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David F. Chang, MD, used this year's Binkhorst Lecture at the 2009 annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS), to pay tribute to what he believes is the single greatest modern-day accomplishment in cataract surgery - the combination of a low-cost, non-phaco procedure practiced within an efficient, high-volume and financially sustainable delivery system to combat the increasing backlog of cataract blindness in the developing world.
With the latest technological advances that characterize cataract surgery today, Dr. Chang said, it's easy to forget the sad irony that cataract remains by far the leading cause of global blindness, with 18 million cases of bilateral cataract blindness around the world.
The challenges of addressing cataract blindness in the developing world are many: the formidable expense of purchasing and maintaining a phaco machine, the high per-case costs of supplies and foldable IOLs, the advanced cataracts seen in poorer populations with limited access to follow-up care, and most importantly, a critical shortage of ophthalmologists.
Dr. Chang described three humanitarian organizations that are making remarkable progress in reducing cataract blindness by delivering inexpensive, efficient, high-volume and quality surgery, through programs that are financially self-sustainable - Aravind Eye Hospital in India, Tilganga Eye Center in Nepal and Project Vision in China .
They each serve as proven models of how to best tackle cataract blindness in developing countries, and while each is uniquely suited to their own communities, they share universal attributes and principles. Seeing firsthand the innovation and progress made at these model programs is truly inspiring, said Dr. Chang.
"Only another cataract surgeon can truly appreciate what these three organizations are achieving," he said. "And the only way to make a significant impact toward reducing global cataract blindness is through the ripple effect of teaching more and more ophthalmologists in developing countries how to organize and replicate these model systems."
In all three programs, the surgical approach is low- tech. They use manual SICS (small incision cataract surgery) performed through a temporal, sutureless scleral pocket incision. To keep costs down, both the Aravind and Tilganga Eye centers manufacture their own supplies, including a $5 PMMA IOL, and re-use any equipment that can be. As you can see in the Aravind video, turnover is increased by prepping the next patient on an adjacent table, and not changing gowns or gloves. The result is a 5-minute, $15 procedure.
Just as amazing is the way that they achieve such high-volume surgery - 12-16 operations per surgeon per hour - by using standardized protocols carried out by efficient teams of ancillary staff trained to work with military precision. Dr. Chang said that he was struck by the skill, speed, and stamina of these cataract surgeons who could maintain this pace while operating on the most advanced and mature cataracts "hour after hour."
While you may not make it India or Nepal, Dr. Chang hopes this video which he showed during his lecture will take you there. Dr. Chang suggested Dr. Rengaraj Venkatesh, his host when he visited Aravind, make this unedited, split-screen surgical film because said he believes "every cataract surgeon in the West should see this."
The Aravind Eye Hospital system has been financially self-sustaining for more than three decades, by charging modest fees to those who can pay and providing surgery for free to those who cannot. According to Dr. Chang, of the 200,000 cataract surgeries performed annually at the five regional Aravind hospitals, about 30 percent are paid for by private patients who often select phaco with a foldable IOL. This subsidizes the other 70 percent (mostly manual SICS) that are provided at no cost to the poor.
In his lecture, he also described two additional models, each adapted for different socioeconomic settings, but with similar core attributes. The Tilganga Eye Center in Kathmandu, Nepal, operates under the direction of Sanduk Ruit, MD, who co-founded the Himalayan Cataract Project with University of Utah ophthalmologist, Geoffrey Tabin, MD. In addition to an Aravind-like urban hospital center, they developed a portable set up to take on the road and serve patients that live in remote, mountainous villages.
Project Vision, coordinated by Dennis Lam, FRCS, FRCOphth, chairman of ophthalmology at the Chinese University in Hong Kong, is a large scale, collaborative effort to transform existing county-level hospitals into charity eye centers throughout rural China, where neither quality nor affordable cataract surgery is currently available. Like Aravind, both of these programs use sutureless, manual SICS, and strive to achieve high-quality and high-volume productivity with efficient, standardized protocols and a high staff-to-surgeon ratio. Both programs are also financially self-supporting by charging modest fees to those able to pay.
Although these non-phaco procedures are more affordable, one important question is to what degree are quality and safety compromised? Two studies Dr. Chang co-authored show that these cost effective techniques also provided quality outcomes. A prospective, randomized clinical trial published in the American Journal of Ophthalmology in January 2007 showed that compared with phaco, manual sutureless small-incision extracapsular cataract surgery achieved excellent visual outcomes with low complication rates for a charity population in Nepal1. A separate study published in the Journal of Cataract & Refractive Surgery in April 2009, showed that the modified sterilization and asepsis protocol adopted to facilitate high-volume cataract surgery at Aravind had only a 0.09% rate of postsurgical endophthalmitis in more than 42,000 consecutive cases at a single hospital2.
Dr. Chang said he hoped his lecture would inspire ophthalmologists in developed countries to help sustain this movement with financial and educational support. Thanks to promising model programs, such as those he highlighted, he believes there is hope for tackling the increasing backlog of cataract blindness in the developing world. He concluded by thanking his colleagues at these three organizations for continually reminding him that "although each year our own society, based on declining reimbursement, seems to value what we do less and less ... because cataracts account for more than half of all blindness, one of the most precious assets for any society is to have good cataract surgeons."
[1] Ruit S, Tabin G, Chang DF, et al. A Prospective Randomized Clinical Trial of Phacoemulsification vs Manual Sutureless Small Incision Extracapsular Cataract Surgery in Nepal. Am J Ophthalmol 2007; 143:32-38.
[2] Ravindran RD, Venkatesh R, Chang DF, et al. The incidence of post-cataract endophthalmitis at an Aravind Eye Hospital: Outcomes from more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009;35: 629-636.