Mahmoud A. O. Traditional operative couching of the lens is not a safe alternative procedure for cataract surgery in Northern Nigeria. Sahel Medical Journal (official publication of the Usman Danfodiyo University Teaching Hospital, Sokoto, Nigeria), 2005; 8(2): 30-32.
Author of correspondence:
Dr A. O. Mahmoud
P. O. Box 13834-Baboko
Ilorin, Nigeria.
Email: mahmoud_ao@yahoo.com
Direct observation of
the procedure of couching of the lens as performed by two traditional eye
couchers in Northern Nigeria was made in February 1998. Following a short
prayer, an un-sterilized crude couching needle was introduced through the
superior pars-plana into the eye to dislodge the lens downwards and backwards
into the vitreous. All patients achieved a visual acuity of counting fingers at
3 meters in the immediate post-operative period, an improvement from perception
of light pre-operatively.
The sterility of the surgeon, the operated eye, the operating environment and the couching needle was not ensured. The couching needle was also crude and blunt and the couchers’ manipulations were rather rough. The procedure is therefore adjudged to be an unsafe alternative to modern cataract surgery.
The provision of easily accessible, affordable, and quality modern cataract surgery would eliminate couching from Northern Nigeria.
(Key words: Couching, Traditional eye medicines, Traditional eye healers.)
INTRODUCTION
Cataract is the leading cause of blindness worldwide and about half of the 45 million blind people in the world is from cataract1. Modern cataract surgery (MSC) – the only means of restoring sight to cataract blind patients – is not readily available in many parts of the developing world due to lack of ophthalmologists and material resources.
Traditional operative couching of the lens (TOCL) was performed by the Hindu Susruta circa 600 BC and later adopted by the Greeks, Egyptians, Romans, and was the operation of choice for two thousand years2. The procedure involves the mechanical displacement of the lens by a sharp instrument.
Jacques Daviel of Marseille established ophthalmology as an independent surgical specialty when he began extracting a cataract instead of merely couching or dislocating the lens in 17453,4. Although TOLC is now considered obsolete in the Western world, it still exists in certain areas of Asia5,6, Africa7-11 and particularly in Northern Nigeria12,13.
Despite the fact that the blinding complications of TOLC frequently follows the procedure5-13, and coupled with the fact that TOLC is not always cheaper for patients7,9, TOLC is not only thriving but even becoming the choice alternative in some places7.
The absence of adequate ophthalmic services, reverence for traditional medicine in West Africa, and some undeniable successes by TOLC practitioners have contributed to the survival of the procedure10. since TOLC is likely to be practiced for some time to come, the ophthalmologists practicing in such areas as Northern Nigeria may have to do more than documenting the blinding complications of this procedure. There is a need to cross cultural barriers by interacting with the couchers and determining possible ways of making their “surgery” less hazardous.
The aim of this paper was to present findings of direct observation of TOLC procedure in Northern Nigeria with a view to evaluating its relative safety from the perspectives of orthodox ophthalmic surgery.
Following delicate and very discreet negotiations a deal was struck in 1998 between a team of orthodox eye-health practitioners and two couchers to directly observe the procedure of traditional operative lens couching. The need for the utmost discretion in matters of the couchers’ identities, their patients, and their addresses for fear of retribution from their fellow couchers for disclosing the “secrete” of couching, was emphasized to the observing team. However video recording of the procedures was permitted.
The actual observations took place in February 1998 in two different clinics belonging to the two couchers. The two practiced in different towns within Kaduna State in Northern Nigeria.
All the actions of each traditional eye coucher, his interactions with patients, the instruments and building facility used, were carefully noted and video-recorded during the pre- intra-, and post-“operative” phase of the couching procedure. The observations made were then evaluated for their safety from the perspective of orthodox ophthalmic surgical practice.
In this paper, the term coucher refers to the traditional eye surgeon who performs couching; the latter term refers to the procedure of displacing the lens into the vitreous by means of the coucher’s needle.
The Couchers: were both male Nigerians of Hausa-Fulani ethnic extraction and in their thirties. Both were well groomed, and dressed in complete traditional Northern Nigeria attires. Both exhibited calm and dignified mein throughout the period of encounter.
The Facilities: Each of the couchers has a separate building housing both an outpatient clinic-cum- “theatre”, and rooms for in-patients. Though all the rooms were clean and well kept, we did not observe any instance where disinfectants were being used to clean the “theatre”.
The only surgical instrument was the coucher’s needle, which was kept in a fountain pen-like case. Each coucher brought out his instrument from his pocket shortly before a couching session, and proceeded without any form of sterilization with the “surgery”. Though one of the couchers immersed his needle for a few minutes in a pot of boiling water between two “surgical” cares, he was not observed to have done this before the first case or after the second case.
Both the couchers and their patients wore their street clothes during the surgical sessions.
The Procedures: Pre-operative: Each coucher said they only select patients who had white (ripe) cataracts, mobile pupils, and could only perceive light. Both the couchers and patients appeared calm and relaxed. Shortly before surgery, each coucher prayed for a few minutes and recited verses from the Holy Quran. Only one of the coucher instilled some undisclosed eye drops into his patient’s conjunctival sac, which he said were for the purpose of inducing topical anaesthesia.
Intra-operative: Each coucher and his patient were seated opposite each other on a carpet. The coucher steadied the patient’s head and eye ball with his left palm and fingers, and he then introduced the couching needle with his right (dominant) hand. The couching needle was introduced downwards and slightly backwards into the eyeball from the superior aspect of the pars plan. The coucher directly monitored the complete dislodgement of the lens downwards and backwards into the vitreous though the papillary space of the patient. Vigorous rocking movements of the needle were made to effect the complete couching of some difficult cases.
No patient displayed any visible sign of pain, even among those operated on by the coucher that did not instill topical anaesthetic drops.
Immediate Post-operative: Both the couchers and the patients maintained their calm mien and none of the patient showed any visible sign of pain. In all instances, the patients, who were subjected to visual acuity test by their couchers, could count fingers at distances of 3 meters. They also correctly identified various objects presented to them. Both couchers applied post-operative topical eye drops. While one of the couchers used cortisone eye drops, the other coucher who had earlier not disclosed the content of his local anaesthetic drops that he used, would not again disclose the content of his post-operative prescription.
Like the other facets of “traditional medicine”, traditional operative lens couching (TOLC) indicates ancient and culture-bound health care practices that existed before the application of science to health amtters14. Being an established part of the culture, TOLC is deeply rooted in the Islamic faith, which is the predominant faith in Northern Nigeria. Northern Nigeria is especially worse off in terms of availability of ophthalmologists who carry out modern cataract surgery (MCS). Nigeria as a whole has about 250 ophthalmologists to service a population of about 120 million. Less than 50 of these ophthalmologists practice in Northern Nigeria, a region that has more than half of the Nigerian population. This dismal picture is made worse by the fact that the productivity of Nigerian ophthalmologists and their other counterparts in the developing world, in terms of cataract surgical rate is generally very low because of inadequate resources and poor health resource management. In effect TOLC would continue to be an unwelcome alternative to MCS for a long time to come in Northern Nigeria. No amount of legislation could banish TOLC from being practiced, and in fact the existing legislation had always forbidden any surgery or incision in human tissue by a non-physician15.
Those who see some temporary use for TOLC until MCS makes a strong presence to displace it, based their argument largely on its sheer necessity. TOLC is readily accessible and affordable for the poor rural dwellers as the couchers live right in their community and the fees couchers charge are adjusted to the individual’s patient’s ability to pay. More so in areas of the world where MCS is not yet readily available, TOLC performed by experienced couchers has been recommended for one eye of patient with blinding bilateral cataract as this might help more than half the patients to regain useful vision5. A much more compelling argument centers on the fact that the visual outcome worldwide from MCS is equally not very satisfactory, and this has necessitated the call for the institution of monitoring tools for ophthalmic surgeons16,17.
Those totally opposed to TOLC cite the unacceptable rate of blinding complications which could result into as many as 50% of the patients losing their sight5,6,10. The unsatisfactory findings from this study, which specifically observed the procedure of TOLC will further strengthen the argument for its elimination. Neither was any attempt made by the couchers to carry out the “surgery” in hygienic environment nor sterility of the eyes and instruments made. The surgical implement appeared crude and rather blunt to make a neat entry into the eye. The crude rocking motions needed to ensure a complete dislocation of the lens could have caused damage to intra-ocular tissues. The “good” points in the observed procedure are not fundamental as they relate to the little or no need for local anaesthesia and sedation relative (to MCS). The short duration (average of 7 minutes) and the minimal invasive nature of TOLC might not make the actual need for these apparent. The fact that the “operated” patients could immediately see might be deceptive as the usual complications and blindness from TOLC take weeks and even months to evolve.
In conclusion, a rare opportunity to directly observe the procedure of couching as practiced by two traditional eye couchers revealed that the procedure is a very unsafe one, with little or no attention paid to ensure the sterility of the surgeon, the operated eye, the operating environment and the couching needle. The couching needle was crude and blunt, and the couchers’ manipulations could cause damage of intra-ocular tissues. TOLC is therefore not adjudged to be a safe alternative procedure to modern cataract surgery. It is recommended that within the context of VISION 2020 – the Right to sight1, quality modern cataract surgery should be made easily accessible and affordable, as only this move will eliminate the need for couching that is prevalent in northern Nigeria.
I thank Prof. Dr Hans
Reinhard-Koch of Clinic Dardene, Bonn for supporting the overall comprehensive
study on couching, from which this surgical aspect was drawn from. Mallam Ikra
Liman, a senior ophthalmic nurse with National Eye Centre Kaduna, facilitated
the delicate negotiations which provided this rare instance of interaction
between orthodox and traditional eye-health surgeons.
My gratitude also goes to the two couchers who could not be named, and their patients.
1. World Health Organization. Global
Initiative for the Elimination of Avoidable Blindness:- VISION 2020. WHO,
Geneva, WHO/PBL/97.61 Rev. 1,1997.
2. Duke-Elder S. System of ophthalmology. Vol. 11, p. 249. Kimpton, London, 1969.
3. Blodi FC. The Tenth Fredrick H. Verhoett Lecture. What else did 1864 contributed to ophthalmology? Trans Am Ophthalmol Soc. 1989; 87: 213 – 300.
4. Koelbing HM. Boldness and Caution: Jacques Daviel’s approach to cataract extraction (1745 – 1952). Klin Monistsbl Augenheilkd. 1985; 186(3): 235 – 8.
5. Brandt F, Hennig A, Prasad CN, Ral NC, Upadhyay MP. Results of operative couching of the lens in Nepal. Klin Nonastsbl Augenheilkd. 1984; 185(6): 543 – 6.
6. Belyaev VS, Barachkov VI. A modern experience with couching for cataract. Ann Ophthalmol. 1982; 14(8): 742 – 5.
7. Schemann JF, Bakayoko S, Coulibaly S. Traditional couching is not an effective alternative procedure for cataract surgery in Mali. Ophthalmic Epidemiol 2000 Dec; 7(4): 271 – 83.
8. Fall H, Minassian D, Sowa S, Foster A. National Survey of blindness and low vision in The Gambia: Results. Brit J Ophthalmol 1989; 73:82 – 87.
9. Ntim – Amponsah CT. Traditional methods of treatment of cataract seen at Korle-Bu Teaching Hospital. West Africa J Med 1995; 14: 82 – 7.
10. ‘Queguinet P. Evaluation of the traditional Arabic technical of couching in the treatment of catarct in Mali. Medicine Tropicale 1981; 41:535 – 40.
11. Mariotti JM, Amza A. Traditional Treatment of cataract in Niger – A report of 22 cases. Journal Francois d Ophthalmology 1993; 16(3): 170 – 7.
12. Goyal M, Hogeweg M. Couching and Cataract Extraction: A Clinic Based Study in Northern Nigeria. Community Eye Health 1997; 10:6 – 7.
13. Ebiloma FA. Couching: Its place in blindness prevention in Nigeria. Nigerian Journal of Ophthalmology 1997, 5: 25 – 30.
14. Bannerman RH. Traditional medicine in modern health care. World health forum 1982; 3: 8 – 26.
15. Ajayi O. The Integration of traditional medicine into the Nigerian health care delivery system: Legal implications and complications. Med Law 1990; 9:685 – 699.
16. Pararajasegram R. Importance of monitoring surgical outcomes. Community Eye Health 2002; 15: 49 – 50.
17. Limburg H. Monitoring Cataract Surgical Outcomes: Methods and Tools. Community Eye Health 2002; 15: 51 – 53.