Assessment of knowledge, attitude, and practice of glaucoma among different cadres of Optometrists

Heartfelt congratulations to Saravanan et al.[1] for bringing out the present KAP of glaucoma among optometrists. Optometrists are the first line of contact for ocular patients in general, and strengthening this pillar can potentially work to uplift the entire public eye health system.

Glaucoma is one of the leading causes of irreversible blindness. There are approximately 11.2 million people aged > 40 years living with glaucoma in India,[2] an estimated prevalence of 2.65%.[3] Of these, 3 million people are blind due to glaucoma, expected to double to 6 million by 2050. In India, glaucoma remains largely undiagnosed (>90%),[3] as most of the population lives in rural areas with poor access to health care. In a KAP study from North India, only 8.3% of the residents were aware of glaucoma while 1.89% had some knowledge about glaucoma.[4] By early identification and intervention, irreversible blindness in the advanced stages can be averted. Opportunistic screening by optometrists is one such chance at earlier detection. The better the optometry practices in the country, the lower the prevalence of visual impairment and blindness.[5] The usual cause for glaucoma diagnosis being missed at a primary care level is perhaps a lack of “comprehensive eye examination” performed by the primary eye care contact.[6]

The ophthalmologist to general population ratio in urban India is 1:25,000 against 1:219,000 in rural India. This discrepancy calls for a mass mobilization of optometrists to the rural areas and to fully train the existing cadre to cater to the comprehensive screening of the population at large. Development of an eyecare ‘team’ which includes 4 optometrists versus 1 ophthalmologist for every 1 lakh people is one such concept.[5] The current optometrist strength stands at 9,000 4-year trained optometrists[7] in our country, which is still short of the target of 1,15,000. As reaching the right numbers in every corner of our country may not be possible in near future, providing the correct training to produce the right quality is called for.

Besides screening and timely referral, optometrists can play an essential role in the visual rehabilitation of glaucoma patients post-intervention. For example, in young children with congenital glaucoma, inappropriate refraction correction and subsequent amblyopia development are one of the major causes of visual disability, more so in unilateral cases.[8] Hence, routine delivery of care by optometrists can help with the periodic change of glasses and the prevention of amblyopia. Besides, optometrists can also aid in the screening of high-risk family members through annual examination along with self or referred assessment of disk photographs as another means of opportunistic screening. Through emerging technologies in COVID-19 times, “Tele-glaucoma” seeks analysis of stereoscopic digital disk imaging transferred electronically to ophthalmologists in cases the disk is suggestive of glaucoma, especially useful in remote and under service areas.[9] They may also play a pivotal role in creating awareness about glaucoma among the public.

Glaucoma was not set as a priority among ocular problems in Vision 2020. Though the target of the World Health Organization Global Action Plan of a 25% reduction in avoidable blindness was not met, there is evidence that the contribution of glaucoma to blindness and vision impairment is reducing. Scaling up integrated people-centered eyecare by embedding glaucoma detection and care in primary health systems will further help reduce glaucoma-related visual impairment and blindness.[10]

Besides acting at the primary care level, optometrists also play an essential role as service providers at secondary and tertiary levels of the health care system by performing diagnostic and follow-up tests for glaucoma like Disk imaging, Visual field, ASOCT of angle, HRT, and ultrasound biomicroscopy (UBM). Precise imaging, as well as interpretation of these investigative modalities by optometrists, can aid the ophthalmologists in better patient management, especially in crowded OPDs.

Hence, it is important to enhance their learning from time to time by conducting regular continuing medical education (CMEs) or workshops. Regular virtual workshops, under the leadership of ophthalmologists can increase dispensing of knowledge to remote areas. From time to time, attending skill transfer training modules should be made mandatory, especially for license renewal by the government. Further, Bachelor’s and Master’s course curriculum for the training of optometrists should emphasize more practical learning including, slit-lamp examination for anterior chamber depth assessment using the Von Herick grading evaluation, identification of angle-closure using gonioscopy (desirable), checking for presence/patency of peripheral iridotomy, performing applanation tonometry, performing 90-D slit-lamp biomicroscopy, along with training of other basic skills like pediatric eye examination, non-contact tonometry, and direct and indirect ophthalmoscopy.

Optometrists form the base of the health care pyramid and the primary contact of millions of patients seeking ocular health care. Tackling the problem at the root level by arming the optometrists with adequate knowledge, skill, and infrastructure can go a long way in reducing the burden of visual impairment and blindness, especially due to preventable diseases like glaucoma and diabetic retinopathy.