Glaucoma Screening Program Research Articles

Screening of Glaucoma: Consensus and Directions.

Glaucoma is a leading public health concern globally. This summary discusses barriers to glaucoma screening and novel strategies for a cost-effective glaucoma screening. We discuss barriers to glaucoma screening and recent advancements in glaucoma detection and care, including targeted screening approach as well as telemedicine, genetic testing, and artificial intelligence (AI). A major barrier to glaucoma screening is the cost-effectiveness of case finding resulting from the low prevalence of the disease and the complexity of the diagnosis. Targeted-screening, as well as multi-level screening, can reduce the false positive rate and increase the cost-effectiveness of the program. Telemedicine, availability of genetic testing and polygenic risk scores, and AI provide the opportunity for novel glaucoma screening programs in primary care, portable, and home-based settings and will be helpful for lowering the costs, identifying patients in need of urgent treatment and enabling timely diagnosis and early intervention. Screening of glaucoma is challenging and changing. Recent advancements in digital technology and genetics have led to the development of tools that are promising for novel screening methodologies. Clinical trials are needed to demonstrate the long-term effect of targeted screening on the burden of glaucoma worldwide.

Barriers and Potential Solutions to Glaucoma Screening in the Developing World: A Review.

Glaucoma is a leading public health concern globally and its detection and management are way more complex and challenging in the developing world. This review article discusses barriers to glaucoma screening in developing countries from the perspective of different key stakeholders and proposes solutions. A literature search was carried out in the electronic catalogs of PubMed, Medline, and Cochrane database of systematic reviews to find studies that focused on barriers and enablers to glaucoma screening. The authors' interpretations were tabulated as descriptive and qualitative data and presented concisely from the point of view of key stakeholders such as the patients and their relatives, care providers, and system/governing bodies. Key barriers to glaucoma care identified are lack of awareness, poor accessibility to ophthalmic centers, inadequately trained human resources, unsatisfactory infrastructure, and nonavailability of financially viable screening programs. Educating care providers, as well as the public, providing care closer to where people live, and developing cost-effective screening strategies are needed to ensure proper identification of glaucoma patients in developing countries. The logistics of glaucoma detection and management are complex. Hence, glaucoma detection programs should be implemented only when facilities for glaucoma management are in place. Understanding the importance of glaucoma screening and its future implications, addressing the various roadblocks, empowering and efficiently implementing the existing strategies, and incorporating novel ones using Artificial Intelligence (AI) and deep learning (DL) will help in establishing a robust glaucoma screening program in developing countries.

Novel Technologies in Artificial Intelligence and Telemedicine for Glaucoma Screening.

To provide an overview of novel technologies in telemedicine and artificial intelligence (AI) approaches for cost-effective glaucoma screening. A narrative review was performed by summarizing research results, recent developments in glaucoma detection and care, and considerations related to telemedicine and AI in glaucoma screening. Telemedicine and AI approaches provide the opportunity for novel glaucoma screening programs in primary care, optometry, portable, and home-based settings. These approaches offer several advantages for glaucoma screening, including increasing access to care, lowering costs, identifying patients in need of urgent treatment, and enabling timely diagnosis and early intervention. However, challenges remain in implementing these systems, including integration into existing clinical workflows, ensuring equity for patients, and meeting ethical and regulatory requirements. Leveraging recent work towards standardized data acquisition as well as tools and techniques developed for automated diabetic retinopathy screening programs may provide a model for a cost-effective approach to glaucoma screening. Leveraging novel technologies and advances in telemedicine and AI-based approaches to glaucoma detection show promise for improving our ability to detect moderate and advanced glaucoma in primary care settings and target higher individuals at high risk for having the disease.

Feasibility of Glaucoma Detection Programs for At-Risk Populations Using Existing Health Care Infrastructure.

Targeted glaucoma screening strategies performed within retail care-based clinics and Federally Qualified Health Centers (FQHCs) uncover a high prevalence of glaucoma. To summarize the glaucoma detection and maintenance programs that utilize existing health care infrastructure to promote up-scalable programs. Health care infrastructure that already exists may facilitate glaucoma detection. This infrastructure includes retail-based optometry practices and FQHC. Persons who are at risk for glaucoma are disproportionately represented within the patient populations served by much of this infrastructure, thus suggesting that it could be useful for deploying glaucoma screening programs. Glaucoma screening within FQHCs reveals a very high prevalence of glaucoma and related disease in the patients seeking care at these facilities. These telemetric-based care delivery programs have a high patient acceptance. A simulated telemedicine program modeled after a telemedicine program based in Walmart Vision Centers for the diagnosis of glaucoma indicated that there was moderate diagnostic agreement between an ophthalmologist's telemedicine diagnosis and an ophthalmologist's in-person diagnosis. There was also moderate agreement between an optometrist's telemedicine diagnosis and the ophthalmologist's in-person diagnosis. Telemetric care delivery programs that capitalize on existing infrastructure within a retail-based care setting or FQHCs may provide a promising setting to cost-effectively screen for glaucoma and other eye diseases that are potentially expandable nationwide.

A residual connection enabled deep neural network model for optic disk and optic cup segmentation for glaucoma diagnosis.

Glaucoma diagnosis at an early stage is vital for the timely initiation of its treatment for and preventing possible vision loss. For glaucoma diagnosis, an accurate estimation of the cup-to-disk ratio (CDR) is required. The current automatic CDR computation techniques attribute lower accuracy and higher complexity, which are important considerations for diagnostics system design to be used for such critical diagnoses. The current methods involve a deeper deep learning model, comprising a large number of parameters, which results in higher system complexity and training/testing time. To address these challenges, this paper proposes a Residual Connection (non-identity)-based Deep Neural Network (RC-DNN), which is based on non-identity residual connectivity for joint optic disk (OD) and optic cup (OC) detection. The proposed model is emboldened by efficient residual connectivity, which is beneficial in several ways. First, the model is efficient and can perform simultaneous segmentation of the OC and OD. Second, the efficient residual information flow permeates the vanishing gradient problem which results in faster converges of the model. Third, feature inspiration empowers the network to perform the segmentation with only a few network layers. We performed a comprehensive performance evaluation of the developed model based on its training in RIM-ONE and DRISHTIGS databases. For OC segmentation, for the images (test set) from {DRISHTI-GS and RIM-ONE} datasets, our proposed model achieves the dice coefficient, Jaccard coefficient, sensitivity, specificity, and balanced accuracy of {92.62, 86.52}, {86.87, 77.54}, {94.21, 95.36}, {99.83, 99.639}, and {94.2, 98.9}, respectively. These experimental results indicate that the developed model provides significant performance enhancement for joint OC and OD segmentation. Additionally, the reduced computational complexity based on reduced model parameters and higher segmentation accuracy provides the additional features of efficacy, robustness, and reliability of the developed model. These attributes of the developed model advocate for its deployment of population-scale glaucoma screening programs.

Diagnostic Accuracy of Frequency-Doubling Technology and the Moorfields Motion Displacement Test for Glaucoma

Portable perimetric testing could be useful for community-based glaucoma screening programs. Frequency-doubling technology (FDT) and the Moorfields motion displacement test (MDT) are portable perimeters that have shown promise as potential screening tools for glaucoma. This study's goal was to determine the diagnostic accuracy of FDT and MDT for visual field defects and glaucoma. Prospective, cross-sectional, diagnostic accuracy study. A consecutive series of patients aged ≥ 50 years who presented to a glaucoma clinic in South India and had never undergone Humphrey field analyzer (HFA) visual field testing in the past. Participants underwent 24-2 Swedish Interactive Thresholding Algorithm (SITA)Standard HFA perimetry, FDT perimetry, MDT perimetry, and iPad perimetry using visualFields Easy in random order. Ophthalmologist grades of HFA and optic nerve head photographs were used as reference standards for glaucoma and field defect presence. Receiver operating characteristic curves were constructed to assess the diagnostic accuracy of various parameters for each test. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Overall, 292 eyes from 173 participants were included, with 112 eyes classified as moderate or worse glaucoma. For moderate or worse glaucoma detection, the best parameter on FDT was mean deviation (MD) (AUROC, 0.84; 95% confidence interval [CI], 0.79-0.89) and the best parameter on MDT was global probability of true damage (GPTD) (AUROC, 0.87; 95% CI, 0.82-0.91). When specificity was set to 90%, the sensitivity for detection of moderate or worse glaucoma was 55% (95% CI, 39%-68%) for FDT MD and 62% (95% CI 52%-71%) for MDT GPTD. Frequency-doubling technology and MDT perimetry had fair diagnostic accuracy for glaucoma detection when administered to naïve test takers in this South Indian population. Although not appropriate for use as a sole glaucoma screening test, these perimetric tests may be useful as ancillary tests. Proprietary or commercial disclosure may be found after the references.

Performance of a Glaucoma Screening Program Compared With Opportunistic Detection in China.

Health examination center-based screening provide a good supplement to clinic-based glaucoma care by detecting early-stage glaucoma, especially those with normal intraocular pressure (IOP) and less visual impairment. Opportunistic glaucoma screening for early case identification is of great value in the prevention of severe visual impairment, however, novel, low-cost models are needed. We aimed to determine whether health examination center-based glaucoma screening identifies diseases earlier than outpatient cases in China. In this case-control study, 76 patients with primary glaucoma identified from a health examination center-based glaucoma screening program and 272 consecutive outpatient cases at the same hospital were enrolled from March 21 to September 30, 2016. Demographic characteristics, best-corrected visual acuity, IOP, mean deviation (MD), and pattern standard deviation (PSD) on Humphrey visual field testing in the better-seeing eye were compared between groups. Screening-detected glaucoma patients had significantly lower IOP (18.3±4.2mmHg) than out-patient cases (26.7±12.6mmHg, P <0.001). Most (71.1%) of the screening-detected patients had IOP<21mmHg compared with 37.1% in the clinic group ( P <0.001). Seventy-five patients (98.7%) in the screening group were diagnosed as primary open angle glaucoma, compared with 44.1% in the clinic group ( P <0.001). Screening-detected patients had significantly less visual impairment than the clinic group (6.6% vs. 38.6%, P <0.05). Mean MD (-4.4±5.0dB) and PSD (4.4±3.6dB) for the screening group were superior to the clinic group (MD: -16.5±10.5dB, P <0.001; PSD: 6.5±3.7dB, P <0.001). The glaucoma screening program was effective at detecting early disease, especially normal tension glaucoma and supplemented opportunistic detection of glaucoma.

Assessment of glaucoma awareness, uptake, and satisfaction with a free, targeted glaucoma screening program Southwest in Nigeria.

Glaucoma is a global public eye health concern, being the number one cause of irreversible blindness. It is commoner, has an earlier onset, and is more aggressive in people of African descent. Awareness creation and screening activities have been identified as key components of the glaucoma care pathway. This was a cross-sectional, descriptive study with analysis. The screening took place at the eye clinic, University College Hospital, Ibadan. Participants comprised all consenting adults aged 40 years and above who presented following a prescheduled telephone appointment during the 2021 World Glaucoma Week (WGW) activities. The main outcome variables were the awareness of glaucoma, and the uptake of and satisfaction with the free screening program. The associations between participants' prior awareness of glaucoma and their socio-demographic and clinical features were explored using the Chi-squared test. A P value of <0.05 was considered significant. A total of 94 (47%) participants presented for the screening out of the 200 people who scheduled an appointment through the telephone appointment booking system. Forty-nine (52.1%) were males, and the mean (SD) age of participants was 55 years (10.9) with a range of 40-80 years. Fifty-eight (61.7%) participants had heard of glaucoma before the 2021 WGW awareness programs and 75.9% (44) gained some new knowledge from the programs. Newly diagnosed glaucoma was 9.6% (n = 9) of which seven (77.8%) had advanced glaucoma (CDR ≥0.9) in at least one eye. One hundred percent of the participants reported that they would recommend the screening to others. Targeted eye screening can help with the early detection of glaucoma. Patient satisfaction should be at the fore of eye health services to improve uptake.

Analysis of Socioeconomic Factors Affecting Follow-Up in a Glaucoma Screening Program.

PurposeTo determine what socioeconomic factors affect follow-up in a glaucoma screening program.Patients and MethodsThis was a retrospective cohort study of six health fairs in South Florida from October 2012 to March 2013 among socially and economically disadvantaged populations. Visual acuity (VA), intraocular pressure (IOP), cup-to-disc ratio (CDR), and visual field testing were obtained to identify glaucoma suspects. Glaucoma suspects were defined as having intraocular pressure ≥24 mm Hg, cup-to-disc ratio of ≥0.6 in either eye, or glaucomatous defects on visual field testing. In July 2015, telephone surveys were administered to assess follow up and socioeconomic factors.ResultsSeventy-two out of 144 (50%) glaucoma suspects responded to the survey and were included in the analysis. Of the 72 respondents, average age was 52.8 years old and 65% were female. The most common race was African American (69%) and ethnicity was Haitian (51%). Glaucoma suspects who followed up were significantly more likely to have health insurance compared to those who did not follow up (74% vs 43%, p = 0.014). No significant difference in follow-up based on age (p = 0.125), education (p = 0.151), gender (p = 0.48), or ethnicity (p = 0.707) was identified. Of the 30 respondents, who did not follow up, the most common reasons were “no insurance” (57%, 17/30) and “not worried” (33%, 10/30).ConclusionInsurance was the main socioeconomic factor in determining whether glaucoma suspects followed up after community health screenings. Streamlining social services could increase clinical access of glaucoma suspects.

Telehealth and Screening Strategies in the Diagnosis and Management of Glaucoma.

Telehealth has become a viable option for glaucoma screening and glaucoma monitoring due to advances in technology. The ability to measure intraocular pressure without an anesthetic and to take optic nerve photographs without pharmacologic pupillary dilation using portable equipment have allowed glaucoma screening programs to generate enough data for assessment. At home, patients can perform visual acuity testing, web-based visual field testing, rebound tonometry, and video visits with the physician to monitor for glaucomatous progression. Artificial intelligence will enhance the accuracy of data interpretation and inspire confidence in popularizing telehealth for glaucoma.

Genetic pre-screening for glaucoma in population-based epidemiology: protocol for a double-blind prospective screening study within Lifelines (EyeLife)

BackgroundEarly detection of glaucoma is paramount to maintain patients’ eyesight, however glaucomatous vision loss tends to begin in the periphery with up to 50% of patients unaware they are affected. Because glaucomatous vision loss is permanent, screening appears attractive, but currently is not cost-effective. Therefore we aim to investigate the utility of genetic pre-screening for glaucoma in a population-based setting, called EyeLife.MethodsEyeLife adopts a double blind prospective design with contrasting groups. Selected participants (n = 1600) from the Lifelines cohort are 55 years of age or older, and of either the highest or lowest 20% of the genetic risk distribution for glaucoma. We obtained a highly curated list of genetic variants from the literature to obtain each participants’ genetic risk for glaucoma. Participants will undergo comprehensive ophthalmic screening. The primary outcome is the relative risk of glaucoma given a high genetic risk compared to a low genetic risk.DiscussionIf genetic pre-screening is successful, it will increase the yield of a glaucoma screening program by focusing on high-risk individuals. This, in turn, may improve long-term visual health of middle-aged and elderly people.Trial registrationEthics approval was obtained on January 31, 2019, and the study was retrospectively registered with the Netherlands Trial Register (NL8718) on the 17th of June, 2020.

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach.

Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified. The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics. A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA). Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident). CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.

Rural Glaucoma in China: Present Status and Future Directions

BACKGROUND: Glaucoma is the commonest cause of irreversible blindness worldwide. Factors associated with the development of glaucoma have been examined in several studies, but not in the Chinese rural population. The China Rural Glaucoma Cohort Study (China-RG Study) was conducted to investigate the present status of glaucoma in China. METHODS: The China-RG Study is a population-based study (June–October 2018) that included 22 rural areas from ten provinces in China and enrolled 52,041 individuals (age >6 years). Participants completed a comprehensive eye examination, including visual acuity, intraocular pressure (IOP), slit-lamp microscopy, direct ophthalmoscopy, and further investigations. Associations of demographics and medical factors with glaucoma were assessed using multiple logistic regression models. Disability (YLD) and quality-adjusted life-years (QALYs) were used to express adverse health outcomes of glaucoma; cost-effectiveness analysis was conducted to evaluate the superiority of glaucoma-screening program. FINDINGS: Overall prevalence of glaucoma was 1.6% (95% CI 1.52–1.77%); 58.2%, and 19.8% had primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG), respectively. Increasing age, history of cerebral infarction, marital status, location, and family history of glaucoma were significant risk factors for both PACG and POAG. Cost–benefit analysis indicated savings of approximately 286,56.57 million yuan in direct medical expenses nationwide by adopting the proposed screening mode. INTERPRETATION: Glaucoma should be included in chronic disease-management programs in China for long-term care and continuous management of high-risk cases. The scope and inclusions of basic public health services should be expanded, especially to include ophthalmic diseases. FUNDING STATEMENT: This research was supported by the National Natural Science Foundation of China (grant no. 81830026) and the Natural Science Foundation of Tianjin (grant no. 18ZXDBSY00030) DECLARATION OF INTERESTS: The authors declare there are no competing interests. ETHICS APPROVAL STATEMENT: Ethics approval for study conduct was obtained from the institutional ethics committee of Tianjin Medical University General Hospital; all participants provided written informed consent prior to study participation.

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre

To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia. Retrospective chart review. Patients from a community glaucoma screening program. Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence. A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence. The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.

Reproducibility of 5 Methods of Ocular Tonometry

To evaluate the agreement between Goldmann applanation tonometry (GAT; Haag-Streit, Bern, Switzerland) and several portable tonometers that could be used for glaucoma screening programs. Evaluation of a diagnostic test. Three hundred twenty-one eyes of 168 participants seeking treatment at the glaucoma clinic of a tertiary eye hospital in India. Participants underwent intraocular pressure (IOP) measurement with GAT and 4 index tests: the Icare TA01i rebound tonometer (Icare USA, Raleigh, NC), a noncontact tonometer (NCT; Topcon CT-80; Topcon; Tokyo, Japan), a pneumatonometer (Model 30; Reichert Technologies; Depew, NY), and the Tono-Pen AVIA (Reichert Technologies). Estimates of reproducibility of IOP measurements between each index test and GAT, including the intraclass correlation coefficient (ICC) and the Bland-Altman 95% limits of agreement. The Icare showed the greatest agreement with GAT (ICC, 0.69; 95% confidence interval, 0.61-0.74), followed by the NCT (ICC, 0.65; 95% confidence interval, 0.58-0.71), the Tono-Pen (ICC, 0.51; 95% confidence interval, 0.43-0.59), and the pneumatonometer (ICC, 0.36; 95% confidence interval, 0.27-0.44). The pneumatonometer and Tono-Pen tended to overestimate IOP relative to GAT, with a mean difference of 3.4 mmHg (95% limits of agreement [LOA], -7.3 to 14.1 mmHg) for the pneumatonometer and 3.2 mmHg (95% LOA, -6.1 to 12.6 mmHg) for the Tono-Pen. In contrast, measurements from the Icare and NCT were on average within 1 point of those for GAT (mean difference, -0.4 mmHg [95% LOA, -8.4 to 7.6 mmHg] and -0.5 mmHg [95% LOA, -8.7 to 7.6 mmHg], respectively). The Icare and NCT both demonstrated good agreement with GAT across a wide range of IOPs and could be considered for glaucoma screening programs.

Early detection of glaucoma suspect by pattern electroretinogram

Aim This study was intended to estimate the significance of pattern electroretinogram (PERG) in evaluation of the retinal ganglion cell function in patients with glaucoma. Patients and methods An observational case–control study was done on 40 eyes of individuals whose age ranged between 30 and 65 years of age. They were divided into two equal groups. Control group had normal visual field and optical coherence tomography optic nerve, intraocular pressure (IOP) less than 21 mmHg, visual acuity more than 0.3, and cup disc ratio (C/D) less than 0.5. The case group was divided into two equal subgroups: group A had IOP more than 21 mmHg and C/D less than 0.5, and group B had IOP less than 21 mmHg and C/D more than 0.5. We excluded all cases with ocular or systemic diseases with negative effect on retinal function such as retinal detachment, retinitis pigmentosa, rheumatoid arthritis on hydroxychloroquine, diabetic patients on insulin or oral hypoglycemic, or cases with abnormal optic disc appearance such as optic disc drusen, coloboma, or tilted disc. All cases underwent full ophthalmological examination, including best-corrected visual acuity, complete anterior segment examination with slit-lamp biomicroscopy, and posterior segment examination using volk 90 D lens, along with IOP measurement using Goldmann applanation tonometer. Visual field assessment was done using Heidelberg Edge Perimeter, optical coherence tomography optic nerve using Heidelberg engineering, and glaucoma screening with ERG using glaucoma screening program. Results There was a highly statistically significant difference between the groups regarding C/D and IOP. Regarding the PERG and different visual fields parameters, there was a highly statistically significant difference between the groups. There was a statistically significant negative correlation between PERG and both IOP and VF parameters in all different groups. No statistically significant correlation was found between PERG and C/D in all different groups. Conclusion PERG has a prognostic value in recognition of retinal ganglion cell dysfunction, as an early indication for glaucoma development.

Diagnostic accuracy of a new thresholding glaucoma screening programme using temporally modulated flicker

Diagnostic accuracy of a new thresholding glaucoma screening programme using temporally modulated flicker

Performance of Deep Learning Architectures and Transfer Learning for Detecting Glaucomatous Optic Neuropathy in Fundus Photographs

The ability of deep learning architectures to identify glaucomatous optic neuropathy (GON) in fundus photographs was evaluated. A large database of fundus photographs (n = 14,822) from a racially and ethnically diverse group of individuals (over 33% of African descent) was evaluated by expert reviewers and classified as GON or healthy. Several deep learning architectures and the impact of transfer learning were evaluated. The best performing model achieved an overall area under receiver operating characteristic (AUC) of 0.91 in distinguishing GON eyes from healthy eyes. It also achieved an AUC of 0.97 for identifying GON eyes with moderate-to-severe functional loss and 0.89 for GON eyes with mild functional loss. A sensitivity of 88% at a set 95% specificity was achieved in detecting moderate-to-severe GON. In all cases, transfer improved performance and reduced training time. Model visualizations indicate that these deep learning models relied on, in part, anatomical features in the inferior and superior regions of the optic disc, areas commonly used by clinicians to diagnose GON. The results suggest that deep learning-based assessment of fundus images could be useful in clinical decision support systems and in the automation of large-scale glaucoma detection and screening programs.

Cost-effectiveness of community screening for glaucoma in rural India: a decision analytical model

ObjectivesStudies in several countries have demonstrated the cost-effectiveness of population-based screening for glaucoma when targeted at high-risk groups such as older adults and with familial history of disease. This study conducts a cost-effective analysis of a hypothetical community screening and subsequent treatment programme in comparison to opportunistic case finding for glaucoma in rural India. Study designA hypothetical screening programme for both primary open-angle glaucoma and angle-closure disease was built for a population aged between 40 and 69 years in rural areas of India. MethodsA decision analytical model was built to model events, costs and treatment pathways with and without a hypothetical screening programme for glaucoma for a rural-based population aged between 40 and 69 years in India. The treatment pathway included both primary open-angle glaucoma and angle-closure disease. The data on costs of screening and treatment were provided by an administrator of a tertiary eye hospital in Eastern India. The probabilities for the screening and treatment pathway were derived from published literature and a glaucoma specialist. The glaucoma prevalence rates were adapted from the Chennai Glaucoma Study findings. ResultsAn incremental cost-effectiveness ratio value of ₹7292.30 per quality-adjusted life-year was calculated for a community-screening programme for glaucoma in rural India. The community screening for glaucoma would treat an additional 2872 cases and prevent 2190 person-years of blindness over a 10-year period. ConclusionsCommunity screening for glaucoma in rural India appears to be cost-effective when judged by a ratio of willingness-to-pay thresholds as per WHO-CHOICE guidelines. For community screening to be cost-effective, adequate resources, such as trained medical personnel and equipment would need to be made available.

Depression and quality of life in a community-based glaucoma-screening project

ObjectiveTo identify the prevalence and risk factors of depression among individuals given a glaucoma-related diagnosis at a screening program. DesignCross-sectional community-based in a university hospital. ParticipantsVolunteers from a community glaucoma-screening program. MethodsAfter collecting sociodemographic information, participants were administered the Geriatric Depression Scale-15 (GDS-15) and the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25). ResultsParticipants were predominantly African American (73.5%), older than 65 years (65.7%), single (75.4%), and female (66.8%). Among 268 participants, 89 were diagnosed with glaucoma and 179 as glaucoma suspects. The frequency of depression among the glaucoma and glaucoma suspect participants was 18% and 16.2%, respectively. The mean GDS-15 score was 2.4 ± 2.7 with no difference between glaucoma and glaucoma suspect groups, p = 0.654. The mean VFQ-25 score was 78.6 ± 15.9 and was lower in glaucoma (74.7 ± 19.7) than glaucoma suspect participants (80.4 ± 13.6), p = 0.003. Risk factors for depression included difficulties with paying expenses (p = 0.017), Asian race (p < 0.001), and poorer scores on the VFQ-25 subscales of “General Health” (p < 0.001), “Distance Activities” (p = 0.024), and “Dependency” (p = 0.001). ConclusionsPrevalence of depression in those diagnosed with glaucoma or glaucoma suspect was higher than previous estimates of the general population. Glaucoma-screening programs might benefit from including depression-screening protocols along with referral services or low-cost treatments of depression.