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With 20 million cataract blind worldwide, cost raises ethical questions

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What is the real cataract crisis in 2013? Irregular capsulotomies? Endophthalmitis? Astigmatism management? Presbyopia?

“I don’t think it is any of the above,” Mark Cherny MD, Melbourne, Australia, told the 2013 American Society of Cataract and Refractive Surgery symposium. The real crisis is 20 million people worldwide blind from cataracts and another 50 million visually impaired, he said.

The cost goes beyond the suffering of those directly afflicted to loss of income, productivity and even educational opportunity for families and communities, Dr Cherny noted. “Many children are taken out of school to care for parents and grandparents who are blind.”

As the ophthalmologists and the eye care industry embrace expensive femtosecond laser technology for cataract surgery, where is global cataract blindness on the agenda? Dr Cherny asked. And what can be done to address the true cataract crisis?

Dr Cherny is hardly a Luddite. An early adopter of femtosecond laser-assisted cataract surgery, he installed a Catalys system (Optimedica) in July 2012. He now uses it for all his cataract cases.

Cost of technology

However, with nearly 1,000 laser-assisted surgeries under his belt, Dr Cherny is also aware that femtosecond technology adds $600 to $1,000 beyond the cost of a conventional phacoemulsification procedure. According to his analysis, the added cost of one femtosecond laser-assisted procedure could fund somewhere between six and 50 entire small incision extracapsular cataract extractions in the developing world.

So if femtosecond technology prevents one in 50 patients from a 20/200 outcome – which assumes a failure rate much higher than typical in the developed world – the $30,000 to $50,000 cost could cure blindness in 300 to 2,500 patients receiving small incision procedures. Assuming femtosecond technology “saves” only one in 200 patients from blindness the trade- off is even starker, with as many as 10,000 small incision surgeries potentially done for the same investment.

Surgical perfection

“To go from a very good platform, conventional phaco, we have to spend a lot of money to take the next step towards surgical perfection,” Dr Cherny noted. Whether the cost is justified in the face of so much untreated blindness, or if the technology will ultimately benefit developing countries, are questions for which he has no easy answer. What can be done is to get personally involved, Dr Cherny said. “I reviewed my own response to global blindness and am embarrassed to say I had done nothing.”

Connecting projects

So Dr Cherny set up a web site,, to help others connect to projects in the developing world. He’s gotten a commitment from Optimedica to donate, and he’s talking to other manufacturers. Donating a small amount for each procedure he does is another way to help.

Patient awareness

Literature in the waiting area helps increase patient awareness, as do online and social media, Dr Cherny said. “Many of us have web sites. How many of us have a link to a global aid organisation? Dr Cherny sees solving global blindness as a central mission of ophthalmology.

“There are a lot of people who get locked into a little room with a slit lamp and a lot of local patients to treat, and we don’t have the international issue on the agenda. We should all make the global blindness crisis a priority and support and encourage those who are doing something about it.”

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