- Email: [email protected]
Pediatric ophthalmology and strabismus in the Kingdom of Saudi Arabia
Special Article Pediatric Ophthalmology and Strabismus in the Kingdom of Saudi Arabia Arif O. Khan, MD, and Saleh Al-Mesfer, MD n the early 20th century, health care and other services in the Arabian Peninsula were underdeveloped. In 1932 the Kingdom of Saudi Arabia was formed, and soon thereafter, its vast oil reserves were discovered. Using its newly found wealth, the country embarked on a series of ambitious projects to modernize infrastructure with attention to health care services. During the second half of the 20th century, state-of-the-art universities, medical schools, and hospitals were successfully built and staffed with expatriate guidance. Saudis were soon able to receive higher education and advanced health care within their country rather than having to travel abroad. The 1982 opening of the King Khaled Eye Specialist Hospital (KKESH) in Riyadh heralded the era of modern ophthalmology in Saudi Arabia.1 Virtually all initial ophthalmic personnel were recruited from abroad (mostly from North America) to provide services to Saudi citizens and training to Saudi physicians and ancillary staff. Two years later, collaboration of KKESH with King Saud University and local hospitals led to the establishment of the well-structured “Greater Riyadh” integrated ophthalmology residency program and allowed the first ophthalmologists to be formally trained within the country. With the development of regional centers providing primary and secondary ophthalmic care, KKESH evolved to become a tertiary care referral facility. Interested residents had the option of extra KKESH rotations in a particular subspecialty during their fourth (final) year; the country’s first subspecialists in pediatric ophthalmology and strabismus received their training in this manner. In 1994 a structured subspecialty program modeled after the American fellowship system was formally inaugurated at KKESH. The inclusion of “Pediatric Ophthalmology and Strabismus” among the fellowships marked its first formal recognition as a subspecialty within the Kingdom. From 1994 to 2003, this structured fellowship program has graduated 17 fellows in
I
From the Department of Pediatric Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia. The authors have no financial interests regarding the subject matter and the manuscript. Submitted March 22, 2003. Revision accepted May 2, 2004. Reprint requests to: Arif O. Khan, MD, Department of Pediatric Ophthalmology, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Kingdom of Saudi Arabia; e-mail, [email protected] J AAPOS 2004;8:513-514. Copyright © 2004 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2004/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2004.05.001
Journal of AAPOS
pediatric ophthalmology and strabismus, many of whom currently provide important services in the country. Saudi Arabia has one of the world’s highest birth rates (⬎3%) and at least half of its 20 million citizen are under 20 years of age.2 Pediatric services are therefore in demand and will continue to be so for some time. Saudi citizens are provided health care by the government via a pyramidal system which requires being evaluated by a primary care facility before being referred for more specialized care. Much routine pediatric ophthalmic care is provided by general ophthalmologists. In the past, such services were mostly provided by expatriate physicians who had varying experience and training depending on their country of origin. Although there are still a number of expatriate ophthalmologists, the percentage of Saudi ophthalmologists providing such services has been rising and is projected to continue to do so.1,3 It is recognized among ophthalmologists that caring for children with eye disease and/or adults with strabismus can require special expertise. Complicated cases and those requiring reoperation are therefore usually referred to pediatric subspecialists. Most major ophthalmology departments and private centers include pediatric ophthalmologists, who are largely concentrated in urban areas such as Riyadh, Dammam, and Jeddah. There is a dearth of orthoptists in the Kingdom, and KKESH is investigating options for establishing an orthoptist training program. The government provides medical training to eligible citizens who successfully complete competitive admission requirements at the end of secondary school. After 6 years of medical school and 1 year of internship, the physiciantrainee is eligible to apply for a 4-year ophthalmology residency. The “Greater Riyadh” integrated program is the major ophthalmology residency in the country, accepting approximately 12 residents per year (about 20% of applicants). The other 2 university-based integrated residency programs are offered in Dammam (2 residents/year) and Jeddah (5 residents/year); both of these centers also provide tertiary eye care. The Scientific Board of Ophthalmology, established by the Saudi Council of Health Specialties, accredits the residency programs and requires certification examinations (oral and written) of their graduates. All ophthalmologists must be certified by the Saudi Scientific Board of Ophthalmology or a recognized foreign equivalent to practice in the Kingdom. For postresidency training in pediatric ophthalmology and strabismus, Saudis have spent time in institutions abroad (e.g., in North America or the United Kingdom), worked with December 2004
513
514 Khan and Al-Mesfer established subspecialists in the Kingdom (an “apprenticeship”), completed the KKESH-based fellowship (up to 3 candidates/year), or have performed a combination of these options. Although the government has been the major employer of ophthalmologists, private practice is rapidly growing.1,3 Pediatric ophthalmologists working for governmental facilities are on salary, whereas those in private practices are self-employed or on salary with bonus incentive. ElMaghrabi Hospital is the largest private ophthalmology group, with branches throughout the Kingdom and pediatric ophthalmologists at most of its locations. Both governmental and private ophthalmologists attend and/or participate in the annual Riyadh “Saudi Ophthalmology” conference that features international speakers, symposia, free papers and posters, and workshops. The meeting, attended by over 1000 ophthalmologists from Middle Eastern countries, is organized by KKESH, King Saud University, and the Saudi Ophthalmological Society.4 It includes pediatric ophthalmology and strabismus as a major theme every few years. In addition, university-based ophthalmology departments and some private groups sponsor their own periodic subspecialty seminars, which include topics in pediatric ophthalmology and strabismus. Pediatric ophthalmic research is supported and performed at governmental facilities and university-based hospitals. KKESH investigators have made numerous important contributions to the field of pediatric ophthalmology and strabismus that have been published in prominent international ophthalmology journals and/or presented at major international ophthalmology meetings. Many of these projects, particularly the genetic studies, are in collaboration with well-recognized institutions around the world. The results of basic science, clinical, and epidemiological research that is of regional interest appear in the Saudi Journal of Ophthalmology and the Middle East Journal of Ophthalmology. Ophthalmic research from the private sector has been more in the field of kerato-refractive surgery than in pediatric ophthalmology and strabismus.
Journal of AAPOS Volume 8 Number 6 December 2004
The practice of pediatric ophthalmology and strabismus in Saudi Arabia is unique. As in other countries, the management of strabismus and amblyopia comprises the majority of pediatric ophthalmic practice. However, because of the high birth rate and tendency for consanguinity in a population that is historically a genetic isolate, the prevalence of pediatric cataracts, pediatric glaucomas, anterior segment dysgeneses, retinal dystrophies, congenital cranial dysinnervation syndromes, and other inherited disease is higher than most of the rest of the world. Pediatric ophthalmologists are therefore well-versed in anterior segment and glaucoma surgery as well as in the care of conditions not frequently seen in North America. KKESH is well-equipped to diagnose and manage the challenging cases it receives, but there may be a lack of suitable facilities at some regional ophthalmic centers. There is a great need for the subspecialty of pediatric ophthalmology and strabismus in Saudi Arabia. Tremendous accomplishments have been achieved in a short amount of time with governmental support and expatriate guidance permitting rapid evolution of the subspecialty over the last few decades. Saudi citizens can currently receive world-class care in the field of pediatric ophthalmology and strabismus given by well-qualified Saudi ophthalmologists who trained within Saudi Arabia. There is, however, a need for more practitioners.1,3,4 Challenges for the future include organization of nationwide pediatric vision screening, provision of more care at regional centers, reaching those in rural areas, and training enough pediatric specialists to meet the manpower demands of the very large young population. References 1. Wagner MD, Al-Rajhi A. Ophthalmology in the Kingdom of Saudi Arabia. Arch Ophthalmol 2001;119:1539-43. 2. Kingdom of Saudi Arabia Central Department of Statistics Survey. Ministry of Economy and Planning, 2000. 3. Badr IA. An overall study and review of eye services in the Kingdom of Saudi Arabia: present and future needs. Mid East J Ophthalmol 1997;5:28-36. 4. Wagner MD, Al-Rajhi A. Ophthalmology in the Kingdom of Saudi Arabia: past, present, and future. Saudi J Ophthalmol 2003;17:1-4.
I
From the Department of Pediatric Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia. The authors have no financial interests regarding the subject matter and the manuscript. Submitted March 22, 2003. Revision accepted May 2, 2004. Reprint requests to: Arif O. Khan, MD, Department of Pediatric Ophthalmology, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Kingdom of Saudi Arabia; e-mail, [email protected] J AAPOS 2004;8:513-514. Copyright © 2004 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2004/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2004.05.001
Journal of AAPOS
pediatric ophthalmology and strabismus, many of whom currently provide important services in the country. Saudi Arabia has one of the world’s highest birth rates (⬎3%) and at least half of its 20 million citizen are under 20 years of age.2 Pediatric services are therefore in demand and will continue to be so for some time. Saudi citizens are provided health care by the government via a pyramidal system which requires being evaluated by a primary care facility before being referred for more specialized care. Much routine pediatric ophthalmic care is provided by general ophthalmologists. In the past, such services were mostly provided by expatriate physicians who had varying experience and training depending on their country of origin. Although there are still a number of expatriate ophthalmologists, the percentage of Saudi ophthalmologists providing such services has been rising and is projected to continue to do so.1,3 It is recognized among ophthalmologists that caring for children with eye disease and/or adults with strabismus can require special expertise. Complicated cases and those requiring reoperation are therefore usually referred to pediatric subspecialists. Most major ophthalmology departments and private centers include pediatric ophthalmologists, who are largely concentrated in urban areas such as Riyadh, Dammam, and Jeddah. There is a dearth of orthoptists in the Kingdom, and KKESH is investigating options for establishing an orthoptist training program. The government provides medical training to eligible citizens who successfully complete competitive admission requirements at the end of secondary school. After 6 years of medical school and 1 year of internship, the physiciantrainee is eligible to apply for a 4-year ophthalmology residency. The “Greater Riyadh” integrated program is the major ophthalmology residency in the country, accepting approximately 12 residents per year (about 20% of applicants). The other 2 university-based integrated residency programs are offered in Dammam (2 residents/year) and Jeddah (5 residents/year); both of these centers also provide tertiary eye care. The Scientific Board of Ophthalmology, established by the Saudi Council of Health Specialties, accredits the residency programs and requires certification examinations (oral and written) of their graduates. All ophthalmologists must be certified by the Saudi Scientific Board of Ophthalmology or a recognized foreign equivalent to practice in the Kingdom. For postresidency training in pediatric ophthalmology and strabismus, Saudis have spent time in institutions abroad (e.g., in North America or the United Kingdom), worked with December 2004
513
514 Khan and Al-Mesfer established subspecialists in the Kingdom (an “apprenticeship”), completed the KKESH-based fellowship (up to 3 candidates/year), or have performed a combination of these options. Although the government has been the major employer of ophthalmologists, private practice is rapidly growing.1,3 Pediatric ophthalmologists working for governmental facilities are on salary, whereas those in private practices are self-employed or on salary with bonus incentive. ElMaghrabi Hospital is the largest private ophthalmology group, with branches throughout the Kingdom and pediatric ophthalmologists at most of its locations. Both governmental and private ophthalmologists attend and/or participate in the annual Riyadh “Saudi Ophthalmology” conference that features international speakers, symposia, free papers and posters, and workshops. The meeting, attended by over 1000 ophthalmologists from Middle Eastern countries, is organized by KKESH, King Saud University, and the Saudi Ophthalmological Society.4 It includes pediatric ophthalmology and strabismus as a major theme every few years. In addition, university-based ophthalmology departments and some private groups sponsor their own periodic subspecialty seminars, which include topics in pediatric ophthalmology and strabismus. Pediatric ophthalmic research is supported and performed at governmental facilities and university-based hospitals. KKESH investigators have made numerous important contributions to the field of pediatric ophthalmology and strabismus that have been published in prominent international ophthalmology journals and/or presented at major international ophthalmology meetings. Many of these projects, particularly the genetic studies, are in collaboration with well-recognized institutions around the world. The results of basic science, clinical, and epidemiological research that is of regional interest appear in the Saudi Journal of Ophthalmology and the Middle East Journal of Ophthalmology. Ophthalmic research from the private sector has been more in the field of kerato-refractive surgery than in pediatric ophthalmology and strabismus.
Journal of AAPOS Volume 8 Number 6 December 2004
The practice of pediatric ophthalmology and strabismus in Saudi Arabia is unique. As in other countries, the management of strabismus and amblyopia comprises the majority of pediatric ophthalmic practice. However, because of the high birth rate and tendency for consanguinity in a population that is historically a genetic isolate, the prevalence of pediatric cataracts, pediatric glaucomas, anterior segment dysgeneses, retinal dystrophies, congenital cranial dysinnervation syndromes, and other inherited disease is higher than most of the rest of the world. Pediatric ophthalmologists are therefore well-versed in anterior segment and glaucoma surgery as well as in the care of conditions not frequently seen in North America. KKESH is well-equipped to diagnose and manage the challenging cases it receives, but there may be a lack of suitable facilities at some regional ophthalmic centers. There is a great need for the subspecialty of pediatric ophthalmology and strabismus in Saudi Arabia. Tremendous accomplishments have been achieved in a short amount of time with governmental support and expatriate guidance permitting rapid evolution of the subspecialty over the last few decades. Saudi citizens can currently receive world-class care in the field of pediatric ophthalmology and strabismus given by well-qualified Saudi ophthalmologists who trained within Saudi Arabia. There is, however, a need for more practitioners.1,3,4 Challenges for the future include organization of nationwide pediatric vision screening, provision of more care at regional centers, reaching those in rural areas, and training enough pediatric specialists to meet the manpower demands of the very large young population. References 1. Wagner MD, Al-Rajhi A. Ophthalmology in the Kingdom of Saudi Arabia. Arch Ophthalmol 2001;119:1539-43. 2. Kingdom of Saudi Arabia Central Department of Statistics Survey. Ministry of Economy and Planning, 2000. 3. Badr IA. An overall study and review of eye services in the Kingdom of Saudi Arabia: present and future needs. Mid East J Ophthalmol 1997;5:28-36. 4. Wagner MD, Al-Rajhi A. Ophthalmology in the Kingdom of Saudi Arabia: past, present, and future. Saudi J Ophthalmol 2003;17:1-4.