Glaucoma Management in the African-Derived Developing World Using Trabeculoplasty

描述(申请人提供)：青光眼是非洲发展中世界导致失明的主要原因，由于疾病负担巨大，这是一个重大的公共卫生挑战。在加纳，40岁以上开角型青光眼的患病率为8.5%。在巴巴多斯，这一比例为7.0%。在邻近的圣卢西亚，青光眼患病率估计为8.8%，单眼或双眼青光眼相关失明的十年发病率为16%。(相比之下，美国成年人的患病率为1.9%)。与青光眼相关的视觉功能障碍的负担在发展中国家也很严重。由于医疗和外科治疗的应用受到成本、可获得性和有限的区域外科专业知识等问题的限制，正在治疗中的情况普遍存在。此外，几乎没有机会获得低视力或视力康复服务，为视障人士提供的社会支持也很少。激光小梁成形术可能是解决发展中国家迅速增长的青光眼负担的一部分。治疗快速、安全、微创，只需要最少的治疗后护理；设备是便携式的；一旦设备和专业知识到位，小梁成形术治疗的增量成本就很小。我们最近在圣卢西亚的研究表明，激光小梁成形术降低眼压的程度可能有利于改变青光眼的临床病程(与不治疗相比)，并有可能弯曲非洲发展中国家的青光眼相关失明曲线。我们的长期目标是通过公共卫生倡议将这一发现转化为建立泛加勒比海青光眼激光计划，为这个服务不足和负担过重的地区提供安全、有效和成本效益高的青光眼治疗方法。在此之前，关于SLT在这一人群中的几个重要研究问题仍然没有得到回答，并构成了这项建议的具体目标。SLT在这一人群中的长期疗效是什么？一旦初次SLT的眼压下降，重复SLT是否有效？在圣卢西亚取得的成果是否可以推广到其他居住着非洲人后裔的发展中国家？在这项应用中，我们提出了一项在圣卢西亚进行的前瞻性队列研究，其中符合条件的开角型青光眼受试者将接受双侧选择性激光小梁成形术，随后将接受首次SLT失败，并将再次接受SLT，直到失败。因此，首次和重复SLT在非洲裔青光眼患者中的长期安全性和有效性将得到确立。此外，我们将在多米尼加复制队列研究，以确认圣卢西亚结果的外部有效性。该提案旨在回答上述问题，从而完成本项目的研究阶段，并便利将研究成果转化为公共卫生领域。考虑到非洲发展中世界的人口、这一群体中青光眼的流行程度以及观察到的激光治疗的初步好处，该项目的成果最终可以降低整个发展中世界数十万人患青光眼相关视觉功能障碍的风险。

DESCRIPTION (provided by applicant): Glaucoma is a leading cause of blindness in the African-derived developing world and represents a significant public health challenge as the disease burden is substantial. In Ghana, the prevalence of open-angle glaucoma over age 40 is 8.5%. In Barbados, the prevalence is 7.0%. In neighboring St. Lucia, the prevalence has been estimated at 8.8% with a 16% ten-year incidence of glaucoma-related blindness in one or both eyes. (In contrast, the prevalence in US adults is 1.9%). The burden of glaucoma-related visual dysfunction is also substantial in the developing world. Because the application of medical and surgical therapies is limited by issues such as cost, availability, and limited regional surgical expertise, under treatment is pervasive. Also, there is little access to low vision or vision rehabilitation services and minimal social support for the visually impaired. Laser trabeculoplasty may be a part of the solution to the developing world's burgeoning glaucoma burden. The treatment is fast, safe, minimally invasive and requires minimal post-treatment care; the equipment is portable; and the incremental cost of trabeculoplasty treatment is small once the equipment and expertise are on-site. Our recent study in St. Lucia demonstrated that laser trabeculoplasty lowers IOP by an amount likely to favorably alter the clinical course of glaucoma (versus no treatment) and has the potential to bend the glaucoma-related blindness curve in the African-derived developing world. Our long-term goal is to translate this finding through a public health initiative by establishing a pan-Caribbean glaucoma laser program to provide safe, effective, and cost-effective therapy for glaucoma in this underserved and overburdened region. Before this can happen, several important research questions remain unanswered regarding SLT in this population and comprise the specific aims of this proposal. What is the long-term efficacy of SLT in this population? Is repeat SLT effective once the IOP reduction of initial SLT wanes? Are the results obtained in St. Lucia generalizable to other developing nations populated by people of African descent? In this application, we propose a prospective cohort study in St. Lucia in which qualifying subjects with open-angle glaucoma will receive bilateral selective laser trabeculoplasty, will be followed to failure of initial SLT, and ill undergo repeat SLT and again be followed to failure. The long-term safety and efficacy of both initial and repeat SLT in glaucoma patients of African descent will thus be established. Further, we will replicate the cohort study in Dominica to confirm external validity of the St. Lucia outcomes. This proposal is designed to answer the questions posed above and thus to complete the research phase of this project and facilitate translation of the research findings int the public health space. Considering the population of the African-derived developing world, the prevalence of glaucoma in this population, and the observed preliminary benefits of laser therapy, this project's output could ultimately reduce the risk of glaucoma-related visual dysfunction in hundreds of thousands of individuals throughout the developing world.