A Sustainable Model For Delivering High-Quality, Efficient Cataract Surgery In Southern India.

Cataracts are a leading cause of reversible blindness in India, where millions of people can be effectively treated for this condition with surgery. The Aravind Eye Care System in southern India developed an efficient system for delivering high-quality and low-cost cataract surgery. We provide a detailed accounting of costs of cataract surgery at the system and a cost-utility analysis. Total costs per operation were US$120, or $195 per quality-adjusted life-year gained. Using these data and population-based estimates of cataract prevalence, we calculate that eliminating cataract-related blindness and low vision in India would cost $2.6 billion and would yield a net societal benefit of $13.5 billion. Factors contributing to the highly cost-effective care at the Aravind Eye Care System include the domestic manufacturing of supplies, the use of a specialized workforce and standardized protocols, and the presence of few regulatory hurdles. Lessons learned from the system can help improve the delivery of cataract surgery and other ambulatory care surgeries in India and abroad.

Eliminating cataract blindness - how do we apply lessons from Asia to sub-Saharan Africa?

The VISION 2020 initiative aims to eliminate avoidable blindness by the year 2020. Cataract, the main cause of blindness and other visual impairment, is a main focus of this effort. In India, the Aravind Eye Care System provides an impressive model demonstrating how high quality eye care, including cataract surgery, can be delivered to large numbers and made affordable to all. Similarly, financially self-supporting systems have not been developed at this point in sub-Saharan Africa. This paper explores the factors that lead to success at Aravind, and compares and contrasts the conditions in India with those found in much of sub-Saharan Africa.

Specialty care systems: a pioneering vision for global health.

Successful health-sector reform in developing countries is built on sustainable service delivery models that meet reform goals while addressing community needs. When government efforts fall short, innovative private-sector solutions can offer more-efficient alternatives that provide care to impoverished populations. We identify organizations that use elements of a focused care approach to overcome barriers to delivering care in low-resource settings. Using the experience of the Aravind Eye Care System, we describe the essential elements of the specialty care model, its replication across countries, and the challenges to extending this model beyond eye care.

The development of the Indian vision function questionnaire: field testing and psychometric evaluation.

OBJECTIVE: To develop and evaluate the acceptability, reliability, validity, and responsiveness of the Indian vision function questionnaire (IND-VFQ). METHODS: Problem statements from previous qualitative studies were reduced to a 45 item interviewer administered questionnaire representing three a priori domains (general functioning, psychosocial impact, and visual symptoms) which was evaluated in patients with cataract (n = 420), glaucoma (n = 120), diabetic retinopathy, or age related macular degeneration (n = 120) and normal controls (n = 120). Standard methods were used for item reduction and to evaluate psychometric properties. RESULTS: Psychometric item reduction produced a 33 item questionnaire. Psychometric evaluation showed that two of the three scales (psychosocial impact and visual symptoms) had good acceptability, and that all three scales showed high internal consistency (alpha >0.80; item-total correlations 0.54-0.86) and test-retest reliability (>0.89). All three scales showed moderate evidence of convergent and discriminant validity. Responsiveness, assessed in cataract patients (n = 120) before and after surgery, was good for all three scales (effect sizes >1). CONCLUSIONS: The IND-VFQ33 is a psychometrically sound measure of vision function addressing a gap in patient defined measures of vision function developed in populations living in low income countries.

Risk factors for age related cataract in a rural population of southern India: the Aravind Comprehensive Eye Study.

AIM: To determine risk factors for lens opacities and age related cataract in an older rural population of southern India. METHODS: A cross sectional population based study of 5150 people aged 40 years and above from 50 clusters from three districts in southern India. The lens was graded and classified after dilation using LOCS III system at the slit lamp for cataract. Definite cataract was defined as nuclear opalescence >/=3.0 and/or cortical cataract >/=3.0 and/or PSC >/=2.0. RESULTS: Definite cataracts were found in 2449 (47.5%) of 5150 subjects and the prevalence of cataract increased with age. The age adjusted prevalence of cataract was significantly lower in males (p = 0.0002). Demographic risk factors-increasing age and illiteracy-were common for the three subtypes of cataract; females were more likely to have cortical cataracts and nuclear cataracts. Additionally, nuclear cataracts were associated with moderate smoking (OR:1.28, 95% CI:1.01 to 1.64), lean body mass indices (OR: 1.37, 95% CI: 1.17 to 1.59) and higher waist to hip ratios (OR: 0.67, 95% CI: 0.54 to 0.82); cortical cataracts with hypertension (OR: 1.39 95% CI:1.11 to 1.72), pseudoexfoliation (OR:1.53,95% CI:1.17 to 2.01), and moderate to heavy smoking; and posterior subcapsular cataracts with diabetes (OR:1.55, 95% CI:1.12 to 2.15), lean body mass (OR:1.32, 95% CI:1.11 to 1.57), and high waist to hip ratios (OR: 0.77, 95% CI: 0.62 to 0.94). CONCLUSIONS: Risk factors for age related cataract in this population do not appear to be different from those reported in other populations. Further studies are required to identify the reason for the high prevalence of age related cataract and to understand better the role of each risk factor for cataractogenesis in this population.

Sex inequalities in cataract blindness burden and surgical services in south India.

AIM: To determine sex inequalities in cataract blindness and surgical services in south India. METHODS: Details of lens status and cataract surgery were recorded for subjects aged 50 years and older identified through cluster sampling as part of population based cross sectional assessments of cataract blindness and surgical outcomes in three districts of south India. RESULTS: Females were less likely to be operated on for cataract (adjusted OR 0.71, 95% CI: 0.57 to 0.87) although the cataract blindness burden was higher for females (p<0.001). Literacy of the subject was a major predictor for being operated on for cataract. Achieving equal surgical coverage between sexes will have resulted in an additional 25.3% reduction of cataract blindness. CONCLUSIONS: Eye care programmes in this population need to be sensitised to the substantial reduction in blindness possible by achieving equal surgical coverage between sexes.

A population based eye survey of older adults in Tirunelveli district of south India: blindness, cataract surgery, and visual outcomes.

AIMS: To assess the prevalence of vision impairment, blindness, and cataract surgery and to evaluate visual acuity outcomes after cataract surgery in a south Indian population. METHODS: Cluster sampling was used to randomly select a cross sectional sample of people > or =50 years of age living in the Tirunelveli district of south India. Eligible subjects in 28 clusters were enumerated through a door to door household survey. Visual acuity measurements and ocular examinations were performed at a selected site within each of the clusters in early 2000. The principal cause of visual impairment was identified for eyes with presenting visual acuity <6/18. Independent replicate testing for quality assurance monitoring was performed in subjects with reduced vision and in a sample of those with normal vision for six of the study clusters. RESULTS: A total of 5795 people in 3986 households were enumerated and 5411 (93.37%) were examined. The prevalence of presenting and best corrected visual acuity > or =6/18 in both eyes was 59.4% and 75.7%, respectively. Presenting vision <6/60 in both eyes (the definition of blindness in India) was found in 11.0%, and in 4.6% with best correction. Presenting blindness was associated with older age, female sex, and illiteracy. Cataract was the principal cause of blindness in at least one eye in 70.6% of blind people. The prevalence of cataract surgery was 11.8%-with an estimated 56.5% of the cataract blind already operated on. Surgical coverage was inversely associated with illiteracy and with female sex in rural areas. Within the cataract operated sample, 31.7% had presenting visual acuity > or =6/18 in both eyes and 11.8% were <6/60; 40% were bilaterally operated on, with 63% pseudophakic. Presenting vision was <6/60 in 40.7% of aphakic eyes and in 5.1% of pseudophakic eyes; with best correction the percentages were 17.6% and 3.7%, respectively. Refractive error, including uncorrected aphakia, was the main cause of visual impairment in cataract operated eyes. Vision <6/18 was associated with cataract surgery in government, as opposed to that in non-governmental/private facilities. Age, sex, literacy, and area of residence were not predictors of visual outcomes. CONCLUSION: Treatable blindness, particularly that associated with cataract and refractive error, remains a significant problem among older adults in south Indian populations, especially in females, the illiterate, and those living in rural areas. Further study is needed to better understand why a significant proportion of the cataract blind are not taking advantage of free of charge eye care services offered by the Aravind Eye Hospital and others in the district. While continuing to increase cataract surgical volume to reduce blindness, emphasis must also be placed on improving postoperative visual acuity outcomes.

The Sivaganga eye survey: I. Blindness and cataract surgery.

PURPOSE: To assess the prevalence of visual acuity impairment, blindness, and cataract surgery among older adults in rural southern India. METHODS: Random selection of village- and urban-based clusters was used to identify a cross-sectional sample of persons 50 years of age or older from the Sivaganga district of Tamil Nadu. Subjects in 25 selected clusters were enumerated through a door-to-door survey and invited to examination sites for measurement of uncorrected, presenting, and best-corrected visual acuity and ocular examination in 1999. The principal cause was identified for eyes with presenting visual acuity worse than 6/18. Quality assurance monitoring of visual acuity measurements took place in five of the study clusters. RESULTS: A total of 5081 persons in 3517 households were enumerated, and 4642 (91.4%) were examined. Thirty-six percent presented with visual acuity worse than 6/18 in the better eye. The prevalence of blindness, based on visual acuity worse than 6/60 in both eyes, was 6.0% (95% confidence interval [CI]: 5.1% to 6.9%) with presenting vision, and 2.5% (95% CI: 1.8% to 3.1%) with best correction. Blindness with presenting visual acuity was associated with older age and illiteracy. Cataract was the principal cause of blindness in one or both eyes in 69.4% of those presenting blind, and uncorrected aphakia and other refractive error affected 35.6% in at least one eye. The prevalence of cataract surgery was 14.7% (95% CI: 13.0% to 16.4%); low surgical coverage among the cataract blind was associated with illiteracy. CONCLUSIONS: It appears that much has been done in the prevention of blindness in Sivaganga. Nevertheless, blindness remains an important public health problem, mainly because of cataract and refractive error. Prevention of blindness programs in the area should target these two causes, with special emphasis on the elderly and the illiterate.

The Sivaganga eye survey: II. Outcomes of cataract surgery.

PURPOSE: To assess the clinical outcomes of cataract surgery in rural southern India. METHODS: Cluster sampling was used in randomly selecting a cross-sectional sample of persons 50 years of age or older for visual acuity measurement, refraction, and ocular examination in 1999. Subjects were queried as to the date and place of surgery for each cataract-operated eye. Surgical complications were noted and the principal cause of reduced vision was identified for eyes with presenting visual acuity worse than 6/18. RESULTS: Within the cataract-operated sample of 682 persons, 13.8% had presenting visual acuity worse than 6/60 in both eyes, 25.2% better than or equal to 6/18 in both eyes, and 37.8% were bilaterally operated on. For aphakic eyes, 50.5% presented with visual acuity better than or equal to 6/18; 82.6% with best-correction. For pseudophakic eyes, the corresponding percentages were 78.0% and 94.5%. Over one-third of all eyes were pseudophakic, and nearly three-fourths had been operated on in non-governmental facilities. Uncorrected aphakia and other refractive error were the main causes of vision impairment. In multiple logistic regression modeling, poor presenting visual acuity in aphakic eyes was associated with illiteracy, rural residence, and surgery in government facilities; gender and time period of surgery were not predictors of vision outcomes. None of these variables were associated with best-corrected outcomes in aphakic eyes, nor with presenting and best-corrected outcomes in pseudophakic eyes. CONCLUSIONS: Visual acuity outcomes in pseudophakic eyes were good. More attention must be given to needless vision impairment among the cataract-operated because of inadequate aphakic correction, especially among those operated on in government facilities, the illiterate, and those living in rural villages.

Pneumococcal nasopharyngeal colonization in young South Indian infants.

BACKGROUND: Streptococcus pneumoniae is the most frequent bacterial cause of morbidity and mortality in young children. Bacteria carried in the nasopharynx of healthy children reflect the prevalent strains circulating in the community. METHODS: We recruited 464 newborns from a rural area in South India with endemic vitamin A deficiency. Nasopharyngeal specimens were collected from each infant at ages 2, 4 and 6 months. RESULTS: Fifty-four percent of study infants were colonized by age 2 months, with 64.1 and 70.2% carriage prevalence at ages 4 and 6 months, respectively. The odds of carriage at 2 months were significantly increased in female infants, infants living in a household in which 20 or more cigarettes were smoked each day, infants whose mothers had less than 1 year of schooling and infants fed colostrum. At age 4 months infants having 2 or more siblings <5 years of age were at significantly increased risk of carriage. At age 6 months none of the potential risk factors examined achieved statistical significance, but maternal night blindness increased the risk of colonization 3-fold. The odds of carrying a PncCRM197 vaccine serotype were increased among infants born to mothers who experienced night blindness during pregnancy. The most prevalent serogroups/types during the first 6 months of life were 6, 9, 10, 11, 14, 15, 19, 23 and 33, accounting for 76.7% of all serotyped isolates. CONCLUSIONS: South Indian infants experience high rates of pneumococcal carriage during the first 6 months of life, which may partially explain their increased risk for pneumonia.

Low uptake of eye services in rural India: a challenge for programs of blindness prevention.

OBJECTIVES: To investigate service uptake in a rural Indian population served by outreach eye camps and to identify barriers to uptake. PARTICIPANTS AND METHODS: A routine eye camp was conducted within 5 km of each of 48 randomly selected villages of typically Hindu, backward-caste communities. Subsequently, participatory rural appraisal-community mapping, focus groups, matrix ranking, and semistructured interviews-was undertaken to explore community views of eye problems. An eye examination was conducted on persons with eye problems who did not attend the eye camp. Predictors of attendance were identified by multilevel regression analysis. RESULTS: Of 749 adults with an eye problem, 51 (6.8%) attended the eye camp. Independent predictors of attendance were being male (odds ratio = 2.3; 95% confidence interval, 1.2-4.5) and living within 3 km of the camp (odds ratio = 4.5; 95% confidence interval, 1.7-12.5). Of the 552 persons who did not attend the eye camps and had an eye examination, 242 (43.8%) had low vision (visual acuity <6/18 to > or =3/60 in presenting better eye) and 38 (6.9%) were blind in both eyes. Cataract surgery was recommended for 197 (35.8%) of the persons who did not attend the eye camps. Of 109 persons with a previous cataract operation, 42 (38.5%) had low vision and 11 (10.1%) were blind. Fear (principally of eye damage), cost (direct and indirect), family responsibilities, ageism, fatalism, and an attitude of being able to cope (with low or no vision) were the principal barriers to attending the eye camps. CONCLUSIONS: A high proportion of people who could have benefited from eye treatment were not using available services. Poor visual outcomes were observed in surgically treated persons.

Estimating costs of programme services and products using information provided in standard financial statements.

The financial viability of programme services and product offerings requires that revenue exceeds expenses. Revenue includes payments for services and products as well as donor cash and in-kind contributions. Expenses reflect consumption of purchased or contributed time and materials and utilization (depreciation) of physical plant facilities and equipment. Standard financial reports contain this revenue and expense information, complemented when necessary by valuation and accounting of in-kind contributions. Since financial statements are prepared using consistent and accepted accounting practices, year-to-year and organization-to-organization comparisons can be made. The use of such financial information is illustrated in this article by determining the unit cost of cataract surgery in two hospitals in Nepal. The proportion of unit cost attributed to personnel, medical supplies, administrative materials, and depreciation varied significantly by institution. These variations are accounted for by examining differences in operational structure and capacity utilization.

Vision-specific function and quality of life after cataract extraction in south India.

PURPOSE: To assess visual and overall patient function after intracapsular (ICCE) and extracapsular (ECCE) cataract extraction in rural South India. SETTING: Aravind Eye Hospital, Tirunelveli, Tamil Nadu, South India, and the Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Baltimore, Maryland, USA. METHODS: This study evaluated preoperative visual acuity and demographic information and postoperative visual acuity and functional status measures in 71 patients having ECCE with posterior chamber intraocular lens (IOL) placement and 73 patients having ICCE with aphakic spectacle correction at Aravind-Tirunelveli Eye Hospital, Tamil Nadu, India. The principal outcomes assessed were visual acuity; quality-of-life score (possible range 0 to 100%); visual function measurement (possible range 0 to 100%). RESULTS: Patients in the ECCE group scored 10.17 (P = .0001) points higher than those in the ICCE group on the visual function scale after adjustment for differences in age, sex, level of education, marital status, residence, and type of employment. The ECCE group scored 7.69 points higher on visual function when adjusting for the differences in best corrected visual acuity, which was also better in the ECCE group. In the quality-of-life assessment, 77.1% in the ECCE group and 46.6% in the ICCE group scored 90% or better (OR 3.85; P = .006). CONCLUSIONS: Patients in rural south India having ECCE with posterior chamber IOL implantation obtained better postoperative visual function, quality of life, and visual acuity than those receiving ICCE with aphakic spectacle correction. These differences, which were not significantly affected by adjustment for age, sex, education, marital status, type of residence, and occupation, indicate that ECCE is clearly superior to ICCE.

The Madurai Intraocular Lens Study. I: A randomized clinical trial comparing complications and vision outcomes of intracapsular cataract extraction and extracapsular cataract extraction with posterior chamber intraocular lens.

PURPOSE: The Madurai Intraocular Lens Study (MIOLS) was designed to compare safety, efficacy, and quality of life outcomes after either intracapsular cataract extraction with aphakic glasses (ICCE-AG) or extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/ PC-IOL). METHODS: The Madurai Intraocular Lens Study was a nonmasked randomized controlled clinical trial conducted at a single hospital. Thirty-four hundred patients with age-related cataracts and having a best-corrected visual acuity less than or equal to 20/120 in the better eye were randomly assigned to either of the two cataract operative procedures. The main clinical outcomes were safety (complication rates) and efficacy (best-corrected visual acuity at 1 year equal to or better than 20/40). In addition, a subset of 1,700 trial participants received questionnaires before surgery, at 6 months after surgery, and at 1 year after surgery to measure visual functioning and vision-related quality of life. RESULTS: Details of study design, study organization, clinical and quality of life outcome variables, sample size calculations, patient eligibility criteria and recruitment, randomization and masking, participant flow, adherence to follow-up, quality assurance, and statistical methods are presented. CONCLUSIONS: The Madurai Intraocular Lens Study has sufficient power to detect clinically significant differences between the treatment options. There were no statistically significant differences between the two treatment groups for any of the major study variables at baseline. A high level of quality assurance was maintained throughout the October 1993 to June 1996 study period. The results should be applicable to all settings where the requisite expertise and resources are present.

The Madurai Intraocular Lens Study. III: Visual functioning and quality of life outcomes.

PURPOSE: To compare the effects of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/PC-IOL) vs intracapsular cataract extraction with aphakic glasses (ICCE-AG) on everyday visual functioning and quality of life. METHODS: In a nonmasked randomized controlled clinical trial, 3,400 bilateral vision-impaired patients, aged 40 to 75 years, with operable cataract were randomly assigned to receive one of the two treatment options. One half in each group were randomly selected for interviewer administration of visual functioning and quality of life questionnaires before surgery and at 6 and 12 months after surgery. RESULTS: Both ICCE-AG and ECCE/PC-IOL produced dramatic improvements in visual functioning and quality of life scores. Patients receiving ECCE/PC-IOL reported larger beneficial changes than did those receiving ICCE-AG, compatible with additional beneficial effects of a moderate magnitude for visual functioning and of a smaller beneficial magnitude for quality of life. All between-group differences were highly statistically significant (P < .00001). The additional benefits of ECCE/PC-IOL are not explained by visual acuity differences. A higher proportion of patients in the ICCE-AG group reported problems on a vision problem checklist at 6 months (more than 50%) than did patients in the ECCE/PC-IOL group (approximately 30%). CONCLUSIONS: In this developing-country setting, ICCE-AG and ECCE/PC-IOL were associated with substantial benefits in improved everyday vision function and vision-related quality of life. Patients who received ECCE/PC-IOL reported greater benefits and fewer problems with vision than did patients who received ICCE-AG.

Measurements of vision function and quality of life in patients with cataracts in southern India. Report of instrument development.

OBJECTIVE: To develop and validate vision function (VF) and quality of life (QOL) instruments in patients with cataracts in the context of large volume surgery in a developing country. MATERIALS AND METHODS: The instruments were developed using a consensus approach. One hundred patients who were undergoing cataract surgery at Aravind Eye Hospital, Madurai, India, were interviewed preoperatively and 3 and 12 months postoperatively. Standard clinical procedures were followed, including measurement of visual acuity. Between-interviewer reproducibility was measured by repeated administration of the preoperative questionnaire. Within-interviewer reproducibility was measured preoperatively in a separate study of 50 patients. RESULTS: Preoperative scores from the VF and QOL instruments were significantly associated with visual acuity (r = 0.4). Internal reliability (Cronbach alpha) was greater than .9. Both instruments showed large changes after surgery, with effect sizes of 3 or greater for most VF scales (range, 1.8-3.7) and 1 or greater for QOL scales (range, 1.0-2.2). Changes in visual acuity after surgery were correlated with changes in the VF (r = 0.44) and QOL (r = 0.41) scale scores. Between-interviewer reproducibility was acceptable (total VF scale, Spearman r = 0.7; total QOL scale; r = 0.74). The kappa values were lower for within-interviewer reproducibility. CONCLUSIONS: The study provided strong evidence for the validity, reproducibility, and responsiveness of the instruments, and for the feasibility of using them in the setting of a large volume of cataract surgery in a developing country.

Attacking the backlog of India's curable blind. The Aravind Eye Hospital model.

The number of individuals in developing nations with preventable blindness from cataract and other disorders is increasing. New programs incorporating local customs and efficiently using available resources must be created to prevent the escalation of blindness and to rehabilitate patients already disabled with cataracts. We describe a system of high-quality, high-volume, cost-effective cataract surgery, using screening eye camps and a resident hospital. This has enabled us to provide efficient low-cost cataract surgery and overcome barriers of adequate eye care in southern India. We have been successful in locating patients with treatable eye problems, educating them about the availability of ophthalmic care, and providing free eye care. Our structure stresses the following: community involvement, identification of individuals most likely to benefit from screening, efficient utilization of both medical and paramedical personnel, and a streamlined approach to screening patients. This system may be capable of modification for use in other developing areas to decrease the backlog of cataract blindness.

Quality of life assessment in blindness prevention interventions.

This article discusses the importance of self-reported visual function and quality of life (QOL) assessment in evaluating the effectiveness of eye care and prevention of blindness interventions. Traditional clinical measurements do not provide an adequate characterization of the burden of visual disability faced by the patient in day-to-day activities. The validity, reliability and responsiveness of QOL questionnaires should be demonstrated before general use of such instruments is advocated. A visual function questionnaire currently undergoing psychometric evaluation as part of a clinical study of cataract surgery in India is presented.

The cost effectiveness of strategies to reduce barriers to cataract surgery. The Operations Research Group.

The cost and effectiveness of eight approaches to reducing barriers to cataract surgery were evaluated in a rural area of South India during 1987-1989. The approaches were based on four intervention alternatives--aphakic motivator (AM), basic eye health worker (BW), screening van (SV), and mass media (MM). Each intervention was offered at two levels of economic incentive: partial, which provides free surgery and hospital stay, and full, which also provides transport from the recipient's village to the hospital and free food during the hospital stay. Evaluations took place in a probability selection of 90 villages, including ten control villages not subjected to either of the interventions. Only costs unique to patients from the intervention villages were considered: Health education and screening costs were included, surgery costs were not. Percentage reductions in the cataract blind backlog and increases in surgical coverage were used as effectiveness measures. Analyses suggest that the SV and AM interventions, both with full economic incentive, offer the greatest advantage. The AM intervention is the more effective of the two, but also the more costly.