Is Frugal Innovation Possible in Ophthalmology?

To meet future economic, resource, and personnel challenges, the global ophthalmological community needs frugal innovations and strategies to sustainably improve global eye care access, especially to underserved communities, explained David F Chang MD, who delivered the International Kelman Award lecture at the 2025 ESCRS Winter Meeting in Athens.

Cataract surgery has seen tremendous advances in the past 5 decades, primarily through new, expensive technologies. However, many of these advances are too costly for patients in low- and middle-income countries (LMIC) to benefit. In fact, the backlog of global blindness continues in many LMICs due to resource constraints and a shortage of cataract surgeons.

Doing more with less

Dr Chang introduced the Hindi concept of Jugaad, which means to find unconventional ways to achieve similar benefits with fewer resources or at a lower cost. In healthcare, frugal innovation would lower rather than raise the costs and resource consumption of delivering quality care. He cited 5 examples of how the Aravind Eye Care System (AECS) in Southern India has brought frugal innovation to cataract surgery.

The 14 hospitals within the AECS perform approximately 450,000 cataract operations each year, of which approximately 60% are at little to no cost to indigent patients who have extremely advanced cataracts. AECS uses a lower-tech method for them—sutureless, manual small-incision cataract surgery (MSICS)—that is well suited for mature cataracts and costs much less than phaco.¹ These patients receive non-foldable, PMMA IOLs with excellent functional outcomes.

Having the surgeons operate in an assembly line fashion allows them to achieve extremely high surgical volumes. For example, the team minimizes turnover time by including two adjacent operating tables per surgeon so the next patient can be prepared while the ophthalmologist operates on the other OR table. With phaco, surgeons position the machine between the two OR tables and don’t change the handpiece, tubing, cassette, or irrigation bottle between cases. Instead, that same phaco cassette is discarded at the end of the OR day.

Dr Chang collaborated with AECS on two other frugal innovations. Posterior capsular opacification (PCO) is an inconvenience in high-income countries (HIC) but a major cause of visual disability in LMICs where access to follow-up examinations and YAG lasers is often limited. Fortunately, adding a square edge to the PMMA IOL dramatically lowers the PCO rate to levels comparable to the best foldable IOLs and costs only US$1 per IOL.² AECS’s manufacturing company, Aurolab, produces the other collaboration he helped introduce: intracameral (IC) moxifloxacin. Approved in India, a 1.0 mL vial of intraocular moxifloxacin costs only US$1 and is enough to inject 0.1 mL into 7 eyes. By adopting the treatment, AECS lowered its endophthalmitis rate from 0.07% to 0.02%.³

Dr Chang believes ophthalmologists in HICs can learn lessons in frugal innovation from LMIC settings, such as the AECS. A prime example is the fifth AECS innovation—reuse of most cataract surgical supplies and drugs that must be discarded after a single use in most HICs. AECS has found reusing surgical gowns, phaco cassettes and tubing, irrigation bottles, cannulas, blades, and intraocular drugs does not result in higher infection rates. Indeed, looking at 2 million consecutive cataract operations in which these supplies were routinely reused, the endophthalmitis rate was only 0.04% (half of the cases didn’t receive IC moxifloxacin)³—identical to the endophthalmitis rate reported in 10.5 million consecutive American cataract operations reported in the AAO IRIS registry. These findings are compelling because reuse of these same supplies is not allowed in the US because of the theoretical risk of infection.

Additionally, this data supports the opinions of most North American and European cataract surgeons who, in surveys, felt OR waste is excessive and single-use mandates for virtually all eye surgical supplies and drugs are unnecessary.⁴ Dr Chang collaborated in another AECS study that found no evidence of bacterial contamination when irrigation bags and phaco handpieces and tubing were cultured after multiple uses.⁵

Spurred by these studies and other data, Dr Chang and others co-founded EyeSustain.org, a global coalition of 53 international eye societies dedicated to advancing sustainability in eye care through education, research, innovation, and advocacy. He currently chairs the advisory board. One of EyeSustain’s goals is to collaborate with industry to develop more multi-use products and environmentally friendly packaging and materials. For example, AECS data suggest an all-day phaco cassette is safe and need not be changed and discarded after one case. Manufacturers could charge a click fee to maintain per-case revenues while passing along some of the savings to surgical facilities. This would dramatically improve OR turnover times and reduce packaging, shipping emissions, shelf storage requirements, and plastic landfill waste.

He concluded by calling on the profession—ophthalmologists, researchers, engineers, industry, and eye societies—to aspire to frugal innovation that can democratize access to quality eye care while reducing unnecessary costs and waste.

For more information on sustainability in ophthalmology, please visit eyesustain.org.

David F Chang MD is Clinical Professor, University of California, San Francisco, US. He chairs the advisory board for EyeSustain. He has no relevant financial disclosures.

1. Haripriya A, Chang DF, Reena M, Shekhar M. “Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital,” J Cataract Refract Surg, 2012; 38(8): 1360–1369.

2. Haripriya A, Chang DF, Vijayakumar B, Niraj A, Shekhar M, Tanpreet S, Aravind S. “Long-term posterior capsule opacification reduction with square-edge polymethylmethacrylate intraocular lens,” Ophthalmology, 2017; 124(3): 295–302.

3. Haripriya A, Chang DF, Ravindran RD. “Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from two million consecutive cataract surgeries,” J Cataract Refract Surg, 2019; 45(9): 1226–1233.

4. Chang DF, Elferink S, Nuijts RMMA. “Survey of ESCRS members’ attitudes toward operating room waste,” J Cataract Refract Surg, 2023; 49(4): 341–347.

5. Shukla AG, Chang DF, Dhanaseelan T, Vivekanandan VR, Gubert J, Robin AL, Venkatesh R. “Reusing Surgical Materials for Cataract Surgery: An Assessment of Potential Contamination,” J Cataract Refract Surg, 2024; 50(10): 993–999.