Glaucoma in the developing world

Abstract

The balance between benefits and harms of surgery varies in different settings P eople living in developing countries have the highest risk of developing blindness from glaucoma.1 2 In east Asia, angle closure glaucoma predominates, whereas in Africa, the Indian subcontinent, and in Hispanic populations open angle forms are more common.1 3 Treatments vary depending on the type of glaucoma and the setting. In this week's BMJ a trial in South Africa by Murdoch's group shows that trabeculectomy augmented with radiation significantly increases the success rate of surgery compared with surgery alone. 4 However, people receiving radiation also had a higher risk of operable cataract. Balancing the benefits of surgery with the risk of cataract formation is dependent on the setting in which glaucoma occurs.Access to eye care is important, and as most ophthalmology services are in urban centres people often have to travel far. 5 6 In Ghana, for example, people in rural areas present later in the course of disease and, therefore, with more blindness than those from urban areas.7 Good surgical treatment for glaucoma in the developing world is not readily available and most disease remains undetected. Funding in preventing blindness has focused on cost effective treatments such as cataract surgery, and conditions such as trachoma and onchocerciasis that can be prevented through primary care measures.1 6 Drugs for glaucoma are expensive, and staffing and equipment are limited.5 Thus compliance with medication is low and surgery is performed before medical treatment, in contrast to the developed world, where surgery is performed later.Unlike cataract surgery, which immediately reverses blindness, treatment for glaucoma prevents deterioration so patients do not notice an improvement. They are told that they have a problem of which they may not be aware. Treatment may even initially make their vision worse. It is therefore not surprising that the acceptance of trabeculectomy is poor. 6 8 African people with glaucoma are affected at a younger age and by a more aggressive disease than white people, 6 8 and medical treatment in this group is less effective.5 Black people also have higher failure rates of conventional trabeculectomy than white people.2 5 This may be related to racial differences in the wound healing response, which predispose black people to increased scar formation at the surgical site. 5Good evidence from randomised controlled trials and case control studies shows that adding antimetabolites such as mitomycin C and fluorouracil to trabeculectomy in African patients can improve success rates. However, there is a learning curve to their use because of increased risks of wound leak, low intraocular pressure, and infection. Regular postoperative follow-up is important, especially in augmented trabeculectomy, as manipulation of the operation site-such as suture removal or adjustment or breaking down of scar tissue-may be needed to maintain the function of trabeculectomy. 10Despite the proved benefits of current augm...

<p>Management Of Glaucoma In Developing Countries: Challenges And Opportunities For Improvement</p>

“…Ensuring that patients receive the optimal management for their disease without increasing the indirect costs is also a critical consideration. In countries such as Africa, patients are sometimes offered surgery as a first line of treatment before eye drops due to the cost of glaucoma drugs and low compliance with medication 44. However, post-surgical follow-ups and post-surgical complications can result in more indirect costs 4.…”

Different strategies and cost-effectiveness in the treatment of primary open angle glaucoma

“…Africa has a higher failure rate to conventional trabeculectomy, which is likely to be due to racial differences in the wound-healing response that predispose patients to scar formation at surgical site. 40 Studies reported greater success in IOP reduction by adding antimetabolites to surgery, with 89% patients achieving >25% reduction in IOP at 3 years. 41 Another trial conducted in South Africa has also proved augmenting trabeculectomy with B-radiation is beneficial.…”

“…Despite proven success, this also implies a higher cost and burden to health care resources, ie, preventable vision loss (more cataract surgeries to counter any complication arising from the primary surgery), regular follow-up (outpatients, transportation, time off work etc). 40 Patients are less likely to perceive this as a beneficial procedure and it would potentially further reduce surgery uptake in the long-run. QALY to assess cost-effectiveness would be helpful to assess the practicality of implementing augmenting antimetabolites and B-radiation in treatment in the developing world.…”

Racial Differences in Selective Laser Trabeculoplasty Efficacy

“…Glaucoma is the world’s second leading cause of blindness, and the highest prevalence of open-angle glaucoma occurs in individuals of African ancestry. 7-10 …”