Organizational issues of glaucoma diagnosis in Kazakhstan

Purpose Analysis of the organizational issues of the diagnosis of glaucoma in Kazakhstan and State programs for health care system: “Salamatty Kazakhstan” and “Densaulyk”. Methods The state of screening for glaucoma was included increased intraocular pressure (IOP) measurement and pachymetry, which was used for the corneal thickness examination. Although the IOP can be increased or be in the normal ranges, thin central cornea thickness generally was ignored by ophthalmologists. In this regard, the indications for examination for glaucoma with systemic hypotension during screening were expanded, and pachymetry was one of the essential diagnostic tool in the clinical guideline for the diagnosis and treatment of glaucoma as a mandatory research method. Results Suciency and effectiveness of the screening program was conrmed by the trend in the number of identied patients with glaucoma depending on age. Correlation between suspected glaucoma and age groups was exposed. The number of registered glaucoma patients was 43,337 patients in 2010. In contrast, after the screening program the gures raised to 68,195 people in 2016. Moreover, there was the increase of newly identied glaucoma cases by 49%: from 70.8 per 100 thousand populations in 2010 to 124 per 100 thousand populations in 2016. Conclusions State programs for health care system development in Republic of Kazakhstan "Salamatty Kazakhstan" (2011-2015) and "Densaulyk" (2016 – 2019) were the initial steps for the prevention of the irreversible blindness and disability due to glaucoma. Screening programs allow to timely and adequate diagnosis of the disease over 40 years of age.

suspected glaucoma and age groups was exposed. The number of registered glaucoma patients was 43,337 patients in 2010. In contrast, after the screening program the gures raised to 68,195 people in 2016. Moreover, there was the increase of newly identi ed glaucoma cases by 49%: from 70.8 per 100 thousand populations in 2010 to 124 per 100 thousand populations in 2016. Conclusions State programs for health care system development in Republic of Kazakhstan "Salamatty Kazakhstan" (2011)(2012)(2013)(2014)(2015) and "Densaulyk" (2016 -2019) were the initial steps for the prevention of the irreversible blindness and disability due to glaucoma. Screening programs allow to timely and adequate diagnosis of the disease over 40 years of age.

Background
Glaucoma is a group of diseases caused by multiple factors and manifested by deterioration of the visual eld and progressive optic neuropathy [1,2]. The main and common pathogenetic symptom is the degeneration of the optic nerve with usual accompany of the increased intraocular pressure (IOP) [3][4][5]. Also, the apoptosis of retinal ganglion cells (RGCs) leads to loss of dendrites of RGCs and retinal nerve ber layer (RNFL) thinning [2,6].
Glaucoma is one of the major cause of blindness [7], especially in developing countries [8]. It is the most frequent cause of irreversible loss of vision in Kazakhstan [14]. According to the data of Islamova S.Ye. [14] the incidence of glaucoma in the Republic of Kazakhstan over the past 10 years has increased by 25%. For the same decade the number of disability due to glaucoma elevated by 3.7 times and rose from fth to second place.
Since 2014, of 37.8% blind people in Kazakhstan suffer from glaucoma among the causes of visual disability. Every fth disabled person (21.6%) is a person of working age. Moreover, almost one third of patients with glaucoma are recognized as disabled in the rst group due to complete or almost complete loss of vision [15].
Considering these changes in the number of people with blindness and age demography, glaucoma is the urgent social and economic issue [9]. However, so far there are no systematic comparative studies of the epidemiology and screening methods of glaucoma in Kazakhstan.
Measurement of IOP has been the general method of screening for glaucoma. Sensitivity and speci city of this technique, however, is low and there is a demand for more extensive methods of detection [10]. The main achievement in the organization of the ght against glaucoma in the Republic of Kazakhstan is the State Screening, which was started in 2011 and aimed at the early detection of the disease [15].

Methods
The mission of the Kazakhstan State screening program was the identi cation of cases of increased IOP among persons over 40 years of age, followed by examination of them for glaucoma in the context of specialized glaucoma o ces. These glaucoma o ces were opened as part of the State programs "Salamatty Kazakhstan" [16] and "Densaulyk" for health care system development in Republic of Kazakhstan 2016 -2019 [17]. The opening of cabinets allowed to raise the quality of the disease management to a higher level due to the availability of the retinal tomography and computer perimeters. The innovative development of diagnostic ophthalmic equipment has led to a change in the standards for the diagnosis and monitoring of glaucoma.
As mentioned earlier, the state of screening for glaucoma is based on identifying cases of increased intraocular pressure (IOP). At the same time, cases of glaucoma with low IOP and cases of underestimation of IOP indices with thin central cornea thickness fall out of the sight of ophthalmologists. In this regard, the indications for examination for glaucoma with systemic hypotension during screening were expanded, and pachymetry was included in the clinical protocols for the diagnosis and treatment of glaucoma as a mandatory research method. Perimetry is also used for the screening method of glaucoma [11][12][13]. However, due to unavailability of the equipment in all regions of Kazakhstan, the visual eld test was excluded from general cohort.

Results
Despite the risks of hypodiagnosis of glaucoma during screening, the effectiveness and adequacy of the screening was con rmed by the trend in the number of identi ed patients with glaucoma depending on age ( Figure 1 and Table 1). A direct correlation was revealed: an increase in the percentage of detectable glaucoma in older age groups, which corresponds to the literature data [1]. One of the key objectives of the program is the integration of all health services around patient needs through the modernization and priority development of primary health care, as well as the development of public health services (PHS). One of the key objectives of the regional divisions of PHS will be to increase public responsibility for their health, including through timely screening and follow-up examination. of the funds go to the inpatient sector, only 34% is allocated for the work of the primary health care service.

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Thus, the implementation of the State program "Salamatty Kazakhstan" [16] and "Densaulyk" [17] played a crucial role in reducing blindness and disability from glaucoma. One of the modern organizational forms of dealing with this socially signi cant ophthalmic pathology is screening examinations, which should be provided for early detection of glaucoma in the population over 40 years of age. It is also necessary to inform the public about effective methods of treatment, prevention of glaucoma and the opportunities provided by domestic medicine, including a list of services within the guaranteed volume of free medical care. Consent for publication -Not Applicable.

Availability of data and materials
Please, see the attached les.

Competing Interests
The authors declare no competing interests.