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Eye health service in Greenland

2002; Wiley; Volume: 80; Issue: s234 Linguagem: Inglês

10.1034/j.1600-0420.80.s234.7.x

1600-0420

Poul Helge Alsbirk,

Glaucoma and retinal disorders

It is the goal of this and the next two short papers in this Supplement to throw light on participation and experience from members of the Danish Ophthalmological Society with eye service in the three North-Atlantic regions. They all belonged to the Danish Kingdom at the beginning of the century when the Society was founded. Greenland obtained Home Rule status in 1979 as the Faroe Islands had done in 1948, and both communities are still members of a common federation (Rigsfællesskabet) under the Danish Crown. Iceland changed its constituency to a loose personal union with Denmark in 1918 and became a republic with full sovereignty in 1944. Greenland represents the most complicated geography and outspread population among the remote North-Atlantic regions. Being the largest island in the world, its area of 2 200 000 km2 is 80% covered by the inland icecap. The population comprises 56 000 inhabitants. About 89% are born in the country: as Kalaallit or Greenlanders, related closely to the Inuit populations of North America and further back to their ancestors: East Asian Mongoloids but also with a marked European admixture over centuries. Their mean life expectancy is still short: 63 years in men and 68.5 in women. The map (Fig. 1) shows the 17 districts of the country, with the home rule 'capital': Nuuk, where a quarter of the population lives, and 16 other districts, all but two on the West coast, some fairly isolated. No road connections between the districts exist. The sea is ice-covered for many months of the year in North-west and East Greenland, where transport using dog sledges and snow scooters prevail, together with air connections by helicopters or Dash 7 flights. Nuuk has a central 'Queen Ingrid's Hospital', since 1993 also with a well-equipped eye clinic. Each district is served by a health clinic in town with a team of one to five medical officers, also having surgical facilities and beds for inpatients. In the 59 villages (bygder) where one-sixth of the population lives, a health worker, ideally nurse/midwife trained but – more commonly – a briefly trained medicine storekeeper takes care of the population. Communication with the central district health centre is by telephone – recently, in a few places using equipment for telemedicine. Map of Greenland. The older Danish names are included for some of the towns and flight connections are shown. The map (from 1999) is printed with permission from Greenland Tourism. Rigshospitalet (RH) in Copenhagen, Denmark serves as the referral centre for more complicated cases, also for eye diseases. Mogens Norn (b. 1925) has given a most comprehensive historical survey in Oftalmolog 1992, cf. Figure 2 (Norn 1992), also based on his long personal experience with Greenland since 1975. He recounted in vivid detail the early colleagues. The first ophthalmological visit took place in 1908–9. C.M. Norman-Hansen (1861–1959) was employed as district medical officer in Nuuk but also with a somewhat vague (unofficial) responsibility to look at eye diseases in the country south and north. He made the first cataract operation in Ivigtut and the most northern in Uummannaq. He was one of the founders of the Danish Ophthalmological Society. Furthermore, he became a successful author of about 50 novels, plays and an opera (Kadarra), many with motifs from Greenland. Title page of Mogens Norn's historical survey of ophthalmology in Greenland. In the following 50 years only five other ophthalmologists travelled – with several years' irregular intervals – on 13 tours, among them Valdemar Hertz (1869–1959) (four tours), Henry Fabricius Jensen (1896–1984) (six tours) and Børge Lawætz (1904–74) (one tour). Viggo Clemmesen (1910–2001) became the pioneer from the 1960s. He undertook the planning of the increasing number of consultant tours on behalf of the Ministry of Greenland. He completed a total of 16 long and busy tours, covering all parts of Greenland from 1960 to 1975. He also arranged the supply of equipment and medicines for use by the consultants and in the district hospitals. In all districts a basic equipment for refraction, Schiøtz' tonometry, simple surgical sets and gradually simple slitlamp models were also supplied. He initiated a still most-valued Compendium of Eye Diseases for doctors in Greenland. He made an original scientific contribution by introducing gonioscopy in Greenland before slitlamps were at hand, using portable equipment with a hand-held microscope and a Koeppe-lens for direct observation of the angle. (3, 4). Thus he showed that a great majority of the many glaucoma cases in Greenland were angle closure glaucomas (Clemmesen 1971, 1973). In continued cooperation with Clemmesen, population studies of anterior chamber depth, corneal diameters, ocular dimensions and refraction were performed by the district medical officer in Uummannaq, P.H. Alsbirk (b. 1936), in order to elucidate the characteristics of the Eskimo eye (Clemmesen & Alsbirk 1971; Alsbirk 1976; thesis). A shallow anterior chamber and a small corneal diameter were the main oculometric findings behind the extreme primary angle closure glaucoma morbidity, soon also confirmed from Canada (Drance 1973) and later from Alaska (Arkell et al. 1987). Figure 5 shows a group of newly detected angle closure inpatients for iridectomy by Viggo Clemmesen in Uummannaq 1970. Viggo Clemmesen just landed on sea ice near Uummannaq, April 1970, in front of 'Storøen'. He carries the 'beauty-box' in his right hand, containing equipment as shown in Fig. 4, prepared for a long gonioscopical screening tour by dog sledge to six villages in the district. Clemmesen's portable equipment from the 'beauty box': a hand-held microscope with battery-light attachment (right), a Koeppe contact lens for gonioscopy (top middle) and a Draeger applanation tonometer (left), plus oftalmoscope and hand-slitlamp. Group of newly detected angle closure glaucoma patients for iridectomy by Viggo Clemmesen, Uummannaq 1970. From 1978 the Danish Ophthalmological Society established a 'Greenland Group' on the initiative of Chairman Professor Eilif Gregersen (b. 1924) with the task of advising the Ministry of Greenland on ophthalmological matters. A paper by our group described the status around 1989 based on a 10-year period (Alsbirk et al. 1989). Generally all districts were now covered, mainly by annual visits, by a total of 8–10 travelling consultants. About 2500 consultations annually were given over a period of about 30 weeks, but using about 17–1800 hours of work, or more than a full normal year. A decreasing number of intrabulbar operations were performed in Greenland throughout this period as RH gradually took over the cataracts, and local iridectomies were replaced by YAG iridotomies in Copenhagen. From 1986 Hans Henrik Seedorff (1922–95) took over the administration on behalf of the Eye Clinic, RH, with the Greenland Group in a current advisor position. In 1992 the Greenland Home Rule took over the administration of the health service for the country. This led to one of its early prestige projects: a fully equipped eye clinic in Nuuk. The task was to 'take home' the great majority of patients referred previously to Copenhagen. For 3 years (1993–96) Knud Erik Sørensen (b. 1946) covered the post as eye surgeon, assisted periodically by a second eye specialist, in order to cope with the long waiting lists. Sørensen introduced, for example, phako-emulsification in cataract surgery as well as YAG laser treatment of angle closure cases and sec. cataract. It was a demanding and busy task and he still had to rely on external travelling consultants, as in earlier periods. From 1996 it became impossible to re-employ another permanent eye consultant in Nuuk; various solutions to this were tried. A great cataract campaign was launched in 1997, based on initial support from the Danish Association of the Blind. The team of four eye surgeons and two nurses operated 440 cataracts in three places in only 5 weeks, thus also providing a remarkable example of efficient region-based modern phako- and IOL-surgery (Simonsen 1997) (Fig. 6). The scenic beauty of the Greenland landscape has also inspired ophthalmologists: here Mogens Norn's drawings from Kap Dan in East Greenland (A) and the glacier 'Politikens Bræ' in Qaanaaq/Thule with icebergs in front (B). A new phase began in late 1998. The Home Rule had negotiated a fresh comprehensive contract with RH concerning eye – as well as ear–nose–throat services for the country (cf. Alsbirk et al. 2000). The details of the contract comprised: • 45 weeks of eye consultant work all over the country (planning by external consultant P.H. Alsbirk); • 3–4 surgical tours dealing with cataracts, squint and tear duct problems and performed partially in regional centres north and south (planning by RH consultant K.E. Sørensen); • current consultantship concerning patient referral issues (K.E. Sørensen) and administration (S. Tinning, b. 1945 until October 2001). The total number of people examined in 2000 was about 3000, on 18 tours by 16 consultants. Nuuk had four visits while other districts still had only one. The length of the visits was based on a rough ratio of 6 days per 1000 inhabitants, also looking at the geographical pattern, number of villages etc. Generally it has been possible to recruit willing and experienced consultants for this alternative job, although conditions and payment show constraints and are not compatible with other extra-job possibilities. A tendency to numerous revisits by elderly colleagues has been a typical and valued trait, but a limited number of new colleagues also take part in the eye service. A few Greenlanders are now posted as district medical officers or surgeons in Nuuk, but so far none have chosen ophthalmology. Mainly the consultants are joined by an optician from one of three Greenlandic shops. It is a great advantage to communicate directly about the patient and to have vision and refraction problems resolved on the same day. The equipment of the travelling consultants has over many years gradually been updated. It now consists of two sets of equipment, each packed in five flight cases at a total weight of 150 kg, as shown in Fig. 7. They contain two boxes with basic examination equipment, two boxes containing the portable YAG laser slit lamp, either a Zeiss Visulas model or a Laserex YAG laser and a (too-heavy) motorized height-adjustable table for the slitlamp. Ophthalmic equipment set, 2000: for basic examinations two boxes, YAG-laser two boxes and height-adjustable table, total 150 kg. The YAG laser slitlamp (Fig. 8) has become a very important piece of equipment, due to the number of people needing careful gonioscopy and possibly iridotomy for risk of angle closure; secondary cataracts also prevail. The total number of YAG-treatments in 2000 was about 180. A hand-held Nikon refractometer has been a great advantage for all vision checks. Laserex YAG laser iridotomy being prepared by PH Alsbirk, on board MB 'Laurent' at the village Illorsuit and Uummannaq, 2001. The surgical equipment for cataract campaigns also consists of portable items: ultrasound A-scan for IOL calculation, operation microscope (Zeiss) and phako-emulsification equipment (Storz Protegé). Two surgeons and two nurses normally work together for up to 3 weeks, operating about 60–70 cataracts per session, or – as in 2000 – a total of 181 cataracts in three tours, about 25% bilaterally. Further squint and tear operations were performed in one tour in 23 cases. Waiting time is often up to 2–3 years and waiting lists are long; for example, a total of 196 people were referred for cataract operation – in one or two eyes – by the consultants in 2000. RH takes care of all the cases from Greenland with more complicated or acute pathology, e.g. for a total of 133 patients in 1999. The list of surgery comprises cases of cataract, glaucoma, vitrectomy and others. From 2002, economic constraints in Greeland have necessitated a revised reduction of the eye consultant service, from 45 to 31 weeks per year. Further, the surgical team tours have been reduced to only two for cataract. Both elements will inevitably reduce the level of eye health service for the population and lead to even longer waiting times. The early ophthalmologists found a blindness prevalence of about 3/1000 and estimated this to be six times higher than in Denmark, in spite of the great difference in age distribution. A survey in 1962 emphasized the great importance of glaucoma in the early total load of blindness (Skydsgaard 1963), as various glaucoma conditions were the cause in 64% of the blind. The National Eye Clinic for the Visually Impaired, Hellerup (Skydsgaard 1908–93, Thomas Rosenberg, b. 1938) took up current annual registration of people with visual acuity VA ≤ 6/60, or in children until 18 years: VA ≤ 6/18. Blindness rates up to 4.7/1000 have been found (maximum in 1986). As seen in Table 1 a marked distribution change has occurred. Glaucoma, mainly angle closure, is still second in importance in 9%, but now the great majority, 49%, are blind due to age-related macula degeneration (AMD), which has a pronounced prevalence and severe morbidity in many of the very old Greenlanders, as reported earlier by Rosenberg (1987) and Ostenfeld-Åkerblom (1999). Based on these findings a major population study of AMD has been performed recently in Nuuk and Sisimiut (by Nis Andersen, b. 1961), based on age groups above age 60 years and including mydriatic fundus photo screening and blood sampling for genetic analyses. The results are being processed. Rehabilitation service for the blind is difficult in such a sparse and scattered population, and service as to optics for weak-sightedness and audiotapes for blind people is poor. Children are offered rehabilitation courses and consultant visits to their home and school through the Danish Institution for Visually Handicapped children: Refsnæsskolen. Norn (1992) surveyed in detail the ophthalmic projects carried out through the first 85 years since Norman-Hansen's first visit. Apart from angle closure and recent AMD studies mentioned above, a few projects will be mentioned. Refraction studies have been of special interest, with Erik Skeller's thesis project (1954) from the Eastern district of Angmagssalik Eskimos as the basic and most important: only 1.2% showed myopia (as spherical refractive error (RE): −1 or −1.25, none had more). It gave support to current theories on refraction genetics, myopia being looked at as an unfavourable, mainly genetic, trait in a population of hunters. However, major changes have occurred. As in other North American Inuit the occurrence of myopia has increased markedly and myopia is now fairly frequent in East and West Greenland. For example, an optician-based survey of prescriptions in Angmagssalik 1982 showed about 10% with myopia stronger than ≥− 1 D (personal communication, Jan Jensen, Synoptik) and in a West Greenland population study 14.1% showed a corresponding rate (Alsbirk 1979). However, Norn (1997) found no tendency to increasing myopia in a follow-up of a cohort of people born before 1942 and examined initially by Skeller. A recent population-based glaucoma survey in Ittoqqortoormiit/Scoresbysund showed 47% with myopia (range of RE: − 5 to − 0.25) in people aged 40 + (Bourne et al. 2001) compared to 12% (RE: − 1.25 to − 0.25) in Skeller's corresponding age groups and 26% in West Greenland (Alsbirk 1979). However, a pronounced adolescent 'epidemic of myopia' such as the one observed in Alaska and East Asia has not occurred in Greenland (for discussion see, e.g. Alsbirk 1979 and van Rens 1988, who found frequent myopia among Alaskan Inuit in all adults until age 40–49 years. The anthropological features of the external eye was a major issue in Skeller's thesis and have been described further in a number of papers by Norn, who also looked at ethnic and geographical characteristics in climatic keratopathy, bulbar conjunctival pigmentation, pingveculae and pterygium. For a detailed survey see Norn (1992), who also conducted an impressive historical ethnographic survey of Eskimo snow goggles with analysis of their valuable protective and optical properties (Norn 1996). A comprehensive Greenland medical bibliography for the years 1970–95 lists 61 papers on diseases of the eye and eye surroundings (Christensen & Bjerregaard 1997) Greenland still has many difficulties to contend with – a complicated outspread arctic geography, poor economy and a shortage of trained health personnel in general. No ophthalmologist(s) are posted permanently to deal with the pronounced eye morbidity of, for example, cataracts, glaucomas, AMD and severe iridocyclitis. In spite of all the hardships encountered it has become a repeated interest – or even a passion – for some eye specialists to continue outreach eye work in Greenland, as this small survey has shown. The country has a remarkable beauty and, generally speaking, a kind, charming population, which is good to know in a world of increasing global interaction. Hopefully it will still be possible also to recruit younger colleagues and continue to establish an improved infrastructure for outreach eye service in Greenland.