Does Training Clinic Nurses to Test Pinhole Visual Acuity as a Screen for Glaucoma Increase Glaucoma Referrals to Eye Care Professionals? A Pilot Study in Malawi

Abstract

Purpose: To test whether general nurses, trained in screening for glaucoma, can increase the number of glaucoma cases seen by eye-care professionals in a rural setting in Africa.Methods: In two districts in Malawi, 87 clinic nurses and two ophthalmic clinical officers were trained in case detection and referral of patients with suspect glaucoma. Data were collected on the number of patients screened and referred over a 12-month period. The clinic nurses and ophthalmic clinical officers received supportive supervision four times during the period and interviews were used to elicit their perspectives on the training and referral procedures.Results: The 87 nurses screened 294 people (mean 3.4 per nurse) and referred 147 (50%) of them. Of the 147 referred, 56 (38%) were seen by the ophthalmic clinical officers who referred 15 (27%) to the ophthalmologist. Only two people were seen by the ophthalmologist. Testing visual acuity in people over 40 years of age was not seen as a priority by primary level clinic nurses. Nurses reported that cost and distance were barriers precluding attendance by patients at the next level. Women were two times less likely to be referred. About one quarter of patients who were offered surgery refused. Fewer than half the patients who had surgery attend for follow-up.Conclusions: Training general nurses to screen for and refer suspect glaucoma cases did not lead to increased glaucoma service delivery. Other strategies to identify high risk patients need to be tested.