To the Editor: I read with interest the personal perspective by Baker, describing her recent visit as part of an ophthalmic surgical team.1 Such teams from Australia have a long and creditable record of service in the Pacific, and their work has been of great value to the people in the countries involved, and of considerable personal satisfaction to those who have taken part in them.

The experience of ophthalmic surgeons working with The Fred Hollows Foundation in developing countries certainly confirms Baker’s observations that the density of the cataracts found in these circumstances commonly makes them unsuitable for phacoemulsification. This does not, however, lead to the conclusion that modern small-incision surgery is not suitable for cataract patients in the developing world.

Sutureless small-incision cataract surgery (SSICS) by manual means has been practised in many parts of the developing world for many years, with a range of techniques being used to extract the nucleus without phacoemulsification.2,3 Such techniques have been shown to give better uncorrected vision when compared with standard extra-capsular surgery, and are quick4 and economical, with fewer problems requiring follow-up than extracapsular surgery.5 The Fred Hollows Foundation, along with many other non-government organisations and authorities, is actively teaching and promoting the use of SSICS in its programs as the operation of choice for cataract extraction in the developing world.

In light of this, I was surprised to see mention of the introduction of phacoemulsification to the Solomons by the team. Not only is this procedure not suitable for a large proportion of the presenting cataracts, but the cost of equipment and consumables in phacoemulsification is several times that of SSICS, and the time taken for surgery is often longer.

In an environment where people suffer vision impairment simply from lack of glasses, and where surgeons are available who can perform modern small-incision sutureless cataract surgery, I wonder if this is an appropriate technology to introduce to the region.

To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program.

The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”.

Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs.

The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara.

Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams.

Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner.

Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.

In reply: Despite increased efforts over the last decade, the burden of blindness due to cataract is still immense. With over 18 million people in the world blind because of cataract1 there is an obvious need for an affordable and efficient cataract surgery technique.

We agree that sutureless small-incision cataract surgery (SSICS) does have an important place in cataract surgery in the developing world. It has advantages over extra-capsular cataract extraction (ECCE) in the longer term, such as decreased cost,2 reduced astigmatism and decreased surgery time.3 There is increasing interest in SSICS among Australian ophthalmologists, and instruction courses are to be held at the forthcoming Royal Australian and New Zealand College of Ophthalmologists meeting. On the other hand, SSICS can be more difficult to learn, and for inexperienced surgeons, there are risks of complications when it is used for a bulky dense cataract.3 ECCE is continuing to evolve, with modern surgical blades giving significantly shelved wounds, which are potentially safer and require fewer sutures, and still has a place.

In the Solomon Islands, ECCE and SSICS are the predominant techniques because phacoemulsification is unsuitable for most patients as their cataracts are too dense.3 SSICS was used successfully for suitable cases by Szetu, who is very experienced in the technique. The phacoemulsification machine was brought to Honiara to perform vitrectomy (which the machine is capable of) for diabetic retinopathy in patients who otherwise would have needed expensive treatment in Australia. Phaco-emulsification was purposely used only as a trial (hence, in only three patients), but in the subsequent Pacific Islands Project (PIP) visit, six children with congenital and traumatic cataracts were successfully treated with with phacoemulsification/lensectomy and the insertion of folding intraocular lenses (these were six of a total of 260 operations). In this group it is an ideal technique.4 Currently, it is sustainable to use phacoemulsification because of generous donations. With the advent of low cost phacoemulsification machines (as presented at the Australasian Society of Catar-act and Refractive Surgeons conference in Broome in 2004) and low cost disposables, it is likely the technique will be increasingly used when the backlog of dense cataracts are reduced.

Phacoemulsification is the accepted standard of care for cataract surgery in the developed world,2 and there are valid reasons for introducing it into developing countries. Professional development is important, and we must consider the aspirations of our colleagues; the appropriate introduction of phacoemulsification can aid this. We are pleased to hear of Szetu’s return to Honiara, and are sure this technology will have a small, but useful, place in his clinical practice in the future.

We cannot agree more strongly that so-called “medical tourism” is wrong. It provides no significant benefit to the community and is disruptive, unhelpful and is, at worst, a burden to the local medical and nursing staff. Unrequested, unhelpful and short-term visits should not be undertaken.

The PIP was specifically set up to avoid the abovementioned problems by providing aid that was substantial and well funded (by AusAID), and teaching trips to countries that have made specific requests at the government level for assistance. Such assistance is provided only with the total cooperation and support of local ophthalmic staff, and is run to the highest standards by experienced and committed volunteers. It has been well received in all Pacific countries visited.

Ultimately, PIP was intended only as a transitory phase in Pacific development and, as each country achieves self-sufficiency through infrastructure development, visits will be scaled down. We are looking forward to the Solomon Islands regaining the place it once had in Pacific ophthalmology before the civil unrest, and look forward to continuing to help develop the Eye Department in the years ahead. We hope that the close to 1500 operations the PIP team have performed over the eight visits since 2000 have been of help during this troubled time.