The Challenge of Cataract Surgery in the oPt

Why phacoemulsification, and why is it so costly?

In the oPt, as in much of the developing world, cataract remains the leading cause of preventable blindness.  Around the world, there are well-established surgical techniques for removing the opaque cataractous lens and inserting a plastic ‘implant’ – or intra-ocular lens – but the challenge is to operate on as many people as possible, in the most cost-effective way and this is not so straightforward in practice.

Firstly, it is necessary to have skilled teams of doctors and nurses; secondly, facilities, which include a fully equipped, sterile operating room and instrumentation; lastly, the patients have to be able to get to the hospital and attend follow-up appointments.

At SJEHG, we are fortunate to have a skilled team and facilities in which to undertake cataract surgery, although access to the hospital may be restricted for patients and sometimes staff.

There is also a debate that is exercising everyone faced with the challenge of reducing cataract blindness in developing countries and that is, ‘what is the safest and most cost-effective surgical method for operating on cataracts, with the best outcome for patients?’

Nowadays there are two established methods for operating on cataracts. Both involve small incisions in the eye with no stitches and the insertion of an implant. One is called phacoemulsification and is regarded as the ‘gold standard’ in developed countries.  It entails the use of very expensive equipment and an ultrasound suction probe, which is used for removing the cataract. The other is called ‘manual small incision cataract surgery’ (SICS) and involves no expensive equipment and simple instrumentation. In skilled hands the results of SICS are as good, the surgical turnover time is 1.7 times faster and the cost per patient (excluding capital costs) is almost 5 times less.

A prospective randomised clinical trial of phacoemulsification vs manual sutureless small-incision cataract surgery was carried out in Nepal.  The conclusion drawn was:

“In the hands of experienced surgeons, both phacoemulsification and manual SICS achieved excellent visual outcomes, with low complication rates in patients with advanced cataracts. Manual SICS was a faster and less expensive technique than phacoemulsification. For this reason, we believe that manual SICS is the more appropriate technique for addressing the large and growing backlog of blinding cataracts in the developing world.”

However, despite the above, and for a number of reasons, there is not a clear case in favour of manual small incision cataract surgery. It is a technique with which few eye surgeons are totally familiar. This is partly because all over the developed world phacoemulsification has become the norm and SICS is simply not taught.

Surgeons who are expert at SICS often work in countries such as India or Nepal and gain their experience by operating on literally hundreds of patients in a week. In addition, many patients who have heard of phacoemulsification express a wish to have their surgery done by that method. Therefore, despite the obvious advantages to SICS of low cost and speed, there is still a duty placed upon eye surgeons (including those at SJEHG) to carry out the ‘gold standard’ procedure, even when working in a more challenging part of the world.

In 2011, SJEHG performed 3,109 phacoemulsification procedures across the oPt. 

Mr Nick Astbury FRCS FRCOphth FRCP
Hospital Group Trustee