Medical treatment of open-angle glaucoma.

Most guidelines that exist for the treatment of primary open-angle glaucoma (POAG) – such the National Institute for Health and Clinical Excellence (NICE) guidelines (page 47) – recommend medicine as initial therapy, though laser treatment may also play a role.None of these guidelines are based on research done in Africa, however, and there also is no evidence yet on the relative effectiveness of different glaucoma medications in African populations.For medicines to be effective at controlling POAG, they must be used every day for the remainder of the patient’s life

The muranga teleophthalmology study: comparison of virtual (teleglaucoma) with in-person clinical assessment to diagnose glaucoma

Purpose: While the effectiveness of teleophthalmology is generally accepted, its ability to diagnose glaucomatous eye disease remains relatively unknown. This study aimed to compare a web-based teleophthalmology assessment with clinical slit lamp examination to screen for glaucoma among diabetics in a rural African district. Materials and Methods: Three hundred and nine diabetic patients underwent both the clinical slit lamp examination by a comprehensive ophthalmologist and teleglaucoma (TG) assessment by a glaucoma subspecialist. Both assessments were compared for any focal glaucoma damage; for TG, the quality of photographs was assessed, and vertical cup-to-disk ratio (VCDR) was calculated in a semi-automated manner. In patients with VCDR \u3e 0.7, the diagnostic precision of the Frequency Doubling Technology (FDT) C-20 screening program was assessed. Results: Of 309 TG assessment photos, 74 (24%) were deemed unreadable due to media opacities, patient cooperation, and unsatisfactory photographic technique. While the identification of individual optic nerve factors showed either fair or moderate agreement, the ability to diagnose glaucoma based on the overall assessment showed moderate agreement (Kappa [κ] statistic 0.55% and 95% confidence interval [CI]: 0.48-0.62). The use of FDT to detect glaucoma in the presence of disc damage (VCDR \u3e 0.7) showed substantial agreement (κ statistic of 0.84 and 95% CI 0.79-0.90). A positive TG diagnosis of glaucoma carried a 77.5% positive predictive value, and a negative TG diagnosis carried an 82.2% negative predicative value relative to the clinical slit lamp examination. Conclusion: There was moderate agreement between the ability to diagnose glaucoma using TG relative to clinical slit lamp examination. Poor quality photographs can severely limit the ability of TG assessment to diagnose optic nerve damage and glaucoma. Although further work and validation is needed, the TG approach provides a novel, and promising method to diagnose glaucoma, a major cause of ocular morbidity throughout the world

The sandwich fellowship: a subspecialty training model for the developing world

Health care systems in many developing countries are rapidly evolving to respond to urbanization and shifting epidemiological profiles, creating an environment favorable for subspecialty development. The struggle for developing nations to train and retain highly skilled clinicians within academic institutions has highlighted the need for creative approaches to subspecialty education in these regions. The “Sandwich fellowship” is an educational model in which a fellow completes rotations at an academic institution in the developed world as well as in his or her home environment. An important component of the model is the expansion of institutional capacity at the fellow’s home institution to create an enabling environment to practice newly acquired skills. The fellowship provides experience in diverse geographic and cultural contexts under the guidance of a preceptor from an institution in the developed world who teaches in both settings. Preceptors are given opportunities to continue professional growth and gain from exposure to pathology not commonly seen at home. Successful pilots of a Sandwich fellowship took place in ophthalmology and orthopedic surgery at the University of Ottawa in 2007–2008 and required funding from multiple sources with bilateral institutional support. Emphasis was also placed on teaching, leadership, management, and research so the fellows could return home and lead the development of their subspecialty areas. Early contact between administrations enables the model to serve as a gateway to a long-term partnership between developed world academic establishments and developing world institutions. Such a relationship yields a mutually beneficial exchange of knowledge and skills. Beneficiaries include the hospitals, their staff, and patients at both institutions

The muranga teleophthalmology study: A comparison of virtual (Teleretina) assessment with in-person clinical examination to diagnose diabetic retinopathy and age-related macular degeneration in Kenya

Purpose: This study compares a web-based teleophthalmology assessment with a clinical slit lamp examination to screen for diabetic retinopathy (DR) and age-related macular degeneration (AMD) among diabetic patients in a rural East African district.Methods: Six hundred and twelve eyes from 306 diabetic patients underwent both a clinical slit lamp examination and a teleretina (TR) assessment by an experienced ophthalmologist. Both assessments were compared for any DR and AMD using the early treatment diabetic retinopathy study and age-related eye disease study grading scales, respectively.Results: Of the 612 TR assessment photos, 74 (12%) were deemed ungradable due to media opacities, poor patient cooperation, or unsatisfactory photographs. The ability to detect DR and AMD showed a fair agreement (kappa statistic 0.27 and 0.23, respectively) between the TR and clinical slit lamp examination. Relative to a clinical slit lamp evaluation, a positive TR diagnosis carried a 75.0% positive predictive value when diagnosing DR and a 27.3% positive predictive value when diagnosing AMD. A negative TR diagnosis carried a 97.2% negative predictive value for the diagnosis of DR and a 98.1% negative predictive value for the diagnosis of AMD.Conclusion: When comparing TR assessments to clinical slit lamp examinations to diagnose DR and AMD, there was a fair agreement. Although further validation is needed, the TR approach provides a promising method to diagnose DR and AMD, two major causes of ocular impairment worldwide

STOP glaucoma in sub Saharan Africa: Enhancing awareness, detection, management, and capacity for glaucoma care

Introduction: Glaucoma in Sub Saharan Africa (SSA) poses a daunting challenge. Communities are often unaware of the serious implications of glaucoma and are faced with limited access to specialists, making early detection and management difficult. For those who have been diagnosed, socioeconomic barriers limit access to treatment.Since 2006, we have been involved in an innovative program we term ‘STOP Glaucoma in SSA’. The four main pillars of this program include building capacity, enhancing awareness, and improving glaucoma detection and management. The aim of this initiative is to train the first generation of highly qualified glaucoma subspecialist leaders and to develop centers of excellence for glaucoma care throughout SSA that are interconnected. Our ultimate aim is to reduce the burden of blindness from glaucoma in SSA.Areas covered: Our review addresses background context, provides learning from the first decade of this program, and offers solutions to help tackle the scourge of glaucoma in SSA.Expert commentary: Research in ocular genetics, primary congenital glaucoma, ophthalmic nanomedicine, and cost effective therapies will continue to improve our understanding of glaucoma as well as access to quality care for glaucoma in SSA

Detecting glaucoma in rural Kenya: Results from a teleglaucoma pilot project in Nyamira, Kenya

Precis: A teleglaucoma (TG) case-finding model was used in Kenya. Of the patients, 3.46% had definite glaucoma and 4.12% were glaucoma suspects. Most cases were of moderate to advanced stage and referred for further assessment.Purpose: The aim was to evaluate glaucoma prevalence in a high-risk population using a TG model.Methods: Patients aged 35 or over were referred to the TG program from the outpatient diabetic and hypertensive clinics at Nyamira District Hospital (NDH) and from community awareness programs. Comprehensive ophthalmic examination included structured history, visual acuity, intraocular pressure, central corneal thickness, stereoptic nerve, and macular images. A glaucoma specialist provided diagnosis and management recommendation through virtual consultation. Glaucoma diagnosis and staging were based on at least 1 eye meeting the optic nerve criteria as specified by the Canadian glaucoma guidelines.Results: In all, 1206 participants were seen and 19 of these could not complete the examination. Of 1187 patients, 56% were women and the mean age was 56.60±12.36 years. Of the patients, 11.8% had images that were ungradable in at least 1 eye. The prevalence of glaucoma and glaucoma suspects was 3.46% (n=42) and 4.12% (n=50), respectively. The proportion of patients with early, moderate, advanced, and absolute glaucoma was 2.4%, 33.3%, 52.4%, and 2.4%, respectively. Other diagnoses (pathology in at least 1 eye) included cataract in 13.2%, diabetic retinopathy in 1.48%, and optic atrophy in 1.98%. Of the patients, 28.2% were referred to the Innovation Eye Centre, Kisii, for further assessment.Conclusion: A structured TG program detected glaucoma in 3.46% of a rural Kenyan population. Timely patient referral was also initiated