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Glaucoma in the Developing World, Part One

Glaucoma  is the second leading cause of blindness worldwide, cataracts being  number one.  Unfortunately glaucoma is often poorly diagnosed and managed.  With the next several blogs,  I would like to lists some  glaucoma caveats that hopefully will prove useful for teaching,  discussion, and management in the developing world and elsewhere. Most of what I  am going to say is well known by all the readers.  However glauoma is  a bad disease in the developing world and patients often show up late with bilateral blindness. Perhaps some of these observations / suggestions from the developing world might prove useful.

 Some of what I’m going to say might be correct for a middle income country but not for a low-income country. Or vice versa. How you treat / manage glaucoma really depends on where you are and who your patient is. If you are treating an upper middle class patient in the capital  your options / approach might be different than if you are in a quite rural isolated area treating someone with  advanced disease and no access to any future drops / treatment. 
 My good friend Jim Stander MD has visited many, many eye training institutions all over the world for many years.  He has a one week glaucoma course that he has taught to prehaps hundreds of  developing - world eye residents over many years. He states that many eye residents are  unfortunately not being trained thoroughly in glaucoma --- diagnosis / management, etc.  Spending time training eye health care providers on glaucoma  is time well spent in the developing world ( middle income  or low income ).
As we all know if you are bilaterally  blind from glaucoma then your visual loss is often more marked / severe than with bilateral maculopathy  or with dense advanced cataracts.  If you are blind from glaucoma then you probably have wiped out both your central and peripheral visual fields. Many patients with bilateral macular scars can still function at a high level which is certainly not  true with glaucoma blindness.  The advanced glaucoma patient often has  trouble walking ( ambulating ). He can’t find your examining chair. If you try to shake hands with him ( her ) , he doesn’t see your hand. You don’t need a formal visual field to diagnose a marked bilateral visual field constriction in these patients. You can often make the diagnosis of  severe advanced bilateral glaucoma when they attempt to walk into the clinic.
#1.A large cup / disc  ( C/D ) ratio does not always mean glaucoma. A patient might have a cup / disc ratio of 0.6 or 0.7 and still be normal.  Sometimes looking at the old chart,  these patients have never had a IOP reading of over 22 mm . Are the discs symmetrical? That’s a big one. Symmetrical C/D ratios suggest physiological ( normal ) discs.  As we all know, any C / D ratio difference of 0.2 or more often suggests glaucoma. Are the  bilateral neuroretinal rims intact and pink --- no notching ?
Glaucoma is often overdiagnosed. Not all optic atrophy is glaucoma. Unilateral optic atrophy may not need treatment. Over the years I have seen many, many patients on two or more anti-glaucoma drops who I did not  think had glaucoma. If possible, you can  suggest slowly tapering the drops and  have the patient come back for further observation. You can also eventually stop all drops in just one eye and have them come back for re-check.  Or if they are on timolol then get the patient to just use it in the morning only ( taper ) and observe ( follow ). Sometimes  you must be diplomatic , telling your host that you do not think their patient has glaucoma.
#1. If you have a large disc, then you will often have a large cup. Look at  the disc using  the smallest light ( circle ) with a direct ophthalmoscope. If the disc is actually larger than the circular image from the ophthalmoscope, then that’s probably a large disc.  In that case don’t be surprised if the cup is also large. That’s a trick I learned from Jim Standerfer MD. 
#2. Many eye residents are not taught  how to perform gonioscopy  There is a video available <>.  Every eye clinic should try to have a three mirror  diagnostic lens  available ( great gift ) and to use it.  K- Y  Jelly can be used as  a gonioscopic / lubricant agent ( like methycellulose, etc. ). 
You must examine a lot of  iridocorneal angles before you can appreciate the normal variations of  the trabecular meshwork,  iris configuration / insertion, etc.  To appreciate a narrow angle,  primary chronic angle closure ( asymptomatic ), peripheral  synechiae, or an occludable  angle you have first to look at a lot of  normal eyes. If you are not quite comfortable with the normal anatomy ( variations ) then good luck on doing a  correct laser trabeculoplasty. Previously I have had two glaucoma specialists in the States  comment that many ophthalmologists often are not directing their laser shots to the trabecular meshwork but blasting the peripheral cornea, peripheral iris, etc.  So  lasering the wrong area  can be a problem / concern everywhere. You have got to know the  normal anatomy and the filtering angle variations.  The Color Atlas Of Gonioscopy  2nd edition is available through the AAO.
#3. Depending on the  location / situation glaucoma is sometimes best treated initially  with laser surgery or incisional surgery rather than drops. Drops are often expensive  / unavailable. I often see patients  with an initial  presentation of advanced severe bilateral  glaucoma, often with an IOP over 35 mm OU. I am quick to do bilateral laser trabeculoplasty  on these patients --  often at the first examination and also start them on drops. Patients should be advised that neither the drops nor the laser or incisional surgery will  improve the vision. As we all know, drops or surgery may prevent more loss ( progression ) of vision. You often need to repeat this message on several occasions. No glaucoma patient wants to hear / accept that message. No drops,  ointment , glasses , surgery, etc. will improve the vision.  We all know that, but the patient needs to be told that several times. What a horrible disease.
#4. Removing a cataract will often reduce the IOP by 1 - 3 mm, sometimes more. That’s often as much as you get with a second drop ( agent ). Therefore a patient with both cataracts and elevated IOP may also have a reduction in IOP post-op cataract surgery.
#5. If you are already on a systemic beta-blocker, then you might not get much additional help with adding a topical  beta- blocker ( timolol ). Not uncommon to see patients on both systemic and topical beta-blockers.
#6. The cheapest anti-glaucoma medicines are timolol and pilocarpine. Pilocarpine 4% bid is sometimes not a bad choice especially  in the pseudophakic patient. If you have a patient on an anti-glaucoma drop, then you must mention the “ G “ word. Many patients are on several drops and no one has ever told the patient that they have glaucoma.
#7. Patients with African ancestry often develop glaucoma earlier, are more difficult to control, and  often show quicker progression.
#8. Ask about a family history of glaucoma.  Did anyone in your family go blind, is a good question. Anyone in your family using drops every day, every day?  Ask the patient to write down the name of the drops their sibling is using and to let you know. If your patient has glaucoma,  then you should suggest their siblings be checked for  glaucoma every two years. Even if they are in a different country. It’s not an emergency but your patient should be told her  / his siblings need to be checked for glaucoma, not just once.
More to come later. I know I have mentioned some quite basic principles concerning glaucoma but many of  these suggestions are not always appreciated by eye health care workers in some developing areas. 

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