Daniel Laroche is an associate professor of ophthalmology with the New York Eye and Ear Infirmary of Mount Sinai, New York University, and President of the PAN-African Glaucoma Association. In this interview with SADE OGUNTOLA at the sideline of the PAN-African Glaucoma Association, he speaks to issues on glaucoma and why individuals need to own their health, particularly now.
When and how do cataracts and glaucoma occur in individuals generally? Can the two causes of blindness coexist in an individual?
Cataract and glaucoma usually start in adults over the age of 50. If you look at the epidemiological data, the increase in the incidence of the two eye conditions starts around over the age of 50. Cataract is part of the ageing of the lens of the eye. When your hair becomes grey, the lens in the eye generally starts to become yellow and cloudy and starts to increase in thickness. As the lens inside the eye increases in size, it can contribute to elevated eye pressure by narrowing the drainage angle. The large lens also rubs up against the back of the brown iris and further releases pigment that blocks its drain.
Everybody will develop cataracts with age over time, but not everybody will develop glaucoma. Those people who have large lenses that develop much larger elevated eye pressure will go on to develop glaucoma. But both cataract and glaucoma can coexist in the two eyes or in at least one of the eyes, in about 2 percent to 15 percent of the population depending on the age. This can be seen both in men and in women. There are other less common secondary causes of glaucoma as well.
Do both cataracts and glaucoma start about the same time in such eyes?
Usually cataracts will start first, and as the lens continues to thicken, glaucoma can start thereafter in many cases. It is usually the lens problem that leads to glaucoma. However, other things like injury could lead to both cataracts and glaucoma. So, the different scenarios are possible.
The lens in the eye becomes larger with age, and this can narrow the drainage angle called Schlemm’s canal. That can be due to genetics, ageing, injury, and diseases like diabetes. So when the lens becomes larger, this can contribute to an increase in eye pressure. The normal eye pressure is about 15 millimetres of mercury. When it gets to about 18 mmHg or higher, that can lead to the development of glaucoma and optic nerve damage in the eye. Usually, in individuals with cataract and glaucoma coexisting, having a cataract surgery and small incision microinvasive glaucoma surgery can help to improve vision, with less dependency on spectacle correction and lowering the pressure in the eye.
Are the blacks or whites more at risk of developing severe forms of these two blinding diseases?
Well, glaucoma and cataracts are seen more often in the black population around the world because of decreased access to care. Whether it’s America, Europe, or Australia, health care has been stratified structurally to benefit more whites and the training of more white doctors and less training of black doctors. In colonial countries, including Africa as well, historically emphasis was more on tourism, agriculture, and exploitation of labour, not training a diverse health care force to really meet the needs of the people in Africa.
So one of the things that we’re doing with the 1st Pan African Glaucoma Congress in Ghana is to train more doctors and enhance glaucoma education in the community. Because of glaucoma, we all need to get eye checked once a year. We have treatment options that can help improve vision and stop blindness through earlier cataract and microinvasive glaucoma surgery and eye drops in helping to lower the eye pressure that causes the damage to the optic nerve that transmits images to the brain.
How do personalised medicine and self-care help early detection and treatment of glaucoma cases in Africa, especially with the exodus of health workers to greener pastures abroad?
Well, first, it’s very important for individuals to take care of their health by eating well. Intake of lots of green leafy vegetables can help to prevent cataracts and glaucoma, likewise minimising the intake of carbohydrate foods. A lot of African diets, like jollof rice and bread, are very big on carbohydrates. And that’s not good for our eyes, and too much can lead to obesity or even diabetes.
Second is to increase exercise. We’re not doing enough exercise. Many people are sedentary, but we have to increase our physical activity level by walking 8,000 to 10,000 steps a day. Individuals can monitor the number of steps taken each day with the health apps or pedometer apps on smartphones. Exercise improves the blood flow throughout the body, including the eye, and this can help prevent glaucoma and other diseases.
Third is meditation, relaxation, and reduction of stress. Sitting down, closing one’s eyes, and taking deep and slow breaths at about five breaths per minute for 10 to 15 minutes can lower the eye pressure by 20%, the blood pressure by 20%, and reduce your stress catecholamines.
Regular wellness checks are also important, particularly after the age of 40 years. Of course, the check should include a vision check for eyeglasses, cataracts, glaucoma, macular degeneration, retinopathy, eye pressure, and optic nerve health by an eye doctor.
What are those innovations that African nations can tap into to stem rising cases of glaucoma on the continent?
Well, Africa is the richest continent in natural resources in the world, but the resources have been exploited. They’ve liberated themselves politically from colonialism, but they’ve not fully liberated economically. So a lot of resources are being drained from Africa to the Western countries and Asia. They have to regain control and make sure that the people benefit from that by investing in infrastructure and healthcare to keep the manpower in Africa and not have manpower leave Africa. That is the starting point.
We also have new techniques for micro-invasive glaucoma surgery and glaucoma screening that we’re teaching here at the conference. There’s a new LaRoche glaucoma calculator that’s online and free. Imputing age, eye pressure, and corneal thickness in, the doctor can tell the person’s risk for glaucoma. These are important new techniques that African nations can tap into to stem rising cases of glaucoma on the continent. There are new online visual field techniques being introduced by Eyonic that are less expensive than traditional visual fields and can be performed at home.
There are also newer techniques for earlier cataract surgery and microinvasive glaucoma surgery, which are minimally invasive surgeries to lower the eye pressure. The surgery could take between 10 to 30 minutes, and so the individual can go home the same day the surgery was done. We had several symposiums on this here at our conference.
In Africa, people with glaucoma are afraid of surgeries. They will never agree to have surgery on a good eye. What is your opinion on this?
Glaucoma is a silent thief of sight. When you have elevated eye pressure in your eye, you don’t feel it, and it’s not uncommon for somebody to have glaucoma for many years and not know that they have it. One day, they may cover one eye only to realise that they cannot see with the other eye. The eye had gone completely blind. Then they are told that there is also a 50 or 60 percent loss of vision in their supposedly good eye. They’re scared of having surgery on their good eye because they don’t want to go blind. But we like to operate on the good eye first to try to preserve the remaining vision, and then the bad eye last just to salvage what vision is left. That approach ensures the best possible outcome.
Oftentimes, people with education on why the surgery is aimed at achieving will come around to have the surgery. But there’s always going to be a handful of people that don’t want to do surgery and, unfortunately, will lose their vision. So it’s about educating people, giving them the knowledge to make these decisions on their own, with the doctor.
Despite the skill transfer in this meeting, how do you see this improving access to glaucoma care in Africa given the cost of health services?
Well, you do need medical equipment and facilities for health. The good news is that some of the new techniques we’re looking at are cost-effective techniques to help save money and to make sure it’s not too expensive. Nonetheless, healthcare costs money. It is not free. And governments have to really take a close look at their resources and make sure the people are benefiting with a well-funded workforce and healthcare system to provide good care. Again, it’s important that African governments look at their economies and make sure that it is benefiting their people and not just foreign interests or foreign multinationals.
Which should be prioritised most when it comes to detection and treatment for glaucoma?
We have a new LaRoche glaucoma calculator that looks at age, intraocular pressure, and corneal thickness. I use that every day in my office to help identify patients with glaucoma early. Those patients that are high-risk and who may have early glaucoma, we do offer them for early cataract surgery or microinvasive glaucoma surgery to lower the pressure. This will help both to preserve and improve their vision. A lot of the time, they end up seeing better without glasses.
In the United States, early cataract surgery and microinvasive glaucoma surgery are covered by insurance. In many African countries, they don’t have that. So it’s an out of pocket expense. The good news is that a lot of the surgeons charge reasonable rates. It’s an affordable surgical option to help treat glaucoma. Manual small incision cataract surgery has also been shown to work very well to lower eye pressure and improve vision in glaucoma patients. One study quoted at this Congress from the Congo showed a nine-point drop on average in eye pressure after this procedure in glaucoma patients.
What are the common myths and misconceptions about glaucoma that you come across in your medical practice?
Well, I think a lot of people don’t know what glaucoma is. So we want to educate people as to what it is and why they should get their vision and eye pressure checked by an eye doctor. Early detection of eye pressure and prompt treatment can help prevent blindness. The mean normal intraocular pressure is 15. When the eye pressure gets to 18 mmHg or more, we are concerned, particularly in patients with thinner corneas. Higher intraocular pressure, particularly in persons with thin corneas, puts them at a higher risk for vision loss and glaucoma. People with thicker corneas greater than 570micrometers are a lot more protected against developing glaucoma.
Q: What are challenges you are facing in ensuring Africans with glaucoma can access care?
A: Funding of health services is one and requires government support. Investing in healthcare workers is an investment into their economies. Africans have to spend their monies within the community as well to strengthen it financially. When we buy European clothes, foreign hair, etc., these are monies that leave our communities and make us poorer. Other major problems are poor awareness among Africans about the disease and a lack of manpower to treat glaucoma. So, we want to train more surgeons. This is an invitation to all the young people that we need you in medicine. This is a great career to really help people. However, with a stronger economy and better infrastructure, people can have better health care since there are higher wages, better jobs, and better employment within a more robust economy. These are all factors that contribute to improving health care in Africa.
Q: Why are African ophthalmologists coming together, particularly now, to talk about glaucoma?
A: The Pan African Glaucoma Association (PAGA) is the preeminent organisation dedicated to improving the lives of all people with glaucoma and those at risk of the disease. It is leading the advancement of education, research, health care access, and advocacy. Its focus is unique in that Africans and persons of African descent throughout the Diaspora have the highest rates of blindness to glaucoma globally. So, the PAGA is grateful to the Ophthalmological Society of Ghana and other bodies like the National Medical Association Ophthalmology Section, Eyonic, New World Medical, and Zeiss for their assistance and support for the inaugural meeting in Accra, Ghana.
Read Also: Onifiditi gets staff of office