Glaucoma society hopes to improve low detection rate throughout India

Issue: December 2007

L. Vijaya, MBBS, MS

Improved examination procedures and increased awareness are needed to combat a low detection rate of glaucoma in India, said L. Vijaya, MBBS, MS, president of the Glaucoma Society of India and director of Glaucoma Services at Sankara Nethralaya.

She spoke to Ocular Surgery News on behalf of the society and Dr. Arun Kumar Narayanaswamy, her colleague at Sankara Nethralaya and treasurer of the Glaucoma Society of India. Dr. Vijaya discussed glaucoma in India and the society’s Glaucoma India Education Program, which is helping bring awareness to physicians about the importance of screening and therapy.

There are about 14,000 ophthalmologists in India, she said, and it is estimated that most of them provide medical treatment for glaucoma patients. Dr. Vijaya explained a routine eye exam for glaucoma screening is not a priority for many patients in India, and some health care professionals do not set a time frame for comprehensive follow-up exams for all patients.

A prevalence study, the Chennai Glaucoma Study, conducted by Dr. Vijaya and colleagues, found that more than 90% of patients with glaucoma were not diagnosed with the disease. In that study, poor detection rates were credited to lack of gonioscopy and optic disc evaluation as a routine part of eye examinations.

“The main concern regarding glaucoma in the country is the large burden of undiagnosed disease, which is partly related to the inadequate examination protocols followed by a large number of practitioners,” Dr. Vijaya said.

State of disease

In India, glaucoma is present in 2.5% to 5% of people older than 40 years, Dr. Vijaya said, adding that angle-closure glaucoma is significantly more common in India than predominantly Caucasian areas.

“In India, every issue has to be dealt with in the socioeconomic status,” she said. “Definitely the trend of disease, its diagnosis and management is influenced by it. Infrastructure and economics influence practice pattern and medical management.”

Patients in urban areas with better income tend to be more educated about the disease and more likely to have exams, while those in more rural and poorer areas tend to not be as aware of glaucoma and its implications. Many poorer patients in the country do not have insurance-based health care and cannot afford exams, and because they do not understand the importance of early intervention, they do not seek treatment, Dr. Vijaya said.

Her practice treats an urban population, whose awareness of the disease is moderate. Once patients in urban areas have been diagnosed with the disease, however, Dr. Vijaya called most patients’ response a “quantum change” in their understanding of the need for regular follow-up and therapy.

Treatment options

In India, when patients are first diagnosed with glaucoma, medical therapy is the predominant first-line treatment used, Dr. Vijaya said.

Lasers are also used but only in specialized eye care centers where access to the appropriate infrastructure is available, she said.

Globally, Dr. Vijaya said, with the advent of stronger drugs, such as prostaglandin analogues, alpha agonists and carbonic anhydrase inhibitors, the trend seems to be a decrease in the need for surgical therapy. In some areas of India, though, economic and compliance issues make surgery the predominant option.

The issue with the surgical option in India is the lack of trained medical personnel to perform glaucoma surgeries, she said. With many advanced cases in the country, this indicates a problem because patients who could soon become blind do not always receive adequate therapy.

For patients with milder forms of the disease who have been prescribed medicine, medical therapy can prove difficult to obtain in rural areas that do not have access to different kinds of glaucoma medications. Dr. Vijaya said pharmacies in many smaller towns and villages are not able to stock newer glaucoma drugs.

“Compliance to therapy is suboptimal across all sections of society. However, awareness of disease is higher among the urban population, and once diagnosed, there is a tendency to stay compliant and seek follow-up,” she said. “The rural population has both lack of infrastructure and funds to sustain medical therapy and surgical management, as an option, scores over medical therapy.”

India does have an advantage in treating glaucoma patients, Dr. Vijaya said. For patients who have access to glaucoma medications, those drugs are often available at a lower cost than in other developing nations.

“Though this does not address the entire problem, a significant proportion of the population can have access to most medications that are prescribed the world-over,” she said.

Glaucoma India Education Program

The key to combating the high rate of untreated cases, Dr. Vijaya said, is in educating patients and physicians about the need for thorough screening exams and medical therapy.

“Education has to be a constant process in awareness about any disease. The main constraints anywhere in the world are to have a sustained impact on the population about any public health problem,” she said. “A sustained campaign on disease education will be the only way to increase awareness and have a meaningful impact, and this depends on adequate funding.”

To meet that need, the Glaucoma Society of India is running a program for physicians’ education. The society, which was started 17 years ago and has 410 members, aims to educate all ophthalmologists in India about the need for thorough exams for diagnosis and treatment options for effective therapy.

“The society and its members should be able to spread the advancement of glaucoma and the new techniques to manage glaucoma,” Dr. Vijaya said.

The society has been organizing and implementing nationwide glaucoma courses since 2005. These are designed and taught by the society to bring updated knowledge of glaucoma diagnosis and management to physicians all over the country, she said. The program is funded by local organizing committees, typically from the local pharmaceutical companies as a source of funding. A small registration fee is also collected, and the society funds faculty travel when necessary.

The courses have been designed to teach the basic principles of exams and therapy, Dr. Vijaya said. The society’s courses are offered to all ophthalmologists in India, in private or government teaching institutions, in residencies and postgraduate work.

The society divided the country into five zones to best organize the courses, she said. The zones are in the north, south, east, west and central parts of the country. They are manned by a representative of the Glaucoma Society of India and a member of the executive committee. The faculty for the courses is composed of glaucoma specialists from the same or adjacent zone. The zones, and areas where courses are held, have been designed to bring the most education to more rural areas.

“The Glaucoma India Education Program has been a popular course that had its goals set on reaching smaller towns and smaller practice groups in various parts of India,” Dr. Vijaya said. “Clearly, major cities were avoided, since the effort was to spread greater awareness in regions with more basic infrastructure and to enhance the knowledge base of general ophthalmologists.”

For more information:

L. Vijaya, MBBS, MS, director of Glaucoma Services at Sankara Nethralaya, 18 College Road, Chennai 600 006; +044-28271616; fax: +044-28254180; e-mail: drlv@snmail.org.

Reference:

Vijaya L, George R, et al. Prevalence of primary angle-closure disease in an urban south Indian population and comparison with a rural population: The Chennai Glaucoma Study. Ophthalmology. 2007 Sept. 13; [Epub ahead of print].