Pakistan Journal of Ophthalmology Vol. 34, No. 2, Apr – Jun, 2018 111 Original Article Dropout of Newly Diagnosed Glaucoma Patient from Follow-up Schedule Anis-ur-Rehman, Jamsed Faridi, S.M Enamul Haque, Mukti Rani Mitra, Md Abdus Salam, Mostak Ahmed Pak J Ophthalmol 2018, Vol. 34, No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Dr. Anis-ur-Rehman Green Eye Hospital Dhaka, Bangladesh. Email: anjumk38dmc@gmail.com …..……………………….. Purpose: To evaluate the impact of verbal counseling alone and verbal with structured written counseling in prevention of drop out of glaucoma patients from follow-up schedule. Study Design: Descriptive study. Place and duration of study: Green Eye Hospital Dhaka, Bangladesh for 18 months, from July 2015 to December 2016. Material & Methods: During the study period, 300 newly diagnosed glaucoma patients were enrolled. They were divided into two groups. Group: A & B. Each group comprised of 150 patients. Group: A patients were verbally counseled and structured written counseling brochures were given and Group: B patients were counseled only verbally. Results: We compared the dropout during follow-up between the two groups. There was significant difference between the two groups (The chi-square statistics was 9.8182. The p value was 0.001728). Moreover, the drop out of elderly patients (>50 years) was less than the patients with < 50 years of age. When there was positive family history of glaucoma dropout was significantly less. In group: A, (p-value was 0.029932, in group B, p value was 0.00011 using chi square test). Conclusion: Drop out during follow up in newly diagnosed glaucoma patients is less if they are given written brochures with verbal counselling. Drop out of elderly glaucoma patients is lesser than the younger age group. Key words: Glaucoma, glaucoma counseling, intra ocular pressure laucoma is a form of disease in which there is a characteristic potentially progressive optic neuropathy that is associated with visual field loss and in which IOP is a key modifiable factor1,2. Because it often goes undetected in its early stages, glaucoma is called the “sneak thief of sight." It is estimated that nearly half of the Americans who currently have glaucoma are unaware of their condition3. Glaucoma prevalence is relatively high in Bangladesh. Prevalence of definite glaucoma was 2.1%. The prevalence of definite and probable glaucoma was 3.1% in subjects of the same age4. It is the second most common cause of blindness5,6. Once nerve fibers die and visual function is lost, it cannot be recovered7. Treatment can only help preserve remaining vision; hence it is imperative to detect the disease in its earliest stage8. Often, glaucoma is asymptomatic. Therefore, people suffering from glaucoma may lose vision without knowing it. Regular eye examinations are an important way to detect glaucoma9. After the diagnosis of glaucoma, about half of the patients do not come for follow up visit. Most prevalent barrier to being lost to follow up is the belief that there is no problem with one‟s eyes10. This sort of belief is irrespective of age, gender, economic status, level of education. If patient has, any idea about G http://www.geteyesmart.org/eyesmart/eye-health-news/sneak-thief-of-sight.cfm ANIS-UR-REHMAN, et al 112 Vol. 34, No. 2, Apr – Jun, 2018 Pakistan Journal of Ophthalmology glaucoma such as when there is positive family history of glaucoma, dropout of follow up is reduced. Most probably it is due to the awareness about the disease. With this concept, we prepared a brochure, which contained some preliminary idea about glaucoma. The brochure contained general concept of glaucoma for the patients and their family and answers to the most frequently asked questions. If the family members have some knowledge about the disease and its ultimate fate, they can persuade the patient for regular follow-ups. The study was undertaken to evaluate the impact of verbal counselling alone and verbal with structured written counselling in prevention of drop out of glaucoma patients from follow-up schedule. MATERIAL AND METHODS It was a prospective descriptive study done in a private eye hospital in Dhaka, Bangladesh. Study period was from January 2015 to June 2016. During this eighteen months 300 patients were enrolled who were newly diagnosed cases of Glaucoma (except acute congestive glaucoma). The diagnosis was made by measurement of intra ocular pressure (IOP) with applanation tonometer, cup-disc ratio by direct ophthalmoscopy, visual field analysis by Humphrey visual field analyzer, assessment of angle structure by Gonioscopy, measurement of corneal thickness by OCT and sometimes analysis of optic nerve fiber layer thickness by OCT14. When there was no visual field damage, we performed the measurement of retinal nerve fiber layer thickness. Decreased RNFL reflectivity may be a predictor of future structural and functional glaucomatous damage15, 16. Most of the patients were diagnosed incidentally. Others had either positive family history of glaucoma or there was frequent change of presbyopic glasses. After diagnosis of glaucoma, some demographic data was recorded and the two groups were further classified according to: age of the patient- above 50 years and below 50 years, gender, economic status- belowand above middle class, level of education- below 12 classes or above, family history of glaucoma. We divided all 300 patients into two groups. Group A (150 patients) included those who got the written counseling brochures after verbal counselling. The brochure was prepared in local Bangla language. Following questions were answered in the brochure: 1. What is glaucoma? Glaucoma is a lifetime disease like diabetes and hypertension. There is mild increase of your intraocular pressure which causes permanent damage of optic nerve (Optic nerve is a part of brain which carries your visual sensation to the brain. If there is damage to the optic nerve, this sensation will not reach to the brain). 2. Is glaucoma a curable disease11? It is not a curable disease but if you control your IOP with the help of medicines (usually eye drops) there will be no chance of damage of vision for glaucoma. 3. Why people cannot realize that he/she is suffering from glaucoma? Most glaucoma patients do not have symptoms. As visual loss usually starts from the far periphery, glaucoma sufferers may not notice any visual loss in the early to moderate stages of the disease. By the time, an individual realizes something is wrong; there is usually already quite considerable irreversible visual loss. There is nothing that can completely prevent glaucoma but you can slow down its development and progression with early effective treatment. 12 4. How long should I treat for glaucoma? You should treat it life long as diabetes and hypertension but you have to go to your eye doctor according to his advice and he will check your eye pressure and other investigation if needed. 5. Is there any chance to be blind due to glaucoma? There is chance of irreversible blindness in glaucoma if you do not control your eye pressure13. 6. How can I get rid of vision loss due to glaucoma? If you contact your eye doctor regularly and use, eye drop in time according to his advice there is no chance of blindness14. 7. Is there any other treatment of glaucoma? Usually eye drops are sufficient for glaucoma but sometimes to reduce the number of eye drops, eye specialists like to use laser. Surgery is other option but if drops and laser cannot stop progression of the disease your doctor may need to advice you for trabeculectomy surgery. Group B included patients who were only counseled verbally. These two groups were advised to come after one month to three months for follow up. No reminder was sent to patients for follow up. We used purposive sampling technique. Patients were enlisted in the groups according to the need of the study. After collecting the data, we compared it with the follow up group and with those who did not come for follow up. DROPOUT OF NEWLY DIAGNOSED GLAUCOMA PATIENT FROM FOLLOW-UP SCHEDULE Pakistan Journal of Ophthalmology Vol. 34, No. 2, Apr – Jun, 2018 113 Association of each group was analyzed by 2x2 Table (Chi-square test). All statistical analysis was conducted using Social Science Statistics for windows 10. RESULTS Table 1 shows the demographic profile of both the groups. There is no significant difference between the two groups regarding age, gender, monthly income, education status and family history of glaucoma. In the two groups, the overall follow up was 165 (55%). In group: A it was 96 (64%) and group: B, it was 69 (46%). In two groups, the overall follow up was 165 (55%). In group A, it was 96 (64%) and group B, it was 69 (46%). The difference is significant it means those who were verbally counseled as well as got the brochure “Glaucoma the silent killer of your vision” were more motivated regarding their follow-up (table 2). According to age group, those above 50 years were more aware of follow up if they were provided with written counseling brochure (table 3). The results according to gender and income of the patient are given in table 4 & 5. The level of education was also found to be positively related with follow-up (table 6). Table 1: Shows demographic profile of glaucoma patients during enlistment. Group A Group B Total Age Below 50 54 51 105 ⁕ NS Chi-squared test was done to find the difference between the two groups ⁕NS: Non significance Above 50 96 99 195 Gender Male 71 77 148 ⁕ NS Female 79 73 152 Income Above average 83 81 168 ⁕ NS Below average 67 69 132 Education Below 12 class 104 98 202 ⁕ NS Above 12 class 46 52 98 + Family history Yes 47 45 92 ⁕ NS No 103 105 208 Table 2: Patient follow up between two groups. Group A Group B p value Present 96 69 0.001728 Absent 54 81 Table 3: Follow-up according to age group. Group A: Came for Follow-up No Follow-up Total p value Below 50 24 30 54 0.000182 Above 50 72 24 96 Total 96 54 150 Group B: 0.231469. Total Below 50 20 31 51 Above 50 49 49 99 Total 69 81 150 ANIS-UR-REHMAN, et al 114 Vol. 34, No. 2, Apr – Jun, 2018 Pakistan Journal of Ophthalmology Table 4: Follow-up according to gender. Group A: Came for Follow-up No Follow-up Total p value Male 45 26 71 0.76338 Female 51 28 79 Total 96 54 150 Group B: 0.88084 Total Male 38 39 77 Female 31 42 73 Total 69 81 150 Table 5: According to income of patient. Group A: Came for Follow-up No Follow-up Total p value >Aver 54 29 83 0.763338 < Aver 42 25 67 Total 96 54 150 Group B: 0.367777 Total >Aver 40 41 81 12 class 36 10 46 Total 96 54 150 Group B: 0.090334 Total > Aver 40 41 81 < Aver 29 40 69 Total 69 81 150 Table 7: According to family history of glaucoma. Group A Came for Follow-up No Follow-up Total p value +family 36 11 47 0.029932 -family 60 43 103 Total 96 54 150 DROPOUT OF NEWLY DIAGNOSED GLAUCOMA PATIENT FROM FOLLOW-UP SCHEDULE Pakistan Journal of Ophthalmology Vol. 34, No. 2, Apr – Jun, 2018 115 Group B 0.00011 Total +family 33 12 45 -family 36 69 105 Total 69 81 150 DISCUSSION Glaucoma is a disease of the optic nerve and some studies have reported glaucoma as a leading cause of permanent blindness worldwide7. Although glaucoma is neither preventable nor curable, the progression of the disease can be halted with appropriate treatment. Glaucoma cannot be cured, but it can be successfully controlled in most cases8. As visual loss usually starts from the far periphery, glaucoma sufferers may not notice any visual loss in the early to moderate stages of the disease. By the time an individual realizes something is wrong (needing more light and blurry vision) quite considerable irreversible visual loss has occurred15,16. The results of our study show that both the groups are demographically homogenous. The overall follow up was found to be 55%, which is more than the Ashaye et al10 study. In their study, dropout from follow-up was 60.5%, which is higher than our study (in our study overall drop out was 45%) but closer to our group: B population (drop out 54%) where only verbal counseling was given. Another study by Gupta V1et al showed that even after trabeculectomy surgery only 30% of patients maintained a 5-year follow-up17. In our study drop out from follow-up in group A is significantly less than group: B (p value is 0.001728). Gender related drop out in our study was not consistent with Ashaye AO et al where males had a higher dropout rate than females (78.6% vs. 34.5%). This was found to be due to male patients coming from a distant locality. However, in our study we did not record the locality of the patient. The drop out of follow-up in relation to economic status was insignificant in our study, which does not correspond to some previous works. Maybe this is because the study was done in a private eye hospital and equal accessibility of poor was not possible18. We found that educated patients were more aware of follow-up, which is consistent with Bradford et al studies19. Level of education is directly proportional with the follow-up rate. In multivariate analysis they showed level of education is directly proportional to follow-up. In adjusted OR for poor follow-up (95% CI) is 1.34 (0.65-2.76) vs. 4.13 (1.44-11.90) educated vs. non- educated19. Glaucoma is 2 to 4 fold more common with positive family history20,21. We found that drop out of follow-up is significantly reduced when there is positive family history of glaucoma irrespective of counseling which is consistent with Green et al22. In their study, follow-up of glaucoma patient was 60% more than those with negative family history of glaucoma, irrespective of counseling. In our study both A (p-value is 0.029932) & B group (p-value is 0.00011) patients came for follow-up (76.6% and 73.3%) whereas the overall was 165 (55%) in A and B groups. In group A it was 96 (64%) and group B, it was 69 (46%)23. CONCLUSION Glaucoma is a slowly progressing, symptomless, sight threatening disease and one of the leading cause of preventable blindness worldwide because of missed or late diagnosis and large number of „follow-up dropouts‟ even after diagnosis. Counseling is an effective method of creating awareness among the diagnosed patients as well as the risk groups. This study clearly shows the effectiveness of a combined verbal with structured written format of counseling over verbal counseling alone in reducing the dropout rate of the diagnosed glaucoma patients irrespective of age, gender, economic status, and level of education. Author’s Affiliation Dr. Md Anisur Rahman. FCPS. Head of Dept of Ophthalmology Dhaka Medical College Dr. Jamsed Faridi. DO Registrar Department of Ophthalmology Department of cornea. NIO & H https://www.ncbi.nlm.nih.gov/pubmed/?term=Ashaye%20AO%5BAuthor%5D&cauthor=true&cauthor_uid=18414110 https://www.ncbi.nlm.nih.gov/pubmed/?term=Gupta%20V%5BAuthor%5D&cauthor=true&cauthor_uid=23350554 https://www.ncbi.nlm.nih.gov/pubmed/?term=Ashaye%20AO%5BAuthor%5D&cauthor=true&cauthor_uid=18414110 ANIS-UR-REHMAN, et al 116 Vol. 34, No. 2, Apr – Jun, 2018 Pakistan Journal of Ophthalmology Dr. S. M. Enam-ul-Haque Soumo MS, Ophthalmology Assistant Professor Dr.Mukti Rani Mitra FCPS Assistant Professor Department of Ophthalmology Dhaka Medical College Dr. Md Abdus Salam MS, FCPS, Consultant Kuwait Bangladesh Friendship Govt Hospital. Dhaka Dr. Md Mostak Ahmed MS Ophthalmology, Associate professor Department of Ophthalmology Manikganj Medical College Role of Authors Dr. Md Anisur Rahman. Conception and planning of the work, analysis and interpretation of the data, drafting and/or critical revision of the manuscript for important intellectual content, Approval of the final submitted version of the manuscript. Dr. Jamsed Faridi. DO Conception and planning, analysis and interpretation of the data, drafting, approval of the final submitted version of the manuscript. Dr. S.M Enamul Haque Soumo Conception and planning, analysis and interpretation of the data, Drafting Dr. Mukti Rani Mitra Conception and planning, analysis and interpretation of the data, Drafting Dr. Md Abdus Salam Conception and planning, analysis and interpretation of the data, Drafting Dr. Md Mostak Ahmed Conception and planning, Analysis & Drafting REFERENCES 1. Brad Bowling. Kanski‟s clinical ophthalmology a systemic approach. 8th edition. Sydney. Elsevier, 2016: 307 P. 2. Open angle glaucoma: POAG. By Admin September 26, 2015. Medic for you ‖ Medical community. 3. Patient's Guide to Living with Glaucoma. Stuart Carduner. Discovering the Sneak Thief: Diagnosing Glaucoma. 4. Rahman MM, Rahman N, Foster PJ, Haque Z, Zaman AU, Dineen B, Johnson GJ. The prevalence of glaucoma in Bangladesh: a population based survey in Dhaka division. Br J Ophthalmol. 2004 Dec; 88 (12): 1493-7. 5. Newspaper: The Daily Star. Glaucoma 3rd biggest cause of blindness. 1:04 AM, March 14, 2015. 6. Suman S Thapa, Kurt H Kelley, Ger V Rens, Indira Paudyal Lan Chang. A novel approach to glaucoma screening and education in Nepal. BMC Ophthalmology, 20088: 2. 7. Leading Causes of Blindness. NIH Medline plus, summer, 2008; 3(3): 14 – 15. 8. Robin A, Grover SD. Compliance and adherence in glaucoma management. Indian J Ophthalmol. 2011;59 (Suppl. 1): S93–S96. Doi: 10.4103/0301-4738.73693. 9. Cindy X Huet al. What Do Patients with Glaucoma See? Visual Symptoms Reported by Patients with Glaucoma. AJMS 2014; 348 (5):403-409. 10. Ashaye AO, Adeoye AO. Characteristics of patients who dropout from a glaucoma clinic. J, Glaucoma, 2008; 17 (3): 227-32. Doi: 10.1097/IJG.0b013e31815768b3. 11. Harry AQ. Glaucoma: What Every Patient Should Know: USA. Create Space Independent Publishing Platform; 1 Edition (May 7, 2011). 12. Goldberg I, Susanna R Jr. How to Save Your Sight. Glaucoma 2015; 13: 978-9062992423. 13. Jackson A. “Glaucoma Research Foundation. San Francisco. Understanding and Living with Glaucoma. 14. Boyd K. What is Glaucoma? American Academy of Ophthalmology. Uploaded on Mar. 01, 2017, cited on 21 Feb. 2018. 15. Lucy KA, Wollstein G. Structural and Functional Evaluations for the Early Detection of Glaucoma. Expert Rev Ophthalmol. 2016; 11 (5): 367–376. 16. “Glaucoma Research Foundation. San Francisco. 5 common glaucoma tests. Available on https://www.glaucoma.org/glaucoma/diagnostic- tests.php uploaded on Last reviewed on October 29, 2017 cited on. 17. Gupta V, Chandra A, Yogi R, Sihota R, Singh D. Prevalence and causes of patient dropout after glaucoma surgery. Ophthalmic Epidemiol. 2013; 20 (1): 40-4. Doi: 10.3109/09286586.2012.741278. 18. Krishnaiah Set al. Awareness of glaucoma in the rural population of Southern India. Indian J Ophthalmol. 2005; 53 (3): 205-208. 19. Bradford W et al. Predictors of and Barriers Associated with Poor Follow-up in Patients with Glaucoma in South India. Arch Ophthalmol. 2008; 126 (10). 20. Budde MM, Jost B. Jonas. Family history of glaucoma in the primary and secondary open-angle Glaucoma. Ophthalmology 1999; 237 (7): 554–557. http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys DROPOUT OF NEWLY DIAGNOSED GLAUCOMA PATIENT FROM FOLLOW-UP SCHEDULE Pakistan Journal of Ophthalmology Vol. 34, No. 2, Apr – Jun, 2018 117 21. Charles W, Monnies J. Glaucoma and risk factors. J Optom. 2017; 10 (2): 71–78. 22. Green CM et al. How significant is a family history of glaucoma? Experience from the Glaucoma Inheritance Study in Tasmania. Clin Ex Ophthalmol. 2007; 35 (9): 793-9. 23. Jeffrey S. Build your own medical optometry practice part 1. 2nd edition. 2017 Virginia 2. Publisher: The OD/MD consulting group.