Response to eLetter: The Estimated Number of Ophthalmologists Worldwide (International Council of Ophthalmology Update): Will We Meet the Needs?

Serge Resnikoff, Ophthalmologist, International Council of Ophthalmology
Van C. Lansingh, Ophthalmologist, Instituto Mexicano de Oftalmologia
Lindsey Washburn, Communications Specialist, International Council of Ophthalmology
William Felch, Former Head of International Council of Ophthalmology, International Council of Ophthalmology
Tina-Marie Gauthier, Medical Writer and Editor, International Council of Ophthalmology
Hugh Taylor, Ophthalmologist, University of Melbourne
Kristen A. Eckert, Medical Writer and Editor, Independent
David W. Parke II, Ophthalmologist, American Academy of Ophthalmology
Peter Wiedemann, Ophthalmologist, International Council of Ophthalmology

Other Contributors:

Lindsey Washburn
William Felch
Tina-Marie Gauthier
Hugh Taylor
Kristen A. Eckert
David W. Parke II
Peter Wiedemann
September 25, 2019

We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of these services will make for more efficient productivity at referral centers, and the patients will avoid having to spend the time and expense to travel to secondary and tertiary centers for basic eye care.3 Practical training of primary care providers is needed to ensure the transfer of skills, but for this training to have long-term impact on service delivery, primary health centers need to be properly equipped and training programs need to be well integrated into the health systems and, in particular, the referral networks, to ensure that patients with more serious conditions are accessing specialists.3-5
Health systems, therefore, need to have adequate financing available, but the costs of universal eye health are a barrier to remote and resource-limited communities in nearly all countries. For example, the burden of out-of-pocket costs of cataract surgery hits the middle-class populations of higher income countries the hardest.6 Innovative, cost-effective solutions must be employed to better tailor the universal access of eye care to a local population. In developing countries, the provision of phacoemulsification and the maintenance of the required equipment are too expensive for most of the patients and facilities. In these settings, manual small-incision cataract surgery (MSICS) is the more appropriate surgical technique, having the same advantages of phaco in terms of outcomes and faster surgical time and recovery, but MSICS also has a shorter learning curve and drastically lower costs.7-9
At the primary care level, cost-effective technology, such as the use of artificial intelligence and smart phones in telemedicine for the purposes of examination and diagnosis, appears to be an appropriate solution to overcoming financial barriers, again saving patients both the time and the expense of traveling to secondary and tertiary care centers.10-13 The diagnostic accuracy of telemedicine models has been validated; however, for the models to work, attention is again placed on the referral network, which has to be strengthened to be able to manage the increase in caseload.12

1. Resnikoff S, Lansingh VC, Washburn L, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology Update): will we meet the needs? Br J Ophthalmol 02 July 2009. doi:10.1136/bjophthamol-2019-314336 [Epub ahead of print]
2. World Health Organization. Universal eye health: a global action plan 2014–2019. [A66/11 – 28 March 2013]. 2013. Available: [Accessed September 5, 2019].
3. Mafwiri MM, Jolley E, Hunter J, Gilbert CE, Schmidt E. Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania. BMC Nurs 2016;15:41.
4. Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Serv Res 2017;17(1):823.
5. Yip JLY, Bright T, Ford S, Mathenge W, Faal H; Rwanda Primary Eye Care Process evaluation group. Process evaluation of a National Primary Eye Care Programme in Rwanda. BMC Health Serv Res 2018;18:950.
6. Lansingh VC, Carter MJ, Eckert KA, Winthrop KL, Furtado JM, Resnikoff S. Affordability of cataract surgery using the Big Mac prices. Rev Mex Oftalmol 2015;89:21–30.
7. Singh K, Misbah A, Saluja P, Singh AK. Review of manual small-incision cataract surgery. Indian J Ophthalmol 2017;65:1281–88.
8. Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. Middle East Afr J Ophthalmol 2015;22:362–9.
9. Ruit S, Gurung R, Vyas S. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol 2018;29:105–9.
10. Delgoshaei B, Mobinizadeh M, Mojdekar R, Afzal E, Arabloo J, Mohamadi E. Telemedicine: a systematic review of economic evaluations. Med J Islam Repub Iran 2017;31:113.
11. Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol 2015;99:823–31.
12. Wong TY, Sabanayagam C. Strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence. Ophthalmologica. 2019 Aug 13:1-12. doi: 10.1159/000502387. [Epub ahead of print]
13. Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017;10:1909–18.

Conflict of Interest

KAE was a paid consultant to this study.