Medical Surprise - and Sadness

Today I saw the result of an ancient cataract surgery technique, called
"couching," that was first practiced in India around 600 BC.

I always wondered why they included this piece of history in my ophthalmology textbooks, but now I see that history is alive and well. Couching is when a practitioner pierces the eye with a needle, dislodging the white opaque cataractous lens and pushing it into the back of the eye (the vitreous). The opaque lens is no longer in the visual axis, so the patient can see again - sort of. But the patient needs strong glasses afterward to see anything, and the risk of complications leading to permanent loss of the eye afterward is high - from infection, retinal detachment, or inflammation leading to glaucoma (high eye pressure).

My patient today was in Point Noir in Congo Brazzaville recently, where he met a practitioner who said he could do cataract surgery without any surgical instruments or operating room. This sounded good to my patient, who underwent the couching surgery. However, over time afterward he had eye pain and worsening blindness. Today when he presented at our hospital in Gabon, he was blind to the level of only being able to tell light from dark. His eye pressure was very elevated at 48 (normal is 10-21), his optic nerve was near-completely destroyed, and he had inflammation in the eye with new pathologic blood vessels growing on his iris, the colored part of the eye. When I first examined him, I didn't know the history and the back of the eye was barely visible because of a small pupil. I thought I saw a mass back there, and was instantly concerned about a cancer, before getting the history and realizing that the "mass" was actually his entire lens that was dislocated into the back of the eye.

Sadly, there is little we can offer this man at this point except pain relief through medicine or surgery. It brings home the urgent need for eye care (and education) in Africa when we see that people are desperate enough to trust a charlatan to perform couching on them. Pray for more workers, and for Africa itself to begin to develop the ability to care for its people.