While public health facilities faced backlogs of cataract patients even before the onset of COVID-19, these have since worsened, and doctors say cataract surgery should become a public health priority.
According to Professor Linda Visser, head of the division of ophthalmology at Stellenbosch University’s Faculty of Medical and Health Sciences, a solution to the backlog is establishing more high-volume cataract units doing only cataract surgery, and higher numbers of surgeries in a given period.
“If you look at the economies of scale, in fact, if you do more surgery, it ends up, for cataracts, being a lot cheaper,” she said.
The recommended cataract surgery rate for SA is 2,000 per million population annually, but “this country has never actually reached that 2,000 surgeries per million population”.
“The closest it came was just more than 1,000. So, we’ve basically always lagged behind by at least 50% of the surgeries we were supposed to do,” she said, adding that this rate is determined using national numbers, and not those of the private sector.”
The Daily Maverick reports that the Western Cape has generally done better than the national average, but is still short of the recommended rate.
Pandemic impact
For a period during the pandemic, only emergency services were available across all disciplines, said Deon Minnies, director of the Community Eye Health Institute at Groote Schuur Hospital, which provides academic training to build management capacity among eye health practitioners.
“Cataract surgery, being an elective type of surgery, is one of the main casualties of that. So, there haven’t been many cataract surgeries done in all facilities, especially during the hard lockdown period.”
At Tygerberg Hospital, no cataract surgeries were performed for at least six months to a year during the pandemic. Due to this being a “non-urgent procedure”, often performed on elderly patients, it was one of the first services to stop during this period.
“It took a long time to get it up and running again. We’ve only recently, for the past six to eight months, been doing cataract surgery again… And not the same numbers as before, so we’re still lagging behind,” said Visser.
At the Eerste River Hospital Eye Clinic in Cape Town, the operating theatre was kept open during the pandemic when there was sufficient staff and it was deemed safe, said Dr David Steven, ophthalmologist at the hospital. “But at the height of COVID, theatre staff were moved to the COVID wards,” thereby reducing capacity for theatre.
The Western Cape Department of Health confirmed that the backlog of patients awaiting cataract surgeries in the province’s public health sector has increased since the onset of the pandemic.
Currently, the province’s two largest hospitals, Tygerberg and Groote Schuur, have backlogs of 1,200 and 2,500 cataract surgeries, respectively.
After the pandemic, the department allocated an additional R20m to tackle general surgical backlogs.
“Many non-urgent cases wait months to years for their surgery, even before COVID, due to insufficient theatre time,” said the department.
Pre-COVID backlog
Limited theatre time for cataract surgeries is one of the long-standing challenges faced by ophthalmologists, Visser said. Ophthalmologists also often have disproportionately fewer theatre lists than other disciplines.
“I think that’s the biggest problem. That on the day, if there’s an emergency, who’s going to stop operating? And it’s usually the ophthalmologist.”
The limited number of cataract surgeons and ophthalmologists in South Africa — particularly in the public sector — is also a challenge, said Minnies.
“In South Africa, and in many countries, the private sector is a lucrative destination for specialists. So it draws a lot of ophthalmologists.”
In the public sector, there is often a shortage of posts for ophthalmologists.
While there are no accurate data on ophthalmologists in South Africa, the Ophthalmological Society of South Africa (Ossa) has 305 full ophthalmologist practising members, while the Health Professions Council of South Africa (HPCSA) had 593 registered on their database in 2019, said Shelley-Ann McGee, national operations manager of Ossa.
“The true number is probably around 400 ophthalmologists working in both the private and public sectors in SA.”
Most are in Gauteng with 42.3%, Western Cape with 23.8%, and KwaZulu-Natal with 13.2%, McGee added.
The majority – 223 members, or 73% – are categorised as working full-time in the private sector.
Living with cataracts
While cataracts may not be fatal, they can significantly reduce a person’s ability to function (working/driving). The risk of falls and injuries become higher, as well as the possibility of being neglected, said Steven.
Where cataracts cause blindness, it usually affects that person’s entire family. A blind person requires a full-time carer: often a younger member of the family takes on that role, meaning two people are unable to work.
“If you actually do a cataract surgery on a patient, you can get two people back into work because the person who had the cataract… can then go back to work, plus the person looking after them can go back (to work),” said Visser.
“Unfortunately, when there’s a shortage of money, they usually cut the numbers. But… certain expenses are there whether we operate or not; my salary has to be paid whether I do the surgery or not. So, if I sit around and don’t operate, I’m actually costing you more than if I’m operating.”
There is a need for better management capacity in eye care programmes, said Minnies. This would ensure organisation and planning for adequate staff, budget and facilities.
“That’s where a big part of the challenge lies, having the specific expert management capacity to organise these things so that services can be delivered effectively and efficiently.”
See more from MedicalBrief archives:
Cataract surgery under pressure — SA Ophthalmological Society
Surgery catch-up stymied by South Africa’s shortage of ICU nurses
Cataract removal may reduce dementia risk by 30% – Washington cohort study
SA’s surgical backlog: 14,000 patients wait two years for 40-minute cataract procedure
Backlog of 7,000 surgery patients at Chris Hani Baragwanath