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May 2008

Clinical Update: International
Global Vision, Part One: The Eyes of the Middle East
By Denny Smith, Senior Editor

The Eastern Mediterranean, the very heart of history in the ancient world, is now the heart of headlines in the modern world. EyeNet was drawn to conversations with several ophthalmologists from the Middle East as a fitting way to begin our six-part series on the state of international ophthalmology.

Learning in Lebanon

Education is held in deep regard in Lebanese society, and the number and quality of physicians having graduated from the American University of Beirut is a proud example of that, according to Muhammad H. Younis, MD, who is a consultant in pediatric ophthalmology and strabismus at the university as well as the vice-president of the Lebanese Ophthalmological Society.

The American University is a fabled institution in Beirut and throughout the Middle East. Historically, it has nurtured a level of medical care that virtually eliminated trachoma and other endemic eye diseases, Dr. Younis said, and now it draws wealthy tourists from around the region seeking the latest techniques in refractive surgery. He added that the availability of contemporary imaging and treatment technologies in Beirut approaches what health care consumers in the West have come to expect.

The waste of war. Dr. Younis recalled the many years of civil turmoil in Lebanon and how medicine itself was deeply wounded. “In the 1970s and ’80s, medical care was very diminished. In those years there were perhaps fewer than 100 ophthalmologists working in all of Lebanon.” But, he said, “In 1993 and ’94 things started recovering, even booming, and many people, including professionals, came back. Now we are graduating so many physicians from the American University that we are exporting them!”

Elias I. Traboulsi, MD, was one of those exports. Dr. Traboulsi studied at the American University and is now head of pediatric ophthalmology and adult strabismus at the Cleveland Clinic and professor of ophthalmology and director of the Center for Genetic Eye Diseases at Ohio State University in Columbus. “The training at the American University parallels very closely the training you would get in the U.S.,” said Dr. Traboulsi. “The hospital attached to the university provides primary eye care to the local population and at the same time serves as a referral center for difficult cases. They have a large surgical volume, a lot of pathology.”

Dr. Traboulsi mourned the tragedies visited on the Lebanese people by the civil war, which ran from 1975 to 1990. “War-related trauma has been a major source of vision loss in the Lebanese population. When I did my residency, between ’82 and ’85, we were still in the midst of the conflict. I remember sometimes operating around the clock, working on victims of fighting and bombings. We had many, many eye injuries, and, unfortunately, some modern techniques like vitrectomy were not available to us then. So patients with serious posterior segment injuries faced disaster.”

Access to care. Lebanon has a private insurance sector, and there is subsidized health coverage for government employees. People who do not have and cannot afford insurance may apply for a limited Medicare-style insurance. But underlying all medical services, said Dr. Traboulsi, is a strong cultural tradition among physicians of caring for the poor. All patients are welcome in the average community practice, and if the physician suspects that a particular patient or family cannot afford to pay for a visit, the fee is often forgiven then and there.

Genetic disease. As in many cultures of the Eastern Mediterranean and South Asia, consanguineous marriage is common in Lebanon, increasing the expression of autosomal recessive genes in some communities. Thalassemia, for example, has been associated with consanguinity in Eastern Mediterranean peoples, as has keratoconus.1

Dr. Traboulsi said that marriage between cousins is common among all sectors of the culturally diverse population—Christian, Muslim and Druze. “The incidence is in the range of 20 to 40 percent. So any recessive disease would be more likely to show itself. In ophthalmology there are many such diseases, including some that are blinding childhood diseases, such as Leber’s amaurosis or congenital glaucoma,” he said.

This experience gave the ophthalmologists who trained at the American University special insight into the diagnosis and treatment of these diseases, Dr. Traboulsi said. “Mansour Armaly, who died a few years ago, was very well-regarded for having described glaucomatous optic nerve changes, and he quantified visual field defects in glaucoma progression.”

Dr. Younis also sees gene-linked eye diseases. “There is a special concentration of keratoconus in Lebanon as well as a high incidence of other congenital eye diseases.” He added that topical collagen cross-linking treatments are now a common component of care in Lebanon for treating keratoconus.

Hope on the horizon? Viewing the troubles of the Middle East through a relatively dispassionate lens, Dr. Traboulsi surmised that physicians may be more able than most to meet on common ground. “If you go back several thousand years, we were just one people! From a medical perspective, at least, there should be a way of capitalizing on our shared history and shared experience. One such example is genetic disease. Because of the high prevalence of recessive diseases and relatively large families, we can build powerful studies of genetics there. Many landmark papers have indeed come out of Lebanon and Israel and, more recently, out of Kuwait and Saudi Arabia. This is where we can have a huge impact and help people around the world.”


Compassion in Syria

Rida Said, MD, sighed as he recounted the last 20 years of events on all sides of Syria, especially the monumental, episodic violence in neighboring Iraq. “Even before the current war, during the embargo, Iraqi physicians lacked a lot of medical supplies. So we sent teams of Syrian physicians to go there to help with equipment and medications,” he said, referring to the Western embargo on trade with Iraq after the first Gulf War. An anterior segment surgeon, Dr. Said is director of the National Program for Blindness Control in the Ministry of Health in Damascus, as well as the current assistant secretary-general of the Middle East African Council of Ophthalmology (MEACO). “In the embargo years, we also trained a lot of young Iraqi physicians in Syrian residency programs. In spite of its limited resources, Iraq always had fantastic doctors. Unfortunately, since the latest war began, many have left Iraq.”

The tatters of war. Like many realms of life in the Middle East, medical care in Syria has been sporadically roiled by regional conflicts and the resulting population displacements. Over the past half decade of war in Iraq, for example, enormous waves of refugees have poured over Syria’s eastern border. More than 2 million Iraqis have fled the conflict, and the World Health Organization estimates that 1.2 million are now in Syria. Thousands of those were Palestinians who were already refugees in Iraq before the war, and then in 2006 almost 700,000 Lebanese people entered Syria to flee fighting in their country. Syrian doctors cared for all of these refugees as readily as they would care for Syrian patients, noted Dr. Said. This is a policy shared by other countries, such as Egypt and Jordan, that also received Iraqi refugees, according to Ala Alwan, MD, assistant director- general of WHO. Dr. Alwan was quoted in a WHO bulletin as saying that many refugees had preexisting illnesses such as heart disease and diabetes, the consequences of which are putting enormous strains on these nations’ health care systems.2

A solid ophthalmic presence. Fortunately, Syria’s health care infrastructure had already been scheduled to expand, Dr. Said noted. “We have 13 new hospitals around the country that are under construction or nearly finished, and each one has an ophthalmology department. Last year we also started mass screenings for refractive errors in schoolchildren and, thanks to donations from several companies, we are providing free spectacles for every child who needs them.” Dr. Said’s next project is a public awareness campaign for glaucoma screening.

Although ophthalmologists are in short supply in many parts of the world, Dr. Said does not consider that to be a problem in the Middle East. “We are graduating enough ophthalmologists each year to anticipate the future population.” One exception may be in the field of retina. “We may not have enough retina specialists to meet existing need. And like many other countries, we face the same challenge of increasing longevity, with more patients surviving to have end-stage retinal diseases, like diabetic retinopathy,” he said.

Corneas and consanguinity. As in Lebanon, consanguineous marriage is not uncommon in Syria, which may contribute to disorders seen in disproportion in some communities. “We have a lot of keratoconus that calls for corneal transplants,” said Dr. Said. “So we have a great need for corneas. And yet historically we have had to rely on international eye banks.” There are two reasons for that.

First of all, he said, cultural mores, just as in many other societies, have discouraged any disassembly of the body after death. “People here have been hesitant to allow cornea donations after death. It is not really a religious problem, it’s just simply too new an idea for them. So we are trying to make the public aware of the problem and make it more acceptable to donate their corneas.”

Second, even if corneas were in sufficient supply, eye banks, until recently, were not. “It once was the national policy that eye banks could only be managed by educational institutions. But that has been relaxed, and Syria has a brand-new eye bank. And we were facing another problem—the law allowed relatives to stop a planned cornea donation after the death of a loved one. That was also changed so now the original decision must remain in effect—the donor’s wishes must be upheld. Furthermore, if the deceased had not said anything one way or the other about organ donation, the next of kin can now consent on behalf of their deceased relative to permit a cornea donation. We are trying to make this known by communicating through the mosques and through television. But I think it will take several years to come up with tangible results.”

Interestingly, the president of Syria, Bashar al-Assad, was himself trained as an ophthalmologist and was finishing postgraduate work in London when he was called to succeed his father eight years ago as head of state. Dr. Said does not think that the president’s medical background has made any particular impact on social policies, especially since Syria already had a nationally administered health system that guarantees medical care to its citizens. “But I am sure,” said Dr. Said, “that we will have all the backing we need, specifically concerning the legislation for tissue grafting.”

Working with neighbors. How would Dr. Said want international collaboration to improve, especially among neighboring countries? “I think that eye banks are a good place to start with collaboration. All of the countries in the region need corneas and we could help each other with that.” He added that even countries that have enough eye banks often end up with not enough corneas. When asked if Syria could be regarded as a leader in expanding eye banking and cornea donation, Dr. Said paused, then smiled. “I hope so!”


Science in Israel

Research is at the core of the Israeli medical establishment, according to Jacob J. Pe’er, MD, professor and chairman of ophthalmology at Hadassah University Hospital in Jerusalem and member of the advisory board of the International Council of Ophthalmology. An ophthalmic oncologist, Dr. Pe’er said that eye research from Israel is well-represented in the published literature, a notion verified by even a casual Web search. For example, it was Israelis over 15 years ago who described the dampening effects of hyperoxia—and the enhancing effect of hypoxia—on vascular endothelial growth factor levels in the eye, closely paralleling the work of the late Judah Folkman.3,4

Unfortunately, the funding for biomedical research provided by the government is lackluster. In fact, Dr. Pe’er said, “For all of medical research the Ministry of Health provides only about $1 million a year. That is like a medium-sized grant for the NIH in the U.S., which spends almost $30 billion a year in medical research! Even if you take into account the difference in population between the two countries, the per capita spending on research in the U.S. is one hundred times that of ours.” That leaves local researchers scrambling for funding from nongovernmental sources, Dr. Pe’er said. Access to health care is not wanting, however. Like Syria, Israel has a national, universal-access health system. It is paid for by a percent—4.8—of income.

The lessons of war. The regional history of the last half century has made trauma experts out of many Israeli physicians, and ophthalmologists have not been an exception, said Dr. Pe’er. “I think that the retina surgeons are especially experienced with these situations, since they are the ones most likely to handle injury from explosions.” Armed with experience, ophthalmic nurses from Dr. Pe’er’s department have developed a trauma protocol that they have presented at a number of international meetings.5

Dr. Pe’er counts many Arab ophthalmologists among his international friends and colleagues. However, the loss of fraternity among local nations, wrought by historic events, has had an impact on interaction between the region’s medical establishments.

A vision of the future? Dr. Pe’er said that Hadassah attempts to be as inclusive as possible. “Residents from Palestinian and other Arab backgrounds are an integral part of our program. Right now we have a resident from Gaza, another from the West Bank, another from East Jerusalem. When you come to Hadassah—to our grand rounds or morning lectures—you don’t feel there is a problem: About a third of our residents are Jewish, another third are Muslim and the other third are Christian. We give everyone a chance according to their talent, not their origin. I hope this shows it is possible to have a different kind of life in this part of the world.”

1 Cao, A. and R. Galanello. NEJM 2002;347:1200–1202.
2 07-030907/en/.
3 Shweiki, D. et al. Nature 1992;359:843–845.
4 Pe’er, J. et al. Lab Invest 1995;72:638–645.
5 Mimran, S. and R. Rotem. Insight 2005;30:10–12.

EDITORS NOTE: Global Vision is a six-part EyeNet series on contemporary issues in international ophthalmology. From now through November, Global Vision will take a close look at topics as diverse as medical education in the Middle East, the causes of uveitis in Latin America, tsunami injuries in Southeast Asia and blinding diseases in African children. This series will also explore the social and professional challenges of ophthalmologists everywhere, and how eye medicine can uniquely affect the health of entire nations and the world.