Elimination of preventable blindness: can success in Nepal be replicated in Africa?

Elimination of preventable blindness: can success in Nepal be replicated in Africa?
Neda Nikpoor,1,2 Eric D Hansen,2,3 Matthew S Oliva,2,4 Geoffrey Tabin,1,2 Sanduk Ruit2,5

1Byers Eye Institute, Stanford University, Palo Alto, CA, USA; 2Himalayan Cataract Project, Waterbury, VT, USA; 3Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 4Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA; 5Tilganga Institute of Ophthalmology, Kathmandu, Nepal

Abstract: 

There are an estimated 36 million people who are blind worldwide: ~1 in every 200 people. A third of these are blind from cataracts and could have perfect vision restored with a simple operation costing less than US$25. Ninety percent of the blind and visually impaired live in the developing world, with particular concentrations seen in South Asia and sub-Saharan Africa (SSA). Innovations in surgical techniques, delivery systems, and material production, developed first in Nepal and India, have provided a viable blueprint to address treatable blindness in the developing world. In fact, Nepal was the first developing country to reverse its trajectory of blindness. This was largely possible because of a collective effort by many international nongovernmental organizations to support Sanduk Ruit and his colleagues as they developed a sustainable eye care–delivery model anchored at Tilganga Institute of Ophthalmology. This model is similar to that of LV Prasad Eye Institute and Aravind Eye Hospital in India, which is also being successfully utilized to combat the enormous burden of needless blindness in Africa. Over the last decade, there have been early successes in transferring the Nepali model of care to Ethiopia and Ghana, and there have been other models successfully implemented across Africa as well. Though there has been significant progress in restoring sight in SSA, the prevalence of avoidable blindness in Africa is higher than any other continent, with about 4.8 million people living blind.

Keywords: blindness, cataract,visual impairment, Nepal, Africa, cataract surgery

Lessons from Nepal
Background

Nepal is one of the only countries in the developing world to reverse its rate of blindness. The manifold lessons gained from Nepal’s transformation are informing coordinated efforts to achieve the same in other regions, especially SSA. In 1981, a national blindness survey conducted in Nepal found the prevalence of blindness to be 0.84%; 72% of blindness in Nepal was caused by cataract.6

At the time, the national blindness survey was published, phacoemulsification was the emerging technique for CS in developed countries. However, phacoemulsification surgery posed significant challenges in the developing world, due to the high cost of necessary medical equipment and consumables, in addition to a steep learning curve for the surgeon. In the early 1990s, the least expensive intraocular lens implant on the world market was priced at US$200, more than the average annual income of a Nepali citizen and thus unattainable for all but the wealthiest Nepalis.

The landscape of eye care in Nepal at this time was further complicated by a paucity of trained ophthalmologists and few suitably trained ophthalmic nurses and ophthalmic assistants. Nepalese surgeons were not performing modern microsurgical cataract operations with routine intraocular lens implantation, and training programs or formal eye-care systems were nonexistent. In addition, governmental input for eye-care delivery was minimal, as eye health lacked prioritization amid an anemic economy and a constrained budget. Given these realities, the total number of CSs performed in Nepal hovered around 1,500 cases per year. Even then, the majority of surgery was done only in the Kathmandu valley, neglecting the majority of the blind who lived in rural Nepal. As a result, Nepal had a backlog of 300,000 people blind from cataracts in 1990, with 60,000 new people going blind every year.7 Considering the lack of trained clinicians and the cost involved, the prospect of eliminating blindness seemed insurmountable.

Facing these obstacles, ophthalmologist Sanduk Ruit returned to his native Nepal in the early 1990s, having trained in India, the Netherlands, and Australia. He set out to improve eye care in Nepal and prove that it was possible to provide modern, high-quality services to all patients, irrespective of their ability to pay. Ruit’s vision galvanized the support of many international NGOs, including The Fred Hollows Foundation, the Himalayan Cataract Project (HCP), SEVA Foundation, Christian Blind Mission, and others. The international community formed a united front to address the problem of cataract blindness in Nepal. The Nepal Eye Program, a not-for-profit, community-based NGO, was officially launched in 1992 to support the prevention and control of blindness in Nepal. Ruit and his colleagues opened the Tilganga Institute of Ophthalmology (TIO), as the implementing body of the Nepal Eye Program in 1994, in Kathmandu. TIO was founded to serve as a center of excellence for delivery of tertiary care and training at all levels of eye-care delivery. As a not-for-profit model, the tenets of TIO focused on training, infrastructure development, and delivery of CS to the maximum number of patients at the lowest possible cost. TIO began close collaboration with other emerging hospitals in Nepal, such as Lumbini, Lahan, and Biratnagar.

Limited by cost and number of ophthalmologists, TIO developed an innovative delivery system for outreach that provided low-cost, high-quality care by employing a team approach that maximized each member’s performance and utilized local lay volunteers in remote areas. This system empowered a small team of one to two ophthalmologists and a cadre of ophthalmic assistants working with local partners to provide hundreds of CSs in a remote setting within just a few days.

With Fred Hollows Foundation support, TIO established the first intraocular lens manufacturing facility in Nepal, cutting the unit cost of an intraocular lens from near US$200 to <US$4. During this time, Ruit et al were also innovating a sutureless, extracapsular manual small-incision CS (MSICS) technique that would eliminate the need for costly, complex instrumentation and expensive consumables. This innovation on manual CS techniques represents one of the most significant steps forward for global ophthalmology.8



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