Introduction
Glaucoma affects a substantial proportion of the adult population worldwide.It is the most common cause of irreversible blindness in the world and is the second leading cause of blindness after cataract accounting for 10% of blindness worldwide and 12.8%of blindness in India. The prevalence of glaucoma in India is reported to be 2.6% to 4.1% in adults. [1,2] Increasing age being a significant risk factor for the disease, a significant increase in glaucoma prevalence is expected with the increasing life expectancy. It is estimated that by 2020, 40% cases of glaucoma worldwide will be in India and China alone. [3,4]
Community based screening programmes for glaucoma are not practical as the tests lack specificity and sensitivity. No single test has adequate diagnostic accuracy in detecting glaucoma. Its late onset, asymptomatic nature, combined with the poor sensitivity and specificity of many screening tools make its early diagnosis challenging.Previous Indian studies have emphasized the unreliability of IOP measurements alone in screening for glaucoma. Careful optic nerve head evaluation is mandatory for accurate diagnosis of glaucoma.
Since the onset of symptoms cannot be reversed in glaucoma,and disability from glaucoma may be mild until later stages of disease, treatment must be initiated to prevent disease progression to the stage where the likelihood of disability is increased.
Aim
To study the pattern of prior ophthalmic consultation in patients presenting with severe visual loss due to glaucoma
Methods
The study was conducted in the Department of Ophthalmology, Pt. J.N.M.Medical College, Raipur. 36 patients presenting with advanced glaucoma from October 2017 to April 2018 were included in the study. Advanced glaucoma was diagnosed on the basis of combination of optic disc and visual field changesaccording to Hodapp,Parrish and Anderson criteriaand on the basis of optic disc changes for those who could not perform the visual field test due to end stage glaucoma.Subjects with secondary glaucoma and congenital glaucoma were excluded from the study.
A detailed history was taken regarding onset and duration of symptoms,family history, socioeconomic history, education and treatment history. The patients were asked leading questions regarding prior ophthalmic consultation. This included consultation fromophthalmic assistants, technicians and ophthalmologists either in hospitals or in camps. The patients were asked if they had been informed regarding the nature of their problem during these consultations. They were also asked about follow-up visits, and their awareness regarding glaucoma.
All patients underwent a detailed ophthalmic evaluation including visual acuity, intraocular pressure measurement, slit lamp examination, fundus examinationwith +90 D lens, gonioscopy and perimetry.Snellen visual acuity measurements were converted to logarithm of minimum angle of resolution equivalents.
Results
36 patients having advanced glaucoma were included in the study. The mean age of the patients was 61.39 ± 7.87 years (range 42 to 74 years). There were equal number of males and females (18). The average UCVA was 0.78 ±0.26, while the average BCVA was 0.49 ± 0.28. POAG was the most prevalent type with only 30% having PACG. 9 patients had undergone cataract surgery in one or both eyes within the past 5 years,out of which 3 had undergone the surgery in the past 2 years.None of the patients had a family history of glaucoma.
89% of the patients belonged to the lower and upper lower socioeconomic class (Kuppuswamy’s Socio-Economic Status Scale). 15 patients out of the 36 studied(41.67%) were illiterate. Only 2 (5.56%) had received a high education level. 22 (61.11%)patients were villagers while the rest 14 were residents of urban areas.
15 patients(41.67%) had consulted an eye care practitioner in the previous two years and had not been diagnosed as glaucoma.5of them had been prescribed glasses and 2 being diabetic were advised to take opinion of retina specialist for their retinopathy status and one of them was under regular care of a retina specialist.5 had consulted in eye camps and had been prescribed glasses or advised cataract surgery.3 patients had undergone cataract surgery in the past two years.
15 (41.67%) patients had been diagnosed as glaucoma previously and prescribed medications for the same. However, they had stopped the medications after few months of use and had not followed up. All these patients belonged to the low socioeconomic strata.
6 (16.67%) patients with advanced glaucoma had not consulted elsewhere previously with any healthcare practitioner prior to consulting with us and were not aware of their disease.
Discussion
Eye care facilities have improved significantly in the past few decades. However,at the community level, emphasis has traditionally been on detection and surgery of cataract.It was alarming to note that 41.67 % of patients presenting with advanced glaucoma had consulted an eye care practitioner in the past two years and had not been diagnosed as glaucoma.Previous studies have also found that glaucoma diagnosis was missed by optometrists and ophthalmologists perhaps because a comprehensive eye examination was not performed.[5,6]ACES also reported that 50% of persons detected with glaucoma had undergone an ophthalmic evaluation in the previous year and yet glaucoma was undetected in 80% of individuals identified by the study. Inadequate identification of glaucoma even in population undergoing ophthalmic evaluation continues to be a major determinant of preventable blindness due to glaucoma in India.
A comprehensive eye examination is essential for early detection and management of glaucoma. An opportunistic screening of all patients above 40 years for glaucoma for whatever problem they present with is mandatory for detecting glaucoma. Community based referrals for all persons with symptoms and signs of glaucoma(diminution of vision, haloes, frequent change of glasses, family history of glaucoma) must be made mandatory. Eyecamps must have facility of tonometry and fundus examination otherwise they give false sense of satisfaction to patients of having consulted an eye care practitioner.Phone based fundus camera for posterior pole photography with subsequent opinion from experts might be an option. Screening of all patients brought from the outreach camps for cataract surgery,for glaucoma is mandatory, though overlooked at times. Target coverage must be more intensive with increasing age since the prevalence of POAG shows a significant rise with age.
An equal number of patients had been diagnosed with glaucoma but had discontinued medications.Adherence to medication once glaucoma is diagnosed can be improved by proper counselling. Previous studies have shown that glaucoma poses a significant economic burden. Expenditure on glaucoma medications ranged from 0.3% of the patient’s monthly gross income in high- income group to 123% in a low income group whilethe total expenditure including travel, stay, and loss of wages of patients and accompanying persons ranged from 1.6% in high income group to 137% of monthly income in the low- income group in a previous Indian study.[7] Subsidy on antiglaucoma drugs or covering them under insurance may be advocated to improve adherence to medications since affordability and compliance are extremely important issues. In the light of lifelong requirement of antiglaucoma medications, glaucoma filtering surgery may be considered an early option, depending upon the socioeconomic and educational status of the patients.
Conclusion
A comprehensive eye examination for every patient presenting to eye care facility can help reduce the burden of blindness due to glaucoma
References
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- Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol2006;90:262-7.
- Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ 1995;73:115-21
- Gogate P, Deshpande R, Chelerkar V, Deshpande S,nDeshpande M. Is glaucoma blindness a disease of deprivation and ignorance? A case-control study for late presentation of glaucoma in India. Indian J Ophthalmol2011;59:29-35
- Vijaya L, George R, Asokan R, et al. Prevalence and causes of low vision and blindness in an urban population: The Chennai Glaucoma study. Indian J Ophthalmol. 2014;62:477-481
- Nayak B, Gupta S, kumar G, Dada T, Gupta V, Sihota R. Socioeconomics of long-term glaucoma therapy in India. Indain J Ophthalmol2015;63:20-4
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