Public Health Control Public Health Control Strategies for Glaucoma: Strategies for Glaucoma:
What do we Need to Know?What do we Need to Know?
Nathan Congdon, MD, MPHNathan Congdon, MD, MPH
Zhongshan Ophthalmic CenterZhongshan Ophthalmic CenterSun Yat Sen UniversitySun Yat Sen University
Guangzhou, ChinaGuangzhou, China
ORBIS InternationalORBIS International
Financial interest
No financial interest
An explosion of new knowledge about glaucoma and other eye disease
Visual burden of glaucoma increasing Visual burden of glaucoma increasing despite new knowledgedespite new knowledge
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
Blind Low Vision All Vision Impaired
Number Blind and Vision Impaired in the U.S. Population Aged 40 and over
2000
2010
2020
This talkThis talk Questions to ask:Questions to ask:
– What model for glaucoma programs in areas of What model for glaucoma programs in areas of limited resources?limited resources?
– What do we need to know to implement these What do we need to know to implement these programs well?programs well?
Introduce ideas this session will focus on:Introduce ideas this session will focus on:– ZAP and EAGLE studies, CREST program, Aravind ZAP and EAGLE studies, CREST program, Aravind
tube shunttube shunt
Emphasis on Asia:Emphasis on Asia:– Evidence of significant disease burdenEvidence of significant disease burden
– Availability of resourcesAvailability of resources
A strategy for glaucoma in rural Asia: A strategy for glaucoma in rural Asia: Start in the clinicsStart in the clinics
Clinic-based case-finding:– Economic models1 suggest that population-based
approach is not cost effective– Uncertainty about morbidity associated with large-
scale programs of PI for narrow angles Target is persons aged 40+ years presenting for
eye care, and who are at risk for BLINDNESS from glaucoma
1 Burr JM, et al. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assess 2007;11(41):iii-iv,ix-x,1-190.
A strategy for glaucoma in rural A strategy for glaucoma in rural Asia: Screening for narrow anglesAsia: Screening for narrow angles
Gonioscopy, possibly with van Herrick testing as a “pre-screen”
The GOOD– Cheap (US$75 goniolenses
available in India)– Still the gold standard, no
proof yet that other modalities are better
The BAD– Highly dependent on
quality of training– Cutoffs for intervention
are not well-defined
A strategy for glaucoma in rural A strategy for glaucoma in rural Asia: Screening for glaucomaAsia: Screening for glaucoma
Principal focus on evaluation of the disc– Emphasis on detecting
patients with severe damage
– Very limited evidence for utility of field testing in persons without field-taking experience
– Post-operative evaluation of the nerve in patients with dense cataract
A strategy for glaucoma in rural A strategy for glaucoma in rural Asia: TreatmentAsia: Treatment
Strategy may differ between urban and rural settings:– Glaucoma drops widely
available in urban China and India for US$1 per bottle
– Barriers of opportunity cost, transportation and availability make long-term medical therapy untenable in most rural areas
– In these areas, surgical therapy will likely predominate
A strategy for glaucoma in Asia: A strategy for glaucoma in Asia: Integrate glaucoma into the eyecare systemIntegrate glaucoma into the eyecare system
In areas of limited resources, a “glaucoma program” is not going to make sense
Similar equipment and training should also build capacity to care for DR (for example)
The patient may have come 100 km, we have to be willing to move 5 mm from the optic nerve to the fovea!
The knowledge gapThe knowledge gap
What do we need to know in order to What do we need to know in order to scale up glaucoma treatment in Asia?scale up glaucoma treatment in Asia?
Treatment of narrow angles, ACGTreatment of narrow angles, ACG
Any expansion of service Any expansion of service provision for persons with provision for persons with narrow angles requires a narrow angles requires a better understanding of the better understanding of the risk-benefit ratio for available risk-benefit ratio for available treatments.treatments.– What are the long-term What are the long-term
effectiveness of cataract effectiveness of cataract extraction versus PI for extraction versus PI for NA/AC? (EAGLE, ZAP)NA/AC? (EAGLE, ZAP)
– What are What are incidence/progression rates incidence/progression rates of cataract, corneal of cataract, corneal decompensation, visually decompensation, visually significant glare, RD after significant glare, RD after PI? (ZAP)PI? (ZAP)
The CREST Network:The CREST Network:CComprehensive omprehensive RRural ural EEyecare yecare SService ervice
and and TTrainingraining A collaboration between A collaboration between
ORBIS International, ORBIS International, Zhongshan Ophthalmic Zhongshan Ophthalmic Center and ten rural, county-Center and ten rural, county-level hospitals in Guangdong level hospitals in Guangdong ProvinceProvince
Aim: To build capacity of Aim: To build capacity of rural hospitals to provide rural hospitals to provide comprehensive eye care comprehensive eye care (including both glaucoma and (including both glaucoma and DR)DR)
Platform for programmatic Platform for programmatic research on management of research on management of glaucoma and DR in rural glaucoma and DR in rural AsiaAsia
Current knowledge and attitudes about Current knowledge and attitudes about glaucoma in rural Chinaglaucoma in rural China
Focus Group studies of Focus Group studies of doctors and patients in doctors and patients in rural Guangdong have rural Guangdong have revealed widespread revealed widespread mis-conceptionsmis-conceptions ( (Arch Arch
Ophhalmol 2012;130:761-70Ophhalmol 2012;130:761-70 ):: – Glaucoma viewed as rare Glaucoma viewed as rare – Highly-symptomatic Highly-symptomatic
diseasedisease Thorough examinations Thorough examinations
of angle and optic nerve of angle and optic nerve only done on rare only done on rare patients with obvious patients with obvious symptomssymptoms
Research on physician trainingResearch on physician training
Change in practice Change in practice patterns:patterns:
– Goal is routine full exam Goal is routine full exam for ALL patients > 40 for ALL patients > 40 yearsyears
– Use of electronic medical Use of electronic medical record network tying 10 record network tying 10 rural hospitals to ZOC to rural hospitals to ZOC to assess documentation of assess documentation of key facets of glaucoma key facets of glaucoma exam:exam:
• IOPIOP• GonioscopyGonioscopy• Optic nerveOptic nerve
– Before and after trainingBefore and after training
Research on physician trainingResearch on physician training
A study of rural physicians’ ability to detect glaucoma A study of rural physicians’ ability to detect glaucoma damage in the optic nerve is also under waydamage in the optic nerve is also under way
Testing before and after training using the GONE Testing before and after training using the GONE Website:Website:– Jonathan Crowsdon, CERA, AustraliaJonathan Crowsdon, CERA, Australia– Chinese-language version of website now existsChinese-language version of website now exists
Research on patient educationResearch on patient education
RCT of intervention to RCT of intervention to increase uptake of increase uptake of glaucoma examinations glaucoma examinations in clinic:in clinic:– Videos made especially Videos made especially
for the projectfor the project Key ideas:Key ideas:
– Glaucoma asymptomaticGlaucoma asymptomatic– Need comprehensive Need comprehensive
exam to detect un-exam to detect un-suspected diseasesuspected disease
– Potential for severe, Potential for severe, irreversible vision loss if irreversible vision loss if wait for symptomswait for symptoms
Research on patient educationResearch on patient education Patients are unsatisfied Patients are unsatisfied
with vision after with vision after glaucoma surgery: glaucoma surgery: “negative social “negative social marketing”marketing”– RCT of educational RCT of educational
intervention including intervention including videos videos
– Explain purpose of Explain purpose of glaucoma surgeryglaucoma surgery
– Prepare patients for Prepare patients for likelihood of blurred VAlikelihood of blurred VA
– Outcome is post-op Outcome is post-op satisfaction level, satisfaction level, willingness to recommend willingness to recommend surgerysurgery
Research on patient Research on patient compliancecompliance
Patient long-term Patient long-term compliance with compliance with recommended DR care recommended DR care and post op glaucoma and post op glaucoma visits is poor visits is poor (Ophthalmology (Ophthalmology 2010;117:1755-62.)2010;117:1755-62.)
– Funding from WDF to Funding from WDF to create automated create automated cellphone SMS reminder cellphone SMS reminder systemsystem
– Increases 6-month Increases 6-month compliance from 36% to compliance from 36% to 86% in peds cataract 86% in peds cataract (Ophthalmology in press)(Ophthalmology in press)
– 95% of local rural 95% of local rural patients have access to cell patients have access to cell serviceservice
Future issues: Research on Future issues: Research on glaucoma treatmentglaucoma treatment
Outcomes of Outcomes of conventional surgeries conventional surgeries (trab, surgical PI) in this (trab, surgical PI) in this settingsetting
Could inexpensive, Could inexpensive, locally-made tube locally-made tube shunts, ExPress valves shunts, ExPress valves etc. be better-suited to etc. be better-suited to rural surgeons and lower rural surgeons and lower patient compliance?patient compliance?
What is impact of this What is impact of this limited, clinic-based limited, clinic-based strategy on preventing strategy on preventing glaucoma blindness in glaucoma blindness in the population? the population?
ConclusionConclusion Many knowledge gaps Many knowledge gaps
still exist in our still exist in our understanding of understanding of managing glaucoma in managing glaucoma in areas of limited areas of limited resourcesresources
Research can help to fill Research can help to fill these gaps, and in doing these gaps, and in doing so to improve the so to improve the effectiveness and effectiveness and efficiency of programsefficiency of programs