MANAGING GLAUCOMA IN AFRICAN CONTEXT

Pr Amel OuertaniChairman of Ophthalmology Department- Charles Nicolle University Hospital-Tunis

Vice-President Middle East African Council of Ophthalmology MEACOSecretary General Middle East African Glaucoma Society ,MEAG’S

Secretary General Nadi Al Bassar

G A - I A P B , S e p t e m b e r 1 7 - 2 0 - h y d r a b a d

WHO: Glaucoma is the 2nd cause of visual impairment & blindness in both the developed and developing world

INTRODUCTION

type cases blind

POAG 13.5 millions 3.0 millionsPACG 6.0 millions 2.0 millionsCongenital 0.3 millions 0.2 millions

Secondary 2.7 millions ?

Total 22.5 millions 5.2 millions2010 60 millions 8,4 millions

Global Prevalence of glaucoma 1990 WHO program for prevention of blindness

INTRODUCTION

Causes Of World BlindnessAvoidable Trachoma Onchocerciasis Corneal opacities

Avoidable/Treatable Cataract Congen. Cataract &

Glaucoma

Still difficult to manage +++ Glaucome D. Retinopathies

♦POAG

In most populations OAG rates: 1% to 4% African-derived pop°: rates of 8% to 9%. Black race : Risk factor for POAG

 

Magnitute of Glaucoma in Africa

♦ PCAG : 0.5% (recent surveys in Africa)

Age Group Prevalence (%)40 – 49 1.7

50 – 59 3.2

60 – 69 4.7

>70 5.4

Overall 3.0

Prevalence Of Chronic Glaucoma Tanzania, Africa & rest of the world

In general, steady increase after Age 40 Often earlier in dark skinned people!

COAG: Worldwide Distribution (WHO 1990 Estimates)

Country/region Cases China 2.5 million

Sub Saharan Africa 2.5 million

Western Europe & North America 2.5 million

India 2 million

Eastern Europe 1 million

POPULAT.

1.2 bil

1.2 bil

0.7 bil

When compared to other regions, COAG is proportionately worse in Africa

And still on the increase!

Glaucoma differ in Africa from elsewhere by its clinical presentation,

agressiveness, resistance to treatment LATE DIAGNOSIS and thus bad

prognosis

Glaucoma Challenges in Africa1. Adequate Infrastructure for early detection, diagnosis,

treatment and follow up of COAG2. Treatment options for the management of COAG3. Availability and affordability of anti-glaucomatous

medicines4. Availability of skilled personnel in the country, trained for

Glaucoma surgery5. Patients continuous education6. Establish National Glaucoma guidelines/policies

Challenges related to early Detection and Diagnosis

♦ Glaucoma is a silent disease, with very few signs or symptoms, until in advanced stages

♦ Loss of vision is slow & progressive, & hardly perceptible:

♦ Diagnosis is difficult especially in early cases, as no one test is sufficient at that stage to diagnose

♦ As a result many patients present late to the clinic (29% of Gl. patients & 53% of Gl. Eyes already blind!)

♦ Diagnosis at a stage where patients still have some usefull vision

What is needed

►HOW ???♦ Community/pop based screening program ??♦ Opportunistic screening ??♦ Identify an inexpensive practical and valid

screening test acceptable by population Surveys?? RAAB??

♦ Agreement on whom to screen and whom to treat

Current Situation

♦ Still very few eye units fully equipped to assess & confirm glaucoma Dg

♦ Still many tertiary units without even functional visual field equipment

♦ Many rural patients are still beyond reach

What is needed

♦ Ensure - all training institutions, - most (if not all) tertiary eye units, as well as- all high volume eye units are fully equipped to manage Glaucoma

♦ For each group, set priorities & a realistic timeframe to achieve it

Infrastructure related Challenges

Challenges related to Treatment Options

♦ Easy , less threatening♦Rare in most parts of many countries, with entireprovinces with no place to buy any♦ Very expensive, even to those with a regular sourceof income♦ hardly sustainable. :Available & affordable only inNGO/Mission supportedstructures ♦ Compliance :Poor Failure Rate is HIGH

Medical Treatment

► NOT SUCH A GOOD OPTION IN AFRICA

What is needed

A national policy framework that could include: ♦a national strategy for the procurement and distributionof anti-glaucoma drugs, ♦ a simple but workable system to identify & subsidize poorPatients ♦ Partners willing to support such a system in the long term

Challenges related to Treatment Options

♦ Easy, satisfactory for patient and doctor

Laser Treatment

►laser needed► Efficacy wears off

Challenges related to Surgery OptionsCurrent Situation

♦More difficult,not easily accepted □In early stages Because it hardly results in “improved vision” □ In advanced cases :additional challenge is Having to perform

surgery on the only good eye

♦ Still too few well trained and confident glaucoma surgeons

►Yet because it is a “one time” type of TT , costs less and requires less follow up, it is often the only realistic option to many

What is needed• Patient education

• Given the current shortage, acceptable strategies to increase the nb of glaucoma surgeons in each country must developed & implemented

• This may require the retraining of many existing surgeons

Challenges related to Limited Skilled PersonnelCurrent Situation

♦Fully trained Gl specialists still toofew in many countries, non existentin some♦ Not all cat surgeons equallyWell trained in glaucoma surgery♦ In many countries, entire regionsStill with no one skilled in clinical&surgical management of gl.♦ Many (of the few) well trained stilloperate with less than the min equipt

What is needed

♦ Update the list of skilled personnel in each country

♦ Identify & support all existing personnel (especially cataract surgeons) needing re-training (+ equipment).

♦ Identify & support training institutions needing subspecialty training

Challenges related to patients’ ignorance of the disease

Current Situation

Knowledge about glaucoma is limited

Because glaucoma is asymptomatic means many patients are likely to report late

At the same time, patient’s education is of little help where back up services either don’t exist or are not operational

What is needed

• First : ensure patients targeted for health education will have easy access to functional glaucoma services and affordable drugs if needed

• Develop a culturally sensitive IEC strategy for glaucoma nation-wide

• Target patients at risk

♦ Advocacy: Glaucoma : Public health problem♦ Include glaucoma in national plans for POB♦ Collection of Epidemiological data at the country

and the continent level♦ Evaluation of the magnitude of the problem:

Surveys?? RAAB??

Steps for challenging glaucomafor the next 10 years

PARTNERS FOR CHALLENGES

Contribution of governments++

♦ Repair and develop health systems (with the help of regional structures such as AU/NEDAP, and with WHO’s technical support.)

♦ Train and retain an additional 1 million health workers by 2015

♦ Increase annual budgets to health ♦ Improve procurement systems (including greater availibility of

pricing information and reference to regularly updated essentiel drug list) can have a

valuable impact.Abolish user fees, as recomended to governments by the commision for Africa

National Political commitment

Supranational and International Organizations

◘WHO◘ PBU◘ MEACO◘ ICO◘ AAO

Community involvment :NGO+++

NADI AL BASSAR CATARACT CAMPAINS

International Aid

1°/ Africa can’t afford high price of medicine.▪ (WTO) TRIPS agreement contains important

flexibilities that can be used to access medicines (like compulsory licence allowing local production of patent protected medicines)

▪ Pharmaceutical compagnies can support by developing differential pricing offers for antiglaucoma drugs,

▪ 2°/ Equipments

The need for National Glaucoma Guidelines/Policies

1. Many of the challenges discussed in this presentation could and should be addressed through such guidelines

2. For many countries this would require at least 2 actions:- update the glaucoma strategy section in their existing national plans- set up an HRD sub-group to oversee the development and implementation of the guidelines

3. In most countries, making anti-glaucoma drugs widely available & affordable will require the development and enforcement of national policies

CONCLUSION

Much of what is needed is to start addressing themany challenges of Glaucoma

Yet, glaucoma patients across Africa are stillamong the least served of all eye care patients

What is needed now is concrete action andsustained support, even in small steps.

Challenges related to Treatment Options

♦ More difficult, and not Easily accepted by mostPatient

Surgical Treatment