Dr. Intili explains RAAB nuts & bolts
The difficulty in performing an assessment like this in an impoverished, rural community is that in the short term, it can be perceived as extractive from the community, rather than contributory and helpful. It is important to clearly convey to the communities in which we interact that we are not eye doctors coming to the community to treat eye problems, but rather we are coming to find community members over 50, and then examining their eyes.
The actual tools used to evaluate the participants include a rope with knots to demarcate 6 meters, 3 meters, and 1 meter from where the patient is standing, a tumbling E (one smaller corresponding to 6/18 and one larger corresponding to 6/60, 3/60 or 1/60 depending on your distance to the patient), a pen light, a pair of pinhole glasses, and a direct ophthalmoscope. All patients who cannot see 6/18 (a 20/60 equivalent) are considered to suffer from impairment of functionally useful vision. If they are not improved with pinhole, they must be dilated to appropriately assess the cause. If a cataract is determined to be the cause, the patients are asked a series of questions to determine why they did not seek intervention. Did they not know that treatment was possible, or was it a cost issue? If patients report having had cataract surgery, a list of questions is asked to determine how the surgery was provided and to whom the burden of cost fell. If treatable pathology is found, the patient is referred to the local health center. For the purpose of this study, which is to evaluate the loss of functionality secondary to visual impairment, if even one eye can see 6/18, the participant ultimately is recorded as having normal visual function overall. If the patient is visually impaired in both eyes by different causes, the principal cause of visual impairment is recorded as the cause that is easiest to treat. For example, if a patient cannot see from the right eye secondary to cataract, and the left eye secondary to refractive error, the principal cause is recorded as refractive error, as surgical intervention is more invasive and elusive intervention.
As described in previous posts, our RAAB consists of 4 ophthalmologists, leading 4 teams. We divided 104 clusters into 26 for each team. Many of the clusters identified by the software are extremely remote, some even on an island, requiring a boat to reach our destination. The first week, we will cover the Eastern Province. After a practice run in which we all comb the same village and cover a cluster together, we will be on our own. While I’ve only been here for a week, there is definitely a sense of purpose and camaraderie that unites us in our mission. Considering the task in front of me, I feel a touch of trepidation but it is most certainly outweighed by the thrill of it. I am being taught directly by Dr. Ciku, who is the keystone of the Rwandan International Institute of Ophthalmology ( RIIO), which is a national organization that creates the policies that shape eye care for the country. I am entrenched in this study with many Rwandan young professionals who will go on to unload the countries burden of curable and preventable blindness during the course of their careers. For the next month, I will wander home to home and connect with subsistence farmers in villages scattered through the countryside. I will have the unique opportunity to engage on an intimate level with so many different aspects of the Rwandan culture and society. This year will provide quite the journey, and there is an intangible exhilaration in being just at the beginning of it.