Too many cataracts, too few ophthalmologists

NGOs have provided some relief, but only about half of all patients who need cataract surgery receive it annually.

At 204 million, Indonesia's population is the fourth largest in the world. As in other particularly large countries, there is tremendous demand for ophthalmic care. Unfortunately, there are just 650 ophthalmologists in Indonesia, or less than one for every 31,400 people.

About 50% of ophthalmologists perform a total of 100,000 cataract procedures annually. Hundreds of thousands of Indonesians require treatment for sight-threatening cataracts, but fewer than half of patients, usually urban dwellers who can afford to pay privately for care, ever undergo the procedure. Estimates for all of Asia suggest that 50% of blindness is caused by cataract, but for Indonesia the estimate is upward of 90%, according to Indonesian Ophthalmologists' Society President Istiantoro, of the Jakarta Eye Center.

Charity-funded mass cataract surgery efforts in rural areas have enjoyed some success, but because budgets are limited, a tremendous number of people go without surgery. When a mass surgery effort is undertaken in a rural area, a waiting list of 6 months or longer occurs almost immediately, according to Indonesian Ophthalmologists' Association statistics. Under a mass cataract treatment effort, one in which physicians are volunteering their time and not accepting fees, surgery can be performed for as little as US$50 per case. In private centers, the fee is as much as US$500 per eye. (Indonesia's economic crisis has decreased the cost for private cataract surgery. Last year, the fee for private surgery was around US$1,000 per eye.)

Widespread blindness

Indonesia's blindness rate is 1.47% of its population, equaling about 300,000 people. Ninety percent of those, or about 270,000 people, are blind due to cataract. With only 100,000 procedures being performed annually, there is a backlog of nearly 170,000 procedures each year. Officials have not estimated how long the annual backlog has existed, but they do cite several key reasons for its existence.

The main reason for the backlog is economic. As a result of the financial crisis, 40 million Indonesians now live below the poverty line. They have no money to pay in the form of taxes, and therefore the Ministry of Health is underfunded and cannot afford programs that might solve the cataract blindness problem.

The second reason for the backlog is a lack of manpower. There are only 560 ophthalmologists in Indonesia, and with only 50 graduating from medical school annually, eye care centers are likely to be understaffed for the foreseeable future.

Geography is also responsible for the backlog. Many of Indonesia's islands are so remote that they cannot be easily accessed by medical personnel. Most potential patients in these regions are just too far from care.

In an attempt to control the backlog, all members of the Indonesian Ophthalmologist's Association, also known as Perdami, must make at least one trip into a remote area to promote the organization's cataract eradication program. Most of the trips involve some surgery, but because conditions in the field are less than optimal, many procedures are performed without IOL implantation.

Eye care infrastructure

Much of the nation's eye care is provided at Indonesia's mostly rural, primary health centers. (See accompanying article.) Primary health centers are equipped to perform simple refractions and to treat cataract, glaucoma and external disease. Nearly 100% of cataract operations in Indonesia are extracapsular. Phacoemulsification represents about 10% of total cataract procedures and is available only in large cities from private physicians.

Secondary care can be found at the nation's provincial hospitals. There are about 100 of these and most are located in urban or suburban areas. Secondary care centers are staffed by at least one general ophthalmologist and are equipped to treat cataract, glaucoma and uncomplicated retinal detachments.

Between the primary care facilities and the referral hospitals are community eye care institutes. Their primary mission is to absorb backlog from the primary and secondary care services. The community eye care centers are funded by non-governmental organizations and receive no money from the Ministry of Health. Community centers are usually staffed by volunteers, with one community-oriented ophthalmologist attending. They provide general ophthalmic care with a special focus on cataract eradication.

The most sophisticated eye care is at the referral hospital level. Referral hospitals are run by state universities and are home to Indonesia's ophthalmology residency programs. Referral hospitals are equipped to provide a full range of ophthalmic services and are considered the best facilities in the nation. Divided along subspecialty lines, these centers provide cataract and refractive surgery, glaucoma treatment, advanced vitreoretinal care, immunology, oculoplastic and reconstructive surgery, neuro-ophthalmology care and pediatrics and strabismus services.

Refractive surgery

The growth of refractive surgery in Indonesia is stable despite the myriad economic problems. Because a small percentage of the population will be able to pay for expensive elective surgery regardless of any economic calamity around them, greater numbers of Indonesian surgeons are moving toward refractive surgery as a means to supplement their income. Indonesian ophthalmologists can earn anywhere from US$8,400 to US$180,000 annually.

Procedures are generally limited to photorefractive keratectomy (PRK), but laser in situ keratomileusis (LASIK) is performed at the nation's largest ophthalmology facility in Jakarta. Radial keratotomy is performed in limited circumstances.

Although there is a willingness to pay for elective procedures, the economic crisis has softened the refractive surgery market. PRK can be had for about US$200 per eye, while LASIK costs about US$500. Under normal economic circumstances, PRK typically costs US$400 per eye, while LASIK is around US$1,000.

There are about four excimer lasers operating in Indonesia.

For Your Information:

Dr. Istiantoro can be reached at the Jakarta Eye Center, Jalan Cik Ditiro 46, Menteng, Jakarta 10310 Indonesia; ++(21) 310-7434; fax: ++(21) 390-4601. For detailed information on the Indonesian health care system, visit their Web site at www.depkes.go.id. Call or write the Ministry of Health at Jl. HR. Rasuna Said Kav 4-9, Jakarta, Indonesia; ++(21) 522-9590; fax: ++(21) 520-3874.