The growth of Indian IOL manufacturing and the resulting availability of affordable IOLs revolutionized the way ophthalmologists perform cataract surgery in India.
“If you look at IOL usage as well as IOL manufacturing, the correlation will be very direct,” Srinivasan Aravind, MS, Aravind Eye Hospitals administrator, told Ocular Surgery News in a telephone interview.
Dr. Aravind and colleagues examined the evolution of cataract surgery in India. They noted that the trend in Indian cataract surgery has moved from intracapsular extraction to manual small-incision extraction with IOL implantation and that the overall number of cataract surgeries performed each year has surged.
“India, in ’93 and ’94, was doing less than a million cataract surgeries a year,” he said.
Today, “in the published records from Vision 2020 India, we are doing 4.8 million surgeries, of which, at least 4 million get IOLs,” he said. “No other country in the world does close to this number.”
The soaring surgery rate is in part due to India’s high incidence of cataract.
“Domestic manufacturing of ophthalmic equipment and IOLs played an important role in bringing down cataract blindness in India,” said Kasthuri N. Ravilla, vice chairman of Appasamy Associates.
Cataract programs, training initiatives and infrastructural development played a role in increasing cataract surgery rates and modernizing techniques, but the transition would not have been possible without lower priced IOLs.
In an article on the large-scale IOL manufacturer Aurolab, managing director P. Balakrishnan, PhD, and colleagues wrote that intracapsular cataract extraction had been the standard of cataract surgery in India for years because affordable IOLs were not available.
Intracapsular extraction was considered unacceptable in developed nations as early as 1984, they said.
“In essence, cataract surgery without the use of an intraocular lens is only half an operation because there is not adequate visual rehabilitation,” they said.
But the Indian ophthalmic community could only move forward with available, affordable IOLs.
In the early 1990s, IOLs were imported to India, carrying the high international prices, Dr. Aravind said.
“The price of PMMA lenses in India was in the range of [Rs. 4,000] and above,” Dr. Balakrishnan said.
In the past 2 decades, many governmental and nongovernmental groups have become involved in cataract surgery in India. have offered grants and infrastructure support and developed surgical quality standards, Dr. Aravind and colleagues said.
“The acceleration took place somewhere in the late ’90s because the government started supporting free eye surgeries” with IOLs, Dr. Aravind said.
One of the key problems these groups initially identified was the lack of affordable, high-quality IOLs.
In 1992, Aravind Eye Care System established Aurolab as a nonprofit public charitable trust. The group would manufacture ophthalmic products for the Aravind Eye Care System.
“The IOL was found to be the costliest consumable item, so Aurolab started with the production of IOLs,” Dr. Balakrishnan said.
Today’s IOL market in India
“Due to the affordability and availability, India has overtaken the [United States], and today is the largest consumer of IOLs in the world,” said Lal Dave, chairman and chief executive officer of EYE O CARE.
Aurolab and the for-profit companies Appasamy Associates and EYE O CARE are the biggest IOL manufacturers in India, each producing millions of IOLs annually, Dr. Aravind said.
Appasamy manufactures 2.5 million IOLs per year, and expect to increase to 3 million in 2008, Mr. Ravilla said.
Dr. Balakrishnan said there are about 150 companies in India manufacturing ophthalmic products, and about 10 produce IOLs. These companies sell IOLs and other products at low prices by fill ing a widespread need. Low costs are offset by high sales, they said.
“Cataract surgery in India fits this profile perfectly because of India’s high prevalence and incidence of cataracts,” they said.
Permeable rigid lenses are the most popular in India, but foldable lenses are gaining ground, Dr. Aravind said.
“For Western manufacturers, hard lenses represent a dead market; in developing countries, however, there is still a large market for hard lenses because the expertise, equipment and funds to support the surgery are often lacking,” Dr. Balakrishnan and colleagues said.
India does not require domestically manufactured IOLs to meet ISO standards or European CE Mark standards, but these large companies conform to them in order to compete globally.
“International exports grew significantly after they got the CE mark and other marks,” Dr. Aravind said.
EYE O CARE lenses are ISO- and CE-certified, Mr. Dave said, which has helped international business.
About 40% of EYE O CARE lenses are sold overseas, and 60% of those to developing countries, Mr. Dave said.
Aurolab does about 40% of its business internationally, selling ophthalmic products to more than 120 countries, many of them developing.
“We feel Aurolab and other Indian-made IOLs are primarily responsible for the increase in the volume of IOL surgery in many developing countries,” Dr. Balakrishnan said. “Also, these IOLs are assisting in training more IOL surgeons, which is necessary to increase the surgery rates and volumes.”
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For more information:
- Srinivasan Aravind, MS, can be reached at Aravind Eye Hospital [Madurai], 1, Anna Nagar, Madurai - 625 020, Tamil Nadu; +45-2535-6100; fax: +45-2253-0984; e-mail: firstname.lastname@example.org. Dr. Aravind has no direct financial interest in the products discussed, nor is he a paid consultant for any companies mentioned.
- P. Balakrishnan, PhD, can be reached at Aurolab, Aravind Eye Care System, 1 Sivagangai Main Road, Veerapanjan, Madurai - 625 020, Tamil Nadu; +45-2244-6100; fax: +45-2244-6200; e-mail: email@example.com.
- Lal Dave can be reached at EYE O CARE, Block No. 310, Dabhasa, Vadodara 391 440; +91-98-2503-4597; e-mail: firstname.lastname@example.org.
- Kasthuri N. Ravilla can be reached at Appasamy Associates and Group of Cos., 20 SBI Officers’ Colony, First Street, Arumbakkam, Chennai (Madras) 600106; +44-3298-0153; fax: +44-2363-0721; e-mail: email@example.com.
- Aravind S, Haripriya A, Sumara Taranum BS. Cataract surgery and intraocular lens manufacturing in India. Curr Opin Ophthalmol. 2008;19:60-65.
- Ibrahim M, Bhandari A, Sandhu JS, Balakrishnan P. Making sight affordable (part 1): Aurolab pioneers production of low-cost technology for cataract surgery. Innovations: Technology, Governance, Globalization. 2006;1(3):25–41.