Cataract surgery

Sheha Hassan Ramadhan MD DO DCEH
Doctor in Charge, Eye Department, Mnazi Mmoja Hospital, PO Box 672, Zanzibar, Tanzania

Dear Editor

I write in response to Dr John Sandford-Smith's letter on intra capsular cataract extraction (J Comm Eye Health 2000; 13: 62). In my experience, most ophthalmologists prefer ECCE with PC IOL to ICCE, because ICCE, the traditional method, has the potential complication of cystoid macular oedema. This is much less common in ECCE. However, there are a number of problems associated with ECCE plus IOLs.

IOLs remain expensive for most of the population of poor countries, especially when we consider that food is the first priority, even for the blind.
There is limited access to operating microscopes and laser equipment in many developing countries. When available, they are based in urban centres where most ophthalmologists also live. The bus fares necessary to reach the service are a big burden for the poor.
Difficult access to YAG lasers is the biggest problem. People may have to be referred to other countries to get this service.
As many people are aware, in developing countries patients do not follow the service, but services should follow them. This means giving priority to social and economic factors, local beliefs, religious taboos or fear of witchcraft, and making every effort to provide health education. Charging for IOLs in this kind of society will be a further barrier to stop people seeking surgery.
I have to say that it is not true that in a developing country an aphakic patient without an aphakic correction is good for nothing. He or she can improve from light perception to counting fingers, which enables the patient to walk around, and this is a significant gain amongst poor blind people in developing countries.

Therefore, if we are to abolish ICCE in developing countries, various facilities need to be provided and maintained, remembering that electricity and reliable water supplies are still the exception rather than the norm in many countries.

It is necessary to have:

Cheap portable microscopes with good co-axial illumination
Very cheap IOLs, viscous fluid and BSS solutions
YAG lasers which can be afforded and operated in third world countries.

More consideration needs to be given to ICCE with A/C IOL which does not need access to microscopes and YAG laser facilities. I think this may be preferable in many developing countries. However, I remain in a dilemma because most ophthalmologists give much less priority to this method.