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