How Aravind Hospitals

Fighting blindness in the developing world

Courtesy of Aravind Eye Care System

Aravind Hospitals do more with less and save sight in the process. Dermot McGrath reports

From humble beginnings as a small clinic with just 11 beds and the audacious goal of curing preventable blindness, the Aravind Eye Care System in southern India has grown into the largest eye care provider in the world and serves as a model for how cataract blindness might effectively be eliminated in the developing world, said David F. Chang in his Ridley Medal Lecture at the 38th Congress of the ESCRS.

“I have long felt that our single greatest challenge in cataracy surgery was not the invention of an accommodating IOL but rather reversing the rapidly increasing backlog of cataract blindness in the developing world, which accounts for half of all global blindness,” he said.

One of the major stumbling blocks to tackling the caseload is the shortage of qualified cataract surgeons in developing countries, said Dr Chang.

“We need to maximise their productivity by allowing them to do rapid surgery at a very high volume. But it has to work well with the advanced cataracts that they face and to be performed with a very low complication rate. And then it also has to be cost effective and affordable,” he said.

Remarkably, the Aravind Eye Care System in India has managed to achieve all of these goals since it was first established in 1976 by Dr Govindappa Venkataswamy, or Dr V as he came to be known, said Dr Chang.

“After reaching the mandatory age of retirement from the government hospital at 58, Dr V needed something new to do. So, he founded this modest family eye clinic, financed it himself and grew the system with the help of his family.”

HIGH-QUALITY AND COMPASSIONATE EYE CARE Dr V’s goal in setting up Aravind was to eliminate needless blindness by providing high-quality and compassionate eye care that was affordable for all.

“It’s a proven model that is now emulated in so many countries and settings around the world, and this has given hope to all of us,” added Dr Chang.

Reflecting on his own association with

Aravind, which dates back to 2003, Dr Chang, Clinical Professor at the University of California, San Francisco, said that there are many lessons to be learnt from the Aravind model of providing large-volume, high-quality and affordable care through its network of 13 eye hospitals and 75 primary eye care facilities.

“I made the observation a few years ago that resource-rich countries like mine in the United States can still learn a lot from resource-poor settings such as in southern India. And I wanted to highlight some of the lessons that we can take from the Aravind model, the most important of which is that there is a proven way to eradicate global cataract blindness,” he said. ASSEMBLY-LINE APPROACH A critical component of Aravind’s model is high patient volume, which brings with Courtesy of David F. Chang it the benefits of economies of scale, noted Dr Chang. Assembly line for cataract surgery. One surgeon alternates between two operating tables with one patient prepped and draped while the other is undergoing surgery through a temporal incision

Aravind’s unique assembly-line approach, with rates often exceeding 14-to-16 cases per surgical blades and equipment. An IOL costs cause of visual impairment due to a hour per surgeon, increases productivity but less than $2 (US) and the entire cost of preponderance of PMMA IOLs. without compromising on safety or quality. disposables per case is just $10. They also “PCO is an inconvenience for us in the

“When I first saw this, I marvelled at how reuse as many supplies as possible such as West but a leading cause of visual disability well choreographed it all was. Around 40% tubing, gowns, gloves and drugs to cut down in developing countries due to poor access of private paying patients subsidise eye care on wastage. Despite this and operating on to care. We showed in long-term studies for the other 60%, who receive services either multiple patients simultaneously in the same with up to nine years of follow-up that free of cost or at a steeply subsidised rate, large OR, their infection rates are no higher adding a square edge to the PMMA optic yet the organisation remains financially self- than in the West,” he said. is an inexpensive modification that greatly sustainable. The message is that we can use Large-scale studies at Aravind show reduces PCO rates,” he said. this type of cost-recovery model to reduce that the MSICS complication rate is lower Another key lesson to emerge from the and eventually eliminate global cataract than that with phacoemulsification for Aravind experience is that intracameral blindness,” he said. less experienced surgeons, and comparable moxifloxacin is safe and effective for

At the heart of Aravind’s approach to for the most experienced surgeons. endophthalmitis prophylaxis. cataract surgery in the indigent is the use of Furthermore, Dr Chang noted that indigent “The data is very robust and is based suture-less manual small-incision cataract populations have a significant burden of on 2 million consecutive surgeries over an surgery (MSICS) explained Dr Chang. The ultra-brunescent and mature cataracts, eight-year period. The rate of postoperative technique uses a long, temporal, scleral- increasing the risk of complications with endophthalmitis dropped from seven per pocket incision that is wide enough to phacoemulsification. 10,000 cases to two per 10,000 with the enable manual extraction of the undivided “Our studies at Aravind concluded that introduction of low-cost intracameral nucleus, after which a low-cost PMMA IOL MSICS is a safer procedure than phaco moxifloxacin,” he said. is implanted. The incision is self-sealing, for many surgeons unless they are very A final lesson to be drawn from the Aravind requires no sutures and is very fast to perform experienced with advanced hard cataracts. experience is that inflexible operating room for an experienced surgeon. The private pay I now use MSICS in my own practice for regulations in developed countries mandating patients receive phacoemulsification with the most advanced cataracts and I would single-use of most drugs and supplies may be foldable IOLs. maintain that many of us in the West would of unproven benefit in reducing infection benefit by doing more of this as well,” he said. rates, said Dr Chang. CONTROLLING COSTS “The single-use rationale is supposedly The system is designed to keep expenses to an absolute minimum without compromising on safety or quality, said Dr Chang. “In order to control costs, Aravind has its own manufacturing company that produces all consumables such as intraocular lenses, surgical sutures, pharmaceutical products, SQUARE-EDGE IOLS TO TACKLE PCO Published studies from Aravind have also shown that a squared posterior optic edge reduces PCO regardless of IOL material, said Dr Chang. This is important in developing countries where posterior capsular opacification (PCO) is a leading to lower the infection rate. And yet our phacoemulsification infection rate in the US, where we dispose of everything after one use, is four times higher than the Aravind hospitals, where supply reuse and intracameral moxifloxacin are routine,” he said. Dr Chang added that both the financial and environmental sustainability of cataract surgery is threatened by excessive surgical waste as the volume of surgery When I first saw this, I marvelled at increases worldwide. “We need to learn from systems such as how well choreographed it all was. Aravind’s how to be more efficient, reduce waste and reduce our carbon footprint Around 40% of private paying patients while performing the most common subsidise eye care for the other 60%... operation in the world,” he concluded. David F. Chang David F. Chang: dceye@earthlink.net