Dr G. Chandrasekhar LVP Eye Health Pyramid Glaucoma Care

LVPEI- Eye Health Pyramid Glaucoma Service Delivery Dr G. Chandrasekhar

Appropriate Available Affordable Accessible Without Compromising Quality From Screening to Management of Complex Diseases LVPEI Eye Health Pyramid Community Secondary Tertiary Adv. Tertiary Primary

Organizing primary-care networks Continuity of care Bringing care closer to the people Responsibility for a well-identified population PRIMARY CARE: PUTTING PEOPLE FIRST

Village Vision Complex Integrated Secondary & Primary Eye Care Secondary Eye Care 10 Vision Centres 100 Vision Guardians + + Direct Service to villages

89 Primary 10+9 Secondary Four Tertiary Center of Excellence Community

Primary 2002 Secondary 1992 Tertiary 2003 Adv. Tertiary 1987 Community 2004

General awareness Refer those with problems Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian Community Level (Vision Guardian)

History High IOP Optic nerve Van Herrick’s Referral Primary Care (Vision Technician) Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian

History Slit lamp Applanation tonometry Gonioscopy Optic nerve Visual fields Medical and Surgical Rx Secondary Care (Ophthalmologist) Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian

Diagnosis & treatment of complicated problems Training Research Tertiary Care (Subspecialities) Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian

Management of complex cases Training of Subspecialists and trainers Educational standards Research Advocacy Capacity building of Training Centres CENTRE OF EXCELLENCE Advanced Tertiary Care (Team of Subspecialists) Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian

Situation analysis Modification of infrastructure Redesigning of physical space Equipment Training of Trainers Implementation Monitoring and evaluation Capacity building of Training Centres Centre of Excellence Training centre Service Centre Vision Centre Vision Guardian CENTRE OF EXCELLENCE Advanced Tertiary Care (Team of Subspecialists)

Village Vision Complex Integrated Secondary & Primary Eye Care Secondary Eye Care 10 Vision Centres 100 Vision Guardians + + Direct Service to villages

Secondary Centres Data ( ) Centre Name Total OPD Glaucoma in OPDTrab.Yag PI Mudhole Tudukurthy Adilabad Karamchedu Markapuram Kandukur Nellore Paloncha Cherukupalli

Glaucoma –Secondary Centres 0.47% of OPD patients in SC- Glaucoma 2.17% of surgeries- Glaucoma Nearly 50% of glaucoma (1465/2949 seen in OPD required surgical intervention Trabeculectomy) Nearly 22% of Glaucoma (644/2949 underwent Yag PI)

Glaucoma – Vision Centres April 2010 to Jan 2012 All Centers (76)ScreeningHigh IOP Total % - High IOP > 21

LVPEI Eye Health Pyramid Glaucoma care Challenges IOP Angle Closure Disc and field damage

Glaucoma Epidemiology and Molecular Genetics Study GLEAMS

Population based cross sectional study Methodology

Inclusion criteria – People aged 40 years and above – Residents for a min 6 months – Willing to participate Exclusion criteria – Cannot be contacted after 3 attempts – People who are immobile Methodology

Vision Guardian Vision Technician 1 Vision Technician 2 Optometrist The Study Plan Vision Technician 1 Vision screening History, VA, Ref FDT, HVF, SL, NMFP, ASOCT Goni, dilated evaluation, OCT, Fundus photo DO, IOP, Gonio

Analysis I Agreement of Optometrists with Glaucoma Specialist Ophthalmologist in gonioscopy and Optic Disc evaluation Analysis II Diagnostic accuracy of a VG in vision screening, pupillary abnormalities and anterior chamber Results

Analysis III Skills of a VT in Gonioscopy and image acquisition Analysis IV Role of Imaging in POAG and PACD diagnosis Results

Gonioscopy 150 eyes with 25 PACS and 25 PAC Optic Disc Assessment 200 eyes with 30 disc suspects and 30 glaucoma eyes Sample Size

Agreement between Optometrists and Glaucoma Expert Results К (SE) Gonioscopy (UK)0.92 (0.12) Optic Disc Assessment (UK)0.90 (0.09) Gonioscopy (JGB)0.84 (0.10) Optic Disc Assessment (JGB)0.89 (0.09)

Progress of the Project No. of villages screened - 10 Number of subjects screened till now – 2000 Data available

Progress of the project Total no. of subjects : 1832 M:F – 777:1055 Mean Age ± SD – 53.6 ± 9.6

No. of eyes with various types of glaucoma

LVPEI Eye Health Pyramid Glaucoma care Challenges IOP Angle Closure Disc and field damage

Weinreb RN etal. Am J Ophthalmol 2004;138: The Glaucoma Continuum

Shallow AC depth on Van Herrick Corresponding ASOCT

BEST NMFP Corresponding OCT BEST MFP

WORST NMFP Corresponding OCT WORST MFP

Primary

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