Glaucoma Rehan Butt

Rehan Shareef Butt Roll number 21

Introduction

Regional strategies

Global and regional situation

Issues and challenges

Global strategies

Proposed strategies

H 40.1

PRIMARY OPEN ANGLE GLAUCOMA (POAG)

H 40.2

ANGLE CLOSURE GLAUCOMA (ACG)

H 40.3

GLAUCOMA SEC TO EYE TRAUMA

H40.4

GLAUCOMA SEC TO EYE INFLAMMATION

H 40.5

GLAUCOMA SEC TO OTHER DISORDERS

H 40.6

DRUG INDUCED GLAUCOMA

Raised IOP. Field of vision defects. Race. Family history and genetics. Ageing. Central corneal thickness. Myopia ( near sightedness). DM. Gender Socio economic deprivation.

Visual Impairment due to Glaucoma: Ages 45 and Over 2010 Target Ages 45 and over

Black White Hispanic Female Male Less than high school High school At least some college With diabetes Without diabetes

0

10

20 30 Rate per 1,000 persons

40

Note: Data are age adjusted to the 2000 standard population. American Indian includes Alaska Native. Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. I is 95% confidence interval. *Data are statistically unreliable.

50

Globally, around 45 million people are blind and a further 124 million are affected by low vision. Around 90% of worlds blind live in developing countries and many people do not receive treatment. More than 75% of world’s blindness is preventable or treatable. WHO has estimated that without major intervention, the number of people who are blind will double to approx 76million by 2020.

Glaucoma is the second leading cause of blindness globally as well as in most of the regions. The number of persons estimated to be blind as a result of glaucoma is 4.5 million accounting for slightly more than 12% of all blindness. Although the prevalence of glaucoma is 12% but the alarming thing is that, this prevalence is gradually increasing by time. A sharp rise in aging population will probably cause a 30% increase in the number of pts with POAG by 2020 with an estimate of 58.6 million affected and 5.9 million bilaterally blind.

According to Pakistan National Blindness and Visual Impairment Survey, the age and gender standardized prevalence of blindness among Pakistan adults (30yrs or older) was 2.7%. The estimated number of blind individuals of all ages in Pakistan in 2003 was 1.25 million. Using population projection for whole population of Pakistan, the number of blind people will increase to approx 2.4million by 2020. Previous studies in districts of NWFP found women to be more likely to be blind or visually impaired than men.

Another study in Northern Punjab found nearly double the prevalence of blindness in women than in men. The age adjusted odds of blindness in women is 43% higher than in men. Underutilization of eye care services and barriers specific to women are the explanations. A significantly high prevalence of blindness is found in districts with a higher deprivation index.

According to Pakistan National Blindness Survey Glaucoma is the 3rd leading cause of blindness in Pakistan.

Vision 2020 The Right To Sight: Launched in 1999 as a partnership between WHO and IAPB. The goal of Vision 2020 is to eliminate avoidable blindness by the year 2020. Strategy includes cost effective disease control interventions, HR management and infrastructure development.

Vision 2020 workshops: Started in 1995 with 6 regional partners including Pakistan. Participants include eye health professionals and health service planners.

World sight day: Annual day of awareness to focus global attention on blindness and visual impairment.

World glaucoma Association: Independent, ethical and impartial global organization for glaucoma science and care. Mission is to optimize the quality of glaucoma science and care through communication and cooperation among glaucoma societies and organizations. World glaucoma congress is the only biennial glaucoma meeting conducted by WGA.

The glaucoma foundation: The mission of TGF is to find ground breaking research and to educate the public about this disease and importance of early detection to prevent blindness.

World glaucoma day: Celebrated once a year to create awareness about glaucoma in general public. Activities include media coverage, public educational events and free screening events .

National program for prevention and control of blindness: This program is in line with Vision 2020. Core objectives: Prevention of blindness in 2 million people. Restoration of vision in 2 million people.

Strategic targets: Establishment of 7 centers of excellence in ophthalomology. Up gradation of 17 TTH eye units. Up gradation of 63 DHQ eye units. Up gradation of 147 THQ eye units. Training of 50,000 LHW,s in prim eye care.

Targets

2005-06

2006-07

2007-08

Progress

COE

7

1

2

4

100%

TTH eye units

19

0

3

10

68%

DHQ eye 63 units

22

8

15

71%

THQ eye 147 units

0

0

0

Nil

There is a lot of work done in prim and sec eye health sector but prim eye care sector is highly neglected. The main reason for not up grading THQ is non availability of trained human resource at these hospitals.

Federal capital Total cost 21.77M incurred in 2007-08

Punjab

Sindh

NWFP

Baluchista n

182.42M

91.29M

91.29M

28.39M

Up gradation of Civil Hospital KCH as COE

Up Up gradation gradation of of Helper Hayatabad Eye Medical Hospital as Complex COE as COE

Up Up Up gradation gradation gradation of FGSH as of Nishtar TTH Hospital Multan as COE

Up Up Up No TTH up gradation gradation gradation graded of 5 TTH of 2 TTH of 2 TTH Up Up Up No DHQ up gradation gradation gradation graded of 7 DHQ of 2 DHQ of 3 DHQ

Training of LHW,s in prim eye care: This program plans to provide training to 50,000 LHW,s in primary eye care all over Pakistan by 2010. A total of 5000 LHW,s have been given training sessions in primary eye care and another 25000 were trained during financial year 2008-09. The main function of LHW,s will be to refer those patients who need immediate attention, to up graded eye hospitals.

Pakistan Institute of community ophthalmology Punjab Institute of Preventive Ophthalmology

International NGO,s include Fred Hollows Foundation, Sight savers International. Pak Australia District Eye Care Program focuses heavily on HR and infrastructure development, the provision of equipment and community education. At primary level it aims to enhance the capacity of health care workers in RHC,s Government dispensaries and BHU,s to treat eye diseases including glaucoma and to educate the community members about eye care.

Pakistan Glaucoma Association: The objective of this association is to promote the awareness, education and research and patient care particularly with regard to current and advanced concepts in glaucoma care both in medical profession as well as in general population. The activities are aimed at pooling the HR to build capacity on a national level in appropriate treatment of glaucoma. Recently a seminar was conducted on Prevention of Glaucoma organized by Jung Group in collaboration with PGA. It was said that prevention and detection at early stage with effective diagnosis and treatment could prevent up to 80% cases of blindness due to glaucoma.

Dearth of trained HR: 2711 additional posts in eye care are required to be created at the up graded hospitals all over Pakistan. Not a single refractionist has been deputed at any of the up graded DHQ. Most of DHQ,s have only one trained ophthalmic technician and in the absence of allied staff , the eye specialist has no support. Except Punjab, no post has been created yet.

Deficient physical infrastructure. Non availability of medicines Deficient data collection and transmission

Baluchistan issue: No eye specialist is available at any of the 6 procured DHQ,s of Baluchistan leading to non utilization of equipment worth millions of rupees and depriving the local population of free eye care facilities. No progress has yet been made despite different meetings with provincial government.

No resources for media campaign. In appropriate vehicles for monitoring and inspection. Low motivation of personnels. Poor surveillance system

Identification of aims and objectives: Aim: Eradication of blindness due to glaucoma in Pakistan by 2020. Objectives : To make prim eye care accessible to everyone. Cadre of trained personnels to be created for eye care. To achieve glaucoma prevalence rate for identifiable sub groups below 1%. Increasing the number of trained eye personnels. Up gradation of BHU/THQ eye units. Raising the awareness of the general public as well as health professionals regarding glaucoma.

Modes of financing: Expanding tax based revenues Standardization of fee structures. Allocation of donor funds according to needs. Expansion of employees’ social security schemes. Development of social protection programs.

Private sector reforms: Updating the knowledge and skills of private sector eye health care providers. Develop criteria for regular inspection of private eye care facilities. Conducting research for evidence on the functioning of private eye health care sector.

Using the National Health policy Forum to build up relationship with Federal Planning division to convince MOH about taking actions and making policies about blindness due to glaucoma. Urging Ministry of Finance to increase the funds for Blindness Control Program with specific allocation for glaucoma control and prevention activities. Involving the provincial secretaries of health in the creation of provincial committees for prevention of blindness due to glaucoma. As a result it will be possible to coordinate, plan and make decisions about the program at provincial levels.

Involving the district administrators in planning of eye care programs. Building the leadership and management skills of the health officials and district ophthalmologists. Specific training of mid level eye care personnels. Recruitment of ophthalmologists and allied staff at the vacant posts specifically in the rural areas. Assigning an expert group which should design public health approaches for control of glaucoma associated blindness in context of Vision 2020. Ensure that training curricula of ophthalmologists adequately address glaucoma, including the skills needed for diagnosis and treatment.

Training centers should be adequately equipped to provide essential services for glaucoma patients. Identifying the opportunities for diagnosing glaucoma for example at the time of refraction testing; before or after cataract surgery. Making glaucoma screening, a part of regular eye checks particularly for persons at risk( with a positive family history, more than 40 years of age). Increasing the compliance with the use of eye drops through health education and counseling. Arranging free glaucoma camps with free eye check ups of all the people with focus or rural and poor areas.

Public awareness campaign • Media coverage through newspaper articles and editorials, radio station coverage, TV channel coverage. This can be done by telecasting at least one program about glaucoma awareness monthly. • Organizing open door eye care days at institutions. • Distribution of IEC material showing the key messages about glaucoma in general population. • Organizing patient educational conference at institutions or public venues. • Organizing free screening days at institutions and public venues. • Celebration of glaucoma days in whole country with increased awareness activities in rural areas.

HR development: Training lady health workers in primary eye care or at least making them aware of the sight threatening conditions such as glaucoma. Mid level eye care personnels should also be given priority training so that they can early diagnose it and at least refer to a secondary eye care facility. Providing performance based incentives to the eye care staff. Training of new ophthalmologists and glaucomatologists and deputing them to vacant posts. Providing more incentives and allowances to the ophthalmologists who agree to work in socioeconomically deprived areas.

Increasing the number of training centers for eye health care staff. Place the personnels trained in management at tertiary and secondary care centers. Train full time managers in larger courses as needed. Appointing biomedical engineers for maintenance and repair of eye care equipment. Infra structure development: Up gradation of DHQ and THQ eye units with provision of indoor facilities. Identify the poorly served areas and engage with partners to secure the resources for infra structure development in those areas.

Support the operational research on increasing the productivity of available infra structure. Improvement of access to infra structure by providing transport facility for ophthalmic teams and patients. Establishment of separate glaucoma clinics at secondary and tertiary level facilities. Provision of high quality affordable equipment to practitioners, hospitals and clinics. Provide appropriate donated equipment to facilities that cannot afford to purchase.

The monitoring and evaluation should be the responsibility of Project Management Unit A separate committee should be made for this specific task which should submit its evaluation report to the project managers every 6 months. The best way for monitoring and evaluation is through specific indicators which are devised after keeping in view the objectives of the program.

Monitoring and evaluation frame work

BCC indicators: Proportion of people who have knowledge about glaucoma and its complications. Number of glaucoma awareness programs telecasted in last 6 months. Number of patient educational conferences held in last 6 months. Number of free screening days organized in last 6 months.

HR Indicators: Number of eye care personnels (including ophthalmologists and mid level eye care staff) per 100,000 population. Proportion of residency programs that have integrated a community ophthalmology module into their curricula.

Proportion of training curricula of eye health care staff which adequately address glaucoma diagnosis and management. Number of eye care personnels trained for glaucoma diagnosis and management (short and long courses) Ratio of ophthalmic medical assistants, officers and nurses to ophthalmologists. Proportion of sec and tertiary level centers with trained ophthalmologists. Number of vacant ophthalmologist and allied staff posts filled. Number of LHW,s trained in primary eye care. Proportion of eye health care staff satisfied with their job.

Indicators for infra structure: Number of primary, sec and tertiary eye care centers. Number of DHQ,s and THQ,s eye units up graded. Number of district eye units with adequate diagnosis and treatment facilities.

Major indicators: Proportion of different types of glaucoma in districts and provinces. Proportion of people with visual impairment in districts and provinces. Proportion of people who are blind in districts and provinces.

The key to success is early and timely diagnosis accompanied with regular follow up of the patients with glaucoma. This can only be achieved by creating awareness about this disease in target groups and changing their behavior through effective BCC strategies accompanied with the provision of high quality primary eye care at the tehsil and district level. This is the only way by which the Vision 2020 goal of reducing the blindness and visual impairment due to glaucoma can be achieved at the global as well as the national levels.

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