It’s a humid summer morning in Santiago de Veraguas, Republic of Panama. It’s just 8:00 a.m., but the sun is already blinding.

With his daughter, Mariyloy, guiding him, Eduardo Barrera walks into the Centro Hopitalario Luis “Chicho” Fabrega.

He’s nervous to hear the results of the cataract surgery performed on his left eye the previous day.

The Ophthalmology Medical Readiness Training Exercise (MEDRETE) team is comprised of 26 U.S. military personnel and several host nation physicians who have partnered together to train medical teams deployment readiness while improving the eyesight of over 250 Panamanian patients during the two-week training exercise. The goal is to provide medical care benefiting the people of Panama while building relationships with the accompanying Panamanian medical professionals. (U.S. Air Force video by: Andrew Arthur Breese)

The itchiness under the eye patch is worrying him. It feels like a grain of sand is stuck under his eyelid. His last cataract surgery, a year and a half ago on his right eye, felt much different.

Barrera was one of 36 patients to have cataract surgery performed by a visiting ophthalmology Medical Readiness Training Exercise (MEDRETE) team, comprised of 26 U.S. military personnel and Panamanian partner physicians. The surgery corrects the condition in which the lens in a patient’s eye has become progressively cloudy, sometimes to the point of being opaque.

Enlarge

A woman and man smile and laugh
Eduardo Barrera and his daughter Mariyoly smile after Eduardo's post-operation surgery appointment, Feb. 7, 2017. He received an extracapsular cataract extraction with intraocular implant surgery the day before at the Centro Hospitalario Luis "Chicho" Fabrega during a medical readiness training exercise in Santiago, Panama. A U.S. military medical team was in Panama to help treat individuals with cataracts that otherwise would have gone untreated.

Photo // Master Sgt. Brian Ferguson

The partnership improved the eyesight of over 250 Panamanian patients during the two-week training exercise, while establishing and strengthening relationships between U.S. and Panamanian medical professionals. The exchange of knowledge and techniques between the partners benefits the medical capability and readiness of both, and gives the U.S. medical personnel operational experience in a deployed setting.

However, coalition building and mission goals are not on Barrera’s mind; he is simply grateful to have been chosen for the procedure.

He takes a seat in the waiting room, waiting his turn to be seen. As the room fills with patients, doctors begin to make their way down the line, removing eye patches from each person.

Enlarge

A crowded room with many wearing eye patches
Eye surgery patients wait for their follow-up appointments, Feb. 6, 2017, after getting cataract surgery.

Photo // Master Sgt. Brian Ferguson

Maj. (Dr.) Brett Davies, an ophthalmologist from the 59th Medical Wing at Joint Base San Antonio-Lackland, Texas, makes his way to Barrera. He carefully pulls off the tape from Barrera’s sun-baked skin and the patch gently falls away.

Barrera’s eyes water, but after a few blinks he opens them fully. Then a smile spreads across his weathered, 73-year-old-face, letting Davies know it’s a job well done.

“It’s why all of us here love ophthalmology, it has what is called a high therapeutic index,” Davies said. “Many things we see we can treat and make them go away completely or make them much better. It’s an instant positive feedback and patient satisfaction and the gratitude is infectious.”

Barrera can’t stop looking around and smiling. He no longer needs his daughter’s assistance to find his way to the exam room to have the results of his surgery evaluated.

170207-F-BP133-503.jpg
Maj. Brett Davies, an ocular trauma and plastic surgeon, looks at the eyes of Eduardo Barrera, Feb. 7, 2017, after he received an extracapsular cataract extraction with intraocular implant surgery the day before. (U.S. Air Force photo/Master Sgt. Brian Ferguson)

Davies asks Barrera to count the number of fingers he holds up from different distances across the room. Barrera responds with all the right answers. The cloudiness is gone and he can see.

Barrera says he gradually began losing his sight 20 years ago. He noticed it was getting harder to read, but his doctor told him it was just age. However, Barrera was never educated about protecting his eyes from the harsh sunlight while working construction. Years of sun exposure led him to develop large, hardened cataracts in both eyes.

As the world got blurrier, Barrera became afraid he would go blind and never again see the faces of his grandchildren.

He was not alone in his fears.

Nearly 400 patients are waiting on backlog for the specific (extracapsular) cataract surgery at the hospital. Like Barrera, most of the patients are elderly and the years of working in the unforgiving sun in the fields of Panama have taken a toll.

Maj. (Dr.) Richard Townley, the MEDRETE officer-in-charge, has seen these conditions before; it’s his fourth exercise to Panama.

“There are numerous reasons to do this mission and training is the most important,” Townley said. “We don’t have the opportunity to do this procedure in the states, therefore we cannot train for it adequately.”

Enlarge

An operating room with two sets of operations happening simoultaneously
American and Panamanian medical personnel work side by side to perform extracapsular cataract extraction with intraocular implant surgery.

Photo // Master Sgt. Brian Ferguson

In the U.S., people who notice a change in their eyesight tend to seek out a physician immediately. Early diagnosis and intervention means the cataracts are soft and can be easily eradicated with an ultrasonic probe. The ultrasonic waves break up the cataract, which is then suctioned out through tiny incisions in the eye, a technique called phacoemulsification, said Townley.

A lack of resources, education and regular eye care in remote areas of Panama contributes to patients often having harder and larger cataracts.

Due to the severity of the cataracts, Townley and his team must perform an extracapsular technique where the whole lens of the eye is removed by a large incision and replaced with a new silicone or plastic lens implanted in the eye.

These MEDRETEs provide the ophthalmologists and support personnel with their only exposure to this type of procedure.

“This larger incision in the eye gives our doctors experience with trauma,” Townley said. “Most ophthalmologists are used to working with incisions less than 3 millimeters at the largest. Closing larger incisions is a skillset that is difficult to train to our young surgeons and for a deployed setting it’s key.”

Enlarge

A close up of eye surgery being performed
U.S. Army Maj. Erin Seefeldt, an ophthalmologist, rinses an eye during an extracapsular cataract extraction with intraocular implant surgery.

Photo // Master Sgt. Brian Ferguson

This type of real-world training is priceless for the MEDRETE staff.

The experience of quickly integrating into a new operational setting while working with foreign-nation partners is crucial to the ophthalmologists as they generally deploy alone. Working alongside the Panamanian medical personnel allows for that operational experience for both partners, but in a safer and more controlled environment than an actual deployment.

“The facilities here at the Hospital Luis Chicho Fabrega rival those back home at Wilford Hall,” Townley said. “We are lucky to be here. The hospital has some new equipment we don’t have available in our surgery rooms.”

In Afghanistan, Townley was responsible for the northern part of the country by himself. When he was not tending to the needs of the troops, he cared for the locals using techniques learned from his six MEDRETE exercises.

“The only way to get experience is missions like this where we can expose the team to a myriad of different conditions. All which adds to their tool set,” Townley said. “It’s incremental improvements that increases the efficiency of these procedures.”

Townley believes missions where deployed personnel are able to see a large volume of patients affords the surgeons, their partners and technicians many opportunities to learn different aspects of these particular surgeries. Everyone works together under conditions of “organized chaos” to bring light to the darkness.

The MEDRETE team is made up of active duty Air Force and Army doctors and technicians, Army reservists and civilians from Joint Task Force Bravo. There is a balance of subject matter experts teaching procedures to team members who don’t have deployed training experience.

There are 70 MEDRETEs per year across Central and South America and the Caribbean. MEDRETEs are categorized into three main types: general multi-medical specialties, special surgery team and dental exercises.

The most common cases attended to during general and dental MEDRETEs are primary medical care, which includes respiratory, gastrointestinal, dermatological issues and tropical diseases. Dental exercises provide care with acute infections, tooth extractions, sealants, preventive medicine education and health assessments.

Special surgery team MEDRETEs include ophthalmology, urology, otolaryngology, pediatric orthopedics, hand surgery, dental, pediatric nutrition and general surgery.

Enlarge

An elderly man in a straw hat with on eye red from recent surgery
Pedro Gonzalez, age 71, waits for his post operation appointment after having an extracapsular cataract extraction with intraocular implant surgery.

Photo // Master Sgt. Brian Ferguson

In all thousands of patients a year are treated through MEDRETEs. Nearly 750 patients a day are seen through general medicine exercises by joint military teams comprised of medical specialists stationed around the world.

“Our team is from all over the globe. We come from as far north as Alaska and as far east as Germany and our JTF doctor is from Honduras,” Townley said. “We are here to provide good medicine with mixed resources.”

Townley insists that mission success cannot be realized without the help of local ophthalmologists, optometrists and technicians.

“It’s imperative to have local support because when we leave our partners are left to care for the patients and ensure the results are successful,” Townley said.

Dr. Ivonne Albarado, chief ophthalmologist of the Luis Fabrega hospital, has worked with Townley during two other MEDRETEs. Her first was in 2015 where she studied under Townley’s guidance.

This time around Albarado is performing the extracapsular procedures alongside him. She’s also mentoring and training the other surgeons on their team.

“I learned a lot of new techniques by the mentoring of Dr. Townley,” Albarado said. “Now I feel we can exchange and share information about these very technical surgeries and it’s a win-win for both of our countries.”

Many of the patients being seen are Albarado’s and most are on a one-year wait list for cataract surgery.

Out of the 250 patients, 75 of them are indigenous people who have travelled from the far northwest regions of the Ngabe-Budle Comarca. In this region, travel is on foot or horseback; making it a nearly two-day trip to the hospital.

“These patients, mostly elderly, have to walk down the mountains many kilometers with their families beginning their day at 3 a.m. They have to wait for a bus to take them to the city where they take another bus to Santiago and then a taxi to the hospital,” Albarado said. “They truly are grateful just to have a chance to be seen.”

Enlarge

An older man stands with two girls in a yard
Eduardo Barrera feeds his chickens with his grandchildren, Feb. 7, 2017, after having an extracapsular cataract extraction with intraocular implant surgery the day before.

Photo // Master Sgt. Brian Ferguson

Albarado says without the MEDRETEs, some of these patients would be blind in the coming years and most may have never sought help.

“In the end the patients feel the biggest benefit,” Albarado said of the cooperation of the MEDRETE team and her staff. “I certainly hope these opportunities to work together continue. I believe in this mission.”

Townley is also a believer. He’s seen the proof in the eyes of many of the past MEDRETE patients he’s treated in Panama.

“As a human being and an Air Force physician this gives me purpose, to help change so many lives in very little time,” Townley said. “Being able to see the smiles on their faces when you take down the patches, that’s priceless.”

As Barrera walks into the family home, his two knee-high granddaughters, both curious about his new sunglasses and surgery, swarm him. The girls sit on his lap and listen to the tale of his trip to the hospital. It isn’t long before they ask him to take them outside to feed the chickens and the ducks, a chore the three of them routinely do together.

Barrera happily grants the invitation as the girls grab his hands to lead him to the back door of the home. It’s guidance he no longer needs, but gladly accepts.