Glaucoma is the second leading cause of global blindness after cataracts, blinding approximately 8.4 million people. In Nepal, however, glaucoma is the third leading cause of blindness after cataracts and opacity of the transparent cornea, according to the National Blindness Survey conducted in 1981. Alarmingly, glaucoma causes permanent damage to visual functioning due to irreversible nerve fibre loss at the back of the eyeball. Hence, the target organs of glaucoma are the nerves responsible for transferring visual messages to the brain from the retina. Optic nerves, if damaged once, cannot be recovered. Owing to this risk and its incorrigible consequences in society, the World Glaucoma Association and the World Glaucoma Patient Committee have been organising the World Glaucoma Week since 2010, which takes place from March 12 to 18. The theme of this year’s glaucoma week was: The world is bright, save your sight.

There are mainly two clinical variants of glaucoma: Primary and secondary. The primary form of glaucoma originates within the eye and its structures, whereas the secondary form is a byproduct of other conditions of the body or the eye. For example, a trauma in the eye or recurrent intra-ocular (within the eyeball) inflammation can cause glaucoma. A treatment of the root cause can automatically control secondary glaucoma. It can be treated initially at a nearby eye centre, seeking regular consultations from glaucoma specialists and ophthalmologists with specialisation in glaucoma treatment. Acute glaucoma is excruciating—causing the affected eye to be profusely red and a severe headache on the same side, and nausea. It is regarded as an eye emergency because if not treated timely, it causes permanent blindness. The specialist, in this condition, works mainly to reduce the pressure of the eyeball (intraocular pressure), responsible for all the symptoms.

To maintain eyeball integrity, there should be some liquid inside the eye (aqueous). It is very similar to water and is produced by the structures within the eye (ciliary body). The liquid flows out through a natural drainage system at the angle between the cornea (outer glassy transparent portion) and iris (coloured portion). The pressure of the eyeball can, then, rise by two mechanisms: If the aqueous production is more than the drainage capacity and if the drainage system is blocked or not functioning properly. In any condition, glaucoma is imminent.

Patients with primary or secondary glaucoma, as discussed above, visit hospitals with pain or other symptoms. This helps to get an early diagnosis. However, there is one insidious form of glaucoma called “open angle”, which secretly keeps damaging the retinal and optic nerves without anyone’s knowledge because it is asymptomatic. It is also found to have a hereditary predilection. If a family member has it, it’s better to screen everyone. In most other sporadic cases, glaucomatous signs are detected accidentally. When people come to check the power of their eyes or allergies, then they are suddenly diagnosed with glaucoma. Increased eye pressure is not a prerequisite for this type of glaucoma. The first suspicion is made on examining the back of the eyeball, known as retina, with a torch-like instrument (ophthalmoscope). After that, we perform a cascade of examinations before coming to the final diagnosis to assess the visual field, eyeball pressure, central thickness of the cornea, and layer-wise photographic analysis of the retina. Suppose a patient with symptoms of primary open-angle glaucoma comes to the hospital. In that case, the treating clinicians can’t do much because the patient’s visual condition is already limited, and he faces problems even with orientation and mobility.

The last symptom of this condition before blindness is characterised by tunnel vision, a small central hole of the viewing area straight ahead. In these previous instances, low vision rehabilitation is advised, whereby optometrists prescribe field-enhancing devices and encourage maximal use of residual vision by adopting different techniques and tools.

People at a higher risk of glaucoma include those over the age of 40, those with trauma to the eye, intraocular surgeries, family history, those wearing high plus power, having corticosteroid medicine for a long time or those who are hypertensive or diabetic. Since glaucoma is a progressive disease, it can’t totally be cured but can be monitored and medically controlled to delay impending vision loss.

One survey conducted a decade back in eastern Nepal revealed that 60 percent of the people who come to the hospital know the word jalabindu, but only 6 percent are knowledgeable. It is highly recommended that glaucoma awareness should be conducted not only during glaucoma week but year-round. The burden of glaucoma blindness can be reduced or delayed by timely intervention. Still, the lack of awareness among the public is a significant obstacle to shortening the time gap between the occurrence of the disease to the presentation in the hospital. As we know, the longer the gap, the poorer the prognosis. Different eye hospitals and NGOs in Nepal marked the glaucoma week, organising free screening for glaucoma, and other awareness programmes. These activities should be expanded to cover a larger population beyond cities.

There should be some initiatives to discover the current prevalence of open-angle glaucoma in Nepal, which will guide us in how we approach designing the programme in the coming days. The commonly organised refractive error screening of school children, and community cataract screening camps should be expanded to include optic disc examination that helps to sort out glaucoma suspects mandating them for further evaluation. Moreover, the annual intake of super speciality training in glaucoma should be increased and made more effective to fulfil the nation’s needs. There is also a dire need to upgrade the existing secondary and tertiary-level eye hospitals in terms of equipment, technology and human resources to regularly run glaucoma clinics.