Eyeworld

JAN 2016

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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EW INTERNATIONAL 58 by Lauren Lipuma EyeWorld Contributing Writer corneal edema. Trypan blue, Malyugin rings, capsule tension rings, a good chopper, and knowing how to do M-SICS would all be great skills to have in one's armamentari- um, he said, and retrobulbar blocks are helpful when there is a language barrier. Although surgeons experienced with M-SICS can have very low complication rates, it is important to work with experienced surgeons as part of a team and always work with local partners, ideally as part of a comprehensive ophthalmic system that has the capacity to manage complications, Dr. Oliva said. "Always strive to 'leave no pa- tient behind' and transport patients with complications from the field to a tertiary care center," he said. "Having negative outcomes can seri- ously damage local reputations and dampen surgical demand for years to come." Dr. Oliva thinks that performing careful biometry in rural or remote areas is undervalued by surgeons. "Most patients in the developing world will never access postopera- tive spectacles, and therefore doing everything possible to give the best postoperative uncorrected vision is critical," he said. Strive to create less surgically induced astigmatism by using temporal incisions with M-SICS rather than superior inci- sions, he added. Dr. Oliva's and Ambati's ex- periences show that combating blindness with effective and inex- pensive treatments would have a huge return on investment, and individual surgeons can do much to further this effort. "Cataract blind- ness can be beaten if experienced surgeons donate their time not only to perform services but also to train surgeons in other parts of the world, and if local governments put resources into programs that fight blindness," Dr. Ambati said. EW Editors' note: Drs. Ambati and Oliva have no financial interests related to this article. Contact information Ambati: bala.ambati@utah.edu Oliva: moliva@cureblindness.org in India, the Tilganga Institute of Ophthalmology in Nepal (supported by HCP), ORBIS, Project Hope, Sight for the Sightless, and Moran Eye Center's Global Outreach Division, according to Drs. Oliva and Ambati. "India is a great success story, with cataract surgical rates im- proving dramatically in the last 25 years," Dr. Ambati said. Currently, physicians and other healthcare providers are using these programs as models of efficient and high quality service delivery that can be exported to areas where infrastructure and funding are lack- ing—most notably in sub-Saharan Africa, Dr. Oliva said. "Ethiopia is a country where I work regularly and I anticipate will have a doubling of the number of cataract surgeries in the next 5 years." What can individual surgeons do? According to Drs. Oliva and Ambati, surgeons can do many things to get involved and help combat global cataract blindness. Becoming profi- cient in manual small incision cata- ract surgery (M-SICS) is a great first step, Dr. Oliva said. For the types of cataracts that physicians encoun- ter in many parts of the world, the M-SICS outcomes are equivalent to phacoemulsification—at a fraction of the cost, he said. Drs. Oliva and Ambati agreed that donating time for service, train- ing ophthalmologists in other coun- tries, and raising awareness among their patients about the problem are 3 things that any cataract surgeon can do. "I encourage individuals to serve as ambassadors for promot- ing cataract surgery in the world and publicizing the huge number of blind patients needing cataract surgery," Dr. Oliva said. "Many of our happy cataract patients here at home can be recruited to donate to- ward eliminating needless blindness in the world." Pearls for operating in the field Posterior capsule rupture, vitreous loss, zonular dialysis, and iris pro- lapse can all happen in the field, Dr. Ambati said, and hard cataracts can make removal difficult and lead to including being less likely to work, having limited participation in social events, having a reduced body mass index, having a negative effect on mental health, and being more likely to be divorced or separated," Dr. Oliva said. "Households with blind individuals were economically disadvantaged compared to other households. The study highlighted that blindness not only leads to individual human suffering, but also affects family members and the entire community considerably." The HCP study and other studies have found that there is also a considerable gender gap when it comes to accessing eyecare, with women being more likely to be blind from cataracts but less able to access surgical treatments, Dr. Oliva said. Blindness impacts women more than men indirectly as well. In de- veloping countries, it is usually the youngest female relative who cares for a blind individual, and therefore that granddaughter or niece can't go to school or work, said Bala Ambati, MD, professor and director of cornea research, Moran Eye Center, Univer- sity of Utah, Salt Lake City, and a volunteer with the ORBIS Flying Eye Hospital. The HCP study also found that restoring sight with cataract surgery in rural populations leads to dramat- ic improvements in basic function- ing, physical and mental health, and community participation. "We hope that publicizing the economic and social impacts of restoring sight will lead health officials to invest more toward providing cataract surgical services in the world," Dr. Oliva said. Efforts underway Most projections estimate that the backlog of cataract surgeries will grow, primarily due to the aging of the population, especially in Asia and Africa, Dr. Oliva said. "We are struggling to meet this demand, as there remains, especially in sub-Sa- haran Africa, a lack of infrastructure and manpower to address the issue," he said. Fortunately, successful blind- ness reduction programs already exist in some regions of the world. These include the Aravind Eye Care System and LV Prasad Eye Institute Individual surgeons can use their skills to help clear the worldwide backlog of cataract surgeries C ataracts are the leading cause of blindness around the globe. According to the World Health Organiza- tion (WHO), cataracts are responsible for bilateral sight loss in 20 million individuals worldwide. While cataracts are operable and surgery often has a high success rate, the vast majority of individuals blind from cataracts live in devel- oping countries and face significant barriers to accessing quality health- care. Specifically, in many of these countries, eyecare is expensive and hard to find—there are often too few doctors and eyecare programs are significantly underfunded. Breaking down these barriers may seem like a challenge suit- ed only for national and regional governments, but physicians from any country can use their skills to combat this growing problem. Here, 2 prominent ophthalmologists and active volunteer surgeons share their views on how individual surgeons can dedicate their time to best serve the eyecare needs of patients around the globe. Scope of the problem Part of the reason that little atten- tion and few resources are allocated to fighting cataract blindness in developing countries is a lack of understanding of how blindness affects individuals, families, and communities, said Matt Oliva, MD, associate clinical professor, Casey Eye Institute, and in private practice, Medford, Ore. Dr. Oliva is a board member of the Himalayan Cataract Project (HCP). The HCP is a non-profit orga- nization that has been providing quality eyecare to rural areas of Africa and Asia for more than 20 years. In 2012, the HCP enlisted the RAND Corporation—a non-profit research institute—to measure the costs of blindness to individuals and communities in rural Ethiopia. "We found that blindness has significant negative impacts, January 2016 Global cataract blindness: a burden and an opportunity

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