depItj TH Need for Routine Glaucoma Screening by Hospitals and Physicians IRVING STARIN, M.D., M.P.H. RECENT EDITORIAL (1) on early de¬ achieving this goal would be the initiation of A tection of glaucoma stated: "We cannot screening programs for patients admitted to urge too strongly the need to question patients hospitals." The generous support of the Public with respect to family history of glaucoma and Health Service in recent years for glaucoma to incorporate tonometry into the routine physi¬ screening programs is in keeping with this cal examination. Since glaucoma can be objective (#). controlled but not cured, early detection of the According to Porter (3), a significant number first elevations of intra-ocular pressure is im¬ of ophthalmologists do not check the intraocular perative to prevent ocular damage." tension in all their patients who are over 40 This exhortation has a direct relationship to years of age. I have also found evidence that glaucoma screening in hospitals. The modern many eye clinics, hospital eye services, and eye, hospital is the training ground for physicians. ear, nose, and throat hospitals do not require Considering the importance of preventing routine tonometry on all adult patients. blindness due to glaucoma, the high casefinding A review of the literature and personal in¬ rate for new glaucoma among hospital patients, quiries revealed that only six glaucoma screen¬ and the ease of tonometry, the tonometer along ing programs are currently being conducted in with the stethoscope, the ophthalmoscope, and hospitals. Most of these programs have re¬ the percussion hammer should be part of the ceived financial assistance, directly or indirectly, armamentarium of all physicians. Unless from Federal, State, or local sources. All but tonometry becomes part of the routine physical one are conducted in hospitals affiliated with examination in hospitals, we cannot expect it to medical schools. The programs are located at become routine in private practice. Freedmens Hospital, Washington, D.C. (^ and According to Dr. John E. Scott, Division of personal communication from Dr. C. L. Chronic Diseases, Public Health Service, one of Cowan); Metropolitan Hospital, New York the goals in testing hospital patients for glau¬ City (personal communication from Dr. B. coma, on both an inpatient and outpatient basis, Friedman and Dr. P. G. Halberg); Gouverneur is "to teach physicians the importance of a to¬ Ambulatory Care Service, New York City (per¬ nometry test as part of every routine physical sonal communication from Dr. H. Brown); examination" and that "a logical step toward Detroit Receiving Hospital (personal communi¬ cation from Dr. A. D. Ruedemann); City of Dr. Starin, assistant commissioner for community Memphis Hospitals (S and personal communi¬ health services, New York City Department of cation from Dr. H. Packer); and the hospital Health, presented this paper at the annual meeting of affiliated with the University of Florida College the New York State Academy of Preventive Medi¬ of Medicine (personal communication from Dr. cine, Syracuse, June 14,1965. H. E. Kaufman). In addition to the six cur- 12 Public Health Reports rent programs, I found thatin recent years brief logic glaucoma. The only study I found in the and relatively small programs were conducted literature of the past 25 years described a 5-year in only seven hospitals or clinics {6-8). followup of 225 patients treated for wide-angle glaucoma. Many of these patients had early Lack of cases, and there was evidence that normaliza- Leadership tion of intraocular tension stabilized the disease A major reason for the unimpressive total in more than 80 percent of all the patients (10). number of glaucoma screening programs is lack The ophthalmologists also point out that pro- of leadership, which must come from depart¬ gression of untreated asymptomatic glaucoma ments of ophthalmology. This almost limits to loss of vision takes from 15 to 30 years, and glaucoma detection to hospitals with at least patients without eye symptoms would be un- 200 general care beds, because only hospitals of likely to persist with treatment over all these at least this size can support active outpatient years. I have found that most of the hospital departments and have more than a token screening programs have no data available as to ophthalmological staff and at least one resident the rate at which patients with new, asympto¬ in ophthalmology. All the larger general hos¬ matic glaucoma lapse from care. At the City pitals have departments of ophthalmology, of Memphis Hospitals, of 219 persons diagnosed some sizable, with full-time staff. However, as having glaucoma during a 3-year period, 29 they rarely have the leadership required for did not return for treatment and 83 returned initiation of glaucoma detection programs. only once. Thus, unless more than a few of the Even if a hospital's medical service were inter¬ lapsed patients sought private care, more than ested in glaucoma detection, its desire would be half of the 219 new glaucoma patients were lost ineffectual without support from the depart¬ to care within 3 years (personal communication ment of ophthalmology. from Dr. H. Packer). Ophthalmologists are in great demand, be¬ The New York City Department of Health cause there are not enough of them (slightly conducts a year-round, nonhospital-based glau¬ more than 5,000 board certified) to meet the eye coma detection program in which from 15,000 needs of the population, and most are engaged to 20,000 adults, most over 40 years of age, are in busy, lucrative practices. Therefore, the $25- screened annually. A study of a random sam¬ $35 most health departments pay specialists for ple of persons with newly diagnosed cases re¬ 2 to 3 hours of their time holds little attraction vealed that 11 percent were lost to treatment for ophthalmologists. Another reason for the in the first 12 months and 26 percent after 30 passive resistance of ophthalmologists to glau¬ months. The low attrition rate is probably the coma screening programs is that many are result of the city's painstaking followup skeptical about casefinding rates, which range program. between 2.5 and 6 percent. They point to the lack The Gouverneur Care Service in of uniform criteria for the of Ambulatory diagnosis glau¬ New York City has, to my knowledge, the only coma by ophthalmologists (#, #, and personal communication from Dr. B. Friedman and Dr. hospital-based glaucoma program for which P. G. Halberg). Some ophthalmologists believe leadership has not been provided by the that if uniform standards were in effect, case¬ ophthalmology department (personal com¬ finding rates might drop to 1 percent. munication from Dr. H. Brown). This city- Some ophthalmologists question whether owned facility, without an on-the-premise in¬ early, asymptomatic, nonpathologic glaucoma, patient service, is operated by Beth Israel Hos¬ the type frequently detected in screening pro¬ pital, a voluntary institution, under contract grams, will progress to loss of vision. They with the city's department of hospitals. contend that the value of treatment for such patients has not been demonstrated as it has for Tonometry patients with symptomatic cases. Also, accord¬ ing to Friedman and Halberg, no longitudinal Assuming that a hospital is willing to under¬ study has been undertaken of treated and un¬ take glaucoma screening, who will do the tonom¬ treated patients with asymptomatic, nonpatho¬ etry? Logically, if tonometry is to become Vol. 81, No. 1, January 1966 13 routine in the physician's office, it should be (personal communication from Dr. F. B. Fra- done by physicians in both inpatient and out¬ lick) have included tonometry in their curricu¬ patient services. However, in five of the six lums. However, I found no evidence that med¬ current hospital-based programs, tonometry is ical students taught tonometry used it in later done by technicians. Physicians are used only years. Without the cooperation of a medical at the Detroit Receiving Hospital, and they are school's department of medicine, such training residents in ophthalmology who do tonometry can have no lasting effect (12). The depart¬ in special glaucoma screening and retest clinics. ment of medicine must inculcate in students Therefore, even at this hospital tonometry is from the first physical examination they per¬ not part of the routine physical examination form that tonometry is an integral and impor¬ performed by clinic and admitting physicians. tant feature of the routine physical examina¬ Hospitals have received little cooperation tion. Unfortunately, a multidisciplinary ap¬ from physicians who are not eye specialists be¬ proach from the departments of medicine, cause many of these physicians are reluctant to ophthalmology, and preventive medicine has use the Schiotz tonometer; they believe the in¬ not yet been introduced into medical school strument has a great potential for producing teaching. trauma. They recoil from further use of the instrument at the sight of the first red eye, even Hospital Program Planning if it is only a transient irritation rather than a Under present conditions, a number of prob¬ corneal injury. This fear can be overcome lems confront hospitals planning glaucoma de¬ with experience in tonometry. The main ob- tection programs. Although the hospitals prob¬ stacle to the use of the tonometer, however, is ably will use one or more technicians, how can the physicians' attitude that tonometry is a they, particularly those not affiliated with a uni¬ nuisance, unproductive, time consuming, and versity, handle the retest load? Most screenees relatively unimportant. They seem to disre- are indigent or medically indigent, and they can¬ gard or be unaware of the ubiquity of glaucoma not be referred to private ophthalmologists. and its aftermath of blindness, and that it can Therefore, some special clinic arrangement must be easily detected by tonometry. Obviously, be available for retesting so that a definitive di¬ education in this phase of preventive medicine agnosis can be made.