March 2009




The greatest challenge in cataract surgery

By Michelle Dalton EyeWorld Contributing Editor


This year’s recipient, David F. Chang, M.D., describes how a 5-minute, $15 procedure can dramatically reduce cataract blindness in the developing world

Both peer-reviewed and trade journals continually update physicians on exciting advances and new technologies that are making cataract surgery even better for ophthalmologists and patients.

“In North America and Europe, most cataract surgeons would say that our greatest remaining challenge is to develop the ideal accommodating lens,” said David F. Chang, M.D., clinical professor of ophthalmology at the University of California San Francisco, and in private practice in Los Altos, Calif. “The forgotten irony is that cataract is still the leading cause of global blindness, and more than half of all blindness in the world is reversible through cataract surgery.” Dr. Chang will deliver the Binkhorst Lecture at this year’s American Society of Cataract and Refractive Surgery (ASCRS), and will focus on the global backlog of cataract blindness.

“In the developed world, who, other than ophthalmologists, can better appreciate just how daunting the challenge of reducing global cataract blindness is,” he said. “In developing countries, the obstacles include the high cost of phaco and foldable IOL technology, a critical shortage of ophthalmologists, and insufficient educational infrastructure to train novice phaco surgeons, let alone those skilled enough to tackle the advanced and mature cataracts typically encountered,” he explained.

“I hope to highlight what I believe is the single greatest accomplishment in cataract surgery – the combination of a low cost procedure within a high volume, highly efficient surgical delivery system that can help stem the epidemic rise in cataract blindness in the developing world,” he said. “When you think about cost effectiveness and impact on human suffering, there are very few medical interventions in developing countries that can match cataract surgery,” Dr. Chang explained. “The key, however, is to train local eye surgeons to perform low cost cataract operations in efficient hospital settings that are financially self-sustaining.” The procedure itself is a manual, sutureless, small incision extracapsular procedure that employs reusable equipment and low cost supplies, he said. Referred to as manual SICS (small incision cataract surgery), the five Aravind Eye Hospitals in southern India have used this technique for years to provide charitable cataract surgery at a cost of less than $15 per case. Charitable manual SICS accounts for roughly 70% of the 200,000 annual cataract surgeries performed within the Aravind system. Dr. Chang said this volume is accomplished by streamlining the surgical process through the use of standardized protocols executed by well-trained ancillary staff. Costs are reduced by manufacturing affordable, low cost PMMA IOLs, viscoelastic, supplies and eye medications in their own in house facility.

“I wish that every cataract surgeon could observe the speed, skill, and efficiency of this procedure as it is practiced at Aravind first hand,” Dr. Chang said. “I will show a video of the remarkable teamwork and orchestration of an Aravind O.R. where a single surgeon performs 12-16 procedures per hour.”

A similar system on a smaller scale is succeeding in Nepal at the Tilganga Eye Center, under the direction of Sanduk Ruit, M.D., who also embraces the manual, sutureless SICS method. While Tilganga is a modern eye hospital serving the urban population of Kathmandu, Dr. Ruit and his team have pioneered a portable high volume cataract surgery system in order to reach the mountainous rural regions of Nepal. Some of these areas can only be reached by foot and all of the equipment must be carried in by the surgical team. Dr. Ruit co-founded the Himalayan Cataract Project with University of Utah ophthalmologist, Geoffrey Tabin, M.D., in order to train other cataract surgeons from developing countries throughout mountainous Asia. “In the U.S., we are accustomed to solving so many medical problems with new technology, but the solution to global cataract blindness is to go low tech,” Dr. Chang said. He noted that historically, many have questioned whether quality is being sacrificed with non-phaco procedures, and he will report on the first randomized, prospective comparison of phaco and manual SICS in a charitable cataract surgical population. In the study, which was conducted in Nepal, patients either underwent phaco by Dr. Chang or manual SICS performed by Dr. Ruit, and the results proved that manual SICS can achieve superb outcomes with advanced cataracts, at a fraction of the cost of phaco.1 Dr. Chang will also discuss Project Vision, coordinated by Dennis Lam, FRCS, FRCOphth, who is Chairman of Ophthalmology at the Chinese University in Hong Kong. Despite its exploding economic growth, China has one of the worst cataract blindness rates in the world, according to Dr. Chang. Project Vision is a creative, large scale collaboration of private philanthropy, academic ophthalmology, and the Chinese government to overcome institutional and demographic barriers to reducing cataract blindness in China. Dr. Chang is hopeful that Binkhorst Lecture attendees “will be educated about the scope of global cataract blindness, and be inspired by the wonderful progress that’s been made at eye hospitals like Aravind and Tilganga.” Having an affordable procedure is an important start, but Dr. Chang stresses that the real accomplishment was in developing these streamlined systems of delivering high volume surgery and maximizing the productivity of the scarcest asset—the cataract surgeon. Slowly but surely, Aravind and Tilganga are training surgeons from other developing countries in these high volume, manual SICS methods. “Only another cataract surgeon can truly appreciate what these model centers are achieving,” he said. “And the only way to make a significant impact toward reducing cataract blindness is through the ripple effect of teaching more and more local cataract surgeons how to organize and replicate these model systems. Aravind, Tilganga, and Project Vision are three different, but complimentary models that offer real hope for reducing the global burden of cataract blindness, and we in the West need to help sustain this movement with financial and educational support.” With “Congress and insurance companies telling us yearly that what we do is less and less valuable, and it is easy to feel demoralized and underappreciated as a result,” Dr. Chang said. “The tireless dedication of our colleagues in developing countries, however, reminds us of just how profound the impact of cataract surgery is, and how incredibly precious our skills and knowledge truly are.”

The Binkhorst lecture and medal were established in 1975 in honor of IOL pioneer Cornelius D. Binkhorst. Each year, ASCRS awards the medal to an individual who has followed in Dr. Binkhorst’s footsteps with outstanding contributions to the understanding and practice of cataract surgery and IOL implantation. Honorees, who present the Binkhorst lecture during the annual ASCRS Symposium on Cataract, IOL and Refractive Surgery, include some of the world’s most prominent pioneering surgeons.

Dr. Chang is serving a 5-year term as chairman of the AAO Annual Meeting Program Committee. He is chair for the AAO Cataract Preferred Practice Pattern Panel, past chair for the AAO Practicing Ophthalmologist Curriculum Committee on Cataract, and chair of the ASCRS Cataract Clinical Committee. He served for five years as co-chief medical editor of Cataract and Refractive Surgery Today.

Dr. Chang was the inaugural recipient of the UCSF Department of Ophthalmology’s Distinguished Alumni Award (2005) and in 2006 became only the third ophthalmologist to ever receive the Charlotte Baer Award honoring the outstanding clinical faculty member at the UCSF Medical School. He was the third recipient of the Strampelli Medal from the Italian Ophthalmological Society (2007), and has been invited to give 17 named and keynote lectures, including the Lim Lecture at the 2009 Asia Pacific Association of Cataract and Refractive Surgery meeting. Dr. Chang serves on the medical advisory board of two global humanitarian organizations, Himalayan Cataract Project and Project Vision, and is also on the Board of Directors for the Pan American Association of Ophthalmology.

Editor’s note: The Binkhorst Lecture will be held during the ASCRS Opening Session, Saturday April 4, 2009, in the Moscone Center.


Chang: (650) 948-9123;


1 Ruit S, Tabin G, Chang D, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143(1):32-38.

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