The true costs of treating paediatric cataracts

Paediatric cataracts is one of the leading causes of reversible childhood blindness, but economic constraints make treatment difficult to access for many patients worldwide. In a presentation at the 2024 European Society of Cataract and Refractive Surgeons, Vinita Rangroo Thrane, MD, PhD, and Alexander S. Thrane, MD, PhD, FEBOphth, explored the cost barriers to global paediatric cataract care.¹

Dr Rangroo Thrane and Dr Thrane are both consultant ophthalmologists near Oslo in Norway and board members for vision charity Right To Sight, dedicated to ending avoidable blindness throughout Africa.

In the paper, Drs Rangroo Thrane and colleagues presented a retrospective analysis of paediatric cataract procedures in Norway, India and Kenya. Comparative data were collected from several centres in the three study countries. The team consulted healthcare facilities, governmental databases and community records to acquire data. Consideration was given to a variety of different costs associated with cataract procedures.

As the investigators pointed out, addressing cataracts is more difficult for both paediatric and adult patients in developing economies, where access to care and appropriate treatment resources may be limited. The actual costs are important to know, in order to advocate for changes in both organising patient workflow and changes in the technique for paediatric cataract surgery.

Sticker price

For example, a single non-foldable PMMA IOL (as sourced from Appasamy Associates) can cost as little as €2 in India, the investigators reported. A small-incision procedure itself may cost only €44 to perform in adults. However, there are other fixed and variable costs at play. Fixed costs can include land, buildings, equipment and personnel including consultants and surgeons. Variable costs, including consumables used in surgery, may cover a wider range of prices, depending on the procedure needed and complications that arise. “The cost of treatment is therefore more than €2 for a PMMA lens,” Dr Thrane explained.

A preliminary cost analysis demonstrated that total costs for paediatric cataract surgery vary by location, but consistently exceed the cost of similar surgeries for adults. In some of the centres surveyed, total cost for adult small incision cataract surgery was as low as €15 per eye. In Norway, the average total cost of paediatric cataract surgery was approximately €1330 per child. In Kenya, the cost for surgery was around €409 per child, but this did not account for the screening and education costs that are “baked in” to existing programmes in Norway. Once additional costs for outreach and screening were factored in, that total cost for patients in Kenya increased to €1107 per child.

Dr Thrane pointed out that the additional costs were mainly non-surgical in nature. For example, paediatric patients had higher costs in general anesthesia. Similarly, these patients also needed more involved long-term postoperative care, and spectacles along with additional screenings for amblyopia prevention and glaucoma detection.

Technique as solution?

Surgical techniques varied by location and between practitioners. In India and Kenya, surgeons relied largely on the lens-in-the-bag or aphakia approach with anterior vitrectomy for the youngest children. In Norway, surgeons have begun using a technique called bag-in-the-lens (BIL). This BIL approach could function as a suitable technique for paediatric cataracts, according to Dr Thrane’s colleague and fellow investigator, Nils-Erik Boonstra, MD, of Haukeland University Hospital in Bergen, Norway. Dr Boonstra implemented the technique at Kwale Eye Centre in Kenya as part of the initiative from Right to Sight. He presented on paediatric cataract surgery with BIL at the College of Ophthalmology of Eastern, Central and Southern Africa (COECSA) Congress in Victoria Falls, Zimbabwe, from 21 to 23 August.

Eyes during bag-in-lens surgery

“We all know the principle of the traditional lens in the bag,” Dr Boonstra said² in his COECSA presentation. “An anterior capsulorhexis is made and the lens removed, before an artificial lens is implanted into the capsular bag. Hence the name ‘lens in the bag.’” When a surgeon uses a BIL approach, the setup looks slightly different. The surgeon uses a ​​biconvex hydrophilic IOL, a specially-designed lens introduced by Professor Marie-José Tassignon, MD, PhD, FEBOS-CR, in 1999. The design features two haptic plates with a groove in the middle, which Dr Boonstra compared to the rim of a bicycle wheel. To administer a BIL procedure, the surgeon makes equally sized anterior and posterior capsulorhexis. Then, the lens is placed like a button, with both rhexises fitted into its “groove,” giving it the “bag in lens” name.

Dr Boonstra said that BIL is a particularly good approach for paediatric patients because it prevents visual axis opacities (VAO). “Remaining lens epithelium cells proliferate much more aggressively in children than in adults," he explained. In the youngest children the anterior vitreous membrane is removed to prevent cell proliferation into the optic axis. Even when this is done, VAO develops.³ Patients could experience vision reduction and increased amblyopia risk, and may need rapid re-intervention with vitrectomy, which would require costly general anesthesia.

But in BIL, the remaining lens epithelium cells cannot migrate to the posterior capsule, as they are captured in the sealed capsular bag. As a result, vitrectomy is not needed, even in very young patients (under 5 years of age) who typically need a vitrectomy alongside lens-in-the-bag procedure. The BIL procedure prevents VAO, protecting clarity of vision. There is also less occurrence of inflammation, requiring fewer postoperative steroids and making the procedure suitable for patients with uveitis. The lack of inflammation and reduced need for secondary intervention are crucial outcomes in developing regions, where many patients are unable to complete necessary follow-up care on the ideal time frame. There are also early indicators that paediatric patients who undergo BIL surgery are less likely to experience secondary glaucoma following cataract surgery, though Dr Boonstra said more research is needed to support this finding.

Implementing the BIL Strategy

Dr Boonstra discussed outcomes from Kwale Eye Centre, where in November 2023, the team from Right to Sight Norway implemented a BIL-focused approach and trained surgeons on the technique. To begin, Drs Boonstra, Thrane and colleagues upgraded the clinic’s microscope, the Opmi Lumera 300 (ZEISS), with a monitor and recording capabilities. Dr Boonstra stressed the importance of a side-scope or monitor for properly teaching the BIL technique. After learning the BIL technique, surgeons performed the surgery on adult patients before moving on to paediatric cases. Surgeons at Kwale Eye Centre were performing paediatric BIL procedures just 2 days after being introduced to the technique.

Data collection began at the clinic in November 2023, following the training. Between November 2023 and early August 2024, surgeons at Kwale Eye Centre operated on 44 eyes in 28 children using the BIL technique. Among these cases, 16 of the eyes belonged to children under 5 years of age. Though the follow-up period remains brief, the results seem promising. Only five eyes required vitrectomies, and two of these patients were below 5 years of age. There were no reports of serious complications, VAO, pupillary membranes or glaucoma among the patient population. Only two eyes have required a secondary surgery in this period. Two patients experienced irregular pupils, which had no vitreous prolapse and required no treatment. One iris capture was medically treated.

Because many of the costs associated with paediatric cataract are non-surgical, Dr Boonstra and colleagues believe using BIL can offset much of the high cost. He noted that, in BIL, the surgeon should still have a backup vitrector, but it will be used less frequently. The biggest barrier, he noted, is the cost of the foldable lens: the pricing of BIL is “enormous,” from a materials standpoint, and must be reduced in order to scale up. However, Dr Boonstra expects this to change thanks to a partnership from Right to Sight, Prof Tassignon and ophthalmic manufacturers based in India. By the end of 2024, he said, "We hope the first production of a bag-in-lens for paediatric cataract surgery will start reducing the price significantly, thus making the technique much more accessible to the many children who require surgery in India and Africa." In the meantime, Dr Boonstra, Dr Rangroo Thrane, Dr Thrane and colleagues from Right to Sight will continue to train surgeons in BIL procedures as a safe and efficacious solution for paediatric cataract.

References

1. Rangroo Thrane, V., Roberts, H., Boonstra, N-E. et al. What Are The True Costs Of Treating Pediatric Cataracts? A Comparative Retrospective Cost Analysis In Norway, India And Kenya. Presentation tktk

2. Boonstra, N-E. Paediatric cataract surgery with Bag in the lens (BIL) in rural Africa. COECSA presentation TK

3. Magnusson G, Gyllén J, Haargaard B, et al. The prevalence of visual axis opacification in the Swedish Pediatric Cataract Register. Acta Ophthalmol. 2024;102(6):e873-e882. doi:10.1111/aos.16630

Vinita Rangroo Thrane, MD, PhD (left); Alexander S. Thrane, MD, PhD, FEBOphth (centre); and Nils-Erik Boonstra, MD (right)

Vinita Rangroo Thrane, MD, PhD | E: vrangroo@gmail.com

Rangroo Thrane is a Consultant paediatric ophthalmologist at Vestfold Hospital and Tønsberg Eye Center.

Alexander S. Thrane, MD, PhD, FEBOphth |E: alexander.thrane@gmail.com

Thrane is a Consultant cataract, refractive and glaucoma surgeon at Memira Eye Center and Tønsberg Eye Center, Norway.

Nils-Erik Boonstra, MD | E: neboonstra@gmail.com

Boonstra is Consultant vitreoretinal and cataract surgeon at Haukeland University Hospital and head of the cataract section.