Doc, nakakakita daw po ba si baby?

A first-time mom came in my clinic with her 5-month-old baby, referred by another ophthalmologist, so I can answer her question “Doc, nakakakita daw po ba si baby?” (Doc, can my child see?). I dreaded the question because of the answer I have to give the mom, should the patient turn out to be suffering from an irreversible eye disease.

After performing several tests and with all findings pointing to poor visual prognosis, I started by asking “Mommy, may nabanggit na po ba si duktor tungkol sa kondisyon ni baby?”. With all smiles, she said “Wala naman po Doc.” The smile made the next part of my job more difficult since it tells me that the mom was not told of anything and was not prepared to receive the incoming bad news. I find that sometimes a simple “baka” or “medyo” in the explanation of colleagues who saw them prior help soften the blow to the parents.

Slowly and gently, I said “Mommy, base po sa eksaminasyon ko kay baby, mababa po yung tsansa na nakakakita siya”. Then I gave a long pause for it to sink in. I received a blank stare and heard a soft “ay ganun po?” After a few seconds, the smile started to fade. I knew it was starting to sink in. And then the sob.

I can only imagine how hard it was, to hear those words I just uttered from her side of the conversation. It must be as hard as being told of a cancer diagnosis, or worse, since the former involves a child, whom the new mom has carried for 9 months and cared for closely after. There was also the consideration of the implication of not just of the mom’s future but more importantly of the child’s.

Then, a harder question followed, “makakakita pa po ba siya?” again, because of the answer I had to give. I told the mom that there are ways to confirm the status as well as the visual prognosis of her baby. A visual-evoked potential test can be done but the nearest institution which offers it is in Manila. This is a concern for some since it entails travelling outside the city with the patient amid the pandemic and entails costs to travel, for the procedure, and to travel back to get the result. And result may not significantly affect the management and the prognosis of the patient. Unfortunately, the underlying cause of visual impairment of the baby was irreversible.

So, I asked the mom, “by any chance, may nabanggit na po ba si duktor tungkol sa maari mong gawin pa pagkatapos”. “Wala naman po”, said the mom. It pains me sometimes that possibilities and other options are not being discussed on a regular basis in situations like this. But I also understand why colleagues refer these set of patients to me, to confirm their findings first. But with that confirmation comes the burden of having to break the news. There is also the opportunity to provide hope and offer more options rather just saying "pasensiya na po, wala na po tayong magagawa".

I then explained to the mom, hoping to widen her perspective on options for her baby, especially for the baby to be independent in the future. Options include timely consults with development pediatrician to know other possible associated medical concerns, with occupational therapists for mobilization training and in performing daily basic tasks and with other NGO for educational opportunities. I pointed it out that we are lucky in the city because there are occupational therapists, schools for the blind and NGOs dedicated to helping visually-impaired individuals.

I also pointed out that it is natural for us parents to be protective of our child especially at this point for her baby. However, we will not be around for them forever. And it would be unfair for them too, to be kept limited and dependent when they grow up, despite the dangers and the challenges our world offers us.

After making the necessary arrangements for the referrals, I ended up the consult with “Pero mommy, I can be wrong. I cannot guarantee 100% on anything, okay?” Then I got what I wanted, as I saw a glimpse of hope from the mom’s face before letting the next patient in.

We are celebrating the Sight-Saving month! The sad truth is we cannot save everyone’s sight. That mom was not the first to sob in my clinic. I can only hope that she will be the last, but unfortunately, reality is she will not be. However, we can offer them options. Let us not stop with just prognosticating our patients and taking away their hope. Let us, as fellow parents or fellow caregivers, be a source of information and strength to prepare them for the long and challenging road ahead.

Addressing ROP in SIMC & gearing towards the future of eye care in Isabela

A year ago, during the celebration of the Sight-Saving month 2022, a wish was made; that no preterm baby in Isabela goes blind from retinopathy of prematurity (ROP). That wish turned into a commitment to decrease the incidence of unscreened and untreated retinopathy of prematurity (ROP) in the Southern Isabela Medical Center (SIMC) in Santiago Isabela. Increasing awareness among the involved medical personnel was the initial step taken. The Department of Pediatrics, headed by Dr. Vicente Dennis N. Dio, and the then Section of Ophthalmology, headed by Dr. Josephine R. Alivia, planned and held an joint conference. A lecture from the ROP Working Group of the Philippine Academy of Ophthalmology (PAO ROPWG) on the basics, screening, treatment and prevention of ROP on October 2022 was given. The 2020 Consensus Statement on ROP Prevention and Screening in the Philippines by the PAO ROPWG and the Philippine Society of Newborn Medicine under the Philippine Pediatric Society was also presented and was well-received.

Consultants and residents of the Department of Pediatrics, headed by Dr. Vicente Dennis N. Dio (fifth from the left at the back), and the then Section of Ophthalmology, headed by Dr. Josephine R. Alivia (second from the left at the back), who attended the lecture on ROP.

As more cases were identified, following up preterm babies with early disease and treating those with threshold cases became the next challenges. Collaboration with Region 2 Trauma Medical Center (R2TMC) in Bayombong, Nueva Vizcaya, thru our retina colleague Dr. Tricia Katrina T. Allas, enabled the monitoring of babies with pre-threshold disease as well as intravitreal anti-VEGF injection of babies with aggressive posterior ROP. The biggest concern then was the absence of a 532 nm laser console which can deliver laser treatment with an Indirect Ophthalmoscope (LIO) in the region. We had to refer babies and coordinate transfer of admitted ones to the nearest facility with the said equipment, the Baguio General Hospital and Medical Center. Our babies were received and attended by our retina colleagues Dr. Marie Christine T. Marcelo-Tan and Dr. Ronald Gonin C. Paraan, their ophthalmology residents, and colleagues in the Pediatric and Anesthesiology departments. Due to logistical concerns, we even had an admitted baby received in Ilocos Training Regional Medical Center (ITRMC) in San Fernando, La Union by our retina colleagues Dr. Junn Pajarillo and Dr. Chester Pataray, their ophthalmology residents and colleagues in the Pediatric department. The referral was also facilitated by the PAO ROPWG and the ITRMC Department of Ophthalmology chair Dr. Charisse Anne S. Tanlapco.

In line with our commitment to reduce patient referrals and conductions as the travel itself presents significant risk to the preterm babies and to already properly enable SIMC, the SIMC administration, headed by the Medical Center Chief II (MCC) Dr. Melchor C. Dela Cruz Jr., together with our chair Dr. Josephine R. Alivia, have continuously worked hard to procure the necessary equipment to make the treatment of ROP and other eye diseases possible. Today, after a year when that wish was made and with the formal launching of the Sight-Saving month celebration 2023, we receive with utmost gratitude a 532 nm laser console with LIO capability. This will now enable us to treat babies with threshold ROP and other retinal diseases as we are also given a fundus Fluorescein Angiography imaging equipment to complement the laser. We already have a handful of diabetic patients who benefitted from both equipment. This will also decrease the need to refer patients to other institutions.

Turnover of the 532 nm laser console with slit lamp delivery system and LIO attachment, and the fundus Fluorescein Angiography imaging equipment by the SIMC Administration headed by MCC Dr. Melchor Dela Cruz and CMPS Dr. Loreto Butch Garcia to the SIMC Department of Ophthalmology during the launching of the Sight-Saving month 2023 celebration.

Our ophthalmic technician is being trained to perform fluorescein angiogram using the newly acquired imaging equipment (posted with permission from the patient).

A diabetic patient of SIMC diagnosed with proliferative diabetic retinopathy, based on the fluorescein angiogram result, undergoes panretinal photocoagulation done by Dr. Jan Domalanta (posted with permission from the patient).

Similarly, the Section of Ophthalmology has been upgraded into a department last January 18, 2023. With the change came appropriations for personnel, one of which is for a soon-to-be retina colleague expected to join us in 2024. To optimize SIMC’s capability to handle retina cases in the future, the department has been appropriated budget for the purchase of a phacoemulsification machine with posterior vitrectomy capability to complement our existing phacoemulsification machine and to enable management of preterm babies with ROP that is > stage 3, and an OCT-Angiogram equipment. These will significantly complement existing ones which include an operating microscope with posterior viewing system, an ultrasound equipment with A- and B-scan capabilities and surgical instruments including those needed for vitreoretinal surgeries. Said equipment were procured during the term of then MCC Dr. Jose Ildefonso B. Costales, Jr. and then Ophthalmology section head, Dr. Dennis J. Punongbayan while the additional instruments came from the Office of the Provincial Governor, Governor Rodito T. Albano III, thru Dr. Leandro Jose G. Domalanta.

Biometry is being done to a patient for cataract extraction by our ophthalmic technician.

Dr. Ryd Dela Cruz, assisted by our hospitalist and our ophthalmic OR nurse, is performing cataract extraction using a top-of-the-line operating microscope and phacoemulsification machine.

All these equipment will be transferred soon to the new home of the Department of Ophthalmology, the SIMC Eye Center in the 8th floor and the planned SIMC Ophthalmology Operating Room Complex at the SIMC Tower A building.

Ongoing construction of the new SIMC Eye Center in the 8th floor of SIMC Tower A building.

The department also welcomed Dr. Maria Katrina Malgapu-Uy, a glaucoma specialist who has been instrumental in the use of our automated visual field analyzer, interpretation of the results, and in our glaucoma-related activities in SIMC. The department was also recently joined by Dr. Danica Tomas-Esteban whom we will be sending to train for an External Disease and Cornea fellowship. Together with the specialists, we have been appropriated items for hospitalists, one of whom is Dr. Eden Joy E. Paraiso, who are vital to the continuous care of our SIMC patients.

One of our department staff undergoes visual field test using the Visual Field Analyzer.

Dr. Myka Uy conducting a public health lecture to our patients in the OPD on glaucoma in coordination with the SIMC Public Health Unit headed by Dr. Maria Theresa Dalmacio .

We would like to take this opportunity to thank all those who have been part of this fulfilling year. We would like to thank all the individuals named above, especially our MCC, Dr. Melchor C. Dela Cruz Jr. We thank our Chief of Medical Professional Staff, Dr. Butch Loreto O. Garcia III, the Professional Education Training and Research Office (PETRO) headed by Dr. Emmanuel M. Salamanca, the Office of Strategic Management headed by Dr. Louella Fatima R. Bascos, heads of SIMC Departments, Sections and Offices, Chief of Administrative Office Ms. Rienajo C. Eresmas, the SIMC Hospital Bid and Awards Committee (HOBAC) headed by Dr. Ramon B. Hilomen, members of the HOBAC Technical Working Group headed by Ms. Teresita Mangahas, the PMO headed by Atty. Majal Margret M. Soriano and and our Chief Nurse Ms. Jenifer S. Manuel for allotting us personnel items and helping us acquire all the equipment.

Members of the Office of the Strategy Management of SIMC including the Executive Committee during the Strategy Refresh.

We would like to thank the consultants, residents, and nurses (especially the NICU nurses) of the Department of Pediatrics, who continually refer, facilitate and endorse preterm babies, especially those for conductions to different points in Northern Luzon. We would like to thank our colleagues in the ROP Working Group who advised us on the management of our ROP patients especially Dr. Andrea Kristine M. Pajarillo and Dr. Darby R. Santiago. Thank you Dr. Rachelle G. Anzures for the ROP lecture from the PAO ROPWG. We would also like to thank our colleagues in the PAO Community Ophthalmology Committee headed by Dr. Rosenie Mae C. Singson for helping us explore other options to acquire a 532 nm laser console with LIO.

One of our hardworking and dedicated SIMC NICU nurses attends to a preterm baby (posted with permission).

We would like to acknowledge the consultants of the department: Dr. Cecilia T. Vispo, Dr. Leandro Jose G. Domalanta, and Dr. Ryd Mark L. Dela Cruz for screening and monitoring the preterm babies, Dr. Dennis J. Punongbayan for facilitating the acquisition of previously existing equipment, and our current chair, Dr. Josephine R. Alivia for making all of the new additions possible for the department. We also thank our resident, nurses and administrative staff for continuously attending to our preterm babies being referred and managed for ROP, and other SIMC patients.

SIMC Department of Ophthalmology medical, nursing and administrative staff during the annual team-building and strategic planning activities.

We also thank our patient transport vehicle drivers for safely transporting our preterm babies. We remember Ms. Ruby Joy L. Sapanla and Ms. Alpha Joy Odato Delapeña who, together with our other security guards, worked and continue to work hard to keep SIMC safe.

There lies a long road ahead for SIMC and the Department of Ophthalmology in achieving our wish of not having a child in Isabela go blind from ROP. We implore everyone for your continued support in this journey. The next step includes partnering with organizations who attend to, train and prepare blind children for their future as we continue to receive patients with ROP stage 5. Some, although screened, were not able to travel for treatment during the COVID-19 pandemic while others were not able to return for follow-up examination after getting discharged from NICU due to financial and logistical concerns. We also wish to share our ROP learnings in SIMC, no matter how small they are, to other hospitals as well as other towns in Isabela. We also now have another private hospital in Santiago Isabela with LIO capability for preterm babies with ROP.

We would like to invite ophthalmology subspecialist as well as hospitalist who are interested to join us in our new and growing SIMC Department of Ophthalmology. Please contact Marisa, our Department Secretary, at 09066430955 for inquiries or visit us in our FB here. Help us better attend to the eye care needs of our fellow Isabeleños and those from neighboring provinces in Northeastern Luzon, optimize all the ophthalmic equipment and prepare the department to train colleagues in the future. God bless us all.

Selecting and Organizing Contents of a Curriculum

Here is a link to my presentation on the principles on the selection and organization of contents in creating a curriculum

https://drive.google.com/file/d/14IQT5agiRyHr99ZNKc0g_REYDT31ipxT/view?usp=sharing