Two patients in particular caught my attention today. One, a 10-year-old boy named Juan Elvis Jananpa, is blind in one eye and has limited vision in the other from an explosion when he was 7. We can fix the blind eye with cataract and lens implant techniques. Smiles abound all around when the translators explain this to his family. The other is a 9-year-old boy suffering from bilateral blindness due to inflammation in his eyes from juvenile rheumatoid arthritis. We cannot restore his lost eyesight, at least not without multiple surgeries accompanied by extraordinary long-term care unavailable in this part of the world right now. His mom and dad cry when this news is translated. The ones who cannot be helped I often remember the most. It is my first day at the _Instituto de Oftalmologia_ in Lima, Peru, and my fourth mission with Orbis. The organization was started in 1980 to fight blindness on a global scale and began when United Airlines donated a 1959 DC-8 for conversion into a flying eye hospital. That first aircraft was converted to house an operating room, laser room, anesthesia capabilities, pre- and post-op areas, and a 20-person classroom. Today the regular 25-member flight and medical crew has been joined by visiting volunteer ophthalmologists like myself, who perform and teach medical and surgical eye treatments in less developed locations around the world -- some 450 missions in more than 80 countries so far. My role in all this is small but I am mindful of 18th century British philosopher Edmund Burke's statement: "No one made a greater mistake than he who did nothing because he could only do a little." In my three previous trips with Orbis -- to Changsha in the Hunan Province of China, to Khartoum in The Sudan and to the outer reaches of Mongolia in the capital city of Ulan Bator -- I have found ophthalmic supplies, technology and skills lacking but local eye doctors eager to absorb medical knowledge to improve their fight against eye disease. Makeshift hospitals, improvisation and a "can-do" work ethic combine to make Orbis a success and support a favorite adage of mine: "Pray for what you need but, when you get off your knees, hustle." We started the clinic exams this morning at 7:30 and will not finish until past 5. This is always the most difficult day for me: trying to shake off jet lag, meeting so many new faces and, hardest of all, trying to limit the surgeries to about a dozen patients among the 40 here for help in my area of expertise. Many have traveled hundreds of miles to be evaluated by an Orbis physician. The selection criteria for choosing patients for surgery have to do with the instructional value of a patient's ocular disease, the ease (or difficulty) of passing the appropriate surgical skills to local physicians and the need to provide surgery because the local doctor would be unable to perform it. For those turned away, I try to take some comfort in the hope that the knowledge I've imparted remains behind after I've gone -- teaching people to fish rather than giving them fish to eat. I begin day two with a lecture on a trans-scleral, sutureless cataract procedure while several of the other doctors and nurses prepare patients for surgery. The DC-10 we now fly includes a 50-seat lecture hall outfitted with monitors and projection screens for various presentations, including views of live surgery. The operating room is well enough equipped that it rivals the best eye hospitals and ophthalmic ambulatory surgery centers in the States. The laser suite comes complete with YAG lasers for secondary cataract surgery, argon lasers for glaucoma surgery and multiple retinal lasers for the treatment of diabetic and other eye diseases. Slit lamp biomicroscopes also are available here. All this comes armed with video cameras to project images on the teaching screens at the front of the plane and, today, in a peripheral classroom set up in the airport hangar for another 100 ophthalmologists. My first surgery of the day is on Juan Elvis, complete with his parents, Orbis staff, local ophthalmologists and Peru television -- _Telemundo_ -- watching. It goes well, although it takes three times longer than usual because of new equipment, unfamiliar nurses and the dialogue with all the other physicians. But I will not know for sure until tomorrow when the bandages are removed. Two more lectures and a Q&A round out the morning, followed by afternoon lectures and surgery on 54-year-old Santiago Pena, bilaterally blind for the past decade due to the most severe cataracts I have ever seen. One distinct difference between cataracts here and in North America is the severity of the disease process. In the United States most patients seek and receive medical and surgical help before they become blind; here in Peru it is just the opposite. So the cataracts tend to be much denser and much more difficult to remove. Another difference is that lens implantation, synonymous with cataract surgery in the States, is less common here. Teaching local doctors how to safely implant intraocular lenses (especially more advanced foldable lens implants inserted through smaller slits without requiring stitches) after cataract removal has been particularly gratifying. The local ophthalmologists did not want to do the surgery on Santiago because of the severe nature of the disease and risk of complications. _Telemundo_ is here to film the event with two local ophthalmologists assisting me in the OR. Ironically I have the chance to use a certain surgical tool for the first time -- it is unavailable in the States for lack of FDA approval. Again, we will gauge our success tomorrow when the bandages are removed. I do think my favorite time as an eye surgeon is not in the operating room but the following day when the bandages come off. The plane and cameras and local doctors add to the drama as the unveiling approaches. At home I often miss out on bandage removal because my nurses usually perform this task and I am busy elsewhere. But today I get to be there to see the smiles on the patients, family and staff. And today is special. We examine Santiago first and, with the wraps coming off and _Telemundo_ filming, are thrilled to see him shield his eyes from the light and then smile. He is soon walking throughout the plane unaided (he had to be led everywhere yesterday) thanking doctors, nurses, translators, pilots -- anyone within view. Young Elvis also is obviously seeing better, but it is his mother who runs through the plane thanking everyone. But the most gratifying moment is watching weathered Santiago and young Juan walking down the plane steps to the waiting bus talking as if they had known each other for years. The following days consist of difficult cataract surgeries demonstrating different techniques based on other ocular conditions (glaucoma in Olga, a previous corneal implant in Maria, corneal scarring and trauma in Matilda), more lectures and, later, assisting and supervising local doctors performing the techniques they are now learning. I also have good visits with Ali Miqdad Al-Ani, M.D., the chief ophthalmologist with Orbis. Because his main area of expertise (anterior segment surgery including cornea, cataract and refractive surgery) is a sub-specialty of mine, we have good talks about the practice of medicine in the United States and his neck of the woods -- Baghdad. We also talk about Muslims, Jews and Christians, racial and national differences, life in Iraq and the rebuilding of their infrastructure after the Gulf War. As is typical on these trips, I find we have more in common than what separates us. One day we are shadowed by Humeyra Dabil of Turkey and Ayodeji Adu from Nigeria, two great organizers and even better people, while Marjorie Coe from the Philippines serves as our scrub nurse and instructs local nurses on surgical details. Our final procedure of that day is performed by Peruvian surgeon Claudio Figueroa on 84-year-old Eloisa Gallarday, who, one-third of the way through the surgery, decides she is about to suffer premature death (as translated to me by the OR staff as she tries getting up off the table to leave). Long past the point of no return (and Claudio now complaining of the same malady as our patient), I am asked to finish the operation, settling Eloisa enough for me to jump in and expedite the surgery ASAP. My final surgery of the trip is the removal of a single mature cataract in Gladys Casas, a 34-year-old mother suffering from an undefined neuro-muscular degenerative disease. The disease had begun 10 years ago, soon after the birth of her son, Raoul Manuel. She is now in a wheelchair with the complete loss of function of her lower extremities, and her paralysis is slowly extending upward -- soon to threaten her respiratory muscles and, consequently, her life. Mature, totally white cataracts can be difficult to remove, even with special dyes used to better visualize parts of the lens during surgery. I feel a certain calm, however, in the OR with her. No doubt the good Lord is watching over us, and I believe the surgery is the best teaching case for the local doctors. They -- and Ms. Casas -- are very appreciative. The light of this day ends with a beautiful sunset over the Pacific Ocean. I take a walk down the cliffs to listen to the gentle waves break on the rocky beach and get my face wet in the ocean that Ferdinand Magellan named over 400 years ago for its "peaceful calm." Tonight it is certainly that, and I am one very lucky person to see it in all its majestic glory. Perhaps it was the conversations with Ali, or simply the work and the people I'd met here -- medical staff, patients and their families -- but it all reminds me of the words of the Middle Eastern writer Kahlil Gibran: "The veil that clouds your eyes shall be lifted by the hands that wove it. And you shall see. . . . For in that day you shall know the hidden purposes in all things, and you shall bless darkness as you would bless light." Maybe Santiago and Juan, Eloisa and Gladys Casas and all the rest will someday look back upon their days of darkness as a blessing of sorts -- a contrast that now serves to heighten their sense of sight for the remainder of their lives.
_Dick Duffey is an ophthalmologist who lives with his wife and six children in Mobile, Alabama. This is adapted from journal entries composed for his family._