Background: Glaucoma is a major cause of visual impairment and irreversible blindness affecting 76 million people globally. The burden of glaucoma is highest in sub-Saharan Africa, where the prevalence is estimated to be 4%, twice the global average. In Uganda, the population-based prevalence of glaucoma is unknown. However, a systematic review of Rapid Assessment of Avoidable Blindness (RAAB) data from Africa in 2013 reported that glaucoma contributed to 38.5% of all blindness in Uganda, the second in Africa after Nigeria, which had 42%. Recent global estimates have predicted a substantial increase in absolute numbers of individuals affected in African populations over the next decade if no interventions are made. Glaucoma is largely asymptomatic until the disease is advanced, at which point very little can be done to save sight. An ideal situation for reducing avoidable blindness due to glaucoma is having a system where the population is knowledgeable about the condition, a strong mechanism to screen and find early cases, strong referral linkages to where the care is, an armamentarium of good treatment options, follow-up and rehabilitative services. Unfortunately, such a system does not exist in Uganda and many other resource-limited settings. Mbarara University of Science and Technology, through the department of ophthalmology at Mbarara University and Referral Hospital Eye Centre (MURHEC), in collaboration with Christian Blind Mission (CBM), piloted a glaucoma screening and treatment project in Uganda that aimed to make a substantial contribution towards fighting this cause of avoidable blindness.

Our project aimed to: 

• Improve awareness of glaucoma among the population and primary health workers • Make screening for glaucoma available at 24 primary health facilities, and

• Decentralise glaucoma diagnosis and treatment to three Regional Referral Hospitals (RRHs) in Southwestern Uganda. The data generated from this project would be useful in informing national prioritisation of glaucoma in mainstream eye health budgeting and financing.

Approach: In summary, MURHEC serves as a centre of excellence and training centre for upskilling ophthalmologists at the secondary level RRHs to provide glaucoma diagnosis and treatment. The ophthalmicclinical officers (OCOs) at the primary health centres (HC IVs) provide screening and referral for patients suspected to have glaucoma. Embedded into this was a baseline and endline assessment of the capacity of the health system to manage glaucoma.

Project milestones Baseline assessment: Following the necessary ethics approvals and permissions, we surveyed 86 health facilities in Uganda to establish baseline data for the reported annual prevalence of glaucoma, capacity and challenges of managing glaucoma in the nation’s health system. The findings were unsurprisingly poor. For example, our study revealed a gross underdiagnosis of glaucoma, at only 0.007%. Therefore, for every glaucoma case diagnosed, about 685 other cases were missed, highlighting the gross under-capacity to diagnose glaucoma within the health system. Underpinning these were low staffing levels, low levels of knowledge among the heath workers and a lack of equipment and drugs. We have since disseminated the baseline survey results on different fora including a GLAST meeting with district health officers, a Uganda Ophthalmology Society meeting and the College of Ophthalmology of Eastern, Central and Southern Africa (COECSA) congress in Lilongwe, Malawi in 2022.

Capacity building of the facilities in glaucoma diagnosis and management:  This included training, equipment support and seed stock of consumables and drugs. Training included glaucoma diagnosis and management (medical, surgical and low-vision care) and eye health data capturing and reporting.

 • Five ophthalmologists from five secondary-level hospitals in Uganda underwent glaucoma surgery training, which was conducted by Dr Fisseha, a Glaucoma Surgeon from the University of Gondar, Ethiopia.

 • Three OCOs received low vision training.

 • Twenty-six OCOs received refresher training on glaucoma diagnosis and medical management.

 • Twenty-six data officers received training on eye health data capture and reporting into the Uganda Ministry of Health HMIS system. Equipment for the secondary-level hospitals included iCare tonometer, slit-lamp with a 90-dioptre condensing lens and a visual field machine. Each hospital also received a bulk seed stock of sutures, lenses, glaucoma and cataract sets, viscoelastic and anti-glaucoma drugs. In one year of project implementation, this has translated into 36,702 patients screened for glaucoma and 1404 diagnosed and treated.

Glaucoma sensitisation and awareness campaign: Perhaps one of the biggest successes of this intervention has been public engagement. This has been achieved through massive distribution of information, education and communication (IEC) materials translated into the local languages, education videos on glaucoma with sign language interpretation, use of local radio talk shows and several advocacy activities with the local political and health leaders. Our previous work showed that radio was an effective community mobilisation tool. In addition, we set up glaucoma patients’ associations in the different regions served by the secondary-level hospitals. In these associations, glaucoma patients organise themselves and pool money to complement government care. They provide peerpatient counselling for new patients and have been key in sensitising the population during radio talk shows.

Glaucoma networking: The glaucoma project in Uganda is linked to the Glaucoma-NET Decision-Intervention Support Cluster (DISC) led by Fatima Kyari and supported by the International Centre for Eye Health, London SchoolGlaucoma networking The glaucoma project in Uganda is linked to the Glaucoma-NET Decision-Intervention Support Cluster (DISC) led by Fatima Kyari and supported by the International Centre for Eye Health, London School Figure 2: Health workers from MUST with the representative of the Ugandan president (centre) and the Uganda People’s Defence Force brass band lead the public through a main street in Mbarara City, Uganda to create awareness during World Glaucoma. The platform runs monthly online meetings that bring together individuals and groups working on glaucoma all over the world for a shared learning experience. These discussions have been instrumental in shaping the project delivery. For example, the session on ‘Mitochondrial dysfunction and neurodegeneration in glaucoma’ guided our approach on screening all relatives of ‘index’ glaucoma cases. The ‘Publicity campaign for glaucoma’ DISC session shaped our publicity campaign to achieve Top of Mind (TOM) and Tip of Tongue (TOT) for glaucoma in Uganda.

Key success:  The project, the first of its kind in Uganda, has been able to create a glaucoma awareness in the mainstream health leadership and amongst political leaders, health workers and the public. Uptake of glaucoma screening, diagnosis and management has improved in the health system. There has been improved glaucoma and general eye health data capture and reporting because of the training of the data clerks from the health facilities. We plan to utilise this data in our advocacy engagement with the government for eye health financing. However, the uptake of glaucoma surgery is still low in the community

Funder: Funded by Christian Blind Mission (CBM)

Contact persons: Dr Viola Ninsiima Arunga and Dr Daniel Atwine.

Start date: 2022

Link:  Eye News | glaucoma 2023 | www.eyenews.uk.com