August 27, 2021
5 min read
Khorram is cofounder and director of Marianas Eye Institute.
Disclosures: Khorram reports serving on the board of directors of Vision Health International.
Imagine doing something 80 to 100 times a day, the same thing again and again, all day long. Now imagine if that something is cataract surgery.
I’m often amazed at the concentration we have as ophthalmologists to sit within the confines of a few millimeters, delicately restoring sight, fully aware that with each movement we are also risking sight. But this amazement reached a new level for me during a trip to a rural hospital in the highlands of Ethiopia with Dr. Matt Oliva and the Himalayan Cataract Project (HCP), simply because of the scale of the surgery and the skill of the surgeons.
Many of you know the story of Nepalese ophthalmologist Dr. Sanduk Ruit and his American counterpart Dr. Geoff Tabin, who together founded the Himalayan Cataract Project (cureblindness.org) and whose efforts led to a 58% reduction in the prevalence of blindness in Nepal over the course of 2 decades. If you don’t know the story, pick up a copy of Second Suns by David Oliver Relin. It’s an inspiring read. With its success in Nepal, HCP set its sights on eliminating cataract blindness in other parts of the world, and I was in Ethiopia to participate in one of its high-volume cataract surgery campaigns.
Eliminating cataract blindness is a complex endeavor. The HCP model relies on a two-pronged approach: build the resources within the country so that there are ophthalmologists to treat the cataracts (which requires building training programs and eye hospitals and equipment and management systems and data collection and biomedical technicians and on and on) and address the current backlog of cataracts through regular high-volume cataract surgery campaigns.
In these campaigns, a team of about five cataract surgeons will go into an area and, over the course of 5 days, perform 1,200 to 1,500 cataract surgeries. Among the team will be two or three highly skilled surgeons, like Matt, Bidya from Myanmar, and Abreham and Daniel from Ethiopia, who will each knock out 80 to 100 cases a day, along with another three or four surgeons, who combined will add another 100 cases to the daily effort.
I know that it’s hard to comprehend a single surgeon doing 80 to 100 high-quality cataracts a day. The focus and stamina required to operate for 11 or 12 hours a day, chained to a stool that is too hard, a microscope without a foot pedal, a room that’s too hot, while being fed a steady stream of white cataracts, brunescent cataracts, black cataracts, small pupils, pseudoexfoliation, lenses dangling by three zonules — well, it’s not for everyone. “Do we have any pupil dilators?” one of the other visiting surgeons asks. Matt calmly responds, “Yeah, it’s called the nucleus.” You get the picture. Every time I go on one of these trips, at the end of the first day, feeling like I’ve been run over by a truck, I ask myself, “Why do I do this?” The answer comes the next morning when the bandages come off, and patients dance and doctors cry.
HCP’s approach works because of its commitment to raising local human resources and developing systems. Before the surgical campaign, HCP’s in-country staff screens thousands of patients in the region to identify those who may need cataract surgery. It requires immense logistical coordination to bring 1,200 to 1,500 people and their families to the center where the surgery will take place, house and feed them during the few days they are there, and efficiently and safely get them through surgery. At the core of the system is the recognition that the rarest component is the surgeon, who should focus on surgery. A medical ophthalmologist screens every patient arriving at the surgical camp and confirms those with cataracts. A team of eye care workers checks vision, performs an A-scan, trims lashes, selects the IOL and blocks the eye, while another team keeps patients moving through these stations and then into the operating room, positioning them on the bed, completing the paperwork and ushering them out at the end of surgery. The scrub nurses and circulators prep and drape the patient and keep the instruments flowing. The surgeon usually will have two beds side by side, with the microscope swinging between them, and moves immediately from one case to the next. The turnover time is the 12 seconds it takes to change a pair of gloves.
Data from Aravind have shown that having multiple patients in the room simultaneously, having multiple sets of instruments open at the same time, wearing the same gown from case to case and other elements that improve efficiency, have no higher rates of endophthalmitis than we experience in the U.S. Science backs up the systems in place.
The other element of the efficiency of the surgery is, of course, the skill of the surgeon and the use of manual small-incision cataract surgery (MSICS). Before my trip to Ethiopia, I was lucky to get through 12 MSICS cases in a day. A really good surgical week would be if I got anywhere more than 50 cataracts done. In those settings, I would block the patient, choose the IOL, walk the patient into the OR, help them onto the bed and do a lot of other things besides surgery. Within the context of the HCP system and with the opportunity to be guided by these world-class MSICS surgeons, I adjusted my technique and managed to get up to 30+ cases in a day.
We ophthalmologists often put a lot of emphasis on these kinds of personal numbers. Although I keep track of them (of course I do), I bear in mind that the priority, above all else, is to do good surgery. As Fred Hollows, the great Australian ophthalmologist, said, “Every eye is an eye.” The grandmother in the village in Ethiopia deserves the same quality of surgery as my grandmother. So, I keep myself in check. Focus on the quality, not the speed. As I watch over Matt’s shoulder, it is hard to believe that one day he was where I am, doing the same slow surgery that I am, struggling as I am, wanting to quit at times, as I do. I watch Dr. Helen Sisay, an Ethiopian ophthalmologist from Hawassa Hospital, do a case. Smooth. Flawless. Despite the challenges. “How many cases do you do during a high-volume cataract campaign?” I ask her. “About 85 a day,” she says. She’s 3 years out of her residency — a residency that was supported by HCP. And she’s now leading the new residency program at Hawassa, also supported by HCP, along with other global partners.
Years ago, I was a bit disillusioned with my work. It had gotten so routine, so ordinary, and I felt like I wanted to do something more. I picked up a book called How to Change the World by David Bornstein. I had ideas of starting some kind of organization to tackle the big problems of the world. What I concluded, as a result of the stories from that book, was that the best way to have an impact is to find someone who is making a real difference and support them in their quest. This is what Himalayan Cataract Project does. It finds people in the countries where cataract blindness is rampant and gives them the training and the tools to lift up their nations. At the high-volume cataract surgery campaigns, visiting HCP doctors work side by side with their local counterparts to get through the backlog of cataract blindness. As a result, there is less need for outside ophthalmologists to parachute in and do surgery. HCP is one of those proven organizations whose work is making a dent in global blindness in Nepal, Ethiopia, Ghana, Myanmar, Bhutan and many other countries.