Lighting the Way

What inspired your transition from general medical practice to ophthalmology?
 

When I finished medical school, I worked in missionary hospitals in Kampala, Uganda, as a general doctor. I was exposed to patients with various ailments, including eye problems, but I realized that I hadn’t learned enough from medical school to be able to treat them effectively or efficiently. I found myself becoming increasingly curious about ophthalmology.

What challenges and opportunities came with the shift?
 

At that time, the economy of the country was doing badly, and some of the more experienced ophthalmologists had left to work elsewhere. During my training, we had a shortage of faculty and we had to do a lot of self-teaching. The equipment we were working with was quite poor; most of it had been purchased many years earlier. And we didn’t have everything we needed to do our investigations and adequately manage the patients. We just had to go through the training with what we had. Afterwards, however, we had the opportunity to work in developed countries and some mid-level countries, where the ophthalmology departments were equipped well enough for us to become more skilled and work independently when we returned to Uganda.

Which mentors have influenced you in your career?
 

As I mentioned, at the beginning of my career there was a shortage of faculty at our training institution. However, a team of ophthalmologists would come over from the UK for short periods to give lectures and instruct us in surgical procedures. Among these ophthalmologists were some of my mentors, including Sanford Smith and Andy Richards. We also had a long-serving British doctor here in Uganda called Keith Waddell. When I moved into pediatrics, one of the instructors I really admire from one of the fellowships I attended is Richard Bowman – a pediatric ophthalmologist from the UK. He is someone I have been working to emulate throughout my career.

What was the eye care situation like in Uganda when you first qualified as an ophthalmologist?
 

I would say it was a desperate situation. There were very few ophthalmologists in the country – around 11 in total. Maybe three of those were already retired and just doing low-level private practice work. So wherever you positioned yourself as an ophthalmologist, you’d have a lot of patients and a lot of work.

It also meant that we needed to do a lot of outreach work to be able to serve the population and have some kind of impact. Throughout this time, we traveled around different parts of the country to offer mobile services. Certainly, this allowed us to meet patients who were unable to travel to us, but it was still a challenge because we were stretched really thin. Sometimes, we needed to deal with 500 patients a day. And when it came to surgeries, we would have long lists and be operating until 8 pm, so that we could satisfy those who had turned up. Despite all that effort, you can’t always offer the same services in outreach as you can in your own practice. Nevertheless, that’s how eye care was delivered in Uganda back then.

How has the eye care situation in Uganda changed since that time?
 

A number of development partners have come to support the Ministry of Health with improving Uganda’s eye care services, through training more ophthalmologists – with some partnerships providing scholarships – and through affirmative action and interventions. For example, there was a program supported by Light For the World called the National Intervention for Uncorrected Refractive Error. This mainly addressed uncorrected refractive errors among school children by training local eye care professionals in refraction and by providing spectacles to the children at an affordable rate. It was so successful that the Minister of Health now owns this type of service; it led to the current “1,2,3 I can see!” eye care program that Light For the World is implementing in Uganda and in other countries where we are involved, such as Ethiopia, Burkina Faso, and Mozambique.

Also, thousands of children were screened between 2021 and 2023, and approximately 3,200 pairs of spectacles were given to children at no cost.

What kinds of technological advances have improved ophthalmological services in the country?
 

When I joined ophthalmology, the standard procedure for cataract surgery was intracapsular lens extraction, and then the provision of thick glasses for better vision. Then we changed to extracapsular lens extraction, with the implantation of the “standard lens,” which was +22D or +21D. Subsequently, we progressed to biometry and implant lens powers specific to the patient’s refraction using small incision cataract extraction. Currently, some centers practice both small incision cataract surgery with intraocular lens implantation and phacoemulsification – all with biometry prior to surgery. These surgery techniques – apart from the intracapsular lens extraction – can lead to some patients developing opacification of the posterior capsule. Previously when opacification occurred, this involved taking the patient back into the theater, but with increasing availability of the YAG laser this can now be done as an outpatient procedure, with no theater nor re-operation required.

What prompted you to specialize in pediatric ophthalmology?
 

During my clinical practice, I started seeing more and more children that needed either surgical intervention or refraction. Some of the most challenging groups of children were those who presented with congenital cataracts. Because of the lack of surgeons, some of these children had not been operated on by the age of five and were functioning with severe vision impairment. Other children had strabismus and were being teased at school. The professionals needed to handle these problems were simply not there. I had an interest in helping children. And because the need for pediatric ophthalmology was so great at that time, I got an opportunity – and a scholarship from Light For the World – to train at the University of California.

In your role as Chief Ophthalmologist in Uganda, how did you advocate for more funded positions for ophthalmologists?
 

First and foremost, we lobbied the government and development partners for scholarships to help train more doctors in ophthalmology. That level of advocacy enabled us to increase the number of ophthalmologists in a relatively short period of time.

Also in Uganda, historically, we didn’t have optometrists in the public sector; we didn’t even have a training program for them. Through support from Light For the World and other development partners, we were able to start a training program for optometrists at Makerere University. But we then had to think about how these optometrists would be absorbed into the public sector, because their positions were not funded. We took up this advocacy point together with the National Prevention of Blindness committee, and right now there are positions – at least in regional referral hospitals – for optometrists who qualify from this training.

How has your early involvement with Vision2020 influenced your approach to eye care?
 

Following the launch of Vision 2020 in Beijing, which I attended as part of a delegation from Uganda, we were able to advocate for the formation of the National Prevention of Blindness committee. In addition, we were able to lobby for the position of National Eye Coordinator, which until that time did not exist in Uganda.

What developments would you still like to see in ophthalmology and training, specifically within developing countries?
 

During the last two decades, we’ve seen development of the infrastructure, including the building of eye departments in regional referral hospitals throughout the country. But they don’t all have ophthalmologists at the moment. We’d still like to have more local professionals trained in ophthalmology, so that we can fill all these available positions.

At the same time, because of the wider use of the internet and an increase in awareness among the population, the demand for subspecialties has also increased. So, if somebody has glaucoma, they’re now starting to ask about glaucoma specialists. Development of subspecialties, then, is another thing that we would like to see progress – and progress quickly because of the demand. Pediatric ophthalmology is one of the ophthalmic subspecialties still in serious shortage.

I would also like to see sustainable eye health programs. A lot of the funding for eye health has come from development partners through the Ministry of Health. But we’d like to have a more sustainable program that comes from the Ministry of Health’s national budget. The Ministry currently provides some funding, but it’s not enough to support the country’s eye health needs.

Again, Light For the World is helping here – they have provided scholarships for some specialty training and equipment for some of the departments as a way of strengthening the health system in Uganda and the other countries we are focused on.

How else could Uganda and other developing countries meet this demand?
 

One of the major needs is awareness – there are still many people who are not aware that they can be helped. One of Light For the World’s strengths is in supporting eye health programs through school screening. When these children have interactions with eye health professionals, they go back and talk about eye health to their families. And that helps raise awareness in the whole community. It’s something we need to promote further. If we can strengthen the eye health program by visiting schools, we will be able to reach many more people.