EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78712
28 EWInternational April 2012 International outlook Beyond cataract backlog, India looks ahead by Matt Young EyeWorld Contributing Editor A s a third-year resident, I spent 6 weeks at the Aravind Eye Hospital in Madurai, India. I was impressed by the extraordinary skill of the surgeons I was trained by and humbled by their dedi- cation to the welfare of their patients. The number of people in need seemed over- whelming to me, but the commitment to providing quality care was never compro- mised. Their goal was to eliminate cataract blindness. Fast forward 20 years and India has started to emerge as a global eco- nomic force. Willingness to embrace tech- nology and innovation is part of the reason for India's growth, and this is reflected in the practices of Indian eye surgeons. Great progress has been made to provide eye- care for all in need, but there is still much to be done. Demand, finite resources, and an aging population are factors that India has in common with the Western nations. In this month's International outlook, three leading Indian ophthalmologists share the challenges they face and their views on the future. I think you may be surprised by how much of this sounds familiar. John Vukich, M.D., international editor Three Indian surgeons discuss cataract surgery challenges—and face issues similar to their colleagues in the West I n December 1997, an article appearing in the Indian Journal of Community Health noted that there were more than 12 million people blind due to cataract in that nation. In January 2010, during a trip to Chennai as part of a Unite for Sight mission to improve eye health in local Indian communities, I learned that the backlog was being eradi- cated bit by bit. At Chennai-based Uma Eye Clinic, 66 visual screening camps in 2005 evaluated 8,663 impoverished patients. By 2009, there were 394 organized camps performing 62,899 screenings. "The backlog can melt like snow if socioeconomic conditions im- prove," Arulmozhi Varman, M.D., medical director, Uma Eye Clinic, told me at the time. "The backlog occurs because the large population can't access [proper ophthalmic] fa- cilities. If the economy zooms up, the backlog will be wiped out be- cause of socioeconomic improve- ment. It's in the meantime—the underlying word is meantime—[that we need to help]." This year, I spoke with three Indian ophthalmologists and asked the following question: "What chal- lenges do you believe are unique to practicing as a cataract surgeon in India?" Interestingly, there were some hints about the backlog, but prob- lems similar to ones faced by the developed world came through more strongly. Certainly no one is turning a blind eye to that continuing prob- lem, but surgeons are focused on technique-related issues much like their Western counterparts, and they talked about upgrading to better technology. The overriding sense from those interviews was one not of hope (that things get better), but of progress (because they have). So what do these three surgeons consider challenges today? Further, D. Ramamurthy, M.D., chairman, The Eye Foundation, Coimbatore, India, and chairman, Scientific Committee, All India Ophthalmological Society (AIOS) The greatest challenges to me are quantity as well as quality. There is a huge number of patients who need cataract surgery. At the same time, not just the upper class but also the middle and [lower] classes need to be informed about their options. They want nothing but the best. Today, 90% of patients at least get an IOL. Non-phaco small inci- sion cataract surgery is also quite popular, but most of the current crop of young ophthalmologists is becoming [used to performing] phaco. More and more foldable lenses are being implanted. There is considerable interest in premium lenses, and not just in bigger cities and bigger centers. Good doctors in small centers are implanting these lenses. I do feel that nowadays, one good thing happening is that I am able to afford and have access to ma- chines like the INFINITI (Alcon, Fort Worth, Texas) and Stellaris (Bausch + Lomb, Rochester, N.Y.). Other sur- geons have good Indian phaco machines that are comparable to mid-level phaco machines that are imported at a considerably higher cost. Toric IOLs are manufactured in India today. In the not-too-distant future, India will be quite self suffi- cient [in terms of manufacturing cataract technology]. Phaco will be- come the norm. India might become a hub of export of these technolo- gies. There is one company called Appasamy Associates (Chennai, India) that has good phaco ma- chines that are being widely used. I hardly use them, but I admire them what technology is being used, and what does the future hold for cataract surgery in India? Here's what they said, in their own words. for the developments they have made. This equipment comes at an affordable price. Amar Agarwal, F.R.C.S., F.R.C.Ophth., chairman and managing director, Dr. Agarwal's Eye Hospital Ltd., Chennai, India, and president, International Society of Refractive Surgery (ISRS) We started our hospital group 35 years back. Now we have 50 eye hospitals all over the country. Our aim is to have multiple hospitals giving high quality eyecare—from the highest vitreoretinal surgical standards to eyeglasses—under one roof. That's the game plan. [As far as challenges,] I don't think they are unique to India alone. Globally, the biggest challenge is when a posterior capsular rupture develops. If you have promised a pa- tient a multifocal IOL and you are not able to implant because of a large rupture, this is a problem for every surgeon. We have started using a technol- ogy called the glued intraocular lens. This employs tissue glue to implant an IOL in an eye without a capsule. The bottom line: It will increase your armamentarium and truly ben- efit the patient. The other challenge in cataract surgery is to explain to a patient how to move to a premium IOL. If the patient moves to a premium IOL, depending upon conditions, he will have a bigger advantage com- pared to using a normal IOL. For ex- ample, if a patient has astigmatism, I will advise him to [get] a toric IOL. A third challenge a cataract sur- geon has is to have topography ma- chines and OCT machines in his setup because if there are some basic problems in the retina or the cornea, these machines should be able to di- agnose the problem. Every surgeon now knows how to do good phaco surgery. What we need to teach is when you get a PC rupture, how to do a vitrectomy and how to fix the IOL inside the eye.