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We were interested to see Roberts, et. al study  which explored whether a hub-and-spoke model using a femtosecond laser (FL) could increase the efficiency and reduce the cost of cataract surgery.
Although the model was not cost-effective when compared to conventional phacoemulsification surgery, more efficient models should continue to be assessed. The Aravind Eye Care system uses an alternative hub-and-spoke model. Instead of separate operating theatres (OTs), the physician alternates between two beds in a single OT. This model, and the safe reuse of surgical supplies, results in phacoemulsification cataract surgery with excellent outcomes at 1/20th the cost and carbon emissions [2-4].
Roberts, et. al recommend that the ideal number of OTs to maximise the utility of an FL in a hub-and-spoke model is four. However, they were not able to evaluate the effect of adding additional OTs to their model as they only had two OTs. We suggest that adopting the Aravind model to jump to the 1:4 model without further building work could significantly alter this paper’s conclusions. We would be interested to know if elements of the Aravind model, two beds one theatre, could be adopted in their setting.
On average patients receiving FLACS spent 5.85±1.99 mins in the laser suite (LS), implying a potential throughput of between 8 and 15 cases per hour. We are interested to know the authors views on the the limits of the FL and what impact the adoption of bilateral...
On average patients receiving FLACS spent 5.85±1.99 mins in the laser suite (LS), implying a potential throughput of between 8 and 15 cases per hour. We are interested to know the authors views on the the limits of the FL and what impact the adoption of bilateral sequential cataract surgery might have on their cost estimates,  assumptions about throughput and the potential viability of more intensive 1:6 or 1:8 models.
Finally, maintaining training standards while improving efficiency is a challenge and we would be interested in the authors views on how training is best catered for within their different hub and spoke models.
1. Roberts HW, Wagh VK, Mullens IJM, Borsci S, Ni MZ, O’Brart DPS. Evaluation of a hub-and-spoke model for the delivery of femtosecond laser-assisted cataract surgery within the context of a large randomised controlled trial. Br. J. Ophthalmol. 2018 doi: 10.1136/bjophthalmol-2017-311319
2. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J. Cataract Refract. Surg. 2017;43(11):1391-98 doi: https://doi.org/10.1016/j.jcrs.2017.08.017
3. Hong-Gam Le JRE, Rengaraj Venkatesh, Aravind Srinivasan, Ajay Kolli, Aravind Haripriya, R. D. Ravindran, Thulasiraj Ravilla, Alan L. Robin, David W. Hutton, Joshua D. Stein. A Sustainable Model For Delivering High-Quality Efficient Cataract Surgery In Southern India. Health Aff. (Millwood). 2016;35(10):1783-90
4. Venkatesh R, van Landingham SW, Khodifad AM, et al. Carbon footprint and cost–effectiveness of cataract surgery. Curr. Opin. Ophthalmol. 2016;27(1):82-88
5. Grzybowski A, Wasinska-Borowiec W, Claoué C. Pros and cons of immediately sequential bilateral cataract surgery (ISBCS). Saudi Journal of Ophthalmology 2016;30(4):244-49 doi: 10.1016/j.sjopt.2016.09.001