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The King is Dead - Long Live the King!
Roger Hitchings, Paul Kaufman, Daniel Grigera and Hidenobu Tanihara
Introduction
To practise glaucoma is to provide long lasting satisfaction. The varieties
of problems on offer can not but excite all ophthalmologists. These range
from the public health issues of efficiency of detection and delivery of
care; in management the immediate satisfaction of goniotomy for buphthalmos
or argon laser iridoplasty for acute angle closure glaucoma, to the subtle
complexities inherent with a chronic disease and the interactions of co-morbidity.
In addition the world of glaucoma is united as never before, with the recent
World Glaucoma Congress, setting priorities and organising teaching and
updates for all. The regional Societies too play their part by developing
Guidelines that appeal to local needs and concerns.
Glaucoma is recognised to be a worldwide problem, becoming of increasing
importance as society's age and visual dependence increases.
So what cloud can encroach on this sunny visage?
Glaucoma has an image problem and is increasingly likely to suffer
for this in the future. It has become too comfortable, and too self
absorbed. This old subspecialty is seen as one that only in the last
decade provided evidence that treatment (by proxy-lowering intraocular pressure)
had any value. The speciality is damned by survey reports that find, wherever
they look, that 50% of the glaucoma's in a society is undiagnosed. We have
no useful case finding policy either for angle closure or for open angle
glaucoma, and we have extremely imprecise methods of monitoring for disease
progression. Our therapeutic approaches are not licensed to treat glaucoma
(only to lower IOP), and we have not provided new approaches to management
since the advent of topical prostaglandins Even more damagingly, from the
point of view of the outside observer, is that our therapeutic agents in
the two Treatment-No Treatment trials published show a significant number
of eyes in the treated group that reveal evidence for progression.
The problem for our speciality goes further than the simple recognition that it has been slow to combat problems with diagnosis and management. There is a perception that disease progression is slow if not very slow, with many patients never becoming aware of their visual loss, so that some patients may receive treatment unnecessarily.
More important is the recognition that age related macular degeneration (ARMD) is a far commoner and more dramatic cause of visual disability and blindness, and that this condition has had new ideas both for pathogenesis and, especially, treatment. The promise of further therapeutic advances in the prevention and treatment of ARMD has caused attention as well as funds for research and therapy to be directed towards this and other retinal conditions.
Money for diagnosis and management as well as for research is likely to be more difficult to obtain in the future unless our speciality can present cogent reasons to continue funding at present levels.Withdrawal of management funds will be seen as a reduction in reimbursement as well as in therapeutic options. A reduction in research allocation will be seen as removal of glaucoma related topics from future calls for grant proposals. Both could lead to stagnation for our speciality.
Proposals
Glaucoma, through the World Glaucoma Association (WGA) and the Regional
Societies, needs to develop and present a coherent strategy both for research
and management. The former needs to show that it can prioritise research
topics. It has to show that in doing so the speciality is looking for topics
that have a direct bearing on both diagnosis and management, and that these
will include cost effective outcomes. This means projects designed to
meet current criticisms- these include; no screening strategy for the common
types of glaucoma, no clear indication of when to start treatment, no clear
plan on how to identify progression, no ability to translate visual disability
into Quality of Life (QoL) outcomes, no therapies directed directly at the
neurodegeneration responsible for glaucomatous visual loss, and no health
economic analysis of treatments. Basic research needs to show a clear
pathway from the laboratory towards these clinical goals, to set a timeline
for a five- and ten-year strategy to achieve them, so as to give funding
agencies an idea of financial commitment.
Management needs to have a better focus on outcomes, relating these to targeting risk, with prioritisation of therapeutic resources. Therapeutic approaches need to be organised according to local budgetary constraints, and here specific concerns need to be urgently addressed. These should include recommendations on best strategies for case finding, follow-up and therapy. There should be a clear line taken by each of the regional societies, probably coordinated by the umbrella organisation that is the WGA.
Communication Unless the glaucoma fraternity can make contact with those around us all these proposals will be in vain. We have to specifically target four groups: the public, the patient, the politician and the physician. The Public need information about the prevalence, age related demographics and the risk. In other words identify 'The Need'. The Patient will be aware of all this information. The Patient needs to be informed on the effects of the disease. These will include disability, and equivalence with other diseases (Utility Values). There should be better information available on patient organisations that individuals can go to for support. Patient organisations in their turn need to be primed with arguments for supporting research, diagnosis and management that are acceptable to both the politician and the public. These organisations provide a vital source of funds, which in turn can be used to influence the thinking of politicians (not least to provide matching funds for specific projects).
The Politician needs information, and needs to receive it not just from us but also from the other three groups for credibility. This should be about the direct and indirect costs of glaucoma and its treatment, together with a health economic and quality of life argument for the benefits of early diagnosis. The politician needs to understand how basic research can benefit the patient, and the consequences of reducing research funds. This information needs to be targeted at both a National (to influence policy) and a local level. Local level arguments need also to target hospital and district administrators. The arguments will be enhanced by good publicity. Glaucoma related publicity for local hospitals will produce a sympathetic ear into which economic and QoL arguments can be put.
Our fellow Physician needs information on Regional and National Societies, to be kept up to date with current views and news. Continuing Professional Development for the trained, and training for the student should be mandatory, and could well be linked to reimbursement.
In addition to all these proposals, there is a major need for one voice to represent the speciality around the world, with the authority to identify priorities and to link in with other causes of visual loss. The World Glaucoma Association (WGA) should be developing this. The WGA needs to link World Glaucoma Day to other worldwide initiatives for combating blindness such as Vision 20:20, but only when the message is correctly focussed.
The King is Dead - Long Live the King!
The World Glaucoma Congress provided the focus for our speciality to rationalise its approach for its constituents and to its public, and for the newly formed WGA to coordinate the approach. Time to get moving.
