Posted on 2020-12-29
Dr. Andrew Blaikie was fresh out of the cataract operating theatre in NHS Fife, Scotland when Megan Webber, Co-Founder of KnowTheGlow sat down to zoom with the ophthalmologist and senior lecturer at the University of St Andrews School of Medicine.
Dr. Blaikie came into focus for Megan Webber and KTG by way of Dr. Ramesh Kekunnaya, head of pediatric ophthalmology LVPEI Hyderabad. Dr. Blaikie shared that he found himself in Hyderabad as a lecturer at an international conference of the American Academy of Ophthalmology, and it was there that he introduced himself to Dr. Ramesh Kekunnaya. As our KTG community learned in our most recent article, Dr. Kekunnaya is a kind and generous colleague who offered to have Dr. Blaikie shadow him for 2 days at LVPEI. The seeds of their friendship flourished from this point on and is one that continues to this day as they collaborate on research and early detection of childhood vision problems. They have literally just this week had research accepted for publication in Eye Nature on the effectiveness of the Arclight in detecting eye disease in children in India.
It is through this “glowincidence”, as Co-Founder Megan Webber likes to phrase it, that we came to learn about the Arclight and about the groundbreaking sight-saving work that the Global Health Team at the University of St Andrews led by Dr. Blaikie is achieving. The Arclight is a low-cost, pocket sized, solar powered ophthalmoscope that can, in the hands of health care workers, revolutionize early detection and vision care in low income countries. Juggling the surgery, outpatient clinics, research and teaching demands of a full time clinical academic job in NHS Fife and the University of St Andrews Dr Blaikie admitted it can be hard to devote the time needed to deliver the implementation of the Arclight. It deserves a lot of time but with the support of a growing local and international team progress and traction around the world is being made. Dr. Blaikie was mentored by Dr. John Sanford-Smith in his first ophthalmology position and was exposed to his work via his best selling books on eye care in hot climates. Through Dr. Sanford-Smith, he was introduced to William J. Williams, an optometrist and helicopter pilot from Liverpool, whose brain-child was the low cost alternative to the traditional ophthalmoscope – the Arclight.
So, how is the Arclight used? Dr. Blaikie explains that it is a multi-purpose tool. A health care provider can examine the front of the eye, perform a red eye “retinal” reflection test and examine the back of the eye as well. Additionally, in the future it will be equipped to test for intraocular pressure for the detection of glaucoma. He shares that with the Arclight they have a very broad approach to eye care but that a major focus of the Arclight is in delivering the Red Reflex Exam globally. As an aside, Dr. Blaikie explained to Megan that he prefers to call it the Retinal or Fundal Reflection Test since in African and Asian children, the glow is more of a pale orange/yellow rather than the red glow that is detected in caucasians. This avoids confusion when teaching the technique and when practitioners are interpreting their findings in the field.
As a consultant pediatric ophthalmologist, Dr. Blaikie keeps an arclight in his pocket at the clinics as his “go-to” ophthalmoscope. It is the small size and portable nature of this clever device that makes ophthalmoscopy more accessible to those in remote rural communities in Africa, where Dr. Blaikie consults, like the Rwanda Charity Hospital and potentially in the eye camps and Charity hospitals throughout India. Dr. Blaikie explains that clinical studies are showing that the Arclight is at least as good as traditional devices and perhaps even better in some ways. The International Agency for the Prevention of Blindness (IAPB) has listed the Arclight as one of the standard recommended devices for use in low and middle income settings.
For our KTG community, Dr. Blaikie explained to Megan how useful smartphones can be for capturing the Glow and gave tips on how to effectively use them. With a conventional camera, you may not be as lucky to capture the glow in your photos if you are too close to the subject. The further back you are from the subject the more likely you are to capture the glow in the image. With a conventional camera the flash is usually apart from the lens and in some cases with professional photography, completely separate from the camera. In these cases, the photographer is trying to limit the possibility of red eye. However, with our smartphones, the flash is usually right next to the lens and occurs simultaneously with photo snap setting up the ideal situation to capture the glow in photos. One should be careful to not activate the red-eye component on the smartphone, because doing so allows the flash to precede the snap of the photo which reduces the dilation of the eye obscuring the back of the eye. Taking a photograph in a dark room will also allow the pupil to be a bit more dilated helping to make the ‘red eye’ more obvious.
As a trained pediatric ophthalmologist, Retinoblastoma and ROP (Retinopathy of Prematurity) are close to his heart, but since they are rare they sometimes are not high priority in low income countries. The good news is that by looking for RB and ROP through the Arclight’s red reflex screening healthcare workers can end up doing a lot of good. There are a great many other eye problems that can be detected and corrected early in children with the Arclight. In many low income countries, Dr. Blaikie explains, there is the problem of “Cultural Inertia.” In some cultures, there can be an almost paralyzing lack of trust in doctors, so even if doctors put screeners in place to recognize the early clinical signs, they often do not have the approval of the patient’s family to move forward with formal diagnosis and treatment especially if it is news they don’t want to hear.
The Arclight shows great promise as a tool in the hands of rural healthcare workers. These workers can with time and effort be trained to a competent level within 2-3 hours on how to use the device, recognize clinical signs and then learn how to interpret and determine next steps. Dr. Blaikie has trained Ophthalmic Clinical Officers (OCOs) to do this in both Rwanda and Tanzania with promising results. In fact, in a recent study in Tanzania performed by a team from London, there was a much higher prevalence of cataracts found in the field than previous studies had projected. This new finding could be due to the screening being piggybacked onto regular and routine child health checks and the immunization program (which has greater access to the 0-5-year-old population) and utilizing the effectiveness and ease of use of the Arclight. Even during these difficult times with COVID-19, travel has ceased to Africa, but because Dr. Blaikie already had the use of the Arclight in place and practice eye simulations set up, his team has been able to continue training virtually using video conferencing platforms
In India, just before the start of the pandemic, Dr. Blaikie had the opportunity alongside Dr. Kekunnaya to run a workshop at the national neonatal conference. Once COVID-19 is behind us, Dr. Blaikie is considering working with Anganwadi workers and Auxiliary Nurse Midwives to include eye screenings in conjunction with their immunization programs in rural communities.
The Arclight is brilliant for its portability and ease of use. It can also attach easily to the back of a smartphone camera allowing a screener to take photos and videos of the front, media and back of the eye then utilize the software of the phone to store then send images for a second opinion or feedback for reinforcement of teaching.
Using the device for assessing the reflex:
Teaching health care workers in low resource settings to use it:
Growing evidence justifying its use: