How to Pick Low Hanging Fruit

Doctors generally go to work wanting to make a difference. Fortunately, there has never been a better time for our patients with glaucoma – there are an ever-increasing number of advanced technology and treatment options. Not only do the latest OCT machines reveal incredible details of the retinal nerve fiber layer and macular ganglion cell layer, we also have the ability to measure corneal hysteresis and corneal thickness, helping further reduce a person’s risk of glaucoma progression.

Recent research promises quantification of apoptosis in retinal ganglion cells in vivo, while new classes of drugs and novel approaches to surgery allow more customized approaches for individual patients. These tremendous advances mean we can offer better care to our patients with glaucoma and they may even allow us to reduce the patients’ risk of vision loss and burden of treatment. However, studies suggest that a large portion of people with glaucoma – perhaps half – are undiagnosed and, as a result, untreated.

Unfortunately, it has proven challenging to identify these patients and get them the care they need; efforts to create screening have been hampered by low disease prevalence, increasing costs per identified case. And when patients fail to return for care, it reduces the impact of finding undiagnosed disease. But there is hope: recent studies suggest that there are simpler and more affordable ways to screen for the disease (1, 2). In the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study (PTGDFS), screenings were done in 23 minutes, and at a cost of less than $8 per screen and less than $65 per vision-threatening diagnosis found. Follow up and retention were improved by a number of small and simple steps, although retention remains a critical challenge.

So, what made the difference? The central aspects of these two studies can be summarized in just a few simple concepts. First, start with high risk populations. Both the Screening to Prevent (SToP) Glaucoma Study and the PTGDFS screened underserved populations at a high risk of ocular disease: people of color, people over the age of 65, and those who had a family history of glaucoma or diabetes. These criteria resulted in 60 percent of those screened having significant ocular diagnoses, including glaucoma and diabetic retinopathy.

Second, use low-level technology to screen. Both studies relied on visual acuity, a focused history, and non-mydriatic fundus and external photography. The cameras used are hand-held, require little training, and cost about $7,000. Remote evaluation of the photos and testing were done in a timely and efficient manner by physicians and trained non-physicians – the latter were used whenever possible to keep costs down. Getting these underserved patients into the eye care system – and retaining them – is a difficult process as people have complex lives with many competing priorities. Elements that bolster success include involving their primary care doctors, arranging follow-ups with local eye care providers, using patient navigators, and engaging the community. 

Remember: when it comes to screening, perfect is the enemy of good. An affordable, efficient screening system cannot catch every case or ensure that every patient is still being cared for a year later. However, a small investment can easily lead to hundreds of people getting care for undiagnosed glaucoma, diabetic retinopathy, and visually significant cataracts – as we found after setting up a screening program in an underserved community with the help of local primary care doctors. 

If all this seems too ambitious, there is an even simpler, cheaper screening program: tell each and every glaucoma patient in your practice to have their close relatives tested annually. Monitoring these higher risk patients will inevitably lead to many saved eyes. Using the latest tools and treatment to make sure an established glaucoma patient gets great (rather than adequate) care is incredibly important – but getting an undiagnosed patient any care before they go blind is even more so. Don’t underestimate the impact it can have on the patient, their family, and their community.