ones. Also, of
My area of interest is retina, more note was the 59th Annual Walter Wright
Symposium – a two-day conference
specifically, retinal vascular disease and hosted by the University of Toronto. At
diabetic retinopathy screening so natu- this conference, I was given the oppor-
rally, I elected to do a medical retina tunity to hear renowned speakers in the
rotation. I was assigned to three sites – fields of neuro-ophthalmology and ocu-
Toronto Western Hospital, Sunnybrook loplastics which were both informative
Health Sciences Centre and Mount and inspirational.
Sinai- under the supervision of five med-
ical retina specialists. As a registered In summary, my time in Toronto was
practitioner in Ontario for the duration of
my elective, I was permitted to see truly a unique one. My exposure and
patients and perform procedures. interactions have been career defining
and many aspects I wish to incorporate
The clinics are fast paced, into my practice of ophthalmology. While
well-oiled machines and were fully out- we have a high standard of practice in
fitted with access to investigative modal- the Caribbean, I believe we can all learn
ities not available in many clinics here in from time spent abroad and it has truly
the Caribbean. The clinics were robust given me the motivation to continue the
with up to 100 patients to be seen by pursuit of my goals.
myself and the consultant. The most
commonly performed procedure was
intravitreal injections by a landslide
given the high prevalence of age- relat-
ed macular degeneration, followed by
retinal laser procedures. Being with five
retinal specialists, I was able to observe
the differences in approach to manage-
ment of various retinal conditions. Each
preceptor also had a different area of
interest within the specialty and given
the large and ethnically diverse popula-
tion in Toronto I was exposed to an array
of retinal pathologies most notably
inherited retinal dystrophies and inflam-
matory/ infectious retinal diseases. I
gained competence in interpreting OCT,
OCTA, fluorescein angiography and
indocyanine green angiography Be-
sides the retinal clinics I also attended
the electrophysiology lab which was
another invaluable experience. Time
was spent performing the investigations
and interpreting the findings of mf ERG,
ff ERG and less commonly, VEPs.

Setting Up Ophthalmology In Dominica

Dr. Hazel Shillingford-Ricketts MBBS (UWI)
FRCSC Consultant Ophthalmologist

Setting up ophthalmology in Dominica – as the only
ophthalmologist from 1996, on an island with a population
of about 72,000 people. This article serves to inform persons of
the health system which facilitated the process and how it evolved
over the past 24 years.

After hurricane David devasted the Commonwealth of Dominica in 1979,
Primary Health Care was the system introduced by which “Health for All by the Year 2000”
(WHO) was to be achieved. It is comprehensive health care accessible to all at the community
level and at no cost to the user. The island is divided into seven health districts financed cen-
trally by government, but managed independently at each health district by a health team with
the District Medical Officer as the head and including a Family Nurse Practitioner, Midwives,
Nurses, Pharmacist, Environmental Officer and Community Health Aids.

In 1985, The Department of Ophthalmology was established by Canadian Ophthalmologist,
Dr. Rollande Michaud. It was funded by the Brenda Strafford Foundation, a charitable organi-
zation based in Calgary, Canada.

The objectives of the eye care program are to prevent and control avoidable causes of blind-
ness, to make essential eye care available to all, to provide eye care as an integrated service
in primary health care, and to use sustainable technology based on scientifically established
protocols.

From its inception, the Ophthalmology Department, though based at Princess Margaret Hospi-
tal (the only Secondary Health Facility in Dominica), has provided mobile eye clinics in each of
the Primary Health Care Districts in addition to the largest nursing home, as per schedule. A
driver transports the staff and eye equipment every Thursday to the districts. Family Nurse
Practitioners are responsible for managing those district eye clinics. Additionally, they carry
out school health screening for students starting primary school (age 5) and students in grade
6 (ages 11-12). Students who fail their vision screening are then referred to the eye clinics.
Eye clinics and surgeries are provided on all other days of the week at the hospital.

Emergency services being provided on-call 24/7. The most common eye surgeries performed
to date are extracapsular cataract extraction and PMMA intraocular lenses implant, pterygium
excision and conjunctival autograft, trabeculectomy with mitomycin C, strabismus surgery,
enucleation/eviscerations, eyelid surgeries and eyeball repairs. The first organ transplant in
Dominica was performed in 1997 when two patients received corneal transplant harvested
locally. Patients are referred overseas for management services that are unavailable in Domi-
nica.

Continuing the timeline of development, a rehabilitation officer for the blind was trained in 1997
by the Caribbean Council for the Blind in Antigua to assist the blind with skills for independent
living. In 1998, Atropine, Tetracaine, Prednisone, Pilocarpine and Timoptic eyedrops started
being compounded at the local hospital pharmacy. This was initiated as part of the Prevention
of Blindness program by the World Health Organization in collaboration with Christoffel Blinden
Mission. Quality checks were performed in Jamaica. This program greatly improved the avail-
ability of the aforementioned eyedrops, however, it has since been discontinued. By 2017,
after years of lobbying, all groups of glaucoma eyedrops were included in the Government
Drug Formulary and are provided free of charge to persons younger than 19 and older than 59.
Having been trained at the University of Ottawa Eye Institute, where training for ophthalmic
technicians is also provided, the invaluable contribution of this category of eye care profession-
als is well recognized. Two Dominican nurses were trained as ophthalmic technicians in
Canada in 1997 and 2005. Including just one ophthalmic technician in the eye clinic has result-
ed in more than double the number of patients seen. Services that are now provided by the
ophthalmic technician include history taking, refractions, keratometry, intraocular pressure,
automated visual fields, A/B ultrasounds, fundus photography, and OCT In 2000, Dominica
participated in the launching of the Vision 2020 “Right to Sight” initiative in Tobago and in
annual meetings subsequently until several years ago. Cataract, glaucoma, diabetic retinopa-
thy, refractive errors and childhood blindness were the preventable causes of blindness to be
prioritized in the Caribbean region. As a result, the National Eye Plan was developed and
included in the Dominica National Health Plan.

The typical year-long waitlist for appointments was detrimental to diabetics who have
vision-threatening diabetic retinopathy. In an attempt to rectify this issue, in 2005 island-wide
screening for diabetic retinopathy by a hand-held Kowa camera using film was implemented.
Reviewing thousands of developed photographs was time consuming, though it realized the
objective of identifying the diabetics at risk who needed early intervention to prevent blindness.
The Pan American Health Organization (PAHO) took note of this constraint and donated a digi-
tal hand-held Kowa fundus camera in 2006. The experience gained in Dominica was invalua-
ble for the preparation of the proposal by the Caribbean Council for the Blind, to be submitted
to the Queen Elizabeth Diamond Jubilee Trust. As a result, funding was obtained for the imple-
mentation of the Diabetic Retinopathy Fundus Photography Screening and Treatment pro-
gram in Jamaica, Belize, St. Lucia and the expansion of the existing program in Dominica. This
was executed under the supervision of the London School of Hygiene and Tropical Medicine
from 2015 to 2019. In Dominica, there are now two internationally certified diabetic retinopathy
screeners/graders and two digital cameras in addition to an upgraded laser unit. July 2018
a Diabetes Mellitus Stakeholder Workshop was held under the theme ‘Prevention and Control
of Diabetes Mellitus- the sustainable means of prevention of blindness from Diabetic Retinopa-
thy’. The DR-NET UK LINK partners were the main facilitators along with their counterparts
from Dominica and Jamaica.

In 2017, a School Vision Screening program to provide free spectacles for all students was
funded as an initiative of the Prime Minister, the Honourable Roosevelt Skerrit. This program
was developed by a Dominican team and implemented by a contracted Cuban Eye team.
Screening for the Body Mass Index of over 95% of the school population, age 5 to 18 (over
11,000), was included under this program and executed by retired nurses. This aimed to help
identify overweight and obese students for intervention in collaboration with the Ministry of Ed-
ucation and is part of the prevention strategy for diabetes mellitus and diabetic retinopathy as
a cause of blindness. The results of the analysis are pending.

Screening and treatment for retinopathy of prematurity and sickle cell retinopathy are well
established. Opportunistic screening for glaucoma is performed for every patient seen. Com-
munity screening is performed during the annual observance of World Glaucoma Week.
Setting up ophthalmology in Dominica included public education and research, collaborations
with a number of ophthalmologists from other countries and non-governmental organizations.
Research into a blinding retinopathy, named La Plaine Retinal Degeneration, which affects
older persons with French ancestry, on the East coast of the island was done in collaboration
with a team of ophthalmologists from Canada. Research into the efficacy of Selective Laser
Trabeculoplasty in Afro-Caribbean patients with glaucoma was conducted with a glaucoma
specialist from the University of West Virginia revealed significant reduction in the intraocular
pressure. International eye surgery missions in Dominica by American, Chinese and Vene-
zuelan teams impacted positively on reducing the number of patients waiting for cataract sur-
gery. From 1997, the Voluntary Optometric Service to Humanity (VOSH) from Michigan has
been conducting annual eye clinics to provide glasses and refer patients who need other forms
of eye care to the eye clinic. The Dominica Association for Persons with disability has been
provided with ongoing support and blind patients are referred to them.

Dominican eye care professionals are provided with international training in an effort to contin-
ually upgrade our service to the public. Biomedical technicians have received training in India
and in Italy to improve the ability to service eye equipment. Additionally, the local optometrist
has received training in India to specialize in low vision aids.

Training has also been provided in Dominica for nurses assisting during eye surgery from
Jamaica, St. Lucia, Guyana and Dominica. Ophthalmology residents from Canada have done
electives in Dominica. Medical interns rotate for one month and student nurses do attachments
in the ophthalmology department. Ongoing education is provided for Family Nurse Practition-
ers. Clinical cases are presented to other medical staff during clinicopathological sessions.
Succession planning is paramount. A Dominican who has successfully completed her ophthal-
mology residency in Canada returned to Dominica and began working from 2019. Another Do-
minican is currently training in Cuba. From 2018, an ophthalmologist has been provided annu-
ally on technical assistance from The People’s Republic of China. The public eye service now
has three ophthalmologists; one optometrist; one ophthalmic technician/screener grader; one
nurse assistant/screener grader; one registered nurse and one ward aid.

A new eye centre, in planning from 2000, with more examination rooms and its own operating
theatre commenced construction in 2019. Upon completion, Dominica will have additional eye
services, with an increased capacity to serve its people (eg. operating theatre time will be
increased from one day a week to five days a week), and with the implementation of informa-
tion technology to improve data management.

It will be equipped by the Brenda Strafford Foundation.Setting up ophthalmology in Dominica
is a work in progress that has embraced the primary care approach: promotive, preventive,
curative, rehabilitative and supportive eye care. Funding from non-governmental organiza-
tions, collaboration, research and training are the pillars which provide additional support and
increase capacity.

Ophthalmology In The Days Of Yore

Dr. Hugh L. Vaughan CD MBBS FRCS, FACS, FRCOphth
Dip Mgnt Stds (Hons)

A BLIND MAN HEALED AT BETHSAIDA RETINAL DETACHMENT

22Then He came to Bethsai- Retinal detachment repair was

da; and they brought a blind a high failure procedure when

man to Him, and begged Him I started. I saw several Arruga

to touch him. 23So He took string procedures in which a

the blind man by the hand and suture was attached to the

led him out of the town. And sclera around the equator and

when He had spit on his eyes tightened to bring the choroid

and put His hands on him, He THE EERYSOPHAKE in apposition to the detached
asked him if he saw anything. retina. Later diathermy to the

24And he looked up and said, This was a similar to a dropper sclera was done to improve
“I see men like trees, walk- with a suction bulb attached to chorio-retinal adhesion. Dia-
ing.”25Then He put His hands the glass tube . Squeezing thermy scleral puncture to
on his eyes again and made the air out of the bulb emptied externally drain the subretinal
him look up. And he was the bulb of air. The open end fluid improved retinal reattach-
restored and saw everyone of the tube was placed on the ment. External cryo therapy to
clearly. 26Then He sent him lens capsule and the release the sclera was introduced and
away to his house, saying, of the pressure on the suction had the advantage of not
[d]“Neither go into the town, bulb applied a vacuum, which causing tissue necrosis. Later
nor tell anyone in the town.” held the lens to the erys- direct visualization of the
This biblical story is over 2000 ophake allowing the lens to be causative retinal breaks with
years old. It is widely specu- pulled from the eye. The the binocular indirect ophthal-
lated that Jesus restored his Intracapsular forceps was moscope came into its own.
sight by couching. 46 Then smooth, which allowed grasp- The real improvement came
they came to Jericho. As ing of the capsule and removal with the Nikon Asheric lens
Jesus and his disciples, of the lens from the eye.
which allowed excellent vis-

together with a large crowd, uaisation at the time of sur-

were leaving the city, a blind ALPHA CHYMOTRYPSIN gery. External retinal plombbs
man, Bartimaeus (which with silicne sponges and

means “son of Timaeus”), was This was a proteolytic enzyme silicone buckles were sutured
sitting by the roadside beg- whish dissolved the zonules to the sclera to produce
ging. 47 When he heard that it allowing the lens to be more indents directly under the reti-
was Jesus of Nazareth, he easily removed. nal hole.
began to shout, “Jesus, Son of

David, have mercy on me!” 48 HYALURONIDASE PARS PLANA VITRECTOMY
Many rebuked him and told

him to be quiet, but he shout- Hyaluronidase was an With the routine use of the
ed all the more, “Son of David, enzyme which was injected to operating microscope pars
have mercy on me!”49 Jesus loosen the adhesion of the plana vitrectomy was intro-
stopped and said, “Call him.”- vitreous to the posterior pole duced. Retinal visualization
So they called to the blind of the lens, also faciliatating during surgery was improved
man, “Cheer up! On your feet! lens removal. with pre-corneal contact
He’s calling you.” 50 Throwing lenses at surgery. Intra ocular
his cloak aside, he jumped to CRYO-CATARACT EXTRACTION maneuvers were done
his feet and came to Jesus. 51 through 20 G instruments via
“What do you want me to do Pionered by Amoils the cryo- the pars plana. This allowed
for you?” Jesus asked extractor was an elegant internal drainage of sub-retinal
him.The blind man said, device. It used the Joule fluid, endo-diathermy was
“Rabbi, I want to see.” 52 Thompson principle. When a applied to the holes. Todays
“Go,” said Jesus, “your faith liquid evaporates, it absorbs BIOM and endo-laser probes
has healed you.” Immediately the heat of evaporation from were the steps that brought us
he received his sight and its surroundings. The cryo- to today-s standards.
followed Jesus along the road. probe had a metal rod with Intra-ocular retinal tamponade
one end in the evaporating with air, sulphur hexafluoride,

COUCHING liquid and the other touching silicone oil and liquid and gas-
the lens. As the refrigerant
The preceding Biblical stories evaporated , the heat from the eous perfluotocarbons have
are over 2000 years old. For lens was conducted to the
the non-Christians in our mul- evaporated liquid freezing the made reattachment highly
ticultural group I intend no probe to the lens.
offence, It is believed by likely. Removal of pre and

sub-retinal propiferative

vireo-retinopathy tissue

improved the success rate.

many, that Jesus healed these The frozen lens adhered to the Pars plana techniques would
men by couching of the probe and allowed the lens to not be feasible without vitre-
Lens.Perhaps this procedure be removed. The use of the ous cutting probes. The osci-
is that which is mentioned in Cryo probe made intra-capsu- lating action of the cutters
the articles of the Code of lar cataract extraction safe reduced vitreous traction
Hammurabi (ca. 1792-1750 and very effective. Care had during surgery.
BC) Maharshi Sushruta, an to be taken to avoid freezing
ancient Indian surgeon, first the Iris or the cornea. IMMUNO-THERAPY
described the procedure in

“Sushruta Samhita, Uttar Vascular Endothelial Growth
Factor (VEGF) is released
Tantra”, an Indian medical WOUND ARCHITECTURE from the hypoxic retina and
treatise (800 BC) I am certain- stimulates new vessel growth

ly not that old and have never The open sky incision with the

seen couching, but until the Grafie knife was the earliest in the eye. In my time, iris,
retinal or disc new vessels
advent of intracapsular cata- technique I saw. Later the often spelt disaster. Ranibi-
ract extraction couching of the Tookes knife was used to zumab, bevacizumab were
lens was a widely used proce- make an incision from the not present in days of yore
dure, and is believed to have external limbus in a more con- and eyes were lost to neo-vas-
been in use in under devel- trolled way. I remember the cularisation These antibodies
oped parts of the world until horror on the scrub nurses to VEGF have largely reduced
fairly modern times. Catarac- face when she saw me use a vision loss due to VEGF pro-
tous lenses were dislocated #15 BP blade to do this. This duction.
into the vitreous thus restor- wound could be extended
ing an optical pathway and laterally with corneal or cor-

restoring vision. It is my neo-scleral scissors. This I have tried to give a synopsis
of the practices and tech-
understanding that couching gave a more secure wound niques used in days of yore. I
have transported the younger
was practiced in Europe China with more accurate closure ones among us back in time to
pre-Christian times. I men-
and Africa. The advent of and less astigmatism. Initial tioned the early days of Indian
ophthalmological glory, and
intracapsular lens extraction in wound sizes were from 11 mm have taken you on a journey
from ancient Europe, Asian
the 18th century started a new with the Grafie to 9 mm with and African practices of
couching to modern monoclo-
kind of cataract surgery. the cryo probe. Compare with nal antibodies.

When I started ophthalmology corneo-scleral tunnels or

I saw patients who had had today’s sutureless small inci-

dehiscence of the lens with sion wound.

needling, Certaily needling of

congenital cataracts was still WOUND CLOSURE
being done. Intra-capsular

cataract surgery became the Closure was improved with
new technique with the use of 8’0’ Virgin silk sutures which
the Intra-capsular forceps and initially the surgeon attached I hope you enjoyed the jour-
the Erysophake. I saw several to a French eye needle. Later ney and the youth among you
cases treated by these tech- they were swaged to the realize the journey travelled to
niques. reach modern standards. It
needle allowing smoother was an indeed a long journey
through time.
passage. The introduction of

THE GRAEFE KNIFE spatulated needles gave even

better closure with less astig-

The Graefe knife was a thin matism. The initial needles IMMUNO-THERAPY
sharp knife with a blade over were round bodied, and were
an inch long. It was passed replaced by reverse cutting A BLIND MAN HEALED AT BETHSAIDA
through the limbus from 3 to needles, which had a cutting
9:o’clock. With one sweep of edge on the curved side of the IMRMETUINANLODE-TTAHCEHMREANTPY
the blade the incision was needle. Spatulated needles
through the linbus and exited replaced the reverse cutting PARS PLANA VITRECTOMY
at 12:o’clock to gain access to needles and had the cutting
the anterior chamber. The edges only on the sides. Of PARTHSEPELEARNYASVOIPTHRAEKCETOMY
corneal flap was retracted and course today’s tunnel incision HYALURONIDASE
the lens removed with an replaced the need for sutures.
Erisophake, a capsular Vitreous was the bane of the CRYO-CATARACT EXTRACTION
forceps or a cryo extractor. cataract surgeon. Anterior
The success of the Graefie vitrectomy with scissors was WOUNWODUCNDLCOLSOUSURREE
knife lay in its sharpness and soon improved with methyl ALPHA CHYMOTRYPSIN
the dexterity of the surgeon. I cellulose sponges(Weck Cell IMMUNO-THERAPY
used this knife in the first year sponges). This was later COUCHING
improved by aspiration of a
in Ophthalmology.
pocket of liquid vitreous via

Preplaced 9’o’ black silk pars plana or through the WOUND ARCHITECTURE
sutures traversed the wound iridectomy. In all cataract sur-
and were looped out of the geries a peripheral iridectomy WOUND ARCHITECTURE
way to allow the passage of was done to prevent vitreous THE GRAEFE KNIFE
the cataract knife. Closure of prolapse into the pupil, which
the wound with good align- would cause pupillary block COUCHING
ment was guaranteed by the causing pupil block. In earlier
days a keyhole iridectomy was
tying of these sutures.
done.

CAOTP HISTORICAL FOOTPRINTS

Marilyn Watkins-Ramdin, COMT ROUB
President and Founder of CAOTP

In 2007 Drs. Johnston, Allan and Singh thought that we should offer
some lectures to the nurses and technicians that had started to
attend OSWI on a regular basis. So with the help of Sunil Moonasar
who was at Alcon at the time, funded our 1st programme in 2008. I
gave a talk to the technicians and we felt it was well-received along with the sessions we
attended with the doctors. Later that year I attended my 1st ACE by JCAHPO in Atlanta and
was introduced to Dr. Lynn Anderson CEO and Dr. William Astle JCAHPO President
I took the opportunity to ask for help with our programme and it was granted on the basis of
JCAHPO coming to visit the OSWI Conference in 2010, I also had to give a presentation on
technician training in the Caribbean at the World Ophthalmology Congress WOC in Berlin
2010.

I returned in 2008 and discussed the JCAHPO meeting with my then employer Dr. Cyril Reifer
along with Drs. Johnston, Allan and Singh. Dr. Johnston reported to OSWI board and its mem-
bers and the decision was taken collaborate with JCAHPO. Dr. Anderson was also invited to
Antigua July 2010 to speak to the OSWI members. In June 2010, Drs. Johnston and Singh
accompanied me to Berlin where I gave my presentation on technician training and the need
for international certification. The presentation was well-received by WOC. We had many
follow-up meetings that week with WOC and JCAHPO.

After OSWI 2010, it was agreed that I would start a small training programme for 1 year in Bar-
bados and Dr. Johnston would be responsible for Trinidad It was also decided that JCAHPO
would return to OSWI 2011, to administer the 1st COA exams held under OSWI. A report was
compiled to the WOC on our progress.

We had 8 candidates in 2011 where 5 achieved COA status, candidates were from Barbados,
Dominica and Trinidad.
Over the years we have held the COA, COT, COMT and ROUB exams at OSWI with increasing
success. We have certified technicians from Barbados, Dominica, Guyana, Jamaica, Suri-
name and Trinidad.

We now have persons certified as COA, CCOA, COT, COMT, ROUB, OSA and OSC, we
have yet to provide a candidate for the CDOS exam the only subspecialty we have not attempt-
ed. It’s been very challenging working full time and preparing classes on a weekly basis along
with coordinating regional training. However many doctors especially our junior doctors were
willing and they assisted the technicians and nurses who have taken the JCAHPO exams.

Our corporate sponsors have been with us from the very beginning and remain with us in offer-
ing up not only funds but equipment and personnel for workshops, Alcon, Medilex, Steede
Medical, LENSTEC, POEN, Eye See You, Caribbean Ophthalmics, Pfizer and recently Vary
Medical.

CAOTP was officially formed in 2014 and approved by OSWI and IJCAHPO who both oversee
our elections and processes. With the advent of the pandemic, we are now looking at the virtu-
al platform to train our technicians and nurses with the support of OSWI and IJCAHPO.

CAOTP continues to provide through OSWI, IJCAHPO approved CME along with IJCAHPO
exams on a yearly basis. Although we were unable to provide a programme this year due to
the pandemic our certified members were able to receive free access the IJCAHPO ACE No-
vember 2020, which many took the opportunity to learn from a wide cadre of international lec-
tures provided by Ophthalmologists, technicians, nurses and other ophthalmic professionals.

We are currently preparing for the CAOTP/ OSWI Conference 2021 in conjunction with IJCAH-
PO. We currently have candidates from Barbados, Guyana and Trinidad preparing for COA
and OSA exams. Hopefully, we can continue weekly training with zoom or other platforms
Happy holidays
Marilyn

DOWN MEMORY LANE - A Personal Journey

Dr. Emsco Remy

Why Memory Lane you may ask? This idea came to mind during an
OSWI’s meeting in Antigua It was obvious to me then that we were blessed
with a number of young, vibrant, highly skilled ophthalmologists. Their presentations were of
the highest calibre. I knew then that OSWI was on a good footing and that the elders could rest
assured that our climb to the summit would not have been in vain. Returning home, I reviewed
the information at my disposal and decided to write my story. I must however admit that there
are some, better placed to give you a more comprehensive account of OSWI’s metamorphosis
than I can, but my article will have a particular focus.

OSWI was officially launched in June 1990 in Jamaica, but my journey down memory lane
begins prior to OSWI’s official launching. Caribbean integration in bygone years was not only a
vision or a dream of our politicians. Professionals in various disciplines also saw the need in
the early years. Some of our colleagues attended this Glaucoma Symposium held in St. Croix
in 1987. Papers were presented by Hugh Vaughn and Althea Connell head of the Department
of Ophthalmology at QEH Barbados. In the Eastern Caribbean a group of us met in Barbados
in March 1988. Part of the agenda at that meeting included the “Formation of a Caribbean
Association of Ophthalmic Personnel” that included Ophthalmologists, Technicians, and
Nurses. That meeting was followed by another in St. Lucia.

Some of our colleagues met in Fort Worth Texas in October 1989 and had discussions on the
formation of some sort of association. Earlier integrationists like Degazon (Jamaica), Johnson
(Guyana) and Rajack (Trinidad) also indicated more than a passing interest in the formation of
a Caribbean Association. Other meetings and discussions in the 80’s included participation of
CCB, NGO’s, PAHO, and IEF. The agenda at these meetings was heavy and sometimes the
discussions were heated. The official consecration of OSWI was held in Jamaica at the
Wyndam Hotel in Kingston in June 1990. That meeting was an important milestone for all Carib-
bean ophthalmologists. With two or three notable exceptions most of the participants at that
initial meeting are still with us.

The highlight of that meeting was the Degazon Memorial Lecture which was delivered by Dr
Lockhart one of our luminaries. He eulogised Dr. Denis Degazon. It was a moving, enlightening
and fascinating presentation. Lockhart described Degazon as a dedicated teacher, a mentor, a
gentleman, a skilled surgeon – a man who accepted only the best. According to Lockhart, De-
gazon believed in Caribbean Unity with a passion and he advised the then new association to
do the same. I suspect that Lockhart was echoing the sentiments of Dr. Degazon when he
admonished us to do the following:

Be strong and united

Write down your constitution and bylaws so that no one territory predominates

Forget insular pride and prejudices and let the body speak with one voice for all ophthal-
mologists in the region

Set your standards and administer these standards yourself

Train your physicians from the region to take over when you are gone. If we don’t train our
own no one else will

Seek to establish meaningful exchanges with colleagues and institutions from outside the
region but do so for the benefit of the Caribbean Community

Resist offers of one way exchange and discourage itinerant surgeons who do not follow
guidelines

No one should be allowed to come in and do things which they are not allowed to do in
their own country

Let visitors be part of your clinic and work the way you do; see that they take your advice.

Try to ensure that this organization leaves a clear path of stepping stones for those who
follow us

The above to me represents the gospel of Big D as presented by the apostle Lockhart.
(Unfortunately I did not understand the jokes about the Priest/Rabbi and TV Evangelist who
went on the fishing trip and the Priest/Rabbi travelling when pork was served. Perhaps Hugh
will enlighten me of these). I knew Dr. Degazon personally. He hails from St. Lucia and he tried
to recruit me to pursue ophthalmology despite my having a lucrative private practice. He was
president of the St. Lucia Medical and Dental Association at the time. As a student I remember
him making a point at one of his clinics that I attended. (The cock and the illiterate patient).

In 1991, along with Dr. Cyril Reifer and Clive Gibbons, I attended the Third Caribbean Glauco-
ma Symposium in St. Croix. It was my first meeting of that group. The presentations made at
that meeting were of a very high standard. Distinguished members of the American Academy
were in attendance. At that meeting I met for the first time a charismatic personality, a man of
many parts, an outstanding ophthalmologist, an academic, a writer, a herbalist, - a man of
many attributes – but most importantly a true friend of OSWI. This friend is Alfred Anduze; he
is like a dedicated companion, a favourite brother. I don’t believe that Alfred has ever missed
an OSWI meeting. He has presented a paper at every meeting of OSWI. His presentations
have been varied and interesting. A few nights ago, I laid my hands on one of his papers enti-
tled ”Controversy in the use of non-conventional medicines in the Caribbean”.

I would like to mention a sad note at the meeting, that is, the announcement of the passing of
Dr Roger Mason – professor of ophthalmology at Howard University. He was a dynamic and
visionary glaucoma specialist who was the lead investigator in the Glaucoma Study that was
done in St. Lucia – the first detailed evaluation of glaucoma in a black population. Later Dr.
Kosako will speak about this project.

Having cemented ourselves as an important organization in Caribbean medical politics, OSWI
grew from strength to strength. Our regional Institutions acknowledged our presence. We
became involved in Eye Care Initiation as well as Eye Care Implementation. Two aspects of
our involvement will be mentioned here:

The Regional Prevention of Blindness Symposium in St. Lucia in 1992 and

Guidelines for Development of Eye Care Programmes and Services in the Caribbean
1997 in Trinidad.

At both these important meetings we were well represented. It would be remiss of me if I did
not briefly mention one or two controversial issues that we were involved in: