Hi I am Dr. Matt Oliva. My Mission: Rid the Developing World of Treatable Blindness. Ask me anything!

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Thanks for the positive feedback.

Like most people who go into medicine, I always wanted to help people. As a neophyte medical student I volunteered to work in a remote part of Tanzania for four months doing glaucoma research. I found I liked bouncing around in the back of pickup trucks on dusty roads to examine peoples eyes and also living in remote locales. There were blind people everywhere(as there are in most of rural Asia and Africa) and it made me realize what a difference restoring sight could make in these communities. Once I made one trip, it opened up a ton of opportunities. I advise people to travel first(ideally with an organization with some experience) and it tends to lead to connections and new pathways. Need is everywhere.

One of my memorable patients in Nepal was a woman who had been totally blind for five years from cataracts. After her bandages were removed from her cataract surgeries she was so overjoyed she began dancing around the room and singing. Her Nepali dancing style was like she was at a grateful dead show with plenty of spins. AFter ten minutes of spinning she was vomiting in the corner(still with the biggest smile on her face :)). The most memorable patients and moments are when people realize they can see again. Their dignity and life is restored. It is a moment that never gets old.

Was it your organization that went to North Korea and had Lisa Ling and a film crew from BBC trying to get an insider look at NK? You can find the doc on you tube and it is one of the most chilling things Ive ever seen. If this was you could you comment if the presence of the NK government and handlers impeeded your work or made it more difficult in any way? Were you able to see standard NK hospitals and if so, what could you say about the medical care available to the majority of people?

I think your work is fantastic and very needed- thank you!

Yes, this is our organization. North Korea has one of of the highest blindness rates in the world. We have now trained 10+ NK doctors and nurses in providing modern cataract surgery by having them come to Nepal and also Nepalese doctors and nurses doing 1000+ skills transfer eyecamps yearly in NK. As Americans obviously we cannot go.

I helped train a NK eye surgeon at an eyecamp in Nepal about 7 years ago. He had an "interpreter" with him that spoke zero English and was there basically to make sure the doctors didnt go anywhere. It was frustrating therefore to communicate. The NK doctors are doing very well. They are like all the other doctors who simply want to be able to do their jobs and help their people.

When the Nepali teams are in NK they are not allowed to visit many places. It is essentially to the eye camp to work and back to the hotel. It is micromanaged very closely by NK handlers. The Nepali doctors and nurses like going there because they feel they are making a huge difference. Dr. Reeta Gurung from Nepal has personally been to NK over five times to train doctors and singlehandedly has helped advance eye care in the country tremendously.

1) How influenced have you been, if at all, by the work of Fred Hollows and the Fred Hollows foundation?

2) How realistic do you view your goal of ridding the world of treatable blindness is, in say the next 20 years, considering the challenges faced in developing countries?

The Fred Hollows Foundation is an amazing Australian NGO that is very similar to HCP and our key collaborative partner in many countries(Nepal, Myanmar, Indonesia). The late Fred Hollows laid the groundwork for much of what has been accomplished. I was at Fred's house and met his wife Gabi several years ago. Fred was one of the rare people who always stood up for what was right even if it was not easy with the message that "even the worlds poorest people have the right to the highest quality healthcare". He trained our codirector Dr. Sanduk Ruit and we at HCP and also the FHF continue to be guided by his vision for equal right to healthcare for Australian aboriginal population and those in need of eyecare services.

Curing the world of blindness is achievable if enough resources are brought to bear. We have the models and skills to make it happen. It is one of the single most cost effective health interventions in medicine. If someone like Bill Gates or Warren Buffet or the worlds governments decided that they wanted to make the world free of cataract blindness it is possible. It would be much cheaper and easier, in my opinion, than eliminating HIV or malaria.

Cataract blindness has a toll of human suffering but also has real worldwide economic costs. Most poor places have many blind people. Blind persons cannot contribute much to communities economically and also typically take a person out of the household life to care for the blind person(kids may not go to school).

We are conducting a large study of the economic impacts of blindness and the economic benefits of restoring sight with the RAND corporation to prove this point.

Hi Dr. Oliva. My father is now retired ophthalmologist from Nepal. (Dr. G.P. Pokharel). I just wanted to say that it makes me very happy to see people like you who have the same passion as my father for giving the Nepalese people a gift of sight. I have been lucky enough to witness first hand the happiness that people are overcome with when they are able to see again after sometimes as longs as 20 years. You guys are the real heroes of this world. My question to you regarding Nepal is, what do you see repeatedly getting in the way of you and your colleagues doing what you love to do, help people?

BTW, I have met Dr. Ruit in person, many times. I also enjoyed the National Geographic special about him going to North Korea to help people and train their doctors.

Wonderful. I believe I have met your father in the past. He is one of the many great Nepalese doctors who have done so much to turn around the blindness problem in Nepal and now begin to teach other countries how to do so.

Nepal can be a challenging place to work. Despite the political issues and poverty though we all have been able to provide world class care. It is very powerful for doctors and nurses from other developing world countries to visit Nepal and see the model and what has happened. Often times a light bulb comes on from the experience to see that "if eye care can succeed in Nepal, why cant it succeed in my country". This model of the "South teaching the South" is much more effective in our opinion than doctors and nurses traveling to the US to see our models. The developing world leaders need to teach other leaders in the developing world how to succeed. Dr. Ruit and his team in Nepal are an amazing example.

Dr. Oliva Thank you for doing this AMA. The Himalayan Cataract Project is making such a huge impact on all those it touches. My first question has to do with American doctors practicing in other countries. What types of resistance, if any, do you come up against when providing healthcare in other countries with laws and values? My second questions come from my own desire, as a medical student, to get involved in international medicine. How would a student or doctor get involved, and specifically do you have students or residents on your teams?

Good question. IT is important that US doctors working in other countries work within the current medical system and the local providers. We always get a local medical license if possible. We also strive to "never leave a patient behind" and ensure that the local partner can provide followup if there are any complications. Long term success requires a collaborative relationship with the local medical team and empowering them. If the quality of the service is high, even the poorest people will recognize this quality and seek the service. Many organizations and doctors can do more harm than good with the "fly in/fly out" model of care.

I work with many medical students and volunteers. Please check out our website at www.cureblindness.org and you can contact us through the site via email at [email protected]

Thanks for the response! Is sounds like a lot of work goes into providing continuing care. What difficulties have you encountered in establishing local partners and maintaining a proper quality of care? Do you think the HCP's model would work for chronic conditions?

Picking the right partners is the most critical and difficult part. There needs to be shared values, a shared vision, a collaborative work ethic, etc. I think the most important part is to find the true leaders in eye care in the countries which we work. We then try to "train the trainers" so that they can then pass on the skills. Interestingly, many US doctors now travel to Nepal and other countries to learn our surgical techniques.

We have had a few misses in training doctors who have then gone on to other careers or emigrated to other countries. This is understandable, although it has fortunately been very rare. In general, WE have had good luck to collaborate with many individuals committed for the long term.

Some aspects of HCP's model will be good for chronic care. Specifically training lower level personnel(health assistants, PA's, nurses) to work in rural areas who are then under the supervision of physicians who are based at centers of excellence.

Really happy to read about your work.

While I am thankful for you and other like you, who have chosen to go to developing and third world countries to treat them of blindness that can be avoided, what about the people back home? I have a co-worker who has had a cataract in his left eye for about 2 months now. He cant go to a doctor because his insurance will not cover his surgery (his insurance is complicated, but all I could get from our talk was that the surgery costs around $4k, and he'll have to wait another 2 months before he insurance covers the whole thing).

I have other friends too who can not go to a doctor/dentist/chiropractor/etc. either because their insurance does not cover it, or they have no insurance.

You rendering your services to these people in need in our "developed nation" would also be greatly helpful.

Other than that, please keep doing what you're doing. There are a lot of unfortunate people in some of the countries you mentioned who do not even know that some of the diseases are easily curable, and they never go to a doctor out of fear that they might be too expensive.

Great point. Giving always begins at home.

I saw three patients yesterday who had serious cataracts that I will do surgery on for free as part of an indigent treatment program.

I trained in Australia for part of my training which had a very comprehensive system which let fewer people slip through the cracks.

Does cannabis actually help glaucoma ?

You have to smoke it every two hours to keep the eye pressure low so you better be motivated.

There are much better treatments :)

How's it goin?

Fantastic. Excited to be participating in this AMA and talking about world blindness and restoring sight.

Good to hear it! I really respect and admire your goal. I can't imagine how terrible it must be to lose your sight...

Have you ever restored sight to someone who had never been able to see in their entire life? Is that still technically called restoring, or would it just be considered storing, since re implies a pre-existence? Anyway, if so, could you describe their reaction?

Many patients in remote parts of asia and africa have been blind for 5+ years. Recently I had a relatively young woman who had been blind for 9 years in Ethiopia. Unfortunately, in the developing world, when you become blind, your life expectancy plummets rapidly. The mortality rate for blind patients, especially young children, is extremely high. Unless they have a very good family to care for them, many blind people die of poor nutrition and neglect. The Nepali term for a blind person is a "mouth with no hands" which sums it up fairly succinctly.

The reactions that patients have to getting their sight back is quite variable. For the first thirty seconds it is typically a very "stunned" look on the patients face. Then slowly this wave of realization spreads across their body as their brain begins to process the vision. Often times a huge smile, a look to the heavens, or shrieks of joy emanate. They search for family members to embrace. They want to touch and stare into their faces.

In Nepal, patients frequently try to start dancing. In Ethiopia, many patients "ululate" making a high pitched rythmic noise, that is then joined by the other patients. Patients are often unsteady on their feet and somewhat stunned. When you see blind patients with their sight restored later in the day they are walking around confidently and they look like completely different people than the blind person that was on the operating room the day before.

What is the worst case scenario when you do the treatments? Have you had a treatment where it was better to not have done the operation?

Good question. WE certainly never want to operate on any patient unless we think that we can help them see better. We try and carefully screen the patients and end up having to turn away many blind patients if we cannot help them. This is difficult because you want to help everyone.

Despite careful screening, it is heart-wrenching when I remove a mature cataract and find the patient has another problem such as a retinal detachment. In many cases, even if a retinal problem is discovered to exist after the surgery, most patients will see better when there cataract is removed as more light is getting into the eye.

Cataract surgery is delicate. Despite the high volumes all of our surgeons perform, the actual surgery is very slow and deliberate. It is the persons one chance to see again and so I do my very best each patient to get them a perfect outcome.

First of all, I want to say that you are awesome and thank you for doing an AMA. :) My question is about the conditions you are working in when you go to developing countries. I assume medical facilities are not always present (although not having read your book or been to any of those countries I could be completely wrong). Have you had to get creative in setting up an impromptu surgery suite? Also, is cataract surgery a very complex procedure that requires an absolute sterile field, or is there a little wiggle room where you can be more lax in your surgical setup? I know there are certain surgeries in the veterinary field (such as a colic surgery on a horse) that MUST be done in a full-on suite versus those that you can do on the ground in a field somewhere (routine castration). I haven't yet taken surgery so forgive me if it's a dumb or obvious question. Thank you!

We always work in concert with the local eyecare team. Our main long term goal is to increase local capacity for delivering eyecare by training doctors, nurses and staff and equipping them with what they need to succeed(microscopes, surgical supplies). We are trying to transfer our successful model for delivering the highest quality care, to the maximum number of blind persons, at the lowest cost.

In Nepal we have built a 140,000 square foot "center of excellence" with USAID assistance, in Kathmandu called Tilganga Institute of Ophthalmology. This is as good as any academic hospital in the united states with world class care. The doctors then do outreach events to "bring the surgery to the masses". These are done usually in schools in the countryside, many times using a generator to run the microscopes. We can do cataract surgery in a remote schoolhouse in the Himalayas or Ethiopia, and get results, as good as at a modern hospital. Doing cataract surgery in a remote location does not increase the risk for infection. We have found that unless you go to the remote places to find the blind persons, it is difficult to cure blindness.

two fold wallet or three fold?

three

Dr. Oliva, I think the work you are doing is amazing in terms of the impact on global public health effect. I'm sure you work with some other physician groups as well aside from the opthalmology field. What do you envision as other opportunities for all physicians for providing this type of dramatic public health benefit on a broad scale, improving not only initial disease treatment but quality of life? I am talking about possibilities of utilizing technology, business, governments, etc for a significantly broad but simple health care need.

This is a nicely worded and complex question.

In brief, I think that as a global health community, we need to study and evaluate all of our health interventions in terms of which ones are the most cost effective in improving quality of life, alleviating human suffering, and in helping to alleviate severe poverty. This should help guide resource utilization for governments and NGO's. Some interventions are certainly more cost effective than others. I am often frustrated by the lack of resources given to eyecare by governments in the developing world.

One of the most thought provoking books I read on this subject was one by the economist Jeffery Sachs called "End of Poverty" which makes a case about comparing interventions(health, education, water, woman empowerment, etc) scientifically(which Dr. Sachs is doing through the Millenium Villages Project).

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Certainly being an advocate for HCP and spreading the word about cataract blindness and the work we are doing around the world is most helpful. I think most people are unaware that for a modest amount of money, sight can be restored to a blind person.

If you are traveling to one of the countries in which we work we always welcome you to visit one of our hospitals and see what we are doing first hand. Spending a day in Kathmandu at Tilganga Institute of Ophthalmology can be life changing.

We take a limited number of people as volunteers for our high volume events annually as well which info can be accessed through our website www.cureblindness.org.

We have a mailing list that you can subscribe to http://www.cureblindness.org/news/newsletters/subscription/

this is a good way to access opportunities.

I hope I am not too late, but I have been monocular since birth. Was never addressed until I was ten (figured that's how all people were supposed to see). My right eye has a massive cataract; all I can see is color and blurred motion. My family was poor, so I had glasses (which never helped) but no surgery. I am 30 now, and my left eye has degenerated to the point where I need glasses to see anything 20 feet away. Odd this is, my right eye has not become lazy. Doc says there is a surgery in which they would remove the lens and implant a new. But the cost is great, and it may not work. Whew

My concern is my left eye, which doctors won't touch because is something goes wrong I could be blind for good. I would be interested in talking to you about what options (if any) there are to get my left eye better and maybe bring focused sight to my right eye. If you could PM me, that would be great!

I would stick with glasses for the left eye which provide good eye safety from trauma.

If your eyes are straight, I would consider cataract surgery in your right eye.

As you state, it is important to treat cataracts in pediatric populations early, as the developing eye needs a clear focus to hard wire into the brain appropriately. Removing the cataract in the right eye will likely help some, but the eye will still be "lazy" or amblyopic. Best of luck.

Are you hiring?

We are looking at adding two people in the next year to our HCP team which is based in Vermont and Washington DC. Currently we have seven full time employees in the US. We spend >90% of every dollar donated on direct care and run things very lean. WE have many, many volunteers(such as myself)

How close are we to curing retinitis pigmentosa and other degenerative diseases of the eye?

Unfortunately we have a long ways to go as the retina involves the central nervous system. There are promising gene therapy treatments and electrical sub retinal implantable devices that are being investigated. It is so hard when you see people around the world that cannot have their sight restored. Certainly there is hope though.

In most of the countries in which we work there is very little social support services for blind people(few blind schools, training programs, etc.) This area is one of huge need.

What are some of your favorite countries you have traveled to over the years? Also, which countries have you seen the greatest change from your work with HCP?

HCP now works in 15 countries currently including Nepal, Indonesia, India, Myanmar, China(Tibet), Ghana, Kenya, and Ethiopia.

My personal favorites are Nepal and Ethiopia. In both of these countries our partner doctors and staff are extremely hard working, bright, and truly dedicated to their people and alleviating blindness. There is a strong sense of national unity and cooperation. Nepalis are the most gracious people on earth. It is a similar situation in Ethiopia. The Ethiopian countryside feels like it has not changed in thousands of years and on of my favorite hospitals is in Tigray, Ethiopia very near where the remains of "Lucy"(the oldest human remains ever found) were discovered. There is a sense of timelessness there.

In Nepal in 1990 there were about 10 doctors performing 1000 cataract surgeries using a very old and poor technique. Nepal had one of the highest rates of blindness in the world. Currently there are over 250,000 cataract surgeries performed in Nepal annually by 200+ doctors. Blindness is disappearing. If the quality of care is high people will find a way to get surgery. We hope to effect this same change in other sub saharan african(ghana and ethiopia) and asian countries(myanmar, indonesia).

Hi Dr. Olivia! I have just bought Second Suns and I cannot wait to read it. My mother is an ophthalmologist practicing in Canada and I was fortunate enough to spend some time with her last month travelling to remote areas of northern Canada in order to see patients who have limited medical access. While there, I was quite surprised to see an extremely high rate of diabetic manifestations of the eye within the Aboriginal populations we treated (their access to fresh and healthy foods are limited and thus many have adopted an unhealthy lifestyle). I am well aware that there are many differences between those living in Northern Canada and the Himalayas, but I was wondering if you have seen many patients with diabetes while serving the HCP, or is this a rare(r) occurrence in the developing world?

Secondly, does the HCP offer placements or allow students to come and assist overseas? Providing ophthalmic treatment on an international platform has always been a dream of mine. Of course I am only finishing my undergraduate studies and have yet to start medical school, but I hope to pursue something like this in the future.

Lastly, thank you for your work and for this AMA. You, and Drs. Tabin and Ruit are role-models of mine.

Great to hear you are traveling with your mother to remote parts of Canada to treat patients. Thanks for the work you are doing.

Diabetes is increasingly common all over the world. There is an upcoming "epidemic" of diabetes related eye complications brewing as blood sugar control in the developing world is often poor. I am seeing more and more retinal disease related to diabetes. This is a huge focus of the WHO and other leading organizations. We are training retinal specialists when appropriate in several countries. However in Ethiopia there is currently only one retinal specialist for 90 million people! WE have quite a bit of work to do as you can see.

We do involve medical students frequently. Please keep in touch.

What are your thoughts on stem cells being researched to treat blindness?

I think retinal stem cells and corneal stem cells hold much promise. The hard part is getting the stem cells into the correct position in the eye. Fortunately there are many smart people working on this dilemma.

Dr. Olivia, this is my first reddit post, as I haven't been sucked into the fad yet, but hearing that you were doing an AMA made me succumb to it!

I am a 3rd (going 4th) year Canadian-citizen medical student in the UK and will be travelling to Tilganga in less than a couple months time at the end of August for 6 weeks (we have 6 weeks in addition to our elective period to go abroad); I am so excited! As you can imagine, I have a strong interest in ophthalmology as well as humanitarianism/global health. I was just wondering if you had any advice for me in the far future in terms of securing an ophthalmology training post (as I realize it's an ultra-competitive specialty), as well as in the near future when I'm in Tilganga in terms of maximizing my experience there.

I look forward to your reply and I can't wait to see the truly amazing/inspirational work you guys are doing for myself! I suspect what I see will further fuel my drive to pursue ophthalmology.

Wonderful to hear you are interested in ophthalmology and traveling to Nepal. I would recommend spending time in the clinics examining patients and also peering over the doctors shoulders in the OR to learn the various surgeries. Please speak with Khem Gurung about the possibility of participating in an outreach event outside of hte kathmandu valley which happen 20+ times per year in the remote locations. Ask the doctors if there are specific research projects that you can become involved with at Tilganga. Dr. Suman and Dr. Indira are good people to approach in this regard.

While ophthalmology is competitive there is plenty of room for more good ophthlamologists with an interest in global health. Keep in touch and let me know if I can help you in your career journey.

Dear Dr. Olivia, thank you very much for your recommendations - I really appreciate you naming specific people to be on the look out for! I would love to keep in touch, but how should I do so?

Further, I'm a bit worried about participating to the fullest given the Nepalese language barrier. Do you have any advice about this? Do all members of the healthcare team speak English there?

what is your email?

everyone speaks fabulous English in Nepal.

First off, incredible. What a gift you're giving people that had no hope or future.

What gave you your calling in a world full of self interests to do this kind of work?

Most people in your position and level of education would be attempting to cash in. What or who do you credit with shaping you to pursue your path?

I first went to Nepal in 1998 to work in a remote eyecamp near Sikkim and was blown away that such a dramatic change could be made in someones life by a relatively straightforward operation. I felt compelled to try and make this possible for others. it was at this time that I met Dr. Sanduk Ruit, who is a Nepalese ophthalmologist and cofounder of HCP, who has been my mentor. Dr. Ruit came from a very remote Himalayan village where he lost three of his siblings to treatable diseases(Tb, diarrhea, etc). He developed the cataract surgery technique(low cost, high volume, exceptional quality) and pioneered doing surgery in remote locations(which was very controversial at the beginning). Dr. Ruit has personally restored sight to 80,000+ patients and now has trained 200+ doctors. I figured if I could contribute a tenth of what this man had done, that would be something.

His entire story(and that of my other partner and good friend Dr. Geoff Tabin) are told in detail in the book Second Suns that has just come out. Its very inspiring.

Hey thanks for doing an AMA. Could you tell me if there are different types of treatable blindnesses other than cataracts? And if so what is the most common illness that you have to treat?

The second most common form of treatable blindness is corneal blindness which is treatable with a corneal transplant. There are estimated to be 10million persons worldwide who need a corneal transplant but only 200,000 We are addressing this by partnering with SightLife(www.sightlife.org) to expand eye banking(obtaining human corneas for transplantation) in nepal, india, ethiopia, etc and also training corneal surgeons.

Corneal transplantation requires more long term followup and is a slower visual rehabilitation process than cataract.

You truly are making a difference for the world to see. What have people said it is like to have their vision either restored or to be able to see for the first time?

Many patients and their family members are overwhelmed at first and in a state of disbelief at being able to see again. They describe it as surreal and miraculous. Many describe a cataract as "living in darkness" and then suddenly having the lights surge on. Most remember seeing their loved ones for the first time and the joy this allowed them.

If one eye is done, they often quickly begin to point to there other eye asking for the surgery to be done. We usually do each eye sequentially, a day apart.

Whoa! Thanks for the AMA, my best friend has Stargardt's (http://en.wikipedia.org/wiki/Stargardt_disease). For those who don't know, it's a progressive blindness disease.

My question for you, Doctor, is whether you know of any cures or workarounds for this disease. He is crippled by this disease, not entirely blind but wanting of sight. If I could help him in any way, I would be so grateful.

Thank you so much for your work, Doctor!

Thanks. I am a corneal specialist and not entirely up to date on the progress towards treatments of Stargardts.

I just had a cataract removed from my right eye and it has changed my sight drastically. I can't imagine how it is for people blind for years. While the surgery isn't overly complex, how do you get the necessary equipment and IOLs in remote places like Nepal?

Im happy to you have experienced the miracle of cataract surgery. Many of our supporters are people who want to give this gift to others.

In the US an intraocular lens costs over $100 USD. In Nepal, Dr. Ruit started a intraocular lens factory with the help of the Fred Hollows Foundation, to manufacture lenses(that are as good as the US lenses in trials) for $4 a piece. Similarly in India and Nepal we have worked hard to bring the cost of the surgery down while maintaining the quality.

We purchase surgical microscopes and other key infrastructure to the hospitals. When teams of doctors and nurses visit Nepal to learn surgery we then equip them with the resources they need to succeed in their particular setting.

We are sending the Nepali made lenses around the world. Low cost consumables in some countries continues to be a barrier to increasing surgical volumes.

Hi Matt, are you one of the several people working with Shane Willard?

No. I am not familiar with that organization. There are certainly lots of great organizations doing excellent work around the world and here at home.

I only really learned about the Deaf community via reddit and similar AMAs to this one, and how some members are opposed to treatments to reduce or remove deafness. Is there a similar Blind community that are against the idea of treating blindness?

Interesting question. I dont know of a blind community that is against restoring sight. I think that those who have been blind for quite some time and then have their sight restored likely experience a remarkable, and at times likely difficult, adjustment to their "new world".

Will my eyes ever 'settle' and stop getting progressively more short-sighted as time goes on? Everyone says they settle in your early 20s, but at nearly 24 mine just seem to be insistent on getting worse and worse, I need a stronger prescription every time I visit the opticians.

I do worry that I will go blind one day. :/

typically the rate of progression slows.

Needing stronger prescriptions should not make one go blind.

I'm really not knowledgeable at all about blindness, but with all the technology we have for treating blindness, what are the problems in countries like America preventing every single person from having the gift of sight?

Unfortunately, diseases that affect the optic nerve and retina are diseases of the central nervous system, much like spinal cord injuries. We are still developing ways to treat these rare problems.

A cataract is a clouding of the lens in the eye. This is much more straightforward. Most blindness world wide is either preventable(vitamin deficiency, infections, trauma, etc) or treatable(cataract, corneal opacity, diabetic eye disease, refractive error, etc).

Some diseases of aging of the eye(macular degeneration) are in various stages of capacity to treat.

I asked the last surgeon that came through here the same question, so I know suppose it will be my mission to ask this question of surgeons who do AMAs:

Have you played Surgeon Simulator 2013? If so what did you think of it, and if not I would highly recommend it.

no, sounds interesting. Ill check it out.

Does your organization have any initiatives to address trachoma?

I got my start working on trachoma in Tanzania many years ago. It is a public health issue primarily.

We are training nurses in several hospitals in doing trachoma eyelid surgery.

Most of the global health work is being done by Hellen Keller international, the Carter Center, WHO, etc

Dr Oliva,

Excellent AMA, thank you very much! As a medical student considering opthalmology, I was wondering what first attracted you to the field. I've always thought being able to restore and protect sight (possibly the most valuable of senses) would be extremely rewarding. How did you first realise your "calling" to the field?

Good for you. I highly recommend ophthalmology. There are not many fields in medicine in which you can actually cure most problems, as there is with the eye. Ophthalmology has a mix of acute and chronic disease. I also was drawn to being able to do treat patients of all ages and to develop long term relationships with patients. Best of luck to you.

How do the children/adults react after they start to see?

Do they see right away when the surgery finishes or were they put to sleep first?

good question...please see my earlier posts for a more detailed answer regarding patient reactions with sight restoration. When the bandages come off, people start to see fairly immediately.

We put children to sleep for the surgery if under 7. However, it is amazing to me how many 8, 9, 10 year old children in the developing world will sit perfectly still for a 10 minute eye operation under a local anesthesia. It is mind boggling, having children of my own. There are many brave children, and they do excellent. There is nothing better than children being able to see out of an eye again and the happiness of the parents also when this occurs.

What's the most cataract surgeries you think you could do in a day? I've heard folks have been able to do more than a hundred in a day, it seems implausible

I can do about 80 cataract surgeries per day. There are several master Nepalese and Indian cataract surgeons that can do over 200 surgeries per day in the world including Dr. Bidya Pant and Dr. Govinda Paudel in Nepal. There are several true heroes such as these in the world that are toiling daily in remote places of the world restoring sight to the blind. Dr. Bidya in Nepal perfored 15,000 surgeries himself one year. They are so experienced that they have minimal complications. An average american surgeon does 400 surgeries per year in contrast.

Hi Dr. Oliva, Do you have need for optometrists during your project? I am currently in OD school, and would LOVE to get involved with something like this once I graduate.

Thank you very much for your service.

We definitely welcome your involvement. Many of the locations we work are working hard to develop sustainable optometry programs and teaching and mentorship especially is always welcomed. We try to connect optometrists and ophthalmologists alike with colleagues to form long term relationships.

As an aside, we have evaluated adjustable eyeglasses for patient "self refraction" in the fields in Malawi and Ethiopia which is promising.

Thank you for doing this ama and especially for the service you do. Do you see an increase in complications either inta- or post-operatively when traveling some of the poorer areas? Just wondering because of overall body condition. Are the patients in relatively good health and well nourished? Any actual diabetic cataracts? Also, have you seen patients with morgagnian cataracts? You also replied to someone about retinal detachment sometimes being noted after the cataract is removed, is there any prescreening done such as electroretinography or ocular ultrasound? Sorry for so many questions, I'm a vet tech at a specialty hospital and this is my favorite surgery:)

Most bilaterally blind patients are malnourished and in poor health. Often they are neglected. Sometimes in Nepal they weigh less than 100 lbs and are carried by their sons in wicker baskets on goat trails for a day or two down from the hills to access surgery. Often when sight is restored a patient will regain their health status. Blindness is associated with a very high mortality rate. Unless you have a family member to feed you...it is quite tough going. WE are working on some documentary film vignettes showing hte human transformation that can occur with sight restoring following patients for one year after their surgeries to see how their lives change. Most start working the fields again, their grandchildren can go to school instead of watching their blind grandparent. The whole family dynamic can change.

I see Morgagnian cataracts frequently and we have special techniques to remove them.

We screen with hand held lights in remote places, with slit lamps at the main centers. We need to develop hand held ultrasound devices that are low cost to improve our screening. Can someone invent this as an Iphone app? There are actually some good Iphone apps being developed to screen for cataract with the camera on the phone. WE hope that technologic advancements will continue to help us improve our capacity to find and treat blind people in the forgotten corners of the world.

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By the time I work with surgeons most have gone on to practice other forms of medicine, if they have a fear of eye surgery.

One of the biggest teaching obstacles is manual dexterity and clinical judgement. WE are working with other organizations to develop teaching simulators and teaching modules. When learning surgery we always have senior surgeons supervising those earlier along the learning curve. Typically trainees do only one part of the surgery and then a senior surgeon completes the case. Patient safety is paramount.

is it not possible to train people in this procedure, if they are not a medical doctor?

Yes. WE train a limited number of high functioning nurses to perform cataract surgery(under the supervision of a master surgeon). Most doctors in the developing world wish to live in urban areas making it difficult to attract cataract surgeons to rural areas. Many people are of the opinion that cataract blindness cannot be addressed adequately without training non doctors to perform the surgery. My opinion is that it is appropriate in some situations as long as the nurse cataract surgeons are carefully selected and part of a comprehensive eye care system so that other eye problems and complications can be appropriately addressed. A cataract surgeon working alone without appropriate backup and supervision could cause more harm than good.

I just saw the TED talk last night about the eradication of smallpox and this work was mentioned. I can't express how amazing I think the work you're doing is. It's an inspiration to me in my efforts toward a career in the medical field. Thank you.

Thanks so much. Smallpox remains the benchmark for eradication of an entire disease. Hopefully we will get there with polio some day. Also, I hope to live to see the day where trachoma is eradicated as it causes much corneal blindness.

Where does the funding for your operations come from? More importantly, how do you find and attract it? I'm asking because here in Russia there area unworthy organizations, with workable plans from the medical side of things, but who can't get get much farther on the fundraising side than their own social media appeals and free ads highlighting specific patients in local newspapers.

Our current budget is close to 6 million USD. Our largest donor is USAID which is the US government program that assists with our large "bricks and mortar" projects. The rest comes from private donors(individuals, foundations, organization, and business) who give between $2 and $500,000 USD per year. Over >90% of every dollar goes directly to programs. It is always a challenge to raise funds.

Probably too late for this but I had to try.

How close are we to curing Glaucoma in humans? I always read stemcells has cured glaucoma in mice every now and then but never read if human trials have started. When would human trials realistically begin?

Unfortunately, I think we are a long ways away. I dont know of any human trials of stem cells for treating of glaucoma. Glaucoma is highly prevalent in Africa and is a "silent stealer of vision". Getting screened by an eye care provider, especially if a family history, is the key as glaucoma is treatable in most cases if recognized earlier. Once the optic nerve has been damaged though we dont have any way of bringing it back. Stem cells one day may pave the way.

When you say, "rid the world of treatable blindness". You mean cure it right? Not turn it into untreatable blindness?

absolutely. awkward wording

Thanks for doing this AMA!

My story: I was born with an underdeveloped optic nerve in my left eye that has left me legally blind in that eye. I can see colors, shapes, movement, but cannot read nor focus, and have a particularly hard time picking up anything farther than 10 feet.

I had surgery as a toddler to remove a cataract and straighten the eye as it didn't track straight.

Have there been any advancements in optic nerve transplants? Or is this a pipe dream?

I am sorry for your left eye problem.

We hope that research on spinal cord regeneration will eventually lead to regeneration of optic nerves....but a pipe dream unfortunately currently to my knowledge.

Great AMA! I have always wondered this: how do you calculate and have inventory of all the IOLs (intraocular lenses to replace the cataract y'all) ?

We measure each patients eye length and corneal shape to determine the appropriate strength IOL in the eye. It is important that those in the developing world have good uncorrected vision as access to spectacles is often lacking. WE bring and manufacture lenses of all strengths.

I have a really bad astigmatism in both eyes. I am just barely able to have lasik surgery, but there are no guarantees. Is it worth it to have the surgery to just get rid of the astigmatism?

Thanks for your help... Also thanks for your work. I have had several family members with cataracts, surgery did wonders!

Difficulty to comment on. Find a surgeon that you trust. Lasik is very safe with proper patient selection.

I hope you're still responding to these. 38 years ago I did research at MIT on clearing opacified corneas. We used a ex-vivo opacified cornea model and infused in monoacrylamide into them, which allowed the stromal ground substance's index of refraction to match that of the collagen fibers (which were no longer in a stable matrix--that is what caused the opacification). By eliminating the variations in index of refraction, the corneas became dramatically clearer. The acrylamide was then polymerized to stabilize it, but acrylamide is a potent neurotoxin so not usable clinically. We proved the concept, and I left to attend medical school (I did not choose ophthalmology). The project was taken over by a PhD candidate but he never completed it. Do you have any idea if this ever went further, or if there was a search for a benign material with which to match the index of refraction?

Thanks for the work you do!

Fascinating. I havent heard of this.

We currently have a form of an artificial cornea called a keratoproshesis but human corneal transplantation remains the treatment of choice. We now frequently replace just the endothelial layer of a cornea if the pathology is only affecting this layer(DSAEK or DMEK).

Also we can strengthen corneas by performing collagen crosslinking utilizing riboflavin drops and ultraviolet light.

You want to make all cases of blindness untreatable? You monster.

Forgive the awkward wording.....it is meant to reflect that not all blindness is treatable in our day and age. Yet 80% of blindness in the world is either TREATABLE or preventable...not with sophisticated technology but with fairly straightforward operations such as cataract surgery.

You want to get rid of treatable blindness? So you want the only kind of blindness to be untreatable? You sick, sick man.

Dont get me wrong, I want ALL blindness to be treatable. Unfortunately, end stage glaucoma, retinal degenerations, and optic nerve injuries remain beyond our current capacity to fix, even in developed countries.

There are 18 million people though that are blind worldwide from cataract that can be cured by a 7 minute operation, that can cost as little as $25(for the supplies). I think we should maximize our resources in finding and treating these people.