An Answer To India’s Cataract Problem

This story is part of a series on the current progression in Regenerative Medicine. This piece is part of a series dedicated to the eye and improvements in restoring vision. It also marks part three of a four-part series on cataracts.

In 1999, I defined regenerative medicine as the collection of interventions that restore to normal function tissues and organs that have been damaged by disease, injured by trauma, or worn by time. I include a full spectrum of chemical, gene, and protein-based medicines, cell-based therapies, and biomechanical interventions that achieve that goal.

The 1980s are known for many things, not only for big hair and bold fashion but also for a time when India faced a significant vision crisis. In the 80s, India struggled as cataracts were a major issue, accounting for 80% of all blindness in the country. Today, cataract surgery is widely available in India, with over 8.3 million surgeries in 2022-2023.

The question is: what changed?

The Beginnings of Aravind Eye Care System

Dr. Govindappa Venkataswamy, a skilled ophthalmologist, was conscious of the widespread issue of blindness in his country early on and performed over 100,000 eye surgeries throughout his career to address it. His passion for helping the underprivileged led him to create Aravind Eye Care, a sustainable and replicable solution that has benefited many.

Founded in 1976 with 11 beds, Aravind Eye Hospital has blossomed into a visionary institution. The overall mission of Aravind is to eliminate needless blindness while providing high-quality, high-volume, compassionate care to all.

Shortly after the development of Aravind, Dr. Venkataswamy began to wonder how Aravind could be scaled up. He is quoted asking, “If Coca-Cola can sell billions of sodas and McDonald’s can sell billions of burgers, why can’t Aravind sell millions of sight-restoring operations, and, eventually, the belief in human perfection? With sight, people could be freed from hunger, fear, and poverty. You could perfect the body, then perfect the mind and the soul, and raise people’s level of thinking and acting.”

Since then, Aravind has grown and scaled up tremendously. It now encompasses five hospitals nationwide in India. The organization has also seen a six-fold increase in annual cataract surgeries, skyrocketing from 29,928 in 1988 to 180,991 in 2007. In 2023, the clinic held over 5.7 million outpatient visits and over 700,000 surgeries.

Aravind Eye Hospitals prioritizes equity by providing free or heavily subsidized treatment to 50% of patients while maintaining financial self-sustainability. Due to their high patient volume, the hospitals benefit from economies of scale. They also follow a standardized protocol for eye screening camps. This protocol ensures a comprehensive examination, including refraction, intraocular pressure measurement, and fundus examination.

Furthermore, Aravind has placed significant emphasis on cataract care. It has been at the forefront of innovative surgical techniques that have greatly expanded access to life-changing procedures for numerous individuals.

Understanding Cataracts and Cataract Surgery

In the previous part of this series, we explored the topic of cataracts and delved into the various treatment options available to patients. Cataracts occur when the eye’s natural lens becomes cloudy, causing hazy vision. Light sensitivity and glare can inhibit daily tasks, such as driving and reading.

Cataract surgery is the most common choice among the treatment options for cataracts. This procedure entails extracting the cloudy lens and substituting it with an artificial intraocular lens (IOL). IOLs are available in different types, including monofocal, multifocal, and toric lenses. These lenses can range in price from $4,000 to $6,000 in the United States, where most of the IOLs are manufactured, which leads to high surgery costs. Premium lenses also have higher prices, raising the overall cost of cataract surgery.

The Introduction of Aurolab

Aravind recognized the importance of intraocular lens prices to surgery costs, so they found a way to manufacture them in India and established a new manufacturer called Aurolab. The first product created by Aurolab was polymethyl methacrylate (PMMA) IOL. This lens changed the affordability of IOLs, dropping prices from hundreds of dollars to below $10 per lens.

Today, with a remarkable price tag of just $3, this lens has significantly changed the affordability of cataract surgery in India. This allows the total surgery expenses to fall to as low as $10 per cataract operation for the hospital. This is part of why Aravind can offer their services at no cost to those in need and at a standardized cost for those who can afford it or want upgraded lenses.

To put this in perspective, in the United States, bilateral cataract surgery can cost anywhere between $2,410 to $5,243, whereas in India, the same procedure now costs $41 to $125. It’s also important to note that at Aravind, a financially well-off patient covers the treatment costs for multiple disadvantaged patients with a single payment. We’ll delve deeper into the complexities and inequalities surrounding cataract lenses and surgery in the next installment of this series.

Over time, the manufacturing operation rapidly expanded from 35,000 lenses in 1992-1993 to an impressive count of nearly 600,000. Around 60% of Aurolab’s intraocular lenses are supplied to non-governmental organizations in India and other developing nations.

Aravind’s Aurolab doesn’t stop at producing lenses. They also make sutures, needles, and solutions for surgery to keep costs as low as possible. Aurolab’s needles have been crafted to deter suture reuse and minimize expenses in ophthalmic surgery. Furthermore, they offer a wide selection of absorbable and non-absorbable options, catering to a diverse range of surgical requirements.

Aurolab exports its products to over 130 countries, making surgery more affordable globally. Still, making intraocular lenses more affordable is only one of the significant factors that allow Aravind to perform so many cataract surgeries safely and efficiently.

Other Factors that Set Aravind Apart

Aravind recognizes that the quality of training for its cataract surgeons is crucial to providing the highest standard of surgical care. Therefore, they emphasize improving the quality of training for eye specialists worldwide. This emphasis ensures that Aravind’s cataract surgeons are well-equipped to provide the best possible care to their patients while also setting a high benchmark for eye care professionals globally.

Aravind’s success is also attributed to efficient service delivery systems and innovative operating practices, such as implementing an ‘assembly line’ system in operating rooms. Aravind doctors perform over 2,000 surgeries annually, surpassing the average of around 300 at other Indian hospitals. An Aravind surgeon can skillfully conduct 50 cataract operations in a single day.

Each operating room has two beds in the system, with one patient waiting while the other undergoes surgery. After each surgery, the surgeon quickly performs a series of sanitation steps before moving on to the next patient. Surgery can sometimes take as little as five minutes from start to finish.

Their surgical efficiency also stems from their strategic approach of allowing surgeons to dedicate their full attention to surgeries. Recognizing the scarcity and high expenses associated with ophthalmologists, who often perform routine tasks like measuring intraocular pressure and assessing refractive errors, Aravind implemented a ground-breaking solution. They introduced a new group of mid-level ophthalmic personnel, which significantly boosted the productivity of each ophthalmologist by over four times.

Further to that, they also implement regular assessments and meetings to determine surgeon fatigue and effectiveness. They also implemented a salary setup that does not link a surgeon’s salary to the number of patients seen, allowing surgeons to take the necessary time and precautions with each patient rather than worrying about their pay.

At this point, it is also critical to note that while scaling up their total number of procedures, Aravind did not suffer a drop in quality or patient outcomes. In fact, Aravind’s rate of complications is actually half that of the United Kingdom’s National Health Service.

What We Can Learn From Aravind

Ensuring high-quality community eye care entails more than just achieving optimal visual outcomes. It encompasses various aspects, such as the efficiency of the caregiving process, patient treatment adherence, and the reduction of multiple visits. An effective community eye care program should be accessible, affordable, and tailored to the community’s needs while staying up-to-date with technological advancements, promoting positive health-seeking behaviors, and creating demand for healthcare among those in need.

The success of Aravind’s cataract operation program has demonstrated that quality care can be provided on a large scale with appropriate technology and processes, leading to affordable costs. In the past, cataract surgery was categorized based on social classes. However, with the introduction of the assembly line system, locally made intraocular lenses, and other surgical consumables, along with the training of local surgeons and nurses, it is now possible to achieve similar results to those in developed countries.

Aravind’s success also inspired other groups across India, such as L V Prasad. Established in 1987, the L V Prasad Eye Institute (LVPEI) is a prominent world-class eye health facility in Hyderabad, India. As a World Health Organization Collaborating Centre for Prevention of Blindness, LVPEI provides comprehensive patient care, sight enhancement, and rural eye health programs. One of the critical components of LVPEI’s success is its unique pricing structure, which allows it to offer fee waivers and discounts to needy patients while maintaining high-quality care.

LV Prasad isn’t the only group that has replicated Aravind’s success. In fact, Aravind has mentored other groups throughout India, Asia, and Africa. The hospitals mentored by Aravind have witnessed a remarkable surge in productivity upon replication. Numerous facilities observed a substantial 40-50% increase in output in the subsequent year, while some even managed to double their output within a single year.

The projected tripling of global blindness by 2050, with South Asia and sub-Saharan Africa being the most heavily impacted regions, underscores the significance of Aravind’s work and business model. Further exploration of the possibility of replicating this impactful model to assist others in need is crucial to combat cataracts and blindness.

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