PROBLEMS AND SOLUTIONS IN TURKEY

Atilla Bayer MD

Some problems unique to our setting and some features of our country have created a variety of obstacles and opportunities in the management of patients with glaucoma. In Turkey the relationship between the physician and the patient is different than in European countries and the US. Although clearly defined by law, the responsibilities of the ophthalmologist and the rights of the patient are not well known by patients. Until recent years ophthalmological services were not available to many people because there were simply too few ophthalmologists. An inadequately organized health-care system plus a key cultural factor – namely, the overly respectful attitude of the Turkish people to the educated class, including doctors -- compounded this health-care delivery problem.

More recently, the rise in the educational level of the population and the increased number of the ophthalmologists have improved the situation. However, more time is required before any dramatic improvements will be seen. Anti-glaucoma medications are finally becoming available, several years behind Europe and the US. Nevertheless, because the educational level of the population is still not too high, patient compliance levels remain poor.1-3

Although the number of ophthalmologists is becoming satisfactory there are still too few glaucoma specialists, placing a large burden on glaucoma clinics. The bright side is that this situation has given these physicians an opportunity to see more patients. Another result of the scarcity of glaucoma specialists is that general ophthalmologists cannot refer all their glaucoma patients to a specialist, forcing all ophthalmologists to increase their knowledge about glaucoma and other ophthalmic subspecialties.

Although malpractice laws are developing, Turkish ophthalmologists are still not under so much stress from the legal system during manipulations, surgeries, and patient management as in Europe and the US. Poor patient compliance, together with the increased cost of medical treatment4 and the relatively small number of anti-glaucoma drugs available (especially in the past)5,6 has forced us to perform surgeries earlier and more often, giving us the opportunity to develop our surgical skills. The upside of the delay in the availability of anti-glaucoma drugs is that it has given us an opportunity to see the results of studies of their side effects, effectiveness, indications, etc.

Economic problems have forced us to find practical ways of performing low-cost operations, including manufacturing our own instruments and devices: home-made glaucoma drainage devices instead of commercially available implants,7 use of the sharp edge of a steel razor blade instead of a disposable blade, or bending the tip of a PPD injector needle instead of using a disposable cystotome. Still, because of Turkey’s poor economy and relatively low educational level, we are encountering more people with advanced glaucoma than in Europe or the US.8,9

Since Turkey is the most developed country in the area, glaucoma patients from the neighborhood countries are naturally referred to us. This is giving us an opportunity to experience a diversity of patient population, with various ethnic origins.

Despite all of these problems, and in addition to the opportunities created by them, it is still a wonderful feeling to have the emotional satisfaction making a special effort to help our patients who are facing the consequences of glaucoma.

REFERENCES

1. Gasch AT, Wang P, Pasquale LR. Determinants of glaucoma awareness in a general eye clinic. Ophthalmology. 2000 Feb;107(2):303-8.

2. Saw SM, Gazzard G, Friedman D, Foster PJ, Devereux JG, Wong ML, Seah S. Awareness of glaucoma, and health beliefs of patients suffering primary acute angle closure. Br J Ophthalmol. 2003 Apr;87(4):446-9.

3. Zimmerman TJ, Zalta AH. Facilitating patient compliance in glaucoma therapy. Surv Ophthalmol. 1983 Dec;28 Suppl:252-8.

4. Ates Y, Sefi N, Cakmakli Z, Kocas M, Ozutemiz A. Cost Analysis in Management of Primary Open Angle Glaucoma. XXXth National Turkish Ophthalmology Society Meeting 1996, p 604.

5. Cunliffe I. New drugs in glaucoma therapy. Hosp Med. 2003 Mar;64(3):156-60.

6. Berggren L. Pharmacological and clinical aspects of glaucoma therapy. Acta Ophthalmol (Copenh). 1990 Oct;68(5):497-507.

7. Bardak Y, Ozerturk Y, Durmus M. Pars plana modified tube implantation combined with vitrectomy for neovascular glaucoma. Fourth International Glaucoma Symposium – I.G.S. Barcelona Spain, 2003, Final Program & Abstracts 105.

8. Negrel AD, Minassian DC, Sayek F. Blindness and low vision in southeast Turkey. Ophthalmic Epidemiol. 1996 Dec;3(3):127-34.
9. Fraser S, Bunce C, Wormald R, Brunner E. Deprivation and late presentation of glaucoma: case-control study. BMJ. 2001 Mar 17;322(7287):639-43.