Cataract Treatment: See Clearly Again
The World Health Organization (WHO) estimates that there are over 39 million people around the world living with blindness. This shocking figure does not include those who are visually impaired, including this group the figure grows to a mammoth 285 million. Without immediate intervention, by 2020, over 75 million people will be blind and 200 million visually impaired.
According to the WHO, the major cause of blindness worldwide is cataracts (47.9%), followed by glaucoma (12.3%), age-related macular degeneration, AMD (8.7%) and others.
What are cataracts?
Sight – a normal lens will allow light to pass to the retina, which is the light-sensitive tissue located at the back of the eye. Cataract, derived from the Latin cataracta (“waterfall”), its opaque appearance resembles just that; clouding the lens of eyes resulting in blurred vision [see image, right], sensitivity to light or the appearance of halos or rings around light. The exact cause of cataracts is unknown, but it is believed to involve proteins (called crystallins), when healthy it functions to maintain the lens structure and transparency. However as we age, these proteins loss their structural integrity, clumping together forming a sheath, leading to the formation of cataract.
Cataracts in most cases is age-related, but children could also develop cataract (congenital cataract), or be due to secondary cataracts from medical conditions like diabetes, toxic substance and sun exposure (ultraviolet) or steroids. Injury to the eyes may also result in cataract formation (traumatic cataract). Other types of cataracts exist, such as radiation cataract and nuclear cataract (center of the lens) and posterior subcapsular cataract (back of the lens). A person can lower their risk of developing cataracts by not smoking, keeping their diabetes in check, protecting the eyes from the sun and limiting alcohol consumption.
Symptoms of cataracts include double vision (diplopia), a glare or sensitivity to light is also common, color vision may become dull or faded. In some types of cataract, a person may experience a temporary visual improvement (close-up) due to the cataract acting as a lens, called second sight. Typically in this case, the person will find that they no longer require reading glasses, but as the cataract progresses, visual acuity worsens. A person developing cataracts may also find that they often require new glasses or contact lens prescriptions.
What is the treatment for cataract?
A cataract is diagnosed by an eye examination using a slit lamp microscope; examination of the lens pupils are dilated in order for the specialist to get a better visual of the back of the eye (where the retina and optic nerve are found). Surgery is indicated when the patient can no longer manage to perform everyday activities due to loss of vision.
Unfortunately cataracts affect millions of people around the world; with no definite way to prevent cataracts, surgery is the only viable option. Astonishingly cataracts could be effectively treated either using laser or scalpels to remove the cloudy film, which is then replaced with an artificial lens. The surgery is mostly pain-free and only lasts around 20-30 minutes under local anesthesia and on an outpatient basis. Following cataract surgery, the patient regains their independence, 90% of patients noticed a great improvement in their vision.
There are two types of cataract surgery, phacoemulsification and extracapsular surgery. Extracapsular surgery (extracapsular cataract extraction, ECCE) involves larger incisions to completely remove a cloudy lens; this method requires stitches and is associated with a longer period of recovery.
On the other hand, cataract surgery involving the use of phacoemulsification and intraocular lens (IOL) has led to a successful outcome. Pharmoemulsification allows for smaller incisions and subsequently a faster recovery period, with minimal complications. Replacing the extracted lens (of a cataract patient) with an improved, flexible IOL allows the surgeon to make smaller incisions, significantly improving the recovery period.
The challenges of cataract treatment in Africa
Cataract surgery - a routine procedure in the West, but in many African countries people continue their lives undiagnosed and untreated. Eventually the patient requires round-the-clock care - inaccessibility to social and medical care has a (further) detrimental effect on their health, and in most cases, a loss of income. The burden of blindness can be prevented by surgery.
According to the WHO, 50% of avoidable visual impairment are due to cataracts in Sub-Saharan Africa, around the world this figure is 47.9%. Around 80% of blindness occurs in people over the age of 50. Although children could develop cataracts too, which account for over 10% of cases of vision loss. Faith, a 3-year-old girl in Kenya that had congenital bilateral cataracts; her mother abandoned her due to her blindness, leaving her aunt (with 5 children of her own) to adopt her. Faith only required a simple surgery to restore her vision, but due to limited resources as in most other developing nations, she had not had prior treatment. Thanks to an international charity, Faith was able to have cataract surgery. The next day post-surgery, her eye patches were removed gently and with watery eyes (from the first light entering her pupils), Faith was reborn again, she replied in Swahili: "Nikipata kalamu, nitaenda shule," ("if I get a pen, I will go to school."), needless to say she was not the only one with watery eyes. This surgery, although a simple procedure in the Western world, is life changing in developing nations.
An international measure of the number of cataract surgeries helps determine the level of general eye care services in a given population (per million) on an annual basis, called the cataract surgical rate (CSR). The CSR varies from country to country, but for comparison, the US has a CSR of around 5,000 and Africa has a CSR of 200. The WHO are leading a global initiative called Vision 2020 to eradicate preventable blindness by 2020.
Many Africans live remotely in rural places making it harder to seek medical attention. Faith’s aunt would have had to walk over 25km to the nearest hospital, where handled by an international charity, she was able to have her surgery. While others are simply not aware that their condition could potentially be cured or prevented by medical treatment.
The cataract burden in Africa is also due to there be limited specialists to carry out the treatment: Take for example, Gambia, in 1986 an eye care program was founded, with only one ophthalmologist to oversee its implementation. Since then, 17 cataract surgeons operate in Gambia, however, the surging population of 0.7 million to 2 million has led to a backlog of over 2,500 patients awaiting cataract treatment – campaigns in collaboration with Gambia’s Ministry of Health and other organizations aim to eliminate cataract blindness by 2018.
The lack of specialist eye doctors and general practitioners in rural areas is problematic, many people are unable to be treated. This is common even in remote areas of South Africa, for instance, a couple both of whom have cataracts living in a village 1,300km away from Cape Town are unable to receive treatment - the nearest eye surgery clinic is 4 hours away and there is a yearlong waiting list. This is the reality for many Africans.
New technologies like the HelpMeSee App utilize images of patients with cataracts, once stored on a cloud-based platform the information together with the patients geographical coordinates are sent to the nearest hospital where the patient is enrolled for surgery. This technology also avoids the weeks of waiting for paperwork to be transferred to the hospital, and hospital staff can determine the best mode of transport to the hospital, as well as follow-up care.
Sadly, many Africans like Faith, young and old are living with blindness due to conditions like glaucoma, trachoma or cataracts, which are often treatable. The late founder (and eye surgeon) Fred Hallows of the charity that treated Faith rightly put: "It's obscene to let people go blind when they don't have to".
Cataract surgery in Israel
Israel has made extraordinary progress, cutting the incidence rate of preventable blindness by half in a decade –unmatched anywhere else in the world. Apart from cataract, this includes glaucoma and AMD. The results were published in American Journal of Ophthalmology, showing 33.8 cases per 100,000 residents in 1999 to 14.8 in 2010. Several factors account for this achievement, namely the number of diabetic clinics for all citizens that promote early prevention and timely treatment of diabetes complications (unchecked diabetes can lead to blindness). In addition, patient compliance and the ability to choose doctors in a private hospital (thereby avoiding surgery waiting times), so the condition has little chance of worsening.
Treatment in Africa where surgeons perform ECCE instead, which as mentioned requires a longer duration for recovery, the IOL is also of a hard non-durable material. Furthermore, there is a higher risk of post-operative complications in Africa, which may include vitreous loss and capsular rupture, as well as infection called endophthalmitis. In addition, although sufficient training is provided at some hospitals, private hospitals in Africa tend to be far better equipped than public hospitals, as well as the scarce number of ophthalmic surgeons, particularly in rural areas. Moreover, health focus in Africa is broadly on malaria and HIV AIDS services, with less emphasis on eye care health.
Cataract treatment at HMC
Herzliya Medical Center (HMC) a private hospital in Israel offers cataract surgery; with thousands of surgeries successfully conducted, the risk of operative and post-operative complications is extremely rare; advanced techniques by the top eye surgeons ensure a full restoration of sight in many patients. Rather than ECCE, phacoemulsification through a 2.2mm incision is performed; the surgeons’ precision and proficient techniques ensure a relatively quick visual rehabilitation for all patients. Once the lens is removed, a suitable intraocular lens is implanted to restore vision.
Top ophthalmic surgeons at HMC
HMC’s ophthalmologists are top-rated in their field; Doctor Oded Ben-Chaim is a senior ophthalmic surgeon at HMC and the first surgeon in Israel to use ultrasound and phacoemulsification in Israel, he also has been performing decades of successful congenital cataract surgeries.
Professor Ehud Assia is a top cataract surgeon; his success has led him to open an upcoming eye surgery center in the heart of Tel Aviv. All surgeons at HMC are skilled in laser cataract surgery, but do not perform it at HMC due to their high degree of precision in performing corneal incisions and opening of the lens capsule manually, they also concluded that the patient has a faster rate of recovery using this method. After completion of surgery, an eye patch is placed and then removed the following day. Eye drops are prescribed for a month; vision is greatly improved the day after surgery, and final stabilization takes up to 6 weeks. HMC usually perform surgery on the second eye after 1-4 weeks, however in selected cases, bilateral surgery is performed.
Israeli innovation and technology have created revolutionary applications for the blind and visually impaired. The OrCam for instance, assists not just the visually impaired people, but also deaf-blind and mute; artificial visual technology in the form of a tiny camera that clips onto glasses – the device verbally identifies complete surroundings and is able to store this information.
Eye health, cataract-free
Older adults should have their eyes checked by their ophthalmologist every two years, and those above 50 annually. Should you have a family history of eye problems or any other medical condition that might put you at risk of developing an eye disease, such as diabetes – more frequent eye examinations are required. Early intervention of cataracts restores not only the gift of sight, but one’s interaction with the surrounding world, and can make a huge positive impact on the patient’s quality of life. Waiting longer for surgery until blindness results is far more difficult to treat, the earlier intervention, the better prognosis for the patient.
Bringing the gift of sight to a blind patient is a very special experience for not just for the patient, but also for HMC’s surgeons that perform these routine, yet life-changing surgeries. Ophthalmologists/ ophthalmic surgeons at HMC's Department of Ophthalmology work collaboratively performing an extensive range of treatments for cataracts and other eye-related conditions ensuring patients lead a maximized quality of life.