The great divide

In his shortlisted essay for the 2018 John Henahan Writing Prize, Dr Lawrence Kindo says marrying innovations in cataract surgery with affordability should be the goal for ophthalmologists

Lawrence Kindo

Posted: Friday, June 1, 2018

What would you say if you were asked, “Has innovation and development in cataract surgery reached its zenith?” With modern technology making inroads into every field of expertise, I would most certainly blurt out, “Maybe cataract surgery has seen its heyday, but there is still much to be desired!”

Consider the following scenario.

Crouched awkwardly over a clunky operating microscope, peering through the oddly placed eyepieces, within the claustrophobic confines of a make-shift operating room in the hindquarters of a pickup van parked right across a grubby street corner, a senior doctor and his cheerful assistant are busy operating on the eye of an old man from the shoddy neighbourhood. Thanks to the mature cataract in both his eyes and to his abject poverty, he is virtually blind. The 20-minute trial in the back of the van is the only way he hopes to see again. With the bare essentials sponsored by a generous benefactor, the surgeon manages to perform an extracapsular cataract surgery, even placing an intraocular lens in the old man’s eye. God willing, it should be an uneventful recovery. He shall see again!

Millions across the world are faced with similar situations, particularly in the Third World countries of Asia and Africa. The odds are so pitiable that even couching, an obsolete and outright dangerous practice with its attendant unacceptable sequelae, is still in vogue among quacks in some parts of Nigeria. Such are the situations where innovation and affordability do not see eye to eye, particularly when resources worth millions are spent on research and development. The urgency to provide basic ophthalmic care to every human being far outweighs the burden of advanced care for the select few who can afford it.

Thinking of cataract surgery as the ophthalmologist’s bread and butter is not a new idea, and rightly so. Not only is cataract surgery the most common ocular surgery performed in the world, it is also one of the commonest surgeries of any kind, ever known to mankind. From the grotesque and almost non-legal practice of couching to the almost magical phacoemulsification surgery practised widely across the globe, the amazing world of cataract surgery has reached its pinnacle with laser-assisted phacoemulsification surgery and intraocular lens implantation. Does the buck stop there? Of course, no.

It was often surmised that not much had changed since the first extracapsular cataract surgery by French ophthalmologist, Jacques Daviel, on April 8, 1747. But, soon enough, it was surpassed by the enterprising discovery of artificial intraocular lens transplant surgery in the 1940s by the English ophthalmologist, Sir Nicholas Harold Lloyd Ridley, despite much opposition by contemporaries in the field. Had it not been for his doggedness and his documented demonstrations of success, the world would have been a duller place for millions across the globe!

Charles D. Kelman in 1967, did one better, inspired by his dentist’s ultrasonic probe when he introduced the Gold Standard in cataract surgery, the phacoemulsification technique, earning him the pseudonym “Father of Phacoemulsification”. Smaller incisions, improved intraocular lens materials and design, development of viscoelastics, safer anaesthetic delivery and surgical techniques have further improved the safety profile, surgical outcome, and patient satisfaction after cataract surgery.

Concepts in cataract surgery have thus evolved from the archaic intracapsular cataract surgery with thick, unsightly, distortion-prone glasses for regular postoperative use, to the almost physiological, accommodative intraocular lens implanted eye. Laser-assisted cataract surgeries are paving the way for newer developments in robotic and robot-assisted cataract surgeries with the promise of precision, accuracy and safety, sans the adverse events. But, how would these futuristic developments take centre-stage if they fail to prove themselves against the current Gold Standard? Scientific innovation cannot prosper without randomised control studies to prove that a certain therapeutic measure is better than, equal to, or non-inferior to the de-facto Gold standard.

While we talk of the latest cutting-edge technology and innovation to deal with the most complex problems faced by ophthalmologists the world over, we should not ignore the underprivileged who are still victims of couching and other substandard practices in a modern world. Our endeavours should be to research, study, develop and compare affordable surgical practices and technology supported by clinical trials, thus hitching advanced technology with patient-safety, ease-of-use, accessibility and affordability. While it poses the biggest challenge for our generation, marrying innovations in cataract surgery with affordability should be our goal, if our aim is to cater to all segments of our society.

Dr Lawrence Kindo is a second-year resident in the Department of Ophthalmology, Armed Forces Medical College, Pune, Maharashtra, India