A Force for Good in Global Eye Care

Despite two decades of progress reducing avoidable blindness, the need remains vast. Globally, about 1.1 billion people have unaddressed vision loss, according to the International Agency for the Prevention of Blindness. Of these, about 43 million are blind, with cataracts the leading cause. About 90% live in low- or middle-income countries, with the 46 countries of sub-Saharan Africa (SSA) making up about 10% of the world total.

To address this critical need, the University of Cape Town in South Africa founded the Community Eye Health Institute in 2008, said Nagib du Toit PhD, who currently leads the programme.

“The idea was to create something international along the lines of the London School [of Hygiene and Tropical Medicine International Centre for Eye Health].”

Since then, the Institute has trained about 600 postgraduate professionals. Most now work in community eye health research and development, organising and managing services benefiting millions in Africa, the Middle East, and Asia, Professor du Toit said.

In 2017, the institute added a surgical skills training programme focusing on small-incision cataract surgery, including simulation training, which was shown to improve surgical skills and outcomes.¹ Based on courses developed by the UK Royal College of Ophthalmologists, it also offers training in trabeculectomy and vitreoretinal surgery.

The institute launched a phacoemulsification wet lab in 2021 and acquired the only EyeSi Surgical simulator in SSA in December 2022.

“There has been a big movement in Africa to upskill to phaco,” Prof du Toit said. However, the steep learning curve requires expert training.

So far, about 90 surgeons have trained at the simulation lab, Prof du Toit said. But training is a bottleneck. At full capacity, the programme’s six stations for manual small-incision cataract surgery (MSICs) and three to four stations for phaco can train just six or eight surgeons at a time. And while the programme has enough phaco machines, it still needs surgical microscopes. Even more critically, surgical trainers—as well as funds to sponsor travel and accommodations for the trainers and trainees at the three-day wet labs—are in short supply.

Those needs align with the resources and skills of ESCRS and its members. That is why the Society, through its Charity Committee, is partnering with the institute. “Collaborating with successful and experienced regional partners such as the Community Eye Health Institute (CEHI) maximises the impact of the Society’s funding to reduce avoidable blindness in sub-Saharan Africa,” said Mark Wevill, who is originally from South Africa and a graduate of the University of Cape Town.

“The benefit of ESCRS funding the CEHI surgical training unit is exponentially multiplied by training sub-Saharan African surgeons at the institute. Because not only are greater volumes of cataract surgery done better and more safely by each surgeon, improving the quality of life of blind people all over sub-Saharan Africa, but education builds a legacy. These graduates pass on the skills learned to other surgeons, and the graduates can return to the institute as trainers, sustaining the great work of the institute,” added Dr Wevill, who has lived, travelled, and worked as an ophthalmologist in Africa for many years. In addition, ESCRS members are welcome to give some of their time and expertise to reducing avoidable blindness by becoming CEHI trainers—and, in so doing, meeting another need of the institute.

Indeed, the shift toward building local capacity is a cornerstone of ESCRS’s charitable strategy, Filomena Ribeiro MD, PhD said. She is working closely with another ESCRS grant programme supporting Eyes of the World in Mozambique.

“When we build more local expertise, we can make sure we have a lasting impact and reduce dependence on external aid,” she said. “It is a more significant and longer-term solution.”

Encouraging equitable access

Eyes of the World is a good example of a collaborative capacity- building programme. It has been operating in Africa and South America for 22 years, said Anna Barba i Giró. To date, it has trained more than 13,000 local professionals, including ophthalmologists, optometrists, eye technicians, traditional practitioners, and teachers in detecting, referring, and treating vision problems. ESCRS and its members have supported the agency in Mozambique for several years, including providing a vehicle to take supplies and staff to remote rural areas, she said.

The current ESCRS three-year grant campaign focuses on Inhambane province, where just two ophthalmologists serve a population of more than 1.5 million, and blindness affects more than 6 percent of the population over age 50. The goal is to deliver 3,300 cataract surgeries, of which 60 percent will be women. “If we don’t make a specific effort to reach women, it will increase inequality. Usually, more men get operated on,” Ms Barba i Giró said. In addition, 80,000 people will have eye consultations.

Training will play a major role. By the end of the project, two ophthalmologists and 15 technicians will be trained in cataract case selection and refraction techniques to promote better outcomes. Operating the same percentage of women and men diagnosed with cataracts is another important end goal.

“We are trying to address the gender gap,” Prof Ribeiro said. A surgical quality monitoring tool also will be implemented to help ophthalmologists improve their performance.

Community infrastructure

Building skills in refraction, case selection, and outcomes measurement and analysis is as critical to addressing vision loss as is direct surgical skills training, said Ype Henry MD, who has extensive experience working with eye health programmes in Africa, Asia, and Oceania. Currently working with an ESCRS-supported programme partnering with the Blantyre Institute for Community Outreach in Malawi, he noted, “Pre and post-operation is often where the bottlenecks are.”

Often in underserved areas, surgeons do the surgery (and do it well), but there is no follow up to ensure residual refractive error and any complications are addressed, Dr Henry said. Measuring visual acuity before and after surgery—and using that data to improve performance—are essential for better refractive outcomes, he added. Along with screening and providing primary eye care, this is another reason why training technicians and other support personnel is so important.

Additionally, Dr Henry advised implementing outcomes registries as another important tool. The ESCRS grant supports registrar training, cataract skills refresher courses, and building systems to better supervise and track cataract surgery at four eye centres in Malawi. Integrating the extensive community and specialty eye care services the institute has fostered into the public health system is another programme goal.

Encouraging higher volume

Individual surgeons also should be encouraged and supported to perform more surgeries, Dr Henry said. Often, surgeons in SSA do only about 100 to 150 cataract cases per year.

“With such a limited supply of doctors, they should be doing 750 per person.”

On average, there are about 2.5 ophthalmologists per million population in SSA, with many low-income countries below 1.0 per million. By comparison, there is a mean of about 76 per million in high-income countries worldwide, according to the International Council of Ophthalmologists.²

St John Eye Hospital in Jerusalem is another programme ESCRS is supporting. A mobile outreach programme earlier this year provided 90 phaco operations in marginalised areas in Palestine. ESCRS supports young ophthalmologists training at St John, including some from Ukraine.

The ESCRS has also made major contributions to ophthalmology in Ukraine, including free attendance at the ESCRS Congress for Ukrainian delegates. ESCRS industry partners have contributed more than €1 million in supplies, and the Society has allocated €100,000 directly.

But as much as all this support helps, the need is greater still. Even in Cape Town, which is relatively well served, only about half of the WHO-recommended number of cataract surgeries are being performed—and the deficits are larger pretty much everywhere else in SSA, Prof du Toit said.

“We have a long way yet to go.”

ESCRS members are invited to donate to support global outreach programmes. Surgeon trainers are also needed. Donations of equipment and supplies in new or good condition to support capacity-building programmes are also welcome. Please contact us for information.

1.     JAMA Ophthalmol. 2021 Jan 1; 139(1): 9–15.

2.      Br J Ophthalmol. 2020 Apr; 104(4): 588–592. 

Nagib du Toit MBChB(UCT), DipOphth(SA), FRCS(Ed), MMed(UCT), FCOphth(SA), PhD(UCT) is Chair of Ophthalmology at the University of Cape Town and head of ophthalmology at Groote Schuur Hospital and Red Cross Children’s Hospital in South Africa. nagib.dutoit@uct.ac.za

Mark Wevill MBChB, FRCS (Edinburgh), FCS (SA) is a cataract and refractive surgeon in Birmingham, UK, and ESCRS Charity Committee member, and a surgical trainer at the University of Cape Town Community Eye Health Institute Surgical Skills Laboratory. mark.wevill@gmail.com

Filomena Ribeiro MD, PhD, FEBO is chair of ophthalmology at Hospital da Luz Lisbon and professor of ophthalmology and biomedical engineering at the University of Lisbon, Portugal. She is ESCRS president-elect and associate editor of the Journal of Cataract and Refractive Surgery. filomenajribeiro@gmail.com

Anna Barba i Giró is director of Eyes of the World, a charity dedicated to reducing avoidable blindness based in Barcelona, Spain. abarba@ullsdelmon.org

Ype Henry MD, FEBO is a retired ophthalmologist in Amsterdam, Netherlands, and an ESCRS Charity Committee member. y.henry@hotmail.com