• Humanitarian Ophthalmology Expeditions to the Amazon

    Ten years ago, I embarked on my first journey to the Brazilian Amazon. I was a 25 year-old junior ophthalmology resident from São Paulo, Brazil, and little did I know that this trip would change my life as a doctor forever. 

    See a slide show of Dr. Richard Nosé's journey to bring eye care to remote parts of the Amazon.

    The expedition was organized by the Piedade Cohen Foundation and its founder Jacob Cohen. We were headed to the city of Parintins, an 18-hour boat ride down river from Manaus, the capital of the Amazonas state. 

    The destination hospital did not have any equipment for ophthalmic surgery, so we had to carry our own. Our boat, the Dona Luna, carried all our gear: two surgical microscopes, two phacoemulsification machines, a biometer, around 200 intraocular lenses, and surgical supplies needed to perform cataract and pterygium surgeries. 

    The boat also carried our crew, three senior ophthalmologists, Jacob Cohen, MD, from Manaus; Rubens Belfort Jr., MD; and my father Walton Nosé, MD, from São Paulo; and two junior ophthalmology residents, Marcos Cohen, MD (Jacob’s son), and me, as well as two nurses and an anesthesiologist. 

    I had never seen a river as wide as the Amazon, and our journey was sheltered by darkness, silence and the most clear skies one has ever seen. We also had plenty of fresh fish to eat along the way. After the long boat ride, we arrived at our destination. All the equipment was loaded into trucks, and we drove to a local hospital to assemble our surgical theater. 

    First-year residents in Brazil are usually  able to perform pterygium surgeries and begin to perform  extracapsular cataract extraction (ECCE) and the first steps of phacoemulsification. I was responsible for triaging pterygium and cataract patients and was eager to learn from experienced surgeons.

    Accustomed to moderate grade pterygium and soft cataracts back home, I was surprised to find advanced stages of both pathologies. The Amazon region is part of the “pterygium belt” due to its geographical location, so pterygiums are common and tend to be bilateral and severe. Also the public health system in remote areas tends to be insufficient and these initially benign  conditions can turn into causes of blindness. Cataracts can turn white and morganian.

    There were a high number of patients with pseudo-exfoliation syndrome, associated with dense cataracts and zonular fragility, creating complex procedures. Our team was responsible for the first post-operative visit and follow-up visits were done by a local ophthalmologist. 

    In the last 10 years, the project benefitted more than 5,000 patients in 20 counties along the rivers on the Amazon basin. Every day, around 150 patients arrived to be triaged. Most of them only had refraction errors. On average, around 40 patients a day underwent surgery and the majority of cases were cataracts. All the patients selected for surgery and family were given a consent form before surgery. 

    After returning to my home in São Paulo, I was amazed by how well-organized the expedition was and how grateful the patients were to be able to see again. 

    In following years, the expeditions became more frequent and as my training advanced, I was able to perform more surgeries and perform life-changing work for the locals. 

    Not only did we go to Parintins, but we also went  up and down the Amazon river, stopping at small cities along the way. We often arrived during the middle of the night, but the locals were always ready for our arrival since they had gotten word from the local government or media that we were coming. They'd present us with local foods like açaí and cupuaçu juice, nuts and fresh fish.

    After a couple of trips, we gained some valuable allies. Institutions such as the Federal University of São Paulo and Federal University of Amazonas contributed with assistants, ophthalmologists, researchers, etc., naming the project “Humanitarian Ophthalmology” and visiting doctors came from all over the world. Pharmaceutical companies supported us with medical supplies, such as brand new surgical microscopes, advanced phaco machines, IOLs and OVDs. . 

    The Brazilian Navy is an important ally, providing us with its medical frigate — a boat with equipment to perform general medicine and dentistry consultations in remote areas — and assisted us with accommodation, logistics, security and navigation guidance along the rivers.

    In 2019, we did the first combined cataract and glaucoma surgeries in Parintins. With industry sponsorship, we implanted 20 micro-invasive glaucoma surgery (MIGS) devices.

    On my last expedition, we arrived at a city called Manicoré and heard about a 103-year-old man who was blind and could not leave his house because he did not have any means of transportation. We arranged to evaluate him at his home, where we discovered he could not see due to bilateral advanced cataracts. He told us that he hadn’t seen his daughter for seven years, and the only way he could tell day from night was through the type of insect that would bite him: wasps during the day and mosquitos during the night. 

    I could tell he could see again the day after the operation on his first eye when I took his bandage off. He smiled at me and said I needed to shave. Then he and members of his family cried. He told me he could see again his family, the palm trees and the Madeira river in front of his very humble house. He thanked me and said he was anxious for the operation on the other eye. 

    Every expedition leaves behind a new lesson but being able to help these patients  reminded me of what it really means to be an ophthalmologist: It is a privilege. A privilege to change someone’s life.

    About the author: Ricardo Menon Nosé, MD, specialized in external diseases and cornea at the Federal University of São Paulo. He is a cataract surgery assistant instructor at the Federal University of São Paulo and at the Santa Casa de Misericórdia de São Paulo.

    Humanitarian Ophthalmology in the Amazon