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| CURRENT OPHTHALMOLOGY |
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| Year : 1995 | Volume
: 43
| Issue : 1 | Page : 3-8 |
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The pattern of cataract surgery in India: 1992
AK Gupta1, Leon B Ellwein2
1 Maulana Azad Medical College, New Delhi, India
2 National Eye Institute, Bethesda, MD, USA
Correspondence Address:
A K Gupta
Vl/10 Maulana Azad Medical College Campus, Kotla Road, New Delhi 110 002
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 8522368 
Surgery for cataract blindness, a major health problem, is undergoing a rapid transition. This study characterizes cataract surgery in India in terms of practice setting and surgical procedure. A survey questionnaire was mailed in December 1992 to 4356 members of the All India Ophthalmological Society, resident in India, requesting data on cataract surgery cases within the past 12 months. Two thousand one hundred thirty-four (49%) ophthalmologists responded to the survey. Of the 1,023,070 cataract cases reported, two-thirds were private patients. Among private patients, 26.0% received extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation and 20.7% received ECCE without an IOL. Among patients operated under government auspices, 9.1% received ECCE with IOL and 22.4% received ECCE without IOL. Overall, 82.8% of active surgeons reported experience with the ECCE procedure. The cataract case load in the private sector and the frequency of ECCE, with or without IOL implantation, among both private and government-operated cases is greater than previously recognized. Keywords: Cataract surgery - Ophthalmology survey
How to cite this article:
Gupta A K, Ellwein LB. The pattern of cataract surgery in India: 1992. Indian J Ophthalmol 1995;43:3-8 |
The Indian subcontinent has a high prevalence of cataract blindness.[1] This is in spite of an estimated 7856 trained ophthalmologists resident in India.[2] The barriers to surgery faced by the cataract blind are, thus, not directly manpower related; although, because the distribution of ophthalmology manpower does not pattern population distribution, access can be a factor in some geographic areas. The principle barriers are related to economic circumstances, apathy among both patients and providers, and inadequacies in the service delivery system.[3]
India is undertaking a new long-term initiative to expand cataract surgery capability and service levels with financial assistance from the World Bank.[4] An important feature of this initiative is the attention given to reaching the cataract blind in rural and tribal areas. Another noteworthy feature is the emphasis placed on modern extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation as the preferred surgical technique, particularly in encouraging cataract surgery before bilateral blindness leads to irreversible economic hardship within the patient and affected family.[5]
Cataract surgery has a long tradition in India. Following couching, which dates to the time of Susruta, intracapsular cataract extraction (ICCE) by the Smith Indian technique became the early standard for lens extraction.[6] With time, capsule-holding forceps, erysiphake, and cryoextraction techniques were developed to improve the safety of ICCE. These techniques were easily adopted for use by the Indian ophthalmologist in rural eye surgery camps with successful results. ICCE as practiced today is a low-cost, safe procedure eminently suited for high-volume surgery.
The modern microsurgery extracapsular procedure (ECCE) with implantation of a posterior chamber intraocular lens (PC IOL) is replacing ICCE as the standard, in large measure because of the quality of vision obtained after cataract surgery. The beneficiary experiences vision in the operated eye not unlike that in the normal eye. The problem of image magnification, introduced with aphakic spectacles, no longer need be a deterrent to cataract surgery.
Reliable data on the extent to which ECCE/PC IOL is being practiced within India are not available. Anecdotal evidence suggests that surgery patterns in India are undergoing rapid transition, paralleling that experienced earlier in Western countries. Significant differences in the rate with which change is occurring are thought to exist among patients operated in the private sector compared to those operated under government auspices. Thus, a survey was designed with the objective of characterizing cataract surgery within India in terms of both surgical procedure and practice setting.[7]
| Materials and methods | |  |
A brief survey questionnaire (Appendix) was prepared to gather data on cataract surgery cases by surgical procedure and practice setting. Members of the All India Ophthalmology Society (AIOS), resident in India, were asked in a transmittal letter dated 10 December 1992 and signed by the Secretary General of the Society to report case experience over the most recent 12-month period. To maximize the willingness of participants to accurately report such data, anonymous responses were requested. The survey form included paid return postage. A second letter went out, on 2 February 1993, again to all 4356 members. Since there was no way to know who had responded to the initial mailing, it was necessary to send the reminder notice to everyone.
Questionnaire data were computer entered at Guru Nanak Eye Center. All responses received by 15 June 1993 were processed. Data tabulation and analyses were carried out to characterize cataract surgery by procedure, patient, surgeon, and State.
| Results | | |
One thousand nine hundred thirty-five active surgeons reported 1,023,070 cataract surgeries [Table:1]. The most common ophthalmology practice was that dealing only with private patients (60.3%). The remaining practices were about evenly split between those devoted to government patients only and composite practices involving both private and government cases.
Private and government practice surgeons report on the order of 500 cataract cases per surgeon (466 and 502 respectively) for the 12-month period. The composite practice ophthalmologist was considerably busier with an average of 738 cases. For the three practices taken together, the average annual number of cataract surgeries was 529. [Table:2] characterizes the distribution of the annual surgical case load for the three practice categories.
An overwhelming majority of active surgeons reported ECCE experience: 82.8% reported some experience with the ECCE procedure, 73.1% with ECCE and IOL. [Table:3]. Even among surgeons operating only government patients, 80.9% reported ECCE experience, 53.4% with ECCE/IOL.
ICCE remains the most common procedure among both private and government patients [Table:4]. Half of all private patients and two-thirds of government patients were operated with this procedure. Also notable is the percentage of ECCE cases not receiving an IOL: 44.4% among private patients and 71.2% among government patients.
The highest surgical volume was reported from the states of Maharashtra, Tamilnadu, Uttar Pradesh, and Gujarat [Table:5]. Except for Tamilnadu, where only 11.7% of cases were government, in these states the percentage of cases being operated under government auspices is near the country's average of 33.4%. Haryana is another state reporting a low percentage of government cases (12.1%). States where a majority of the reported cases are government include the relatively high-volume states of Rajasthan (55.0%) and Madhya Pradesh (58.9%), and the smaller volume ones of Chandigarh (64.9%), Goa (59.9%), and Pondicherry (96.3%).
Normally one would expect nearly all cases not receiving an IOL to have been operated with ICCE, but this is not what is happening. States with approximately 40% or more of non-IOL cases operated with ECCE instead of ICCE are Chandigarh, Gujarat, Goa, Karnataka, and Maharashtra. As already noted, ECCE without IOL implantation is very common. Except for Chandigarh, ECCE alone is more common than ECCE with IOL in the aforementioned states. The same holds true for the states of Andhra Pradesh, Assam, Bihar, Haryana, Jammu Kashmir, Madhya Pradesh, Manipur, Orissa, Pondicherry, Rajashthan and Uttar Pradesh.
The average cataract surgery case load reported by active surgeons in the AIOS survey varies more than three-fold, from less than 200 cases per year for reporting surgeons in three states to more than 700 cases in five states [Table:6]. A question arises as to whether surgeon case load is influenced by the total number of active surgeons within the state. One would expect an inverse relationship if competition for patients was becoming an issue. Examination of the relationship between surgeon case load and ophthalmologist density (number of ophthalmologists per 100,000 population) fails to shows a correlation. When cataract surgery volume is adjusted to account for population size, considerable variation among states also exists. States with low surgery rates are generally remote. Less than 50 cases per 100,000 population were reported from Assam, Jammu Kashmir, Manipur, Meghalaya, and Orissa. Except for Assam and Orissa, these are states with relatively small populations. At the other extreme are states where more than 200 cases per 100,000 population were reported: Chandigarh, Delhi, Gujarat, Haryana, Maharashtra, and Pondicherry. These states include the large urban areas of Bombay and Delhi, which may have attracted cases from near-by states. The average for all of India is 122 cases per 100,000 population.
Comparing survey data to cataract performance reported as part of the National Programme for the Control of Blindness (NPCB) gives some indication of survey incompleteness.[8] The NPCB reported 1,604,928 surgeries for 1992-93, i.e., from April 1992 to March 1993. These NPCB data are in contrast to the 1,023,070 cases identified in the AIOS survey. It is interesting that for several states/union territories (e.g., Delhi) the reported number of surgery cases actually exceeds NPCB numbers [Table:6]. Based on NPCB data, an average of 191 cases per 100,000 population were operated, with variation between states paralleling that found from survey data.
| Discussion | | |
These data document a shifting of emphasis from the ICCE procedure to ECCE, even among cases operated under government auspices. What is surprising is the high percentage (51.2%) of total ECCE procedures where an IOL was not implanted [Table:4]. Undoubtedly, some of these cases were planned as ICCE but ended-up as ECCE, e.g., cases where the lens capsule ruptured during intracapsular delivery of the lens. It is reasonable to assume, however, that most of these cases were planned as ECCE even though IOLs were not available. This unavailability of IOLs for ECCE cases was particularly acute among patients operated with government resources,-- 71.2% did not receive IOLs. In several states, the proportion of all non-IOL cases (both ICCE and ECCE without an IOL) receiving ECCE is approximately 50%. Developing and maintaining skill in ECCE with or without PC IOL is clearly of interest to the contemporary ophthalmologist. The survey data provide clear evidence of this trend.
The low percentage of survey patients being reported as government patients (33.4%) is of interest. It might be conjectured that the survey data are deficient in capturing cases among ophthalmologists serving primarily government patients. Under the assumption that NPCB data are complete for government-operated patients and that the short-fall in survey data is due to underrepresentation of government patients, we can make inferences about what the upper boundary on the government-private mix might be. The 1992-93 NPCB data imply an underreporting of 581,858 cases, and if these are all considered as additional unreported government cases, the government-private mix in the survey would be 58/42 instead of 33/67. Wherever the mix actually lies within this range, there is an important message regarding charity cases operated in the private sector: Considering the relatively low economic level of the majority of the population, the private patient case load must include a significant proportion of cases operated at no or little cost to the patient -- including cases operated in eye camps and non-profit charitable institutions. (If all private cases were paying cases, then surgery rates as high as those in the United States would be occurring in the paying population, assuming it is drawn from the 160 million Indians in the top 20% of income levels - a clearly unrealistic scenario.)
Underreporting is not a problem limited to this survey. Survey data suggest underreporting in NPCB data, in that, for some states survey reported cases were higher than those reported by NPCB. It is possible that private surgery cases are underreported in NPCB data.
It is difficult to quantify the exact extent to which the AIOS survey results are biased because of underreporting. It is speculated that among the AIOS membership non-responders were those performing little or no cataract surgery. Only 199 of those responding reported no cataract surgery, where in reality it is known that many AIOS ophthalmologists have restricted themselves to essentially a non-surgical practice, i.e., devoted to refraction and other minor eye conditions.
In reality, the survey data may accurately represent cases operated by AIOS members. Its main deficiency may have been in not surveying ophthalmologists who are not AIOS members. Because nearly half of the 7856 ophthalmologists in India are not AIOS members, it is important to not only increase the respondent rate among AIOS members, but to develop a method to identify cataract surgery performed by non-AIOS ophthalmologists in future surveys of this nature. One such step would be to reach ophthalmologists through state society membership rosters.
| Acknowledgements | | |
The authors wish to thank Dr. P.A. Lamba, Dr. Anju Rastogi, and Diane Barber for their comments and help during preparation of the manuscript.
The study was supported by Japan's Policy and Human Resources Development Fund as part of the preparation activities by the Government of India for a Cataract Blindness Control Project financed with funds from the International Development Agency of the World Bank.
| References | | |
| 1. | Mohan M. Survey of blindness in India (1986-89). National Programme for Control of Blindness, 1989. (Unpublished report).  |
| 2. | Kumar R. Ophthalmic manpower in India: Need for a serious review. International Ophthalmology 17:269-275, 1993. |
| 3. | Venkataswamy G, Brilliant G. Social and economic barriers to cataract surgery in rural South India. Visual Impairment and Blindness, December 1981, pp. 405-408. |
| 4. | Directorate General of Health Services. Policy Norms and Standards Adopted under the World Bank-Assisted Cataract Blindness Control Project. Government of India, New Delhi, 1994. |
| 5. | Ellwein LB, Kupfer C. Strategic issues in cataract blindness prevention in developing countries. Bulletin of the World Health Organization (In Press). |
| 6. | Duke-Elder S. Diseases of the Lens and Vitreous. Vol. XI. Henry Kimpton, London, 1969. pp. 249 & 264. |
| 7. | Gupta AK. Cataract surgery survey in India. All India Ophthalmological Society, New Delhi, 1993. |
| 8. | Directorate General of Health Services. Present status of National Programme for Control of Blindness (NPCB) 1993. Government of India, New Delhi, 1993. |
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