Tattered Serbian health system draws on ECOSG in fight against blindness

By Ana Hidalgo-Simón MD, PhD

WITH just one ophthalmologist for every 12,000 people, Serbian eye care is clearly feeling the repercussions of political upheaval as the country struggles to secure socio-economic stability after breaking away from the former Yugoslavia.
The public health care delivery system is in a state of collapse and ophthalmic operation numbers have tumbled in the last 10 years.

Slobodanka Latinovic MD, PhD, who works in the eye clinic of the Clinical Centre at Novi Sad, Serbia, joined the ECOSG four years ago. Her unit’s participation in the study has yielded some positive results for Serbian ophthalmology and a health care system in acute need of salvation.
With the help of a World Health Organisation (WHO) programme for cataract therapy in Serbia, the total number of operations performed in 2001 was around 9,000. Of these, as many as 35% did not undergo IOL implantation and only around 17.5% were performed using phacoemulsification.

“Both the mean age and the number of women operated on are lower in our study than in the rest of the ECOSG. For example, results for 2001 showed a mean age of 66.3 against the European average of 73.4,” Dr Latinovic noted.
Women constitute only 40.5% of total number of cataracts performed, while in the rest of Europe they account for 62.7% of cases.
She blamed those findings on a combination of risk factors present in Serbia which favour the development of cataracts in younger patients and a lower life expectancy, especially for women.
The use of phacoemulsification is on the increase, having risen from 79% in 1998 to 81% in 2001. The insertion of foldable IOLs after cataract extraction shows a similar trend.
The number of combined glaucoma and cataract operations has decreased but is still well above ECOSG average.

For example, in 2000 the proportion of combined procedures performed in the Serbian study group was 12.8% compared to the ECOSG average of 1.1%.
By 2001 the number of combined procedures had dropped to 2.7% in Dr Latinovic’s group compared to an ECOSG average of 0.7%.
“The economic situation forces us to avoid performing a separate operation whenever possible,” she explained.
The last four years have seen the transition from mainly general anaesthesia (61% of patients in 1998) to exclusively local anaesthesia (100% in 2001) in Dr Latinovic’s unit.
She highlighted the current widespread use of local retro- or peri-bulbar anaesthesia as one of the changes introduced in her practice as a consequence of participation in the ECOSG and interaction with practices in other units in Europe. Topical drops and intracameral anaesthesia are not widely used.

A similarly dramatic change was observed in the number of ambulatory operations. All procedures were performed on an in-patient basis in 1998.
Since then, Dr Latinovic’s unit has reduced in-patient procedures progressively: 91.9% in 1999; 53.8% in 2000 and 8.1% in 2001. Postoperative visual acuity and levels of astigmatism are similar to other European participants.
The tight economic situation was, Dr Latinovic’s view, the main reason for the low levels of second eye surgery in Serbia.
The level of second procedures performed began at 25% four years ago (compared with 41.5% for ECOSG), and dropped even more in 1999 and 2000 to 18.9% and 12.8% respectively.

However, the trend has begun to reverse, with an increase in second eye operations to 29.7% noted in 2001. This was still below the ECOSG average rate of second operations for 2001 of 38.1%.
Complications during surgery were seen in some 8% of cases, higher than the European average of 3%. The rate of complications has continued to increase.
The two main complications seen are posterior capsule rupture, seen in 15.8% of cases, and vitreous loss, experienced 8% of cases, she noted.
Ocular co-morbidity was significantly below European levels for the first two years of Serbia’s participation; 27.1% versus 37.5% in 1998 and 21.6 % versus 39.8% in 1999. However, the level has now reached Europe’s average in the last two years; 35.1% versus 42.6% in 2000, Dr Latinovic added.

“More than 80% of our patients have mature white cataracts and the percentage of ocular co-morbidity we see has increased, especially in the last two years, mainly glaucoma, diabetes and myopias.
“These high co-morbidity levels are worsened by the fact that operations are performed with old equipment, insufficient instruments and less than optimal surgical materials,” she said.

In addition to the elements of the procedure audited as part of the ECOSG study, Dr Latinovic’s unit felt inspired to assess the benefits of cataract surgery at their unit with an additional evaluation of vision-related quality of life.
A questionnaire that includes a visual function index is used and helps to record the extent of the improvement of patient’s quality of life.
“The participation in the ECOSG has enabled us not only to compare our outcomes with European average, but also to monitor our progress over the four years of our participation.

“I look forward to the forthcoming changes in our country’s economic and health-care delivery. More modern units, better surgical materials and improved staff training will surely result in an improvement in both the quantity of operations and the quality of cataract surgery,” Dr Latinovic said.
The ECOSG continues to study practice patterns across Europe. If you are interested in learning more or possibly participating in the project, please visit the ECOSG web page at www.eurocat.ne.

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