Schönfeld et al.

Int J Ophthalmol Clin Res 2015, 2:5

International Journal of ISSN: 2378-346X

Ophthalmology and Clinical Research

Research Article: Open Access

Introduction of Basic and Advanced Techniques of Ophthalmic Surgery

in Myanmar
Carl-Ludwig Schönfeld1,3*, Chaw Wai Lwin2, Volker Klaub3, San Hlaing2, Thazin Shwe2, Mya
Thandar So2, San Myint2, Claudia Klaub4, Tomas Schaal5, Martin Grüterich4 and Tin Win2
1
Augenklinik Herzog Carl Theodor, Germany
2
Yangon Eye Hospital, Myanmar
3
Department of Ophthalmology, University Ludwig Maximilian München, Germany
4
Private practice, München, Germany
5
Private practice, Bad Tölz, Germany

*Corresponding author: Carl-Ludwig Schönfeld, Augenklinik Herzog Carl Theodor, Nymphenburger Str. 43, 80335
München, Germany, Tel: +49-89-1270930, Fax: +49-89-1290341, E-mail: [email protected]

the causes of blindness can be removed when sufficient resources are

Abstract available leads to an extreme worldwide disparity of the prevalence
Purpose: We report our first experience with the introduction of an of blindness: Of the officially estimated 37 million blind people
external teaching programme in Myanmar, a country that has only in 2002 (best corrected visual acuity of the better eye <3/60)-an
recently opened to the rest of the world.
approximation that may be way too conservative [1,4] -, a total of
Methods: 19 eyes in 18 patients were treated by surgical teams 80% lived in developing and least developed countries, respectively
comprising a German senior surgeon and a local ophthalmologist.
[4]. Accordingly, up to 1% of the population in LDC is blind [5]. In
Diagnoses and treatment procedures were recorded, and visual
acuity was measured before and 1-7 days after surgery. the early 1990s, WHO predicted a number of 75 million blind persons
by the year 2020 without well-directed measures and initiated a
Results: Available resources were more appropriate than expected,
but supply of consumables and hygienic procedures required
programme (‘VISION 2020’) in 1999 to reduce this number to 25
improvement. Retinal detachment and vitreous haemorrhages million by the year 2020 [6,7]. The goal of this programme is ambitious
played a dominant role in presenting pathologies. All eligible eyes by any standard, and it definitely overtaxes the means of developing
(n=19) received PPV, frequently combined with other procedures. and least developed countries; therefore, foreign cooperation and
Despite the short observation period, some improvement of visual input of some kind is a certain prerequisite for its accomplishment.
acuity could be obtained.
Currently, knowledge about prevalence, incidence and causes
Conclusions: Our programme is in line with the VISION 2020
initiative and yielded tangible benefits for everybody involved. of blindness in Myanmar is scanty due to the decade-long seclusion
Recommendations for the implementation of such programmes are of the country (a MEDLINE search with the key words ‘blindness’
given. and ‘Myanmar’ yielded a mere 19 published articles since filing and
indexing began in 1966), but there are some studies-most notably and
Keywords
recently the ‘Meiktila Eye Study [8-11]-that provide valuable insights.
Vitreoretinal surgery, Cataract surgery, Blindness, Myanmar, According to presently published evidence, 40% of the population
International cooperation
above 40 years in the rural Meiktila district in Myanmar suffer from
significant visual impairment (visual acuity <6/18 in the better eye),
Introduction and a shocking 8.1% are blind (<3/60) [10]. Approximately 90% of
the incident blindness in Myanmar is avoidable [12], with cataract
Blindness is one of the oldest and most dreaded health problems (>50%), glaucoma (~16%) and corneal pathologies (~15%) leading
of mankind, and most of the underlying diseases are preventable, the way in terms of causes. In children specifically, corneal pathologies
curable (or at least, controllable) with modern treatment modalities. are a much more important cause of serious visual impairment, and
Whereas avoidable blindness has largely been overcome in developed measles keratitis is the single most important identifiable cause [13].
countries, it continues to represent a major problem up to this day The most prominent reasons for non-treatment of cataract are cost/
in developing countries and in particular in the-currently 48-‘least availability and fear of surgery, respectively [14], i. e. presenting
developed countries’ (LDC) of the world [1-3]. The fact that most of solvable problems in the greater scheme of things.

Citation: Schönfeld CL, Lwin CW, Klaub V, Hlaing S, Shwe T, et al. (2015) Introduction
of Basic and Advanced Techniques of Ophthalmic Surgery in Myanmar. Int J Ophthalmol

ClinMed Clin Res 2:035

Received: April 13, 2015: Accepted: August 25, 2015: Published: September 01, 2015
International Library Copyright: © 2015 Schönfeld CL. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and source are credited.
 Previous experience of combined collaboration and training Table 1: Leading diagnoses of patients upon presentation
programmes [15-17] taught us that foreign aid only makes sustainable Leading diagnosis Number Percentage
sense when local surgeons are trained to do the required jobs on their Retinal detachment 12 31.6%
own. Facing the magnitude of the problem of blindness in LDC, there Vitreous hemorrhage 6 15.6%
is no way that foreign doctors can solve it all by themselves. This Macular hole 5 13.2%
kind of substitution only reaches few people and is far from being Proliferative diabetic retinopathy 5 13.2%
sustainable. It may even interfere with local efforts to build eye care Proliferative vitreoretinopathy 3 7.9%
programmes. However, our previous experience also taught us that Uveitis 1 2.6%
we may encounter unexpected and unprecedented complications, Branch vein occlusion 1 2.6%
challenges and pitfalls when implementing support programmes. Macular edema 1 2.6%
Those problems may pertain to local or national political and Retinoschisis 1 2.6%
bureaucratic peculiarities, tribal issues, and in particular unexpected Eales disease 1 2.6%
shortfalls in equipment availability. Central artery occlusion 1 2.6%
Melanoma 1 2.6%
Foreign medical aid has been a reality for decades in most parts Total 38 100,0%
of the developing world, and therefore it is difficult to distinguish
between intrinsic and extrinsic reasons for difficulty or failure. In Table 2: Operations
this regard, the recently emerging opening of Myanmar to the world
Procedures Number Percentage
not only presents a major development demand, but also a unique
Pars plana vitrectomy 19 100.0%
research opportunity. The fact that Myanmar is practically ‘aid-
… in combination with
naïve’ allows for the unbiased quality control of aid implementation
endolaser 11 57.9%
and the analysis of potentials and pitfalls of ophthalmological aid
membrane peeling 8 42.1%
programmes. The aim of the present paper is to objectively analyse
retinotomy 3 15.8%
our first experience with the teaching programme in vitreoretinal
… with implantation of
surgery in Myanmar and outline a ‘cookbook’ for future activities in
posterior chamber intra-ocular lens (PCIOL) 8 42.1%
similarly undersupplied countries or, more importantly, regions. anterior chamber intra-ocular lens (ACIOL) 1 5.3%

Methods … with application of perfluorodecalin 3 15.8%

… and tamponade with
Design of the programme silicone oil 7 36.8%
perfluoroethan (C2F6) 3 15.8%
Before onset of the programme, consent was obtained from the
responsible local authorities after comprehensive information about
scope, participants, and methods. Pertinent approval documents can Patient profile
be obtained from the corresponding author. Upon presentation, patients were between 10 and 81 (mean, 51.3
Patient examination and treatment took place in the Yangon Eye ± 18.0) years of age. The presenting diagnoses are shown in table 1;
Hospital (30, Natmauk Road, Tamwe Township, Yangon, Myanmar) most frequently, the leading cause of visual impairment was retinal
between Monday, October 28th and Wednesday, November 6th, 2013. detachment (n=12, 31.6%), followed by vitreous haemorrhages (n=6,
15.6%), macular hole, and proliferative diabetic retinopathy (both
On the first day of the programme (October 28th, 2013), 38 n=5, 13.2%). The non-assignment to surgical treatment was due to
patients with visual impairment and various retinal pathologies decisions of patients and surgeons, respectively.
were examined by the author (CLS) and another member of the
ophthalmological staff of the hospital. Patients in whom surgery was Treatment and outcome
indicated received an appointment for the operation on Tuesday,
October 29th through Tuesday, November 5th. The final evaluation Two operations were performed by the visiting surgeon (CLS)
of all patients who underwent surgery took place on Wednesday, alone, and the remaining 17 procedures by CLS and one of the
November 6th, 2013, i. e. 1-7 days after the operation. participating local ophthalmologists. The operations lasted between
40 and 225 minutes (mean, 125.3 ± 45.1 minutes), and the operation
Evaluation theatre was utilized for a total of 57.5 hours over 6 days of surgery.
The comparably long duration of surgery is a consequence of the
Diagnoses, procedures, and visual acuity were determined upon
teaching/supervision situation and indicates that this was taken
presentation and on the final day of the programme, respectively.
seriously.
The technical difficulty of the required operation was graded by the
author (CLS) in three increments (‘easy’, ‘difficult’, ‘very difficult’). Due to the underlying pathology, all patients were treated with a
23-gauge pars plana vitrectomy (ppv). The small-calibre instrument
Results was chosen because it simplifies the surgical procedure (lack of
suturing), causes less discomfort, and yields a faster improvement
Resources
of visual acuity in comparison to ‘conventional’ 20-gauge
With respect to the availability of resources, we found clearly instrumentation [18].
distinguishable situations: The level of education and skill both in
In addition to ppv, a variety of procedures were performed
surgeons and nursing staff were very high, and surgeons were quite
according to the individual patient’s requirements (Table 2).
experienced in cataract, albeit not in vitreoretinal, surgery (CSR
Most frequently, the vitrectomy was combined with endolaser
1,600/1 million inhabitants). Another area of sufficient resources was
photocoagulation (n=11, 57.9%) and membrane peeling (n=8,
that of surgical and optical devices: Operating microscopes, lasers,
42.1%). Phacoemulsification and implantation of a posterior chamber
and surgical systems-even including small incision instruments-were
intra-ocular lens (PCIOL) was performed in 8 cases (42.1%), and all
largely up to developed countries’ standards. However, most of the 12 cases with retinal detachment as the leading diagnosis received a
more advanced equipment came from unaccompanied donations and precautionary scleral suture.
was to some extend unused. On the other hand, there was a notable
shortage of especially expensive devices (e. g., Binocular Indirect Three of the operations were graded ‘easy’, two ‘difficult’, and the
OphthalmoMicroscopes) and consumable tools and materials (i. e., remaining 14 operations ‘very difficult’.
perfluorodecalin, silicone oil, curved laser probes, etc.), and standards Despite the short observation period, the visual acuity improved
of hygiene and sterilization were not matching surgical standards. noticably; the median visual acuity after surgery was 1.6 logMAR

Schönfeld et al. Int J Ophthalmol Clin Res 2015, 2:5 ISSN: 2378-346X • Page 2 of 5 •
 Figure 1: Visual acuity 1-7 days after vitreoretinal surgery as compared to baseline

as compared to 1.9 logMAR before the operations, and the median making sure that the ultimate goal-improvement of a population’s
difference was -0.1 logMAR, equalling one line on visual chart. 11 of health status-is being met. On the contrary, our Myanmar experience
the operated eyes (57.9%) showed some degree of improvement of shows that the availability of technical equipment as such is one of
visual acuity, and in three eyes (15.8%) the difference exceeded 1.0 the areas with relatively low deficiencies, but that the utilization of
logMAR (Figure 1). advanced equipment requires local education and training.

Discussion Overall, the assessment of the one-week training programme was

very positive from the side of the participants and the instructors,
There is a great demand for vitreoretinal surgery in developing respectively. In the meantime, one of the participants (CWL) has
countries, and consequently the need for tertiary eye care centres spent 6 months at the Department of Ophthalmology, University
with the required units and equipment as well as appropriate training Ludwig Maximilian Munich, and an upcoming programme in
facilities of vitreoretinal surgeons is eminent. As a result of out long- Myanmar is scheduled for May, 2014.
standing experiences in Kenya, Nepal and Myanmar we can state:
The first lesson to be learned from the first implementation of
• International cooperation should respond to demand from
the programme is the high standard of surgical skill already present;
institutions and/or ophthalmologists in the host country as opposed
the cataract surgical rate (CSR) in Myanmar was 1,600/1,000,000,
to being superimposed by foreign countries or NGOs (“paternal
indicating a fairly high penetration of ocular surgery in comparison
philanthropy”).
to other LDC and developing countries [21,22]. Although this
• A long-term perspective with well-defined targets and a didn’t pertain to the more complex-and technically demanding-
clear-cut phasing-out strategy must be defined at the beginning of vitreoretinal procedures, it did indeed facilitate the teaching and
the partnership. made the one-week instruction/supervision programme all the more
worthwhile. As a matter of fact, in retrospect the very good standards
The improvement of the population’s health in poor countries is
an immensely demanding and complex task, and the treatment of eye in basic ophthalmological surgery were a precaution of success of
diseases and prevention of blindness are no exception to this rule. While the fairly short period of teaching. Based on this experience, short-
improvements are attainable even under limited funding circumstances term residencies of Myanmar colleagues in high-volume tertiary eye
[19], they require an integrated approach that homogeneously considers care centres in developed countries would be an excellent method
the aspects of availability and affordability of resources, their accessibility of stepwise qualification; unfortunately, Myanmar’s current system
for and utilization by the general public, and the quality of delivered of postgraduate education requires 12-month periods of abroad
care. Evaluations of health care development programmes have shown residency to be spent in a single country, which is less than ideal from
that substantial funds can be expended without much benefit for the this point of view.
population in impoverished environments; moreover, introduction of A definite positive is the generous approval of foreign surgeons’
treatment facilities without an integrated approach for their utilization teaching and operating by the Myanmar government; this facilitates
may even aggravate poverty due to non-sustainable financial efforts for sandwich programmes that allow foreign surgeons to gather practical
their accession [20]. experience and provide substantial benefits for all involved, first and
Consequently, it is not beneficial (and may even be detrimental) to foremost including the patients afflicted by vision-threatening or
simply purchase and deliver machinery for modern treatment without -destroying eye disorders.

Schönfeld et al. Int J Ophthalmol Clin Res 2015, 2:5 ISSN: 2378-346X • Page 3 of 5 •
 While the initial situation in terms of human resources and be taught and implemented within the training programme. This
technical appliances was better than expected (and a more than also applies to complex procedures: For instance, the combination
adequate basis for the teaching programme), we identified two of phacoemulsification, PCIOL and ppv is beneficial in terms of
distinct areas with deficiencies: Hygiene and sterilization standards completeness of vitreous removal and consequently postoperative
on the one, and supply of consumable tools and materials on the convalescence; however, the slightly longer duration requires careful
other hand. The former issue is theoretically relatively easy to address, maintenance of intra-ocular pressure, and mastery of the appropriate
but nevertheless represents a pressing global concern: Health- techniques requires some skill.
care associated infections-being a major problem in industrialized Implementation of sandwich training programmes creates an
countries as well-are 5 to 25 times more frequent in developing and enticing win-win situation with substantial benefits for every involved
LDC, and post-surgical infection rates frequently exceed 25% [23]. stakeholder.
In recognition of this issue, the WHO has launched the ‚World
Alliance for Patient Safety’ in October 2004, emphasizing hand Along with teaching and training of ophthalmological surgeons,
hygiene in healthcare as the key method for improvement [24,25]. it is paramount that nursing staff in operating theatres, emergency
The Hippocratic principle of non-maleficence (‘primum non nocere’ rooms and wards receives equivalent attention with special respect
[first, do no harm]) dictates that this issue should be taken seriously, to the issues of hygiene and asepsis. This should include short-term
and our observation of room for improvement underlines its residencies abroad and certifications for obtained qualifications.
importance especially in a resource-replete environment. The aforementioned ‘staggered’ approach equally applies to
A rapid and substantial improvement of the hygienic standards regional penetration of available methods. Without any reasonable
in the Yangon Eye Hospital is certainly attainable without any extra doubt, a development programme for vitreoretinal surgery in
Myanmar has to originate in Yangon, but must not end there. In a
expenditure, but it requires a distinct and targeted educational effort.
country with roughly 60 million inhabitants, sufficient supply of
Just as in teaching surgical skills, short-term residencies in European,
only the capital region (with about 10% of the population) merely
North American, Australian, or Singaporean eye care centres would
scratches the surface of the underlying issue that must not be forgot:
prove to be extremely helpful for the obtainment of appropriate
Prevention of global blindness.
techniques and procedures.
It should be noted that this ‘cookbook’ is mostly based on
The shortage of consumables reflects a structural problem that
personal experience and does not claim completeness. However, said
we consider typical for developing and least-developed countries
experience spans over 14 years and three countries on two continents,
based on previous experience in countries like Kenia [15,17,26] and
so we are fairly confident that it is comprehensive.
Nepal [27], respectively: Due to the relatively slow turnover, the local
distributors have no particular interest in stocking the very expensive Acknowledgements
and perishable goods because they fear financial losses if they are not
There was no relevant funding. Hartmut Buhck assisted the authors in data
sold before their date of expiry. In LDC the majority of patients can analysis and manuscript preparation.
contribute nothing or little to the cost of surgery-“cost sharing” -,
but models from India and Nepal demonstrated that even in poorer References
rural populations a significant financial contribution can be achieved
1. Dandona L, Dandona R (2006) What is the global burden of visual
[28]. Primarily, the supply of consumables is the local government’s impairment? BMC Med 4: 6.
responsibility and should only become foreign governments’ or
2. Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, et al.
NGOs’ duty in serious crises.
(2004) Global data on visual impairment in the year 2002. Bull World Health
Whereas the method of examination, discharge and re-admission Organ 82: 844-851.
for surgery did not impose serious logistical problems in the urban 3. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP (2008) Global magnitude
Yangon area, it would have complicated patients’ access to the of visual impairment caused by uncorrected refractive errors in 2004. Bull
World Health Organ 86: 63-70.
programme in more rural regions where transportation can represent
an insurmountable obstacle. For the future, it would be preferable to 4. Pizzarello L, Abiose A, Ffytche T, Duerksen R, Thulasiraj R, et al. (2004)
integrate diagnosis and treatment into one hospital visit. VISION 2020: The Right to Sight: a global initiative to eliminate avoidable
blindness. Arch Ophthalmol 122: 615-620.
In conclusion, the following aspects should be considered in 5. Lewallen S, Courtright P (2001) Blindness in Africa: present situation and
planning and execution of future programmes for teaching and future needs. Br J Ophthalmol 85: 897-903.
training of vitreoretinal surgery in LDCs:
6. World Health Organization: What is “VISION 2020: The Right to Sight”?
• The surgical skill of local ophthalmologists can be 7. Yorston D (1999) The global initiative vison 2020: the right to sight childhood
unexpectedly high; the cataract surgical rate CSR provides a good blindness. Community Eye Health 12: 44-45.
‘rule-of-thumb’ assessment method.
8. Abdul-Rahman AM, Casson RJ, Newland HS, Muecke J, McGovern S, et
In countries with a low CSR, development of basic surgical skills al. (2008) Pseudoexfoliation in a rural Burmese population: the Meiktila Eye
Study. Br J Ophthalmol 92: 1325-1328.
and implementation of safe cataract surgery should be implemented
before the more complex procedures. This ‘staggered’ approach yields 9. Casson RJ, Newland HS, Muecke J, McGovern S, Abraham L, et al. (2007)
faster and more population benefits because up to 75% of blindness Prevalence of glaucoma in rural Myanmar: the Meiktila Eye Study. Br J
Ophthalmol 91: 710-714.
worldwide is caused by cataract [29].
10. Casson RJ, Newland HS, Muecke J, McGovern S, Durkin S, et al. (2007)
Development programmes must be preceded by an analysis of Prevalence and causes of visual impairment in rural myanmar: the Meiktila
locally available resources and adapted to its results. This should Eye Study. Ophthalmology 114: 2302-2308.
include a photographic documentation of available facilities that 11. Durkin SR, Casson RJ, Newland HS, Aung TH, Shein WK, et al. (2007)
can be electronically submitted to the visiting consultant to allow for Prevalence of trachoma-related trichiasis and corneal opacity in rural
demand-adapted planning. Myanmar: the Meiktila Eye Study. Ophthalmology 114: e7-11.

12. Nemet AY, Nemet P, Cohn G, Sutton G, Sutton G, et al. (2009) Causes of
A working infrastructure for the continuous supply of blindness in rural Myanmar (Burma): Mount Popa Taung-Kalat Blindness
consumables and the obtainment of expensive equipment needs to be Prevention Project. Clin Ophthalmol 3: 413-421.
established. Since device and consumable acquisition is often a subject
13. Muecke J, Hammerton M, Aung YY, Warrier S, Kong A, et al. (2009) A survey
of bureaucratic approval, it may help to lend expensive devices like of visual impairment and blindness in children attending seven schools for the
the BIOM for the teaching period and later negotiate acquisition with blind in Myanmar. Ophthalmic Epidemiol 16: 370-377.
the background of a demonstrable benefit. 14. Athanasiov PA, Casson RJ, Newland HS, Shein WK, Muecke JS, et al. (2008)
Cataract surgical coverage and self-reported barriers to cataract surgery in a
Novel surgical techniques, e. g. 23/25-gauge ppv, can and should rural Myanmar population. Clin Experiment Ophthalmol 36: 521-525.

Schönfeld et al. Int J Ophthalmol Clin Res 2015, 2:5 ISSN: 2378-346X • Page 4 of 5 •
15. Schönfeld CL, Kollmann M, Nyaga P, Onyango O, Klauss V, et al. (2013) 11 23. Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, et al. (2008)
Years of experience in vitreoretinal surgery training in Nairobi, Kenya, from Infection control as a major World Health Organization priority for developing
2000 to 2010. Can J Ophthalmol 48: 324-330. countries. J Hosp Infect 68: 285-292.

16. Schönfeld CL, Kollmann M, Nyaga P, Onyango OM, Klauss V, et al. (2008) 24. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva,
[Training program for vitreoretinal surgery in Nairobi, Kenya from 2000 - World Health Organization, 2009.
2006]. Klin Monbl Augenheilkd 225: 857-862.
25. Allegranzi B, Storr J, Dziekan G, Leotsakos A, Donaldson L, et al. (2007) The
17. Schönfeld CL, Nyaga P, Onyango OM, Klauss V, Kampik A, et al. (2012) First Global Patient Safety Challenge “Clean Care is Safer Care”: from launch
Benefits, limitations and outcomes of vitreoretinal surgery, Nairobi, Kenya: to current progress and achievements. J Hosp Infect 65: 115-123.
8-year experience. Acta Ophthalmol 90: e244-245.
26. Schönfeld CL, Kollmann M, Nyaga P, Onyango O, Klauss V, et al. (2010)
18. Recchia FM, Scott IU, Brown GC, Brown MM, Ho AC, et al. (2010) Small- New approach in training in East Africa: vitreo-retinal surgery from 2000 to
gauge pars plana vitrectomy: a report by the American Academy of 2007 in Kenya. Br J Ophthalmol 94: 1402.
Ophthalmology. Ophthalmology 117: 1851-1857.
27. Schönfeld CL, Hennig A (2013) Restoration of severely impaired eyesight in
19. Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, et al. (2013) an adolescent with Down syndrome and bilateral cataract in South Asia. Case
Good Health at Low Cost 25 years on: lessons for the future of health systems Rep Ophthalmol 4: 184-187.
strengthening. Lancet 381: 2118-2133.
28. Muralikrishnan R, Venkatesh R, Prajna NV, Frick KD (2004) Economic cost
20. Haddad S, Nougtara A, Fournier P (2006) Learning from health system of cataract surgery procedures in an established eye care centre in Southern
reforms: lessons from Burkina Faso. Trop Med Int Health 11: 1889-1897. India. Ophthalmic Epidemiol 11: 369-380.

21. Habtamu E, Eshete Z, Burton MJ (2013) Cataract surgery in Southern 29. Tabin G, Chen M, Espandar L (2008) Cataract surgery for the developing
Ethiopia: distribution, rates and determinants of service provision. BMC world. Curr Opin Ophthalmol 19: 55-59.
Health Serv Res 13: 480.

22. Rao GN, Khanna R, Payal A (2011) The global burden of cataract. Curr Opin
Ophthalmol 22: 4-9.

Schönfeld et al. Int J Ophthalmol Clin Res 2015, 2:5 ISSN: 2378-346X • Page 5 of 5 •