IMPRI Team

Our eyes are the locus of primary access to the world around us. They allow us to interact with it and facilitate physical, emotional and mental well-being. Vision loss and impairment affect more than how people see; it has implications for inequities in employment, healthcare access, and income. India was the first country to launch a publicly funded program solely dedicated to controlling blindness and visual impairment, with the National Programme for Control of Blindness and Visual Impairment in 1976. Since then, conscious steps have been taken to achieve the objectives of the Program and periodic population-wide surveys have been conducted to ensure that the country is moving in the right direction. 

Special emphasis has been laid on cataracts and their surgeries as they are a major cause of both blindness and visual impairment in India. Relevant manuals and guidelines are provided to eye care institutions. This stems from the estimates that vision loss costs the global economy $411 billion every year in lost productivity alone. Improved eye health can increase access to wider and frequent employment opportunities and subsequently increase household income and reduce hunger. For instance, 46% of households moved up an income bracket following cataract surgery.

In a study done by Prajnya Elinar Digalit, it was found that the total medical expenditure of cataract surgery would be Rupees 11243 and the Out of Pocket expenditure would come close to Rupees 9327. It also showed that the medical expenditure in rural areas was Rupees 8542 and in the urban area was 15594.

Background

Cataracts are the leading cause of blindness globally (17.8 million) and the second leading cause of moderate or severe vision impairment (83.2 million). Most cataracts are the result of age-related changes, but cataract is also linked to UV damage, smoking, dehydration crisis, metabolic disturbance such as diabetes, galactosemia, and steroid use. Blindness and vision impairment due to cataracts are more common among women than men. Young children may also be affected.

Cataract surgery with intraocular lens (IOL) implantation, usually under local anesthesia, is a very effective treatment. There are several different types of procedures. Most patients (70%-90%) attain a best-corrected visual acuity of 6/18 or better by 2 months. Cataract surgery is a highly cost-effective intervention. Cataract surgery for young children is more complex and requires expertise and a general anesthetic.

Incidence of Cataracts

According to the National Blindness and Visual Impairment Survey of 2015-19, untreated cataract was the major cause of both blindness and visual impairment, for the population above 50 years, accounting for 66.2% and 71.2%, respectively.  Further, the proportion of blindness due to complications of cataract surgery has increased.

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Figure 1: Causes of blindness for population over 50 years in 2019
Source:  National Blindness and Visual Impairment Survey of 2015-19
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Figure 2: Causes of visual impairment for population over 50 years in 2019
Source:  National Blindness and Visual Impairment Survey of 2015-19

For the age group below 50 years, in case of visual impairment, untreated cataracts remained the key concerns, accounting for 25.4%.

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Figure 3: Causes of blindness for the population below 50 years in 2019
Source:  National Blindness and Visual Impairment Survey of 2015-19

Dandona L. et al. (1996) published a list of the causes of childhood blindness and strategies to reduce its prevalence. The authors identified a set of factors responsible for childhood blindness like genetic/hereditary, intrauterine, neonatal, and those related to infancy and childhood. Other miscellaneous factors included cataracts, glaucoma, and retinoblastoma

The National Programme for Control of Blindness and Visual sets annual targets for each state and union territory in terms of cataract operations, distribution of free spectacles to school children, collection of donated eyes, and treatment of Other Eye Diseases, such as diabetic retinopathy, glaucoma, squint, among others. 

In the year 2018-19, the performance of northeastern states is underwhelming across all the four parameters mentioned above. Few states and union territories lag behind their targets for cataract operations. However, the gap is not steep.

However, these targets are vague, as a particular number of cataract surgeries are performed, does not indulge in breaking down the target according to Private hospital or public hospital or urban or rural. This highlights the urban-rural divide that exists in the provision of eye-care treatments.

Since Cataract is a commonly encountered procedure and the incidence of people getting operated on for cataracts is increasing, so are the complications arising from cataract surgeries, it is required to keep a check on these. In a study by Dr. Ashok Kumar Jindal in a hospital in Rajasthan (2018), the chief early complications from cataract surgeries were Corneal Oedema and Hyphema.

Barriers and Challenges

For the age group of 50 and above, major barriers to receiving cataract surgeries were evaluated to be local reasons, for instance having no one to accompany and personal preferences, followed by, financial constraints, need for surgery not felt, fear of surgery, and could not access treatment or were denied treatment. Thus, comprehensive and inclusive health financing and awareness among the population regarding the procedure would mitigate these barriers. 

Another major challenge in eye care is pediatric cataracts, which still remain one of the most important causes of preventable blindness in children and present an enormous problem to a developing country like India in terms of human morbidity, economic loss, and social burden.

Women bear a disproportionate burden of health inequity anywhere around the world, and the case is no different for visual impairment. The coverage of cataract surgery among women is always lower, sometimes even half of that of men.

Recent literature supports Intraocular Lenses (IOL) implantation in most cases of congenital/developmental pediatric cataracts. In many developing countries, primary IOL implantation is performed almost exclusively for toddlers and older children after cataract surgery. Surgeons are still cautious about implanting an IOL in infants, particularly in bilateral cataracts, keeping in mind the severity of the intraoperative and postoperative complications including exaggerated inflammatory response, high rate of Visual Axis Obscuration (VAO), and secondary Glaucoma. Thus, surgeons must be extremely cautious in planning primary IOL implantation in infant’s eyes, and if they do perform IOL implantation, rigorous follow-up is mandatory (Vasavada, A. R., & Vasavada, V., 2017).

India has achieved high cataract surgical coverage and currently, nearly 65 lakh cataract surgeries are performed every year with an average cataract surgical rate of more than 5000 surgeries per million population per year. The participation of NGO hospitals under the program is significant with the majority of cataract surgeries being performed by the NGO sector.

But, in spite of the significant reduction in the burden of blindness, untreated cataract remains the major challenge for the country. It is still persisting as the major cause of blindness and visual impairment since the inception of the national program.  According to the National Blindness and Visual Impairment Survey of 2015-19, following operations for cataracts for population above 50 ages, 57.8% of total operating eyes resulted in very good visual outcome (6/12 vision),17.7% with good outcomes (<6/12 to 6/18)), 13.6% with the borderline visual outcome (<6/18-6/60) and 10.9% had poor visual outcome (<6/60).

The target for the number of cataract surgeries was 66000 between 2014-18. This must increase to at least accommodate more than one lakh people and for the purpose of early diagnosis and treatment more Primary Eyecare centers must be developed and established in rural areas.

The country does not have a national registry on cataract surgical outcomes, which could be utilized to collect and analyze information and make recommendations for policymaking. 

The coverage of interventions for cataract and refractive error has to be expanded so that the current and future demands are duly met. Further, standard prototypes for reporting performance and expenditure by district blindness control societies and usage of standard cataract surgery records and patients’ discharge cards should be ensured.