Advanced glaucoma: management pearls

A significant proportion of glaucoma patients present late, particularly in the developing world, and unfortunately, in an advanced stage of the disease. They are at imminent danger of losing remaining vision, and may also be afflicted with various socioeconomic and health challenges. The encounter with such a patient is typically characterized by anxiety/fear and sometimes hopelessness from the patient's perspective. The physician may also feel that they are in a difficult position managing the patient's disease. When dealing with such cases, we suggest a holistic, individualized approach taking into account the [biopsychosociospiritual] [BPSS] profile of each patient. The BPSS model takes into account relevant ocular as well as systemic biology [factors such as the mechanism of glaucoma, level of intraocular pressure [IOP], rate of progression, life expectancy, general health], psychological considerations [e.g., fear, depression], socio-economic factors and spiritual/cultural values and beliefs before being able to decide with the patient and their care partner [s] what treatment goals should be and how they can best be approached. Treatment for advanced glaucoma can be highly effective, and patients and their care partners should be informed that aggressive IOP lowering to the low teens or even single digits offers the best chance of protecting remaining vision. This can be achieved safely and effectively in most cases with trabeculectomy [including an antimetabolite], and in some cases with medical and/or laser therapy. Vision rehabilitation and psychosocial support should also be considered in order to optimize remaining vision, replace fear with hope as appropriate, and thus improve the overall quality of life

Teleglaucoma: improving access and efficiency for glaucoma care

Teleglaucoma is the application of telemedicine for glaucoma. We review and present the current literature on teleglaucoma; present our experience with teleglaucoma programs in Alberta, Canada and Western Australia; and discuss the challenges and opportunities in this emerging field. Teleglaucoma is a novel area that was first explored a little over a decade ago and early studies highlighted the technical challenges of delivering glaucoma care remotely. Advanced technologies have since emerged that show great promise in providing access to underserviced populations. Additionally, these technologies can improve the efficiency of healthcare systems burdened with an increasing number of patients with glaucoma, and a limited supply of ophthalmologists. Additional benefits of teleglaucoma systems include e-learning and e-research. Further work is needed to fully validate and study the cost and comparative effectiveness of this approach relative to traditional models of healthcare

muranga teleophthalmology study: comparison of virtual [teleglaucoma] with in-person clinical assessment to diagnose glaucoma

While the effectiveness of teleophthalmology is generally accepted, its ability to diagnose glaucomatous eye disease remains relatively unknown. This study aimed to compare a web-based teleophthalmology assessment with clinical slit lamp examination to screen for glaucoma among diabetics in a rural African district. Three hundred and nine diabetic patients underwent both the clinical slit lamp examination by a comprehensive ophthalmologist and teleglaucoma [TG] assessment by a glaucoma subspecialist. Both assessments were compared for any focal glaucoma damage; for TG, the quality of photographs was assessed, and vertical cup-to-disk ratio [VCDR] was calculated in a semi-automated manner. In patients with VCDR > 0.7, the diagnostic precision of the Frequency Doubling Technology [FDT] C-20 screening program was assessed. Of 309 TG assessment photos, 74 [24%] were deemed unreadable due to media opacities, patient cooperation, and unsatisfactory photographic technique. While the identification of individual optic nerve factors showed either fair or moderate agreement, the ability to diagnose glaucoma based on the overall assessment showed moderate agreement [Kappa [id statistic 0.55% and 95% confidence interval [CI]. 0.48-0.62]. The use of FDT to detect glaucoma in the presence of disc damage [VCDR > 0.7] showed substantial agreement [K statistic of 0.84 and 95% CI 0.79-0.90]. A positive TG diagnosis of glaucoma carried a 77.5% positive predictive value, and a negative TG diagnosis carried an 82.2% negative predicative value relative to the clinical slit lamp examination. There was moderate agreement between the ability to diagnose glaucoma using TG relative to clinical slit lamp examination. Poor quality photographs can severely limit the ability of TG assessment to diagnose optic nerve damage and glaucoma. Although further work and validation is needed, the TG approach provides a novel, and promising method to diagnose glaucoma, a major cause of ocular morbidity throughout the world

Improving diabetic retinopathy screening in Africa: patient satisfaction with teleophthalmology versus ophthalmologist-based screening

To assess patient preference for diabetic retinopathy [DR] screening with teleophthalmology or face-to-face ophthalmologist evaluation in Nairobi, Kenya. Fifty seven diabetic patients from a one-stop multidisciplinary diabetic clinic [consisting of a diabetologist, nurse educator, foot specialist, nutritionist, ophthalmologist, and neurologist] in Nairobi, Kenya were included if they had undergone both a teleophthalmology [stereoscopic digital retinal photographs graded by an ophthalmologist remotely] and a traditional clinical screening exam [face to face examination]. A structured questionnaire with a 5-point Likert scale was developed in both English and Swahili. The questionnaire was administered over the telephone. Ten questions were used to compare patient experience and preferences between teleophthalmology and a traditional clinical examination for DR. A mean score >3.25 on the Likert scale was considered favourable. Successfully telephone contact was possible for 26 [58% male, 42% females] of the 57 patients. The mean ages of the male and female patients were 52.4 and 46.5 years respectively. Patients were satisfied with their teleophthalmology examination [mean 4.15 +/- 0.97]. Patients preferred the teleophthalmology option for future screenings [mean 3.42 +/- 1.52]. This preference was driven primarily by convenience, reduced examination time, and being able to visualize their own retina. In this study, diabetic patients preferred a teleophthalmology based screening over a traditional ophthalmologist-based screening. The use of teleophthalmology in Africa warrants further study and has the potential to become the screening model of choice. Cost effectiveness in comparison to an ophthalmologist-based screening also requires evaluation