1. Public Health Control Strategies for Glaucoma: What do we Need to Know? Nathan Congdon, MD, MPH Zhongshan Ophthalmic Center Sun Yat Sen University Guangzhou, China ORBIS International

2. Financial interest  No financial interest

3. An explosion of new knowledge about glaucoma and other eye disease

4. Visual burden of glaucoma increasing despite new knowledge

5. This talk  Questions to ask: –What model for glaucoma programs in areas of limited resources? –What do we need to know to implement these programs well?  Introduce ideas this session will focus on: –ZAP and EAGLE studies, CREST program, Aravind tube shunt  Emphasis on Asia: –Evidence of significant disease burden –Availability of resources

6. A strategy for glaucoma in rural Asia: Start in the clinics  Clinic-based case-finding: –Economic models 1 suggest that population-based approach is not cost effective –Uncertainty about morbidity associated with large- scale programs of PI for narrow angles  Target is persons aged 40+ years presenting for eye care, and who are at risk for BLINDNESS from glaucoma 1 Burr JM, et al. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assess 2007;11(41):iii-iv,ix-x,1-190.

7. A strategy for glaucoma in rural Asia: Screening for narrow angles  Gonioscopy, possibly with van Herrick testing as a “pre-screen”  The GOOD –Cheap (US$75 goniolenses available in India) –Still the gold standard, no proof yet that other modalities are better  The BAD –Highly dependent on quality of training –Cutoffs for intervention are not well-defined

8. A strategy for glaucoma in rural Asia: Screening for glaucoma  Principal focus on evaluation of the disc –Emphasis on detecting patients with severe damage –Very limited evidence for utility of field testing in persons without field- taking experience –Post-operative evaluation of the nerve in patients with dense cataract

9. A strategy for glaucoma in rural Asia: Treatment  Strategy may differ between urban and rural settings: –Glaucoma drops widely available in urban China and India for US$1 per bottle –Barriers of opportunity cost, transportation and availability make long-term medical therapy untenable in most rural areas –In these areas, surgical therapy will likely predominate

10. A strategy for glaucoma in Asia: Integrate glaucoma into the eyecare system  In areas of limited resources, a “glaucoma program” is not going to make sense  Similar equipment and training should also build capacity to care for DR (for example)  The patient may have come 100 km, we have to be willing to move 5 mm from the optic nerve to the fovea!

11. The knowledge gap  What do we need to know in order to scale up glaucoma treatment in Asia?

12. Treatment of narrow angles, ACG  Any expansion of service provision for persons with narrow angles requires a better understanding of the risk-benefit ratio for available treatments. –What are the long-term effectiveness of cataract extraction versus PI for NA/AC? (EAGLE, ZAP) –What are incidence/progression rates of cataract, corneal decompensation, visually significant glare, RD after PI? (ZAP)

13. The CREST Network: Comprehensive Rural Eyecare Service and Training  A collaboration between ORBIS International, Zhongshan Ophthalmic Center and ten rural, county- level hospitals in Guangdong Province  Aim: To build capacity of rural hospitals to provide comprehensive eye care (including both glaucoma and DR)  Platform for programmatic research on management of glaucoma and DR in rural Asia

14. Current knowledge and attitudes about glaucoma in rural China  Focus Group studies of doctors and patients in rural Guangdong have revealed widespread mis-conceptions ( Arch Ophhalmol 2012;130:761-70:  Focus Group studies of doctors and patients in rural Guangdong have revealed widespread mis-conceptions ( Arch Ophhalmol 2012;130:761-70 ): –Glaucoma viewed as rare –Highly-symptomatic disease  Thorough examinations of angle and optic nerve only done on rare patients with obvious symptoms

15. Research on physician training  Change in practice patterns: –Goal is routine full exam for ALL patients > 40 years –Use of electronic medical record network tying 10 rural hospitals to ZOC to assess documentation of key facets of glaucoma exam: IOPIOP GonioscopyGonioscopy Optic nerveOptic nerve –Before and after training

16. Research on physician training  A study of rural physicians’ ability to detect glaucoma damage in the optic nerve is also under way  Testing before and after training using the GONE Website: –Jonathan Crowsdon, CERA, Australia –Chinese-language version of website now exists

17. Research on patient education  RCT of intervention to increase uptake of glaucoma examinations in clinic: –Videos made especially for the project  Key ideas: –Glaucoma asymptomatic –Need comprehensive exam to detect un-suspected disease –Potential for severe, irreversible vision loss if wait for symptoms

18. Research on patient education  Patients are unsatisfied with vision after glaucoma surgery: “negative social marketing” –RCT of educational intervention including videos –Explain purpose of glaucoma surgery –Prepare patients for likelihood of blurred VA –Outcome is post-op satisfaction level, willingness to recommend surgery

19. Research on patient compliance  Patient long-term compliance with recommended DR care and post op glaucoma visits is poor (Ophthalmology 2010;117:1755-62.) –Funding from WDF to create automated cellphone SMS reminder system –Increases 6-month compliance from 36% to 86% in peds cataract (Ophthalmology in press) –95% of local rural patients have access to cell service

20. Future issues: Research on glaucoma treatment  Outcomes of conventional surgeries (trab, surgical PI) in this setting  Could inexpensive, locally-made tube shunts, ExPress valves etc. be better-suited to rural surgeons and lower patient compliance?  What is impact of this limited, clinic-based strategy on preventing glaucoma blindness in the population?

21. Conclusion  Many knowledge gaps still exist in our understanding of managing glaucoma in areas of limited resources  Research can help to fill these gaps, and in doing so to improve the effectiveness and efficiency of programs