India is predicted to become the second largest containment zone of glaucoma by 2020.2 Globally the total number of glaucoma patients is estimated to rise by a massive 74% from 2013 to 2040.3 To effectively manage this mammoth health problem and reduce preventable blindness, early diagnosis and treatment are crucial. Early diagnosis of glaucoma remains a difficult task owing to the asymptomatic nature of the disease and lack of effective population screening tools. It is reported from Chennai Glaucoma Study that 50-90% of the glaucoma cases from both urban & rural India are undiagnosed and a vast majority of them are diagnosed late in the disease11. The important lack of awareness about glaucoma in the general population is the main cause of late presentation as well as higher risk of blindness from the disease12. Awareness is estimated to range from 0.32% among the rural population in Southern India13, 8.3% in rural population in northern India14 to 13.5% in urban population in Southern India15. This contrasts with a slightly better 27% awareness among patients who visit the eye clinic of a city hospital in central India16, though this again is not optimal for robust eye health. The absence of knowledge regarding disease is not limited to the developing countries like India. As high as one-quarter of patients in USA cannot follow verbal or written commands from health care staffs in hospital environment, referred to as poor health literacy17. To counterbalance the poor awareness of this important disease in the community, we could have benefitted from a sound screening program. Developing countries lack the required infrastructure to detect, treat and follow up the test positives from various screening tests18. Currently, the best approach to managing glaucoma in developing countries is case detection19. Ideally, every new patient visiting an eye clinic, irrespective of presenting complaints, must undergo a comprehensive eye examination. This includes vision measurement, refraction and assessment of the pupil reflex, biomicroscopy, tonometry (preferably applanation), gonioscopy wherever indicated, and a dilated fundus examination with emphasis on the disc and posterior pole. This would enable detection of the true burden of the disease problem. A significantly more number of patients in 2018 in our study presented with a higher intraocular pressure and a worse visual acuity, compared to 2013. This indicates the overall rise in the disease load and likely late and advanced presentation. Approximately 40% of the patients in either year had advanced disease at presentation. To ensure this burden does not add to the load of irreversible blindness, it is essential to deliver comprehensive ophthalmic examination to every patient.
The minimum basic clinical tests done or advised for glaucoma diagnoses were significantly less in patients who have been referred for glaucoma. This reflects the lack of awareness among general ophthalmologists about the need for routine glaucoma tests before diagnosis or treatment of glaucoma in any patient. In a country like India, where even the self-proclaimed glaucoma specialists do not perform standard applanation tonometry or indentation gonioscopy routinely in all glaucoma patients 20, is it not obvious, therefore, that those clinical tests are further less performed for “other routine” patients with eye problem. What is more worrisome is that the missing of clinical tests has not shown any improvement in a tier-2 capital city like ours in a span of 5 years.
It was also observed that most of the referral patients were initially labeled to have non-specific diagnoses like disc suspect/raised intraocular pressure. A complete glaucoma diagnosis was missing in the majority. Luckily, this trend showed an improvement down the years. Significantly less number of patients in 2018 had an incomplete diagnosis than in 2013.
Almost 1/3rd of the patients in both time periods, who were already under one or more anti-glaucoma medications, were weaned from them. This indicates a component of over –treatment and overdiagnosis—which are already reported from European countries.5,21.
What could have gone wrong here? Professor Thomas had pointed some possible explanations in his article like—preferential interest among general ophthalmologists for doing routine cataract & refractive surgeries (easy and safe way to generate revenue) and a grossly inadequate residency program that teach most of the would-be doctors nothing other than routine torch-light examination19. The need of the hour, hence, is the repeat training of the doctors and other health care staffs, as advocated by a WHO panel22. There is some positive news about the efficacy of such glaucoma training programs for health care providers. These include improved patients satisfaction in staffs’ communication23, improvement in medication adherence24 and better communication among doctors-and-patients25.
Limitation of our study is its retrospective nature, inability to trace and reach out to the referring doctors about the problems in referring the patients. We agree that an interview with the primary physician would have given some inputs into how the problems could have been resolved—be it in time-constraint or lack of investigative tools like gonioscopy, visual field for glaucoma diagnosis. Sadly, the contact details of the referral doctor are often missing in referral letters. We also did not evaluate the qualifications of the referring doctor which could have given us an insight into possible reasons for missing details. The high percentage of missing of IOP values in referral letters in both the years can somewhat be related to a lack of registering the detail by the primary doctor or the patients themselves. We regret that these finer details are difficult to elucidate in every case referred to us. We chose a period of 5 years gap without evaluating the effect of any particular interventions/training programs targeted at improving ophthalmic examination skills of general ophthalmologists in the state. This is a hospital based study; therefore results cannot be extrapolated to general ophthalmologists from other areas/countries. Results of this study should be treated as an internal audit and a method of self-assessment of general ophthalmologists trying to diagnose and treat glaucoma. Nevertheless, our study reveals serious lacunae in basic ophthalmic skills required for glaucoma screening and referring ability among local practitioners with no significant improvement in 5 years. Hence it is recommended to have more doctor-oriented education programs to improve learning at the ground level.