Beaconsfield, FRCS, FRCOphth, FEBO, president of the UEMS ophthalmology
section, noted the wide variation in the numbers of ophthalmologists throughout
Image: Beaconsfield M
The population profile of Europe is projected to become older in the
coming decades, with an uneven growth rate expected in the various countries.
The percentage of the total population age 65 years or older is predicted to
increase from 17% in 2008 to 23.5% in 2030.
The graying of Europe will have an impact on disease distribution and
the overall growing demand for health care services. At the same time, a
consistent decrease in the number of specialist physicians is expected,
creating concern about whether the diminished workforce will be able to cope
with an even larger medical workload.
Age-related diseases will be main challenge
The main challenge for eye care professionals will be in age-related
diseases, such as age-related macular degeneration, diabetic retinopathy and
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 EU nations.
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.
“Besides the growing number of people who will require surgical
treatment for presbyopia, we expect an increase in the demand for other
refractive procedures. Looking at the distribution of refractive errors, we can
see that there is only a very small group of ametropic people. About half of
the European population are hyperopic, and 25%, more than 100 million now, are
myopic, 64% of which is mild, 32% moderate and 4% high,” he 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.
“At the bottom of the scale there is the U.K., where the aggressive
numerus clausus and the strongly centralized national health system have
traditionally imposed limitations. We are about two ophthalmologists per
100,000 population,” she said. “At the opposite end there is Greece,
with no numerus clausus and more than 14 ophthalmologists per 100,000
population. France and Germany are somewhere in the middle.”
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.
Causes behind workforce decrease
Experts agree that the numerus clausus, implemented by an increasing
number of medical faculties in Europe to address overcrowding and to meet
governmental workforce planning, may be responsible for the shortage of
specialists in the coming years. In addition, in countries where the balance
between number of patients and number of specialists is positive at present,
there will soon be an insufficient number of physicians to replace those who
will be retiring.
“In France, in the next 10 years, we will have lost 1,500
ophthalmologists due to the too strict numerus clausus implemented in 1990. We
are now 5,500 to manage 35 million medical acts. In 2020, we will be 4,000
dealing with 45 million,” Jean-Bernard Rottier, MD, president of the Trade
Union of French Ophthalmologists, said.
The growing number of medical lawsuits is also having a significant
impact on the number of students who choose surgical specialties in which the
risk of medical error and malpractice claims is high. In countries such as
Italy, where physicians who commit medical errors can be — and usually are
— charged with a criminal act, the decrease in the number of practitioners
is dramatic, approximating 30% compared with the previous decade.
“Although 80% of medical lawsuits in Italy end with a favorable
verdict, the high risk and disproportionate potential consequences are a strong
deterrent. As a further consequence, premiums for liability insurance are
becoming prohibitive,” Costantino Bianchi, MD, senior vice president of
the UEMS Ophthalmology Section, said.
“In absence of a more favorable legislation, we will face a
dramatic shortage of surgeons, increased by massive migration to countries that
offer better protection and more favorable working conditions,” he said.
The European Union is conceptually based on the free movement of people,
goods and services. In the field of health care, a concerted European strategy
is being developed to facilitate the movement of patients and professionals.
However, in the current situation, cross-board mobility raises more
questions than answers, according to Dr. Beaconsfield.
Countries with fewer resources, such as Eastern European countries, see
their already insufficient workforce migrating to where better working
conditions are offered. On the other hand, richer countries offer incentives to
Eastern European professionals because the richer countries lack qualified
workers. This trend is having dramatic consequences in some places: Clinics and
medical institutions are forced to close as standards of care can no longer be
As far as patients are concerned, cross-border mobility is likely to be
the response by some consumers due to health care system overload. But behind
the apparent advantages, there are challenges that need to be considered.
“With patients increasingly seeking abroad what they cannot get in
their own country, uncertainty exists about the application of rights to
reimbursement and over how the necessary frameworks for quality and safety
should be ensured for cross-border health care. Who ultimately carries
medicolegal responsibility when things go wrong has yet to be clarified,”
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.
According to this definition, stated in an official document issued by
the UEMS council: “The medical act encompasses all the professional
actions, eg scientific, teaching, training and educational, organisational,
clinical and medico-technical steps, performed to promote health and
functioning, prevent diseases, provide diagnostic or therapeutic and
rehabilitative care to patients, individuals, groups or communities in the
framework of the respect of ethical and deontological values. It is the
responsibility of, and must always be performed by a registered medical
doctor/physician or under his or her direct supervision and/or
The extent and modalities of task delegation are currently being
discussed within individual countries.
“There is no need to be uniform, as long as provisions are made in
the interest of the patient,” Dr. Beaconsfield said. – by Michela
Should paramedical staff be entitled to perform surgical procedures such as YAG laser capsulotomy?
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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:
- Costantino Bianchi, MD, can be reached at Via Ciro Menotti 1/A,
20129 Milano, Italy; +39-02-740793; fax: +39-02-7386612; 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: firstname.lastname@example.org.
- 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: email@example.com.
- 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:
- Jean-Bernard Rottier, MD, can be reached at 37 avenue du Gal
Leclerc, 72000 Les Mans, France; +33-2-43391767; e-mail: