1. Dr G. Chandrasekhar LVP Eye Health Pyramid Glaucoma Care

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

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

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

5. Village Vision Complex Integrated Secondary & Primary Eye Care Secondary Eye Care 10 Vision Centres 100 Vision Guardians + + Direct Service to 100-200 villages

6. 89 Primary 10+9 Secondary Four Tertiary Center of Excellence Community

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

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

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

10. 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

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

12. 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

13. 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)

14. Village Vision Complex Integrated Secondary & Primary Eye Care Secondary Eye Care 10 Vision Centres 100 Vision Guardians + + Direct Service to 100-200 villages

15. Secondary Centres Data (1998-2011) Centre Name Total OPD Glaucoma in OPDTrab.Yag PI Mudhole 213108 1162814409 Tudukurthy143528534377118 Adilabad71603866623 Karamchedu8499748110930 Markapuram44638303880 Kandukur1385415650 Nellore219874100 Paloncha20990156664 Cherukupalli21553000 61686029491465644

16. 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)

17. Glaucoma – Vision Centres April 2010 to Jan 2012 All Centers (76)ScreeningHigh IOP Total2491601709 0.68% - High IOP > 21

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

19. Glaucoma Epidemiology and Molecular Genetics Study GLEAMS

20. Population based cross sectional study Methodology

22. 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

23. 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

24. 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

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

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

27. 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)

28. Progress of the Project No. of villages screened - 10 Number of subjects screened till now – 2000 Data available - 1832

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

30. No. of eyes with various types of glaucoma

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

32. Weinreb RN etal. Am J Ophthalmol 2004;138: 458-467 The Glaucoma Continuum

33. Shallow AC depth on Van Herrick Corresponding ASOCT

34. BEST NMFP Corresponding OCT BEST MFP

35. WORST NMFP Corresponding OCT WORST MFP

36. Primary

37. L V Prasad Eye Institute www.lvpei.org Thank you! ExcellenceEquityEfficiency