March 2007




Perspectives in Cataract & IOL Surgery Bridging the gap

by Haripriya Aravind, M.D.


The Aravind system of clinics and surgery centers in India has been spectacularly successful in bringing excellence in cataract and IOL implant surgery to underserved patient populations. The system has become a model for much of the developing world. It focuses on how to address such critical issues and serves as a training site for surgeons from around the world. It has been inordinately helpful in the establishment and running of the ASCRS Foundation’s pediatric cataract clinic in Addis Ababa, Ethiopia. Haripriya Aravind M.D., chief consultant, cataract and IOL services, Aravind Eye Hospital, Madurai, India, is a spectacular surgeon, teacher, and author, who, in this article, provides an overview of how we can bring excellence in cataract surgery to a patient population that is not only underserved but overly represented in cataract cases. She is also a member of the ASCRS Foundation’s clinical committee on pediatric cataract surgery. As ophthalmology becomes more global, all surgeons should be increasingly interested in what is happening within our specialty all over the world.

I. Howard Fine, M.D. Column Editor



Advances in ophthalmic technology have preserved the sight of millions of people whose vision would have otherwise failed them. There are various astounding innovations in cataract technologies. The era has changed from couching to microphaco and from aphakic correction to the insertion of foldable multifocal intra-ocular lenses. The future promises an entirely new perspective of automated ultra miniature incisions, IOL designs incorporating wavefront technology, optical biometry and more.

As we marvel at these ever-changing advancements we realize that only one segment of the population enjoys this. At the other end are underdeveloped countries in West Africa where couching is the norm and in between we have Asian developing countries where we find a blend of development and advancement.

Let’s pause to look at the gaps that separate various nations and within these nations, the regions and what separates one individual from another, in enjoying these innovative technological advancements in cataract surgery

The gap in prevalence and management of cataract

Prevalence of cataract increases with age and tends to occur earlier in developing countries; for example, in an Indian study, cases of visually significant cataract occurred 14 years earlier than in a comparable study in the United States.1 During the next 20 years, the number of people over 65 years of age will more than double. This aging population will grow in both developing and developed countries. These demographic changes will lead to a doubling in the amount of cataracts developed, visual morbidity, and the need for cataract surgery.

The gap in surgical rate

The number of cataract operations performed per year, per million population is called the Cataract Surgical Rate (CSR). Economically well-developed countries usually perform between 4000 and 6000 cataract operations per million people per year. India has dramatically increased its CSR in the last 10 years from less than 1500 to a figure estimated at 3600 today. However, there is little evidence as yet that this CSR of 3600 in India is sufficient to keep pace with the incidence of cataract causing acuity of less than 20/200.2 India shoulders the largest burden of global blindness. Almost 15 million of the 1.08 billion world population is visually challenged and 52 million visually impaired. In most of Africa, China and the poorer countries of Asia the CSR is often less than 1000.

The major reasons for low cataract surgical rates in developing nations include: • Fear of surgery • Low demand because of poor visual results • Lack of eye surgeons in rural areas • No knowledge of where to seek help • No escort • Monetary reasons

Barriers in skill and technology

• Poor training facilities • Lack of infrastructure • Non-utilization of the available resources • Financial constraints for those keeping abreast with modern technology Bridging the gap To best tackle the problems associated with visual disability, one must mobilize resources in the most cost efficient manner. Development of high quality, high-volume, cost-effective cataract surgery with the help of programs that reach out to patients will help address the cataract backlog. The goal of any high quality program designed to reduce blindness is to make eye care services available, accessible, and affordable to all, through a sustainable delivery system. The high incidence of CSR in Tamil Nadu, a southern Indian state, is achieved mainly through outreach camps where the patients are screened for cataract and brought into the base hospital for surgery. Through this system many of the barriers for uptake of cataract services such as surgical cost, fear of surgery, access to ophthalmic care, transportation etc. are addressed.

The surgical technique adopted in a majority of these patients has a very good qualitative and quantitative visual outcome—manual sutureless extracapsular cataract extraction (ECCE).

In this technique the wound is a self sealing 6–7mm sclerocorneal tunnel constructed either superiorly or temporally based on the pre-operative astigmatism. Through a large capsulorehexis the nucleus is hydroprolapsed into the anterior chamber and the nucleus is extracted using an irrigating vectis. The advantages of this technique over conventional ECCE include the absence of suture related complications, a self-sealing wound, and capsular fixation of IOL with better centration and lesser incidence of PCO. The visual outcome, astigmatism, and endothelial cell loss are comparable to phacoemulsification.3,4 Ruit et al. in their prospective randomized clinical trial have proved that sutureless ECCE is significantly faster, less expensive, and less technology-dependent than phacoemulsification and hence might be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.5 The performance of surgery plays only a small part in the cure of cataract. It must be supported by a whole gamut of linked activities: •Revamping medical education •Ensuring optimal utilization of human resources •Adequate and proficient training of surgeons, nurses, and administrators Integration and coordination of all these activities, as well as many others, are required for a successful sustainable cataract intervention and delivery of good quality visual rehabilitation.

Advancement in technology will happen at one end of the spectrum and that has to occur to help find solutions for the visually impaired. On the other end there are factors such as population growth, aging, etc. due to which cataract blindness is increasing at a fast pace. A global effort to bridge the gap between advancing technology and outreach of clinical care will help reduce the incidence and backlog of cataract blindness. h

Editors’ note: Dr. Aravind has no financial affiliations in relation to this article.

Contact Information



1. Chaterjee A, Milton RC, Thyle S. Cataract prevalence and etiology in Punjab. Br J Ophthalmol. 1982 ; 6635-42 2. Allen Foster. Vision 2020: The cataract challenge. J Comm Eye Health 2000;13(34): 17-19 3. Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol. 2005 Sep; 89(9):1079-83.

4. George R, Rupauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. Ophthalmic Epidemiol. 2005 Oct; 12(5):293-7.

5. Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, Shrestha M, Paudyal G. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007 Jan; 143(1):32-38. Epub 2006 Sep 5.

Perspectives in Cataract & IOL Surgery Bridging the gap Perspectives in Cataract & IOL Surgery Bridging the gap
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