Thursday, April 2, 2009

The Cataphract's Cataracts

Ophthalmology is global health's low hanging fruit. The treatments for the most common diseases are effective and low cost. With the WHO/IAPB goal of eliminating preventable blindness by 2020 (clever), I think starting with cataracts, this is one goal we can hit as a civilization.

Humans depend on vision more than any one of their other senses. A loss or compromise in vision can have large detrimental effects on quality of life for an individual and economic loss for a society.

There is perhaps no better example in ophthalmology, or medicine for that matter, than treatment of cataracts.


(Courtesy of the WHO)

Cataracts are an clouding of the lens of the eye. The leading cause of cataracts, as most eye disease, is birthday candles (senile cataracts). However, several other genetic conditions and infectious diseases can exacerbate their manifestation. Radiation can also play a large part: airline pilots are three times more likely to develop cataracts than their non-airborne counterparts. So wear sunglasses.

Cataracts have afflicted humans for centuries. Galen a Greek physician for the Romans developed "couching," which is quite literally sticking a sharp point into the lens to move it to one side or the other, sans anesthesia.

The treatment is the removal of the lens through surgery, and replacing the lens with an artificial "intra-ocular lens" or IOL. With modern technology, the lens can be broken up using "phacoemulsification," or using ultrasound to break up the lens and suck it out of the eye with an incision no more than millimeters across. In countries that do not have "phaco" machines, the cataract needs to be removed manually with a larger incision.

More information on the manifestations and treatment of cataracts is below.

What is stupendous about cataracts is they account for 48% of the worlds preventable blindness. That itself might not sound like cause for celebration, but for twenty dollars, and twenty minutes, a trained ophthalmologist can take someone who couldn't even detect light, and restore their vision to 20/20, barring any other vision disease. In India, within the next year, a surgery can more than 1,500 times pay for itself for some patients. With the pie chart below from the WHO, we can see cataract's role in global blindness compared to other eye conditions.



There are many groups whose mission statement is to eliminate blindness in their populations. Some groups do it better than others, and some have a unique model for "cost recovery" that allows them to continue operations without an over-reliance on donations. In short, you have about 40% of your patients pay for surgery, and about 60% of your patients don't. The most well known groups work in West and South Asia for the same reason Willy Sutton robbed banks: that's where the blindness is.



One of the more studied models for eye care delivery to patients around the world at low to no cost is the Aravind Eye Hospital in India. The founder, the late Dr. Venkataswamy describes Aravind.'Our effort is to make Aravind an instrument of the Divine Will. We strive to forget our limitations and work with the direction of the Divine Will, not in a vain superficial way but with a deep commitment and faith that guidance comes from a higher level of consciousness. Then one is able to work with the great confidence that comes only with that faith and realization that we are all part of a spiritual capacity or spiritual power. It is then that all of nature works with you. You don't feel that you are a superior being but you are an instrument in the hands of a higher force and it is in that spirit that we meet our day to day struggles and successes.'

What is also unique about Aravind is their creation of Aurolab, which makes their own IOLs and suture at cost. The sutures and IOLs are then available around the world for other groups to use at cost. Aravind is studied all over the world for their cost-recovery model and commitment to the treatment of blindness.

A unique method of eye care delivery is the ORBIS Flying Eye Hospital. They took a huge plane and fitted it with teaching classrooms, treatment rooms, an operating room, and a recovery room. The plane flies all around the world. You can check out the itinerary here.



With all these different groups giving different models of care delivery, which one is the "best?" How can we define "best?" Cost-effective might be a good place to start. Equity of patient care might be another. The year is 2009, and the WHO with the International Agency for Preventable Blindness set the Vision 2020 goal: to eliminate avoidable blindness by the year 2020. "International Organizations" love to set arbitrary years for some percentage of an arbitrary goal to be reached. But with eleven years to go, and a near majority of preventable blindness treatable with effective and cost-effective therapeutics, I think this is a goal we can actually meet as a civilization.

I like cost-recovery models that after a clinic/hospital is built, it can pay for itself within three years and be generating money after that. Those dollars can then go into expanding services, or to pay investors who now have a vested interest in expanding the reach of the hospital. Another venue of social entrepreneurship, like everything else, with it's drawbacks.

Cataract Fun Fact- Although I do not have a copy of his slit lamp microscope exam, many scholars believe that Monet had cataracts. I mean, who comes up with this?



Further Reading-

WHO Cataracts- http://www.who.int/topics/cataract/en/
NEI Cataracts- http://www.nei.nih.gov/health/cataract/cataract_facts.asp

Economic Impact of Blindness- http://www.who.int/ncd/vision2020_actionplan/documents/frickfosterAJO1354712003.pdf

International Agency for the Prevention of Blindness- http://www.iapb.org/

Vision 2020 Campaign- http://www.v2020.org/

Aravind Eye Hospital- http://www.aravind.org/

Combat Blindness Foundation- http://www.combatblindness.org/cms/

Himalayan Cataract Project- http://www.cureblindness.org/

ORBIS- http://orbis.org/blindness.aspx?lang=1

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