Is Ophthalmology Residency Training in India Geared to Tackle the Glaucoma Challenge?

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To the Editor:
Glaucoma is the leading cause of irreversible blindness globally. Recent large surveys from India put glaucoma as a significant contributor to visual impairment and blindness.1,2 Missing glaucoma during a routine evaluation is an important cause of late presentation.2,3 Two recent publications that looked at residency training in India from the Residency Evaluation and Adherence Design Study (READS) painted a rosy picture about the ability of young ophthalmologists to opportunistically screen for glaucoma.4,5 Those trained in the 21st century reported better exposure to autoperimetry, pachymetry, applanation tonometry, optical coherence tomography, and +78/+90 D lens optic disc evaluation, as compared with those trained in the 20th century (Table 1). Although this is encouraging, a self-assessment of skills may be inherently biased, as it is based on an individual’s arbitrary assessment of the skill set imparted to them.
Early diagnosis and treatment is the only way to limit disability and visual impairment in glaucoma. An eye care practitioner must be vigilant to “catch” this “silent thief of vision.” As primary glaucoma may present without any symptoms, it is incumbent on the ophthalmologist to be alert to its signs of narrow angles, cupping of the disc, raised intraocular pressure, and visual field loss.6 The huge burden of undetected glaucoma in India can only be addressed if all ophthalmologists actively look for the disease in their patients (opportunistic screening). In population-based studies carried out in the country, a significant proportion of those with undetected disease had undergone a recent evaluation by an eye care professional.2,3 Among those with detected disease, both the Chennai Glaucoma Study and the Andhra Pradesh Eye Disease Study (APEDS) reported that two thirds of those with angle-closure glaucoma, who were already on treatment for glaucoma at the time of detection, had not undergone laser iridotomy, either because gonioscopy was not performed or was inappropriately interpreted.2,7 This could be related to inadequate clinical skills required to detect glaucoma.
The poor self-reported skills with YAG laser iridotomy in the READS survey were again a cause for concern. Although all the ∼24 million persons with primary angle-closure disease may not require a peripheral iridotomy, most of those who meet the criteria for undergoing treatment will have to be treated by general ophthalmologists.7,8 It is essential that residents get adequate exposure to this simple technique. The decreasing number of trabeculectomies performed by residents trained recently was perhaps a reflection of the global reduction in rates of glaucoma surgeries with the advent of newer classes of antiglaucoma medications. However, it is essential that a general ophthalmologist be at least acquainted with the basic surgical techniques and postoperative evaluation following trabeculectomy.
The READS studies do provide us with useful insights on future glaucoma management.4,5 The large standard deviations for most of the parameters again highlight the huge disparities in the quality of training programs. This is even more of a concern in a postgraduate examination system that does not include skill testing.8 Improved detection rates with improvements in self-reported clinical skills juxtaposed against inadequate management training (YAG PI, trabeculectomy) may not result in large reductions in glaucoma blindness in the near term. Although glaucoma management has undergone a sea change in the past few decades, a lot more needs to be done for glaucoma to be successfully challenged, as cataract has been, in the coming years.
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