Primary open angle glaucoma in northern Nigeria: stage at presentation and acceptance of treatment

Global estimates on the number of people blind or visually impaired by glaucoma: A meta-analysis from 2000 to 2020

OBJECTIVES

To estimate global and regional trends from 2000 to 2020 of the number of persons visually impaired by glaucoma and their proportion of the total number of vision-impaired individuals.

METHODS

A systematic review and meta-analysis of published population studies and grey literature from 2000 to 2020 was carried out to estimate global and regional trends in number of people with vision loss due to glaucoma. Moderate or severe vision loss (MSVI) was defined as visual acuity of 6/60 or better but <6/18 (moderate) and visual acuity of 3/60 or better but <6/60 (severe vision loss). Blindness was defined as presenting visual acuity <3/60.

RESULTS

Globally, in 2020, 3.61 million people were blind and nearly 4.14 million were visually impaired by glaucoma. Glaucoma accounted for 8.39% (95% uncertainty intervals [UIs]: 6.54, 10.29) of all blindness and 1.41% (95% UI: 1.10, 1.75) of all MSVI. Regionally, the highest proportion of blindness relating to glaucoma was found in high-income countries (26.12% [95% UI: 20.72, 32.09]), while the region with the highest age-standardized prevalence of glaucoma-related blindness and MSVI was Sub-Saharan Africa. Between 2000 and 2020, global age-standardized prevalence of glaucoma-related blindness among adults ≥50 years decreased by 26.06% among males (95% UI: 25.87, 26.24), and by 21.75% among females (95% UI: 21.54, 21.96), while MSVI due to glaucoma increased by 3.7% among males (95% UI: 3.42, 3.98), and by 7.3% in females (95% UI: 7.01, 7.59).

CONCLUSIONS

Within the last two decades, glaucoma has remained a major cause of blindness globally and regionally.

[Global ophthalmology : Update]

The aim of global ophthalmology is to maximize vision, ocular health and functional ability, thereby contributing to overall health and well-being, social inclusion and quality of life of every individual worldwide. Currently, an estimated 1.1 billion people live with visual impairment, 90% of which can be prevented or cured through largely cost-effective interventions. At the same time, 90% of people affected live in regions with insufficient eye health coverage. This challenge drove the World Health Organization (WHO) and a group of nongovernmental organizations to launch "VISION 2020: the Right to Sight", a global campaign which recently concluded after 20 years. The achievements, challenges and lessons learned were identified and incorporated into the current campaign "2030 IN SIGHT".

Factors limiting glaucoma care among glaucoma patients in Nigeria: A scoping review

Glaucoma currently accounts for 11% of irreversible visual loss worldwide. Due to many factors, patients do not access the glaucoma care pathway and present late with poor vision, while many are undiagnosed or untreated. These factors may be personal-level dispositions or Institutional-level dispositions, limiting the awareness, diagnosis, and treatment of glaucoma or adherence to medications or follow-up clinic visits. This scoping review followed the JBI methodology for scoping reviews and was pre-registered on the open science platform (https://osf.io/wqx57/?view_only=727eb6c803764509a2809e5d0794e214). The PUBMED, EMBASE, WEB OF SCIENCE, AJOL, and GOOGLE SCHOLAR databases were systematically searched for studies published in English between 1990 and June 2023. Data were extracted and analysed along a conceptualised framework of factors limiting access to glaucoma care in Nigeria. Of the 336 records retrieved, 13 studies were included in this scoping review. These included one (1) mixed method (quantitative/qualitative) study, three qualitative studies, and nine quantitative studies spanning 2008-2022 covering eight states and 2,643 sampled respondents. Nine studies reported personal-level dispositions limiting glaucoma care, including low levels of education, unemployment, gender, living distance from the hospital, cost of care, and faith/religion. Four reported institutional-level dispositions, including the lack of proper equipment and expertise to diagnose or manage glaucoma. The factors limiting Glaucoma care in Nigeria are varied and may act alone or combined with other elements to determine the awareness or knowledge of glaucoma, uptake of glaucoma surgery, medication adherence, or clinic follow-up. While most of these factors limiting glaucoma care in Nigeria may be amenable to policy, a bottom-up approach is needed to improve the community's awareness and uptake of glaucoma services. A shift from the over-dependence and reliance on tertiary hospitals, which are often far away from the people who need them, is required to bridge the information and service gap currently being witnessed.

Impact of a short online course on the accuracy of non-ophthalmic diabetic retinopathy graders in recognising glaucomatous optic nerves in Vietnam

PURPOSE

To test an online training course for non-ophthalmic diabetic retinopathy (DR) graders for recognition of glaucomatous optic nerves in Vietnam.

METHODS

This was an uncontrolled, experimental, before-and-after study in which 43 non-ophthalmic DR graders underwent baseline testing on a standard image set, completed a self-paced, online training course and were retested using the same photographs presented randomly. Twenty-nine local ophthalmologists completed the same test without the training course. DR graders then underwent additional one-to-one training by a glaucoma specialist and were retested. Test performance (% correct, compared with consensus grades from four fellowship-trained glaucoma experts), sensitivity, specificity, positive and negative predictive value, and area under the receiver operating (AUC) curve, were computed.

RESULTS

Mean age of DR graders (32.6±5.5 years) did not differ from ophthalmologists (32.3±7.3 years, p=0.13). Online training required a mean of 297.9 (SD 144.6) minutes. Graders' mean baseline score (33.3%±14.3%) improved significantly after training (55.8%±12.6%, p<0.001), and post-training score did not differ from ophthalmologists (58.7±15.4%, p=0.384). Although grader sensitivity reduced before [85.5% (95% CI 83.5% to 87.3%)] versus after [80.4% (78.3% to 82.4%)] training, specificity improved significantly [47.8 (44.9 to 50.7) vs 79.8 (77.3 to 82.0), p<0.001]. Grader AUC also improved after training [66.6 (64.9 to 68.3)] to [80.1 (78.5 to 81.6), p<0.001]. Additional one-to-one grader training by a glaucoma specialist did not further improve grader scores.

CONCLUSION

Non-ophthalmic DR graders can be trained to recognise glaucoma using a short online course in this setting, with no additional benefit from more expensive one-to-one training. After 5-hour online training in recognising glaucomatous optic nerve head, scores of non-ophthalmic DR graders doubled, and did not differ from local ophthalmologists. Intensive one-to-one training did not further improve performance.

Glaucoma Treatment Patterns in Sub-Saharan Africa

PRCIS

Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma. Laser therapy was underutilized where they were available. Physicians were more likely to recommend surgery in severe glaucoma, laser therapy in mild glaucoma, while recommendation of medical therapy did not depend on glaucoma severity.

PURPOSE

To characterize treatment patterns for newly diagnosed glaucoma in sub-Saharan Africa (SSA).

METHODS

This was a multicenter cross-sectional study of adults newly diagnosed with glaucoma at 27 eye care centers in 10 African countries. In addition to demographic and clinical data, physician treatment recommendations (medication, laser, surgery, or no treatment) were recorded. Statistical analyses were performed using STATA version 14.0.

RESULTS

Data from 1201 patients were analyzed. Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma (69.4%), with laser (13.2%), surgery (14.9%), and no treatment (2.5%) recommended to the remaining patients. All sites had medical therapy available and most (25/27, 92.6%) could provide surgical treatment; only 16/27 (59.3%) sites offered laser, and at these sites, 30.8% of eyes were recommended to undergo primary laser procedures. As glaucoma severity increased, the laser was recommended less, surgery more, and medications unchanged. Patient acceptance of medical therapy was 99.1%, laser 88.3%, and surgery 69.3%.

CONCLUSIONS

Medical therapy for first-line glaucoma management is preferred by most physicians in SSA (69%). Laser therapy may be underutilized at centers where it is available. These findings underscore the need for comparative studies of glaucoma treatments in SSA to inform the development of evidence-based treatment guidelines and of programs to reduce glaucoma blindness in SSA. Strategic approaches to glaucoma therapy in SSA must address the question of whether medical therapy is the most optimal first-line approach in this setting.

The Impact of Simulation-Based Trabeculectomy Training on Resident Core Surgical Skill Competency

PRCIS

Simulation-based surgical education shows a positive, immediate, and sustained impact on core surgical skill competency in trabeculectomy among resident ophthalmologists in training.

PURPOSE

To measure the impact of trabeculectomy, surgical simulation training on core surgical skill competency in resident ophthalmologists.

MATERIALS AND METHODS

This is a post hoc analysis of the GLAucoma Simulated Surgery trial, which is a multicenter, multinational randomized controlled trial. Resident ophthalmologists from 6 training centers in sub-Saharan Africa (in Kenya, Uganda, Tanzania, Zimbabwe, and South Africa) were recruited according to the inclusion criteria of having performed zero surgical trabeculectomies and assisted in <5. Participants were randomly assigned to intervention and control arms using allocation concealment. The intervention was a 1-week intensive trabeculectomy surgical simulation course. Outcome measures were mean surgical competency scores in 8 key trabeculectomy surgical skills (scleral incision, scleral flap, releasable suturing, conjunctival suturing, sclerostomy, tissue handling, fluidity, and speed), using a validated scoring tool.

RESULTS

Forty-nine residents were included in the intention-to-treat analysis. Baseline characteristics were balanced between arms. Median baseline surgical competency scores were 2.88/16 [interquartile range (IQR): 1.75-4.17] and 3.25/16 (IQR: 1.83-4.75) in the intervention and control arms, respectively. At primary intervention, median scores increased to 11.67/16 (IQR: 9.58-12.63) and this effect was maintained at 3 months and 1 year ( P =0.0001). Maximum competency scores at primary intervention were achieved in the core trabeculectomy skills of releasable suturing (n=17, 74%), scleral flap formation (n=16, 70%), and scleral incision (n=15, 65%) compared with scores at baseline.

CONCLUSIONS

This study demonstrates the positive impact of intensive simulation-based surgical education on core trabeculectomy skill development. The rapid and sustained effect of resident skill acquisition pose strong arguments for its formal integration into ophthalmic surgical education.

Effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria

PURPOSE

To determine the effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria.

METHODOLOGY

This was a prospective study in which two cohort of participants were recruited in Nigeria: 1 from 24 outreach screenings and another from consecutive patients presenting spontaneously to a tertiary eye clinic in Nigeria. Sociodemographic and clinical data were obtained from participants and compared.

RESULTS

Our sample consisted of 120 patients with glaucoma or suspected glaucoma (6.38% of 1881 screenees) recruited from the 24 outreach screenings, and another 123 patients with glaucoma who presented spontaneously at the eye clinic. Participants from the screenings were significantly older (p=0.012), less educated (p<0.001), had lower incomes (p<0.001), lower glaucoma knowledge scores and were less aware of their glaucoma (both p<0.001) and were more likely to be dependent on relations and children (p=0.002) compared with clinic participants. Of the 120 patients identified at the screenings and referred to the clinic for definitive care, 39 (32.5%) presented at the clinic within 3 months. Reasons for poor uptake of referral services were lack of a felt need and lack of money for transportation. Considering only patients who accepted referral, they were still less educated (p<0.001), poorer (p=0.001) and less knowledgeable about glaucoma (p=0.003) than spontaneous clinic presenters.

CONCLUSION

Outreach screening improved equity of access but its effects were somewhat reduced by poor uptake of referral care. Interventions such as free transportation and educational efforts may improve the uptake of referral services and maximise equity gains.

Visual Impairment and Blindness among Patients at Nigeria Army Eye Centre, Bonny Cantonment Lagos, Nigeria

Background: Visual impairment (VI) is a public health problem that can affect an individual’s social wellbeing. The study aims to determine the distribution and causes of vision impairment (VI) and blindness among patients at Nigerian Army Eye Centre Lagos, Nigeria. Method: An institutional cross-sectional study was conducted, and a systematic random sampling technique was used to enrol study participants from their medical records. Information about their demography, presenting visual acuity (VA), best corrected visual acuity and cause of VI and blindness, were retrieved. Result: A total of five hundred (500) medical records of patients aged from 4 to 96 years, with a mean age of 54.07 ± 21.43 years, were considered for the study. Among the participants, more than half were males (51.2%) and ≥60 years (53.0%). A large (47.2%) proportion of the patients had moderate VI at the time of presentation, followed by blindness (22.0%). The major cause of blindness was cataract, while glaucoma and refractive error were the major causes of VI. Blindness and VI were significantly associated with the type of VI before and after the provision of intervention (p < 0.05) across different age groups (children, youths, adults, elderly) with an adjusted p < 0.003 after an intervention. Conclusions: Cataracts, glaucoma and uncorrected refractive error (URE) were the major causes of VI and blindness in Lagos State. VI was more prevalent in males than females; however, there was no significant difference between the two proportions. The prevalence of VI among age groups was more significant for those 60 years and above. Early screening for the detection and management of cataract, URE and glaucoma is highly advised to reduce the burden of VI.

A Survey on Patients' Opinions of Alternative Drug Delivery Systems for the Treatment of Glaucoma in South-South Nigeria

PURPOSE

Despite the human ocular surface being easily accessible, ocular drug delivery can be challenging. When applied improperly, topical medications, the most popular first-line treatment used to treat glaucoma, can have a very brief contact time with the ocular surface and may not have the desired therapeutic impact. Drug delivery devices are gadgets that can address some of these problems. This study aims to determine patients' opinions on ocular drug delivery devices used in the treatment of primary open-angle glaucoma (POAG).

METHODS

A pretested interviewer-administered questionnaire was used in a cross-sectional study of 115 POAG patients recruited from outpatient clinics in two Nigerian tertiary health institutions. Participants were asked about their understanding and acceptance of five Ocular drug delivery systems (ODD), namely drug-emitting contact lenses (CL), punctual plugs, subconjunctival injections, intracameral implants, and trabecular meshwork micro-stents, for the treatment of POAG.

RESULTS

Sixty (52.2%) participants, whose average age was 50 ± 9.8 years, were men. Self-pay was used for eye health treatments by 65% of participants. Of the participants, 68.7% admitted to using eye drops on their own. 57% of people were said to take their glaucoma medications consistently. CL and subconjunctival implants were seen to be most acceptable according to 39% and 30% of participants, respectively. Major factors determining the acceptability of ODD for POAG treatment were observed to be cost and effectiveness.

CONCLUSION

Patients in our cohort who are being treated for POAG have a fairly positive attitude towards ODD. The prospective use of these devices for POAG treatment in Nigeria will depend on their efficacy and cost, as well as how ophthalmologists will weigh ODD options.

Clinical Characteristics and Stage at Presentation of Glaucoma Patients in Sub-Saharan Africa

PURPOSE

To explore regional variations in the presentation of newly diagnosed glaucoma in Sub Saharan Africa (SSA).

METHODOLOGY

This was a multi-centre, cross-sectional study in which newly diagnosed, consecutive, glaucoma patients aged ≥18 years were recruited from 27 eye clinics in 10 countries throughout SSA. Demographic and ophthalmic examination data were collected. Glaucoma severity was based on optic nerve head and visual field assessment. Statistical analyses were performed using STATA version 14.0.

RESULTS

Among 1214 enrolled patients with newly diagnosed glaucoma from Western, Eastern and Southern Africa, the overall mean (standard deviation) age was 59.9 (17.1) years. More than half of all patients (716/1178; 60.8%) presented with severe glaucoma in the worse eye, and one third (36.9%) had severe glaucoma in both eyes. Primary open-angle glaucoma was the commonest form of glaucoma in all regions (77.4%). A family history of blindness (260/1204, 21.6%) was common. Patients from Western Africa had lower mean presenting IOP (26.4 [11.1] mmHg, P <0.001), but had worse glaucoma in the better eye based on mean cup-disc ratio (0.8; P <0.001) and mean visual field mean deviation [10.4 (8.4)] dB, P =0.016) compared to other regions. Exfoliation glaucoma was more common in Eastern Africa (30/170=17.7%, P <0.001) compared to other regions.

CONCLUSION

The initial presentation of glaucoma varies meaningfully across SSA. A comprehensive strategy with regional customization based on local differences is needed to reduce glaucoma blindness in SSA.

Factors associated with adherence to treatment in patients with open angle glaucoma in Sierra Leone, West Africa: patient demographics and questionnaire

BACKGROUND

Glaucoma is a significant cause of blindness worldwide. It is more common, presents earlier and is more aggressive in those of African descent. Non-adherence and poor knowledge of glaucoma is a significant barrier to treatment and has been associated with low health literacy. We aim to establish the factors contributing to late presentation, treatment non-adherence and disease progression in glaucoma patients in Sierra Leone. This will help better understand the challenges eye services face, highlight fields requiring development in patient-clinician interaction and identify areas or specific vulnerable patient groups in which resources should be focused.

METHODS

Prospective, consecutive recruitment of 120 patients with POAG attending the Lowell and Ruth Gess Eye Hospital and the Connaught Government Teaching Hospital, Freetown, Sierra Leone between February and April 2020. Data were collected from 3 sources: (1) review of clinical notes since first attendance, (2) semi-structured interviews and (3) assessment of study participant's drop instillation technique using a structured checklist. Descriptive statistics was performed for demographic data and other relevant data points. Logistic regression was used for analysis of target variables.

RESULTS

The average age was 62 years with more males (52.6%). Agricultural workers and informal street traders represented 13.2% of participants' occupation. 25.8% of participants had no formal school, and 47.4% had either a degree or a diploma. This is out of proportion with the general population and may represent a hidden demographic of glaucoma patients. Drop instillation technique was successful in 52% of study participants. Notable responses to the questionnaire were 30% of patients did not know the name of their eye condition and 22% had no knowledge of glaucoma.

CONCLUSION

Investment in a wide-ranging and robust screening programme and public health campaigns targeting these vulnerable groups and high-risk individuals, for example with a positive family history, alongside improved patient education and staff training is required to improve glaucoma care. Support from government, international organisations and the private sector is required to reduce the economic burden of blindness in Sierra Leone.

Determinants for late presentation of glaucoma among adult glaucomatous patients in University of Gondar Comprehensive Specialized Hospital. Case-control study

Introduction

Glaucoma is a disease which causes optic nerve damage and remains a major public health concern worldwide. Late presentation is a major risk factor for glaucoma induced blindness. The aim of this study was to assess determinants for late presentation of glaucoma among adult glaucomatous patients.

Methods

A hospital-based case-control study was conducted among 452 adult glaucomatous patients. Late presenters were glaucoma patients diagnosed with cup to disc ratio (CDR) > 0.8 and mean deviation of greater than -14 decibel in either of the eyes at their first presentation. Study participants were selected among glaucomatous follow-up patients by using systematic random sampling. Data were entered into EPI Info version 7 and exported to SPSS version 22 for analysis. Bivariable and multivariable logistic regression analysis was done to identify determinants. Variables with P-value < 0.05 were considered as statistically significant.

Result

The mean age of participants were 55.1 ± 13.2 years. Being > 60 years of age, 4.51 times (AOR: 4.51; 95% CI: 1.74, 11.67), resided > 53 km away from the hospital 6.02 times (AOR: 6.02; 2.76, 13.14), Presenting IOP > 30 mmHg, 4.49 times (AOR: 4.49, 95% CI: 2.10, 9.12), poor knowledge of glaucoma, 4.46 times (AOR: 4.46, CI: 2.62, 7.58) and absence of regular eye checkup, 2.35 times (AOR: 2.35, 95% CI: 1.09, 5.47) higher odds of being late presenter.

Conclusion

Increasing age, high IOP, poor knowledge of glaucoma, residing far away from the hospital and absence of regular eye checkups were significantly associated with late presentation.

COVID-19 and the Rationale for Primary Selective Laser Trabeculoplasty and Diode Laser Transscleral Cyclophotocoagulation in Africa

The recent COVID-19 pandemic has affected ophthalmologists' practices worldwide. Consequent global drug shortages and the limitations of medical glaucoma treatments in sub-Saharan Africa have highlighted the need for innovation in global ophthalmology to provide accessible, affordable, and effective glaucoma care. The role of lasers rather than medications for glaucoma patients in developing nations is emerging. Since lasers are easier to master than glaucoma surgery, it is pertinent to discuss the primary use of lasers in treating glaucoma in such nations. In particular, selective laser trabeculoplasty and diode laser transscleral cyclophotocoagulation seem to present a promising future for the treatment of glaucoma in Africa. In this report, we provide an evidence-based discussion exploring the emerging role of lasers in Africa.

Assessment of parasympathetic cardiovascular activity in primary open-angle glaucoma

PURPOSE

To describe the pattern of quantitative parasympathetic cardiovascular autonomic function among patients with normal-tension glaucoma (NTG) and high-tension primary open-angle glaucoma (HTG) patients.

METHODOLOGY

This was cross-sectional study of ninety-two subjects enrolled into three groups: HTG (31 patients), NTG (31 patients) and Control (30 patients). All the participants had anthropometric assessment, ophthalmic examination, baseline cardiovascular examination and the three parasympathetic components of Ewing's battery of autonomic cardiovascular function tests namely heart rate (HR) response to deep breathing, HR response to Valsalva manoeuvre and HR response to standing.

RESULT

The baseline PR intervals were significantly prolonged in HTG (0.18 ± 0.03 s) and NTG (0.18 ± 0.04 s) groups compared with control (0.15 ± 0.03 s) (p = 0.008). The HTG group had a significantly longer mean RR interval (1.09 ± 0.17 s) than the NTG group (1.03 ± 0.20 s) and control (0.97 ± 0.17 s) during the expiratory phase of the HR response to deep breathing test (p = 0.037). The HTG group also had significantly longer mean RR intervals around the 15th beat (p = 0.033) and 30th beats (p = 0.202) post-standing during the HR response to standing test. The HR response to Valsalva manoeuvre test showed a significantly higher mean Valsalva ratio in the NTG group (1.65 ± 0.48) compared to the HTG group (1.45 ± 0.31) and control (1.43 ± 0.25) (p = 0.034).

CONCLUSION

This study demonstrated that normal-tension and high-tension primary open-angle glaucoma have higher parasympathetic cardiovascular activity than normal individuals.

Selective laser trabeculoplasty versus 0·5% timolol eye drops for the treatment of glaucoma in Tanzania: a randomised controlled trial

BACKGROUND

Glaucoma is a major cause of sight loss worldwide, with the highest regional prevalence and incidence reported in Africa. The most common low-cost treatment used to control glaucoma is long-term timolol eye drops. However, low adherence is a major challenge. We aimed to investigate whether selective laser trabeculoplasty (SLT) was superior to timolol eye drops for controlling intraocular pressure (IOP) in patients with open-angle glaucoma.

METHODS

We did a two-arm, parallel-group, single-masked randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Eligible participants (aged ≥18 years) had open-angle glaucoma and an IOP above 21 mm Hg, and did not have asthma or a history of glaucoma surgery or laser. Participants were randomly assigned (1:1) to receive 0·5% timolol eye drops to administer twice daily or to receive SLT. The primary outcome was the proportion of eyes from both groups with treatment success, defined as an IOP below or equal to target pressure according to glaucoma severity, at 12 months following randomisation. Re-explanation of eye drop application or a repeat SLT was permitted once. The primary analysis was by modified intention-to-treat, excluding participants lost to follow-up, using logistic regression; generalised estimating equations were used to adjust for the correlation between eyes. This trial was registered with the Pan African Clinical Trials Registry, number PACTR201508001235339.

FINDINGS

840 patients were screened for eligibility, of whom 201 (24%) participants (382 eligible eyes) were enrolled between Aug 31, 2015, and May 12, 2017. 100 (50%) participants (191 eyes) were randomly assigned to the timolol group and 101 (50%; 191 eyes) to the SLT group. After 1 year, 339 (89%) of 382 eyes were analysed. Treatment was successful in 55 (31%) of 176 eyes in the timolol group (16 [29%] of 55 eyes required repeat administration counselling) and in 99 (61%) of 163 eyes in the SLT group (33 [33%] of 99 eyes required repeat SLT; odds ratio 3·37 [95% CI 1·96-5·80]; p<0·0001). Adverse events (mostly unrelated to ocular events) occurred in ten (10%) participants in the timolol group and in eight (8%) participants in the SLT group (p=0·61).

INTERPRETATION

SLT was superior to timolol eye drops for managing patients with open-angle high-pressure glaucoma for 1 year in Tanzania. SLT has the potential to transform the management of glaucoma in sub-Saharan Africa, even where the prevalence of advanced glaucoma is high.

FUNDING

Christian Blind Mission, Seeing is Believing Innovation Fund, and the Wellcome Trust.

TRANSLATIONS

For the Kiswahili, French and Portuguese translations of the abstract see Supplementary Materials section.

Clinical and sociodemographic characteristics of glaucoma patients at a tertiary referral facility in Zimbabwe

Purpose

To evaluate the clinical and socio-demographic profile of patients living with glaucoma and receiving care in a tertiary eye center in Zimbabwe.

Method

A hospital-based retrospective study of clinical records of glaucoma patients from January 2014 to December 2018. The study involved collating demographic information of patients, visual acuities, (VA) intraocular pressure, (IOP), cup-to-disc ratios, (CDRs), average retinal nerve fibers thickness, (RNFL), cup volume, cup-to-disc area, vertical cup-to-disc ratio, (VCDR), rim area, disc area, glaucoma hemifield test, visual field indices and the management of glaucoma.

Results

Nine thousand one hundred and eighty-five (9,185) folders were retrieved. Out of these, 432 (4.7%) qualified for the study and were analyzed. There were 267 (61.8%) males and 165 (38.2%) females. The mean age (± Standard deviation, SD) of the patients was 62.66 ± 15.94 years, (range 10 - 110 years). The means visual acuity (VA): OD =1.30 ± 1.06 Logarithm of the Minimum Angle of Resolution, (logMAR), OS = 1.33 ± 1.06 logMAR; IOP: OD = 29.51 ± 12.89 mmHg, OS: 29.17 ± 12.59 mmHg; CDRs: OD = 0.91 ± 0.14 D, OS = 0.92 ± 0.14 D; and the average RNFL thickness was 72.76 ± 18.26 µm and 71.24 ± 23.17 µm in the right and left eye respectively. The mainstay of treatment was medication only.

Conclusion

There were more males than females receiving glaucoma care at the tertiary level. Glaucoma cases included juveniles but the mean age was mostly the elderly. It was characterized by high IOPs, large CDRs, and thin RNFL suggestive of late presentation.

A Review to Populate A Proposed Cost-Effectiveness Analysis of Glaucoma Screening in Sub-Saharan Africa

To populate a proposed cost-effectiveness analysis of glaucoma screening in Sub-Saharan Africa (SSA).A complete search was conducted on PubMed, Medline and African Journals Online (AJOL) to obtain relevant published articles, which were included in this review. All relevant articles on prevalence of glaucoma in SSA and among other African-derived populations, severity of glaucoma, cost of diagnosis and management, clinical effectiveness of glaucoma screening and treatment and the different glaucoma screening strategies in SSA were reviewed.Population screening interventions for glaucoma may be considered as follows: standalone screening for glaucoma, screening for glaucoma during cataract outreach, and screening incorporated with diabetic retinopathy image review using tele-ophthalmology. Our review suggests that cost of glaucoma treatment is relatively low with cost of medical treatment ranging from USD 273 to USD 480 per year/patient and surgical treatment cost of USD 283 per patient as with other developing countries. Compliance with medication is moderate to good in about 50% of glaucoma patients. Prevalence of glaucoma is much higher in SSA and almost 50% of glaucoma patients are blind in at least one eye at presentation in clinics (without outreach screening). Our review suggests a moderate sensitivity and specificity in identifying glaucoma with basic equipment (direct ophthalmoscope, contact tonometer and frequency doubling technology) during outreach screening although about a third or fewer take up glaucoma services in clinics.Our review provides the necessary information to conduct a cost-effective analysis of glaucoma screening in SSA using the decision Markov model.

Visual field-based grading of disease severity in newly diagnosed primary open angle glaucoma patients presenting to a tertiary eye care centre in India

PURPOSE

To evaluate the severity of primary open angle glaucoma (POAG) at presentation using visual field analysis and its relationship to demographic and ocular factors in patients presenting to a tertiary eye care centre.

DESIGN

Cross-sectional study.

METHODS

Newly diagnosed POAG patients were classified as early, moderate, or severe stage in the worse eye based on the Humphrey visual field testing using Hodapp-Parrish-Andersons criteria. The groups were compared for differences in demographics and ocular characteristics. Statistical analysis was done using STATA 14.1 (Texas, USA).

RESULTS

The average age of 71 eligible patients was 60.04 ± 9.53 years, and the cohort had 29.5% females. Among the subjects, 19 (26.7%) had early, 24 (33.3%) had moderate and 28 (38.89%) had severe POAG at presentation. There was no statistically significant difference among different stages of glaucoma with respect to age and sex groups. No statistical association was found with education, occupation status, presenting complaints, family history of glaucoma, or systemic diseases between the different stages of severity. 5.6% with severe disease presented with a relative afferent pupillary defect (RAPD). The mean intraocular pressure (IOP) in the severe stage was 22.54 ± 5.27 mmHg, which was not statistically higher than the other groups (P = 0.726).

CONCLUSIONS

Newly diagnosed POAG patients predominantly present at moderate or severe stage of disease, reflecting either the asymptomatic nature of the disease or a lack of access to vision care services. Existing screening programmes need to be improved, with special attention to women and individuals less than 50 years of age.

Smartphone-based Ophthalmic Imaging Compared With Spectral-domain Optical Coherence Tomography Assessment of Vertical Cup-to-disc Ratio Among Adults in Southwestern Uganda

PRECIS

Using optical coherence tomography (OCT) measurements as a reference standard for vertical cup-to-disc ratio (vCDR), a smartphone-based ophthalmic camera has a sensitivity of 67.7% and specificity of 96.7% to detect a vCDR>0.5.

PURPOSE

The purpose of this study was to assess the performance of a smartphone-based ophthalmic camera system using an Apple iPhone 6S and an adapter, Paxos Scope, to obtain adequate dilated fundus photos to measure clinically useful vCDR cutoffs.

PATIENTS AND METHODS

Adult patients from a government tertiary level eye hospital in Southwestern Uganda were prospectively recruited from January to April 2019. All patients experienced a comprehensive eye examination, dilated posterior segment indirect ophthalmoscope imaging with the Paxos Scope, and spectral-domain OCT imaging with a Cirrus HD-OCT to measure vCDR. Patients' eyes excluded had media opacities or existing disease precluding a view of the fundus. Fundus images underwent a single masked review to assign vCDR at increments of 0.1. Descriptive statistics, parametric and χ2 tests for significance, repeated measures correlation, κ, receiver operating characteristics curve, and Bland-Altman were used to assess the data.

RESULTS

Among 467 (consecutive) individuals, fundus photographs acquired with the Paxos Scope demonstrated a 67.7% [95% confidence interval (CI), 63.0-72.0] sensitivity and 96.7% (95% CI, 94.2-98.3) specificity to detect a vCDR>0.5, using OCT as the reference standard. A total of 138 eyes were excluded due to poor imaging acquisition, such as dense cataract, rendering 796 eyes for analysis. The vCDR from graded Paxos Scope images and OCT correlated well with repeated measures correlation of 0.82 (95% CI, 0.77-0.86, P<0.001) and agreement, dichotomized as >0.5 or ≤0.5, was 80.9% (κ=0.63±0.034, P<0.001). Among glaucoma and glaucoma suspects (85 eyes), the sensitivity and specificity dichotomized using vCDR>0.5 were 97.5% (95% CI, 91.3-99.7) and 80.0% (95% CI, 28.4-99.5), respectively. The area under the receiver operating characteristics curve was 0.92 (95% CI, 0.89-0.94) for all eyes and 0.98 (95% CI, 0.78-1.0) for glaucoma and glaucoma suspects.

CONCLUSIONS

The Paxos Scope produced images that can be reliably used to estimate vCDR, which is closely aligned with the automated algorithm from the OCT optic disc cube scan. The low-cost, ready-to-integrate adapter, and minimal training requirements make it a viable option for population-based screening in low-resource settings.

What Glaucoma Surgical Rate could Serve as a Target for West Africa? A Systematic Review

Aim and objective

This study aimed to use the available evidence to model a glaucoma surgical rate (GSR), which could serve as a target for West Africa.

Materials and methods

A comprehensive literature search was performed in Medline, Embase, Global Health, and CINAHL, and studies published between January 1, 2000, and June 19, 2020, were retrieved. Study selection, quality appraisal, and data extraction were performed and the results of individual studies aggregated and presented using a narrative synthesis. Using these data, we aimed to construct a target GSR per million population per year that is sufficient to offer trabeculectomy to most patients with glaucoma who are diagnosed, and for whom other treatment options are either ineffective or inappropriate. The findings were then used to develop a trabeculectomy target for West Africa.

Results

Initial searches returned 633 references, of which 33 unique studies were eligible for inclusion. The glaucoma prevalence population-based surveys identified, reported a wide range of prevalence of primary open-angle glaucoma (POAG) ranging from 1.0 to 8.4%. The studies on glaucoma medications reported intraocular pressure (IOP)-lowering effects ranging from 12.8% (beta-blockers) to 63.7% (Timolol–Latanoprost combinations). The adherence rate to antiglaucoma medications spanned from 10.3 to 82.3%. Regarding selective laser trabeculoplasty (SLT), only two studies were found. All the studies on trabeculectomy showed a significant reduction in IOPs at different follow-up periods with many reporting the absence of vision-threatening complications. From these available data, a GSR of 50 trabeculectomies was suggested for countries in West Africa.

Conclusion

This trabeculectomy target metric is expected to minimize POAG blindness in the West African subregion.

Clinical significance

The proposed GSR will enable eye care workers involved in glaucoma care in West Africa to assess their efforts compared with the proposed target. The gap will signal the potential for improvement.

How to cite this article

Eni EN, Nolan W, Eval B, et al. What Glaucoma Surgical Rate could Serve as a Target for West Africa? A Systematic Review. J Curr Glaucoma Pract 2021;15(1):19–27.

Assessment of Reasons for Presentation in New Primary Glaucoma Patients and Identification of Risk Factors for Late Presentation

PURPOSE

To evaluate the reasons for seeking care among South Indian primary glaucoma patients and to determine the relationship of various patient characteristics to glaucoma severity at presentation.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred sixty-one new primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) patients seeking treatment at a tertiary eye hospital.

METHODS

After confirmation of diagnosis, participants' clinical information and their reported reasons for presentation were assessed. Data collected include age, gender, education, occupation, rural or urban residence, distance traveled to the hospital, method of transportation, need for an accompanying person, place of screening before referral or whether they came by themselves for testing. Advanced glaucoma was defined by a cup-to-disc ratio of 0.85 or higher in either eye.

MAIN OUTCOME MEASURES

The primary outcomes were the various reasons for presentation. The secondary outcome was to determine whether a relationship existed between the patient characteristics mentioned above and presentation with advanced glaucoma.

RESULTS

The mean age of the participants was 60.8 years. The primary reason for presentation was defective vision (55.2%) followed by routine ophthalmic evaluation (13%). Sixty-four patients (39.8%) showed advanced glaucoma in at least 1 eye at presentation. Unilateral blindness was noted in 18 patients (11.2%). The mean vertical cup-to-disc ratio was 0.66 (standard deviation [SD], ±0.16) in the better-seeing eye and 0.76 (SD, ±0.12) in the worse-seeing eye. The mean presenting intraocular pressure was 22.9 mmHg in POAG and 25.5 mmHg in PACG patients. Multivariate logistic regression analyses showed that people who are currently unemployed (P < 0.001; odds ratio [OR], 4.19; 95% confidence interval [CI], 1.95-8.99) and rural residence (P = 0.04; OR, 0.46; 95% CI, 0.21-0.99) had greater odds of demonstrating advanced glaucoma at presentation. Presentation with defective vision, older age, and education less than college graduation were associated with greater odds of showing advanced glaucoma in univariate analysis, but not in multivariate analyses.

CONCLUSIONS

In a South Indian population, absence of work and rural residence was associated with advanced glaucoma at presentation. The population in whom these risk factors are common should be targeted for screening and outreach.

Prevalence of primary open-angle glaucoma in a Somalia population

PURPOSE

To determine the prevalence of primary open-angle glaucoma (POAG) in patients over 40 years that presented to our tertiary hospital in Somalia Mogadishu.

METHODS

This prospective cross-sectional study included 1550 patients older than 40 years that presented to the ophthalmology clinic of Somalia Mogadishu - Turkey Training and Research Hospital. The patients were evaluated in terms of age, gender, intraocular pressure, and optical cup/disk (C/D) ratio, and central corneal thickness measurements were taken.

RESULTS

The prevalence of glaucoma in the study population over the age of 40 years was 7%. The prevalence of glaucoma was 40% in the 40-50-year group, 6.8% in the 50-60-year group, 7% in the 60-70-year group, 9.9% in the 70-80-year group, and 12.3% in the 80-90-year group. The prevalence of glaucoma statistically significantly increased with advancing age (p < 0.001). The mean intraocular pressure was measured as 16.7 ± 3.3 mmHg for the overall patient population, 16.3 ± 2.9 mmHg for the female patients, and 17.1 ± 3.1 mmHg for the male patients. The mean intraocular pressure of the patients diagnosed with POAG was 27.3 ± 4.2 mmHg, and their mean corneal thickness was 507.9 µm, which was significantly lower than the value of the patients without POAG (545.8) (p < 0.001). The mean C/D ratio was calculated as 0.56 ± 0.21 for the patients with POAG and general 0.24 ± 0.16 for the overall patient population, indicating a statistically significant difference (p < 0.001).

CONCLUSIONS

A high rate of POAG is seen in patients over 40 years of age in Somalia. The mechanism underlying POAG needs to be investigated in this population.

Association of sex with the global burden of glaucoma: an analysis from the global burden of disease study 2017

PURPOSE

To investigate the association of sex with the global burden of glaucoma by year, age and socio-economic status using disability-adjusted life years (DALYs).

METHOD

The global, regional and national sex-specific DALY numbers, crude DALY rates and age-standardized DALY rates caused by glaucoma, by year and age, were obtained from the Global Burden of Disease Study 2017. Human development index (HDI) in 2017 as a national socio-economic indicator was obtained from the Human Development Report. t-Test and linear regression were performed to explore the association between sex difference in age-standardized DALY rates and HDI.

RESULTS

Globally, changes in glaucoma DALY number and crude rates were similar of both sexes between 1990 and 2017. After controlling for population size and age structure, age-standardized DALY rates decreased consistently from 10.7 in 1990 to 9.4 in 2017 among men and from 8.8 in 1990 to 8.0 in 2017 among women. In 2017, the global average age-standardized DALY rates were 11.6 ± 8.6 (mean ± standard deviation) in women and 14.9 ± 12.1 in men. The sex difference in age-standardized DALY of 195 countries was significant (t = 3.109; p < .01) in 2017. Men had higher rates than women of the same age, and sexual differences increased with age. t-Test revealed that age-standardized DALY rates among men were higher than those among women for low-HDI countries (t = 3.102; p < .01) and high-HDI countries (t = 2.110; p < .05). The difference (male minus female) in age-standardized DALY rates (standardized β = -0.434, p < .001) and the female-to-male age-standardized DALY rate ratios (standardized β = -0.315, p < .001) were inversely correlated with HDI.

CONCLUSION

Although global glaucoma health care is progressing, sexual differences in glaucoma burden showed little improvement in the past few decades. Worldwide, men have higher glaucoma burden than women. Older age and lower socio-economic status are associated with greater sex differences in glaucoma burden. Our findings may enhance public awareness of sexual differences in global glaucoma burden and emphasize the importance of making sex-sensitive health policy to manage global vision loss caused by glaucoma.

Amsler grid test for detection of advanced glaucoma in Ethiopia

Objective

This study was done to determine the validity of amsler grid test black on white (BOW), as well as white on black (WOB) for identifying central visual field (VF) defects in patients with advanced glaucoma.

Design

Prospective study.

Participants

We prospectively included 100 consecutive eyes of 88 adult patients with advanced glaucoma and 100 eyes of 100 normal individuals. We used a lottery method to choose the side of the eye for the control groups.

Methods

All participants had reliable Humphrey 10–2 Swedish Interactive Threshold Algorithm (SITA) standard VF. Both the BOW and WOB amsler grid tests were done for each group. Sensitivity, specificity, and positive and negative predictive values of the amsler grid scotoma area were calculated with the 10–2 VF as the reference standard.

Results

The mean ± standard deviation (SD) of age and the 10–2 VF mean deviation (MD) of advanced glaucoma eyes were 59.8 ± 11.8 (range 34–84) years and -19.94 ± 9.8(range -34.98–-0.52) respectively. Among 108 eyes with normal 10–2 VF test, 103 had a normal BOW amsler grid test and 5 had an abnormal BOW test. Among 92 eyes with an abnormal 10–2 VF test, 74 had an abnormal and 18 had normal BOW amsler grid test. Sensitivity, specificity, and positive and negative predictive values of the BOW amsler grid test were 80.4%, 95.4%, 93% and 85.1% respectively whereas that of the WOB amsler grid test were 71.7%, 95.4%, 93% and 72.8% respectively.

Conclusion

The sensitivity and specificity of both BOW and WOB amsler grid tests were high in detecting VF defects in advanced glaucoma.

Eye care practices, knowledge, and attitude of glaucoma patients at community eye outreach screening in Nigeria

Background:

Community eye outreach (CEO) screening is an important model which has been widely employed to detect eye conditions such as cataract and glaucoma in high-risk groups. There is a dearth of data on the eye care practices of glaucoma patients identified using this model in South West Nigeria.

Objectives:

The aim of this article is to assess the eye care practices, knowledge, and attitudes of glaucoma patients/suspects identified at CEO screenings in Nigeria.

Design of the Study:

This was a mixed method study with quantitative and qualitative approaches.

Setting in Which the Study Took Place:

The study was carried out at 24 outreach screening centres in communities in Oyo and Osun states.

Materials and Methods:

The quantitative component of this study was a cross-sectional survey of patients with suspected glaucoma identified at routine CEO in South West Nigeria. Surveys were administered by trained personnel and gathered information on knowledge and attitudes towards glaucoma. The qualitative component consisted of structured interviews with providers to assess their knowledge and perspectives of glaucoma patients’ attitudes and behaviours.

Results:

A total of 1881 patients were screened at 24 outreach screenings in South West Nigeria, among which 120 glaucoma cases/suspects were identified. Fifty-six (46.7%) of the glaucoma patients were aware of glaucoma, but only 39 (32.5%) patients could answer at least one knowledge question correctly. Predictors of awareness of glaucoma were minimum of secondary school education [adjusted odds ratio (OR) 8.76; 95% confidence interval (CI) 3.18–24.13] and having had an eye check-up in the past (adjusted OR 5.87; 95% CI 1.92 – 17.92). Patients said cost and ‘not knowing the disease was serious’ were reasons for not following up at the main hospital. Health workers interviewed said that cost and poor knowledge were the main reasons glaucoma patients frequently attended free outreach screening events rather than seeking definitive care.

Conclusion:

Although CEO screenings improve access to eye care, provision of appropriate health education programs and strengthening of the health insurance scheme are needed to improve its impact in glaucoma care.

Glaucoma Features in an East African Population: A 6-Year Cohort Study of Older Adults in Nakuru, Kenya

PURPOSE

Glaucoma is a leading cause of blindness in people of African descent. Minimal data is available from African population-based cohort studies. The primary aims of this study were to describe the normative distribution of glaucoma features to enable glaucoma classification and to assess risk factors for those with glaucoma at follow-up among people aged 50 years and above in Kenya.

MATERIALS AND METHODS

Random cluster sampling with probability proportionate to size was used to select a representative cross-sectional sample of adults aged 50 years and above in 2007 to 2008 in Nakuru District, Kenya. A 6-year follow-up was undertaken in 2013 to 2014. Comprehensive ophthalmic examination included visual acuity, digital retinal photography, visual fields, intraocular pressure, optical coherence tomography, and independent grading of optic nerve images. We report glaucoma features, prevalence and predictors for glaucoma based on the International Society for Geographical & Epidemiological Ophthalmology (ISGEO) criteria. Measures were estimated using a Poisson regression model and including inverse-probability weighting for loss to follow-up.

RESULTS

At baseline, 4414 participants aged 50 years and above underwent examination. Anterior chamber optical coherence tomography findings: mean anterior chamber angle of 36.6 degrees, mean central corneal thickness of 508.1 μm and a mean anterior chamber depth of 2.67 mm. A total of 2171 participants were examined at follow-up. The vertical cup to disc ratio distribution was 0.7 and 0.8 at the 97.5th and 99.5th percentiles, respectively. A total of 88 (4.3%, 95% confidence interval, 3.5%-5.9%) of participants at follow-up had glaucoma consistent with ISGEO criteria. A relative afferent pupillary defect and raised intraocular pressure were associated with the diagnosis.

CONCLUSIONS

Glaucoma is a public health challenge in low-resource settings. Research into testing and treatment modalities in Africa is needed.

Severity of Visual Field Loss at First Presentation to Glaucoma Clinics in England and Tanzania

Purpose: To compare severity of visual field (VF) loss at first presentation in glaucoma clinics in England and Tanzania.Methods: Large archives of VF records from automated perimetry were used to retrospectively examine vision loss at first presentation in glaucoma clinics in Tanzania (N = 1,502) and England (N = 9,264). Mean deviation (MD) of the worse eye at the first hospital visit was used as an estimate of detectable VF loss severity.Results: In Tanzania, 44.7% {CI_95%: 42.2, 47.2} of patients presented with severe VF loss (< -20 dB), versus 4.6% {4.1, 5.0} in England. If we consider late presentation to also include cases of advanced loss (-12.01 dB to -20 dB), then the proportion of patients presenting late was 58.1% {55.6, 60.6} and 14.0% {13.3, 14.7}, respectively. The proportion of late presentations was greater in Tanzania at all ages, but the difference was particularly pronounced among working-age adults, with 50.3% {46.9, 53.7} of 18-65-year-olds presenting with advanced or severe VF loss, versus 10.2% {9.3, 11.3} in England. In both countries, men were more likely to present late than women.Conclusions: Late presentation of glaucoma is a problem in England, and an even greater challenge in Tanzania. Possible solutions are discussed, including increased community eye-care, and a more proactive approach to case finding through the use of disruptive new technologies, such as low-cost, portable diagnostic aids.

Glaucoma care in Nigeria: Is the current practice poised to tackle this emerging sight-threatening disease?

PURPOSE

To investigate the current practice on glaucoma care with the aim of highlighting its poise to tackle this emerging sight-threatening disease in Nigeria.

METHODS

This was a cross-sectional, descriptive, population-based survey involving 88 ophthalmologists. Information on their demographic characteristics, practice profile, challenges and prospects on glaucoma care was collected using a semi-structured, self-administered questionnaire in August 2016. Data were analysed using SPSS 20.

RESULTS

The participants are comprised of 46 (52.3%) males and 42 (47.7%) females, with a mean age of 42.2 ± 8.7 SD years. They were 45 (51.1%) consultants, 31 (35.2%) residents and 12 (13.6%) diplomates. Their years of practice were 8.8 ± 6.7 SD years. They worked mainly in government hospitals located at the southern part of Nigeria. The current practice was mainly comprehensive ophthalmology, 63 (71.6%). Only 2 (2.3%) had strict subspecialty practice. Others, 23 (26.1%), had combined practice. Eleven (12.5%) were glaucoma specialists and had combined practice. The majority of the participants, 57 (64.8%), were routinely diagnosed glaucoma properly. Sixty-three (71.6%) participants underwent trabeculectomy, 48 (54.5%) combined cataract surgery with trabeculectomy, 7 (8.0%) drainage implants, 5 (5.7%) laser trabeculoplasty, and 2 (2.3%) minimally invasive glaucoma surgery. Poor patients' acceptance and satisfaction, fear of complications, lengthy post-operative care and cost were the main deterrents to surgeries. Advocacy, public awareness, training of glaucoma specialists, provision of equipment and health insurance were the major recommendations on improving glaucoma care.

CONCLUSION

Given the meagre number of specialists and lack of strict subspecialty practice, optimal glaucoma care in Nigeria is still far from reality.

The Rationale for Selective Laser Trabeculoplasty in Africa

Glaucoma is the leading cause of irreversible blindness in Africa. The condition is treatable but not curable. There are numerous obstacles to glaucoma care in Africa, including availability, accessibility and affordability of treatments, as well as medication nonadherence among patients. Medical therapy is costly relative to the average income in Africa and it requires daily self-dosing by patients. Surgery is of limited availability in many regions in Africa, and a high proportion of patients refuse surgery because it is expensive. Selective laser trabeculoplasty (SLT) proves to be a favorable alternative to medical or surgical care, as it is highly effective and safe in people of African descent, more cost-effective than medical therapy, quick and easy to perform, and portable. The procedure also requires no postoperative care, thus obviates the issue of nonadherence. In uncontrolled studies, SLT has a high response rate and it lowers intraocular pressure by 30% to 40%, which exceeds the goal in international guidelines for initial therapies. The African Glaucoma Consortium (AGC), a member-driven stakeholder collective, has been formed in part to develop the infrastructure for continent-wide improvements in glaucoma care. It embraces SLT as a potential key tool in their development plans. The mission of AGC includes improving clinical care by educating existing and new health care professionals to expand the provider network, by conducting trials to identify optimal care strategies for glaucoma in Africa, and by facilitating the development of an integrated network of Centers of Excellence to bring SLT and other crucial glaucoma therapies to communities throughout Africa.

Safety and effectiveness of primary transscleral diode laser cyclophotoablation for glaucoma in Nigeria

Importance

To investigate the safety, effectiveness and follow‐up rates after transscleral diode laser cyclophotocoagulation as primary treatment for seeing eyes with primary open angle glaucoma in Bauchi, Nigeria.

Background

There is a high prevalence of primary open angle glaucoma in Africa where adherence to medical treatment and acceptance of surgery are poor.

Design

Prospective case series.

Participants

New glaucoma patients where surgical intervention was recommended.

Methods

A diode 810 nm laser G‐probe was used under retrobulbar anaesthesia to deliver approximately 20 shots for 2000 ms, titrating the power. If both eyes were treated the first was the study eye. Repeat treatment offered if the intraocular pressure (IOP) was >21 mmHg on two consecutive visits.

Main Outcome Measures

IOP < 22 mmHg, change in ≥2 lines of Snellen visual acuity (VA), and complications.

Results

201 out of 204 eyes with complete data analysed. Mean age 52 years, 17 (8.3%) eyes were re‐treated. Mean pre‐treatment IOP was 39 (SD 11) mmHg. 106 (53%) attended at 12 months when the mean IOP was 19 (7–45) mmHg; 77 (73%) had IOP < 22 mmHg. VAs were better in 13 (12.3%) and worse in 23 (21.7%) eyes. Postoperative complications included mild uveitis (5.5%), corneal oedema (2.5%), severe uveitis (0.5%) and transient hypotony (2.0%). No hypotony at 12 months.

Conclusions and Relevance

Transscleral diode laser cyclophotocoagulation controlled IOP in almost three quarters of eyes at 12 months with short‐term preservation of vision and minimal complications. Poor follow‐up in this setting highlights the need for an effective, safe and acceptable treatment where regular follow‐up is less critical.

Investigating the level of glaucoma awareness and perception of its risk factors in Anambra State, Nigeria

OBJECTIVES

The purpose of this study was to investigate the level of awareness of glaucoma and perception of its risk factors in Anambra State, and to examine and evaluate the health seeking behaviour of this target population and its relationship with the development glaucoma.

STUDY DESIGN

This is a qualitative study that utilised face-to-face semi-structured interviews to investigate the level of glaucoma awareness in the state.

METHODS

Purposive, non-random sampling technique was used to recruit the participants, and data were collected from 28 participants [aged 21-73 years] using semi-structured interview. The resulting data were analysed using Nvivo 10 software and Interpretative phenomenological analysis framework.

RESULTS

Of the 28 interviewees, 15 (53.6%) live in urban areas, and 13 (46.4%) live in the rural areas; 11 (39.3%) of the participants were male and 17 (60.7%) were females. In this study, people with more education, and people that live in the urban areas tend to have heard about glaucoma compared with people with less education, and who live in the rural areas; although this sample was too small to make substantive claims. Glaucoma was perceived as 'a dangerous eye disease that can cause blindness if not treated early; serious eye problem; an incurable eye problem that can eventually result to blindness, and a dangerous eye problem that can easily render a person blind'. Four a priori themes and ten emergent themes were identified.

CONCLUSIONS

There is low awareness of glaucoma in this population, and this encourages people to indulge in certain risk behaviours that could predispose them to glaucoma. Therefore, providing sustained health promotion programmes and improved eye care services could help this population immensely in the current struggle against glaucoma blindness.

West Indies Glaucoma Laser Study (WIGLS): 1. 12-Month Efficacy of Selective Laser Trabeculoplasty in Afro-Caribbeans With Glaucoma

PURPOSE

To characterize the 12-month intraocular pressure (IOP)-lowering efficacy of selective laser trabeculoplasty (SLT) as sole therapy for primary open-angle glaucoma (POAG) in an Afro-Caribbean population.

DESIGN

Stepped-wedge trial.

METHODS

Subjects in St. Lucia and Dominica with established POAG were randomized to prompt washout of IOP-lowering medications followed by SLT, 3-month delay followed by washout and SLT, or 6-month delay followed by washout and SLT. Baseline IOP was obtained on 2 different days after washout. Bilateral 360-degree SLT was performed in 1 session. Posttreatment assessments took place 1 hour, 1 week, and 3, 6, 9, and 12 months post-SLT. The main outcome measure was SLT success (defined as IOP ≤ target IOP in both eyes) at 12 months. Target IOP was a 20% or greater reduction in IOP from postwashout baseline.

RESULTS

Overall, 72 patients underwent SLT treatment. Mean IOP at enrollment was 15.4 ± 3.6 mm Hg in right eyes and 15.4 ± 3.6 mm Hg in left eyes, which rose to 21.0 ± 3.3 mm Hg and 20.9 ± 3.0 mm Hg, respectively, after washout. Mean IOP at 3, 6, 9, and 12 months ranged from 12.5 mm Hg to 14.5 mm Hg (29.7% to 39.5%; P < .0001 in each eye at each time point). The 12-month success rate was 78%. Transient photophobia and discomfort were common.

CONCLUSIONS

SLT monotherapy safely provides significant IOP reduction in Afro-Caribbean eyes with POAG. This treatment can play a significant role in preventing glaucoma vision loss and blindness in people of African descent living in resource-limited regions.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Can Adapted Motivational Interviewing Improve Uptake of Surgical or Laser Treatment for Glaucoma in Nigeria: Randomized Controlled Trial

PURPOSE

To assess whether adapted motivational interviewing (MI) has any impact on the proportion of participants who subsequently underwent surgery or laser treatment for glaucoma.

MATERIALS AND METHODS

A single site randomized controlled trial in Bauchi, Nigeria. Participants were new patients with a confirmed diagnosis of primary open-angle glaucoma in 1 or both eyes, where surgery or laser was recommended. Intervention was a session of MI adapted for glaucoma and the local context, using an interview guide based on local qualitative research. Participants were randomly allocated to intervention or usual care. Usual care was routine explanation by an ophthalmologist and an educational pamphlet. After the interview, a 12-item Working Alliance Inventory questionnaire was administered to patient-interviewer pairs to assess the collaborative relationship.

RESULTS

Two hundred seventy-six glaucoma patients participated; 70% males. One hundred thirty-five (49%) were assigned to adapted MI and 141 to usual care. All received the intervention as allocated. Uptake (ie, the proportion who underwent treatment) of laser or surgery in the MI group was 52% compared with 45% in the usual care group (risk difference 7.2%; 95% confidence interval, -4.5% to 18.9%). Mean Working Alliance Inventory scores were 68.0 for interviewers and 68.5 for participants with a combined reliability coefficient of 93.9% (ie, high internal consistency and reliability).

CONCLUSIONS

We observed only a small increase in the uptake of surgery or laser with MI compared with usual care which was not statistically significant. Although only 1 in 2 patients accepted surgery or laser in this trial, this is a much higher proportion than in other studies.

Awareness and knowledge of glaucoma and associated factors among adults: a cross sectional study in Gondar Town, Northwest Ethiopia

Background

Raising public awareness and knowledge about glaucoma is a key for early case identification and prevention of blindness. However, awareness and knowledge about glaucoma is unknown at community level, making provision of interventions difficult. This study was intended to assess the awareness and knowledge of adults about glaucoma and the factors affecting it in Gondar town, Northwest Ethiopia.

Methods

Community based cross - sectional study was conducted on 701 adults 35 and above years in Gondar from April 12–30, 2016. Multistage sampling technique was used to select study participants. Interviewer administered pretested structured questionnaire was used to collect data after verbal informed consent. Data were entered into EpiData version 3.1 and analyzed by Statistical Package for Social Sciences version 20. Bivariate and multivariate logistic regression models and Odds ratio with 95% interval were used to identify factors. P–value <0.05 was considered statistically significant.

Results

Seven hundred one adults age 35 and above years were participated with a response rate of 99.3%. The male to female ratio was 1:1.6 with median age of 48 years with interqurtile range of 20. The proportion of awareness was 35.1% (95% CI: 31.5%, 38.6%). Good knowledge was demonstrated in 49.6% (95%CI: 43.3%, 55%) of glaucoma aware participants. Education (primary [AOR: 3.21; 1.73, 5.95], secondary [AOR: 4.34; 2.30, 8.22]; college and above [AOR: 9.82; 4.27, 22.60]) and having eye examination [AOR: 2.78; 1.86, 4.15] were positively associated with awareness of glaucoma whereas older age (65 –74 years [AOR: 0.31(0.21, 0.76]) was inversely related. Level of Education (primary[AOR:2.83;1.04,7.71],secondary[AOR:3.45;1.33,9.41],college and above [AOR: 4.86;1.82,12,99] and having eye examination [AOR: 2.61;1.53,4.45] were significantly associated with knowledge.

Conclusion

The study has indicated higher level of awareness and knowledge about glaucoma in urban communities than previous studies. It has also identified educational status, eye examination at least once in life are related with better awareness and knowledge. The present awareness and knowledge should be enhanced through public oriented glaucoma education via mass media and incorporating eye check up as a routine in older people.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-017-0542-z) contains supplementary material, which is available to authorized users.

Improving services for glaucoma care in Nigeria: implications for policy and programmes to achieve universal health coverage

Glaucoma in Africa is sometimes referred to as the silent thief of sight. In Nigeria, glaucoma is common, it is serious, ophthalmologists face many constraints in managing it, people do not even know they have it until it is advanced, patients do not understand or comply with treatment after they are diagnosed and the poor are more likely to be glaucoma blind. Available evidence indicates that the health system in Nigeria is failing to meet the needs of patients with glaucoma. Based on evidence, we propose future directions for improving services for glaucoma care in Nigeria, and the implications for policy and programmes to control glaucoma blindness, using a health system-oriented approach. Three complementary strategies are required: (i) strengthening clinical services for glaucoma-by developing models of glaucoma care, improving clinical treatment options, making medicines and equipment available, financing glaucoma care and training eye care workers; (ii) introducing initiatives for earlier detection of glaucoma in the clinic and approaches in the community and (iii) strengthening health system governance. Glaucoma is a complex disease to manage and addressing it as a public health problem is challenging. However, we need to change the paradigm to recognise that glaucoma is a potentially avoidable cause of blindness in Africa.

So let me find my way, whatever it will cost me, rather than leaving myself in darkness: experiences of glaucoma in Nigeria

BACKGROUND

Blindness from glaucoma is associated with socio-economic deprivation, presumed to reflect poor access to care and poor adherence to treatment.

OBJECTIVES

To determine why people with glaucoma are presenting late for treatment and to understand access to glaucoma care. Additionally, we sought to identify what patients and the community know, do and think about the condition and why the poor are the most affected with glaucoma blindness.

DESIGN

Study participants were from four communities and two hospitals in Abuja-FCT and Kaduna State, Nigeria. A total of 120 participants were involved, including 8 focus group discussions, 7 in-depth interviews with blind/visually impaired glaucoma patients, 5 rapid direct observation visits with these patients and 13 exit interviews of glaucoma patients in the hospital. The data were analysed using content analysis, interpreting participant experiences in terms of three key steps conceptualised as important in the care pathway: what it takes to know glaucoma, to reach a diagnosis and to access continued care.

RESULTS

This article presents multiple narratives of accessing and maintaining glaucoma care and how people manage and cope with the disease. People may be presenting late due to structural barriers, which include lack of knowledge and awareness about glaucoma and not finding an appropriately equipped health care facility. What keeps glaucoma patients within the care pathway are a good hospital experience; a support structure involving family, counselling and shared patients' experiences; and an informed choice of treatment, as well as agency. The high cost of purchasing care is a major factor for patients dropping out of treatment.

CONCLUSION

The findings suggest the need to address economic and social structural drivers as glaucoma presents another case study to demonstrate that poverty is a strong driver for blindness. There is also a need for clear glaucoma care pathways with early case finding in the community, two-way referral/feedback systems, well-equipped glaucoma care hospitals and better eye health care financing.

Ophthalmologists' practice patterns and challenges in achieving optimal management for glaucoma in Nigeria: results from a nationwide survey

PURPOSE OF THE STUDY

Glaucoma, a chronic non-communicable disease, and leading cause of irreversible blindness worldwide is a public health problem in Nigeria, with a prevalence of 5.02% in people aged ≥40 years. The purpose of this nationwide survey was to assess Nigerian ophthalmologists' practice patterns and their constraints in managing glaucoma.

STUDY DESIGN

Ophthalmologists were sent a semistructured questionnaire on how they manage glaucoma, their training in glaucoma care, where they practice, their access to equipment for diagnosis and treatment, whether they use protocols and the challenges they face in managing patients with glaucoma.

RESULTS

153/250 ophthalmologists in 80 centres completed questionnaires. Although 79% felt their training was excellent or good, 46% needed more training in glaucoma diagnosis and surgery. All had ophthalmoscopes, 93% had access to applanation tonometers, 81% to visual field analysers and 29% to laser machines (in 19 centres). 3 ophthalmologists had only ophthalmoscopes and schiøtz tonometers. For 85%, a glaucomatous optic disc was the most important feature that would prompt glaucoma work-up. Only 56% routinely performed gonioscopy and 61% used slit-lamp stereoscopic biomicroscopy for disc assessment. Trabeculectomy (with/without antimetabolites) was the only glaucoma surgery performed with one mention of canaloplasty. Poor compliance with medical treatment (78%) and low acceptance of surgery (71%) were their greatest challenges.

CONCLUSIONS

This study indicates that a systems-oriented approach is required to enhance ophthalmologist's capability for glaucoma care. Strategies to improve glaucoma management include strengthening poorly equipped centres including provision of lasers and training, and improving patients' awareness and education on glaucoma.