Cataract surgery is among those services in the public health sector that continues to bear the long-term implications of the Covid pandemic. While public health facilities faced backlogs of cataract surgery patients even before the onset of the pandemic, these have since worsened.

The recommended cataract surgery rate for South Africa is 2,000 per million population per year, according to Prof Linda Visser, head of the Division of Ophthalmology at Stellenbosch University’s Faculty of Medical and Health Sciences.

“This country has never actually reached that 2,000 surgeries per million population. The highest it came was about just over 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 Western Cape has generally done better than the national average, but has still fallen short of the recommended rate, according to Visser.

Read in Daily Maverick: “What is behind the massive cataract surgery backlogs in Gauteng?”

Pandemic impact

For a period during the pandemic, only emergency services were available across all disciplines, according to 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’s not been a lot of cataract surgeries done in all facilities, especially during the hard lockdown period,” said Minnies.

At Tygerberg Hospital, no cataract surgeries were performed for at least six months to a year during the pandemic, according to Visser. Due to cataract surgery 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. I think we’ve only recently, for the last six to eight months, been doing cataract surgery again… And not the same numbers that we used to do, 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, says Dr David Steven, ophthalmologist at the hospital.

“At the height of the Covid waves, theatre staff were taken away to work on the Covid wards,” he said, 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.

“The department had to significantly de-escalate, as staff were deployed to Covid-19 services. This resulted in a large increase in the backlog of operations, including cataract surgeries. Some hospitals also suspended cataract outreaches during the height of the pandemic, which resulted in cuts to surgical output.”

Currently, the province’s two largest hospitals, Tygerberg and Groote Schuur, have backlogs of 1,200 and 2,500 cataract surgeries, respectively.

Read in Daily Maverick: “Groote Schuur Hospital starts drive to tackle huge surgery backlog caused by pandemic”

Following the pandemic, the department has allocated an additional R20-million from the internal prioritisation of funds to address general surgical backlogs.

“Many non-urgent cases wait months to years for their surgery, even before Covid, due to insufficient theatre time,” according to the department.

Pre-Covid backlog

Limited theatre time for cataract surgeries is one of the long-standing challenges faced by ophthalmologists, according to Visser.

“It comes back to the whole issue of urgency, and ‘are your patients dying or not dying’. So, if there’s ever a cut in theatre time, it’s usually the people who… don’t have patients who are going to die [without surgery] that get cut,” she said.

Ophthalmologists often have disproportionately fewer theatre lists than other disciplines.

Said Visser: “I think that’s the biggest problem, actually. That on the day, if there’s an emergency that comes in, 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, says Minnies. 

“In South Africa, and in many countries, the private sector is a very lucrative destination for specialists. And so it draws a lot of ophthalmologists, as they graduate and set up practices.”

Dr Steven told Maverick Citizen that for those interested in joining the public sector, there is often a shortage of posts available for ophthalmologists.

While there is no accurate data on how many ophthalmologists there are 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 ophthalmologists registered on their database in 2019, according to Shelley-Ann McGee, national operations manager of Ossa.

“The HPCSA number reflects those who obtained their qualifications in South Africa, but may be practising within and outside the country’s borders, as well as those who may have stopped practising ophthalmology altogether,” said McGee. 

“The true number of those working within the country probably rests at around 400 ophthalmologists working in both the private and public sectors.”

An analysis of the addresses provided for ophthalmologists in the HPCSA database suggests that the provinces with the greatest number of ophthalmologists are Gauteng with 42.3%, Western Cape with 23.8%, and KwaZulu-Natal with 13.2%, according to McGee.

The database indicates that the provinces with the fewest ophthalmologists are Limpopo (1.6%), Northern Cape (1%) and Mpumalanga (0.5%).

The majority of Ossa’s membership — 223 members, or 73% — is categorised as working full-time in the private sector.

“There is no reliable database which pinpoints which sector ophthalmologists are practising in — many of those employed in the public sector are also permitted to engage in remunerated work outside of the public service, whereby their facilities agree to them performing limited hours of work in the private healthcare sector,” said McGee.

“Traditionally, ‘private’ practitioners may also help out in the public sector through organised programmes like Ossa’s Right to Sight initiative, which provides cataract surgeries to indigent patients at private facilities, or through other arrangements made with local and provincial authorities.”

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, according to Steven.

Where cataracts cause blindness, it usually affects that person’s entire family, says Visser. A blind person requires a full-time carer, and often a younger member of the family will take on that role, meaning two people become unable to work.

“If you actually do a cataract surgery on a patient, you can get two people back into some kind of work because the person who had the cataract… can do whatever they need to do and they can go back to work, plus the person that had to look after them can go back [to work],” said Visser.

The way forward

Cataract surgery should be a public health priority, according to Visser. A solution to the backlog is establishing more high-volume cataract units only doing 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,” said Visser. 

“So, 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 I don’t operate, I’m actually costing you more than if I’m operating.”

High-volume units would also reduce the competition between ophthalmologists and other specialists when it comes to theatre space, she continued. 

“The Eerste River Hospital does have a high-volume cataract unit, and they do… more cataracts there than I think in most other parts of the country, so that’s probably why we [Western Cape] are not as badly off as some people,” said Visser.

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.

“Ophthalmologists and the clinical staff, ophthalmic nurses, optometrists, they are clinicians and we expect them… to do the sight restoration, to do the cataract surgeries, the treating of a patient,” said Minnies.

“Frequently, in our services, these same people are also required to do management — to make sure that resources are available, the infrastructure is sorted.”

However, clinicians often do not have the training or time to take on both sets of duties, he said.

“That’s where a big part of the challenge lies — having the specific expert management capacity to be able to organise these things so that services can be delivered effectively and efficiently.” DM/MC