Describe glaucoma as a public health problem.

WHY Glaucoma Is Difficult to Control

• Glaucoma is the leading cause of irreversible blindness worldwide, and affects some twelve million people in India. As cataract is progressively controlled, glaucoma becomes proportionately more important
• IT fails almost every criterion that makes cataract easy, and setting the two side by side explains why programmes have struggled:
• The damage is irreversible — cataract surgery restores vision that was lost, whereas glaucoma treatment can only preserve what remains. There is no dramatic result to show the village

What Can Be Done

• Population screening for glaucoma is not currently justified — the WHO criteria are not met because no single test has adequate sensitivity and specificity, and the cost per case detected is high. This is the honest position, and stating it is more useful than advocating a programme that would not work
• Opportunistic case-finding is the practical approach: examine the optic disc of every adult whose fundus is being viewed for any reason — during diabetic retinopathy screening, at a refraction, before and after cataract surgery, and at any routine eye examination. This is where most glaucoma is actually found, and it costs nothing additional
• Targeted screening of high-risk groups is more defensible than population screening: first-degree relatives, in whom the risk is several-fold higher — and telling every glaucoma patient to bring their siblings and children is the single most efficient case-finding measure available; age over 40; African ancestry; high myopia; diabetes; and long-term steroid use
• Angle closure deserves separate emphasis in ASIA, because it is proportionately more common, blinds faster, and is preventable. Detecting an occludable angle and performing a laser iridotomy before any damage occurs genuinely prevents blindness — which is not true of open-angle disease. Gonioscopy or a Van Herick assessment in anyone over 40 is therefore worth doing
• Practical measures for a programme — train primary and mid-level personnel to assess the disc and to measure the pressure; fundus photography with remote or AI-assisted grading.
• Compliance is the central problem of treatment, and it is worse in glaucoma than almost any other chronic disease because the patient gains nothing perceptible. Laser trabeculoplasty removes the compliance problem entirely, and the LiGHT trial supports it as a reasonable first-line option
• Control the one avoidable cause we create ourselves — steroid-induced glaucoma, from the freely available over-the-counter steroid drops used for months in India. Regulating their sale and educating pharmacists and practitioners would prevent a substantial and entirely iatrogenic burden