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Clear Vision

August 2, 2004

Susan Sarver
tulanian@tulane.edu
Michael DeMocker

For more than two decades, Delmar Caldwell, professor and chair of the Tulane Department of Ophthalmology, has journeyed to some of Mexico's poorest regions to help restore vision to more than 12,000 people. They squeezed into the walkways, stairwells and empty crevices of the churchyard in Huejutla, Mexico. Most had come for just one reason--a miracle. News of the blind being made to see travels swiftly.

tulaniansum04_vision1_1When the word gets out that those who can work such wonders are returning, people travel for days, often covering the miles by the most widely available means--bare feet on a dusty road. The ophthalmologists who repeatedly journey to some of Mexico's poorest regions rarely speak of miracles; they talk of numbers.

"You do as many cases as you can as quickly as you can," Delmar Caldwell said. For more than two decades, Caldwell, professor and chair of the Department of Ophthalmology at the Tulane University Health Sciences Center, and Tom Robinson, a general ophthalmologist in Alexandria, La., who completed his residency at Tulane in 1971, have helped restore vision for more than 12,000 people in Mexico.

As a health writer and a trained nurse, I had heard of these marathon missions during which ophthalmologists completed more than 100 operations in the course of a few days, and I wanted to see one for myself. I had also heard of the many that were left behind to await another mission.

"They're blind, and they'll be blind forever if we don't go," said Caldwell. "If you're unfortunate enough to become blind and you don't have the money to pay, you stay blind." Huejutla is located in the state of Hidalgo, where 93 percent of the population is considered poor and 73 percent live in extreme poverty. Here, as in other parts of the developing world, the incidence of curable blindness is high. According to the World Health Organization, between 40 and 45 million people worldwide are blind and nine out of 10 live in developing countries. About half of the world's blind suffer from cataracts.

Hoping for a chance for treatment, people often arrive days before a medical mission. Though a crowd awaited us at the church that would serve as our clinic, Premera Iglesia Bautista, that early March morning, absent was the typical sensory blight of large gatherings-- the smoke and butts of cigarettes, ringing cell phones and litter from snack foods. In its place was an aura of hope that was almost palpable, and a collective patience that is all but extinct in our modern world.

A murmured blend of Spanish and Nahuatl, the language of the Aztecs, surrounded us as we eased our way to the operating room. It was hard not to look at the eyes--those that could see focused on us in our Tulane-green scrubs; many were marked with the frosty cast of ripened cataracts; others were simply closed, having lost a reason to open. Even before the first case, Caldwell's words had surfaced in my mind: "This experience will change you."

The Called

Robinson launched the ophthalmologic effort in Mexico in 1977, when he joined John Hall, a general practitioner who had been serving in Cordoba. Initially, Robinson performed surgery atop Hall's kitchen table, but later, they ventured up into the mountains to reach more people. "We would go into places where there were no roads and use generators for electricity and operate on dirt floors under thatched roofs. We'd land in a plane and go by donkey or boat to different places and operate," said Robinson. Eventually nurses and other doctors became interested in going. "We found it better to operate in several places and have the people come to us and we could do more."

For the past seven years, an established team of ophthalmologists, including Caldwell and Robinson, have supported several Mexico missions a year. Occasionally, other physicians are able to help, including Robinson's son, Carey, an ophthalmologist in Roanoke, Va., who also completed his residency at Tulane. The team's commitment to coming regularly has enabled missionaries to establish three main sites in Cintalapa, Cordoba and Huejutla that offer basic facilities, supplies and equipment. Having a structure in place allows the physicians to get to work quickly and to treat more of those who are desperate for care.

"The cases are all difficult," said Robinson. "These people are much worse off than the usual cataracts we see in the United States. The infections are bad, the cataracts are bad, and the problems that they bring are late." Though the hours are long, the work is intense, and breaking away from highly successful practices back home is challenging, these ophthalmologists continue to come for reasons that are often deeply personal and spiritual.

"It's addicting," said Caldwell, who got hooked on mission work 26 years ago after going to the Dominican Republic to transform a trailer into two operating rooms, with tents on either side serving as pre-op and post-op facilities.

Caldwell also has served in Haiti, Pakistan, Korea and Abu Dhabi and was involved in the inaugural mission of Project ORBIS in 1982, helping to design the program's first aircraft-based operating room facilities. While the poor and medically underserved have many unmet needs, blindness can be particularly paralyzing. The blind are a real liability to their families, said Robinson, because most of them need assistance with the activities of daily living.

Robinson recalls a 12-year-old girl with dense cataracts who refused go anywhere without her mother. "In order to ambulate or do anything, she would stand behind her mother and put her arms over her mother's shoulders, and they would walk in tandem," said Robinson. "It was a great joy to be able to give her some vision so she could get around again."

Unexpecting the Expected

The medical mission journey is seldom an easy one. Sometimes just getting there is a challenge. On a previous trip to Huejutla, the team arrived at a small landing strip at a ranch near the city, believing they had permission. "We landed about six planes out there," said Caldwell, "and we were busy going around unloading and all of a sudden the army shows up. They surround us-- young guys with M-16s, and they're all pointing at us. We didn't have a soul with us at that point who could speak Spanish."

tulaniansum04_vision2_1The boxes of supplies suggested they might be group of drug traffickers. Finally the rancher's son, a boy of about 10, explained to the captain that these were doctors. Not until the boxes were opened and the supplies exposed was the team allowed to proceed.

Avoiding the ranch landing strip on the March trip, the team planned to arrive at the Cintalapa airport, a two-hour ride from Huejutla on a road pocked with such cavernous potholes they made the infamous hollows of New Orleans thoroughfares seem like mere divots. However, foul weather forced one small plane carrying three of the surgeons to land in Brownsville, Texas.

Caldwell, Carolyn Fowler, Caldwell's assistant of 28 years, and I faced similar problems when both weather and a broken part grounded our small chartered plane. At the last minute, Jayne Nicholas, executive secretary, booked us on a commercial flight. After a quick change of plans, a dash to the airport, and the repacking into checked baggage of surgical instruments, deemed by security to be "dangerous weapons," we were more than ready for a sigh of relief. Then Caldwell announced in his trademark, nosweat Oklahoma drawl, "I forgot the corneas."

Eight precious donor corneas--all that could be gathered from eye banks around the country--were safe at home in Caldwell's fridge. He called Nicholas, who took it from there.

Ultimately, Caldwell's son picked up the corneas, drove them to the Baton Rouge airport, and slipped the guard an extra $45 to stick around until Robinson, a pilot, could arrive with his plane and retrieve them. Nicholas is accustomed to shifting gears at the last moment. A mission is always on her agenda, for as soon as one trip ends, she begins planning the next. Nicholas handles much of the invisible effort so critical to a successful mission. She gathers equipment, inventories supplies, labels boxes, and provides copies of essential documents--licenses and passports--to the Mexican government.

Along with extensive behind-the-scenes planning, it goes without saying that medical mission work calls for patience, as well as a certain willingness to work with what you've got, and if that doesn't work, to work around it. Hours after our 3 a.m. arrival, Fowler went to work setting up the church fellowship hall to serve as a non-stop operating room. Experienced in the mission effort, she modified the Tulane routine considerably. Without an autoclave, she poured tubs of alcohol and sterile water to sterilize instruments, created a large sterile area at one end of the room to serve several patients at once, and laid out a stock of supplies, some donated by pharmaceutical companies, others rescued from disposal and re-sterilized.

tulaniansum04_vision3_1After serving here, you look at things differently, says Fowler, who thinks twice before throwing out unused surgical supplies that could be easily spared for a future mission.

Meanwhile, Caldwell went around checking equipment, duct-taping a loose electrical cord, and changing burned-out bulbs. Finally, he requested the first instrument of the day: "I need a soldering iron," he said, eyeing a loose wire on the decades-old microscope that had likely bounced over too many rough roads between missions. A volunteer appeared out of nowhere with the essential tools, freeing Caldwell to examine patients.

The Chosen

A tiny room at the back of the church served as the screening area. Like the biblical miracle of loaves and fishes, it was made to stretch far beyond its capacity, accommodating a multitude of tasks, equipment and people. In one corner, Caldwell performed slit-lamp exams on adults; in another, Brad Black, a pediatric ophthalmologist from Baton Rouge, examined children; in the third, a local health officer directed patients and managed records; in the fourth, volunteers took A-scan machine measurements for intraocular lens size. Adding several blind patients, a few family members, two interpreters, and simultaneous conversations in three languages might have been a set-up for Chaos--anywhere but here. There was no pushing or shoving, no "me firsts," no flares of temper.

While most cases involved cataracts, also seen were damaged corneas and eye muscle and orbit conditions. In little more than an hour, Caldwell had identified the first group of patients to receive surgical treatment--all marked with a patch of white tape above the operative eye. Among them was a teenaged boy with a broad smile who had suffered ongoing infections since shortly after birth. His corneas were scarred, and he needed a corneal transplant.

"We can help you," Caldwell said. Patients undergoing surgery at Tulane move through a strict routine of preoperative procedures. They sign a proper consent, don't eat or drink after midnight, receive a dose of medication to ease anxiety, don a hospital gown, ride a real gurney through a set of high-tech doors, hook up to an array of precautionary implements--an I.V., heart monitor, automatic blood pressure device and a special apparatus called a Honan balloon to soften the cornea before surgery. In Huejutla, there was no concern about dining history.

Patients, stretched out on cots, received a series of eye drops and the jab of a long needle below the eye as a local anesthetic to block pain, and the pressure of a rubber ball tied in place over the eye to soften the cornea. The area set aside for pre-op preparation was quiet, almost prayerful. Occasionally, patients told stories--one elderly man reflected on his childhood memories of the Mexican Revolution. Another recalled the personal events surrounding the year he became blind. Volunteers guided each patient to the operating room.

The first patient to walk through the curtain that served as the door to the O.R. was an elderly woman with cataracts. She wore a bright blue dress that matched her surgical blue hat and paper booties, and she climbed onto the table without a hint of fear. Though most people are anxious about surgery, here a sense of relief is the norm. The woman was wide awake yet perfectly still as Caldwell spread out a sterile drape, positioned the retractor to keep her eyelids apart, and pulled the surgical microscope into place. He leaned in and adjusted the focus and began what would become hours of maintaining the same position while peering through two bright barrels of magnification.

Whether at Tulane or in Huejutla, eye surgery demands precision and the fine manipulation of delicate instruments. Any unexpected movement of a patient or a bump of the table can be disastrous. Caldwell began with a suture in the superior rectus eye muscle to keep the eye in position. Then he made a small incision in the cornea to remove the lens. When he attempted to use the one available phacoemulsification unit, which eases removal by breaking up the lens and vacuuming out the small particles, the decades-old machine proved dysfunctional.

So Caldwell rigged up an instillation and aspiration device. Finally, he pulled out the lens, which was the color of tea. In other parts of the world, cataracts are removed much earlier--when the lens is cloudy and vision is merely impaired. Next, Caldwell picked up the intraocular Lens--a small piece of acrylic with a diameter comparable to a pea--and positioned it inside the eye. Finally, using a suture one-fourth the thickness of a strand of hair, he closed the opening, injected Decadron into the eye to prevent inflammation, instilled a few drops of topical antibiotic, and taped a patch and shield over the eye. Within moments, the woman was walking alongside a volunteer through the curtain to rejoin her family.

Caldwell wasn't far behind. He injected and blocked another patient while Fowler re-sterilized instruments in time for the next patient to climb onto a table. And on it went throughout the morning, during the afternoon, and long into the evening. That night a band played outside for the captive crowd that had grown significantly larger during the day. When Robinson arrived with the corneas that evening, he brought good news--another surgical microscope was making its way across the border enroute to Huejutla. The next day, Caldwell and Robinson took on the adult patients alone while the two pediatric ophthalmologists treated children at a different location.

tulaniansum04_vision4_1Though three surgeons were unable to make the trip, nurses and assistants had arrived to circulate, sterilize instruments and prepare patients for surgery.

With the extra help, Caldwell figured he could treat more patients if he worked on one case with Fowler assisting while I set up and prepared to assist on the next. We implemented the plan, and soon he was pausing merely for little more than a hand wash and a glove change, and more patients were getting in and out of the curtain.
 
At last, in walked the young boy with the big smile who, before reclining, posed a question: "No dinero?" "No dinero," several of us reassured Him--there would be no charge for the transplant. A cornea was retrieved from the refrigerator in the upstairs kitchen. Donor corneas last for about a week in storage, and though screened for diseases such as AIDS and hepatitis, they do not require blood and tissue matching as with other transplants.

Caldwell is internationally known for corneal transplantation and for developing many of the instruments used in the procedure; however, like Caldwell's other Huejutla patients, the young boy had no idea that a preeminent ophthalmologist was treating him. Caldwell first removed the damaged portion of the boy's cornea. Then, using a cookie-cutter-like device, he cut a circular piece out of the donor cornea to form the transplant and sutured the entire perimeter of the disk of cornea onto the boy's eye. Through the microscope, it looked like a fine piece of embroidery. "Just like sewing a hem," said Caldwell.

Less than 24 hours later, Caldwell removed the shield and patch from the young man's eye. His enormous smile made a universal statement. Then he said, "No sabia que las cosas se veian asi." ("I didn't know things looked like that.") Though sight-restoring miracles are routine on these journeys, there are patients whose conditions are untreatable, too complex, or require special expertise to treat effectively.

About six years ago, Caldwell encountered such a case, involving a 12- year-old boy, who as a young child had been wrapped in a blanket and abandoned on a roadside. The child became blind after ants had bitten his eyelids and corneas. Caldwell knew he could help the boy through a more complex corneal transplant than could be achieved in a mission setting. So Caldwell brought him to Tulane, performed the surgery, and arranged for someone to take care of the hospital bill. The young man, now 16, plays the piano and guitar, writes his own songs, and has performed on television. Restoring sight in one eye in one person can transform many lives.

Occasionally, both Caldwell and Robinson have a chance to observe the impact of their efforts. On one of trip, Robinson operated on three blind children he had seen clutching hands and being led around by a missionary. "They were from 7 to 10 years old," said Robinson. "They were no longer able to go to school." He performed cataract surgery on one eye in each of the children--the usual limit with so many in need.

On the next mission, Robinson saw the same children outside running and playing. Caldwell recalls the response of a blind man in Abu Dhabi, who was overjoyed at being able to see again. As it is the cultural expectation to give one's most prized possession to anyone who does you a great service, the man told Caldwell a gift was waiting outside. Caldwell was a bit surprised when he saw a camel's head popping up above the back of the man's truck. While expressing his gratitude, Caldwell was also thinking hard about what to do with such a gift.

Finally, he asked a favor. "If you'll take care of the camel for me," said Caldwell, "I'll let you keep its offspring." The man happily agreed. Though short three physicians, the team completed 89 surgeries during the three-day mission in March. However, many more were waiting for treatment as we prepared to depart. "There is no way to care for all the needs for everyone in Mexico or the rest of the world," said Robinson, "but you can do something and help as much as you can and, hopefully, enable them to see humanity as God created us to be able to share and help one another."

Despite the quaint facilities, the bugs and bad water, and the black beans at nearly every meal, Huejutla is one of the privileged places on earth where you can glimpse the best of what we are as humans. Witnessing some of the finest in the medical profession serving so many who are desperate for care is one of those life experiences that is woven into you and can never be forgotten. As I pulled the suitcase packed with instruments toward the churchyard gate and started to step into the street, about a dozen people reached out to shake my hand.

Seeing the look of unwavering hope on their faces made it difficult to leave. Only one thought made it a little easier to get through the gate--knowing the team would be back, and if ever again I'm so fortunate, I'd be joining them.

Susan Sarver is a registered nurse and a grants manager in the Section of Hematology and Medical Oncology at Tulane. Her essays and columns have appeared in Reader's Digest, Country Living, Christian Science Monitor, and CASE Currents.

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