PerspectiveThe Value of Tests in the Diagnosis and Management of Glaucoma
Section snippets
Addressing Glaucoma in Resource-Poor Settings
Glaucoma is the world's leading cause of preventable irreversible blindness, affecting an estimated 60.5 million persons and responsible for vision loss among 8.4 million in 2010.14 Damage to vision from glaucoma has been associated with a significant impact on activities of daily living, even at levels well before blindness.15 As pressure-lowering treatment for glaucoma has been demonstrated to reduce the rate of progression of vision damage,16, 17 there is potential value in screening for the
Addressing Glaucoma in Resource-Abundant Settings
The basic technologies essential for diagnosis of glaucoma in resource-poor circumstances are, in resource-abundant areas, universal and familiar. But they are available with so many variations and alleged enhancements that confusion often surrounds what is genuinely essential for glaucoma care. The fundamentals remain simple: IOP is the only physiological parameter we can currently alter to interrupt the progression of glaucoma; the optic nerve (and surrounding nerve fiber layer) is our
The Value of Glaucoma Tests in the Context of Time
Having surveyed testing technologies used in glaucoma from the contexts of focus (structure or function), of resources, and of conceptual frameworks, we now address an important but implicit context that also affects any assessment of a test's value: the perspective of time. Looking backwards to ophthalmic history, it is important to remember the primacy of technology in defining any disease such as “glaucoma.”94 The direct ophthalmoscope revealed to von Graefe the optic nerve's pallor;
Discussion
Let us summarize by integrating the multiple contexts we have touched upon. For the vast majority of the world's patients with glaucoma, most of whom live in settings of constrained resources, the importance of disease management pales before a larger reality: most glaucoma in the world remains undiagnosed, screening paradigms are neither useful nor practical, and access to therapy is severely limited. At the most basic level we have yet to determine: 1) at which stage of disease is the
Conclusions
There is a great gulf of values between the woefully inadequate allocation of funds to prevent glaucoma blindness among the resource-poor and the enormous expenditure on unproven technologies to address early disease without significant functional loss among the resource-abundant. More thoughtful prioritization in our use of wealth in both resource-poor and resource-abundant (but not resource-infinite) areas could alleviate much suffering—but insufficient consideration is given to how these
Marc F. Lieberman, MD, completed his medical degree at the Johns Hopkins Medical School in Baltimore, Maryland and his internship at St. Joseph Mercy Hospital in Ann Arbor, Michigan. He then pursued an ophthalmology residency at the Wilmer Institute, Johns Hopkins, and a glaucoma fellowship at University of Calfornia, San Francisco. He is currently the Director of Glaucoma Services, Department of Ophthalmology, California Pacific Medical Center, and Clinical Professor Ophthalmology at
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Marc F. Lieberman, MD, completed his medical degree at the Johns Hopkins Medical School in Baltimore, Maryland and his internship at St. Joseph Mercy Hospital in Ann Arbor, Michigan. He then pursued an ophthalmology residency at the Wilmer Institute, Johns Hopkins, and a glaucoma fellowship at University of Calfornia, San Francisco. He is currently the Director of Glaucoma Services, Department of Ophthalmology, California Pacific Medical Center, and Clinical Professor Ophthalmology at University of California, San Francisco. He founded and serves as Executive Director of the Tibet Vision Project, voluntarily teaching modern ophthalmic skills to Tibetan surgical teams since 1995.