ASCRS News
Summer 2024
by Ellen Stodola
Editorial Co-Director
David F. Chang, MD, gave the Charles D. Kelman, MD, Innovator’s Lecture at the 2024 ASCRS Annual Meeting on “frugal innovation,” highlighting this as “the key to tackling our greatest challenges in cataract surgery.” We tend to think of innovation in terms of new cutting-edge, advanced technologies, Dr. Chang said. However, the Hindi term “jugaad” describes frugal innovation, which in the engineering world refers to an inexpensive and creative alternative to a more expensive technology. How would frugal innovation be applied to healthcare systems? “It would mean achieving the same outcomes in much larger populations by employing more cost-effective solutions that are sustainable long term,” he said. To illustrate the concept of jugaad, Dr. Chang asked the audience to imagine that for decades we had to rely on a femtosecond laser to perform the anterior capsulotomy. Then a creative individual discovered that you could achieve the same outcome more efficiently using a $0.15 bent needle as an irrigating cystotome.
In his 2009 Cornelius D. Binkhorst, MD, Lecture, Dr. Chang highlighted why the increasing global backlog of cataract blindness was the biggest challenge facing cataract surgeons. He said this was due to insufficient numbers of ophthalmologists and resources in low-income countries (LIC) around the world. In 2024, that burden continues in LIC, but we now foresee the looming problem of access to cataract surgery even in high-income countries (HIC). “This will be due to insufficient manpower to keep pace with increasing demand, while we consume and waste resources at rates that are financially and environmentally unsustainable,” he said.
Source: ASCRS
Dr. Chang used the Aravind Eye Care System (AECS) to illustrate the benefits of frugal innovation in cataract surgery. Starting with his first visit in 2003, he and colleagues at AECS have published 2 dozen papers to share these lessons with ophthalmologists in HIC. He described five frugal innovations: manual small incision cataract surgery (MSICS); a high-volume, assembly line surgical model; developing a square-edge PMMA IOL; developing low-cost intraocular moxifloxacin; and methods to reuse surgical supplies and devices that are discarded after one use in HIC.
MSICS enables low-cost surgery with PMMA IOLs in the charity population at AECS. The astigmatic outcomes are comparable to phaco because of the sutureless temporal incisions. One study found that phaco had a much higher complication rate for inexperienced surgeons, such as many of those practicing in LIC. MSICS might be a safer option to begin with in those settings. By standardizing instrumentation and supplies across all 14 hospitals, by manufacturing most supplies in-house, and by reusing surgical gowns, gloves, phaco cassettes, I/A tubing, irrigation bottles, blades, sutures, and intraocular drugs, a single surgeon can perform 10 or more MSICS cases per hour while spending less than $15 per case in supplies for the charity patient population. Paying patients receive phaco, and this subsidizes the charity care, which amounts to 60% of the nearly 450,000 cataract operations performed annually at AECS.
Aravind also developed a square edge for its PMMA IOLs at a cost of $1 per lens, which dramatically reduced posterior capsular opacification in their MSICS population. They developed a 0.5% intraocular moxifloxacin solution costing $1 per vial, which is approved in India and reduced their endophthalmitis rate by 3.5-fold. Finally, their reuse of most supplies and devices that are routinely discarded after single use in HIC has reduced the carbon footprint of one phaco performed at Aravind to 5% of that of one phaco performed in the U.K.
“Although it is infuriating to realize that we are generating 20 times more carbon emissions and waste by discarding everything after a single use with no apparent benefit, there is cause for optimism.”
David F. Chang, MD
Dr. Chang pointed out that the reason single use of virtually every supply is mandated in HIC is to prevent infection. However, he presented data showing that AECS reported the same 0.04% endophthalmitis rate in 2 million consecutive cases as did the AAO IRIS Registry during an overlapping period with 8.5 million consecutive surgeries. “Although it is infuriating to realize that we are generating 20 times more carbon emissions and waste by discarding everything after a single use with no apparent benefit, there is cause for optimism,” Dr. Chang said. “This means that we could significantly reduce our waste and spending without endangering patients.”
Dr. Chang highlighted EyeSustain, a global coalition of 49 ophthalmology societies wishing to advance sustainability in ophthalmology. Co-sponsored by ASCRS, ESCRS, and AAO, EyeSustain is an online hub of resources, tools, and educational materials to help ophthalmologists and surgical facilities reduce waste and environmental impact.
Beyond the need to become more sustainable, Dr. Chang ended his lecture by wondering if fully autonomous robotic cataract surgery might someday mitigate our manpower shortage by allowing one surgeon to simultaneously supervise multiple robotic surgeries on routine cases. He showed himself performing an entire procedure on a porcine eye using the ORYOM (Forsight Robotics) semi-autonomous system where he operated robotic arms from a workstation located 20 feet away from the eye. “If you could develop AI-powered, machine learning software that performed as well as a competent surgeon, you could conceivably mass produce robotic surgical systems for less than it would cost to train and compensate an equal number of new cataract surgeons, hence a frugal innovation,” he concluded.
Relevant disclosures
Chang: Alcon, Carl Zeiss Meditec, Forsight Robotics, Johnson & Johnson Vision
Contact
Chang: dceye@earthlink.net
