Writer Adolfo Perez-Gascon sees firsthand the huge efforts being made to end avoidable blindness across Cambodia. Photography by Enric Català.

As we climb the poorly kept flight of stairs on our way to the third floor of Phnom Penh’s Khmer-Soviet Friendship Hospital, a cacophony of voices foreshadow the chaotic scene we are about to encounter. Dozens of people pace around the narrow balcony, some wearing post-surgery eyepatches. Doctors in white lab coats scurry by, their faces stern and focused. Sitting on benches, people – young and old – happily and loudly chat away.

Here sits Dy Khan, who has just a cataract removed from her right eye. Wearing a protective eye-patch and a wide grin that exposes a nearly toothless denture, the 80-year-old shares her experience of the operation with fellow patients from her village in Kampong Thom. This was Dy’s second cataract operation. The first one was carried out in April, on her left eye.

After years living in the dark due to the presence of very dense cataracts in both eyes, she was contacted by a group of volunteers visiting her village in search of people with eye deficiencies. After a short screening process, she was asked if she wanted the cataracts removed for free by a team of foreign doctors operating out of the capital. It took some convincing, but she finally agreed.

A few weeks later, Dy travelled to Phnom Penh with a group of neighbours, all of them afflicted by eye conditions. The first operation was performed by a team of British doctors. The surgery went as planned, and, the next day – one cataract short – she could see the figure of her grandson for the first time in years. She was told that a second team of ophthalmologists from Australia, would deal with her remaining cataract in July.

Both teams of eye specialists were brought into the country by local NGO Khmer Sight. Since 2007, this volunteer-based organisation has been scouting rural and remote areas of the country for people with eye diseases to bring them to the operating theatre in Phnom Penh.

“Sight is the most massive impact you can have,” says Khmer Sight founder Sean Ngu. The organisation helped arrange more than 6,000 cataract operations last year alone. In 2017, their aim is to surpass the 10,000 mark, an ambitious goal that they are on course to achieve, thanks to the support of some of the world’s most renowned professionals in the field. “We have six of the top 50 eye surgeons in the world working with us,” adds Ngu.

With a backlog of more than 400,000 cataract operations in Cambodia, Khmer Sight’s work in bringing international eye doctors to the country to perform surgery is invaluable. According to the Australian Government’s Avoidable Blindness Initiative, an estimated 43,800 Cambodians are blind in both eyes, with more than 90 percent of cases falling under the category of “avoidable”.

As a member of Vision 2020: The Right to Sight – a global initiative launched by the World Health Organisation (WHO) – ending avoidable blindness is one of the Cambodian government’s health priorities. Despite this goal still being far from accomplished, when it comes to advancements in the eye care system, Cambodia has plenty to feel proud about.

An Avoidable Plight

Cataract is by far the biggest cause of blindness in the Kingdom, but glaucoma, corneal scarring, trauma and refractive errors also play a role in increasing the country’s blindness prevalence, which now stands at 0.38 percent.

“The biggest factor is that, for a such a long time, people in Cambodia haven’t had access to cataract surgery,” says Dr David Worsnop, an ophthalmologist visiting the country as a member of the Australian Health Humanitarian Aid, one of the organisations that Khmer Sight partners with to provide free eye surgery to Cambodians who cannot afford the operation.

While most agree that the development of eye care in the Kingdom in the last decade has been impressive, there remain thousands of people across the country who lack access to even the most basic eye services because they live too far away from a clinic with the capacity to handle eye treatment.

There are currently only 21 facilities in the Kingdom that can provide eye treatment, including national and regional hospitals and clinics. Four of them lack an ophthalmologist on site and are unable to handle surgery.

While some areas may have relatively easy access to eye care, such as Phnom Penh and the provinces of Battambang and Takeo, other parts of the country, including Koh Kong and Oddar Meanchey, do not have a single eye clinic or hospital. Many Cambodians live hundreds of miles away – and several long driving hours – from their nearest eye care-providing facility. The lack of qualified professionals, however, may pose an even bigger challenge. Dr Worsnop, who was in Cambodia for the fifth time as an AHHA volunteer, says the number of cataracts per head is probably the same in Australia as it is in Cambodia. He adds that Australia has around 1,100 eye specialists, while in Cambodia there are only 38.

Dr Sun Sarin, a member of the Cambodian Ophthalmological Society and president of the Continuing Professional Development (CPD) programme – an online database with study materials for eye specialists – says Cambodia currently has approximately one ophthalmologist per province, and argues the number should be at least doubled in order to achieve an adequate eye care system. The dearth in human resources that afflicts the eye care system is rooted deep in Cambodia’s tragic history.

“Only one ophthalmologist survived the Khmer Rouge regime,” says Sith Sam Ath, country manager of the Fred Hollows Foundation, an organisation that has been operating in the Kingdom since 1998 to improve eye health across the board. “Building up from there hasn’t been easy, but I believe the progress achieved to date has been quite spectacular.”

To create more inclusive eye health coverage and realise the goal of ending avoidable blindness by 2020, WHO estimates Cambodia should have at least one ophthalmologist per 100,000 people.

According to Sam Ath, this translates to 140 eye specialists operating throughout the country. To achieve the Vision 2020’s objectives, Cambodia would need to nearly quadruple the number of ophthalmologists in the upcoming years.

Stepping Into the Light

Despite these glaring deficiencies in the system, the country is undoubtedly moving in the right direction. Every year since 2007, five to seven new ophthalmologists have graduated from their studies, doubling the number of eye professionals in the country. The newly enhanced ophthalmic workforce includes the first cohort of ophthalmic nurses who graduated in 2016, as well as the country’s first female eye surgeon, Dr Ouk Soleaphy, who graduated in 2011.

“The quality of treatment, surgery and the equipment available have all improved dramatically in the last few years, as well as the workforce,” says Dr Sarin, who highlights the creation in 2007 of an ophthalmology residency programme at the University of Health Sciences and the first formalised online continuing education programme for ophthalmologists as the biggest milestones.

In 2007, under the auspices of the Cambodian Ophthalmological Society and with the support of the Fred Hollows Foundation, the country’s first residency training programme for ophthalmologists started. Held at the University of Health Sciences in Phnom Penh, it allows basic eye doctors to become specialist ophthalmologists. Since its creation, the number of Cambodian ophthalmologists has multiplied.  The programme ensures eye specialists are present where they are needed the most, requiring doctors to work in rural and remote areas for at least five years upon completion of the residency.

Pheng Lundi, 24, is a medical student in his sixth year of study. Passionate about restoring sight to those who can’t afford basic eye treatment, Lundi volunteers regularly with Khmer Sight and plans to apply for a place in the ophthalmology residency programme next year.

“I will apply to the programme because I feel I can play a crucial role in this field,” he says. Asked about his motivation for wanting to become an ophthalmologist, Lundi says Cambodia simply doesn’t have enough eye specialists to cover the whole country, and he wants to help.

“Ophthalmologists are extremely useful for society because so many people in Cambodia suffer from pterygium and cataracts,” he explains.

A New Strategy

Other recent major achievements in eye care include the creation in 2007 of an online professional development system – containing study materials that ophthalmologists can download at their complete disposal – as well as the introduction of an eye health education programme into primary schools, an initiative of the Fred Hollows Foundation in partnership with the Ministry of Education, Youth and Sports.

But, perhaps even more game-changing was the development and introduction in 2011 of the National Strategic Plan for Blindness Prevention and Control for 2010 to 2015, a significant step forward in the fight against avoidable blindness and a useful framework to guide governmental efforts in eye care policy.

According to Sam Ath, a new strategy, covering the period 2016 to 2020, is being finalised and will focus on extending eye care coverage and tackling a greater scope of eye-related diseases. Since 2000, six new eye centers have been built across the country in cooperation with a range of international organisations, including the Eye Care Foundation, the Fred Hollows Foundation, the Brien Holden Vision Institute, Caritas and CBM International.

Two new eye centres will soon come online in the capital. Khmer Sight will finish the construction of the Khmer Sight Institute before the end of the year. Located by the Cambodia-Japan Friendship Bridge, this new facility will be capable of handling complex eye surgery.

The institute will also serve as a training facility for upcoming generations of Cambodian eye doctors. Recent medical graduates will benefit from hours of practical experience alongside professionals from the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), the Fred Hollows Foundation and the Brien Holden Vision Institute.

“We will be the only independent training centre facility in Cambodia with an international supported curriculum aimed at improving all standards for eye surgery and eye care,” says Ngu.

Another major development will be the conclusion of the Metro Medical Centre in the capital’s Doun Penh district, an upscale facility that will open this month with the aim of upping standards for private eye care in the country to bring them in line with regional hubs.

“When people have eye issues in Cambodia, they cross the border to Thailand, or they go to Singapore,” says Boren Tan, manager of the new clinic. “They have no faith in the options available locally. We want to remedy this.”

Boren says the Metro Medical Centre will duplicate the systems of advanced medical facilities in Singapore and Malaysia, bringing in identical standard operating procedures and hygiene guidelines. It will be able to handle complex eye conditions, such as glaucoma, lazy eye and vitreoretinal cases, as well as offering pediatric ophthalmology, a discipline that Boren says does not really exist in the Kingdom yet. The centre will employ foreign doctors that, Boren explains, will be passing their knowledge and skills to the local cadre.

Despite the challenges that mine its way, the development of eye care in Cambodia in the last decade has been nothing short of meteoric. Its story is the story of the dozens of organisations, local and international, that have worked relentlessly to reduce the incidence of eye disease in the country, bringing the prevalence of blindness from 1.2 percent in 1997 to the current 0.38 percent. It’s also the story of the many people that, like Dy, have been returned the gift of sight.

“Seeing my grandson after five years blind was one of the most beautiful experiences of my life,” Dy says, her right eye still covered by a protective patch. “I will never be able to thank the doctors enough for this.”