Cataract Surgery

How much a Cataract surgery cost in India?

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Cataract surgery has no fixed formula to calculate a cost, but there are few rules which worth to be mentioned to help decide right place get operated. Having a relative getting operated is often a ‘once in a lifetime’ experience, and biggest question is how much is it going to cost. Am I been quoted a fair price or I am getting fooled. 

Surgery packages:

Most of the cataract surgeons in India practice what they call as surgical packages for what they charge for doing cataract surgeries. It is mainly limited to uncomplicated age related cataract done under without giving the general anesthesia.

The” Package” include, pre-operative examination, surgeons fee, surgery charges, anesthesia charges, medication given during and before surgery, cost implant (Lens) and hospital stay. it varies from, hospital to hospital , surgeon to surgeon, city to city, type of surgery ( SICS> Phaco> Femto Laser) , type of lens ( Indian Mono-Focal > Indian Multifocal> Multifocal )  and so on. Cost may vary from 10k -150k depending on the combination of doctor, hospital, surgery, lens you have chosen for you.

Cost of the post-operative drugs and additional intervention after the surgery are usually separate.

How to confirm that you have got what you have promised?

At the time of discharge, patient gets the discharge and treatment summary, which mentions name of surgeon, anesthesia, details of surgery and details (name and brand of lens) implanted in the eye. Brakes down of the charges for each item are usually not provided.

Can you bring the lens of your own and hospital to implant it?

Most of the hospital gives a fairly long list of Lens to choose from. One can choose from the available options. Hospitals usually do not allow surgical implants and disposables from outside. It is because hospital has to maintain a huge inventory of each and every disposable and lens in different sizes and numbers and often in multiple numbers as the backup. If a lens or any disposable gets damaged or contaminated while handling it during implantation, hospitals have multiple similar pieces in back up. It is not possible if patients bring a single piece from outside.

More over surgeons often have expertise and a certain comfort level with certain brands of lens, which they implant daily. Most of the surgeons have serious reservations against trying a new lens, in that event of stress of doing a surgery. So they usually do not agree for this.

Brands of Lens

There are many different types of intra-ocular lenses available in India. Most surgeon/hospitals offer surgical packages based on Indian (cheap) and imported (expensive) lenses. Imported lens are costlier than their Indian counterpart and are preferred by both patients (rich) and doctors alike. There are no scientific studies which validate the difference in the quality of the two, this notion continue due the common perception that imported goods are superior in quality.

Indian versus imported lenses

In eighties and nineties, when ophthalmologist began to switch to lens implantation (rather than leaving the eye without the lens and giving the patient thick glasses). At that time the lens needed to be imported from US and Europe, as there were no lens manufacturers in India. Though the imported lens were of good quality but were very expensive. In nineties some Indian companies started manufacturing lens in India. The lens manufactured were quite cheap, but the quality wan not as good as those of the imported once.

Now days there are many Indian companies who are manufacturing the lenses in India, and also exporting it to many other countries, which include US and Europe. Since they have to meet stringent FDA and EC guidelines for that, overall quality of lens manufactures in India matches with any of the manufacturers from abroad.

So in my view, it as far as the  quality  of the comparable lens (similar lens material and design) is concerned, there is no difference.  The imported Lens usually cost 3 to 5 times as much as an Indian lens. Various government bodies are raising concern of this pricing of the lens in India. Quite likely, we may have some government regulation on price control of lens, in day to come.

Imported: Alcon, AMO, Zeiss, Bausch & Lomb, Hoya.

Indian companies: Appasamy, Omni, Aurolabs, Biotech, Care,

Foldable lens versus non foldable (rigid) lens?

Foldable lenses are more popular and expensive that their non-foldable (rigid) counterparts if all other parameters are same (design, brand, country of origin). There are only two scientific studies (one from Thailand, other from France ) which were designed to see the difference  in the vision and other outcomes after the surgery, among these type of lenses. Neither of the two studies reported any difference among the two.

Tips regarding selecting lens packages in cataract surgery.

  • Surgery packages: 10K-150K INR chose as per your budget.
  • How to confirm that you have got what you have promised?  Discharge Summary 
  • Can you bring the lens by your own ? No 
  • Which Brands of Lens is better? All are same. 
  • Indian versus imported lenses, which are better? All are same
  • Fold-able lens versus non-fold-able (rigid) lens, which one is better? All are same

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Cataract

Inappropriate cataract surgery: is it a myth or reality ?

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There have been media reports in which the doctors and the hospitals have been accused of performing cataract surgeries when these are not actually required. The question is, are these really fake news or are actually happening?

Media reports a recent media report, attributed rapid rise in the number of certain type surgeries being done at various hospitals , to the fact that some of these surgeries are been done for economic reasons only. The patient may not have actually needed one. Among the many surgical procedure, the cataract was reported to be the commonest.

Targets to meet: News report say that in corporate hospitals, the doctors are pressurized to perform more surgeries to increase the corporate profits as surgeries offer greater financial return in shorter time. Consequently some of the patients are advised to undergo cataract surgery in spite of the fact the patient can manage without it. It further suggested that those who are advised to undergo surgery should better have a second opinion, which is very much concerning. Similar concern are also been reported from advanced counties as well.

The Optometric-Ophthalmic Kickback Scheme: Dr Robert P. Gervais reported the arrangement of kick back system practiced in US, in which patients are predominantly operated to make money, by ophthalmologist in cooperation with optometrist. It is surprising that it is practiced in a country like US where documentation and other regulations are so diligent followed. The scenario could be much worse in India where it is difficult to enforce government regulations.

Also read: 

cataract surgery : an ultimate patients guide
How much a Cataract surgery cost in India?

 

Scientific reports: a number of scientific publications have reported the documentation of performing unnecessary surgeries to be as high as 30 percent for certain type of surgeries. Practices of unnecessary surgical procedures in Indian scenario are been well documented in case of caesarean deliveries and hysterectomies under government insurance schemes .

Government stand: a senior government minister have expressed concern on this issue and share the perception that kick back, cut and commission is prevalent in some segment of practice. They have also ” considering to bring some type of oversight for pathological laboratories and diagnostic centers to end the corrupt practices including possible nexus between doctors and the laboratories, and cartelization among diagnostic centers

Doctors and representative medical bodies: They largely dismissed the concerns over profit-driven tests and procedures as a “perception,” saying corruption is less widespread than the media would have it appear. “The medical profession is noble and will remain noble,” “There are people who are corrupt, they are facing charges and they are being punished.”

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Credit: Pixabay

Conclusion: Though the actual figures may actually be debated as what percentage of doctors are indulging in these kind of practices but these reports certainly points to the maligning of reputation of whole profession. These will only add to stricter government regulation and legal scrutiny of clinical practice and practitioners.

Please share your comments below.

Cataract Surgery

Cataract surgery: an ultimate patient’s guide

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What should you do if you are told that you have cataract. It’s a step wise guide to help you decide what to pick when you have multiple options to choose. The aim is to enable you to take an informed decision at every cross road of your treatment plan.

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You had  problem in reading the fine print in the newspaper . You went to a doctor and he/she says you have cataract. You ask him why is it has happened, and he/she consoles you that it’s simply because of aging and not much you could have done. When you ask him/her, what should you do, the often the answer is “go for surgery”.

Such an experience leaves a patient with more question than any answer to his problem. here is the list of steps you should take to handle it.

Step one: Do not panic.

Cataract is a very common clinical condition and is treatable.

At any point of time, there are about 20 million people in whole world who have cataract, and about third of them are in India. Around half a million people undergo cataract surgery every year in India alone, which means that it is very much treatable. Internet has lot content on this topic, but I would recommend NIH and Wikipedia as reference sites for basic information about cataract. Do not correlate that information with your case as it will leave you more confused.  Ask you doctor the questions you have about yourself.

Step two: Confirm why you developed the cataract?

Usually its age, but there could be others reasons also. There are many types cataract, and many ways to classify it. Do not try to find the answers on internet because it require lot of professional expertise to decide the cause. Just because you have , diabetes, does not mean you are having a diabetic cataract.  Ask your doctor to explain. Its important to know the reason . discuss with your doctor, the other medical conditions , you have,  like diabetes, hypertension, asthma, thyroid dysfunctions etc.

Step three: Do you actually need surgery?

Just because you have the cataract, does not automatically means you immediately require surgery. Mostly it is the compromised vision resulting from the cataract that people decide to have the surgery. Sometimes there could be other reasons as well, which are decided by your doctor only. You should discuss with your doctor, the extent to which your vision is compromised due to cataract, in involved eye and with both the eyes open, and the likely visual gain after cataract surgery in these situations.

An important reason for people to be unsatisfied with surgical outcome, is the lack of significant improvement in vision after surgery. You should also discuss what exactly is the room for improvement in your vision after surgery, in involved eye and with both the eyes open.

Step four: Can it be postponed?

Mostly it is not an emergency. Discuss with your doctor, about the duration for which it can be conveniently postponed. Cataract due to aging, unless contraindicated by the doctor, can be easily postponed for few months to accommodate more pressing employment and family matters.

Step five: when to get operated?

I think the two conditions mentioned below should be met before surgery is planned in age related cataract.

  1. Reasonable expectation of improvement in vision after surgery
  2. Stable associated diseases like, diabetes, hypertension, asthma etc.

Step six: where to get operated?

There are no rule of thumb to identify a good hospital from the rest, but certain general guidelines may be followed.

  1. Prefer a hospital/ facility which accredited by some accreditation agencies like NABH in India.
  2. Dedicated eye hospitals have better developed facilities for eye care that an eye department in a multi-specialty hospital.
  3. A facility with multiple eye surgeon practicing different eye specialties has better services than single surgeon facility.
  4. If you have personal acquaintance with the reputed individual surgeon, that’s the best choice.

Step seven: what type of surgery should you have ?

Most commonly surgical method for age related cataract is Phaco-emulsification with posterior chamber lens implantation, commonly known as Phaco. It’s neither required nor  possible in every patients.  There are other surgical methods also which are required in certain conditions in certain types of patients. You should discuss with your doctor which surgery is best in your situation. You should never insist for a particular type of surgery with your doctor.

Step eight: what type of anesthesia should you have ?

It’s same as surgery. Topical anesthesia in which the eye is anesthetized with a drop of anesthetic, is common way the age related cataract is operated, but there are other methods of anesthesia which are required in certain situations. You should discuss with your doctor which anesthesia is best in your situation. Insisting for surgery under topical anesthesia only, is a bad idea.

Step nine: what type of lens should be implanted ?

Posterior chamber lens are commonly used, unless it is not possible to implant that lens in eye due to medical reasons. They rigid and fold-able. Fold-able lens are better. They are available by different brands, and place of manufacturing (Indian /imported). Often the imported lens are expensive. I could not find a single scientific report which says that visual gain after surgery has any relation with the brand or the place of manufacturing of lens.

Monofocal and a multifocal lens

Other important issue is to decide between monofocal and a multifocal lens. The latter is supposed to provide functional vision for both near and distance, but lens are expensive. But that does not guarantee spectacle free life after the surgery. Some cases may still need glasses for certain type of task, even after an uneventful cataract surgery with multi-focal lens. Moreover it is associated with certain type of vision related complications like glare and reduced contrast of images. An article by Dr. Evans appropriately explain the pros and cons. If you want to know more, than there are many good scientific publications on this issue. Discussion with your doctor is the best way out. If you are still in doubt, gamble on mono-focal lens.

Robotic/Laser assisted cataract surgery

It’s a new technique in which some critical surgical steps are done using high precision laser. Other steps are common between laser assisted and traditional method. The down side is that it is more expensive that traditional method. The available scientific evidence by researchers (Popovic MDay AC) does not document any significant in the visual outcome after either of these techniques.

 Step ten: What are complications of surgery of surgery?

Complications during and after surgery are associated with every surgical procedure. Cataract surgery is no exception to this rule.

 Posterior capsular Rent ( PCR ) is (relatively common complication ) occurring during the surgery  and Endoththalmitis ( infection in the eye after cataract surgery) is uncommon complication happening after completion of the cataract surgery. These may require vitreo-retinal surgical support.  Discuss with your doctor regarding the availability of back up facility in hospital and its policy regarding the management of this complication.

Step eleven: Post operative care  after cataract surgery

Eye hygiene, protection and regular use of eye drops/medications constitutes the basic post operative care. But the care is individualized as per surgery and patient parameters. Its important to clearly understand it and follow the instructions issued.

share you opinion  on this issue in the comment section. Point out the issues i have left or you have a different take.

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Artificial Intelligence

Artificial Intelligence (AI) in ophthalmology practice: Are Ophthalmologists ready ?

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From accurate clinical diagnosis to autonomously operating surgical robots, AI has more to offer than we have asked for.

The ophthalmic practice had changed with the advent of every new technological breakthrough. The intra-ocular lens in sixties and minimally invasive cataract surgeries in nineties had a significant impact on the practice. Both of these technologies revolutionized the clinical out come in the terms of speed and accuracy of visual restoration making it the ophthalmic surgeries, fast and predictable.

The idea of artificial intelligence (AI) to correctly identify diseases and then effectively treat patients as good as doctors do might be possible in the future. That idea will definitely take some time to take a shape, till than an ophthalmologist will be an indispensable cog in the wheel of patient care. Not many of us will reject the possibility of this revolution but we do believe that this is not happening any time soon.

Clinical diagnosis and management decisions

Reports about the upcoming AI related platforms in eye care, are painting an entirely different picture. Erping Long , China had tested An artificial intelligence platform  for the management of congenital cataracts. They used a deep-learning algorithms to create AI agent involving different functional networks to perform three important task (i) identify potential congenital cataracts patients in populations (Screening) (ii) Comprehensive evaluations of disease severity (lens opacity) with respect to three different indices (opacity area, density and location) (Risk stratification) (iii) Provide the final treatment decision (Surgery or follow-up). The researcher explored its feasibility, versatility and utility in management of congenial cataract and compared its real-world performance with an individual ophthalmologist. The training data for this deep-learning network included 410 ocular images of CC of varying severity and 476 images of normal eyes from children, categorized by an expert panel.

The results of the study were simply amazing. The AI machine could distinguish cataract patients from healthy individuals with an accuracy of 98.87%. It could provide a treatment suggestion (surgery or follow-up) with an accuracy of 97.56%. They further validated its  ability to identify the diseased patients in  a realistic  real-world ratio of rare-event disease to normal cases. In this case, the test data consisted of a total of 300 normal cases and 3 cataract cases of differing severity. The agent successfully excluded the normal cases, identified the three cataract cases and provided accurate evaluations and treatment decisions.

Its performance, when compared with individual ophthalmologists, was even more remarkable. In terms of accuracy, the AI agent out-performed individual ophthalmologists on every parameter analyzed, be it diagnosis or management decision.   The ophthalmologists were categorized in three degrees of expertise (expert, competent and novice) for comparison. The AI agent performed better that experts in terms of false positives and missed detections.

From the AI context, the results were on expected line. As data heterogeneity is inevitable in clinical practice, and AI has inherent advantage over human in their ability to tackle multi source and wide-format data. Increasing computational speed, evolving deep learning algorithms and increasing sophistication of image recognition capabilities have tilted the balance simply in the favour of the AI machines only.  In this particular case,  the phenotype of congenital cataract  has lot of variations , which makes the classification of congenital cataract  images difficult, influencing decision-making and patient prognosis. The illumination intensity, angle and image resolution, eyelids, eyelashes and pupil size etc., make the identification peculiarly complex for an ophthalmologist.  The AI machine with  advantages of deep-learning algorithms,  learns from the cumulative data and becomes more and more intelligent with increasing use and widening of the input base. Its predictions becomes  ever more accurate with every possible cycle of use. Though validated in case of congenital cataract, similar collaborative platforms will soon be  extended to the management of other  diseases, and find  validations  in different clinical scenarios. Google DeepMind,  in   collaboration with the NHS, is working on a machine learning system which will eventually be able to recognize sight-threatening conditions such as wet age-related macular degeneration and diabetic retinopathy, from a digital scan of the eye.   And very soon, we will have similar platforms for other diseases as well.

Available in market already available in market. Recently FDA has given clearance to an artificial intelligence-powered IDx-DR diabetic retinopathy detection system which is supposedly the first device cleared to diagnose a medical condition autonomously. What is more interesting is the fact that it is authorized to do so without requiring a review by a specially trained clinician. It will not only drastically increase the number of diabetic people receiving screenings but also reduce the requirement of an ophthalmologist.  This has also received a green signal in Europe and the initial trails are been reported to have encouraging results.

Surgical robots

The AI assisted robotic surgical devices setting newer standards in the field of ophthalmic surgery.   R2D2,  developed by Preceyes BV, a Dutch medical robotics firm can perform complex retinal surgeries like epiretinal peeling surgery. Though it was been guided by the surgeon during the surgery, the robot was capable of performing it autonomously as well.   It is not the only robot which is capable of operating on human eyes.   Axsis developed by  Cambridge Consultants, can precisely navigate in a small space as eye and could also be used to operate senile  cataract. What is more interesting is the facts that these robots  will enable surgeons to perform surgical procedures which are not yet possible, like  in sub retinal space and in and around   blood vessels in the eye.

CONCLUSION: 

It is evident that the role of an ophthalmologist will be redefined in practice,  by these upcoming technologies. Ophthalmologists will have to find their roles more important than diagnosis and surgery, as the AI will not have the element of human error and learning gaps. Now it is up to  us to identify how  we  adopt ?

Also read

Scientific studies report that most individuals (81%) say that they “learned something new” regarding their health, the last time they went online. The majority (80%) of people found the information through a search engine as reliable.

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Blindness control

Role of NPCB in control of preventable blindness in India

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India is also home to around 9 million blinds out of which one third have preventable blindness. Later means that we can treat it if we have capabilities and intention to treat. NPCB has done a great job in containing the problem of preventable blindness in India.

When comes to delivery of results in any social programs, people have serious doubt about the capabilities and intentions of government agencies. The suspicions are not entirely unfounded as corruption, inefficiency, lack of coordination, poor planning, and political interference are some attributes commonly associated with any government agency.

National Program for Control of Blindness, NPCB.

As a launch of any social benefit program attracts media attention, we often are in a hurry to do that. No surprise that India was the first country in the world to launch a 100% public funded programme for the control of blindness also called the National Program for Control of Blindness, NPCB. National Programme for Control of Blindness was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness in India.

As a launch of any social benefit program attracts media attention, we often are in a hurry to do that. No surprise that India was the first country in the world to launch a 100% public funded programme for the control of blindness also called the National Program for Control of Blindness, NPCB. National Programme for Control of Blindness was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness in India.

Experience of  China

Just to put things into perspective, in China, the estimated numbers of blind people in 1990 were 6.7 million.  The China population of people 50 years of age and older (who are at higher risk of blindness) in 2002 had increased by 27% compared to that in 1990. In 2002 there were an estimated 6.9 million blind people in China. That means that with all the efforts and resources the china invested in blindness control, an increase of 3% in the number of blind people was noticed in China, in the year 2002. The may well be attributed to the errors in estimations and projections to calculate these data.

Our achievements

In comparison with that, In India, the estimated numbers of blind people in 1990 was 8.9 million, which was around 2.2 million more blinds than what China had. Just like China, the Indian population of people 50 years of age and older (who are at higher risk of blindness) in 2002 had increased by around 30 % compared to that in 1990. But what’s most surprising is that in 2002 the total number of blind people estimated in India was 6.7 million. It was not only 0.2 million less than what China had,  but also that India reported a decrease of 25% blind people over the numbers published in 1990.

This achievement is partially attributed to factors like patient awareness, and socioeconomic development but the credit primarily goes to the concerted national efforts to control blindness sphere headed by NPCB. This success is attributed to an emphasis on evidence-based practice for planning and policy formulation besides the implementation and identification of strategies appropriate for local needs.

But the story is not over yet. Cataract surgical rate (CSR) is described as number of cataract surgeries done in a year per one million population. The cataract surgical rate (CSR) is one of the major WHO indicators used to assess overall level of blindness control efforts done in a country. WHO recommends an ideal CSR range of 3000-5000 per year per million population to meet the need. In India, CSR is estimated to be more than 5000. Under 11 five year plan (2008-12) around 3 million (2, 94, 07,355 to be exact) cataract cases were operated. From 2013 onward, with exception of few states like UP and Panjab, most of the states are regularly exceeding the target of cataract surgeries planned every year under NPCB.

But then these are just numbers, and often the actual needy is left behind and government funded benefits are taken by socially and economically strong sections of the society. A study reported from Madhya Pradesh, the female patient’s outnumbered males both is outdoor patients and operated patients in the eye camps organized under NPCB. Though this may be partially attributed to higher incidence of cataract in aged females, but it is no less achievement that government is able to deliver them the services. In one of the series of around 2200 cases, author reported that around 88% of the patients were from socially back ward communities. Author added that “A combination of these three factors – female gender, poverty, and backward class – lays an individual in utmost undesirable position. These camps were an immense aid to them”.

Concluding

So next time when you are making a list of what India does better than the rest of the world, do not just include ISRO and Bollywood . Blindness control program NPCB, certainly deserve a place in that list.