Glaucoma’s insidious nature—killing up to 40% of retinal ganglion cells before symptoms occur—pretty much guarantees that patients who suffer from it will be caught off guard. The same can’t be said for the doctors and public health officials tasked with managing it. The severity of the problem and the Herculean effort needed to tackle it are plain as day. We have a huge base of fixed-income patients, often dispersed geographically away from care centers, experiencing inexorably progressive field loss that’s held in check only by the frustratingly indirect method of IOP control, trying (and usually failing) to marshal the motivation and dexterity needed to put drops in their eyes every day.
Though glaucoma’s challenges are self-evident, numbers sometimes help, even if only to give us a sobering look at the scale of the problem.
We lead off our news section this month with a review of glaucoma’s epidemiology, and some worrying trends therein. Glaucoma’s current toll of 76 million people worldwide will rise to 112 million in the next 20 years. The disease disproportionately affects non-white ethnicities, with a prevalence of 5.7% among Black individuals vs. 2.2% in white populations, and that disparity will grow more acute. “The severity of glaucoma begins at an earlier age and at a more aggressive course in Black people than in white people and Asians,” wrote the study authors, citing the perfect storm of intractable socioeconomic barriers to care and a genetic predisposition toward the disease. And the annual price tag for glaucoma care in the US alone is $5.8 billion, a number that will double in a decade.
Phew! Ready for more? The problems are just as formidable on the provider side. With ophthalmology’s capacity stagnant, it falls to optometry to pick up the slack. A survey we conducted last year found most ODs see about 10 glaucoma patients or suspects per week, far fewer than the volume needed to meet the demand. Worse, nearly 20% of the ODs who see these patients refer them out right away. The survey participants cited the high cost of equipment and inability to bill medical insurance plans as key impediments to greater attention to glaucoma. A less concrete (and hence less addressable) problem is a reluctance to take on glaucoma care that affects too many ODs.
Today’s students get a great education in glaucoma, but these skills can wither on the vine if new grads move into a retail setting after college. Chain ODs often find themselves without the patient base, equipment or time to address glaucoma. In short, the incentives are all wrong in retail culture for medical optometry to thrive, and primary care–minded doctors may feel they have to “spin and grin” until they can transition to private practice. The worry is they’ll bring retail culture with them and struggle to meet the needs of the more time-consuming cases that are the bread and butter of glaucoma.
Corporate optometry is often a necessary first job for newly minted ODs desperate to pay down debt. No one should be faulted for taking the best, or perhaps only, path available to them. But the mismatch of skills and culture in that setting—and the spillover consequences for patients—is just one of the tangles in the Gordian knot that is glaucoma.