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Visit Report by Suzanne Martin, November 2011

A team of 8 professionals from Swansea visited The Gambia from the 11th to 18th November. The team consists of David Laws, Consultant Ophthalmologist, Stella Elliott, Link Co-ordinator, Suzanne Martin, Orthoptist, Susan Williams, Theatre Sister, Jatinder Singh, Pharmacist, Constantin Magurean, Medical Engineer, Martin Wasik, Ophthalmologist and Elinor Laws.

Here is Suzanne’s report:



My objectives of the visit were:


  1. To take some equipment and more toys for the play area. I took fixation sticks, torches and small toys to attract the patients’ attention, and occluders.
  2. To observe the refractionists testing vision in children to see if the skills taught during previous visits are being put into practice.
  3. To teach refractionist students how to assess vision.
  4. To see if patients with glaucoma are having their fields tested
  5. To give a presentation on binocular function and show a DVD showing different children’s motility disorders and demonstrating the cover test.




The team met with Mr Sillah and the Gambian team and discussed our objectives for the week. We then gave them all the equipment we had brought with us and had a tour of the hospital. I was introduced to the students on the optometry course one of whom was Babucarr who I had previously met working at SZRECC and also on one of the visits of the team toSwansea. The students come from other countries in Africa however there are two from theGambiaincluding Babucarr..

I spent some time with the refraction students in two groups of three and taught them how to assess vision. The teaching went well and a timely interruption to assess vision on a baby gave the students a chance to practice their newly acquired skills. They were most surprised to discover that children’s vision can be measured from the age of six weeks.

I then met Adam, Alagie and Wallace the refractionists currently working at SZRECC. I gave Adam and Babucarr a tutorial on testing vision in children and using the cover test to assess for a squint. They picked this up really quickly. I then went through the equipment they had to see what condition it was in. Unfortunately the Kays picture test had fallen apart.I asked Babucarr to e mail me in future when they needed new equipment to see if I could help

We discussed the visual fields machine which was located in the middle of the small room. Adam said it had stopped working recently and wouldn’t print. I was under the impression that they had run out of paper. I discussed this later with Constantin who said they should be able to source paper cheaply.

When I left the clinic Elinor and I went to the meeting room and started to write up the blog for the website and gave out some of the staff questionnaires which Elinor had prepared with Claire Walker. These would be used to gather information on improvements and achievements made over the first three years of the link from the staff’s perspective.



In the morning I gave a presentation to the staff on Binocular Vision and briefly showed a video of different motility disorders that we had made in Singleton. I gave this to Isatou for her to use in future. I then went to the out-patient clinic and firstly looked at the Humphrey fields machine. It did have paper but wouldn’t start up – it looked like it could be a bulb problem Constantin came to have a look with Mr. Cham. I found out that Alagie is the refractionist who usually tests fields. Alagie told me that there was no problem in buying more paper for the machine.

I then gave a tutorial to the students on cover test and ocular movements and gave them the medical student handout that we use in Singleton. We discussed our objectives for the rest of the week which included practical testing of children’s vision and cover test in the paediatric clinic held every Wednesday and possibly teaching documentation.

I then spoke at length with the refractionists about the link and also their roles. I asked if they carried out cyclo refractions. They said that they did when cyclo was available but there were often supply problems.



The morning started with another teaching session. I then went to clinic where it was paediatric clinic. The waiting room was packed and as I arrived I was handed about 15 case records. I worked with Adam and the refraction students. Everyone had a go at testing vision using Keeler cards,Cardiffcards, Kays pictures and Keeler cards. We saw a range of patients of varying ages. The test that is used mostly is theCardiffcards as children of three and four didn’t understand the matching concept or were too shy to talk. When we assessed the patients they went through to see Mr. Laws and Dr Ernest.  Many of the children were blind so tests were limited.



I met with Mr. Cham and asked him if there was another room we could use for the fields machine as it was in the middle of the children’s testing room. We found a better space for it in the low vision room so moved it in there. However it was still not working but luckily there was another Humphrey not being used in a storeroom. Mr Cham and Constantin swapped the machines and managed to get the second one to work.

There were very few patients in clinic so I was able to spend time with the refractionists and taught them vision testing and cover test. Then the students were free so I was able to answer the many questions they had as they had read the handout I had given them the day before. I then taught them prism cover test, convergence, ocular movements, Duanes, nerve palsies, alphabet patterns and a brief outline of treatments for amblyopia, squint and diplopia. They were very enthusiastic and I was glad they were there as the refractionists seemed to be busy refracting for most of the clinic sessions so it was hard to find time to teach them.






  1. I taught the three refractionists at SZRECC and the six refraction students the following:
  • Introduction to binocular vision, suppression and amblyopia
  • Vision testing
  • Cover Test and the different types of squints
  1. In addition I taught the students ocular movements, convergence, prism cover test, Duanes syndrome, alphabet patterns, nerve palsies, treatment of diplopia and documentation.
  2. I was able to assist in moving the Humphrey visual field analyser to a more convenient location and alerted the engineers to mend the printer so that the fields service could be resumed.



  1. The room in which I worked needs to be more child friendly. The posters need to be replaced and also some of the equipment. A notice board could be installed so that posters and information for clinicians could be displayed. There needs to be fixation sticks and other small fixation toys suitable for children available in order to do the cover test, ocular movements and prism cover test.
  2. All children should have their vision assessed at every visit..
  3. All children should have a cover test for near and distance.
  4. All children with reduced vision/squint should have an annual refraction
  5. One of the refractionists could become the lead for assessing vision and cover test on children in order to become competent – this could be Babucarr’s role when he has finished the refractionist course.
  6. Refractionists and students could have records of their competencies in vision testing and cover test.
  7. Nurses who assess vision could ask the refractionist to test those adults who are unable to do the standard “E” vision test usingCardiffcards.



Suzanne Martin

Orthoptist, Singleton Hospital, Swansea

November 2011

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