Research Agenda for Global Blindness Prevention:

Clinical Conditions: 1. Cataract

Research opportunities

• Short-Term (largely analytical)
  
  
• Short- to Medium-Term
  
  
• Medium- to Long-Term

Among all ocular conditions, cataract takes "pride of place" as the single greatest cause of blindness in the world, primarily because poor people living in poor conditions do not have access to sight restoring cataract surgery.

The primary challenge, from this perspective, is to reduce the cost and increase the efficiency of cataract surgery (with excellent sight restoring outcome), and find ways to provide these resources to poor living in remote rural areas or urban slums.

These problems can respond to short- to medium-term operations research, including delineation of the level of education and training needed by eye health workers delivering cataract surgical services.

Cataract is also a major problem in wealthy countries, primarily because of the economic and human cost related to the large numbers of operations performed (increasingly at marginal levels of visual impairment that are nonetheless critical to maintaining employment and maximizing quality of life).

Preventing cataractogenesis requires innovative epidemiologic studies seeking factors that increase the risk of disease (short- to medium-term) and mechanistic studies of lens biology (medium- to long-term).

Short-Term

(largely analytical):

• Estimate the "burden of disease" posed by cataract, adjusted for differing levels of visual demands and visual deficit.
  
  
• Compare the cost-benefit of cataract surgery performed at different levels of visual acuity (adjusted for visual demands)
  
  
• Identify those factors responsible for regional and global variations in "per surgeon" cataract surgical rates (financing, facilities, expectations, culture, training, patient demand) adjusted for the age distribution of the population, the visual criteria justifying surgery, etc.
  
  
• Assess factors that determine local indications for cataract surgery, and their appropriateness
  
  
• Identify constraints to cataract surgical manpower (number of physicians/ ophthalmologists trained; proportion adequately trained in modern pseudophakic surgery)
  
  
• Identify resources and incentives required to motivate/train existing cataract surgical manpower to better meet quality standards and higher surgical volumes, and to provide services to the less accessible poor.
  
  
• Develop simple methods for monitoring and evaluating surgical outcomes and benchmarking these against quality standards
  
  
• Mathematically model alternative approaches to best meet today's demand/needs, and those of the future (given changing demographics, visual demands, geographic distributions of patients and providers, reimbursement schemes and technology)
  
  
• Compile and assess data on the severity and extent of cataract visual impairment and blindness attributable to different types of cataract (may require additional, sophisticated – if relatively small – population surveys)

Short- to Medium-Term

(largely operational research directed at increasing the amount of effective, high-quality cataract surgery provided to those presently underserved, primarily by identifying ways in which to reduce the marginal costs of cataract surgery and increase geographical and financial access to effective surgical services):

• Devise and evaluate alternative approaches to increasing access of underserved populations to trained cataract surgeons:

1. Incentives for/requirements of ophthalmologists (mandatory service in underserved areas at completion of training; regular rotations to underserved areas)
   
   
2. role of non-physicians/non-ophthalmologists in delivering care to populations suffering a chronic paucity of trained ophthalmic surgeons (alternative formulation: "What is the minimal education, training and experience required to perform different roles in the delivery of safe and effective cataract surgery, including the surgery itself?")
   
   
3. role and impact of certification and credentialing, CME, and clinical guidelines on performance standards and outcome

• Identify ways to minimize costs associated with each component of cataract surgery (preoperative workup; facilities; equipment; supplies and consumables [sutures, visco-elastics, IOLs]; personnel, etc.), including alternative and emerging surgical techniques/ technology
  
  
• Determine longer-term (3 to 10 years) post-operative outcomes following alternative surgical approaches
  
  
• Develop and test ways to optimize case-finding and generate patient demand (compliance)
  
  
• Identify the attributes that distinguish those systems for delivering services that are effective and efficient
  
  
• Compare cost-benefit trade-offs between techniques that reduce the need for follow up (primary posterior capsulotomy; preoperative/ interoperative antibiotics; greater precision in determining IOL power; multi-focal lenses)
  
  
• Evaluate alternative cost recovery mechanisms and their ability to contribute to long-term sustainability of local cataract surgical services
  
  
• Compare the cost-effectiveness of alternative organizational schemes for maximizing "through-put" of the operative process (one vs. multiple operating tables; maximal delegation of responsibility) suitable to local conditions
  
  
• Design and test pricing and marketing strategies that result in sustainable cataract surgical programs (cross-subsidization between higher and lower fee facilities), adjusted for the elasticity of pricing/disposable income distribution of the local population (e.g., general ability/willingness to pay 1-3 months wages for cataract surgery)

Medium- to Long-Term

(progress in understanding lens biology and developing interventions that reduce the incidence/progression of cataract):

• Search for epidemiologic insights into environmental causality (e.g., compare environmentally disparate, genetically similar populations with different age-specific incidences of clinically significant cataract)
  
  
• Conduct basic ("mechanistic") lens research to identify the biologic basis of different forms of cataract.

Next: 2. Trachoma

Also see: Table of Contents of the Research Agenda for Global Blindness Prevention