CComommmunityunity EEyyee HHeeaalltthh AN INTERNATIONAL JOURNAL TO PROMOTE EYE HEALTH WORLDWIDE SUPPORTING VISION 2020: THE RIGHT TO SIGHT

EDITORIAL: THE ADULT GLAUCOMAS Gordon J Johnson MD FRCS FRCOphth Professor and Director International Centre for Eye Health Institute of Ophthalmology 11-43 Bath Street London, EC1V 9EL, UK here is little doubt that the glaucomas Tnow constitute the second cause of global blindness, after cataract. With the ageing of most populations, new surveys suggest that even Harry Quigley’s 2000 projection of 6.7 million blind due to glau- coma was an underestimate.1 Yet glaucoma has not been included as one of the priority conditions for disease control in the first 5- Primary angle-closure glaucoma is more common in East Asians while primary open angle year programme of the Vision 2020 initia- glaucoma occurs more often in Africans and Europeans Photos: Pak Sang Lee tive. Why is this? Although it is agreed that the burden of must be a ‘good thing’ and should be glaucoma, and so meet the rigorous require- blindnessdueto differenttypesofglaucoma encouraged. However, at present there is no ment for a satisfactory screening test. is high, the problem has been that we have single inexpensive, practical and valid In the meantime, we need simple and not had either reliable ways of detecting screening test. practical methods of detecting those people these diseases or straightforward ways of Maria Papadopoulos and Peng Khaw with moderately advanced chronic glauco- treating them in large populations, within refer to a number of new devices for obtain- ma who need immediate treatment. Colin prevention of blindness programmes. In the ing images of the optic nerve head or the Cook has outlined a practical approach to past few years, however, there have been retinal nerve fibre layer in POAG. Although case detection in Africans, developed from some rapid developments which are chang- they involve sophisticated technology and his extensive experience in KwaZulu-Natal. ing our perspective. at present are expensive, it is quite pos- It must be pointed out that the criteria for It would seem self-evident that screening sible that further refinements of these types the ‘either-or’ decision as to whether a per- of populations for primary open angle glau- of instruments may turn out to be the son should be referred for further investiga- coma (POAG) – the common form in popu- most cost-effective method of screening tion, and for deciding whether treatment is lations of African and European origin – large populations for primary open angle needed, are not the same as the criteria for case-definition of glaucoma in an epidemio- logical study. The common form of glaucoma in East Editorial: The Adult Glaucomas Gordon J Johnson 33 Asian populations is primary angle-closure Primary Open Angle Glaucoma Maria Papadopoulos & Peng T Khaw 35 glaucoma (PACG). From his studies in Primary Angle-Closure Glaucoma Paul J Foster 37 Singapore, Paul Foster found that patients The Secondary Glaucomas R Krishnadas & R Ramakrishnan 40 with PACG were more likely to be blind in Glaucoma Case Finding at least one eye than those with POAG.2 and Treatment Colin Cook 43 PACG appears to be the largest cause of Ocular Injuries in Ethiopia Abebe Bejiga 45 irreversible blindness in Asia. The risk of an Trachoma Control in eye developing angle-closure between the Southern Africa Erika Sutter & Selina Maphorogo 47 trabecular meshwork and the peripheral iris

33 Ed i t o r i a l

is usually indicated, in turn, by the depth of in the next 5-year strategy for Vision 2020. Communi ty the anterior chamber in the optic axis. During the next 3 to 4 years we, therefore, These anatomical features form the basis need to be refining our methods for screen- for practical screening tests, either at the ing (or case-detection) and for treatment so EEyyee HHeeaalltthh slit-lamp or by ultrasound, so that a true that they can be applied to very large num- Volume 14 Issue No. 39 2001 screening programme in those populations bers of people. at high risk now seems a real possibility. The secondary glaucomas account for References up to 25–30% of all glaucoma in some 1 Quigley H A. Number of people with glaucoma surveys. Eyes with secondary glaucoma worldwide. Br J Ophthalmol 1996; 80: 389–393. are also more likely to be blind than those 2 Foster P J, Oen F T S, Machin D, et al. The suffering from POAG. Drs Krishnadas and prevalence of glaucoma in Chinese residents in Singapore. A cross-sectional population survey Ramakrishnan outline the main causes of of the Tanjong Pagar District. Arch Ophthalmol International Centre secondaryglaucoma.Thesecanbegrouped 2000; 118: 1105–1111. for Eye Health under 4 mainheadings:neovascular, uveitic, Institute of Ophthalmology lens-related and traumatic. The relative ✩ ✩ ✩ University College London importance of these forms will vary from 11– 43 Bath Street location to location. Since they are all London EClV 9EL usually associated with a high intraocular pressure and reduced vision, the cases can Tel: (+44)(0)207 608 6909/6910/6923 Fax: (+44)(0)207 250 3207 bedetectedatprimaryandsecondarylevels Eye Health E-mail: See box using the protocol outlined by Cook. Web-site: www.jceh.co.uk Because of the burden of blindness Now available on-line World Health Organization caused by the glaucomas and the progress ww w .jc e h . c o . u k Collaborating Centre for that is being made in controlling some of Prevention of Blindness the other major causes of blindness, it is On-line edition by OAS I S/ X a l t Editor likely that the glaucomas will be included Dr Murray McGavin Nurse Consultant Ms Susan Stevens Administrative Director Ms Ann Naughton Eye Health Editorial Secretary Mrs Anita Shah The Journal of Community Eye Health is pub lished four times a year. Editorial Review Committee FREE TO DEVELOPING COUNTRY APPLICANTS Dr Allen Foster 2001/2002 Subscription Rates for Applicants Elsewhere Dr Clare Gilbert Professor Gordon Johnson 1 Year: UK£25 / US$40 2 Years: UK £ 4 5 /US $ 7 0 Dr Darwin Minassian (4 Issues) (8 Issues) Dr Ian Murdoch Dr Daksha Patel To place your subscription, please send an international cheque/banker’s order made Dr Richard Wormald payable to UNIVERSITY COLLEGE LONDON or credit card details with a note Dr Ellen Schwartz of your name, full address and occupation (in block capitals please) to: Dr David Yorston Journal of Community Eye Health, International Centre for Eye Health, Language and Communication Consultant Institute of Ophthalmology, 11–43 Bath Street, LONDON, EC1V 9EL, UK Professor Detlef Prozesky Tel: 00 44 (0)20 7608 6910 Fax: 00 44 (0)20 7250 3207 E-mail: [email protected] Website: www.jceh.co.uk Consulting Editors Dr Harjinder Chana (Mozambique) Dr Parul Desai (UK) Readersareaskedtousethefollowing specifiedE-mailaddressesonly whencontacting Dr Virgilio Galvis (Colombia) Professor M Daud Khan (Pakistan) the Journal or other Departments at ICEH: Professor Volker Klauss (Germany) Journal mailing list requests – [email protected] Dr Susan Lewallen (Canada) Dr Donald McLaren (UK) Journal editorial – [email protected] Dr Angela Reidy (UK) Resource Centre (information service) – [email protected] Professor I S Roy (India) Professor Hugh Taylor (Australia) Research enquiries – [email protected] Dr Randolph Whitfield, Jr (Kenya) Courses – [email protected] Typeset by Regent Typesetting, London © Journal ofCommunity Eye Health, Printed by InternationalCentre for Eye Health, London The Heyford Press Ltd. Articles may be photocopied, reproduced or translated provided these are not used On-line edition by for commercial or personal profit. Acknowledgements should be made to the OASIS/Xalt author(s) and to the Journal of Community Eye Health. ISSN 0953-6833

34 Community Eye Health Vol 14 No. 39 2001 Review Article

What’s New in Primary Open Angle Glaucoma? M Papadopoulos MBBS FRACO Consultant Ophthalmic Surgeon P T Khaw PhD FRCP FRCS FRCOphth FIBiol Professor of Glaucoma and Wound Healing & Consultant Ophthalmic Surgeon Director, Wound Healing Research Unit Glaucoma Unit and Department of Pathology Moorfields Eye Hospital and Institute of Fig. 1: Image obtained using Heidelberg Retinal Tomograph (HRT II) Ophthalmology Photos: T Garway-Heath Bath Street, London EC1V 9EL, UK ised programmes for serial visual field prevent further glaucoma damage?’ has rimary open angle glaucoma (POAG) analysis (PROGRESSOR), which assess recently been addressed by a multicentre, Pinvolves a spectrum of disorders typi- progression of disease by accounting for prospective clinical trial.1 Patients with fied by a characteristic optic neuropathy test variability are available. Other modes advanced POAG and IOP consistently less and field loss in eyes with open drainage of testing which involve motion detection than 18 mmHg after surgery (mean IOP angles. It is currently a leading cause of may enable earlier diagnosis. 12.3 mmHg) were found to have no visual blindness worldwide, and in the future field progression after 8 years of follow up. should become even more important as B. Treatment The clinical implication is that we should populations age throughout the world. aim for a low normal target IOP range in Recently, we have witnessed a number of Medical patients with moderate to severe glaucoma. exciting advances in glaucoma. Develop- The introduction of sustained release, once The use of the antimetabolites, 5- ments have occurred regarding diagnosis, a day form of β blocker or pilocarpine has Fluorouracil (5FU) and Mitomycin-C treatment, genetics and the relationship of provedusefulintermsof better compliance (MMC), topreventsurgicalfailurehasbeen intraocular pressure (IOP) to disease pro- and convenience. However, prostaglandin the greatest advancement in glaucoma gression. analogues, which increase uveoscleral out- surgery over the last two decades. Single, flow, have had the most significant impact. intraoperative application has improved Recent New Findings Latanoprost (Xalatan) appears to be the convenience of drug delivery. Strategies most effective IOP-reducing agent current- that change bleb morphology favourably A. Diagnosis ly available, with a low incidence of ocular are now available to avoid the development and systemic side effects. Unoprostone of focal, thin, avascular cystic blebs associ- Optic nerve and retinal nerve fibre (Rescula), Bimatoprost (Lumigan) and ated with antimetabolite use. These include imaging Travoprost (Travatan) have all recently a larger surface area of antimetabolite Limitations in optic disc and retinal nerve been approved for use by the Food and treatment,2 a fornix based conjunctival flap fibre layer assessment have stimulated the Drug Administration in the United States. to reduce posterior restriction and a large development of imaging devices that Topical carbonic anhydrase inhibitors, scleral flap with closure that diverts aque- measure either the optic disc cup and such as Dorzolamide (Trusopt), lower IOP ous posteriorly (Fig. 2). These simple mod- neuroretinal rim area or the retinal nerve but less effectively fibre layer. The most advanced at present than oral acetazo- are scanning laser tomography (Fig.1) and lamide.Another form, scanning laser polarimetry (retinal nerve Brinzolamide (Azopt) fibre analyser). They offer greater objectiv- has a more physio- ity but are limited by potential sources of logic pH and so less error and so the results must still be inter- topical side effects. preted in association with clinical findings. The alpha agonist, This quantitative imaging may be useful in Brimonidine (Alpha- early diagnosis before obvious visual field gan) is claimed to be loss occurs and may allow increased sensi- neuroprotective, but tivity to detect progression of the condi- no clinical evidence tion. exists.

Visual field and psychophysical testing Surgical New fast test visual fieldstrategies,such as One of the most fun- SITA (Swedish Interactive Thresholding damental questions in Fig. 2: Changes in surgical technique to reduce the incidence of Algorithm), have become available which glaucoma, ‘How low cystic blebs with antimetabolite use improvepatienttestcompliance. Computer- must the IOP be to Diagram: Alan Lacey Community Eye Health Vol 14 No. 39 2001 35 Primary Open Angle Glaucoma

A. Diagnosis patients at risk and ultimately lead to new treatments that prevent or cure the disease. Another scanning device cur- rd rently being developed is 3 Vision 2020 generation optical coherence tomography with ultrahigh res- The main problem continues to be identify- olution (2–3 µm). It allows in ing patients who are in need of interven- vivo visualisation of retinal tion, particularly individuals in developing structures and may prove use- countries who account for 85% of patients ful for early diagnosis. affected with glaucoma. In the industri- Similarly, multifocal visual alised world, only 50% of people with evoked potentials (mVEP) established POAG are diagnosed, usually objectively may identify visual through the course of routine eye examina- field defects earlier than white tion. But in the developing world, patients on white perimetry. frequently present with severe visual loss beforetheyareidentified.However,screen- Fig. 3: Diffuse, non-cystic bleb using Mitomycin-C B. Treatment ing a population for a rare disease such as 0.5mg/ml. Large surface area of treatment, fornix based glaucoma is difficult, especially when the flap to reduce posterior restriction and large scleral flap Medical to divert aqueous backwards infrastructure to deal with positive cases is Photo: PT Khaw lacking. To achieve the Vision 2020 goals As the role of IOP-independent to reduce blindness from glaucoma in ifications can achieve a much more diffuse, mechanisms becomes increas- developing countries, we need strategies non-cystic bleb even with high dose ingly recognised, innovative treatments that identify individuals with obvious glau- antimetabolites (Fig. 3). include agents that improve ocular blood coma, using simple tests. Detection rates Recently, there has been renewed inter- flow or are neuroprotective. Furthermore, can be increased by improving the training est in non-penetrating trabecular surgery the possibility of a ‘medical trabeculecto- of staff in optic disc, IOP and visual field because of the desire to avoid potential my’ based on biochemical and genetic examination and also by increased public complications associated with ocular entry, manipulation of the trabecular meshwork awareness of the potential benefits of regu- such as hypotony and subsequent cataract. to restore function is very exciting as is lar eye examination. Although prospective, comparative studies work on trabecular meshwork cell trans- Currently, glaucoma filtering surgery of these new methods with trabeculectomy plantation. with adjunctive anti-scarring therapy offers have demonstrated fewer complications, it the best single intervention strategy to slow has become evident that non-penetrating Surgical the rate of disease progression by suffi- surgery is not as successful in reducing ciently lowering IOP to prevent blindness. The healing process is the main determi- IOP.3 However, a higher incidence of cata- The challenge will be to deliver this in a nant of IOP following glaucoma filtration ract formation following trabeculectomy form that is relatively simple, safe, fast and surgery. The ongoing search for safer, less may in fact entirely reduce this advantage. inexpensive with an acceptable long-term toxic and more effective antiscarring success rate. Given what we now know, agents has led to a number of exciting this may soon be possible. C. Genetics developments. Transforming growth fac- Our understanding of the genetic basis of tor β (TGF β), a potent stimulator of heal- References ing, can be successfully neutralised in vivo glaucoma has improved considerably over 1 The advanced glaucoma intervention study the past decade. It is likely that the aetiolo- and in vitro with humanised antibodies (AGIS) 7. The relationship between the control gy of POAG is multifactorial 4 resulting and studies are currently underway to of intraocular pressure and visual field deteriora- assess clinical efficacy. Ultimately, other tion. Am J Ophthalmol 2000; 130: 429–440. from a combination of mutations in more 2 Cordeiro MF, Constable PH, Alexander RA, than one gene and as yet unidentified envi- specific agents may allow us to set the IOP Bhattacharya SS, Khaw PT. Effect of varying ronmental factors. With regard to juvenile safely after surgery in the 10–14 mmHg the mitomycin-C treatment area in glaucoma range. filtering surgery in the rabbit. Invest Ophthalmol and adult-onset POAG, several loci have Vis Sci 1997; 38: 1639–1646. been identified. However, only one gene is 3 Chiselita D. Non-penetrating deep sclerectomy known, namely the myocilin / TIGR (tra- C. Genetics versus trabeculectomy in primary open angle becular meshwork inducible glucocorti- glaucoma surgery. Eye 2001; 15:197–201. The transmission of disease in GLC1A 4 Budde WM. Heredity in primary open angle coid response) gene at the GLC1A locus families is autosomal dominant with vari- glaucoma. Curr Opin Ophthalmol 2000; 11: on chromosome 1q21-q31. More than thir- 101–106. able penetrance. Presymptomatic diagnosis ty mutations of this gene have been identi- of at risk individuals in pedigrees with fied in ethnically diverse populations Acknowledgements GLC1A mutations is already possible. But, worldwide. Studies have shown that it is as the mutation is responsible for a small We are grateful to the Medical Research responsible for only about 5% of POAG fraction of POAG, the most useful role of Council (G9330070), the International overall. screening will be in large families with Glaucoma Association and Moorfields early onset, severe disease where early Trustees who are supporting our glaucoma Research Issues diagnosis and intervention may improve and wound healing research programme. Although impressive advancements have prognosis and also allow for genetic coun- We would also like to thank Mr Alan occurred in glaucoma, the future appears to selling. Hopefully, a greater understanding Lacey for his help with the diagrams. be even more exciting. of basic genetic biology will identify ✩ ✩ ✩

36 Community Eye Health Vol 14 No. 39 2001 Review Article

Advances in the Understanding of Primary Angle-Closure as a Cause of Glaucomatous Optic Neuropathy Paul J Foster drainage angle are rare before BmedSci FRCS(Ed) FRCOphth the age of 40 years. After this, Department of Epidemiology and the prevalence of disease 1,2 International Eye Health increases with age. Female Institute of Ophthalmology gender is recognised as a 11-43 Bath Street major predisposing factor London, EC1V 9EL, UK toward development of PAC. & The prevalence of occludable The Glaucoma Unit drainage angles, PAC and Moorfields Eye Hospital PACG (Table 1), all tend to be 1,2 City Road higher in women than men. London, EC1V 2PD, UK Incidence of Angle-Closure n the last few years the classification of While prevalence is the stan- angle-closure glaucoma has undergone I dard measure of population Fig.1: Damage to ocular tissues in revision. This is a result of population morbidity at a specific time, angle-closure glaucoma research in regions where angle-closure events that are of short dura- glaucoma is a major cause of blindness. Ethnic groups that have a high prevalence tion are more effectively quantified by cal- Several studies have shown that most cases of PAC have shallower anterior chambers.9 culating incidence (the number of new of angle-closure that cause glaucomatous The depth of the anterior chamber is cases occurring over a specified period). optic neuropathy occur without the determined by the position of the lens with- The acute, symptomatic form of PAC is symptoms that Western ophthalmologists in the globe, which in turn determines the one such event. Incidence figures (given as associate with episodes of acute angle- width of the drainage angle. Although the cases/100,000 persons/year for the popula- closure.1–3 We have, therefore, started relationship is not a simple geometric one, tion aged 30 years and over) range from using the classification scheme detailed in we examined anterior chamber depth 4.7 in Finland to 15.5 in Singapore. As Table 1 in our research. (using an optical pachymeter) and gonio- with prevalence, incidence increases with Other ocular tissues may be damaged scopic configuration (assessed in four advancing age and shows that an excess of by angle-closure. These are illustrated quadrants, using Shaffer’s grading scheme) females are afflicted.8 in Fig. 1. Damage to different structures in 942 Mongolians, aged 40–87. We found should be specifically described when Ocular Characteristics Associated that 74% of variation in the width of the recording case details. with Angle-Closure drainage angle could be explained solely on the basis of variation in anterior cham- Prevalence of Angle-Closure A shallow anterior chamber has long been ber depth (Foster PJ, Baasanhu J, Johnson Ethnicity recognised as a factor that predisposes G J: 1995 Unpublished). toward angle-closure. The depth of the Refractive status, anterior chamber Ethnic background is one of the major fac- anterior chamber reduces with age and depth, lens thickness and axial length are tors determining susceptibility to primary tends to be shallower in women than men.9 usually associated. Anterior chambers are angle-closure (PAC). Population surveys show PAC is more common among people Table 1: Classification of Primary Angle-Closure of Asian descent than those from Europe. 1. Primary angle-closure suspect Among people aged 40 years and over, the An eye in which appositional contact between the peripheral iris and posterior trabecular meshwork prevalence of PAC (the number of cases is considered possible. present at one point in time) ranges from 2. Primary angle-closure (PAC) 0.1% in Europeans,4 through 1.4% in East (a) Non-ischaemic: an eye with an occludable drainage angle and features suggesting trabecular Asians 2,5 and up to 5% in Greenland Inuit.6 dysfunction, such as peripheral anterior synechiae, elevated intraocular pressure or excessive In Africa, a clinic-based study found the pigment deposition on the trabecular surface. The optic disc and visual field are normal. rate of primary angle-closure (gonioscopi- (b) Ischaemic: the presence of iris whorling, stromal atrophy or glaukomflecken signify previous cally verified closure of the angle with ‘acute’ PAC. However, as these are areas of ischaemic necrosis, we suggest that ‘ischaemic raised IOP) was equal among the black and PAC’ is the correct description. Differentiating between non-ischaemic and ischaemic PAC is white populations of Johannesburg. supported by experimental evidence that the iris and ciliary body are the ocular tissues most Among the white population 66% of cases sensitive to pressure-induced ischaemia. Damage to the optic nerve only occurs at higher pres- were symptomatic, whereas only 31.5% of sures, and therefore anterior segment ischaemic sequelae indicate that nerve ischaemia may the black patients reported symptoms.7 have occurred, but do not confirm it. 3. Primary angle-closure glaucoma (PACG) Age and gender Glaucomatous optic atrophy, with a characteristic visual field defect in the presence of an occlud- The manifestations of ocular damage able drainage angle or signs of PAC. resulting from primary closure of the

Community Eye Health Vol 14 No. 39 2001 37 Primary Angle-Closure Glaucoma

DETECTION-AXIAL AC DEPTH DETECTION- LIMBAL AC DEPTH of the tests of 17% and 99%. These figures mean that 17% of people ‘failing’ the screening test and being referred for con- firmatory examination will have occlud- able drainage angles. Put another way, about 1 out of 5 people referred to an oph- thalmologist for gonioscopic examination would require treatment. One person in 100 would be incorrectly classified as nor- mal.13,14 The suitability of the tests for mass screening varies. Both axial and limbal chamber depth grading have been used in thefieldonover1,700peoplein Mongolia, and were found to be acceptable and safe. The limbal chamber depth (van Herick) Specificity Specificity grading requires a slit-lamp, and probably an ophthalmologist or experienced techni- Fig. 2: Detection of narrow drainage Fig. 3: Detection of narrow drainage cian. It is, therefore, limited by the need for angles by measurement of axial AC angles using the Van Herick technique sophisticated equipment and highly trained depth using optical pachymetry (limbal chamber depth estimation) staff. Axial chamber depth measurement (diamonds ), slit-lamp using traditional grading (dashed line) by optical pachymetry has the same limita- mounted ultrasound (triangles ) and a modified grading tions. Ultrasound measurement of anterior and hand-held ultrasound (squares ) scheme (solid line) chamber depth with a hand-held probe shallower in hypermetropes than in However, although raised IOP is sufficient avoids the need for a slit-lamp, but gives myopes. Angle-closure is typically associ- to cause glaucoma, it is not necessary. much less reproducible measurements than ated with a hypermetropic refractive state. Between one-half and two-thirds of POAG slit-lamp-mounted ultrasound.15 Using a Increasing living standards and higher edu- cases have an IOP consistently within the hand-held device in a population-based cational attainment in Asian and Inuit pop- ‘statisticallynormal’range.Psychophysical screening programme would result in a ulations seem to have been paralleled by an tests and disc imaging techniques offer small but significant degradation in test increasing prevalence of myopia.10,11 In promise although the technology is imma- performance.13 Therefore, the ideal method Singapore, half the male Chinese popula- ture and remains to be proven. would use a joy-stick directed ultrasound tion aged 15 to 25 years is myopic. Among probe mounted on a stabilised base-plate those with a university education, this fig- Anterior chamber depth with a chin-rest. It is envisaged that a self- ure rises to 66%. 10 This raises the question contained screening kit would fit into a of whether the high rate of PAC previously In contrast, PACG does have features that small suitcase. A prototype of this device is encountered in these populations is des- are more readily identifiable. Closure of currently in production. tined to decline. the drainage angle requires the iris and the trabecular meshwork to be in relatively Management Screening for Primary Angle-Closure close proximity prior to the development Glaucoma: An International of the closure process. The association The next consideration, after detection, is Perspective between PACG and a shallow anterior the management of persons found to have chamber has prompted the investigation of occludable drainage angles. Prophylactic Glaucoma is now probably the leading measurement of central and limbal anterior laser peripheral iridotomy (PI) offers a cause of irreversible blindness world-wide. chamber depth measurement as tools for non-invasive, quick procedure that has few It is suggested that 73 million people suffer screening for PACG. significant short-term complications. from glaucoma, and, in 1996, Quigley esti- In the context of a screening programme Probably the most significant complication mated that 6.7 million were blind.12 The for PACG, the intention would be to detect from the point of view of care of a patient population of Asia account for the majority persons with appositional angle-closure, in with glaucoma is the post-laser pressure of this number and in a recent study of the the ‘latent’ phase of the disease before spike, although adequate pre-medication prevalence of glaucoma in Singapore, we glaucomatous optic neuropathy has devel- should prevent this. However, pre-medica- found that only 24% of POAG sufferers oped. These people can be reliably detect- tion, either with topical apraclonidine or were blind in at least one eye, but 57% of ed by either measurement of the axial ACD oral acetazolamide, may have serious side- PACGsuffererswereblind in one eye. This (either by optical pachymetry or A-mode effects. Use of apraclonidine has been difference was highly significant. 3 ultrasound), or grading of the limbal cham- associated with collapse in one elderly The epidemiology and natural history of ber depth by the van Herick technique female patient undergoing laser treatment. POAG are relatively well understood.Until where the slit-lamp beam is shone at right The risk of erythema multiforme with recently the epidemiology of PACG was angles to the cornea at its periphery, close acetazolamide is small but present. In a not as clearly understood, but over the last to the limbus. Both these tests will give a regional or national blindness prevention 5 years there has been an increased sensitivity and specificity of over 80%. campaign where the number of people researcheffort,andthisdeficiency is gradu- Assuming a population prevalence of 5% treated might run into thousands, these rare ally being re-dressed. Previously, IOP was for people aged 40 years and over with but severe adverse effects may become sig- held to be the most suitable risk-factor for occludable drainage angles, this translates nificant factors in the risk benefit equation. POAG that could be used for screening. to positive and negative predictive values More importantly, the efficacy of laser 38 Community Eye Health Vol 14 No. 39 2001 Primary Angle-Closure Glaucoma

PI as a prophylactic measure for PACG is Conclusion uncertain. It has been suggested that PACG in Asian people may often be caused by a The understanding of the epidemiology non-pupil block mechanism, which would and management of primary angle-closure not be amenable to laser iridotomy. How- has advanced considerably in the last ever, a follow-up study performed in 1998 decade. PACG is possibly the leading looking at Mongolian people with occlud- cause of blindness in East Asian countries. able drainage angles treated in our 1995 There is great interest in the natural history and 1997 surveys found that the median of narrow drainage angles and eyes with angle width had increased by 2 Shaffer PAC. Only longitudinal data will help us grades following laser PI. Patent peripheral determine who should receive treatment. Further information is also needed on the Grading the limbal chamber depth by the iridotomies were found in 98%. Iridotomy van Herick technique alone failed in 3% of eyes with narrow effect of laser iridotomy on eyes in the very Photo: Paul Foster drainage angles and either peripheral ante- earliest stages of angle-closure. Most of rior synechiae or raised IOP, but normal these low risk eyes will never suffer signif- optic discs and visual fields. However, in icant loss of vision from PACG. It is Singapore. A cross-sectional population survey important to be sure that laser PI does not in Tanjong Pagar district. Arch Ophthalmol eyes with established glaucomatous optic 2000; 118: 1105–1111. neuropathyatdiagnosis,iridotomyfailedin cause significant side effects (such as 4 Hollows FC, Graham PA. Intraocular pressure, 47%. None of the eyes with narrow angles cataract) in a small number of people, that glaucoma and glaucoma suspects in a defined that were normal in all other respects and may outweigh its benefits in preventing a population. Br J Ophthalmol 1966; 50: 570–586. few cases of PACG. However, there is now 5 Hu Z, Zhao ZL, Dong FT. [An epidemiological underwent iridotomy, developed glauco- investigation of glaucoma in Beijing and Shun- matous optic neuropathy or symptomatic considerable optimism that screening and yi county]. [Chinese]. Chung-Hua Yen Ko Tsa angle-closure within the short follow-up prophylactic treatment for PAC and PACG Chih [Chinese Journal of Ophthalmology]. period. This suggests that Nd:YAG laser may be a viable method of preventing 1989; 25: 115–118. blindness in very large numbers of people 6 Clemmesen V, Alsbirk PH. Primary angle- iridotomy is effective in widening the closure glaucoma (a.c.g.) in Greenland. Acta drainage angle, and reducing elevated IOP in Asia. Ophthalmol 1971; 49: 47–58. in East Asian people with primary angle- 7 Luntz MH. Primary angle-closure glaucoma in References urbanized South African caucasoid and negroid closure without glaucomatous optic neu- communities. Br J Ophthalmol 1973; 57: ropathy. 1 Salmon JF, Mermoud A, Ivey A, Swanevelder 445–456. Furthermore, it suggests that pupil-block SA, Hoffman M. The prevalence of primary 8 Seah SKL, Foster PJ, Chew PT, et al. Incidence is a significant mechanism causing closure angle-closure glaucoma and open angle glauco- of Acute Primary Angle-closure Glaucoma in ma in Mamre, Western Cape, South Africa. Arch Singapore. An Island-Wide Survey. Arch of the angle in this population. Once glau- Ophthalmol 1993; 111: 1263–1269. Ophthalmol 1997; 115: 1436–1440. comatous optic neuropathy associated with 2 Foster PJ, Baasanhu J, Alsbirk PH, Munkhbayar 9 Foster PJ, Alsbirk PH, Baasanhu J, Munkhbayar synechial angle-closure has occurred, iri- D, Uranchimeg D, Johnson GJ. Glaucoma in D, Uranchimeg D, Johnson GJ. Anterior cham- Mongolia – A population-based survey in ber depth in Mongolians. Variation with age, sex dotomy alone is less effective at control- Hövsgöl Province, Northern Mongolia. Arch and method of measurement. Am J Ophthalmol ling IOP 16 and trabeculectomy will usually Ophthalmol 1996; 114: 1235–1241. 1997; 124: 53–60. be necessary. 3 Foster PJ, Oen FT, Machin DS, et al. The preva- 10 Au Eong KG, Tay TH, Lim MK. Race, culture lence of glaucoma in Chinese residents of and myopia in 110,236 young Singaporean males. Singapore Med J 1993; 34: 29–32. 11 Johnson GJ. Myopia in arctic regions. A survey. Acta Ophthalmol (Suppl.). 1988;Suppl. WRITE TO US AND SHARE YOUR EXPERIENCE! 185: 13–18. 12 Quigley HA. Number of people with glaucoma The next issue of the Journal will be on the theme of Improving Patient Care. We worldwide.Br J Ophthalmol 1996;80: 389–393. inviteyoutosendus a shortreport ofyourownexperienceinimproving thequality 13 Devereux JG, Foster PJ, Baasanhu J, et al. of patient care, written with the patients’own views and perspectives in mind. Anterior chamber depth measurement as a screening tool for primary angle-closure glau- Guidelines coma in an East Asian population. Arch Ophthalmol 2000; 118: 257–263. We are seeking to report ways of improving the support and care of patients, other 14 Foster PJ, Devereux JG, Alsbirk PH, et al. than direct medical/surgical treatment itself – care that makes a difference, for Detection of gonioscopically occludable angles example, to the patient’s recovery, to their levels of satisfaction with the service and primary angle closure glaucoma by estima- provided and/or their willingness to attend for follow-up or to recommend the tion of limbal chamber depth in Asians: modi- fied grading scheme. Br J Ophthalmol 2000; service to others. 84: 186–192. Choosing one example where change was made and accepted, describe this 15 Seah SKL, Foster PJ. Anterior Chamber Depth Measurement Variation. Invest Ophthamol Vis initiative under the following suggested headings: Sci (ARVO Suppl). 1997; 38: S164(Abstract). 1. Title 2. Method(s) 3. Findings 16 Nolan W P, Foster P J, Devereux J G, et al. YAG laser iridotomy treatment for primary 4. Action(s) taken 5. Consequences of action(s) angle closure in east African eyes. Brit J Reports should be confined to 300–400 words and must reach us by 31 January Ophthalmol 2000; 11: 1255–1259. 2002. One good photograph may be sent, if available. ✩ ✩ ✩ D D Murray McGavin MD FRCS(Ed) FRCOphth Editor, Journal of Community Eye Health International Centre for Eye Health 11-43 Bath St., London ECIV 9EL, UK Fax: 00 44 20 7250 3207 E-mail: [email protected]

Community Eye Health Vol 14 No. 39 2001 39 Review Article

Secondary Glaucomas: The Tasks Ahead R Krishnadas MD Lens Induced Secondary Glaucomas Although recent advances in sutureless Aravind Eye Hospitals and Postgraduate small incision cataract surgery and pha- Lens induced glaucomas due to hyperma- Institute of Ophthalmology coemulsification and improved IOL ture cataracts are an important cause of 1 Anna Nagar designs have resulted in vastly superior secondary glaucoma in the developing Madurai 625020 outcomes with reduced complications world. Cataract accounts for 50–80% of India related to wound repair and secondary the world’s blind and in the developing R Ramakrishnan MD glaucomas, several problems still remain. world financial, cultural and psychosocial These require training of ophthalmologists Aravind Eye Hospital and Postgraduate barriers to accessing excellent surgical ser- Institute of Ophthalmology in the emerging, new techniques and tack- vices still exist. There is an ever increasing ling complications peculiar to the new Tirunelveli backlog of cataract due to the population India surgical methods, which may include glau- explosion, increased life expectancy and coma and inflammation secondary to low productivity in terms of utilisation of Introduction retained lens fragments. These measures the available surgical services. The uptake will also reduce complications such as of eye care services by the rural communi- While the prevalences of morbidity and pseudophakic glaucoma, for example, yet ty has also been suboptimal in countries visual impairment due to primary open another significant cause of secondary like India3 where lens induced glaucomas angle and angle-closure glaucomas have glaucoma. are a common cause of ocular morbidity. It been fairly well established by population should be recognised that reduced vision is surveys in the west and, recently, in the Phacomorphic glaucoma not the only indication for cataract surgery. developing world, the issue of blindness An enlarged, cataractous lens can cause from secondary glaucomas has received The cataractous lens may become swollen phacomorphic glaucoma (see below), the little attention from most investigators. (intumescent) which causes relative pupil treatment of which is removal of the lens. Individuals with secondary glaucoma tend block, the iris root is moved forward and Under Vision 2020, the global initiative to report promptly to the ophthalmologist this may result in blockage of outflow of of the WHO and voluntary service organi- aqueous fluid at the angle of the anterior since there is often marked reduction in sations, to reduce significantly ‘avoidable’ visual acuity, apart from pain and ocular chamber. This is a secondary form of blindness by the year 2020, it is intended angle-closure glaucoma. discomfort. As a consequence, these are that cataract surgeries performed will largely self-reported. increase, particularly in the developing Information on secondary glaucomas in nations.Currently,itisestimatedthatabout Phacolytic glaucoma published eye surveys is limited and the 12 million cataract operations are per- Lens material may cause blockage of cause of glaucoma seldom identified, formed each year the world over. Vision outflow of the aqueous at the drainage although in several prevalence studies 2020 aims to achieve a target of about 20 angle and this may occur after injury secondary glaucomas are numerically million cataract operations by the year (including cataract surgery) or when lens important (Table 1). Based on the WHO 2010 and ultimately reach a target of 32 material leaks through the lens capsule of a Blindness Data Bank, Thylefors and million people receiving cataract surgery mature/hypermature lens. Macrophages, Negrel, in their world estimate of glaucoma annually by 2020. attempting to remove this abnormal mater- blindness, found it was not possible to determine the number of blind from Table 1: Prevalence of Secondary Glaucomas as Reported by Population Based Surveys secondary glaucoma, although they esti- mated the world prevalence to be 2.7 mil- (Adapted from Johnson GJ. The Glaucomas. In: Johnson GJ, Minassian DC, lion.1 Quigley emphasised that few studies Weale R. The Epidemiology of Eye Disease. Chapman & Hall, 1999) describe secondary glaucomas as a sepa- Prevalence Study Age Groups Evaluated Prevalence Rate (in rate entity and most investigators do not (in years) population sampled) provide the criteria used in defining this potentially blinding disorder. The mean Ferndale, Wales 40-74 0.26 prevalence of this condition is 0.44 [SD Dalby, Sweden 55-69 0.27 0.36%] or 18% of the mean prevalence of Baltimore, Maryland primary open angle glaucoma in the Caucasians >40 0.68 world.2 Quigley estimated that 6 million African Americans >40 1.42 people in the world have secondary glauco- Rotterdam, Netherlands >55 Nil ma compared with 67 million with the pri- Blue Mountains, Australia >49 0.15 mary glaucomas. Barbados 40-84 0.7 Umanaq, Greenland >40 1.00 The Glaucoma Services at the Aravind NW Alaska >40 Nil Eye Hospital, a large tertiary eye care cen- Japan >40 0.48 tre in South India, registered 367 individu- Hövsgöl, Mongolia >40 0.30 als with various secondary glaucomas Mamre, South Africa >40 0.81 (Table 2) in the year 2000. This represents Madurai, India* >40 0.40 about 6.0 % of total new cases of glaucoma seen annually. *The Aravind Comprehensive Eye Survey, unpublished data

40 Community Eye Health Vol 14 No. 39 2001 Secondary Glaucomas

Table 2: Common Causes of Secondary Glaucomas seen in a Tertiary Eye Care Hospital in South India.* Diagnosis Number of Individuals with Percentage of Total Secondary Glaucoma Glaucoma Lens induced glaucomas 158 2.50 Neovascular glaucomas 58 0.95 Pseudophakic glaucomas 38 0.62 Uveitic glaucomas 25 0.40 Traumatic glaucomas 16 0.26 Steroid-induced glaucomas 12 0.20 Secondary glaucomas of unspecified cause 60 1.0 Secondary glaucomas. Pseudoexfoliative *Retrieved from the statistics of the Glaucoma Services of the Aravind Eye Hospital, material on the anterior lens face (top left). Madurai, India in the year 2000 Pigment dispersion syndrome (top right). Post-traumatic angle recession (bottom left). Steroid-induced glaucoma can occur ial, together with the abnormal lens materi- ma) results from angle-closure secondary with topical corticosteroids (bottom right) Photos: Paul Foster, Gordon Johnson, al itself may cause blockage at the angle of to a fibrovascular membrane in the anterior John DC Anderson, Murray McGavin the anterior chamber. This is described as chamber due to ocular diseases charac- phacolytic glaucoma. terised by retinal ischaemia and angiogene- sels in primate eyes.7 Suppressor gene ther- ‘Lens-induced’ glaucoma, in the broad- sis. Thrombosis of the central retinal vein apy to prevent predisposition of individu- est sense of the word, can be prevented by will result in disturbance of the circulation als to neovascular glaucoma is also a dis- excellent cataract surgery, by operating on within the eye and this may result in new tinct possibility in the future. unilateral dense cataracts, and on second vessel formation within the anterior seg- eyes if it is considered likely that the ment. These abnormal blood vessels may Eye Injuries and Secondary patient will not return for follow-up. affect the angle of the anterior chamber, Glaucomas where the blood vessels can be visualised, Neovascular Secondary Glaucomas and secondary glaucoma can result. Ocular injuries have been recognised as a Ischaemic central retinal vein occlusion common cause of monocular blindness8 in Diabetic retinopathy and central retinal (thrombotic glaucoma) is the second most several studies and secondary glaucoma is vein occlusion account for nearly two- common cause of ocular neovascularisa- one of the principle causes of visual thirds of patients with neovascular glauco- tion and glaucoma is seen in 58–86% of impairment. Although there is no large ma.4 these eyes.6 Essential hypertension and pri- population based series study on the preva- mary open angle glaucoma remain the lence of the traumatic glaucomas, the Secondary glaucomas associated with principle aetiological factors in the patho- Aravind Comprehensive Eye Survey has proliferative diabetic retinopathy and genesis of central retinal vein occlusion. found a prevalence of 0.2% of glaucoma in central retinal vein occlusion individuals with trauma (unpublished Neovascular glaucoma may occur in dia- Management of the neovascular data). Most ocular trauma and ocular mor- betics where abnormal new blood vessel glaucomas bidity has been reported in males in the formation has occurred causing distur- younger age group, accounting for severe bance to the outflow of aqueous at the Ideally, eyes with conditions where neo- economic burdens in terms of days lost in angle of the anterior chamber. vascular glaucoma is likely should be iden- work and expenditure on treatment. Early Ocular neovascularisation and glaucoma tified early, and prophylactic panretinal recognition of trauma and elucidation of may develop in 33–64% of eyes with laser photocoagulation given. Fundus fluo- the mechanism of glaucoma is vital to untreated, proliferative diabetic retinopa- rescein angiography (FFA) can be used to prevent visual loss. thy.5 Diabetic retinopathy is a leading detect retinal capillary closure in eyes with cause of blindness in persons aged 20–74 central vein occlusion, and this should be Haemorrhage into the anterior chamber years. With improved treatment available done 6–8 weeks after the onset, once the (hyphaema) and angle recession for diabetes, life expectancy has been retinal haemorrhages have cleared. All dia- greatly increased, resulting in many more betics with retinal neovascularisation Degenerate red blood cells may block the individuals with diabetic retinopathy. should have panretinal photocoagulation. trabecular meshwork at the angle of the Effective metabolic control of diabetes in If facilities are not available for FFA, clini- anterior chamber and there may be a sec- the population, efficient screening for early cal signs of ischaemia should be used to ondary rise of intraocular pressure. A total detection and treatment of diabetic detect eyes at high risk (i.e., extensive cot- oralmosttotalhyphaemamaybeassociated retinopathy and retinal photocoagulation of ton wool spots). with a rise in pressure and, also, blood eyes with proliferative diabetic retinopathy Treatment by panretinal photocoagula- elements may penetrate the cornea result- are vital in prevention and management of tion of established ‘rubeotic’ glaucoma is ing in corneal blood staining – which is neovascular glaucoma. Glaucomas which often not successful, as permanent changes very slow to clear. This type of hyphaema remain uncontrolled with lasers and con- occur in the drainage angle. should be surgically released by paracent- servative therapy may be treated with Future research is directed at evolution esis. cyclophotocoagulation with the newer Nd: of the inhibitors of angiogenesis to combat Further, if the haemorrhage has been the YAG or semiconductor diode lasers with neovascular glaucoma. Antibodies to vas- result of a severe blunt injury, for example, the option of glaucoma filtering surgery cular endothelial growth factor(VEGF), the with damage to the trabecular meshwork and adjunctive antifibrosis agents. principle peptide involved in angiogenesis, and the angle of the anterior chamber, later Neovascular glaucoma (rubeotic glauco- have been succesful in reversing new ves- healing with fibrosis may cause a severe Community Eye Health Vol 14 No. 39 2001 41 Secondary Glaucomas type of secondary raised intraocular pres- Pigment Dispersion Syndrome/ hyphaema; removing a hypermature lens), sure (post-traumatic angle recession). Pigmentary Glaucoma plus other interventions to restore sight. Long term treatment to control the IOP Drug-induced Secondary Glaucoma In certain eyes, pigment particles may may be required, or glaucoma surgery once circulate abnormally in the aqueous fluid, the eye has become quiet and stable Corticosteroid-induced glaucoma and these in turn may cause blockage at If there is not the potential for useful the drainage angle. There is some debate as vision (i.e., secondary glaucoma due to Longer term use of topical and systemic to whether this form of glaucoma should CRVO or end stage diabetic retinopathy), corticosteroids can result in a rise of be described as primary or secondary the aim of management is to give sympto- intraocular pressure, which is usually glaucoma. matic pain relief (e.g., mydriatics and reversible once the medication is discon- steroids, injection of retrobulbar alcohol). tinued. Glaucoma due to the indiscriminate Exfoliation Syndrome/ use of topical corticosteroids for allergy Pseudoexfoliative Glaucoma Comment and spring catarrh has left children blind from glaucomatous optic atrophy. Abnormal accumulation of particles (not Though secondary glaucomas numerically Ophthalmologists have a pivotal role to unlike dandruff in appearance) may accu- represent a smaller percentage than the play in preventing such needless blindness mulate in the anterior eye. This abnormal primary forms of the disease, they never- by enabling appropriate education of material can cause blockage of the theless cause significant ocular morbidity health workers and the general public, drainage angle. Pseudoexfoliative glau- and visual impairment. Early identification together with control of the availability of coma is particularly found in Sudan, of the primary ocular and systemic dis- corticosteroids. Somalia, Ethiopia and Tanzania. It is less eases that predispose to the secondary common in West Africa. Some consider glaucomas would play a significant role in Uveitis and Secondary Glaucomas this to be a form of primary glaucoma. limiting the burden of needless blindness.

In uveitis, cells and proteins in the ante- Epidemic Dropsy References rior chamber disturb the normal outflow of aqueous fluid through the trabecular mesh- This acute toxic disease is caused by the 1 Thylefors B, et al. Global data on blindness: an unintentional ingestion of Argemone mexi- update. WHO/PBC/94.40, World Health work, causing raised intraocular pressure. Organization, 1994, Geneva. Using a focal light and magnification a cana oil, an adulterant of cooking oils. It 2 Quigley H A. The number of people with ‘flare’ may be seen in the anterior cham- has been reported in India, Mauritius, Fiji, glaucoma worldwide. Br J Ophthalmol 1996; ber—like a shaft of sunlight streaming into Bangladesh and southern Africa. Rash, 80: 389–393. oedema of the lower limbs, gastrointestinal 3 Fletcher A, Thulasiraj RD, et al. Low uptake of a room full of dust. As a result of the eye services in rural India: A challenge for inflammatory reaction within the eye there and cardiovascular disturbances may be programs of blindness prevention. Arch may be adhesions between the pupil mar- accompanied by a secondary form of glau- Ophthalmol 1999; 117:1393–1399. coma and retinal vascular abnormalities. 4 Grant W M. Management of neovascular gin and the anterior lens surface (posterior glaucoma. In: Leopold IH,ed. Symposium on synechiae) and/or in the angle of the anteri- ocular therapy, vol 7, St.Louis, The CV Mosby or chamber (peripheral anterior synechiae). Prevention of Secondary Glaucomas Co,1974. The pupil will dilate irregularly if posterior 5 Madsen P H: Rubeosis of the iris and haemor- • Accessible, affordable cataract services rhagic glaucoma in patients with proliferative synechiae are present. Occasionally the of high quality to prevent lens induced diabetic retinopathy. Br J Ophthalmol 1971;55: adhesions may be total, affecting the entire 368–371. glaucoma pupil margin, and this is described as 6 Sinclair S M, Gragoudas E S. Prognosis for • Good management of hypertension to seclusio pupillae. The iris bows forward as rubeosis iridis following central retinal vein reduce retinal vein occlusions occlusion. Br J Ophthalmol 1979; 63: 735–742. aqueous fluid cannot pass through the • Good control of diabetes to prevent 7 Adamis A P, et al. Inhibition of vascular pupil and this further embarrasses the endothelial growth factor prevents retinal neovascular glaucoma drainage angle of the anterior chamber— ischaemia- associated iris neovascularisation in • Early detection and good management a non human primate. Arch Ophthalmol 1996; described as ‘iris bombé’. of conditions associated with the 114: 66–71. Glaucoma secondary to uveitis is an 8 Katz J, Tielsch JM. Lifetime prevalence of ocu- potential for retinal ischaemia and important clinical entity, often with severe lar injuries from the Baltimore Eye Survey. Arch neovascularisation Ophthalmol 1993; 111: 1564–1568. visual impairment. The management is • Increased awareness among eye care 9 Panek WC, Holland GN, Lee DA, Christensen complex since complicated cataract, macu- professionals, the public and RE. Glaucoma in patients with uveitis. Br J Ophthalmol 1990; 74: 223–227. lar oedema and media haze largely con- pharmacists of the dangers of topical ❏ tribute to ocular morbidity apart from glau- (and systemic) steroids comatous optic nerve damage. It has been • Health education about avoiding eye TEACHING EYE HEALTH reported that between 5.2 and 19% of eyes injuries. with uveitis develop secondary glaucoma.9 Detlef Prozesky MBChB MCommH PhD Though most uveitic entities are idiopathic, Treatment known causes include infections like lep- The seventh article in the Teaching Eye tospirosis, toxoplasmosis, AIDS, oncho- The management of eyes with secondary Health series on cerciasis and drug-resistant tuberculosis. glaucoma depends on whether there is the Evaluation of Courses Adequately combating these microbial potential for useful vision: infections can significantly reduce ocular If there is, then treatment should be will be in the next issue of the Journal morbidityduetouveitis – apartfromaddres- aimed at lowering the IOP, reducing any Volume 14, Issue No. 40 sing the cause of elevated ocular pressures associated inflammation, and treatment of Editor and the institution of appropriate therapy. the underlying cause(s) (i.e., removal of a

42 Community Eye Health Vol 14 No. 39 2001 Questions & Answers

Chronic Glaucoma Case Finding and Treatment in Rural Africa: Some Questions and Answers Colin Cook All persons 40 years and over who are MBChB FCS(Ophth)SA seen by primary health care workers for whatever reason could be screened in this FRCOphth way at least once every 2 years. KwaZulu-Natal Blindness Prevention Programme Case Finding at the Secondary Level: PO Box 899 Should it Be Done? Hilton 3245 South Africa Ophthalmic nurses and ophthalmic med- rimary health care workers (clinic ical assistants could carry out case finding Pnurses, community health workers, tra- at the secondary level. As a part of their ditional healers, and others) who work in training, these cadres of eye workers should be trained to case find glaucoma by: Cupping of the optic nerve head the community and at primary care clinics Graphics: Hugh Lugg should be involved in case finding of 1. Discoscopy and measurement of the Photos: Pak Sang Lee, Gordon Johnson patients who have glaucoma. vertical cup : disc ratio. & Moorfields Eye Hospital 2. Tonometry (either Schiotz or Case Finding at the Primary Level: applanation). examination, and this screening could be Can it Be Done? • IOP on Schiotz tonometry <28mmHg + done at least once every 2 years. While it → As a part of their training in primary eye vertical cup : disc ratio <0.6 ‘normal’ would be possible for presbyopia to be • IOP on Schiotz tonometry >28mmHg + treated at the primary level, confining this care, primary health care workers could be → vertical cup : disc ratio <0.6 ‘suspect to the secondary level would provide good trained to case find glaucoma by: → case’ refer to tertiary level for opportunity for glaucoma case finding in 1. Testing the visual acuity (‘normal’ or confirmation of diagnosis and treatment these patients. ‘reduced’). • IOP on Schiotz tonometry <28mmHg + 2. Examining the colour of the pupil vertical cup : disc ratio >0.6 → ‘suspect Confirmation of Diagnosis at the (‘black’ or ‘white’). case’ → refer to tertiary level for Tertiary Level: How Should This Be confirmation of diagnosis and treatment • Reduced visual acuity in one or both Done? eyes + black pupil = ‘blackblindness’/ • IOP on Schiotz tonometry >28mmHg + → visual loss (‘glaucoma’) →refer to vertical cup : disc ratio >0.6 ‘diag- All ‘suspect cases’ and ‘diagnosed cases’ → secondary level nosed case’ refer to tertiary level for should be seen by the eye doctor at the ter- confirmation of diagnosis and treatment. Many of these patients with ‘black blind- tiary level, for confirmation of the diagno- ness’ will not have visual loss due to glau- All persons 40 years and over who are seen sis and then for treatment. Visual field test- coma but may have a refractive error or by secondary level eye workers for what- ing should confirm the diagnosis, but it other pathology that should still be dealt ever reason could be screened for glau- may be impractical and unreliable in some with at the secondary level. coma in this way as a part of their routine patients. If it is considered inappropriate to use these, it would be necessary to rely on Proposal: What About a Glaucoma Surgery Rate (GSR)? tonometry and discoscopy. We have a ‘cataract surgery rate’ that we use for the planning of our cataract services. Would it be helpful to use a ‘glaucoma surgery rate’ for the planning of our glaucoma services? Treatment at the Tertiary Level: If we make a number of assumptions, we could derive such a ‘GSR’ as follows: Should it Be Medical or Surgical? 1. For a population of one million people, the population over 40 years who are at risk is What are some of the arguments in favour 25% = 250,000. of medical treatment? 2. The prevalence of glaucoma in people over 40 years is 1-2% = 2,500 – 5,000 cases (in Africa, the prevalence could be double this rate). • It avoids the inconvenience and expense 3. Of the 5,000 cases, 50% have early glaucoma, 10% are already blind, and 40% (2,000 cases) of surgery, and it avoids the risks of have moderate, detectable, and treatable glaucoma. surgery. 4. As patients develop glaucoma, they progress slowly through the early to the intermediate to the What are some of the arguments against late phase of the disease. If it takes 10 years to progress from ‘onset of disease’ to ‘blind’, it takes medical treatment? 4 years to progress through ‘moderate / intermediate disease’. • It is expensive, it is life-long, it is incon- 5. Cases with moderate / intermediate disease are the priority target group for community case venient, it may cause unpleasant side detection and surgery. effects, the treatment regimens may be 6. Therefore, each year the glaucoma surgery rate should be 500 per million population. confusing, it may be difficult for patients Whilst there are still too many assumptions about the prevalence, incidence, and rate of progression to collect and to store their medicines, of the disease to be able to derive a reliable glaucoma surgery rate, this figure of 500 per million patient compliance is poor, and it may population per year is a conservative estimate of the numbers of glaucoma surgeries that we be difficultfor theservice providerto probably should be doing. ensurereliable supplies ofthemedicines.

Community Eye Health Vol 14 No. 39 2001 43 Glaucoma Case Finding

What are some of the arguments against Summary of an Approach to Glaucoma in a Blindness Prevention Programme surgery? 1. For a population of one million people, there are an estimated 2,000 people with moderate, • It is inconvenient, it is expensive, it car- detectable, and treatable glaucoma. ries risk, and there may be failure of the 2. Case finding at the primary level can be undertaken by: surgery. • Testing the visual acuity and examining the colour of the pupil • All people who are 40 years and over who are seen for whatever reason should be screened What are some of the arguments for • Reduced visual acuity + black pupil = ‘black blindness’ (glaucoma); refer to secondary level. surgery? 3. Case finding at the secondary level can be undertaken by: • It is less expensive than medical • Tonometry and discoscopy treatment in the long run, there is better • All people who are 40 years and over who are seen for whatever reason should be screened control of the intraocular pressure • Cases should be categorised as ‘normal’, ‘suspect case’, and ‘diagnosed case’ according to the ≥ ≥ compared with medical treatment, and intraocular pressure (< 28mmHg, or 28mmHg) and the vertical cup: disc ratio (<0.6, or 0.6) there is less visual field loss compared • ‘Suspect cases’ and ‘diagnosed cases’ should be referred to the tertiary level. with medical treatment. 4. Confirmation of diagnosis at the tertiary level may be done by repeat examination, with or without visual field examination. After weighing up the arguments for and 5. Treatment of glaucoma should be as follows: against medical and surgical treatment: • Primary trabeculectomy, with adjunct if indicated, should be the first line of treatment (the 1. In our blindness prevention program- glaucoma surgery rate should be 500 per million population per year) mes, glaucoma should be considered • Medical treatment should be used if there is inadequate intraocular pressure control following primarily a ‘surgical’ rather than a trabeculectomy. ‘medical’ condition. 6. Patients whose intraocular pressures have been adequately controlled following trabeculectomy should be followed up at the secondary level at regular 6 monthly intervals. The keeping of a 2. Primary trabeculectomy (with adjunc- glaucoma register would ensure that no patients are lost to follow-up. tive treatment with cytotoxic drugs or beta – irradiation, using a strontium 90 plaque if there is a risk factor for bleb What About Follow-up? tonometry, and discoscopy. fibrosis and failure) should be the first The ophthalmic nurse / ophthalmic med- line of treatment. Patients who have had surgery could be ical officer could keep a register of glauco- 3. Medical treatment should be reserved followed up at the secondary level. Assum- ma cases in their health district, so that for ‘failure’ of surgical treatment (that ing adequate intraocular pressure control, patients can be contacted if they fail to is, bleb fibrosis and failure or inade- they could be seen at regular 6 monthly attend for follow-up. quate intraocular pressure control fol- intervals, when their examination should Relatives of patients with glaucoma lowing trabeculectomy). include measurement of the visual acuity, should attend for assessment. ❏

ROYAL COLLEGE OF OPHTHALMOLOGISTS 17 Cornwall Terrace, Regent’s Park, London NW1 4QW, UK

Diploma Examination in Ophthalmology DRCOphth ANNOUNCING A CHANGE TO THE STRUCTURE From November 2001, there will be no Practical UK and Overseas Examination Calender 2002 Refraction section in the Diploma Examination Exam Dates of Examination Location Closing Date The New Diploma Examination (DRCOphth) is a test of ophthalmic knowledge including relevant basic Part 1 21–22 January UK 10 December sciences and clinical skills for candidates who have MRCOphth 22–23 April UK, India 11 March worked in ophthalmology for one year (full-time or 7–8 October UK, India 26 August equivalent). This work experience need not have been gained in the UK. Part 2 17–21 June UK 6 May MRCOphth 9–10 October India 26 August 4–8 November UK 23 September Information, Exams syllabi, Applications from: The Head of the Examinations Department at Part 3 4–8 March UK 21 January the above address MRCOphth 9–13 September UK 29 July Or Tel: 00 44 (0) 20 7935 0702 10–11 October India 26 August Or Fax: 00 44 (0) 20 7487 4674 Or E-mail: [email protected] DRCOphth 27–28 June UK 16 May Or visit the College website www.rcophth.ac.uk 18–19 November UK 7 October Overseas Locations: • Aravind Eye Hospital, Madurai, Tamil Nadu, India • The British Council, Cairo, Egypt

44 Community Eye Health Vol 14 No. 39 2001 IGA

which are freely available to all. Over the last year we have been improv- International Glaucoma ing our systems so as to be of service to more people. These developments will be Association implemented and available over the next year tosupportallthose whoneedourhelp. he International Glaucoma Associ- ledge or support canbecome a major factor in the deterioration of any medical condi- As a charity we are funded entirely by Tation, a registered charity based in the donations of our members, friends and London, is a membership organisation with tion. Failure to understand the need for early the general public. This generosity from 26 years experience in helping people with those we have helped and colleagues glaucoma. detection and effective treatment leads to much unnecessary blindness in the world enable us to fund our information services The aims today are the same as those of and helpline, run awareness campaigns and 26 years ago, when our founders and first today. The Association is developing a number of different initiatives to provide research into the causes and treatment of members, a group of patients, doctors and glaucoma. medical staff at Kings College Hospital, information to the public and professionals alike wherever they may be. Further, we The vision and spirit of service of our London gave us a vision in our articles of team; members, friends, donors,doctors and association: have an international individual personal and professional membership together with staff has not changed in a new century – we • To preserve sight by the education of an affiliate programme for similar organi- are willing and able to help those who need patients,the public,medical practitioners sations anywhere in the world. our help. and allied professions in the problems of Our information service and support to For further information please contact us: glaucoma, especially (but without the community is, we believe, second to International Glaucoma Association limiting the generality of the foregoing) none: 108c Warner Road, London SE5 9HQ those problems involved in its early United Kingdom recognition and the maintenance of a • Our website at www.iga.org.uk which high standard of treatment receives over 30,000 enquiries a month Tel: (+44) 20 7737 3265 • To advance or facilitate research into the • Our Sightline on (+44) 207 737 3265 Fax: (+44) 20 7346 5929 causes, treatment and alleviation of (09.30 to 17.00 GMT) Development Department Direct Line: glaucomaandtoensurethedissemination • Over the internet from [email protected] (+44) 20 7346 5928 of the results of such research to the pro- These services are supported by a range of E-mail: [email protected] fessions and the public. leaflets (developed from the questions of Web: www.iga.org.uk In many cases, lack of awareness, know- our friends and members to our Sightline) Report Causes and Visual Outcomes of Perforating Ocular Injuries among Ethiopian Patients Abebe Bejiga MD country has not been studied previously. and sex distribution, post-operative comp- Department of Ophthalmology This review was conducted to assess the lications, visual outcome of open globe Faculty of Medicine magnitude, causes and visual outcomes of injury and duration of follow-up. The Addis Ababa University ocular trauma cases at Menelik II Hospital patient was categorised as monocular blind PO Box 9086 in Addis Ababa. if the visual acuity of the injured eye was Addis Ababa, Ethiopia less than 3/60 (or counting fingers (CF) Patients and Methods at less than 3 metres). However, the new Introduction standardised ocular trauma classification 2 All patients with open globe injury who was not applied and as a result was not Ocular trauma, in particular open globe were operated on at the Department of used in this analysis. injury, is an important cause of monocular Ophthalmology, Faculty of Medicine of visual impairment and blindness in the Addis Ababa University, Menelik II Results younger and economically active age Hospital, Addis Ababa over a one year group.1 Besides loss of vision, earnings period (January 1998 – December 1998) Two hundred and four patients with perfo- (job opportunities) and productivity, it were reviewed. rating ocular injuries underwent surgery increases the cost to society because of The chart numbers of patients with open during the study period. All had injury to increased healthcare spending. globe injury were obtained from the reg- only one eye. Of the total eye operations Although it affects all age groups, previ- istry book of the major operating room. In done in the major operating room during ous reports have indicated that ocular trau- addition to those obtained from the operat- the study period, 8.4% were due to perfo- ma victims are predominantly males and ing room registry book, data such as cause, rating ocular injury. Male patients were young, with the majority under 30 years of date and duration of injury, visual acuity, threetimesthenumberoffemales,asshown age. In those between 20 and 44 years of type and extent of injury, medical treat- in Table 1. The age ranged between 1.5 and age, injuries account for 10% of incident ment given before surgery, and profession 65 years, with the average being 19.4 bilateral blindness.1 of the patient were documented. years. One hundred and fifty-four (75.5%) The magnitude of ocular injuries in our Finally, analysis was made as to the age patientswereaged30yearsorunder. Community Eye Health Vol 14 No. 39 2001 45 Eye Injuries in Ethiopia

The most common causes of perforating ous reports have indicated that ocular trau- Table 3: Anatomy of Eye Injuries ocular injuries were wood, metal and stone ma victims are predominately young with a Types No. of Patients (%) objects in 67 (32.8%), 58 (28.4%) and 29 majority under 30 years of age. Males Cornea 40 (19.6) (14.2%) respectively (Table 2). Most of the greatly outnumber females as victims of Cornea + Lens 88 (43.1) injuries occurred during chopping or cut- eye injuries with a male to female ratio Corneo + Sclera 23 (11.3) ting wood, hammering metals or nails and ranging from 3:1 to 12:14,5 and the greatest Sclera 14 ( 6.9) carving stone. These are associated with number of eye injuries occurred in school- Ruptured globe 39 (19.1) 6 professions such as farming, garage work age children. Our results were in agree- Total 204 (100 %) and carpentry in adults. Children, on the ment with this trend as 75.5% of other hand, mostly sustained accidental the cases were males and 75.5% Table 4: Pre-operative and Post-operative injuries by rubber bands, needles, pencils, were also aged 30 years or under. Visual Status of the Eyes etc. while playing with others. Work-related injuries are des- Visual Acuity Initial (%) Final (%) In the majority of cases, 151 (74%), the cribed as the commonest cause of NLP 39(21.2) 39(21.2) cornea was involved either alone (40 cases) ocular trauma among adults.3,5 On LP 87(47.3) 30(16.3) or in association with the lens (88 cases) or the other hand, the most common CF < 3 metres 39 (21.2) 72(39.1) the sclera (23 cases), as seen in Table 3. cause of paediatric injuries were CFat 3 metresorbetter 19(10.3) 43(23.4) Twenty patients (9.8%) were too young to accidental blows and falls. Indus- Total 184(100%) 184(100%) have their visual acuity taken. Of the trial injury to the eye is rare in our to manage the complications of injury. We remaining 184 patients, 165 (89.7%) had country, and here the major causes were do not have trained personnel in corneal pre-operative visual acuity recorded as related to farming, carpentry or garage transplantation. We also lack a vitreo- blind in the involved eye (Table 4). Post- work. retinal surgeon to manage vision threaten- operatively, 141 (76.6%) cases had visual The visual outcome of perforating ocu- ing posterior segment injury such as acuities of less than 3/60 (CF < 3 metres). lar injuries depends on the type of trauma vitreous haemorrhage or retinal detach- Thirty-nine (19.1%) cases with ruptured sustained. Injuries from sharp objects have ment. In our cases, 89.7% were blind globe were eviscerated. a better prognosis compared with those before surgery as opposed to 76.6% after caused by blunt objects. This is because surgery to the injured eye. The improve- sharp objects cause laceration with damage Discussion ment in the visual acuity of some patients confined to the underlying tissue whereas 3 was due to cataract extraction with lens A hospital based study has revealed that those caused by blunt objects result in implantation performed in these cases. severe injuries such as ruptured globe, widespread damage which, in the case of The Department is a tertiary centre intraocular foreign bodies, hyphaema and sufficiently high force, may rupture the where patients are referred for better orbital or facial fractures constitute about globe. management. Efforts must be made to 5% of all ocular trauma cases. In this study, The severity of trauma is also among the strengthen the capacity of the Department only perforating ocular injuries were prognostic factors used to predict the final to handle perforating ocular injury cases looked at rather than the whole spectrum of visual outcome. Injuries associated with a appropriately. eye trauma cases. However, ocular injury wound 4mm or longer,3 combined anterior cases constituted 8.4% of all ocular opera- and posterior segment injuries,5 lens dislo- References tions performed in the major operating cation, vitreous haemorrhage, intraocular room during the study period. foreign bodies, scleral wounds and afferent 1 Tielsch J M, Parvel L, Shankar B. Time trends in Although it affects all age groups, previ- pupillary defect 7 were found to have poor the incidence of hospitalised ocular trauma. Arch Ophthalmol 1989; 107: 519–523. Table 1: Age and Sex Distribution of Cases prognoses. In this retro- 2 Kuhn F, Morris R, Witherspoon C D, et al. A with Ocular Injury spective review, the severi- standardized classification of ocular trauma. ty of injury was difficult to Ophthalmology 1996; 103: 240–243. Age (yrs.) Sex Total (%) ascertain. 3 Schein O D, Hibberd P L, Shingleton B J, Kunzweiler T, Frambach D A, Seddon J M, Male Female 5,7,8 Previous studies Fontan N L, Vinger P F. The spectrum and bur- <10 43 20 63 (30.9) have indicated that an ini- den of ocular injuries. Ophthalmology 1988; 11-20 42 8 50 (24.5) tial visual acuity of the 95(3): 300–305. 21-30 33 8 41 (20.1) 4 Eagling E M. Perforating injuries of the eye. Br J 31-40 18 10 28 (13.7) traumatised eye has a pre- Ophthalmol 1976; 60: 732–736. 41-50 13 3 16 ( 7.8) dictive value in regard to 5 Quah B L, Yeo Y S I, Ang C L. A retrospective 51-60 3 0 3 ( 1.5) the final visual outcome. study of open globe injuries seen at Singapore 61-70 2 1 3 ( 1.5) They showed that initial National Eye Centre (SNEC) in 1995. Asia- Pacific Journal of Ophthalmology 1997; 9(2): Total 154 (75.5%) 50 (24.5%) 204 (100%) visual acuity of 5/200 18–23. (1.5/60) or better was asso- 6 Strahlman E, Elman M, Daub E, Baker S. Table 2: Causes of Injury ciated with a favourable prognosis. Causes of pediatric eye injuries: A population The management of ocular injury seeks based study. Arch Ophthalmol 1990; 108(4): Cause No. of Cases (%) 603–606. Wood 67 (32.8) to restore the anatomy and function of the 7 Juan E D, Sternberg P, Michels R G. Penetrating Metal 58 (28.4) eye to its pre-injury state. Visual rehabilita- ocular injuries: Types of injuries and visual Stone 29 (14.2) tion of the injured eye often requires the results. Ophthalmology 1983; 90(11): ‘Man-induced’ 18 ( 8.8) 1318–1322. involvement of several sub-specialists. 8 Williams D F, Mieler W F, Abrams G W, Lewis Miscellaneous causes Diagnostic means such as ultrasonography H. Results and prognostic factors in penetrating (glass, fall, rubber, and radiography need to be readily avail- ocular injuries with retained intraocular foreign pencil, animal, explosive) 20 ( 9.8) able with trained personnel. bodies. Ophthalmology 1988; 95(7): 911–916. Unknown 12 ( 6.0) About 2/3 of our patients remained blind Total 204 (100 %) in the injured eye. This was due to failure ✩ ✩ ✩ 46 Community Eye Health Vol 14 No. 39 2001 Report

T h e E l i m C a r e G r o u p s : A C o m m u n i t y P r o j e c t for the Control of Trachoma Erika Sutter MBBCh DO re-infection by motivating mothers to Bachlettenstrasse 31 improve hygienic conditions in their CH-4054 Basel homes. This rationale led us to involve the Switzerland communities themselves in the control of trachoma. Selina Maphorogo PO Box 471 Approaching the Community Elim Hospital 0960 Northern Province, South Africa The project was set up in 1976 to establish groups in villages in the area around the Introduction hospital. Because the majority of the men were working in distant cities, the groups, Good standards of personal hygiene The Far North of South Africa, where Elim Photo: Erika Sutter Hospital is situated, has been known as the later called Care Groups, were mostly trachoma belt. The disease was the main joined by women. The Project Co-ordina- thus be built upon traditional wisdom, and cause of preventable blindness in the area. tor, based in the hospital, was assisted by a the feeling that their ideas were respected In the 1970s the local epidemiological pat- number of Motivators. The idea spread won the people’s trust and interest. tern of trachoma was studied in the region very rapidly, and by the end of the first Mothers were keen to learn more about the served by Elim Hospital.1 Several ran- year 24 of the approximately 80 settle- nature and spread of trachoma in order to domised population surveys were carried ments served by the hospital already had a protect their own and their neighbour’s out, and the results indicated that pre- Care Group. children from infection. Thus, starting in school children aged 2–4 years represented Trachoma was well known in the area, three villages, interested women joined the main reservoir of infection in the com- and the people were concerned about it. together to form Groups of unpaid volun- munity; that spontaneous cure tended to Several popular beliefs about the disease, teers. Their aim was to improve health and occur at school-going age; and that repeat- handed down over many generations, testi- the quality of life in their homes and in ed re-infections later in life eventually led fy to this concern. Some examples illus- their community. In most cases they started to blinding complications, especially in trate the remarkably accurate observations, with trachoma and later moved on to gen- women tending young children (Fig.1). which have become disguised in so-called eral health and development. Men who were absent from their homes superstition. For example, people insist The Groups chose their own steering most of the time as migrant labourers, were that every child should have ‘mavoni’, i.e., committees which formed the liaison much less affected. These findings discharging eyes in childhood, in order to between the Groups and the hospital-based explained why many years of school treat- see well later in life. In fact, the majority of project leadership, i.e., the Co-ordinator ment schemes had not reduced the overall children acquire trachoma within the first and the Care Group Motivators. The prevalence of intense trachoma and its three years of life, and by the time they go Motivators visited the Groups regularly for complications in the population, as pre- to school the disease has usually resolved ongoing health education and discussions. school children continued to spread the without affecting vision. Also, it was said Alternatively, the Clinic Nurse or the disease. Hence, measures to control tra- that a multiparous woman who fails to Community Health Worker took care of choma should have two main goals. First, inform her mother-in-law about her new the local Group. to reduce the infective load in the commu- pregnancy will get eye trouble after the nity by treating young children with tetra- birth of the child and her mother-in-law The Training of Care Groups cycline eye ointment. Second, to prevent will get ‘xinyeku’, that is entropion, or will go blind (‘mahlo ya Working with communities is bound up xidzhwele’). Obviously with a long learning process for organisers, people have observed facilitators and the people in the communi- that blinding complica- ty. There is no room here to discuss this 3 tions occur most fre- process at length. Instead we shall confine quently in large families ourselves to the methods and outcome of with many children – a health education concerning trachoma. fact we also found in our Having tried both nurses and less edu- surveys.2 Finally, the cated assistant nurses as Care Group word ‘xinyeku’ is also Motivators, we found that the latter were used to describe a care- suited for this particular task. They were less, poor and untidy local people with limited schooling, and woman, i.e., entropion were thus culturally nearer to the villagers has long been associ- and related easily to them. In many ated with poor hygienic respects they were more innovative than conditions favouring re- their seniors who had had more formal infection with Clamydia education. However, even these Motivators had first to go through a Fig. 1: Population-based Surveys of Trachoma in a trachomatis. lengthy process of ‘un-learning’ to become Rural South African Community Health education could

Community Eye Health Vol 14 No. 39 2001 47 Trachoma Control in Southern Africa proficient health educators, because their the cornerstones of the control of blinding children, and others talked to waiting own educational experience had been trachoma. Since the supply of tetracycline mothers at the child health clinic. authoritarian one-way instruction. Then, eye ointment was seldom adequate, we In the beginning people were not sure they learnt the skills of leading group dis- were forced to limit treatment to a few whether they could trust a fellow villager cussions, awareness building and encour- selected settlements. The main emphasis who had as little school education as they aging the women to find their own solu- was therefore directed towards the had or was even illiterate. But soon they tions to their problems. There was all too improvement of hygienic practices. These realised that these women had learnt much little guidance for them in the beginning, included digging refuse pits and erecting from their Motivators, and so people began but in spite of this, most managed remark- toilets to reduce the fly population, and to listen to the Care Groups. The health ably well to improve their methods. They washing face and hands frequently. At that messages were easy to understand, because soon realised that routine health talks did time people had already stopped washing they were practical, addressed common not change people’s behaviour. The themselves with their bare hands and had communityproblemsandweredelivered in women needed ample time to absorb the adopted the ‘more distinguished’ Western the villager’s every day language. Further- message, ask questions, argue and discuss face cloths. In practice one single cloth was more, people could watch progress made in until every one understood and agreed on shared by the whole household, thus trans- the homesteads where Care Group mem- action to be taken. In addition, grandmoth- mitting Chlamydia trachomatis from eye- bers were practising what they had learnt. ers had to be drawn in and given an oppor- to-eye. The health message had, therefore, Care Group members were no different tunity to voice their opinion. On their own to stress the use of individual cloths – any to the rest of their community, and strug- initiative, Motivators visited old folk in vil- piece of rag would do, as long as it was gled like the others to survive under the lages, discussed with them their traditional clean. prevailing conditions of poverty and lack way of life and asked them for advice. This In addition to health education for dis- of infrastructure, water, fuel and jobs. good relationship made it easier for young ease prevention and health promotion, the Their example was thus made more con- mothers to introduce new methods in their Group members were also taught to instil vincing, having significant influence in the homes, where traditionally the mother-in- eye ointment. When shown what trachoma community, so that the villagers felt moti- law is dominant. This kind of give and take looks like they too wanted to learn to evert vated to compete with their neighbouring is only possible in smaller groups like the the upper eyelid so that they could identify Care Group members. In our experience Care Groups, and is more promising than cases in their neighbourhood. After having Care Group members proved to be more health lectures to larger audiences where verified that they were careful about wash- believable and more successful than pro- there is little personal commitment. ing their hands each time before touching fessional health workers with higher edu- Care Group members, in their turn, an eye, and performed the procedure gently cational standards, who came from outside were well motivated to apply their new and correctly, we allowed them to go ahead the community, and after the job was done knowledge, because most were in some with case finding. This was a great encour- returned to homes with running water, way affected by the problem trachoma agement to their self-confidence. bathroom and toilet. caused, and, moreover, they had struggled The health messages spread fast in their discussions to find their own solu- Trachoma Control by the Care throughout the communities. After about a tions. They also discussed their difficulties Groups in their Communities year most people understood the dangers amongst themselves and helped each other of trachoma, how it was transmitted and to introduce the necessary change in their The Groups understood that keeping their what to do for its prevention. Many vil- homes. Thus, the famous KAP-gap own homesteads clean was no guarantee of lagersbegantosetnewpriorities,especially (Knowledge, Attitude, Practice) was over- avoiding infection as long as the rest of the for the proper use of the little water which come with relative ease, at least when village did not do the same. It was, there- was available. As they became conscious changes were within the limited financial fore, very important to share their new about the importance of face washing, and social possibilities of the Group mem- knowledge with everyone else in their water was set aside for this purpose, and bers. community. Each Group developed its afterwards used to water the vegetables. As mentioned earlier, treating young own method of communication. Most Refusepitsweredug,andsometoiletswere children and avoiding re-infections were found that it was best to make home visits erected, though too few, because material in small groups where they could was too expensive. Even in very poor support each other and were better settlements the appearance of the home- received by the villagers than steads improved. Fig. 2 shows the effect when they went individually. Care Groups had in their communities on Other Groups made up their own hygienic practices and on knowledge about health songs and went singing and trachoma.4 dancing through the village, Although the Groups’ activities were arousing the curiosity of the vil- predominantly preventive and promotive, lagers, who then joined the according to their slogan, ‘Cleanliness is dancers. When the crowd was big the best medicine’, their message had to be enough Group members told the supported by curative care when neces- audience what they had learnt. At sary. The occasional supply of tetracycline many festive occasions in the eye ointment to the Groups was always community, Care Groups per- encouraging, for both the Groups and the formed sketches about health. community, because they could then actu- Fig. 2: Standard of Hygiene and Knowledge Some Groups decided on their ally carry out treatment. In addition, the hospital strengthened the Care Groups’ about Spread of Trachoma before (1976) own to visit the local school and credibility by a two-way referral system. and after Care Group Activity (1979) instruct and examine the school 48 Community Eye Health Vol 14 No. 39 2001 Trachoma Control in Southern Africa

Groups were allowed to refer patients to regions which had no Care the clinic or to the eye hospital for treat- Groups,toexcludeconfound- ment, and the hospital referred trachoma ing factors. cases to the patients’ local Care Group for further health education. The same system Conclusion was later used for malnourished children. In a few places where the prevalence of tra- The impact of Care Group choma was especially high, mass treatment activity on the improvement through the local Care Group was organ- of health factors such as per- ised to cover the whole community. But sonal and environmental even with no, or only occasional treatment, hygienic conditions or the prevalence decreased significantly in set- prevalence of trachoma has been measured, and proved tlements where Care Groups were active, Fig. 3: Prevalence of Trachoma (TI) to be statistically significant. while there was no change in comparable and Entropion in Relation to the Duration of 4 However, social and human villages which had no Group. Care Group Activity in the values which determine the After 3–4 years the Groups abandoned North of South Africa (1976–1995) their preoccupation with trachoma, as they quality of life, even more were satisfied with the results of their cam- than health does, cannot be measured and agement teams composed of Care Group paign, and turned to general health care, expressed in actual figures. Over the years members, who have taken over responsi- vegetable gardening and community devel- we observed many remarkable changes in bility for the Groups in their area. Thus, opment. Our fear, that the incidence of the Care Group members’ attitudes to variation in motivation or changing inter- trachoma could rise again when the Groups themselves and their communities. They ests can more easily be accommodated. discontinued their specific preventive discovered their skills as health advisors, in The continuous presence of the Groups and activities against the disease, was not sub- problem solving and in leadership, and the size and popularity of the movement stantiated. On the contrary, its prevalence experienced that as a Group they were have contributed to an ongoing high level continued to fall.5 This is demonstrated in strong and could achieve much. This of health consciousness in the population. Fig.3, where all population surveys on boosted their self-confidence and helped trachoma in the area where Care Groups them to regain their human dignity as References Black rural women, which the discrimina- operated have been summarised. After 5 to 1 Ballard R C, Sutter E E, Fotheringham P. 10 years trachoma was no longer blinding, tory tribal and apartheid society had denied Trachoma in a Rural South African Community. and had ceased to be a public health prob- them. Am J Trop Med Hyg 1978; 27 : 113–120. lem. Accordingly, patients with entropion Now, more than 20 years since its begin- 2 Ballard R C, Fehler H G, Sutter E E, Treharne J D. Trachoma in South Africa. Soc Sci Med 1983; presenting at the hospital had become rare. ning, the Care Group Project is still thriv- 17 : 1755–1765. This development was surprising, as ing and continues to adapt to the changing 3 Sutter E, Foster A, Francis V. Hanyane, a unemployment and poverty in the area was needs.6 There are Care Groups in almost Village Struggles for Eye Health. Macmillan every settlement in the region, amounting Publishers, London, 1989. rather on the increase. Other factors may 4 Sutter E E, Ballard R C. Community also have contributed to the control of the to approximately 250 Groups with a total Participation in the Control of Trachoma in disease, such as improved water supply of 10,000 women. The Project differs from Gazankulu. Soc Sci Med 1983; 17 : 1813–1817. and a general change in people’s attitudes, the majority of other community health 5 Ijsselmuiden C B, Bucher P J M, Baloyi C T, Sutter E E. Unpublished study, 1985. which meant that despite low incomes, bet- institutions in its emphasis on Group action 6 Sutter E, Ijsselmuiden C. Still going after all ter housing and improved hygienic stan- rather than individual health workers. Such these years …?! Bull medicus mundi 1998; 69: dards were considered to be important. a system is more stable, especially as the 12–15. Unfortunately, it has not been possible to Groups are networking with each other, ✩ ✩ ✩ perform control studies in comparable aided by strong and capable regional man- Manual Price: UK£6.00/US$10.00 each incl. Post S u p p u r a t i v e and Packing Payment Details: Credit card or cheque/banker’s order drawn on K e r a t i t i s UK£ or US$ bank accounts payable to: UNIVERSITY COLLEGE LONDON AK Leck, MM Matheson, J Heritage Address:InternationalResourceCentre, A laboratory manual and guide 11-43 Bath St., London ECIV 9EL Tel: 00 44 20 7608 6910 to management of Gram –ve rods (Pseudomonas) and white microbial keratitis cells Fax: 00 44 20 7250 3207 Photo: Melville Matheson E-mail: [email protected]

A very useful and much-needed guide with • Identifying bacteria and fungi colour photographs. The 25-page manual • Lactophenol cotton-blue mount has the following sections: • Culture techniques • Schematic guide to identification of • Corneal ulcer patient proforma common causative organisms • Corneal scrape • Fungal culture/Filamentuous fungi • Gram Stain • Acanthamoeba sp. Gram stain may show fungal hyphae • Using the microscope • Treatment recommendations Photo: Melville Matheson Community Eye Health Vol 14 No. 39 2001 49 Abstracts

from 775,000 to 1,169,000. When the E v a l u a t i o n o f a N a t i o n a l E y e C a r e results were standardised for age, a west to P r o g r a m m e : R e - s u r v e y a f t e r 1 0 Y e a r s east gradient was found for changes in risk of blindness over the 10 year period. This Hannah Faal account the marked increase in population matched the phased west to east introduc- Darwin C Minassian in the Gambia, west Africa. Samples of the tion of the NECP interventions. There was whole population in 1986 and 1996 were a modest but significant increase in the risk Paul J Dolin taken. The definition of blindness is pre- of low vision across the whole country. Abdirisak A Mohamed senting vision less than 3/60 in the better Conclusions: The overall reduction in risk Jeff Ajewole eye, or visual fields constricted to less than ° of blindness, in those areas where the Gordon J Johnson 10 from fixation. Low vision is less than NECP has been active, appears to justify 6/18 but 3/60 or better. Causes of blindness the programme and the support of donor Aim: To re-survey the Gambia after an were determined clinically by three oph- organisations. The low vision cases due to interval of 10 years to assess the impact of thalmologists. cataract must now be addressed. a national eye care programme (NECP) on Results: The crude prevalence of blind- Published courtesy of : the prevalence of blindness and low vision. ness fell from 0.70% to 0.42%, a relative Br J Ophthalmol 2000; 84: 948–951 Methods: Comparison of two multistage reduction of 40%. During the same 10 year cluster random sample surveys taking into period, the population increased by 51%

Patterns of Open-angle Glaucoma in the Barbados Family Study M Cristina Leske interview, and genotyping. Generalized intraocular pressure (IOP), myopia, and Barbara Nemesure estimation equation methods were used to lower diastolic blood pressure – IOP dif- evaluate risk factors in the siblings, includ- ferences were related to OAG, whereas Qimei He ing demographic, medical and ocular char- hypertension and diabetes were not. Suh-Yuh Wu acteristics. Conclusions: Based on standardized pro- James Fielding Heftmancik Main Outcome Measures: Presence of tocols and examinations, approximately Anselm Hennis OAG in the relatives, as defined by both one quarter of the relatives had OAG or Objective: To describe the Barbados visual field and optic disc findings, after suspected OAG, despite their relatively Family Study of open-angle glaucoma ophthalmologic exclusion of other causes. young age. Risk factors for OAG in sib- lings were similar to risk factors in unrelat- (OAG) and present risk factors for OAG in Results: The median ages of probands and ed individuals. Although definitive conclu- siblings of study probands.* relatives were 68 and 47 years, respective- sions about the extent of OAG among the ly. In the 207 families, 29% of the Design: Observational study of families of relatives are not possible at this time given probands had one relative with OAG and probands with OAG. their relatively young age, a future follow- 10% had two or more relatives affected. Of up of these individuals may yield addition- Participants: Twohundredthirtyprobands the 1056 family members, 10% had OAG, and 1056 relatives (from 207 families). al information on the genetic transmission 13% had suspect OAG, and 6% had ocular of OAG. Analyses are ongoing to deter- Methods: Probands and their family mem- hypertension. One fifth of the 338 siblings mine OAG inheritance and to localize bers underwent standardized examinations, had OAG (n = 67); they tended to be older potential gene(s) involved. including automated perimetry, applana- and more often were male. Multivariate tion tonometry, ophthalmologic evalua- comparisons between siblings with and Published courtesy of : tion, fundus photography, blood pressure, without OAG found that age, higher Ophthalmology 2001; 108: 1015–1022 [* Proband – a person with, e.g., a physical disorder, who is a ‘starting point’ for a genetic study – Editor]

Prevalence of Glaucoma in a Rural East African Population Ralf R Buhrmann refraction, automated 40-point Dicon (San = 3.5, 4.9%). Primary open-angle glauco- Harry A Quigley Diego, CA) suprathreshold screening field ma (OAG) was diagnosed in 3.1% (95% CI test, Tono-Pen (Bio-Rad, Inc., Boston, = 2.5, 3.8%), primary angle-closure glau- Yolanda Barron MA) intraocular pressure (IOP) measure- coma (ACG) in 0.59% (95% CI= 0.35, Sheila K West ment, and standardized examination by an 0.91%), and other forms of glaucoma in Matthew S Oliva ophthalmologist of anterior segment, optic 0.49%. The prevalence of glaucoma was Boliface B O Mmbaga nerve head, and retina after pupil dilation. found to be sensitive to changes in the Gonioscopy and Glaucoma-Scope (Oph- diagnostic criteria. Purpose: To determine the prevalence of thalmic Imaging Systems, Sacramento, Conclusions: The high prevalence of glaucoma in an adult population in rural CA) optic disc imaging were performed on OAG in this group was similar so that of central Tanzania. those with IOP higher than 23 mm Hg and African-derived persons in the United Methods: Six villages were randomly cup-to-disc ratio (c/d) more than 0.6 and on States but less than in African-Caribbean selected from eligible villages in the a 20% random sample of participants. populations. ACG was more prevalent in Kongwa district, and all residents more Results: Of 3641 eligible persons, 3268 east Africans than suggested by anecdotal than 40 years of age were enumerated and (90%) underwent ophthalmic examination. reports. invited to a comprehensive eye examina- The prevalence of glaucoma of all types Published courtesy of : tion including presenting visual acuity, was 4.16% (95% confidence interval [CI] InvestOphthalmolVisSci. 2000; 41: 40–48 50 Community Eye Health Vol 14 No. 39 2001 Letters to the Editor

In Nepal, for example, you can hardly At the Bamako, Mali, launch of Vision Update on Ocular find anybody who would be doing ICCE 2020, Dr Daniel Ety’aale of the WHO, Leprosy either in outreach camps or in the hospi- reminded delegates that the majority of tals. It would be incredible to think of this ophthalmologists in Francophone West Dear Editor 10 years ago! I do not believe that ICCE Africa had only been trained in ICCE. can be done faster than ECCE + PCIOL As John Standford-Smith suggests, he report by Professor Gordon once one starts doing it. anterior chamber IOLs are a useful way TJohnson and the recommendations by Nepal’s experience in developing eye forward, enabling surgeons doing ICCE Dr Paul Courtright summarise beautifully care infrastructure for cataract surgery to offer their patients the benefits of the Workshop on Practical Eye Care through coordination with the NGOs and pseudoaphakia. GuidelinesforLeprosyPatients. (J Comm INGOs can be an example for many Another factor in the ICCE/ECCE Eye Health 2001; 14: 25–26). developing countries with huge cataract debate is cost. To set up for ECCE + In addition, I would like to clarify one backlogs. PCIOL requires more expensive equip- point on treatment of lagophthalmos: ment than for ICCE+ACIOL (micro- Recent lagophthalmos, independent of Badri P Badhu MD scope, YAG laser, etc.) The extra con- size of lid gap, should be treated first with Associate Professor sumables for ECCE+PCIOL are more a course of systemic steroids as per Department of Ophthalmology expensiveandlesseasilyproducedlocally general guidelines for type 1 reaction and B P Koirala Institute of Health Sciences (Ringer’s lactate solution, methyl cellu- recent nerve damage in leprosy. Usually a Dharan, Sunsari, Nepal lose, nylon sutures, maintenance of durationofnervedamageof ≤ 6 months, is expensive equipment, etc.). The main taken as indication for steroid treatment Dear Editor consumables for ICCE + ACIOL are the in leprosy. cryo refrigerant and the sutures. Now that Even recent lagophthalmos with a lid agree with John Standford-Smith (J ozone friendly refrigerants are available gap of 8–10 mm in mild closure may re- I Comm Eye Health 2000; 13: 62) that in many African cities, this is less of a cover, provided steroid treatment is given intracapsular cataract extraction (ICCE) problem. in time. Meanwhile the cornea should has been relegated to the history books Also, certain types of cataract such as be protected by conservative means in without necessary discussion taking all intumescent with a tough capsule, hyper- combination with blinking exercises.1 the facts into account. mature with a shrivelled cortex are better Like others in the 80s, I trained to do dealt with by ICCE. In this part of Africa, Reference ICCE using a loop. We face the choice of these types of cataract are still very having to retrain to carry out ECCE + common. 1 Treatment of recent facial nerve damage with PCIOL, or continue to practice what is Perhaps we need a certain amount of lagophthalmos, using a semi-standardized increasingly regarded as a substandard steroid regimen. Kiran KU, Hogeweg M, humility in realising that a mixture of SuneethaS.LeprosyReview 1991; 62:150–154. technique. methods is needed to deal with the many While ICCE has its complications (vit- varied types of cataract that we meet. We Margreet Hogeweg MD reousloss, macularoedema,retinaldetach- also need to take into account what our Netherlands Leprosy Relief ment, etc.), so does ECCE even when patients can realistically afford. POB 95005 performed in good conditions (posterior Dr Andrew Perkins DO MRCOphth 1090 HA Amsterdam capsule opacification, etc.). Perhaps the truth is that all methods can give sub- Projet Sante Oculaire de la Mission The Netherlands optimal results despite the best of inten- Evangélique au Sahel, Yelimane, Mali tions. Cataract Surgery Dear Editor Teaching Slides/Text Sets Available from the International Resource Centre Cataract Surgery in Developing Countries • Examination of the Eyes • The Eye in Primary Health Care I wish to write in response to the expres- • The Glaucomas • Prevention of Childhood Blindness sions of various ophthalmologists pub- • Trachoma • HIV/AIDS and the Eye lished in the last issue of the Journal of Community Eye Health 2001; 14: 30–31, • Onchocerciasis • Leprosy and the Eye on the method of cataract surgery in • Practical Ophthalmic Procedures, Vol 1 developing countries. • Practical Ophthalmic Procedures, Vol 2 It seems that couching is still practised in some parts of the world with better Each set includes a handbook and 24 slides results than ICCE. Because the advan- tages of ECCE + PCIOL can hardly be Price: UK£15.00/US$27.00 each + Post and Packing exaggerated,themajorityofnewlytrained Post & Packing: UK£3/US$5 (surface), £5/US$8 (airmail) eye surgeons perform ECCE more confi- Payment Details: Credit card or cheque/banker’s order drawn on UK£ dently than ICCE even in developing or US$ bank accounts payable to: UNIVERSITY COLLEGE LONDON countries.Sofarastheissueofavailability Address: International Resource Centre, ICEH, of YAG laser is concerned, the use of 11-43 Bath St., London ECIV 9EL primary posterior capsulotomy can be Tel: 00 44 20 7608 6910 Fax: 00 44 20 7250 3207 Email: [email protected] advocated to avoid its need.

Community Eye Health Vol 14 No. 39 2001 51 Book Review

tion of small incision techniques, but not Eye Surgery in Hot phacoemulsification as this is unsuitable Communi ty C l i m a t e s 2n d E d i t i o n for remote places. No doubt experienced surgeons would want to do things differ- ently here and there, but less experienced EEyyee HHeeaalltthh surgeons can be confident that each step as supported by described is safe and tested. There are also extensive chapters on other operations Christian Blind Mission International such as for glaucoma and lid problems, but some conditions like squint are under- standably omitted. If no teacher is avail- CBM able it might be possible for someone with International surgical aptitude to undertake extraocular operations successfully just using the book. JOHN SANDFORD-SMITH But it is certainly not intended to be ‘Teach Sight Savers International FRCS FRCOphth Yourself CataractSurgery’. For intraocular Published by surgery, proper instruction in a structured Ulverscroft Large Print training programme is essential. This book and is a good text book for such training, and International Centre for Eye Health for places such as where I work (rural Africa). I do not know of any to rival it. I n the Vision 2020 campaign to eliminate understand there was difficulty in finding a Iglobal avoidable blindness, surgery publisher for this edition. This is regret- plays a major part, especially for cataract table considering all the blindness world- and for trachomatous trichiasis. If elimina- wide which is avoidable by surgery, and Conrad N. Hilton Foundation tion is to succeed, we need a great increase we are indebted to those who did undertake very soon in the number of people who can publication. carry out safe eye surgery. Much surgery Keith Waddell CBE FRCP FRCOphth has to be done in remote and resource-poor International Glaucoma Association places with little support. This is the aim of Ordering Information the book and it succeeds. UK & Developing Country Rate: Anyone familiar with the first edition UK £7/$13 + £3/$5 (surface) will know its clear and detailed descrip- Or £5/$9 (airmail) postage. tions of a wide range of eye operations, and Payment by banker’s order its good line drawings. There is also cover- and cheques drawn on UK£ or US$ age of ‘background’ subjects like theatre bank accounts can be accepted. preparation and instruments. However since intraocular lens implantation for Please makes cheques payable to cataract is now advocated everywhere, that UNIVERSITY COLLEGE LONDON Tijssen Foundation first edition has become obsolete. This new and send with your order to: edition has descriptions of lens implanta- International Resource Centre, ICEH tion (for both posterior chamber and anteri- 11-43 Bath Street, London, ECIV 9EL or chamber) written with the same clarity. Fax: + 44 20 7 250 3207 Foundation Dark and Light It even briefly includes the recent adapta- E-mail: [email protected]

17th International Society for Geographical and Epidemiological Ophthalmology (ISGEO) Congress 21 - 26 April 2002 The 17th ISGEO Congress will be held at Sydney Convention and Exhibition Centre Dutch Society Darling Harbour, Sydney, Australia for the The Congress will be in collaboration with the ICO and IAPB meetings. Further information: Prevention of Blindness Professor Hugh Taylor Department of Ophthalmology, University of Melbourne 32 Gisborne St., East Melbourne, Victoria, Australia Fax: 00 61-3-662-3859 E-mail: [email protected] The West Foundation Registration information on our website at: www.interchange.ubc.ca/bceio/isgeo/

52 Community Eye Health Vol 14 No. 39 2001