Dr G. Chandrasekhar

LVP Eye Health Pyramid

Glaucoma Care

• Appropriate

• Available

• Affordable

• Accessible

Without Compromising Quality

From Screening to Management of Complex

Diseases

LVPEI Eye Health Pyramid

Community

Secondary

Tertiary

Adv. Tertiary

Primary

Organizing primary-care networks

•Continuity of care•Bringing care closer to the people•Responsibility for a well-identified population

PRIMARY CARE: PUTTING PEOPLE FIRST

Village Vision Complex

Integrated Secondary & Primary Eye Care

Secondary Eye Care

10 Vision Centres

100 Vision Guardians+

+

Direct Service to 100-200 villages

89 Primary

10+9 Secondary

Four Tertiary

Center of Excellence

Community

Primary 2002

Secondary 1992

Tertiary 2003

Adv. Tertiary 1987

Community 2004

• General awareness

• Refer those with problems

Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

Community Level(Vision Guardian)

• History

• High IOP

• Optic nerve

• Van Herrick’s

• Referral

Primary Care(Vision

Technician)

Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

• History Slit lamp

• Applanation tonometry

• Gonioscopy

• Optic nerve

• Visual fields• Medical and Surgical

Rx

Secondary Care

(Ophthalmologist)Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

• Diagnosis & treatment of complicated problems

• Training

• Research

Tertiary Care

(Subspecialities)Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

• Management of complex cases

• Training of Subspecialists and trainers

• Educational standards

• Research

• Advocacy

• Capacity building of Training Centres

CENTRE OF EXCELLENCE

Advanced Tertiary Care

(Team of Subspecialists)

Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

• Situation analysis

• Modification of infrastructure

• Redesigning of physical space

• Equipment

• Training of Trainers

• Implementation

• Monitoring and evaluation

Capacity building of Training Centres

Centre of Excellence

Training centre

Service Centre

Vision Centre

Vision Guardian

CENTRE OF EXCELLENCE

Advanced Tertiary Care

(Team of Subspecialists)

Village Vision Complex

Integrated Secondary & Primary Eye Care

Secondary Eye Care

10 Vision Centres

100 Vision Guardians+

+

Direct Service to 100-200 villages

Secondary Centres Data (1998-2011)

Centre NameTotal OPD

Glaucoma in OPD Trab. Yag PI

Mudhole 213108 1162 814 409Tudukurthy 143528 534 377 118Adilabad 71603 86 66 23Karamchedu 84997 481 109 30Markapuram 44638 303 88 0Kandukur 13854 156 5 0Nellore 21987 41 0 0Paloncha 20990 156 6 64Cherukupalli 2155 30 0 0  616860 2949 1465 644

Glaucoma – Vision Centres

April 2010 to Jan 2012

All Centers (76) Screening High IOP

Total 249160 1709

0.68% - High IOP > 21

LVPEI Eye Health Pyramid

Glaucoma careChallenge

sIOPAngle ClosureDisc and field damage

Glaucoma Epidemiology and Molecular Genetics Study

GLEAMS

Population based cross sectional study

Methodology

• Inclusion criteria– People aged 40 years and above– Residents for a min 6 months– Willing to participate

• Exclusion criteria– Cannot be contacted after 3

attempts– People who are immobile

Methodology

Vision Guardian Vision Guardian

Vision Technician 1Vision Technician 1

Vision Technician 2Vision Technician 2

OptometristOptometrist

The Study Plan

Vision Technician 1Vision Technician 1

Vision screeningVision screening

History, VA, RefHistory, VA, Ref

FDT, HVF, SL, NMFP, ASOCT

FDT, HVF, SL, NMFP, ASOCT

Goni, dilated evaluation, OCT, Fundus photo

Goni, dilated evaluation, OCT, Fundus photo

DO, IOP, GonioDO, IOP, Gonio

Analysis I• Agreement of Optometrists with

Glaucoma Specialist Ophthalmologist in gonioscopy and Optic Disc evaluation

Analysis II• Diagnostic accuracy of a VG in vision

screening, pupillary abnormalities and anterior chamber

Results

Analysis III• Skills of a VT in Gonioscopy and image

acquisition

Analysis IV• Role of Imaging in POAG and PACD diagnosis

Results

Gonioscopy• 150 eyes with 25 PACS and 25 PAC

Optic Disc Assessment• 200 eyes with 30 disc suspects and 30

glaucoma eyes

Sample Size

• Agreement between Optometrists and Glaucoma Expert

Results

К (SE)

Gonioscopy (UK) 0.92 (0.12)

Optic Disc Assessment (UK) 0.90 (0.09)

Gonioscopy (JGB) 0.84 (0.10)

Optic Disc Assessment (JGB) 0.89 (0.09)

Progress of the Project

• No. of villages screened - 10• Number of subjects screened till now –

2000• Data available - 1832

No. of eyes with various types of glaucoma

LVPEI Eye Health Pyramid

Glaucoma careChallenge

sIOPAngle ClosureDisc and field damage

Weinreb RN etal. Am J Ophthalmol 2004;138: 458-467

The Glaucoma Continuum

Shallow AC depth on Van Herrick

Corresponding ASOCT

BEST NMFP Corresponding OCT

BEST MFP

WORST NMFPCorresponding OCT

WORST MFP

L V Prasad Eye Institutewww.lvpei.org

Thank you!

Excellence

Equity

Efficiency