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The Age

The eyes have it By Tom Noble

February 18, 2005

In a small hospital in East Timor a father smiles. His once-blind son has seen the light, literally, after an operation by Australian doctors. It's a small miracle. A gift of sight.

It's a simple test that takes less than a minute. In the breezy hospital ward in rural East Timor, Australian surgeon Nitin Verma again goes through the routine. He removes a patch from a 10- year-old boy's eye and examines the result of the previous day's operation. Verma waves his hand, then a torch in front of the boy, who has been blind since birth. For a moment, nothing happens. The boy's face remains blank.

"Tell him to reach out, to touch my hand," Verma tells an interpreter. Moments pass, nothing happens. Then the boy's arm slowly comes out, at first moving in random directions. Then it follows the movement of the torch. "He can see," says Verma, putting the torch down on the bed. The boy, Mariano Amaral, is still expressionless, his face frozen - but his eyes are moving rapidly, seemingly uncontrolled.

"This is common for people who have never seen before. They don't know how to process what's happening. It will come good in time." The boy's father, Silverto, anxiously waits for the translation, then smiles. "I am very happy my son will be better," he says through an interpreter. "And I am very thankful to the doctors." Verma smiles, before heading back to the operating theatre. "We'll do his other eye tomorrow." AdvertisementAdvertisement

Welcome to the East Timor Eye Program, where Australian doctors, nurses and optometrists donate their time and skills and where, in the past few years, thousands of people have had their sight saved, restored or improved. In surgical conditions far from the typical Australian hospital - patients in street clothes and bare feet undergo surgery alongside each other - the medical volunteers come across eye conditions that are only found in textbooks in Australia.

For Brisbane surgeon Kevin Vandeleur, the trips are a chance to re-evaluate life and perspectives. "It brings you back to earth a little bit," he says. "You see things you learnt in textbooks, things you never see in developed countries, disease that would be nipped in the bud at home but here has run an unchecked course.

"In Australia, we devote a lot of time, effort and energy to maximum visual outcomes - keeping people driving a car or reading. Almost every case here is the difference between being able to see nothing and see something."

On the most recent trip to East Timor, The Age travelled with four doctors and two nurses to Baucau, the country's secondbiggest city and once a popular tourist destination. From Dili, the three-hour bumpy drive in United Nations' vehicles follows a stunning coastline of plunging cliffs and crystal-clear seas. There are also countless burnt-out buildings, the legacy of the 1999 violence that followed an independence referendum, in which pro-Jakarta militia and sympathisers destroyed 70 per cent of the country's economic infrastructure. He can see: Dr Nitin Verma removes the patch on Mariano Amaral?s eye.

He can see: Dr Nitin Verma removes the patch on Mariano Amaral?s eye. Photo:Angela Wylie

Damaged, too, is the countryside. Many hillsides are bare and affected by erosion, the result of slash-and-burn agriculture, forestry and chemical deforestation, damage that came during Indonesia's rule from 1974.

In Baucau, the medical team sets up its base at the 120-bed hospital, which was stripped of its equipment when Indonesian troops left the country. Some equipment has been replaced, but East Timor is one of the world's 10 poorest countries. The annual budget for the country of 1 million people, which covers everything from health and education to the army and customs, is about $130 million.

The hospital's operating theatre has been set aside for the week and on the first afternoon it is thoroughly cleaned, which includes removing dried blood from underneath the main table.

Portable sterilising equipment is set up and special microscopes for the surgery are unpacked and installed. In a nearby room, three optometrists set up charts and tables, where patients will be first seen. By 8am on Monday, an expectant crowd has arrived. Many are elderly and have trouble seeing. Those who are blind, or as good as, navigate using sticks or are led by younger relatives. All have a cloudy cataract covering one or both eyes. They are led to a waiting room by the operating theatre and told about the surgery.

Each patient has to sign, or in many cases put a thumbprint on, a consent form. Expectations can be high about people being able to see again, so doctors make sure people do not expect their sight will be restored if it is unlikely.

Disposable equipment such as gloves, masks and clothing is used for each operation, the kits funded by AusAID and donations. Equipment is sterilised to Australian standards. While patients do not wear gowns, as they would in Australia, their clothes are clean and pressed. They are wearing the equivalent of their "Sunday best", having dressed up to see the foreign doctors. Before surgery, patients are given an injection to block the nerve to the eye, so they feel and see nothing during the operation. The surgery itself takes about 30 minutes. It is an operation that literally allows the blind to see.

Under a microscope, the skin above the eye is cut and the cloudy cataract removed. A replacement lens is slid into place and the incision sewn up. It is fine work that requires hard concentration, particularly in a hot room where the air-conditioner is struggling and sweat is building up around the face and under the rubber gloves.

Patients are conscious throughout the procedure and occasionally squirm on the table, prompting local theatre staff to tell them firmly not to move. Surgeons operate on only one eye at a time, in case something goes wrong. If equipment is somehow infected, losing one eye is not as catastrophic as losing two (such adverse events have yet to happen in the East Timor program). Each patient files out with a patch over the eye and is told to come back the next morning.

The following day, about 40 elderly people with eye patches are ushered into a dark room. Once the patches are removed, the smiles and laughter are priceless. The reward makes the unpaid work worthwhile, says nurse Barbara Taylor. "A smile or a squeeze of the hand, it is always very emotional for me. The rough working conditions are erased with that one smile or hand squeeze."

Surgeon John Kearney agrees. His greatest moment of personal satisfaction came in Papua New Guinea after removing the bandages of a 36-year-old man. "For the first time in his life, he saw his baby boy. The smile on his face was one of the most magnificent smiles I have ever seen." How does he feel about the power to give sight? "As a doctor I'm aware of its power," he says. "We use it to improve the trust a population has in its health system."

It will take some weeks for the eyes to improve, but already the vision is clearer and the patients leave clutching antibiotics and wearing sunglasses to shield their eyes. In the meantime, the optometrists test eyes and prescribe glasses. In the week before the doctors arrived, they scouted the countryside around Baucau, finding blind people in communities and encouraging them to visit the hospital for assessment and surgery.

The eye teams are promoted on Timorese radio and in sermons by priests in Catholic churches. Mariano Amaral's father, a farmer in a remote village several hours' drive from Baucau, took his son to the hospital by bus after hearing of the eye doctors in church.

For Verma, this is his 18th trip. AusAID pays for fares and some equipment, with the rest donated.

On Thursday morning, we drove back to Dili where the steady work of the week continued. In the operating room, Vandeleur is closely involved with the training of a local doctor Marcellino Corriea who, within two years, should take over the work of the Australian doctors and make their visits unnecessary. Corriea, 34, spends the week removing cataracts and implanting intraocular lenses.

"He's made a lot of progress from when I last saw him operate," says Vandeleur. "I was thinking how horrible I was when I started doing my first cataracts. I used to shake, I was terrible. You tend to forget that, but it's worth remembering when you are teaching someone - and really, he's a lot better than I was when I started."

Corriea will begin his formal training later this year through a Sydney university. He will get specially prepared lessons via the internet that match his practical training. The eye team plans to fly him to Australia for further training later this year. And as his skills improve, Verma wants to ensure there is enough equipment and adequate facilities for Corriea to work. "There's no point teaching him how to drive then not giving him a car," says Verma.

The eye program has received significant support from East Timor's political elite. In July, East Timor's President Xanana Gusmao will visit Australia to support fund-raising efforts to ensure a successful handover of the program. Verma wants to raise $100,000 to keep the work going.

The eye team leaves Dili airport at 9am on Saturday, six days after arriving. Two hours before departure, Verma is removing bandages from two children who had their cataracts removed the previous day. He checks their eyes with the simple test that takes less than a minute. Both operations have gone well.

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