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ORDINARILY, it makes more economic sense to bring the patient to the surgeon rather than taking the surgeon to the patient’s bedside. But how do you deal with the needs of an elderly, vision-impaired population spread over a large territory? This was the problem faced by Svetlana Y Anisimova, MD and her team at the East-Sight Recover Eye Centre in Moscow, Russia. The solution: a mobile ophthalmic surgery unit equipped to perform a full array of diagnostic and therapeutic procedures. "Many elderly patients face great difficulties visiting doctors because of the lack of travel infrastructure. If they live away from the centre, where most of the clinics are, the expense of travelling and the lack of help in moving becomes a serious problem," Dr Anisimova told EuroTimes. Russia has been a pioneer in taking mobile ophthalmological services to its vast territories and beyond. Over the years, planes, trains, boats and buses have all been utilised to deliver essential ophthalmic surgery services. Although successful in their own right, these initiatives had a high monetary cost and were constrained to relatively large cities of over 500,000 inhabitants. In 1998, a new scheme was introduced - a mobile ophthalmic surgical unit designed and equipped to travel to patients’ houses. Facilities on the moderate-sized vehicle includes an operating table with a microscope with X-Y and zoom systems, lateral and coaxial lighting, a vascular coagulator, A-scan ultrasound and a set of microsurgical instruments. The human element consists of a pool of two or three surgeons, a nurse, an anaesthesiologist, an engineer and a driver. Since its launch in 1998, both the unit and the operating procedures have been refined and a successful routine established. After a room is selected to serve as the operating theatre, it is first sterilised by ultraviolet radiation for 10 minutes. A period of six minutes of irradiation provides 99.9% bactericidal effect for a volume of 100 cubic metres of air, she noted. The operating area is then covered by a set of sterile disposable linens. The surgical field is sterilised and the eye cavity is also washed with kanamycin solution. Anaesthesia is provided by epibulbar anaesthesia. Sedative medications are used very rarely and are only given orally. Some 95% of patients report that their operations are devoid of pain or discomfort, she said. Before commencing the operation, the surgeon instils the conjunctival cavity with 0.5% Tetracain solution for 10 or 15 minutes. Mydriacil, Neosinephrine and Trusopt solutions are also used before tunnel cataract extraction or combined interventions. The Russian mobile service had its debut in the greater Moscow area. The diagnostic team visited bed-bound patients and the surgical team followed when required. The second phase took the mobile unit to various regions of Russia. The van visited 13 towns during 24 individual expeditions. The unit typically stays in a town for three days, of which one-and-a-half days are used for surgery. Local ophthalmologists provide the follow-up. From July 1998 to December 2001 the mobile team examined 2,852 patients, and operated on 509 eyes. Patients ranged in age from 34 to 103 years. The most common operation was cataract extraction using extracapsular with phaco techniques and IOL implantation. The majority of the cataracts operated were mature (72%). The IOP levels of patients operated for glaucoma were 27mmHg or less in 27 eyes, between 28mmHg and 30mmHg in 56 eyes and over 31mmHg in 29 eyes. Patients with mature or nearly mature cataracts and intraocular pressures up to 30mmHg underwent combined surgery consisting of non-penetrating deep sclerectomy plus tunnel cataract extraction and IOL implantation. Routine postoperative care included subconjunctival injection of 0.3ml of dexamethasone and 0.3ml of Gentamicin. Patients all received Garasone (or Maxitrol) and Naclof (or Indocolir) drops and Mydrum or Mydriacil depending on clinical needs. Dr Anisimova reported that there were no intraoperative complications in this series. Follow-up ranging from three months to three years showed four cases of lens subluxation, six cases of transient corneal oedema, eight cases of transitory IOP rise (subsequently eliminated by one instillation of Trusopt or Xalatan), nine cases of iridocyclitis (which required additional treatment with dexamethasone injections) and two cases of postoperative hyphaema. She attributed the success of the programme to recent advances in preoperative diagnosis and operative and postoperative evaluation. New methods of achieving satisfactory anaesthesia and sedation, less invasive operations and the reduction of intraoperative and postoperative complications allow conversion to outpatient surgery in many cases. ‘Custom packs’ for specific operations and the new sterilisation and disinfections procedures also play a key role. Among the advantages of this mobile unit approach are the minimal physical and emotional disturbances to the patient. The fact that those patients are generally elderly and have severe movement restriction makes a trip to a hospital an extremely stressful experience. "Practically all patients operated for cataracts showed some visual improvement. In some cases, accompanying retinal pathology made the improvement modest, but even in those cases many patients regained the ability to look after themselves," Dr Anisimova commented. Svetlana Anisimova MD |
