MANAGING GLAUCOMA IN AFRICAN
CONTEXT
Pr Amel Ouertani
Chairman of Ophthalmology Department- Charles Nicolle University Hospital-Tunis
Vice-President Middle East African Council of Ophthalmology MEACO
Secretary General Middle East African Glaucoma Society ,MEAG’S
Secretary General Nadi Al Bassar
GA- IAPB, September17-20-hydrabad
INTRODUCTION
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 millions
PACG
6.0 millions
2.0 millions
Congenital
0.3 millions
0.2 millions
Secondary
2.7 millions
?
Total
22.5 millions
5.2 millions
2010
60 millions
8,4 millions
Global Prevalence of glaucoma 1990 WHO program for prevention of blindness
Causes Of World Blindness
Avoidable
 Trachoma
 Onchocerciasis
 Corneal opacities
Avoidable/Treatable
 Cataract
 Congen. Cataract &
Glaucoma
Still difficult to manage
+++
 Glaucome
 D. Retinopathies
Magnitute of Glaucoma in Africa
♦POAG
In most populations OAG rates: 1% to 4%
 African-derived pop°: rates of 8% to 9%.
 Black race : Risk factor for POAG

♦ PCAG : 0.5% (recent surveys in Africa)
Prevalence Of Chronic Glaucoma
Tanzania, Africa & rest of the world
Age Group
Prevalence (%)
40 – 49
1.7
50 – 59
3.2
60 – 69
4.7
>70
5.4
Overall
3.0
In general, steady increase after Age 40
Often earlier in dark skinned people!
COAG: Worldwide Distribution
(WHO 1990 Estimates)
POPULAT.
Country/region
Cases
China
2.5 million
1.2 bil
Sub Saharan Africa
2.5 million
0.7 bil
Western Europe & North America
2.5 million
India
2 million
Eastern Europe
1 million
1.2 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 Africa
1. Adequate Infrastructure for early detection, diagnosis,
treatment and follow up of COAG
2. Treatment options for the management of COAG
3. Availability and affordability of anti-glaucomatous
medicines
4. Availability of skilled personnel in the country, trained for
Glaucoma surgery
5. Patients continuous education
6. 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!)
What is needed
♦ Diagnosis at a stage where patients still
have some usefull vision
►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
Infrastructure related Challenges
Current Situation
What is needed
♦ 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
♦ 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
Challenges related to Treatment Options
Medical Treatment
♦ Easy , less threatening
♦Rare in most parts of many countries, with entire
provinces with no place to buy any
♦ Very expensive, even to those with a regular source
of income
♦ hardly sustainable. :Available & affordable only in
NGO/Mission supported
► NOT SUCH A GOOD
structures
OPTION IN AFRICA
♦ Compliance :Poor
 Failure Rate is HIGH
What is needed
A national policy framework that could include:
♦a national strategy for the procurement and distribution
of anti-glaucoma drugs,
♦ a simple but workable system to identify & subsidize poor
Patients
♦ Partners willing to support such a system in the long term
Challenges related to Treatment Options
Laser Treatment
♦ Easy, satisfactory for patient and doctor
►laser needed
► Efficacy wears off
Challenges related to Surgery Options
Current 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 Personnel
Current Situation
♦Fully trained Gl specialists still too
few in many countries, non existent
in some
♦ Not all cat surgeons equally
Well trained in glaucoma surgery
♦ In many countries, entire regions
Still with no one skilled in clinical&
surgical management of gl.
♦ Many (of the few) well trained still
operate 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 retraining (+ equipment).
♦ Identify & support
training institutions
needing subspecialty
training
Challenges related to patients’ ignorance of the
disease
Current Situation
What is needed
 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
• 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
Steps for challenging glaucoma
for the next 10 years
♦ 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??
PARTNERS FOR CHALLENGES
Contribution of governments++
National Political commitment
♦ 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
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 the
many challenges of Glaucoma
Yet, glaucoma patients across Africa are still
among the least served of all eye care patients
What is needed now is concrete action and
sustained support, even in small steps.
Challenges related to Treatment Options
Surgical Treatment
♦ More difficult, and not Easily accepted by most
Patient