Towards better management of glaucoma in India

Epidemiological studies on glaucoma involving adults aged 40 years and above have estimated glaucoma prevalence between 2.7 and 4.3% among Indians.[1-5] Glaucoma is estimated to affect 27.8 million more people by 2040 in Asia, and India and China will share the maximum burden.[6] Glaucoma is responsible for blindness in 1.2 million people and accounts for 5.5% of total blindness, putting it as leading causes of irreversible blindness in India.[7] The blindness associated with glaucoma is multifactorial. A majority of them either remain undiagnosed or are diagnosed at an advanced stage. The critical challenges in glaucoma management in India are low levels of awareness, undetected and undiagnosed cases, poor access to glaucoma diagnostic and therapeutic services, and issues related to compliance with treatment. Therefore, there is an emerging need to address challenge of glaucoma management as a public health problem at different levels targeting the public, service care providers, and the eye healthcare system.

Raising Awareness

A global initiative of celebrating glaucoma week was taken up to increase awareness about glaucoma in the community more than a decade ago.[8] However, awareness about glaucoma continues to be low in India.[9,10] The current strategies to raise awareness are carried out as an “event” rather than a regular “ongoing” affair. Information is not readily available on a mass level.[11] There is a need to adopt strategies focused on spreading awareness about glaucoma in community as well as at individual level. Similar to opportunistic screening, hospital waiting areas and passages should be used as opportunistic information spaces. The time spent in the hospital waiting area is an excellent opportunity for health education.[12] An individual can be educated in the hospital through information brochures, QR code-linked resources, and running advocacy messages on television in waiting areas. Local ophthalmological societies or group of doctors can conduct awareness walks and screening camps in their localities. Glaucoma forums or forums for eye care can be constituted on social platforms through which information can be dispersed. Mass media channels like newspaper, television, and social media platforms should be utilized to raise community awareness through government, state, or glaucoma society-sponsored advertisements. The awareness campaign should focus on the importance of regular screening for early detection of glaucoma while stressing the asymptomatic nature of disease. Professionals should address myths and perceptions about glaucoma prevalent in local society.

Increasing Detection

Undetected glaucoma, hence untreated glaucoma, results in faster progression, early visual impairment, and blindness. In India, the proportion of undiagnosed glaucoma is estimated at 90%.[13] Therefore, early detection is the key to prevention of glaucoma associated blindness. Asymptomatic nature in early course of glaucoma is main reason for missing the diagnosis and necessitating the screening. Population-based screening has not been cost-effective in Western countries, but found to be relatively cost-effective in Asian countries, including India.[14-17] The challenges associated with population-based glaucoma screening can be overcome through opportunistic screening and be performed in at-risk adults at every eye healthcare system during encounter. The prevalence of glaucoma increases with increasing age after the age of 40 years.[6] Hence, people coming for presbyopic glasses are at-risk of glaucoma. This encounter can be an excellent opportunity for glaucoma screening and educating the patient about need for regular screening with increasing age. This opportunistic screening has been shown to be effective in detecting glaucoma.[18] The scope of opportunistic screening can be elaborated to detect glaucoma in first-degree relatives of glaucoma patients.[19,20] Beside ophthalmologists, optometrists can also be trained to detect glaucoma during routine check-ups to increase case detection. There are over 42,000 eyecare practitioners in India, which includes optometrists, refractionists, and ophthalmic assistants.[21] Currently, the community-based glaucoma detection by optometrists is not effective but targeted training can improve the outcomes.[22,23] Artificial intelligence-based algorithms and teleophthalmology may be a boon in this direction. These task-shifting approaches are likely to be relevant and highly cost-effective in countries such as India, which have a large proportion of the aging population and limited resources.

Enhancing Diagnosis

Glaucoma care is part of comprehensive eye care and is mainly provided by a general ophthalmologists. However, it seems that glaucoma is a commonly dealt with but inadequately addressed disease. A survey done in India during a conference looked at shortcomings associated with glaucoma practice.[24] The increased IOP is the single most parameter for diagnosis of glaucoma in clinics. The underlying cause for raised IOP may be missed in many of cases.[25,26] The population-based Chennai glaucoma study found that 40% cases of primary angle closure glaucoma (PACG) were being treated as primary open-angle glaucoma (POAG).[3] The ratio of prevalence of POAG/PACG in population-based studies from India is 1.8–10.[1-5] Vellore eye study estimated the burden of primary angle closure diseases at 10.3% in the eligible Indian population.[27] This differentiation is significant in terms of available therapeutic interventions and the progression of two types of glaucoma. An algorithmic approach to the comprehensive ocular examination may minimize the problem of under or over-diagnosis of glaucoma.[25,26]

Improving Accessibility

Availability and affordability are two essential dimensions of accessibility in health care.[28] Nearly 65% of India’s population resides in rural areas.[29] There is no accurate data on availability of eyecare services in rural areas of India. The prevalence of blindness in rural populations is 1.18 times higher compared to urban population.[7] The challenge in rural India is not only the lack of availability of eyecare services but also poor uptake.[30] Only study in India found that two-thirds of glaucoma patients did not avail dedicated eyecare services available in vicinity due to financial, logistic, and social reasons.[30] In our survey to evaluate the accessibility and affordability of glaucoma medications, we observed low access and poor affordability in Haryana (unpublished), one of Indian states with the highest per capita income. This may be even a more significant challenge for economically backward areas of India. We need to devise strategies to improve access to glaucoma care, in fact eyecare as whole, and more specifically affordability issues in glaucoma. The Government of India’s Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) scheme is for providing quality generic medicines and surgical equipment at affordable prices to general public. A total of 11 topical glaucoma medicines are included in the product list, and these are priced at much lower cost than equivalent branded drugs (http://janaushadhi.gov.in/ProductList.aspx). The government should ensure the availability of topical glaucoma medicines in these stores, add leftover drugs and glaucoma surgical devices in its preview, and most importantly, make the public aware about this scheme, so that glaucoma treatment become available and affordable to every citizen.

Affordability is a barrier not only for glaucoma drugs but also for investigations. The diagnostic array of glaucoma is based on modern technology and costly equipment, making it unaffordable for many. Repeated visual field testing is often required for early detection of progression. The diagnostic tests are not covered under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, a Government of India scheme to provide health coverage to underprivileged families. For equitable access to glaucoma care services, accessibility and availability of diagnostic and therapeutic service must be improved.

Addressing Compliance

Adequate compliance and adherence to treatment is a challenge in chronic condition.[31] In North India, nearly 50% of glaucoma patients were non-compliant.[32] The pharmacological options to control IOP have increased in the last three decades, but that has pushed up the daily dosing frequency and adversely affected treatment compliance.[33] In addition to dosing frequency, our own experience has shown that side effects, cost of therapy, forgetfulness, depletion before the scheduled appointment, and lack of understanding about dosing are among several factors affecting the compliance.[32,34] Global experience has shown poor compliance, and adherence is significant risk factor for glaucoma-associated blindness.[35] Lifelong adherence to drug treatment and disease monitoring is essential if blindness associated with glaucoma is to be prevented. Some of the compliance-related issues can be effectively addressed by educating the patients. The counseling encourages the compliance and adherence to treatment.[36] The compliance barrier should be identified to provide a simple and specific solution. The optometrist or paramedical staff can record such issues during history taking and initial evaluation.

Conclusion

Blindness from glaucoma is preventable but only when an optimum, timed intervention is offered. As a caregiver of a chronic disease like glaucoma, which requires lifelong care, we need to identify gaps and set priorities, should the blindness associated with glaucoma be prevented.

About the author

Dr Parveen Rewri

Dr Parveen Rewri is serving as Professor and Head of the Department of Ophthalmology at Maharaja Agrasen Medical College, Agroha (Hisar) in Haryana. A graduate from Government Medical College, Bellary and post-graduate from RNT Medical College Udaipur, he did is fellowship in clinical and research disciplines of glaucoma from Sankara Nethralya, Chennai. He tends to devote his time between patient care, teaching and clinical research. As a teacher he tends to simplify the teaching methods and contents for students. His focus is to improve glaucoma awareness in community and case detection in clinic. He has over 35 publications in peer-reviewed journals to his credit.