Nepalese doc brings sight to poor worldwide with ‘assembly line’ cataract surgery

Nepalese doc is God of Sight to poor

HETAUDA, Nepal — Raj Kaliya Dhanuk sits on a wooden bench, barefoot, with a tattered sari covering thin arms as rough as bark. Thick clear tears bleed from her eyes, milky saucers that stare at nothing.

For nearly a year, cataracts have clouded out all sight from the 70-year-old grandmother’s world. With no money, she assumed she’d die alone in darkness. But now she waits quietly outside the operating room for her turn to meet Nepal’s God of Sight.

“I am desperate. If only I could see my family again,” she whispers in her native tongue. “I feel so bad when I hear the baby cry because I can’t help him. I want to pick him up.”

Dhanuk and more than 500 others — most of whom have never seen a doctor before — have traveled for days by bicycle, motorbike, bus and even on their relatives’ backs to reach Dr. Sanduk Ruit’s mobile eye camp. Each hopes for the miracle promised in radio ads by the Nepalese master surgeon: He is able to poke, slice and pull the grape-like jelly masses out of an eye, then refill it with a tiny artificial lens, in about five minutes. Free of charge.

It’s an assembly-line approach to curing blindness that’s possible thanks to a simple surgical technique Ruit pioneered, allowing cataracts to be removed safely without stitches through two small incisions. Once condemned by the international medical community as unthinkable and reckless, this mass surgery ‘in the bush’ started spreading from Nepal to poor countries worldwide nearly two decades ago.

Thousands of doctors — from North Korea to Nicaragua to Nigeria — have since been trained to train others, with the hope of slowly lessening the leading cause of blindness that affects 18 million people worldwide. And later this year, U.S. military surgeons will train under Ruit for the first time.

Ruit estimates sight has been restored to about 3 or 4 million people through his method. Most of them live in the developing world, where a loss of vision can be worse than death because of the added burden thrust on families already drowning in hardship. The soft-spoken portly doctor in acid-washed jeans and sneakers guesses he alone has removed 100,000 cataracts over his 30-year career.

“You realize there are drops which make an ocean,” says Ruit, 55, an ethnic Sherpa who grew up poor in a remote mountain village on the border near Tibet. “They’re such wonderful cases that make you fully convinced of the power of the work.”

Sometimes the four-day mass eye camps are held in hospitals. Other times the surgery is performed in a classroom or government building in areas so remote or mountainous, they can only be reached by helicopter. Ruit has traveled to Afghanistan, Myanmar, Tibet and many other difficult places to work.

“I’ve never seen anything like this,” says Dr. Paul Yang, chief resident at the University of Utah’s Moran Eye Center, who came to the Nepal eye camp to learn Ruit’s trademark technique. “In the U.S., all the technology is more modern and more optimized, but it can’t compete with the volume here. … You take back what’s learned here and apply it elsewhere for your whole life.”

Cataracts, which form a white film that cloud the eye’s natural lens, commonly occur in older people but also sometimes affect children or young adults. The condition first causes vision to blur or become foggy because the eye is unable to focus properly. As the cataract grows and matures, it can eventually block out all light. Exposure to harsh ultraviolet radiation, especially at high altitudes as in Nepal, is a major risk factor.

Dhanuk is one of three elderly women at this camp who’s blind in both eyes from cataracts. She and the long queues of other skinny, barefoot patients move like choreographed ants from eye exams to dressing rooms for blue gowns and scrub caps, then to local anesthesia and finally to one of four operating tables.

Ruit is at ease while peering into the microscope hanging over the operating table as upbeat Nepalese music plays in the background. When the electricity goes out, his latex-clad fingers continue moving confidently with only one backup light shining into the eye he’s restoring.

Dhanuk, who’s the size of a 10-year-old child, is carried in and laid on the table. She cannot see Ruit or the visiting Thai surgeon who’s practicing the technique on patients across the room.

“I’m afraid,” she says, worried it won’t be successful. Her long silver-streaked hair is pulled into the scrub cap, and thin golden bangles glow against her dark, cracked arms.

But she lies still and silent. All she really wants is to be able to feed herself again, go to the toilet alone and get back to her chores. She doesn’t want to be lonely and frightened in one of the world’s poorest countries, where life is as harsh and rugged as the Himalayas that shape it.

After smoothly creating a tunnel and a cut into the eye that Ruit compares to entering a boiled egg, the Indian-trained ophthalmologist pulls out a thick yellowish mass and uses a vacuum to clean out the rest of the eye. He carefully slides a tiny lens into place for focus, and Dhanuk’s eye is now clear and brown, instead of opal. A quick, painless procedure.

Ten minutes later — after two other patients’ surgeries are completed — she returns to the table for removal of the second cataract. Both eyes are then bandaged, and she’s led downstairs to a small room filled with other patients just out of surgery. Here, she sleeps on the floor bundled under her son’s watch.

The scene at this eye camp held at a hospital on Nepal’s plains near the Indian border resembles an orderly refugee camp. Massive tents filled with wooden pallets, blankets and about 300 patients and relatives cover a huge section of the lawn. Women stir giant cauldrons of lentils, rice and vegetables over smoking fires outside, providing patients with three meals. Buses are constantly arriving with more people in need. No one pays for anything, and the entire cost is about $25 per surgery. That’s $12,750 for all 510 patients, equal to only about three or four surgeries in the U.S.

Costs are kept down by keeping things simple. Using lenses manufactured at Ruit’s Tilganga Eye Center in Katmandu, these remote eye camps are sustained through donations and fees from more affluent Nepalese patients seeking surgery.

At the teaching hospital, Ruit does more sophisticated surgeries. There’s an eye bank for cornea transplants, and every day about 900 people — from a former prime minister’s relatives to beggars off the street — arrive for outpatient treatment. Millions of lenses produced there have also been exported to dozens of countries, from Germany to Japan and Vietnam.

But it’s not the technique or the lenses or the hospital Ruit is most proud of. It’s the ripple effect from all of the doctors who come to Nepal to train under him and then go on to teach others who repeat the cycle.

Ruit says this is the master plan he and the late Dr. Fred Hollows, from Australia, always had not just in Nepal, but for the entire developing world. One French surgeon, for example, trained in Nepal under Ruit and took the technique to West Africa where 300 doctors in 15 countries are now using it.

With Ruit’s stitch-free method, the vision restored is not quite as sharp as with the more expensive Western-style surgery. But it’s close, according to a study conducted by Dr. David Chang, a prominent cataract surgeon from the University of California, San Francisco. It’s also cheap, and the risk of complications is no higher.

“Dr. Ruit is as skilled as any cataract surgeon I know, and I suppose it is natural to wonder what he could earn with these same skills in an affluent country,” says Chang.

Ruit admits life could have been much more comfortable if he’d simply left Nepal for a job in the West. But not many people have the opportunity he has had to make life better for others, he says.

“This is really too good for money,” he says.

The next morning at the eye camp in Hetauda, Ruit stands in front of the hospital in the warm sun looking at five rows of about 200 patients from the day before. All of them, bundled in worn shawls and knit caps, have eye patches waiting to be removed.

Dhanuk is third in line on the front row. As soon as the bandages are removed, her face fills with life. She leaps to her feet smiling and pulling her hands to her chest in a prayer position, a traditional Nepalese way of giving thanks.

After nearly a year of total blindness, Dhanuk drinks in the blue sky, the green grass and all the other patients around her. She easily counts fingers, and then Ruit asks her to squeeze his nose if she can see it. It only takes a second for her jump up and grab it with both hands. Applause erupts in this moment Ruit calls the power of vision.

“It’s so nice to see everything! I had a very slim hope, but god has blessed me!” Dhanuk says, smiling. “I used to pray before going to sleep to all the gods and goddesses for my sight to come back. I prayed to god, but I think god did it through this doctor.”

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On the Net:

www.tilganga.org/index.php