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Lessons from India

Cost and social pressure spark innovations in access, efficiency – and research

Howard Larkin

Posted: Saturday, February 1, 2020

Developed nations have much to learn about eye care from the developing world, particularly in reducing costs, improving the environment, increasing efficiency and patient access – and leveraging huge patient data sets to improve outcomes, Alan L Robin MD told Glaucoma Subspecialty Day at the 2019 ASCRS ASOA Annual Meeting in San Diego, USA.
Pressure to treat millions of patients with little or no income, and a lack of regulation, have promoted rapid innovation in India, said Dr Robin, who is the Executive Vice President of the American Glaucoma Society, Professor of Ophthalmology and international health at Johns Hopkins University in Baltimore and Professor of Opthalmology at the University of Michigan, Ann Arbor.
By focusing on low-cost systems and products to meet broad population needs, organisations including the Aravind Eye Care System have developed networks that dramatically increase access to eye care with predictable quality.
Aravind’s networks include local eye care outposts run by female technicians it recruits and trains that offer routine eye exams and screening for the equivalent of approximately €0.45. By manufacturing its own intraocular lenses and other surgical supplies, and highly systematising its hospitals, Aravind has reduced its cataract surgery costs to as little as €40 per case with a standard lens, noted Dr Robin, who is on the board of the Aravind Eye Foundation and has conducted multiple research projects with the organisation.
This enables Aravind to more than cover the cost of free and reduced fee care to low income patients through charges to patients who can pay. In 2017 and 2018 the organisation conducted 4.1 million outpatient examinations, nearly half-a-million surgical, laser and intravitreal injection procedures, and prescribed and dispensed 630,000 prescription spectacles. Aravind’s comprehensive electronic record system enables benchmarking individual surgeon performance, and comprehensive outcomes and quality improvement studies, Dr Robin added. Among recent findings: cataract surgeons who do 350 or more cases per year have much lower complication rates than surgeons who operate less; sharp-edged PMMA lenses resist PCO much longer than acrylic lenses; there is no difference in outcomes between single- and three-piece IOLs in patients with pseudoexfoliation at five years; and intracameral moxifloxacin reduces the risk of endophthalmitis 11-fold for phaco surgery, based on more than 600,000 cases.
“Where else are you going to find 600,000 cases at the same institution? I don’t know of anywhere else.”
This huge data resource helps put Aravind on the cutting edge of artificial intelligence as well. For example, an algorithm derived by Google from millions of patient retinal images may predict five-year risk for myocardial infarction and stroke.
Further innovations are coming that will improve health care around the world, Dr Robin believes.
“It’s amazing. Let’s see what happens when glaucoma becomes part of the artificial intelligence algorithm.”
Studies are already under way at two Aravind centres, with more to begin soon.

Alan L Robin: arobin@glaucomaexpert.com