Glaucoma is a chronic optic neuropathy resulting in visual field defects and progressive, irreversible vision loss. Glaucoma is the second leading cause of blindness in the United States. Primary open-angle glaucoma is the most common form. Rates of glaucoma are projected to increase by 50% to 3.36 million people by 2020, causing a significant economic and quality of life burden. Risk factors for glaucoma include advanced age (65+ years), family history of glaucoma, race (African American, Asian), and ethnicity (Hispanic/Latino). Diabetes is also an independent risk factor for glaucoma. African Americans develop glaucoma at a younger age, progress more rapidly, and are almost 7 times more likely to go blind than non-Hispanic Caucasians. Despite the advanced technology and available diagnostic testing, 50% of people with glaucoma remain undiagnosed. When glaucoma is diagnosed in its early stages, appropriate treatment and management can almost always prevent blindness. Under the leadership of L. Jay Katz, MD;Julia A. Haller, MD;and Lisa Hark, PhD, RD, the Wills Eye Glaucoma Research Center will conduct a 5-year prospective, randomized controlled trial to test an innovative community intervention using fundus photography of the optic nerve and macula (telemedicine) to detect, treat, and manage high-risk patients with previously undiagnosed glaucoma and other eye diseases. Our diverse, targeted at-risk population includes African Americans, Hispanics and Asian over age 40;older adults (aged 65+);and those over age 40 with a family history of glaucoma and/or diabetes. Phase 1 will consist of recruiting approximately 2,000 patients from 14 primary care offices and 10 federally qualified health centers across Philadelphia and Chester counties with our community partners. Using telemedicine, we will detect eye disease using telemedicine (Visit 1) followed by a comprehensive eye exam by a glaucoma specialist to confirm the diagnosis (Visit 2). Based on preliminary data, 30% of patients (approximately 600) will have abnormal optic nerve and/or macula images. The predictive accuracy of the optic nerve images to detect glaucoma and glaucoma suspect as confirmed by the comprehensive eye exam will be evaluated. Phase 2 will involve consenting, enrolling, and randomizing 300 patients to either the usual care group (n=150) or the enhanced intervention group (n=150) and scheduling follow-up eye exams with local, general ophthalmologists (Visit 3). The enhanced intervention will consist of using patient navigators and a social worker to reduce barriers to follow-up eye care. Phase 3 will consist of following patients proximally (6 months) and distally (3 years) while they attend ophthalmology appointments (Visits 4-8). Adherence to follow-up recommendations for eye care will be the primary outcome measure. A comprehensive cost study to estimate the intervention costs and cost-effectiveness of detecting eye diseases and vision impairment in a high-risk population will also be conducted. Protocols, materials, and results will be disseminated to other communities in order to expand detection of glaucoma, other eye diseases, and visual impairment, and to further refine these approaches.
The Wills Eye Hospital proposes a new public health model to improve detection, management, and follow-up eye care of individuals at high-risk for glaucoma, other eye diseases, and vision impairment in Philadelphia. With the support of governmental, community, and university partners, Wills Eye Glaucoma Research Center will utilize telemedicine technology to detect glaucoma and other eye diseases and will confirm ocular diagnoses by conducting comprehensive dilated eye exams, both in the primary care offices and federally qualified health centers. This innovative 5-year, evidence-based, randomized controlled trial can serve as a model for integrating primary care and public health in community settings that can easily by sustained, replicated, and disseminated nationally.
