Editorials

Providing spectacles in developing countries

BMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7158.551 (Published 29 August 1998) Cite this as: BMJ 1998;317:551

Intraoperative lens implants are best in cataract surgery

Editor

We agree with Dr Potter that the provision of affordable spectacles
in developing countries could transform the lives of millions1. While this
is the appropriate remedy for children with refractive errors and adults
with presbyopia, people with cataracts would be better served by cataract
surgery with an intra-ocular lens implant. Simple intracapsular extraction
is of limited value; even in the developing world. Reports from KwaZulu in
Africa2 and Nepal3 indicate, that less than a quarter of patients ended up
using aphakic glasses, even when they were provided free. Thus cataract
blindness was merely replaced by uncorrected aphakic blindness. The use of
intraocular lenses leads to better results and a greater proportion of
satisfied patients, whilst also permitting earlier intervention. Most
importantly, early intervention prevents cataract blindness rather than
curing it. A major advantage is that the best advertisement for cataract
surgery (and the organisations and eye-camps offering it) is a satisfied
patient. More satisfied patients are likely to motivate more people to
come forward for surgery.

The high cost of intra-ocular lenses has been a limiting factor to
their widespread use in the developing world. Intra-ocular lenses are now
manufactured in India, Nepal and Eritrea for under £ 5 per lens, enabling
the cost of cataract surgery with lens implantation to be kept to around
£10. This is comparable to the cost of intracapsular catract surgery with
provision of aphakic glasses. A large randomised trial, in a developing
country setting4, has reaffirmed that extracapsular cataract surgery with
an intraocular lens is safer than intra-capsular cataract extraction and
that patients who received an intraocular lens reported greater benefits
and fewer problems with vision than those who received aphakic glasses.
Exemplary initiatives in Madurai 4 (India) and Tianjin5 (People's Republic
of China) have demonstrated that the practical difficulties which limit
the use of intraocular lenses in the developing world can be overcome.

Although cataract extraction without intra-ocular lenses is still
being widely performed in the developing world, all available efforts
should be directed to the incorporation of lens implantation into the
routine cataract surgery done there. Aphakic glasses should no longer be
considered an acceptable alternative for the developing world's cataract
blind.

Somdutt Prasad
Fellow, Department of Ophthalmology
Arrowe Park Hospital, Wirral, L49 5PE

Sanjiv Banerjee
Lecturer in Ophthalmology
University of Bristol, Bristol

Manish Nagpal
Fellow, Aso-Palov Eye Hospital
Shahibaug
Ahmedabad-380004, India

References:

Potter AR, Providing spectacles in developing countries(Editorial).
BMJ 1998;317:551-552 (29 August)

Cook CD, Stulting AA. Impact of sight-saver clinic on the prevalence
of blindness in northern KwaZulu. S Afr Med J 1995;85:28-9.

Hogeweg M, Sapkota YD, Foster A. Acceptability of aphakic correction.
Results from Karnali eye camps in Nepal. Acta Ophthalmol 1992;70:407-12

Prajna NV, Chandrakanth KS, Kim R, Narendran V, Selvakumar S, Rohini
G, Manoharan N, Bangdiwala SI, Ellwein LB, Kupfer C. The Madurai
Intraocular Lens Study II:Clinical Outcomes. Am J Ophthalmol
1998;125(1):14-25.

Lim AS. Eye Surgeons-Seize the Oppurtunity (Editorial). Am J
Ophthalmol 1996;122(4):571-573.

Competing interests: No competing interests

11 September 1998
Somdutt Prasad
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