Fighting blindness in the developing world

The inpatient building at the Aravind Eye Hospital, Madurai, India From humble beginnings as a small clinic with just 11 beds and the audacious goal of curing preventable blindness, the Aravind Eye Care System in southern India has grown into the largest eye care provider in the world and serves as a model for how cataract blindness might effectively be eliminated in the developing world, said David F. Chang in his Ridley Medal Lecture at the 38th Congress of the ESCRS. “I have long felt that our single greatest challenge in cataracy surgery was not the invention of an accommodating IOL but rather reversing the rapidly increasing backlog of cataract blindness in the developing world, which accounts for half of all global blindness,” he said. One of the major stumbling blocks to tackling the caseload is the shortage of qualified cataract surgeons in developing countries, said Dr Chang. “We need to maximise their productivity by allowing them to do rapid surgery at a very high volume. But it has to work well with the advanced cataracts that they face and to be performed with a very low complication rate. And then it also has to be cost effective and affordable,” he said. Remarkably, the Aravind Eye Care System in India has managed to achieve all of these goals since it was first established in 1976 by Dr Govindappa Venkataswamy, or Dr V as he came to be known, said Dr Chang. “After reaching the mandatory age of retirement from the government hospital at 58, Dr V needed something new to do. So, he founded this modest family eye clinic, financed it himself and grew the system with the help of his family.” High-quality and compassionate eye care Dr V’s goal in setting up Aravind was to eliminate needless blindness by providing high-quality and compassionate eye care that was affordable for all. “It's a proven model that is now emulated in so many countries and settings around the world, and this has given hope to all of us,” added Dr Chang. Reflecting on his own association with Aravind, which dates back to 2003, Dr Chang, Clinical Professor at the University of California, San Francisco, said that there are many lessons to be learnt from the Aravind model of providing large-volume, high-quality and affordable care through its network of 13 eye hospitals and 75 primary eye care facilities. “I made the observation a few years ago that resource-rich countries like mine in the United States can still learn a lot from resource-poor settings such as in southern India. And I wanted to highlight some of the lessons that we can take from the Aravind model, the most important of which is that there is a proven way to eradicate global cataract blindness,” he said. Assembly-line approach A critical component of Aravind’s model is high patient volume, which brings with it the benefits of economies of scale, noted Dr Chang. Aravind’s unique assembly-line approach, with rates often exceeding 14-to-16 cases per hour per surgeon, increases productivity but without compromising on safety or quality. “When I first saw this, I marvelled at how well choreographed it all was. Around 40% of private paying patients subsidise eye care for the other 60%, who receive services either free of cost or at a steeply subsidised rate, yet the organisation remains financially self-sustainable. The message is that we can use this type of cost-recovery model to reduce and eventually eliminate global cataract blindness,” he said. At the heart of Aravind’s approach to cataract surgery in the indigent is the use of suture-less manual small-incision cataract surgery (MSICS) explained Dr Chang. The technique uses a long, temporal, scleral-pocket incision that is wide enough to enable manual extraction of the undivided nucleus, after which a low-cost PMMA IOL is implanted. The incision is self-sealing, requires no sutures and is very fast to perform for an experienced surgeon. The private pay patients receive phacoemulsification with foldable IOLs. Controlling costs The system is designed to keep expenses to an absolute minimum without compromising on safety or quality, said Dr Chang. “In order to control costs, Aravind has its own manufacturing company that produces all consumables such as intraocular lenses, surgical sutures, pharmaceutical products, surgical blades and equipment. An IOL costs less than $2 (US) and the entire cost of disposables per case is just $10. They also reuse as many supplies as possible such as tubing, gowns, gloves and drugs to cut down on wastage. Despite this and operating on multiple patients simultaneously in the same large OR, their infection rates are no higher than in the West,” he said. Large-scale studies at Aravind show that the MSICS complication rate is lower than that with phacoemulsification for less experienced surgeons, and comparable for the most experienced surgeons. Furthermore, Dr Chang noted that indigent populations have a significant burden of ultra-brunescent and mature cataracts, increasing the risk of complications with phacoemulsification. “Our studies at Aravind concluded that MSICS is a safer procedure than phaco for many surgeons unless they are very experienced with advanced hard cataracts. I now use MSICS in my own practice for the most advanced cataracts and I would maintain that many of us in the West would benefit by doing more of this as wel,” he said. Square-edge IOLs to tackle PCO Published studies from Aravind have also shown that a squared posterior optic edge reduces PCO regardless of IOL material, said Dr Chang. This is important in developing countries where posterior capsular opacification (PCO) is a leading cause of visual impairment due to a preponderance of PMMA IOLs. “PCO is an inconvenience for us in the West but a leading cause of visual disability in developing countries due to poor access to care. We showed in long-term studies with up to nine years of follow-up that adding a square edge to the PMMA optic is an inexpensive modification that greatly reduces PCO rates,” he said. Another key lesson to emerge from the Aravind experience is that intracameral moxifloxacin is safe and effective for endophthalmitis prophylaxis. “The data is very robust and is based on 2 million consecutive surgeries over an eight-year period. The rate of postoperative endophthalmitis dropped from seven per 10,000 cases to two per 10,000 with the introduction of low-cost intracameral moxifloxacin,” he said. A final lesson to be drawn from the Aravind experience is that inflexible operating room regulations in developed countries mandating single-use of most drugs and supplies may be of unproven benefit in reducing infection rates, said Dr Chang. “The single-use rationale is supposedly to lower the infection rate. And yet our phacoemulsification infection rate in the US, where we dispose of everything after one use, is four times higher than the Aravind hospitals, where supply reuse and intracameral moxifloxacin are routine,” he said. Dr Chang added that both the financial and environmental sustainability of cataract surgery is threatened by excessive surgical waste as the volume of surgery increases worldwide. “We need to learn from systems such as Aravind’s how to be more efficient, reduce waste and reduce our carbon footprint while performing the most common operation in the world,” he concluded. David F. Chang: dceye@earthlink.net

Tags: aravind eye clinic, david chang, ESCRS Virtual Congress 2020