Reducing Barriers to Glaucoma Screening

A community-based project in Philadelphia increased access to care in high-risk populations.

By L. Jay Katz, MD; Michael Waisbourd, MD; and Lisa A. Hark, PhD, RD

Sometimes the work we do in the interest of research affords us the opportunity to have tremendous impact on the communities we serve as physicians. Such is the case with the community-based mobile glaucoma program initiated by the Wills Eye Hospital Glaucoma Service and Glaucoma Research Center. The program, called the Philadelphia Glaucoma Detection and Treatment Project, was a demonstrational project designed to find out if it might be possible to bring the tools needed to diagnose and treat glaucoma to high-risk populations, rather than waiting for patients to come to us. Patients were educated, enrolled, examined, and, if a diagnosis was positive, offered a same-day, on-the-spot intervention, such as laser therapy.

Traditionally, screening programs have a significant problem with follow-up. For one reason or another, often despite the best intentions, many patients diagnosed with an eye disease though screenings get lost to follow-up, and, hence, an opportunity for treatment is lost. Glaucoma is particularly insidious on this account, as the disease burden is often highest among those who have suboptimal access to care. This is a big reason why almost half of all glaucoma cases go undetected.1

COMMUNITY PROJECT

Several national programs have been launched in attempts to improve screening, diagnostic, and referral services for glaucoma among patients considered to be most at risk, including older adults, Hispanic or Latino populations, and black populations.2,3 Wills Eye Hospital received funding from the US Centers for Disease Control and Prevention (CDC) to test the viability of a community-based glaucoma detection and treatment program in traditionally underserved populations in Philadelphia.

This ongoing program has two objectives: (1) to establish community partners, such as senior centers, that can be used as sites to identify patients in need of glaucoma services, and (2) to conduct educational workshops and comprehensive eye examinations in these community sites, immediately connecting patients in need of treatment with care. We received generous support from the laser manufacturer Lumenis in the form of a donated Selecta Laser Duet laser platform so that we could offer patients on-the-spot treatment options, specifically selective laser trabeculoplasty (SLT) for individuals with open-angle glaucoma and laser peripheral iridotomy (LPI) procedures for those with anatomically narrow angles.

The rationales for providing these treatments were simple. SLT has been shown to be as effective as a single topical glaucoma medication regimen.4-7 It may therefore help to eliminate the need for drop therapy,8 avoid exposing patients to potentially harmful additives and preservatives,9 and provide more cost effective therapy than drop regimens.10,11 Second, LPI can prevent disease progression in patients with narrow angles,12-14 and it is feasible to offer bilateral same-day treatments with the Selecta device.

For the program, we sent a mobile unit staffed with an ophthalmologist and stocked with diagnostic equipment and the laser to 43 program sites (senior centers, senior housing buildings, and community centers) in areas with a high population density of African American individuals in West Philadelphia, North Philadelphia, Northeast Philadelphia, and South Philadelphia. Our experts led awareness workshops to educate patients about glaucoma and recruit into the program. Each patient who enrolled received a complete eye examination at no cost, including a visual acuity check, slit-lamp examination, intraocular pressure (IOP) measurement, and visual field testing.

More than 1,600 patients were enrolled; African American patients had to be older than 50 years, and others had to be older than 60 years. Patients who were positively diagnosed with any type of glaucoma were followed up at the community sites. To minimize patient attrition, however, we also offered patients with open-angle glaucoma the opportunity to receive SLT and patients with narrow angles the opportunity to receive bilateral LPI at the community site on the same day or a future follow-up date.15

We returned to each program site at least twice: 4 to 6 weeks after the initial visit to assess those who had glaucoma or who had received a laser treatment, and at 4 to 6 months after the initial examination.

WHAT WE LEARNED

Through the program, we learned a lot more than we expected. A significant number of patients were diagnosed with glaucoma-related conditions, including glaucoma, glaucoma suspect, or narrow angle. Other eye diseases were also detected. Overall, patients were very satisfied with the program, especially the convenience and quality of care they received from the Wills Eye team.

An analysis of the results of patients who underwent LPI bilaterally on the same day was performed. A total of 132 eyes of 66 patients underwent this treatment at the community sites. All patients tolerated LPI treatment without serious complications. The most frequent adverse event was IOP spike: eight patients (12.1%) had IOP spikes greater than 5 mm Hg after treatment, and four patients (6.1%) has spikes of greater than 10 mm Hg. IOP returned to normal in all but one patient, who was diagnosed with chronic angle-closure glaucoma.

There were perhaps more patients than we initially expected who needed LPI, but having the equipment at the site allowed us to provide treatment. Although there are limited data regarding the safety and efficacy of bilateral LPI, in our program it was deemed safe. Based on our results, it seems plausible to offer this treatment strategy to individuals with poor access to health care services who have anatomically narrow angles.

Additional follow-up will help to elucidate how effective we were in preventing glaucoma onset in glaucoma suspects, but it is safe to say that attempting a prevention strategy among individuals at risk for worsening disease and subsequent loss of vision has tremendous potential for benefit.

CONCLUSION

The results described here reflect the program’s outcomes between January 1, 2013, and May 31, 2014. The Partridge Foundation supported ongoing follow-up of these patients for an additional year. We have also received funding from the CDC for an additional 5-year study, in which Wills Eye is partnering with Temple University, Philadelphia Health Management Corporation, the Philadelphia Department of Health, and the Health Federation of Philadelphia to reach and examine patients in seven primary care offices and 10 federally qualified health centers treating underserved patients in Philadelphia, primarily in predominantly African American communities. We have added a telemedicine component using a handheld camera to examine the optic nerves and retinas of patients, with images and data streamed back to our hospital to be read by glaucoma and retina specialists.

The definition of public health is that it is concerned with the health of populations, as opposed to the care of individual patients. Despite the seemingly impersonal nature of a ubiquitous public health program such as the one described here, however, it is easy to see the impact that can be made on individual lives. Glaucoma is a particularly difficult disease to treat, with many nuances and factors that affect treatment outcomes. In addition, treatment can be successful only if patients can gain access to services; by removing barriers to valuable screening and treatment services, we have the ability to affect real outcomes for the good of our patients—benefits that do not always show up in the data points reported in research efforts.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. n

1. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol. 1996;80(5):389-393.

2. National Eye Health Education Program. Effective Education to Target Populations.
https://nei.nih.gov/sites/default/files/NEHEP-pdfs/NEHEP_Five-Year_Agenda_2012-2017.pdf

3. Centers for Disease Control and Prevention. Improving the Nation’s Vision Health: a Coordinated Public Health Approach. http://www.cdc.gov/visionhealth/pdf/improving_nations_vision_health.pdf. Accessed March 24, 2016.

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6. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol. 2003;121(7):957-960.

7. Nagar M, Ogunyomade A, O’Brart DP, et al. A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma. Br J Ophthalmol. 2005;89(11):1413-1417.

8. Jindra LF, Gupta A, Miglino EM. Five year experience with selective laser trabeculoplasty as primary therapy in patients with glaucoma. Poster presented at: American Academy of Ophthalmology Annual Meeting; November 10-13, 2007; New Orleans, LA.

9. Latina MA, Park C. Selective targeting of trabecular meshwork cells: in vitro studies of pulsed and CW laser interactions. Exp Eye Res. 1995;60(4):359-371.

10. Lee R, Hutnik CM. Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan. Can J Ophthalmol. 2006;41(4):449-456.

11. Dirani M, Crowston JG, Taylor PS, et al. Economic impact of primary open-angle glaucoma in Australia. Clin Experiment Ophthalmol. 2011;39(7):623-632.

12. Prum Jr BE, Rosenberg LF, Gedde SJ, et al. Primary open-angle glaucoma preferred practice pattern guidelines. Ophthalmology. 2016;123(1):P41-P111.

13. Thomas R, Parikh R, George R, et al. Five-year risk of progression of ocular hypertension to primary open angle glaucoma. A population-based study. Indian J Ophthalmol. 2003;51(4):329-333.

14. Wilensky JT, Kaufman PL, Frohlichstein D, et al. Follow-up of angle-closure glaucoma suspects. Am J Ophthalmol. 1993;115(3):338-346.

15. Hark L, Waisbourd M, Myers JS, et al. Improving access to eye care among persons at high-risk for glaucoma in Philadelphia: design and methodology. The Philadelphia Glaucoma Detection and Treatment Project. Ophthalmic Epidemiol. 2016;23(2):122-130.

L. Jay Katz, MD
• Director of the Glaucoma Service at Wills Eye Hospital in Philadelphia
• Professor of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia
• (215) 928-3197; ljkatz@willseye.org
• Financial interest: none acknowledged

Lisa A. Hark, PhD, RD
• Director of the Glaucoma Research Center at the Wills Eye Hospital in Philadelphia
• Professor of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia
• (215) 928 3045; lhark@willseye.org
• Financial interest: none acknowledged

Michael Waisbourd, MD
• Research Manager at the Wills Eye Hospital in Philadelphia
• Assistant Professor of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia
• (215) 928-3123;
• Financial interest: none acknowledged