|Gullipali N. Rao,
MD, said the LVPEI pyramid of eye care model is an efficient and effective
model for delivering eye care to a large population such as India’s.
Image: Rao GN
Faced with an aging global population, industrialized and underdeveloped
regions will also be coping with a dwindling number of ophthalmologists in
coming years. While vastly different in many ways, the aging populations and
lifestyle changes around the world have deep reaching affects on ophthalmology
in Asia, Europe and the United States. Ophthalmology organizations around the
world are trying to respond to the expected shortfall in ophthalmologists that
will correspond with an increase in age- and lifestyle-related disease. Nowhere
is this more acutely recognized than in the Vision 2020: The Right to Sight
initiative of the World Health Organization and the International Association
for the Prevention of Blindness.
According to the World Health Organization, without major intervention
the number of blind people worldwide is projected to increase to 76 million by
the year 2020.
Currently, approximately 314 people worldwide are affected by low vision
or blindness, but 80% of blindness is avoidable and the majority of low vision
With the aging populations and lifestyle changes, conditions such as
age-related macular degeneration and diabetic retinopathy are expected to rise
The WHO also estimates that 90%of the blind live in low-income
Responding to the global challenges
With so many challenges to face, Vision 2020: The Right to Sight was
begun in 1999 with the aim of combating preventable blindness and low vision on
a global scale.
Through its member organizations, Vision 2020 seeks to provide technical
support and advocacy worldwide for the prevention of blindness. It works on a
national level through a Vision 2020 committee that brings together ministries
of health, non-governmental organizations, professional societies and civic
groups. These committees work together to develop effective and sustainable
national eye care plans.
In the area of human resource development, Vision 2020 aims to achieve a
ratio of at least one ophthalmologist per 250,000 people, according to the
Vision 2020 Action Plan for 2006-2011. Among other strategies, the plan is to
increase the number of training centers and support existing ophthalmologists.
India is one country that has developed an effective and sustainable
integrated eye care model.
Gullipali N. Rao, MD, in his Bernardo Streiff Medal lecture at the World
Ophthalmology Congress in Berlin addressed the strides that have been made in
India, and discussed how the LVPEI model has been successful in treating
avoidable blindness for so many there and is now a training model
“In the last 15 years or so, it has multiplied into a huge number
of training programs that has changed the entire scene with cataract
surgery,” Dr. Rao said. “From 1.5 million 15 years ago annually, we
now perform more than 5 million cataract surgeries. This can only be achieved
through enhanced quality of care, education that is needs based and competence
based, targeted research to find solutions to our problems and integrated eye
The LV Prasad Eye Institute model of eye care is based on a pyramid
developed to create sustainable facilities with progressively greater levels of
technical care balanced against broad community involvement at the local level.
The first level of the pyramid is made up of Vision Guardians, young
people in the local community with a high school education who are trained in
basic vision screening and survey methods who help monitor a community of about
5,000 people, Dr. Rao said.
At the second level are Vision Centers, staffed locally to serve the
primary eye care needs of around 50,000 people. The Vision Centers are linked
to Secondary Eye Care Centers providing cataract surgery and diagnose other
ophthalmological diseases. The Secondary Eye Care Centers serve a population of
500,000. Beyond that, Tertiary Care Hospitals and Training Centers provide a
much larger range of ophthalmological services to 5 million.
At the top of the pyramid are Centers of Excellence, which treat complex
ophthalmic conditions and perform all subspecialty services while also being
subspecialty training centers and centers for advocacy.
The LVPEI model is being exported to other countries as well. Through
his work with Vision 2020, Dr. Rao has helped develop the LVPEI model into a
global resource center, and LVPEI is a WHO Collaborating Center for the
Prevention of Blindness.
“We get trainees from all over the world, and we are actively
developing programs that meet the current needs in developing countries,”
Dr. Rao said.
Fragmentation affects Europe
While the demographics vary from Asia, Europe faces similar challenges.
According to the EUREYE study, 3.3% of the European population age 65 years or
older has AMD. The prevalence is 40% higher in women than men and rises steeply
with age. This would indicate approximately 2.5 million AMD cases within the 27
In addition, the number of diabetic retinopathy cases is expected to
rise, due to the increasing prevalence and earlier onset of diabetes.
Data from the International Diabetes Federation show that there are
currently 55 million adults and 112,000 children with diabetes in Europe; 10
million to 12 million more cases are expected by 2030.
“The increasing rate of diabetes is connected with the aging of the
population, but also dietary and other lifestyle factors have an impact. They
explain the earlier onset of the disease and the increasing prevalence of type
2 diabetes in children,” Pascale G. Massin, MD, head of a large clinical
practice at Lariboisière Hospital in Paris, said.
As demonstrated by several studies, almost all patients with a 15-year
history of type 1 diabetes develop retinopathy. The disease also affects
patients with type 2 diabetes: 50% to 80% will develop retinopathy after 20
years of their diabetes diagnosis. The European Diabetes Study investigated
patients from 31 centers in 16 European countries. The overall mean prevalence
of diabetic retinopathy in 3,250 type 1 diabetes patients was 35.9%, while the
mean prevalence rate for proliferative diabetic retinopathy was 10.8%.
With people living longer, glaucoma will also become more common.
Currently, the number of people bilaterally blind from glaucoma is
approximately 8.4 million worldwide. By 2020, this number is estimated to rise
to 11 million.
“Europe is witnessing a fast rising incidence of glaucoma, from 5%
in 2000 to 10% to 11% in 2010 in people older than 75,” Julian
Garcia-Feijoo, MD, PhD, professor of ophthalmology at Universidad Complutense
and head of the glaucoma department at San Carlos University Hospital in
Higher demand for refractive procedures
Ophthalmologists also expect a higher demand for refractive procedures
in the coming years.
With the aging of the population, presbyopia will become a fast-growing
problem, resulting in a large demand for refractive surgeons.
“In Germany, 17 million people are currently over 65 years of age,
and in the next few years, there will be an estimated increase of 4
million,” Thomas Kohnen, MD, deputy chairman of the ophthalmology
department at Goethe University in Frankfurt, said.
Europe is a composite territory
Europe is small geographically, but it is densely populated, with an
uneven distribution between countries.
Data from the European Union of Medical Specialists (UEMS) show that
there are 40,000 ophthalmologists in Europe to care for a total population of
500 million — an average of eight ophthalmologists for every 100,000
“Also from this point of view, Europe is a composite territory. The
number of ophthalmologists varies enormously from country to country,”
Michèle Beaconsfield, FRCS, FRCOphth, FEBO, president of the UEMS
Ophthalmology Section, said.
The investment in health care is also unevenly distributed. Data show a
positive correlation with gross domestic product, although differences exist
within countries such as Italy, where the rich areas of the north are better
served than the poorer southern regions.
“Generally speaking, if you put the number of ophthalmologists
against the ability to spend on health care, you see that where there are
insufficient ophthalmologists there is also insufficient money to invest in
more,” Dr. Beaconsfield said.
Moving toward shared care
Ophthalmologists from different countries agree that task delegation is
one way future challenges can be met without sacrificing quality of care.
“Paramedics, like orthoptists, can share the consultation with the
ophthalmologist. By dealing with patient history, refraction, ocular motility
and tonometry, they will save 30% of medical time,” Dr. Rottier said.
The overall monitoring and care of specific eye diseases such as
glaucoma and diabetic retinopathy can also be rescheduled within shared care
programs, he suggested.
“In the U.K., we have a long tradition of shared care programs and
have significantly expanded the role of paramedics in recent years. Properly
constructed training for paramedics and the publication of professional
practice guidelines ensure that these specific extended roles are delivered to
a high standard,” he said.
There are a number of medical, technical and possibly even surgical acts
that can potentially be transferred to ophthalmic paramedics. The role of the
ophthalmologist, however, remains central and essential in selecting suitable
candidates, providing the appropriate training, supervising the procedures and
assessing the outcomes.
“Controlled delegation is the key, and the UEMS definition of a
medical act is what protects us all from role confusion, by shaping boundaries
and responsibilities,” Dr. Beaconsfield said.
“There is no need to be uniform, as long as provisions are made in
the interest of the patient,” Dr. Beaconsfield said.
U.S. faces own need for integrated models
The aging baby boomer generation and the looming demographic shift in
the U.S. population foretell a dramatic increase in the need for ophthalmic
services. But the growing number of older individuals moving through the health
care system in the next decade also has the potential to redefine both how eye
care is delivered and how ophthalmologists remain economically viable.
Experts estimate that the 15% of gross domestic product currently spent
on health care could rise to as high as 20% in 2020 if left unchecked As the
number of individuals aged 65 years and older swells, a likewise increase is
expected in the number of eyes affected by age-related degenerative conditions
such as cataract, dry eye, glaucoma, macular degeneration and presbyopia.
Epidemiologic predictive models, designed to measure the prevalence of
blindness in the U.S., estimate that about 937,000 individuals are legally
blind, but that figure could rise 70% to 1.6 million by 2020.
Researchers have also predicted a dramatic rise in specific eye
conditions brought on by the aging process. According to one study, about 20
million Americans have cataract in at least one eye, but that figure could rise
to 30 million in the next 10 years. Other research, pointing to the aging
population, has predicted an increase in the prevalence of age-related macular
degeneration — currently affecting about 1.75 million individuals but
expected to increase to about 2.95 million — and open-angle glaucoma
— currently about 1.8 million cases with an expected increase to 3.36
million cases, with black individuals exhibiting three times the age-adjusted
prevalence — by 2020.
For ophthalmology as a specialty, the rise in expected need comes amid a
stagnating number of new providers entering practice and at a time when many
practitioners are nearing retirement age. Moreover, health care reform, viewed
by some as a necessary step to lower health care costs before the surge in
demand as a result of the aging baby boomer population, may both lower
physician reimbursement while adding even more individuals to patient rosters.
“It’s really going to strain the way our offices are
structured, and I think people are going to have to change the way they do
things and the way they practice,” Robert J. Noecker, MD, MBA, a professor
of ophthalmology at the University of Pittsburgh School of Medicine, said.
According to Dr. Noecker, the growing ranks of seniors may offer a
promise of stable or even new business opportunities, but it also presents a
unique set of challenges for ophthalmology.
“Certainly, it’s an opportunity, but it’s also a risk
given our current economic environment and increasingly limited resources to
deal with these things,” Dr. Noecker said.
However, Dr. Noecker added, the coming increase in patient demand
suggests an opportunity to critically review operations to maximize patient
flow-through, with the overarching goal being to find a way to deliver
high-quality care at minimal overhead cost to the provider.
At the facility level, that may mean identifying bottlenecks in patient
flow and correcting them so that more patients can be seen. “You always
want the doctor to be the rate-limiting step,” Dr. Noecker said.
Delegating responsibility for certain tasks may also increase
efficiency. For instance, diagnostic testing can be performed by technicians
while the physician is in the operating room. In that vein, optometrists may be
called on to handle refractions and diagnostic exams.
The need for ancillary support staff to aid in the delivery of eye care
is borne out of the greater role that technology is playing in ophthalmology,
Dr. Noecker said. In the future, innovations such as teleophthalmology may
become more useful to triage less acute medical needs while identifying those
patients most in need of the expertise provided by ophthalmologists.
The University of Pittsburgh School of Medicine has already set up a
teleophthalmology pilot program to screen for diabetic retinopathy. According
to Dr. Noecker, diabetic retinopathy is a disease state in which revenues are
largely driven by surgical fees, but routine screening of patients with
diabetes to find those in need of surgical follow-up may also help revenues.
“If you can shift that and have a camera up in the primary care
office or elsewhere, you can basically read the images that are taken without
increasing the stress on the system,” Dr. Noecker said. “Plus, you
have a built-in referral source.”
Remote screening may also be applicable for other disease states, such
as glaucoma, in which technology is already helping to identify patients who
require more intense follow-up. The incorporation of optical coherence
tomography, retinal tomography and nerve fiber analysis, in addition to
traditional fundus photography, has added quantitative data that has improved
confidence in tracking disease progression.
“I think we are getting better at targeting the right population,
distinguishing between the patients that are stable vs. the ones that are
getting worse,” Dr. Noecker said. – by Bryan Bechtel, Michela
Cimberle and David W. Mullin
Should paramedical staff
be entitled to perform surgical procedures such as YAG laser
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- Michèle Beaconsfield, FRCS, FRCOphth, FEBO, can be reached
at Moorfields Eye Hospital, 162 City Road, EC1V 2PD London, United Kingdom;
+44-20-75662010; fax: +44-20-75662019; e-mail:
- Julian Garcia-Feijoo, MD, PhD, can be reached at Departamento de
Glaucoma, Hospital Clinico San Carlos, Martin Lagos sn, 28040 Madrid, Spain;
+34-91-3303977; e-mail: email@example.com.
- Thomas Kohnen, MD, can be reached at Goethe Universitat, Klinik fur
Augenheilkunde, Theodor-Stern-Kai, Frankfurt/Main, Germany; +49-69-63016739;
fax: +49-69-63013893; e-mail: firstname.lastname@example.org.
- Pascale G. Massin, MD, can be reached at Department of
Ophthalmology, Hôpital Lariboisière, Université Paris 7,
Paris, France; +33-1-49956488; fax: +33-1-49956483; e-mail:
- Gullapalli N. Rao, MD, can be reached at L.V. Prasad Eye Institute,
L.V. Prasad Marg, Road No. 2, Banjara Hills, Hyderabad 500 034, India;
+91-40-3061-2609; fax: +91-40-2354-8271; e-mail:
- L.V. Prasad Eye Institute can be reached at L.V. Prasad Marg,
Banjara Hills, Hyderabad 500 034, Andhra Pradesh, India; +91-40-3061-2345; fax:
+91-40-2354-8271; website: www.lvpei.org.
- Jean-Bernard Rottier, MD, can be reached at 37 avenue du Gal
Leclerc, 72000 Les Mans, France; +33-2-43391767; e-mail: