Five lessons can be learned from 'greatest team of cataract surgeons in the world'
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There are five compelling lessons to be learned from the ophthalmologists at Aravind Eye Care System in southern India, which David Chang, MD, called “the greatest team of cataract surgeons in the world.”
These five lessons, which were the topic of his Ridley Medal Lecture at the virtual European Society of Cataract and Refractive Surgeons meeting, could help Western ophthalmic care make gains in cost-efficiency, environmental sustainability and compassion, he said.
Chang’s collaboration with the Aravind team of surgeons began with his first visit there in 2003. In Aravind’s pursuit to fight cataract blindness, it developed a model that conjugates efficiency and high-volume surgery with quality and financial self-sufficiency despite large numbers of patients who are too poor to pay for care.
“They do this by using revenue from paying patients to subsidize cataract surgery for the indigent, in a way that allows them to do 60% of their surgical volume on people who pay nothing. This cost-recovery model that is now emulated all over the world is the first important lesson,” Chang said.
Aravind accomplishes this by using a low-tech method called sutureless manual small-incision cataract surgery (MSICS), which achieves safe and effective outcomes at a significantly lower cost.
“Particularly for the very advanced cataracts that are so prevalent in the developing world, MSICS has an even lower complication rate than phaco in the hands of less experienced surgeons, and this is the second lesson. I often use MSICS in my own practice for the most challenging cataracts, and I think that many surgeons in the West would benefit from having this in their armamentarium,” Chang said.
The third lesson is that placing a square edge on even inexpensive PMMA IOLs will prevent posterior capsular opacification.
“Unlike in the West, where PCO is an inconvenience that we easily treat with YAG capsulotomy, it is a leading cause of visual disability in the developing world because of poor access to long-term care and a scarcity of YAG lasers. Despite costing only US$2, Aravind’s square-edge PMMA IOLs have been shown to do as well as any of our more expensive foldable IOLs in terms of PCO prevention,” Chang said.
Aravind has been able to provide the best data to demonstrate the safety and efficacy of intracameral moxifloxacin for antibiotic prophylaxis, and this is the fourth lesson. In 2019, it reported registry data on 2 million consecutive cataract surgeries performed over an 8-year period, the first half of which were performed without moxifloxacin and the second half with intracameral moxifloxacin.
“There was a 3.5-fold reduction in the overall infection rate, and the infection rate in 335,000 consecutive phacos was one per 10,000, which amazingly compares with the four per 10,000 endophthalmitis rate in the U.S. per our AAO nationwide registry. The main reason for this I believe is that roughly one-half of American cataract surgeons don’t employ intraocular antibiotics due to the lack of approved and commercially available solutions in the U.S.,” Chang said.
These data from Aravind are among the strongest in support of using intraocular antibiotic prophylaxis, he said.
Finally, reuse protocols and waste minimization have been implemented with the double aim of reducing the cost and the carbon footprint of cataract surgery at Aravind.
“Nothing is thrown away that can be reused, and this not only applies to phaco tips, tubing, irrigation solutions and pharmaceuticals, but even gloves and gowns, which they use and change after about five or six patients,” Chang said.
Surgery is performed in an assembly-line fashion, with multiple patients in the OR.
“These practices would be in violation of multiple regulations in the U.S., but the truth is that the phaco infection rate at Aravind is one per 10,000. Many of the regulations we have that mandate single use of most drugs and supplies are of unproven benefit in terms of preventing surgical infection, while they certainly result in a tremendous amount of OR waste,” Chang said.
“As a result, Aravind’s carbon footprint for a single phaco is 5% of one phaco performed in the U.K. or U.S. When you consider that the health care sector is responsible for 10% of all greenhouse gas emissions in the U.S. and 5% in Canada and U.K., you realize that our OR waste for so common a procedure as cataract surgery is not only financially but also environmentally unsustainable,” Chang said.
The COVID-19 pandemic has imposed changes in Aravind’s OR protocols, regarding both the number of patients in the OR and the reuse of gowns and gloves because of potential contamination. It is expected that Aravind will take this opportunity to collect new data to compare bacterial endophthalmitis rates pre- and post-COVID-19 with these differing protocols.
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Chang D. Five compelling lessons from the greatest team of cataract surgeons. Ridley Lecture. Presented at: European Society of Cataract and Refractive Surgeons meeting; Oct. 2-4, 2020 (virtual meeting).
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