Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 4 | Page : 667 - 670

Early Detection of Primary Open Angle Glaucoma: Is It Happening?

Uma Kulkarni

1. Associate Professor, Department of Ophthalmology Yenepoya Medical College, Yenepoya University, Mangalore, India - 575018.

Correspondence Address :
Uma Kulkarni
Lakshmi Keshava, 4th Cross Shivabagh
Mangalore, India - 575002
Phone: 09448150032
E-mail: umasripada@gmail.com

Abstract

Context (Background): Glaucoma is the second leading cause loss of vision in the world and it is aptly described as the silent thief of vision. The absence of symptoms leads to a delayed presentation and irreversible blindness. The present study was designed to determine the stage of glaucoma at the time of presentation.

Aim: To detect the proportion of cases which presented in different stages of glaucoma.

Settings & Design: A prospective, observational, non-interventional study was conducted in a medical college hospital.

Methods and Material: 50 newly detected cases of glaucoma [primary open angle glaucoma (POAG) and normal tension glaucoma (NTG)] were analyzed for the severity and the stage of glaucoma at the time of their presentation.

Statistical Analysis Used: The results of the study have been discussed in terms of the proportions and percentages. The statistical comparisons were done by using Pearson’s chi square test.

Results: Of the 100 eyes which were studied, only 25% had mild, 40% had moderate and 35% had severe glaucoma at the time of the diagnosis. There was no statistically significant difference in the distribution of the different stages of glaucoma in the different age and sex groups. (Pearson’s Chi square=4.909 p value=0.086). Only 1 case had a family history of glaucoma. Absolute glaucoma was more common in the females and in the 6th decade and it was seen in 7 eyes. 10% patients had bilateral blindness (legal blindness) and 18% had unilateral blindness. Up to 28% had blindness in at least one eye. 48% cases had undergone at least one eye check up in the past 5 years, either in a hospital, an optical shop or at an eye camp and yet, had not been diagnosed /suspected as having glaucoma.

Conclusion: This study concludes that late presentation of glaucoma cases, failure in detecting glaucoma during the previous eye check ups and the high prevalence of blindness which was caused by glaucoma, point out to an alarming situation which reflects an inherent weakness in the methodology for detecting the glaucoma cases. An increased awareness about the causes of blindness among the population and intensification of the present efforts is needed to bridge the gap. The shift of the spectrum of the detected cases to the left may help in increasing the years of sight and in improving the quality of life of glaucoma patients.

Keywords

Stages of glaucoma, Mild glaucoma, Moderate glaucoma, Severe glaucoma, Advanced glaucoma, Absolute glaucoma, Blindness, Glaucoma

Introduction
Glaucoma is the second leading cause of vision loss in the world (1) and as many as 11.2 million people in India are blind due to glaucoma (2). Primary open angle glaucoma is estimated to affect 6.48 million persons (2). It may be aptly described as “the silent thief of vision”, which causes a bilateral, progressive loss of vision which is essentially painless. The absence of appreciable symptoms precludes its early presentation to the ophthalmologist. The optic nerve damage which is caused by glaucoma is irreversible and therefore, the delayed presentation adversely affects its management, thus leading to irreversible blindness. An early diagnosis of glaucoma is therefore crucial. The age- and gender-adjusted prevalence of glaucoma in south India is 2.56% in people over the age of 40 years (3) and 92.6% were diagnosed for the first time. The high prevalence, the bilateral blinding nature and the high percentage of the undetected cases of glaucoma prompted the author to study the distribution of the severity of the cases of glaucoma at the time of their presentation. The present study was designed to determine the stage of glaucoma at the time of presentation. The study will help in evaluating the Original Article possible reasons for the delayed diagnosis of glaucoma and it will enable us to plan corrective measures.

Material and Methods

This prospective, observational study included 50 newly diagnosed successive cases of primary open angle glaucoma (including normal tension glaucoma), who attended the ophthalmic OPD of a medical college hospital (Yenepoya Medical College, Mangalore, India) during the year, 2005. The cases were aged more than 40 years and they belonged to either gender. The sample size was calculated by using the formula: Sample size = t2 x p(1-p)/m2 Where t = confidence level at 95% (1.96), p = prevalence of glaucoma in south India= 2.6% (0.026), m = Allowable error of 5% (0.05) and the sample size = 40.5184, 50 patients were included in the study.

The diagnosis of glaucoma (4) was established after taking a complete ocular and systemic history with an emphasis on risk factors like family history of glaucoma, diabetes, myopia, etc. A detailed ocular examination was done, which included visual acuity and thorough anterior segment slit-lamp examination, which includedGoldmann Applanation Tonometry (corrected for central corneal thickness), gonioscopy, posterior segment evaluation by using slit lamp biomicroscopy and a +78 D lens and perimetry using 30-2 programme using Humphrey visual field analyzer.

Inclusion criteria ‘Newly detected’ cases of primary open angle glaucoma and normal tension glaucoma were included in the study. At least two of the following three criteria were required for the diagnosis of glaucoma in addition to open angles on gonioscopy: 1. Intra-ocular pressure > 21 mmHg with Goldman Applanation Tonometry after correction for central corneal thickness. 2. Typical glaucomatous cupping (with vertical cup: disc ratio > 0.5:1 or asymmetry of the vertical cup: disc ratio of > 0.2:1 between the two eyes) 3. Typical glaucomatous visual field defects as detected by 30-2 programme in automated perimetry on two occasions following Anderson’s criteria (5). Anderson’s Criteria for the diagnosis of glaucomatous visual field defects:

1. The Glaucoma Hemifield Test is ‘Outside normal limits’ 2. 3 contiguous non-edge points on the pattern deviation plot within the Bjerrum’s area have a probability of <5%, one of which has a probability of < 1% 3. Pattern standard deviation has a probability of < 5%

Exclusion criteria 1. Known cases of POAG and NTG 2. Secondary glaucoma 3. Primary angle closure glaucoma 4. POAG suspects where perimetry could not be done or with unreliable perimetry results 5. Ocular hypertension Staging of glaucoma cases [Table/Fig-1]: The visual fields at the time of diagnosis of glaucoma were used for classification of the glaucoma into 3 stages. The eyes of the glaucoma cases were classified into three groups, following the criteria suggested by the Preferred Practice Patterns of the American Academy of Ophthalmology (4).

Ethics This study was in accordance with the ethical standards of the Responsible Committee on Human Experimentation and with the Helsinki Declaration of 1975 which were revised in 2000 and it was reviewed and cleared by the institutional ethics committee. The cases were included after an informed written consent was taken from the patients and only non-identifiable data was used for the study.

Statistics The results of the study have been discussed in terms of proportions and percentages. The statistical comparisons were done by using the Pearson’s chi square test.

Results

(Table/Fig 2) & (Table/Fig 3) The groups were analyzed for age-sex distribution, risk factors, laterality and blindness and they were correlated statistically. • Demographic distribution of the newly detected glaucoma cases: The prevalence of glaucoma in the present study was slightly higher in males than in females and in the older age group (>60 years), but this was not statistically significant (Pearson’s Chi-square= 1.173; P-value=0.4246). • Distribution of the stages of glaucoma: At the time of the diagnosis, among the 100 eyes, the proportion of cases with mild glaucoma was less as compared to that of cases with moderate and advanced glaucoma. However, there was no statistically significant difference in the distribution of different stages of glaucoma in the different age and sex groups. (Pearson’s Chi square=4.909 p value=0.086). • Distribution of absolute blindness: The prevalence of absolute glaucoma (defined as end stage glaucoma with not even perception of light) was more common in the 6th decade and in females more than in males. The fellow eyes of the patients with absolute glaucoma also had advanced disease (moderate glaucoma-3 and advanced glaucoma-4). There was no case of bilateral absolute glaucoma. • Distribution of blindness in the study group: Legal blindness (WHO) was found to be more in females than in males. More males presented with unilateral blindness than the females. • The proportion of the late presenters was high and the distribution was as in [Tables/Fig-2 & 3] and it included: • Moderate glaucoma • Severe glaucoma • Absolute glaucoma (complete blindness) • Bilateral blindness • Unilateral blindness • Total number of cases with at least one eye blind:

blind: Goldmann Applanation Tonometry (corrected for central corneal thickness), gonioscopy, posterior segment evaluation by using slit lamp biomicroscopy and a +78 D lens and perimetry using 30-2 programme using Humphrey visual field analyzer. Inclusion criteria ‘Newly detected’ cases of primary open angle glaucoma and normal tension glaucoma were included in the study. At least two of the following three criteria were required for the diagnosis of glaucoma in addition to open angles on gonioscopy: 1. Intra-ocular pressure > 21 mmHg with Goldman Applanation Tonometry after correction for central corneal thickness. 2. Typical glaucomatous cupping (with vertical cup: disc ratio > 0.5:1 or asymmetry of the vertical cup: disc ratio of > 0.2:1 between the two eyes) 3. Typical glaucomatous visual field defects as detected by 30-2 programme in automated perimetry on two occasions following Anderson’s criteria (5). Anderson’s Criteria for the diagnosis of glaucomatous visual field defects: 1. The Glaucoma Hemifield Test is ‘Outside normal limits’ 2. 3 contiguous non-edge points on the pattern deviation plot within the Bjerrum’s area have a probability of <5%, one of which has a probability of < 1% 3. Pattern standard deviation has a probability of < 5% Exclusion criteria 1. Known cases of POAG and NTG 2. Secondary glaucoma 3. Primary angle closure glaucoma 4. POAG suspects where perimetry could not be done or with unreliable perimetry results 5. Ocular hypertension Staging of glaucoma cases [Table/Fig-1]: The visual fields at the time of diagnosis of glaucoma were used for classification of the glaucoma into 3 stages. The eyes of the glaucoma cases were classified into three groups, following the criteria suggested by the Preferred Practice Patterns of the American Academy of Ophthalmology (4). Ethics This study was in accordance with the ethical standards of the Responsible Committee on Human Experimentation and with the Helsinki Declaration of 1975 which were revised in 2000 and it was reviewed and cleared by the institutional ethics committee. The cases were included after an informed written consent was taken from the patients and only non-identifiable data was used for the study. Mildglaucoma GHT-‘ Within Normal Limits’, ‘Generalised Reduction in sensitivity’ or ‘Borderline’ Other features of glaucoma-IOP > 21mmHg, CDR >0.5suggestive of glaucoma Moderate glaucoma Glaucomatous cupping, CDR > 0.5 Grey scale showing scotomasin one hemifield GHT-‘Outside Normal Limits’ Severeglaucoma Advanced glaucomatous cuppingGrey scale showing scotomas in both hemifields GHT-‘Outside Normal Limits’ [Table/Fig-1]. Classification of eyes with Glaucoma <50 years 50-60 years >60 years Total Total M F M F M F M F MildGlaucoma 2 8 8 2 1 4 11 14 25 ModerateGlaucoma 6 3 6 5 15 5 27 13 40 Severe Glaucoma 4 1 2 (1) 13 (3) 10 (2) 5 (1) 16 (3) 19 (4) 35 (7) Total 12 12 16 20 26 14 54 46 100 24 36 40 [Table/Fig-2]: Age-Sex distribution of the 100 eyes M=Males F=Females The figures in parenthesis indicate the number of absolute blind eyes. www.jcdr.net Uma Kulkarni, Early Detection of Primary Open Angle Glaucoma Journal of Clinical and Diagnostic Research.2012 April, Vol-6(2): 000-000 3 • Age-wise distribution of the different stages of glaucoma: The older age groups had more advanced stages of the disease than the younger age groups. (Chi-square=1.3; P-value=0.5169) But, it was interesting to note that the youngest patient with bilateral advanced glaucoma was a 41 year old male and that the youngest patient with absolute glaucoma was a 50 years old female patient. Below the age of 50 years, a very high proportion of eyes had moderate glaucoma and severe glaucoma. • Gender-wise distribution of the stages of glaucoma: Only 20% of the eyes in the male patients and 30% of the eyes in female patients had mild glaucoma. The severe glaucoma and absolute glaucoma were more common in the females. Legal blindness was more common in the female patients, whereas the unilateral blindness was more common in the male patients. • Prevalence of the risk factors of glaucoma: 4 cases had a family history of glaucoma, which itself was a risk factor for glaucoma. There was an increasing but statistically not significant prevalence of the known risk factors like hypertension and diabetes in the severe glaucoma cases (Chi-square = 3.688 P-value = 0.7189). Only one patient had a family history of glaucoma and one had myopia. • Recent Eye check-up: 48% cases had undergone at least one eye check up in the past 5 years, either in a hospital, at an optical shop or at an eye camp and yet, they were not diagnosed/suspected of having glaucoma. This means that ‘the chance to detect’ the cases was lost. This was despite the fact that 4% had a family history of glaucoma.

Discussion

Several studies have indicated the prevalence of glaucoma, but there is a paucity of literature which have stated the stage of the disease at the time of the diagnosis. An advanced stage of the disease indicates the likelihood of adding another blind person to the burden of blindness. Therefore, it is not only important to know the prevalence of glaucoma in a population, but it is also imperative to know the stage at which a glaucoma case presents to the ophthalmologist. This is indicative of the magnitude of blindness today, as well as that of potential blindness in the near future. The detected cases indicate only the tip of the iceberg and it has been predicted that for every case of glaucoma which has been detected, there is another one which has remained undetected. The undetected mild stages are the cases which will be potentially blind after a decade or two if they are left untreated, contributing to blindness in the near future. In view of this, an analysis was made of the stage of glaucoma at the time of diagnosis in the present study.

The proportion of mild glaucoma was a mere 25%, suggesting that only a few cases are detected in their early stages. This indicates that the spectrum of different stages of glaucoma atthe time of their diagnosis has a peak towards the right, with a tendency to detect the most cases in the advanced stages rather than early. This is an alarming situation which refers to an inherent weakness in the methodology for detecting the glaucoma cases. Influence of age: Advanced disease was seen in the older age group, thus reflecting the natural course of the disease. However, 3 cases with bilateral advanced disease were found to be under the age of 50 years, indicating that the present system of glaucoma detection is failing to detect cases in younger individuals. Influence of gender: Females had higher prevalence of severe disease, legal blindness and absolute glaucoma (p=0.086). This may be attributed to the cultural weaknesses in the society and to the lack of glaucoma awareness among the lower socio-economic classes and the rural community.

Recent Eye check-up: 48% cases had undergone at least one eye check up in the past 5 years either in a hospital, at an optical shop or at an eye camp and yet, they were not diagnosed /suspected of having glaucoma. This means that the ‘the chance to detect’ the cases was either lost or it was incomplete. This was despite the fact that 4% cases had a family history of glaucoma. Implication of a delayed presentation: Advanced glaucoma and blindness which was caused by glaucoma were present in a considerable percentage of the total cases, thus indicating a late presentation of the cases at diagnosis. Also, the proportion of the moderate cases was more than that of mild glaucoma. This indicates that an early diagnosis of glaucoma which is important in its early management, was not made. These stages were common in the older patients, but not uncommon in the younger age group. This indicates that the screening for glaucoma should start at a younger age and not at 40 years of age, as is generally done, considering the fact that the glaucoma patients are otherwise asymptomatic. dvanced stages and blindness due to glaucoma were also more common in the female patients than in the males. This may only be explained by the social structure of the rural community.

Our hospital caters mainly to the neighbouring rural population. Their lower socio-economic status and the lack of awareness among them may have led to the late detection of the cases. The lack of health care facilities may not have been the reason, because of the presence of about 7 medical colleges and several private and government hospitals in and around the city. However, the failure of the screening programmes in reaching out to this population cannot be ruled out. The hidden message is that the previous attempts have failed to detect these cases in their early stages. This demands a refinement of the present screening methods, lest we miss them again. This includes an enhancement of the screening programmes, widening of the age group which was screened, identification and follow up of the glaucoma suspects, coverage of the rural and remote areas, up-gradation of the screening tools to detect the very early cases and further research in this field. Not to mention, an increase the awareness of glaucoma and the blindness which ensues from it.

Conclusion

The late presentation of glaucoma cases indicates a general lethargy of the patients in presenting to the ophthalmologist without any factor which is significantly associated with their delayed presentation. To combat this lethargy, the present screening programmes are either insufficient or they are not very effectiveapplication of the available infrastructure, it is possible to detect glaucoma at an early stage. The cases remain undetected, probably due to a gap between the facilities and the population. An increased awareness about the causes of blindness among the population and intensification of the present efforts is needed to bridge this gap. The shift of the spectrum of the detected cases to the left may help in increasing the years of sight and in improving the quality of life.

Acknowledgement

I am grateful to the support which was offered by the senior staff members of the department, Dr. A N Adisheshan, Dr. Neelam Puthran and Dr. Vishnu Prabhu who encouraged me to work in the field of my interest. I thank Ms Neevan who helped me with the statistical analysis.

References

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(Author unknown). American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern® Guidelines. Primary open-angle glaucoma Suspect PPP. San Francisco, CA: American Academy of Ophthalmology; 2010. Available at: www.aao. org/ppp accessed on Feb 1 2012.
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