The Gambia – Swansea Vision 2020 Eye Link

Saturday 28th and 29th December

After arriving on the Friday the weekend was a chance to meet The Gambian team and relax. We visited Kartong on the Senegal border and then on to Lamin Lodge for a delicious lunch. On Sunday we went bird watching, first at Tanin wetland complex and then to the wooded Abuko nature reserve

Monday 30th November

On my first day I met Mr Cham and Fofina the technicians in The Gambia who I was to shadow for the week. My first job was to fit the four tonometers that the team had brought over from Swansea to the Zeiss Slit lamps.  We checked their calibration and also the accuracy of the existing tonometer.

We then went to look at the theatre equipment. The Scan Optics microscope in theatre 1 was working  but I was handed a teaching arm that did not appear to fit. Theatre 2 had a very modern microscope and anaesthetic machine.

We looked at the Humphrey field analyser that had been moved from the Royal Victoria Hospitaland removed the RAM batteries that I believe caused the “freezing” that was reported. Fofina demonstrated that he was able to solder and I showed him how to desolder components, and prepare for replacement batteries. The machine appeared OK but the room very warm and too bright; Mr Cham said he would try and move it to an air conditioned room. Sue Pickering tried it and apart from printer problems (resolved the following day but print ribbon needs re-inking) was happy that it was working. The relevant pages of the manual were missing for the printer.

We then looked at the Topcon Fundus camera. This had an SLR and so the film had to be developed, Polaroid film was not available. The manual for the machine talks of the possibility of fitting a video camera and there is a socket for synchronising the Polaroid. Therefore, it may be possible to rig up a camera/computer so that images can be stored, if this would be helpful.

We went to the Technicians workshop and I was impressed by the way Mr Cham had looked after the Operating and Service manuals that he had been given. In the workshop was the Geuder Vitron 2020 machine and a Biovision A/B Scan but there was no B probe and the triaxial wire for the A scan was in 3 pieces. I brought the A scan probe back to attempt a repair. I doubt that we will be able to get hold of a B scan probe.

Mr Cham has been on a full training course for Ophthalmic technicians in Nigeria and very kindly provided me with a training video. There were no decent tools within the workshop and so I am hopeful that the tools that I took over will be useful. Accessing spare parts was also a problem. He said that he had fitted lamps with the filament incorrectly oriented as the ones he needed were not available locally.

On Monday evening we went to a fund raising event in a hall adjacent to Serrekunda Football stadium. They had hired a Chora player, of world renown, called Jaliba Kuyateh and we all had fun dancing. It was the custom to give a small donation during each song, asking another to donate on your behalf was thought to bestow even greater good luck. We met an English gentleman who had had his cataract successfully removed by Nnennaya a few months earlier.

Tuesday 1st December

Much of  Tuesday morning was spent in the Optometry workshop looking at a machine for cutting lenses for glasses. A rather old machine was blowing fuses and appeared to have multiple faults (some service induced). They had a newer machine that was working well and an unused machine from China with no manual. They also asked me to look at a water bath used for tinting that had clearly had its day.

Babucarr, one of the optometrists asked me to look at an autokeratometer which was an old Nikon machine. After I cleaning it he checked my eyes and the machine appeared to be working correctly (apart from the lack of paper, which was not essential). I had brought details with me outlining how they worked and also giving some contraindications for use. I left this with Babucarr and asked Huw Bellamy to look at the machine with him. I believe the machine to be working correctly. I have an operating manual for a newer version of this machine.

At lunchtime we went to look at the computer as I had brought some manuals on CD and wanted to show Mr Cham. I tried, unsuccessfully, to run a broadband speed check as I think that it would be very useful to be able to hold video conferencing over the internet. This could improve the link and allow more immediate access.

In the afternoon I went through the service procedure for the slit lamp with Mr Cham and Fofina. I talked about the importance of cleaning them on a regular basis and showed them how to grease/Vaseline the necessary parts. We then checked and labelled the tonometer. Mike Austin kindly checked Musa’s eyes to ensure that we had done a good job.

Wednesday 2nd December

On Wednesday I had arranged to go up country with Mr. Cham to visit the outlying centres at Basse and Bansang. We had an early start at 5.30 to get the ferry across to Barra as the road on the North side of the river is much better. We then travelled to Kerewan, Farafenni and to the Janjanburay island (Georgetown) to catch two more ferries. The roads then deteriorated to Bansang and we arrived at Basse at 1 pm.

Basse

There I met Ibram who assisted the cataract surgeon and Alfa who turned out to be a Nyateros(friend of the eye.) He said that he had been trained by Per (the cataract surgeon) to screen in the community and then he tried to ensure that a villager would come to the hospital if necessary rather than going to the witchdoctor. He said that he was not paid for his work.

We looked at the three  microscopes that were in theatre, one Scan Optics (which have Olympus optics) and 2 Metzers (made in India). The Metzers had been given to them but were not the model of choice. The Scan Optics had poor lighting because of the lamp and so I was able to repair that. The optics I could not repair properly. The top covers of the lenses on both eyepieces were missing and the lenses had fallen out. One  lens spacer had gone missing. Mr Cham had ingeniously manufactured top covers using drink bottle tops. I made a spacer with plastic sheet but it is not ideal. We need the proper parts or access to a mechanical workshop.

I looked at the Metzer microscopes and one, on a floor stand, appeared to be working  (as good as the optics would allow and easier to use with rubber eye cups) but the other, that clamped to the operating couch was unusable as the optics were out of alignment. I think that the damage to this and the scan optics was due to poor handling when they were going on the “Cataract camps”. They have a SES2000 autoclave for sterilizing the instruments.

We then went to the clinic and serviced the slit lamp. The dust really penetrates the machines and does damage. We fitted a new chin rest. The slit lamp had a working tonometer that had an error of 4mmHg. Presently they use Schiotz. The electricity is not as reliable here and this causes lamps to blow. They only have electricity between 8am and 3 pm. I got used to doing jobs while waiting for the power to be restored.

Bansang

At Bansang we met Dukure(?)  and he took us to a slit lamp that was in very poor shape and looked like it was not used. It was a Grafton Optical version but had lots of other makes of parts on it. The light cover was broken and Mr Cham had tried to fix in place using wire. I cut 2 new slots in the cover and this worked well. The wheels were not parallel and after fixing the wheels I had to realign the tracks. I also noticed that the optics were loosely mounted. After service I was not entirely happy with it’s function. Time did not allow to investigate further but I have suggested that Mr Cham try the focussing bar as I am not convinced that the light and optics are convergent. Perhaps the optics can be repositioned if they are out of alignment. There was no Goldmann tonometer available and they used Schiotz.

We then went to look at theatres and adjusted the lamp for the best light. The seal on the SES2000 autoclave was brown and in need of changing. Dukure demonstrated his electrical know how by pressing the earth in on a mains socket and then forcing a European plug into a broken British socket.

After getting a take away we stayed in the residence for doctors over the road. The water pressure was not sufficient to allow a shower.

Thursday 3rd December

We left at 6.30 but had to wait for the ferries at Janjanburay. Arrived at Farafenni at about 10am.

Farafenni

I met Alijesen and we looked at theatre while they found the key for the room with the slit lamp. The mains cable on the Scan Optics microscope had been smashed and pushed the IEC plug into the power supply for the operating microscope lamp and so I connected inside the enclosure as a temporary measure. We then repaired the SES200 Autoclave that was leaving everything wet. This was a quick job of removing, cleaning and then replacing the filter. The problem was that there was no electricity and so we could not ensure that it all worked.

Access was still not possible to the slit lamp and so we looked at an Archaic focimeter. It was lighting up but “there were no numbers”. We took it away for further investigation but I suggested to Mr Cham that the Kowa LM6 in his workshop would probably be easier to get going.

I was asked if we could help with a Heine handle for a Ophthalmoscope. We left without seeing the slit lamp. Reportedly it was a new one that had been set up incorrectly and then plundered by the Royal Victoria staff.

We had hoped to go to Soma and then back but as it was late decided to go and get the ferry and see Royal Victoria and Brikama (there’s optimism). After getting to Barra at 1pm approx, the next 5 hours was spent waiting for the ferry across to Banjul.

Friday 4th December

Royal Victoria

Mr Cham took me to Royal Victoria where we met Bakare Cesar a retired Cataract surgeon. We repaired the light on his Scan Optics microscope; there was also a Takagi microscope that was used clinically. A zeiss colposcope and OPMI1 were used for training. They also brought out an older Scan Optics microscope but it had no eyepieces (left at a cataract camp?).

We were asked to look at an autoclave and I decided to use an RCD extension for safety when working on it. The RCD did a wobbly as soon as I applied the power and it transpired that the socket was faulty.

We went down to the OPD and they had 2 Haag Streit slit lamps with Goldmann tonometers that we serviced/calibrated. They were using a lamp that I had not seen before and so that may be useful for us at Singleton. There was also a Topcon slit lamp in the corner gathering dust. Time did not allow an assessment. We looked at a slit lamp on the ward and the slit could not be reduced small enough. It had one part bent and another had been dismantled badly. Mr Cham says that this may have been when they were training technicians how to service them. I hope to get the information needed from Haag Streit and relay it to Mr Cham.

As we were leaving, we met with Peter, a Kenyan technician who works there. He had just returned from leave since August and was waiting for his papers come through.

SZRECC

We returned to Mr Cham’s workshop where a microscope and autoclave from Brikama had been left. We repaired the lamp on a scan optics microscope that also had loose screws and repaired the autoclave by cleaning the filter.

Conclusion

I enjoyed the trip and was grateful for the opportunity to see so many hospitals. The problem was that so much time was spent repairing that no time remained to teach good maintenance. Also, time did not allow me to take all the equipment details or install the database in SZRCC. I do have some of the equipment details and so I can enter these so that there is some data within the database when it is handed over. At present there is no phone or computer in the workshop and so I am not convinced that the database would have been of great value.

Mr Cham is doing a very good job under very difficult conditions. He is aware that he should spend time visiting the secondary centres but has trouble organising transport. Some of the problems at the secondary centres are due to a lack of maintenance while others are handling problems. More frequent visits would certainly reduce the risks of break downs but they also need to be able to access spare parts. I am unsure whether it is within the remit of the link to help with this problem. Mr Cham has suggested that it would be useful if I visited again and that we spend more time at each centre. This would allow time to compile a comprehensive list, repair faults, service equipment that is working (to stop it failing) and provide advice on the storage and transportation of equipment to the staff at the centre. I agree with Mr Cham and would also suggest that we compile a maintenance schedule for each centre. I would recommend that Mr Cham then visit each centre twice a year to carry out these procedures. This hinges on transport being made available.

Before my visit I had some reservations about the worth of bringing Mr Cham to the UK but I now think that there would be some benefits. This would need to be timed to coincide with service visits by ophthalmic engineers (especially Haag Streit) to Singleton. He could go through the servicing of the autoclaves with Estates and I would also try and find a UK hospital that serviced it’s own ophthalmic equipment and arrange a visit with him.

I did not understand what the Swansea Gambia link was until my visit. The staff in the Gambia are doing a very good job under very difficult circumstances. Equipment problems are hampering the cataract surgeons, particularly in the secondary centres. I believe that Mr Cham has the necessary knowledge but needs help with access to spare parts, information and transport. This will enable the cataract surgeons to continue doing their excellent work. The clinical focus of the group visiting with me was Glaucoma. Their tonometry instruction will be of use in Banjul but most of the secondary centres do not have Goldmann tonometers. This will need to be addressed before GAT is available to all referral centres.

Communication with people is a problem. I had hoped to check the broadband speed to see if we could set up a video link but on the day I tried, it was not possible.