High-Quality, High Volume Cataract Surgery at Aravind as a Model for Male Circumcision

Investigator: James Kahn, MD, MPH
Sponsor: Bill & Melinda Gates Foundation

Location(s): India


The Aravind Eye Care System in Madurai, India has refined the methods of high-quality and high-volume cataract removal over several decades. The programme has engaged in continuous innovation guided by rigorous evidence review to identify best methods. All steps from training and community recruitment to patient intake, surgery and recovery employ explicit systems to maximize the services provided, contain costs and assure world-standard care. The Aravind method, employed in a single facility in the 1970s, now encompasses five hospitals, three managed eye hospitals, a manufacturing centre for ophthalmic products, and an international research foundation. Through its resource and training centre the Aravind method has been adopted in more than 200 hospitals worldwide, including ones in Africa. 
The surgery itself relies on a team approach. Lower health cadres conduct the majority of steps in the surgery, before and after the surgeon conducts the delicate cataract removal and artificial lens implantation. A patient is prepared for surgery in an anaesthesia room, where a specially-trained provider administers a retro-orbital block for local anaesthesia. The patient is then transported into the surgical theatre. A senior surgeon operates on two side-by-side tables with a scrub nurse at each. While the surgeon operates on one table (table 1) assisted by one nurse, another nurse drapes and prepares the second patient up to the bridle suture on table 2. When the procedure on table 1 is over, the assistant gives the subconjunctival injection and bandages the patient. The surgeon, after disinfecting her or his gloves, moves on to table 2, where the next patient is ready for surgery. Thus the output of a surgeon with a single microscope is almost doubled. An experienced surgeon can perform 6–8 extracapsular cataract operations in an hour.