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  1. HANS LIMBURG
  1. DANPCB, A1/148, Safdarjung Enclave
  2. New Delhi 110 029, India

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    Editor,—I am grateful to Dr Seshubabu for the opportunity to expand a bit more on some of the operational concepts that might not have been explained well enough in the context of the article.1

    (1) From a public health point of view, the main problem of blindness due to cataract is the disability. This can be corrected by a successful operation of one eye. Operating on the second eye may increase quality of sight, but does not reduce blindness. Ideally, both eyes should be operated, but since resources are limited, the challenge is to spread out the same resources among a larger number of individuals and to restore sight in as many people as possible. The author of the letter himself states that the questions of equity and justice matter more than quality in developing countries with limited resources. In India, it is estimated that half of all people blind from cataract die without ever being operated.

    (2) The use of the indicator sight restoration rate (SRR) has been termed ’unsuitable’. In blindness control programmes, the most crucial question to assess the impact is: how many blind people had their sight restored as a result of the intervention? Most programmes cannot answer that question. The total number of cataract operations performed is known, but that reflects the workload, not the impact. The SRR is an attempt to measure the percentage of all cataract operations performed that resulted in changing a blind person into a sighted person. It measures the quality, efficiency, of the intervention programme. It is not designed to measure quality of vision in the individual. The SRR has to be used in combination with the other variables to monitor changes over a period of time, not as a one time assessment based on one observation only. Surgeries on cataract patients with VA better than 6/60, to prevent them getting blind, are captured in the other indicators used, such as the cataract surgical rate.

    (3) In India, two groups of non-operating ophthalmologists exist. One group are general duty medical officers—doctors posted in a position of a general doctor. Specialists accept such posts since there is a surplus of specialists and a shortage of generalists in the government health services. The other group are ophthalmologists in the private sector who prefer to do medical ophthalmology only, or who are unable to invest in a hospital set up. It is a well accepted strategy to involve these ophthalmologists. However, the experience with refresher courses for such non-operating ophthalmologists so far has been poor. The norm of 700 operations per year per eye surgeon is set by the Ministry of Health.2 Many surgeons in the government, NGO, and private sector achieve this already. In all these situations, efficient management is a key factor.

    (4) A scheme of subsidies, to assist NGOs and private eye surgeons to establish eye clinics in underserved areas, has already been introduced and many applications were received.

    (5) Besides the demographic changes, case selection is the key to understanding why cataract blindness is increasing despite more operations being performed. Whether we like it or not, there is already a lot of ‘case selection’ in eye care, and certainly not only in India. With the shift to high technology during the past decade, patient charges have increased and ophthalmologists have been targeting the wealthier urban population in order to pay back their investments. At the same time, basic cataract surgical services in the rural areas are reduced. Surgical camps, mainly practising ICCE + aphakic spectacles, are replaced by screening camps, where cataract cases are diagnosed and subsequently transported to base hospitals. These screening camps do not reach the more remote rural areas, since that would increase the transport costs too much. So these are held repeatedly in accessible places only. This is visible in the pattern of surgeries: 5 years ago 75% of the surgeries was in first eyes and 25% in second eyes; at present, 40% are in first eyes and 60% in second eyes. What we see is an increased coverage of accessible areas and an erosion of services in more remote areas. What the authors suggest is a programme of active case finding of bilateral cataract blind people all over India, including the remote places. The number of bilateral cataract blind people in India is increasing rapidly,2 mainly in the rural areas where eye care facilities are limited. Active case finding of patients who were operated earlier, and whose addresses are available, may assume less priority.

    (6) See (1).

    (7) Prevalence of blindness data are available for 5 year age groups only, therefore I used the population projections for 5 year age groups.

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