For the past 18 years, the East Timor Eye Program (ETEP) has restored eyesight and improved eye health in Timor-Leste, one of the world’s newest and poorest countries, with more than 37% of the population living below the poverty line.
The prevalence of curable blindness and visual impairment in Timor-Leste is high. Recent statistics on the ETEP website indicate that more 33,000 Timorese (2.8% of the population) are blind, and that cataract is the leading cause of blindness (79.4%).
By training local doctors, eye care nurses and eye care technicians, the program has been instrumental in delivering curative eye care services for cataract and other ophthalmic conditions. Dr. Manoj Kumar Sharma, international consultant ophthalmologist and a long-term adviser for RACS in Dili, Timor-Leste, says that more than 10,000 cataract surgeries have been performed in recent years, with more than 1,200 surgical outputs annually.
The program aims to make Timor-Leste’s eye care services self-sufficient by 2020 and eradicate preventable blindness by 2025. Many of the country’s eye impairment problems are caused by refractive error, cataract, vitamin A deficiency and trauma – many of which are preventable or treatable.
ETEP is made possible by support from partners like the Royal Australasian College of Surgeons (RACS), an organization that provides specialist medical education, training, capacity development and aid to 16 countries in Asia-Pacific. Other partners include the Perth Eye Hospital Foundation, St. John Ambulance Australia and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO).
Dr. Sharma says that ETEP’s eye care program can be traced to Australian ophthalmologist teams who used to visit and provide surgical outreach. Since then, significant progress has been made to reduce the country’s severe cataract backlog. With ETEP’s effort, the population suffering from vision impairment has also been reduced.
The first RAAB (Rapid Assessment of Blindness) survey was conducted in Timor-Leste in 2005. It showed blindness prevalence at 4.1% and visual impairment at 17.7% among adults over 40-years-old. More recently, a 2016 RAAB survey reported that the prevalence of blindness has dropped to 2.8% and those with severe and moderate visual impairment were 4.5% and 12.5%, respectively.
Dr. Sharma said that in recent years, ETEP is becoming more focused on expanding its outreach program to improve access to eye care services for people living in rural or isolated areas outside Dili. The program is shifting from service delivery to capacity building around postgraduate teaching, training and infrastructure development.
“Since 2014, the program has focused its activity in infrastructure building and training higher level manpower in the country and abroad, as well as training general doctors to the diploma level of specialization in ophthalmology,” explained Dr. Sharma, who is responsible for teaching basic medical and surgical ophthalmology skills to the postgraduate trainees. He says that by the end of this year, 10 Timorese will be graduating from the local university through this program.
Another key member of the outreach program team is Mr. Belmerio Jeronimo, head of the Department of Ophthalmology at the National Hospital of Dili. He organizes the outreach program for one week each month. Mr. Jeronimo is also trained as an ophthalmic nurse and performs patient eye checks during outreach.
“Our team consists of an ophthalmologist, one registrar, two theater nurses and three refractionists. We perform surgeries from Monday to Thursday, and see postoperative patients on Fridays,” said Mr. Jeronimo. “We perform between 45 to 60 during the trip, covering mainly cataract and other minor surgeries.”
Access to eye care is particularly difficult for people living in the more rural areas, who have to walk long distances for medical treatment. Mr. Jeromino says that the outreach team visits remote areas in the country that don’t have adequate space to perform surgery, such as Uatulari, located in the eastern part of country.
“Due to lack of eye care in the country, we need to bring services close to the people who cannot come to us. Some of these patients have no family in Dili to stay with and no one to take them to the city,” shared Mr. Jeronimo.
To reach patients in need, the team conducts pre-screening and promotional work before their surgical week begins. In some remote, inaccessible mountainous regions where the operating theater is not adequate, Dr. Sharma says that they’ve started performing surgeries in a mobile surgery van: “Now, we do around 1,200 cataract surgeries and around 250 different types of eye surgeries per year, in the city as well as outreach in the country.”
For Dr. Sharma, many memorable moments occur during outreach. “Once I operated on a 92-year-old man with bilateral cataract blindness . . . he had been blind for 10 years. He was so happy to have his vision back, he was crying in excitement and joy. He hugged one of his intimate friends tightly and he told us it was like his second birth after the cataract operation,” said Dr. Sharma.
Mr. Jeronimo echoes that sentiment: “It is amazing when the team restores someone’s sight after they have been blind for many years. On the next day when we open the bandage covering their eyes, we hear them shout in joy, saying that miracles exist.”
In addition to helping patients, Dr. Sharma also takes comfort in the registrars who he’s trained. They have begun to perform surgeries independently and are now able to contribute to the elimination of preventable blindness in Timor-Leste.
“Soon, there will be a core group of highly educated eye specialists in the country who can manage the bulk of eye health issues and make vision services in Timor Leste self-sufficient. There will be no need to have a resident overseas ophthalmologist like me here anymore,” he said.
He highlighted that the aim of ETEP is to make Timor-Leste’s eye care program self-sustaining. The program is gradually reducing its outreach as government funding increases. In the coming years, the government will conduct the outreach programs itself. However, there are still many challenges. The biggest hurdle is the low socio-economic condition of the people and the inconsistent supply of consumables and drugs. Education is also important as many patients are still going to traditional healers for treatment.
Dr. Sharma is confident that ETEP has laid a strong foundation for the outreach program, especially with the assured support from the Timor-Leste government. “There will be more highly-educated and responsible ophthalmologists before ETEP‘s departure in 2020, and they are expected to carry this program further. The progress of the outreach’s surgical program indicates that we can have hope for a brighter future,” he said.
