Interview

Tracking New Options to Treat Glaucoma

Dr Devindra Sood

Dr Devindra SoodBlindness from glaucoma is irreversible. By the time the first visual loss occurs, its too late to improve that vision. Dr Devindra Sood, Director & Head, Glaucoma Services & Dean of Academics, Eye-Q Institute of Glaucoma, discusses the sneaky eye disease with Shahid Akhter, ENN

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India retains the unfortunate distinction of having the largest number of people with visual impairment globally. Please comment on the factors leading to such a scenario? Your suggestive solutions ?
In India, it is estimated that glaucoma affects 12 million people and by 2020, this is expected to be 16 million. Statistics say that one in eight persons above the age of 40 years in India are afflicted by glaucoma which is also the second leading cause of blindness after cataracts. However, if we look at irreversible blindness, glaucoma is the leading cause worldwide. Glaucoma causes 12.8 per cent of the total blindness in the country. In India, more than 90 per cent of the glaucoma in the community is undiagnosed.
The risk of developing glaucoma increases by five times if a parent has glaucoma, and by almost nine times if a sibling has glaucoma. Also, hypertension and diabetes are the other risk factors. People under high risk category should must go for eye check up every year after turning 40.

“Glaucoma affects about 70 million people worldwide, of whom about 10 per cent are believed to be bilaterally blind. It is estimated that by the year 2020, this number would rise to around 79.6 million”

What causes glaucoma?
Glaucoma is the name given to many different diseases, characterized by a typical damage to the optic nerve. In most cases there is an accumulation of fluid within the front part of the eye which exerts a pressure on the back of the eye. The increased back pressure reduces the blood supply to the optic nerve. The health of the optic nerve then begins to get compromised. Damage to the optic nerve is a hallmark of glaucoma. As damage to the optic nerve progresses, part of what we see around us is lost. First the edges of the picture blur and disappear.
As the damage spreads, the view of the world becomes narrower and narrower, in effect producing tunnel vision. If the entire nerve is destroyed, blindness results.

Any precise reason for escalation of glaucoma in the India ?
Glaucoma is essentially a disease of the aging population. With increasing life spans we are seeing a large number of geriatric diseases. Glaucoma is one such disease. However blindness from glaucoma is irreversible and occurs usually because of a raised eye pressure. Damage to the optic nerve can also occur in the absence of a raised eye pressure. The other concern in diagnosing glaucoma is that the common forms of glaucoma usually have no symptoms in the early stages of the disease. Also when symptoms develop, they mimic other conditions.
Example: Blurred vision can happen with cataract and also with advanced glaucoma. The vision loss from cataract can be restored by surgical removal of the opaque lens. However, vision loss from glaucoma cannot be reversed.
Again, glaucoma as a disease is diagnosed by signs and not from symptoms. Symptoms of glaucoma when they appear do so when the disease is advanced. Since the damage from glaucoma is irreversible, the emphasis is on early diagnosis of glaucoma. Also the textbook description of symptoms for glaucoma are usually absent amongst us Indians.

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Precisely, which aspect of glaucoma afflicts India ?
All aspects of glaucoma affect us in India. Essentially glaucoma has no classical symptoms and when they do occur they mimic other diseases. In fact just because you can read this piece of information or drive independently does not rule out glaucoma for you. If lack of awareness prevents us from getting an eye check up, so does our busy lifestyle. Also of the 12,000 eye doctors in India, most are in cities, thus leaving a large part of India inaccessible to eye care.

How is glaucoma diagnosed ? Any preventive measures that you may suggest?
Blindness from glaucoma is irreversible. The key to prevention lies in early detection. Today science and technology has progressed to a level where we can prevent further damage but we cannot reverse the damage. Hence detection in the early stages with appropriate treatment can prevent the blindness from glaucoma.
The diagnosis of glaucoma is made by the TOPG test.

T stands for Tonometry where the eye pressure is measured, preferably with an instrument which uses blue light. It is important to know that the eye pressure should be checked at every visit.
O stands for Ophthalmoloscopy where damage to the optic nerve is assessed (structural damage). The optic nerve is the end organ of damage in glaucoma which results in a gradual painless loss of vision which is irreversible. Examining the way the optic nerve looks is very important to diagnose glaucoma.
P stands for Perimetry and is a measure of ones field of vision. Field of vision is the part of space we can see with one eye closed. The field of vision is irreversibly reduced in glaucoma (functional damage). Assessing ones field of vision is essential for diagnosing glaucoma as structural damage to the optic nerve is currently documented as a functional loss on perimetry.
G stands for Gonioscopy and involves assessment of the angle outflow structures. Gonioscopy is the single test which determines the kind of glaucoma one has. Amongst the common types of glaucomas, the open type and the closed type are treated differently. The open type is treated first with medication failing which one looks at other alternatives including surgery. The close type is treated with a laser iridotomy first followed by medications. Surgery for glaucoma is always a last resort.

In India, glaucomas present differently. The open type of glaucoma presents in the advanced stages with blurred vision similar to cataract. The closed type does not show the typical features described in the text book

What are the problems associated with the various stages of angle closure in pigmented eyes?
In India, glaucomas present differently. The open type of glaucoma presents in the advanced stages with blurred vision similar to cataract. The closed type does not show the typical features described in the text book “ headache, coloured haloes and redness. Also the presentation in the closed type mimicks the open type of glaucoma. However the differentiation is important because treatment for different glaucomas is different. The open variety is treated with eye drops failing which surgery needs to be considered. The closed type is treated with a laser iridotomy first and combined with medication the aim is to keep surgery as a last resort. The problem in the closed type is essentially the difficulty in diagnosis.

With more than 18 years of experience in glaucoma care, can you please suggest the way out. How do you salvage the situation?
For any blinding disease to be detected, we need to create an awareness about it. Since blindness from glaucoma is economic blindness we need to strengthen our health care systems. Most patients are dependent on out of pocket expenses to take care of themselves. The need for medication, frequent checkups and investigations can create havoc with ones budgeting. Remember other diseases like diabetes, hypertension and possibly others are going to add to the burden.
As ophthalmologists we must hone our skills in the context of diagnosing and managing glaucomas in the Indian perspective.

Any particular programme that you have implemented for mass awareness and routine check up for all, particularly the elderly ?
Net worked glaucoma care at Eye Q Super Specialty Eye Hospitals ensures that its apex centre Eye Q Institute of Glaucoma co ordinates, implements and audits glaucoma care at all its 33 centres in India. Quality at affordable costs with the judicious use of technology is our focus.

With technological advancements shaping up modern treatments, what does one expect in glaucoma detection and treatment ?What to expect at Eye Q Super Speciality Eye Hospital ?
We provide quality glaucoma care to all, for life. The Eye Q Institute of Glaucoma deals exclusively with glaucoma to provide increased awareness about its diagnosis and management. Our main focus is the care and treatment of patients with glaucoma, from the common types to the rare forms of glaucoma which require treatment not available elsewhere in India. We follow world class management practices in glaucoma, customized to us Indians, in a cost effective manner, employing advanced sight saving medical and surgical techniques. From the initial examination to treatment and management of complex situations, the entire range of glaucoma care is covered.
The Next Generation of Glaucoma Care (NGGC) represents an amalgamation of validated newer technology, a gamut of new thought processes in glaucoma management and the implementation of these processes for the best possible outcome for our patients. We treat people at our main hospital at Shalimar Bagh, New Delhi and several other locations in and around the capital, enabling us to provide expert treatment closer to our patients homes.

To facilitate early detection and help preserve vision in glaucoma individuals at risk –

>>age over 40 years of age

>>glaucoma in the family those with diabetes/ thyroid disease / hypertension

>>have received steroid containing preparations : tablets/ drops/ointments/ puffs/ injections

>>see rainbow coloured rings around bright light

>>have a rapid change of glasses

>>take medication for sleep/ anxiety / depression / asthma/ parkinsonism

>>have had an injury to the face / eye

>>myopia

>>Have headaches

How well equipped is your centre to deal with high risk cases with advanced glaucoma or failed glaucoma filtering surgeries?
We are the first standalone Glaucoma Institute in the country. Thanks to our team of glaucoma specialists who have been trained at leading institutions in India and the world we are equipped to manage all forms of adult and paediatric glaucomas, advanced glaucomas, high risk and refractory glaucomas. Our focus is on quality glaucoma care to all in the Indian perspective.

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