PROBLEMS IN AN AREA WHERE RESOURCES ARE LIMITED:
SAUDI ARABIA

Tarek Eid, MD

A major problem in dealing with the glaucoma patient is his lack of understanding of the disease, which I think is our fault as medical and health-care personnel. Patients do not understand the difference between cataract and glaucoma. I spend a lot of time trying to convince patients that they should never stop their medications without the approval of their eye doctor. Some patients think that glaucoma surgery is the end of the road and they never show up again. I see many patients coming to me with almost total optic nerve atrophy and high pressure without any medications who have never been checked for the last 5 years or so since they had their surgery. With this problem in mind I organized a large symposium last May entitled: "Surgical management of glaucoma: Is it the end of the road?" All of the the speakers presented different types of glaucoma surgery. My main concern was to urged these doctors to explain to their patients that glaucoma surgery is not the end and that periodic follow-up is the key for proper glaucoma control.

Another major problem comes from patients coming from rural and remote areas in the kingdom here for a few days to have surgery and then return home. In some of these places an efficient ophthalmologist is not available to follow the patient and this patient may come back to me after two or three months with a failed or complicated trabeculectomy. To solve this problem, I tend to do viscocanalostomy for these patients unless trabeculectomy is highly recommended.

Another point related to ophthalmologists and even some glaucoma or anterior segment specialists is the old thinking that it is nothing except pressure. Sometimes I see patients on glaucoma medications for years who have never had a visual field test! Nothing is mentioned about diurnal IOP measurement. I used to take a patient off medications and re-evaluate the whole picture. Many of these patients are ocular hypertensives or have only a large cup without any signs of damage.

Physicians here do not pay much attention to the adverse effects of ocular medications. The simplest thing is to prescribe a beta-blocker to a patient who has high pressure.

Of course, real progress in medical service to patients has been made here at Magrabi Hospitals and Centers with the subspeciality systems. We maintain a very strict standard of care, which has gained us a good reputation among health administrators as well as patients. My hope is that this quality of practice will spread to all sectors of the health-care system, including public and governmental hospitals.

If I wanted to characterize the main problems of the medical service in either Egypt or Saudi Arabia I would consider the following factors:

Character of the community

1. Cultural effects.
2. Geographic effects.
3. Economic and financial effects
4. Religious factor
5. Relations with outside world

Characters of the patients

1. Cultural and educational status
2. Social relations
3. Yearly income
4. Insurance coverage
5. Patient understanding and orientation about his/her disease and treatment plans
6. Compliance re: medications and follow-up

Characters of the physicians

1. Graduation and postgraduate training
2. Yearly income
3. Specifications of the medical service: general and subspeciality units
4. Miscommunications among physicians regarding patients and ability to have second opinions and a referral system
5. Lack of research activity and active participation in establishing specific medical plans of community-based studies

Character of the medical service in each community

The main problems of the medical service in Egypt:

1. Poverty of both the individual and the government.
2. Lack of good quality insurance
3. The private clinics system
4. Malpractice law

The main problems of the medical service in Saudi Arabia:

1. Traditions and habits of the community
2. Lack of mass insurance
3. A large majority of the personnel running the medical services are foreigners.
4. Presence of multiple races with a diversity of racial diseases