For decades, vitreoretinal care in North India followed a centralized pattern where patients traveled 200–500 kilometers to metropolitan centers, incurring substantial costs for travel and accommodation. Local areas lacked specialized services. The COVID-19 pandemic appeared to catalyze change. Systematic analysis reveals the transformation was driven by decade-long economic and strategic trends beginning in 2015–2017. The Pre-COVID Foundation (2015–2019) Private equity investors identified single-specialty healthcare’s superior returns early. Investment share grew from 15% (2015–2018) to over 40% (post-2019) before the pandemic. 1 The Vitreo-Retinal Society of India demonstrates workforce expansion: Membership grew from approximately 300 specialists (2017) to 500+ (2019), a 67% increase. By 2024, membership exceeded 1500+ specialists. 2 This pre-COVID acceleration enabled geographic redistribution across tier 2/3 cities. Equipment economics shifted during 2015–2018. Domestic manufacturers like Appasamy Associates introduced vitrectomy systems at ₹28–35 lakhs versus ₹52–87 lakhs for imported equivalents, a 46% cost reduction. Complete setup costs fell from ₹2. 2–2. 8 crore to ₹1. 3–1. 7 crore. Monthly break-even thresholds dropped from 55–65 to 28–35 procedures. Ayushman Bharat was launched in September 2018, well before COVID, creating government-funded demand that justified tier 2/3 expansion. Recent evidence demonstrated that laminar air flow and HEPA filtration systems provide no additional safety benefit over standard air conditioning for ophthalmic surgery. 3 This finding eliminated ₹15–25 lakhs per operating room from setup costs, further improving tier 2/3 economics. Corporate Investment Patterns Private equity investment shifted to single-specialty focus by 2018–2019. Major eye care chains received over ₹5, 000 crore during 2019–2025. ASG Eye Hospitals received ₹1, 500 crore and expanded to 160+ hospitals through Vasan Eye Care acquisition. 4 Centre For Sight secured 100 million from ChrysCapital, establishing 83 centers across 15 states. Dr. Agarwal’s Eye Hospital raised ₹1, 000+ crore from TPG Growth and Temasek. Maxivision Eye Hospitals received ₹1, 300 crore from Quadria Capital. These strategies were formulated during 2017–2019, with COVID accelerating implementation rather than creating the impetus. What COVID Actually Changed During pandemic restrictions, a Central India study documented 47. 8% decreased hospital visits, with only severe cases traveling. Patients who discovered local alternatives often continued preferring them after pandemic restrictions ended. This preference shift built upon infrastructure systematically constructed during 2015–2019: Specialist workforce expansion, equipment cost reductions, financing innovation, and AB-PMJAY created the government insurance foundation in September 2018, providing the demand-side support that justified corporate expansion strategies. The hub-and-spoke model allowed efficient specialist deployment. Metropolitan-based subspecialists make periodic visits to peripheral centers where cases accumulate. This approach ensures tier 2/3 cities receive expert care without permanent high-cost staffing5 Table 1. Table 1: Economic advantages driving tier 2/3 city viabilityBroader Implications This transformation represents permanent healthcare economics restructuring. The successful model may apply to other medical specialties facing geographic disparities. Corporate investment reduced setup costs by 40–50%. Government schemes provide volume stability. Hub-and-spoke deployment enables efficient specialist utilization. Patient travel to metropolitan centers for routine vitreoretinal care may decrease 60–70% by 2030 based on systematic corporate investment continuing through this decade. Technology advancement supports this trajectory. The democratization of specialized care, driven by economic fundamentals rather than pandemic adaptation, continues today. Conclusion The transformation of vitreoretinal care delivery across North India represents significant improvement in healthcare access based on our clinical experience over the past decade. What we have witnessed from 2015 through 2025 appears to be permanent restructuring of healthcare economics Table 2. The democratization of vitreoretinal care has been happening throughout the past decade, and its momentum will likely continue accelerating. Table 2: Timeline of transformation (accelerated by COVID) (2015–2024) Author contributions Dr Obuli Ramachandran N: Concept, design, Literature search (corporate data, PE reports, eye care chains), Data acquisition (financial data, investment reports, chain, expansion data), Manuscript preparation, Manuscript review; Dr. Gauri Khare: Clinical expertise, Manuscript review; Dr. Lalit Verma, MD: Concept, design, Literature search (VRSI data, clinical practice patterns, government schemes), Manuscript editing, Manuscript review; Dr. Sagnik Sen: Data analysis (economic modeling, cost comparisons), Statistical analysis, Manuscript editing and review; Dr. Piyush Kohli: Clinical expertise, Manuscript review
Nandhakumar et al. (Thu,) studied this question.