Download Eye Care for the Developing World: The Next Frontier

EDITORIAL
Eye Care for the Developing World: The Next
Frontier
Marc F. Lieberman, MD* and Robert Ritch, MDÞ
he article by Lawlor and Thomas1 in this issue brings to the fore a stage in the evolution of eye care
delivery in the developing world: an approach to the detection and management of glaucoma, the
leading cause of irreversible blindness. Whereas blindness due to cataract can be treated surgically, and
great headway has been made in this area, the focus now needs to evolve into the detection and management of noncataractous causes of preventable blindness, the major entities being glaucoma and diabetic retinopathy. The predicted prevalence of 80 million cases of glaucoma worldwide several years
from now will disproportionally impact the populations in the Asia-Pacific region, an area that will
contain half of the world’s glaucoma patientsVthe bulk of whom suffer from angle closure, which is a
disproportional cause of glaucoma blindness.
In looking back over the past 30 years, although cataract remains the world’s leading remediable
cause of blindness, strategies for efficiently and effectively addressing it have rapidly developed. Both
large-volume mobile cataract camps and, in areas of high-density population, efficient ‘‘hub’’ centersV
which coordinate the screening and transport of patients in need of quick, sight-restoring extracapsular
cataract extraction/intraocular lens surgeryVhave become the norm for large-scale cataract care in parts
of the developing world. Fortunately, cataractous visual impairment is amenable both to simple diagnosis by screening without the necessity for expensive instrumentation and to correction by a
standardized and affordable 1-time procedure, which can be mastered by dexterous surgeons with
varying levels of ophthalmic knowledge. Moreover, such large-volume approaches use standardized
and portable equipment and require only short-term follow-up.
A favorable side development of this model has been the facilitation of many beneficial interactions
among volunteer surgeons from the developed world who visit host venues, participate in training, and
impart invaluable diagnostic and surgical skills. Cataracts may be envisioned as relatively ‘‘low-hanging
fruit’’ in terms of the simplicity of conceptualizing and mobilizing discrete resources to eliminate
blindness for so many. The authors state that most government agencies and many nongovernmental
organizations concentrate mainly on cataract because the numbers dealt with, both in screening and
treatment, attract publicity, appeal to donors, and generate awareness of ocular health.
Lawlor and Thomas1 are now sounding the call to gird for the next stage in attacking preventable
blindness from an altogether more insidious affliction: the glaucomas, in their various manifestations.
This will require an entirely new paradigm and developmental level of commitment. The key point is
the need to intensify training efforts at the local level. And for skilled ophthalmologists to be available
locally, they must be adequately trained in large numbers. Hence, intensive, long-term support and
proctored education at the residency level of training must focus on the mastery of comprehensive eye
examinations capable of detecting and managing a variety of sight-threatening ocular conditions. In
other words, to address the unmet challenges of glaucomatous pathology, efforts need now to focus on
managing multiple ophthalmic conditions by better trained ophthalmic generalists, rather than focus on
transferring cataract surgical skills.
This article highlights basic issues that differentiate the recognition and care of glaucoma from
cataract detection, which is usually accomplished by screening large numbers of patients and arranging
prompt treatment. With respect to glaucoma strategies, there are 3 major weaknesses in population
screening: (i) faulty detection and discrimination of different types of glaucoma when assessed by
technicians, (ii) the ophthalmologist’s need to master distinctive management protocols for different
glaucomas, and (iii) difficulties providing follow-up for patients after interventionVeither iridotomy or
trabeculectomy. Especially after filtration surgery, the demands are greater: for systematically monitoring for the possible surgical sequelae of infection or of late-onset cataractVeither of which ‘‘resets’’ the
need for new interventions and more careful follow-up.
T
From the *University California San Francisco; Director of Glaucoma Services, California Pacific Medical Center; and Tibet Vision Project, San Francisco,
CA; and †New York Eye and Ear Infirmary and Mount Sinai School of Medicine, New York, and New York Medical College, Valhalla, NY.
Received for publication December 30, 2011; accepted December 31, 2011.
The authors have no funding or conflicts of interest to declare.
Reprints: Robert Ritch, MD, New York Eye and Ear Infirmary, 310 East 14 St, New York, NY 10003. E-mail: [email protected].
Copyright * 2014 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000038
Asia-Pacific Journal of Ophthalmology
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Volume 3, Number 1, January/February 2014
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Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
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Asia-Pacific Journal of Ophthalmology
Editorial
Population screenings for glaucoma, so popular 2 decades
ago, consisted primarily of measuring intraocular pressure. This
unfortunately produced large numbers of false positives, overloaded the medical system, and missed many cases of normaltension glaucoma and angle closure; in addition, glaucoma
patients whose intraocular pressure may have been normal at the
time of screening but elevated at other times (eg, diurnal fluctuation) were not detected. Successful negotiation of these hurdles
will require a significantly higher level of skill sets than the
training of nonphysicians for large-scale cataract management.
Thus glaucoma’s distinctive needs are clearVbut perspectives on
how to effectively and efficiently meet them are just now being
elaborated, as Lawlor and Thomas1 outline here.
Regrettably, even skilled population-based screening has
proven deficient in both cost-effectiveness and efficacy of detection of either primary open-angle glaucoma (POAG)2 or primary
angle-closure glaucoma (PACG).3 The sobering conclusion is
the inescapable need to ‘‘ratchet up the game’’: by committing
intensive and prolonged resources for residency-level mastery of
comprehensive eye examinations and familiarity with clinical signs
requiring skilled intervention and providing long-term follow-up.
The shift from the solitary focus on screening and cataract
surgery to investing in the infrastructures needed for quality residency training in general ophthalmic skills is formidable. In an
evaluation of ophthalmology residency programs in India a decade ago, despite specific guidelines and investment in equipment
and training, reassessment after a multiyear follow-up was disappointing in virtually all categories.4 Moreover, both glaucoma
and cataract care face the twin ‘‘head winds’’ of persistent worldwide povertyVwhereby disease severity and poor access to care
are directly related both to low socioeconomic status5 and to
continued population growth, which increases the number of the
elderly. Despite massive worldwide efforts for cataract care, these
trends have frustrated the reduction of either the prevalence of
blindness or of significant visual impairment.6
The sobering perspective of Lawlor and Thomas’1 article
is nevertheless embedded with hopeful glimmers on how to proceed. First is their calling explicit attention to the need for a major
change of focus for public health and ophthalmic thought leaders
to recognize that this next stage of care, side-by-side with ongoing
and successful cataract strategies, is whole-hearted investment in
educational infrastructures, which will reap benefits in many
ways. This challenge is reminiscent of the Flexner Report of 1910,
issued in the United States for American medical schools to explicitly achieve 3 goals: (1) to enact higher admission and graduation standards, (2) to adhere strictly to the protocols of mainstream
science in their teaching and research, and (3) to develop and apply
criteria for experiential and hands-on teaching. Many American
medical schools fell short of the standards advocated; subsequent
to its publication, nearly half of such schools merged or were closed
outright. Nevertheless, the high standards and requirements for
modern medical training this revolution engendered, a century
later, remain the de facto universal, transnational foundations for
health care excellence throughout the developed world.
Although new technologies hold promise, such as telemedical evaluation of visual field results and optic nerve images
for remote glaucoma screening,7 a comprehensive historical assessment of the value of tests in diagnosing and managing glaucoma cautions against the persistent fallacy of ‘‘techno-lust,’’
whereby inflated expectations fall far short of evidential performance. Training informed and competent clinicians, rather than
excessively relying on new instrumentation, is the most indispensible
investment of human, time, and financial resources.8 Residency
training in glaucoma must focus on detection, proper diagnosis,
and knowledge of approaches to treatment and the methods of
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treatment, including appropriate management of surgical complications and long-term follow-up. Even in the United States,
gonioscopy was not routinely performed a generation ago, and
it was the advent of laser trabeculoplasty that forced many ophthalmologists to learn the procedure. Indentation gonioscopy is
essential to the management of angle closure. Examination of the
optic disc and its variations and appearance in glaucoma, with
photographic documentation, has become another essential feature in proper diagnosis and management. Unfortunately, these
procedures are not taught in residency programs in many programs
in developing countries, and if the instructors are not familiar with
them, then they cannot teach them.
The very inclusion of the word ‘‘opportunity’’ in the title of
Lawlor and Thomas’1 piece reflects an optimistic nod that such a
shift toward comprehensive ophthalmic education is slowly preceding. For example, they illustrate that under conditions of high
population density, models such as that of LV Prasad Institute in
Hyderabad, whose innovative pyramidal levels of screening in
remote centers by technicians are integrated with staged, referred
care to higher levels of generalists and specialists as needed.9 Or
that the skill set a surgeon masters for small-incision cataract/lens
implant surgery can be translated, with training, into mastery of
trabeculectomy surgery for glaucoma.10
The authors’ focus on the glaucomas is crucial: as the second
leading cause of visual impairment, many of whose forms can be
successfully surgically addressed if detected early enough, enormous benefits accrue: to the treated patient whose vision is saved,
to the ophthalmologist’s sense of involvement and mastery, and to
rising community expectations of the availability of quality comprehensive eye care.11 And by integrating the more demanding skills
of clinical detectionVgonioscopy, optic nerve and retinal assessment, perimetric interpretation, and so onVinto systematic and
comprehensive eye care, the wider public health spectrum of
vision loss and ocular disease are engaged. Implicit in the development of more comprehensive eye care is its integration into
larger health systems, as envisioned by the most current World
Health Organization Global Action Plan for the prevention of
Avoidable Blindness 2014Y2019.12
This tightly reasoned article is well worth re-reading and
pondering. It is nothing less than a manifesto that specifically
highlights crucial elements of the next steps on the map for addressing preventable blindness among our fellow human beings.
When the ideas and approaches conveyed in this article are widely
adopted, the major proportion of blindness from glaucoma, now
the leading cause of irreversible, but potentially preventable blindness, can and will be overcome, saving millions from a lifetime of
suffering, economic disadvantage, and lack of fulfillment of their
potential, in addition to the savings to society itself.
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2. Moyer VA. Screening for glaucoma: U.S. Preventive Services Task
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4. Thomas R, Dogra M. An evaluation of medical college departments in
India and change following provision of modern instrumentation and
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* 2014 Asia Pacific Academy of Ophthalmology
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology
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Volume 3, Number 1, January/February 2014
5. Wesolosky JD, Rudnisky CJ. Relationship between cataract severity
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Editorial
9. Rao GN. An infrastructure model for the implementation of Vision
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"History is a vision of God’s creation on the move."
V Arnold J. Toynbee
* 2014 Asia Pacific Academy of Ophthalmology
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