Eyeworld

EW INTERNATIONAL 104 September 2015 by Tony Realini, MD, MPH profile, and potential cost-effec- tiveness. Once the technology and expertise are onsite, the incremental cost of performing one additional procedure is negligible. Preliminary results are promising, and our work is ongoing. Next steps The problem is complex, and the solution will similarly not be a sim- ple one. Franz Grehn, MD, Germa- ny, enumerated potential steps to addressing Africa's growing glauco- ma burden. "The first unmet need is a stable infrastructure," he said, alluding to the widespread political and civil unrest that threatens the perma- nence of any healthcare delivery model. Also important, he said, is education for both providers and patients. There is an unmet need for screening to identify glaucoma in its earlier stages and for providers to learn techniques of glaucoma sur- gery and postoperative care. EW Editors' note: Dr. Realini has financial interests with Lumenis (Yokneam, Israel). Drs. Grehn, Gupta, Mermoud, and Olawoye have no financial interests related to this article. Contact information Grehn: grehn_f@ukw.de Gupta: guptan@smh.ca Mermoud: amermoud@gsvn.ch Olawoye: solaolawoye@yahoo.com In such poverty, even generic beta-blocker therapy often remains out of reach. In the developing Caribbean nation of St. Lucia, where our team has been evaluating cost-effective delivery of care for glaucoma for more than 5 years, a month's supply of generic timolol costs approximately as much as it does in the U.S.: $4 U.S. The medi- an income in St. Lucia, however, is one-tenth that in the U.S., making that same bottle cost $40 in relative terms. As Andre Mermoud, MD, Switzerland, pointed out, "A year's worth of medical glaucoma therapy costs 2 days' labor in Europe and 3–6 months' labor in Africa." Surgery as a solution also has critical limitations. Chief among these is that there are few if any trained glaucoma surgeons in the areas hardest hit by glaucoma. The cataract model—in which a visiting surgeon performs large numbers of cases and local providers handle the usually uneventful and routine postoperative care—cannot be easily scaled to glaucoma surgery, which requires intensive postoperative care often involving reoperation. Our group is actively exploring the role of selective laser trabecu- loplasty as a first-line therapy for glaucoma in several developing countries in the Caribbean. Laser has a number of potential advantages, including its fire-and-forget nature, no need for postoperative drops or follow-up, a highly favorable safety A different kind of glaucoma Further compounding the problem is that in Africa, glaucoma is often a more severe disease than what we are accustomed to in the U.S. "Our patients typically present at an earlier age, with higher IOP, and often experience very rapid pro- gression," Dr. Olawoye said. The disease is also more aggres- sive in Africa. "Africans are 4 times more likely to go blind from glau- coma than Caucasians," she said. "Half of patients are blind in 1 eye at presentation." The late stage presentation is likely attributable to both a lack of proven screening tests and to a widespread lack of awareness about glaucoma. "In one small study, 80% of those surveyed had never heard of glaucoma, 15% were not sure what it was, and only 5% were knowl- edgeable about the condition," Dr. Olawoye said. Viable solutions In developed nations, cost plays a relatively small part in the utilization of a therapy. Consider if a cure were found for glaucoma. Even with a price tag of $10,000 U.S., vir- tually all developed countries would find a way to make the therapy available to its afflicted citizens. In many developing countries, such as those in Africa where 71% of people live below the poverty line, a cure existing at that cost may as well not exist at all. T he burden of glaucoma worldwide is large and growing larger. Nowhere is the disease burden greater than in sub-Saharan Africa. This region has glaucoma prevalence rates that approach 10%. Many of the more than 40 countries in sub-Saharan Africa are developing countries, with limited resources, and even more limited healthcare resources. Recently, the World Glaucoma Association launched an African Glaucoma Initiative. Its goals are to define the scope of the problem, identify resources and solutions—in- cluding viable therapies—and bring together the regional community facing this crisis and researchers from around the world engaged in identifying solutions to the growing problem. This program launched at the recent biannual meeting of the World Glaucoma Congress in Hong Kong with a symposium focused on identifying barriers and solutions. Enormous disease burden Compared to the rest of the world, Sub-Saharan Africa has the greatest poverty and the highest prevalence of glaucoma with up to a third of blindness due to glaucoma, accord- ing to Neeru Gupta, MD, PhD, MBA, Toronto. Recent estimates indicate the prevalence of glaucoma will increase significantly in the next 25 years, with worldwide numbers approaching 100 million by 2040. Of these, African glaucoma cases will increase from 8.3 million to 19.2 million by 2040. "Glaucoma affects Africa in a scale unparalleled in the world," said Olusola Olawoye, MD, Nigeria. "Sub-Saharan Africa has 25% of the world's eye disease burden and only 1% of the ophthalmologists." Each of the countries has its own unique socioeconomic, cultural and geographic issues, said Dr. Gupta. The problem is staggering considering that the ratio of oph- thalmologists to people is approx- imately 1 per million, and in rural areas, that ratio plummets to less than 1 per 7 million. Glaucoma presents a particular challenge to this region with such limited healthcare infrastructure. "There is no cure, it is chronic, and it requires complex care," Dr. Gupta said. Tackling Africa's glaucoma burden

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