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

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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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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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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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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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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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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Best regards,
C.S. Ramesh Babu,
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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
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : NC01 - NC06 Full Version

Knowledge, Attitude and Practice in Medical Management of Glaucoma: A Cross-sectional Study from a Tertiary Care Hospital at Uttarakhand, India


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59381.17024
Priyanka Gupta, Vatsala Vats, Ashish Kakkar, Aeshvarya Dhawan, Tarannum Shakeel, Monika Jain

1. Assistant Professor, Department of Ophthalmology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India. 2. Associate Professor, Department of Ophthalmology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India. 3. Associate Professor, Department of Ophthalmology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India. 4. Fellow, Department of Ophthalmology, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India. 5. Professor, Department of Ophthalmology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India. 6. Assistant Professor, Department of Ophthalmology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India.

Correspondence Address :
Dr. Aeshvarya Dhawan,
Doctors Hostel, Sitapur Eye Hospital, Sitapur-261001, Uttar Pradesh, India.
E-mail: aeshvarya.dhawan@gmail.com

Abstract

Introduction: Glaucoma is most common cause of irreversible blindness in the world. Hence, awareness about the disease, importance of drugs effect and its side-effects and accurate method of eye drop instillation is very crucial.

Aim: To assess Knowledge, Attitude and Practice (KAP) at the medication, doctor and patient level in clinical practice.

Materials and Methods: It was a cross-sectional, descriptive, questionnaire based study conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, for duration of two years from July 2020 to June 2022. It included 290 patients diagnosed with glaucoma. They were asked to demonstrate method of instillation of eye drop to assess correct method and to cover a few aspects of questionnaire regarding medication instillation. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 21.0. The p-value was determined for questions in the questionnaire using Chi-square test. The p-value <0.05 was considered significant.

Results: About 88 (30.34%) patients were educated about the nature and progression of glaucoma. Punctal occlusion was explained to 40 (13.79%) patients and assisted instillation to 25 (8.62%) patients. Approximately 62 (70.45%) patients were educated about their disease. About 244 (84.14%) patients noticed that their ophthalmologist clinic had a television in Outpatient Department (OPD). Family screening was advised in only 67 (23.1%) of the patients. Only 53 (18.28%) patients were emphasised on strict control of associated systemic illness.

Conclusion: Proper patient education about glaucoma and treatment by healthcare provider plays a crucial role. Most of the patients were not educated about method of instillation of drops. Correct instillation of drops was crucial to achieve target Intra Ocular Pressure (IOP), minimising side-effects and reducing the cost of treatment. Family screening and control of associated systemic conditions were often missed by majority of ophthalmologists however, it is important to keep in mind.

Keywords

Awareness, Eye drop instillation, Screening, Topical antiglaucoma medications

Glaucoma is a chronic progressive optic neuropathy, associated frequently but not always with raised IOP. There is plethora of topical medications in the form of eye drops in armamentarium for glaucoma treatment. Several new drugs like Rho-kinase inhibitors are in pipeline showing promising results to lower IOP (1),(2). Inspite of this fact, the burden of blindness due to glaucoma in India has increased from 60 million in 2010 to 80 million in 2020 (3). Previously, there are studies done to see compliance of topical Antiglaucoma Medications (AGM) (4),(5). However, considering the rising graph of glaucoma, it is time to take a pause and reinforce compliance not just at the level of medication but also factors at the patient and doctor level. Awareness and understanding about the disease, its pathogenesis and course helps the patient to be more alert about the disease. A good communication between the treating ophthalmologist and patient explaining the importance of drugs effect and side-effects, proper timings, accurate method of eye drop instillation is very crucial. Apart from treating IOP which is the major modifiable risk factor there are other aspects like associated hypertension, diabetes, migraine, obstructive sleep apnoea, migraine etc. which hasten the disease progression (6),(7),(8),(9),(10). These conditions have to be kept in consideration while treating glaucoma. These facts have been well known, but not being incorporated in day to day practice, especially by comprehensive ophthalmologists. Importance of family screening and controlling co-morbid systemic conditions, which increases optic neuropathy has not been touched in other papers in the literature.

Present study reinforced the need to understand and give appropriate attention to the under looked issue of eye drop instillation. Thus, the aim of study was to analyse the accurate KAP at medication, doctor and patient level, which can play a pivotal role in bringing down the burden of glaucoma.

Material and Methods

It was a cross-sectional, descriptive, questionnaire based study conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, for duration of two years from July 2020 to June 2022. Ethical clearance was obtained from Institutional Ethical Committee (IEC) ECR/710/Inst/ UK/2015/RR-18 (Reference no. SGRR/IEC/43/18) and adhered to the tenets of the declaration of Helsinki. The informed consent of subjects was obtained. The identity of subjects had not been revealed anywhere in the study. All the Coronavirus Disease-2019 (COVID-19) protocols and safety measures were followed during patient handling.

Inclusion criteria: Subjects included the diagnosed cases of primary and secondary open angle glaucoma, primary and secondary angle closure glaucoma, taking treatment in same hospital/elsewhere and administering topical AGM for atleast past one month, subjects who successfully filled the questionnaire and who gave informed consent were included in the study.

Exclusion criteria: Patient using topical AGM for less than one month were excluded (as the few aspects of the questionnaire related to attitude and practice of patients could not be assessed with such a short duration of treatment), patients not willing to participate in the study were excluded from the study.

Sample size calculation: It is assumed that the prevalence rate of glaucoma is 3.54% from the previous study (11).

Confidence level=95%, Precision (d)=±2.25%, Formula used: n=(Z2a×P×(1-P))/d2, where,

Za=Value of standard normal variate corresponding to a level of significance, P=Likely value of parameter, Q=1-P, d=margin of errors which is a measure of precision. With these assumptions the sample size calculated was 260. Finally, 290 patients were taken for study.

The previous works of literature were searched using PubMed and Google Scholar on the available KAP questionnaires. Relevant articles using the search were picked up. All the articles were reviewed by the departmental glaucoma experts and the items for the questionnaire were developed (12),(13),(14),(15). The experts had more than 10 years of experience (clinical, research, and teaching) in field of ophthalmology. After validating the questionnaire by Cronbach coefficient alpha (rkα=0.803), the experts finalised 20 questions, addressing factors related to the patient, medication and physician for the current study. Subjects were asked to respond to the questionnaire drafted.

Study Procedure

In the present study, six aspects in view of knowledge of patients about their disease were considered in the questionnaire. It was enquired whether patients were educated about nature and progression of disease and who imparted this education. Patients were enquired, if they were educated about timing of instillation of drops and correct method of instillation of drops, including punctal occlusion and assisted instillation. Two aspects were assessed to know the attitude of patients regarding their disease. They were enquired, if they understood the nature, progression and effect of disease. They were asked whether or not they understood the importance of method of instillation of drops. Seven aspects were analysed to ascertain the gap at patient level with regard to visits to the treating eye doctor and instilling eye drops. Five questions were included pertaining to practice of treating ophthalmologist.

Patients not carrying their past glaucoma treatment records were asked to show records on subsequent visit. Their record papers were analysed to fill a few responses of questionnaire pertaining to role of clinician in glaucoma diagnosis. After filling the questionnaire, the patients were taken to a designated room in the OPD. The facilities for washing of hands, availability of mirror and couch for lying down or sitting were available. Patients were asked to instill eye drops using a bottle of sterile Carboxy Methyl Cellulose (CMC 0.5%) in either of the eye depending on patient preference. This was done to check the method of instillation of AGM. If the method demonstrated by the patient was wrong, then the doctor demonstrated the correct method of instillation. Firstly, the patients were advised to wash hands properly before instilling drops and then pouring a single drop on retracting the Cul de sac followed by performing punctal occlusion for 10-20 seconds [Annexure].

Statistical Analysis

All the responses were entered on a Microsoft excel sheet (windows 10) and tabulated. Percentages were calculated as (number of response/total number of subjects)×100. The statistical analysis was done using SPSS software version 21.0. The p-value was determined for questions in the questionnaire using Chi-square test. The p-value <0.05 was considered significant.

Results

A total of 290 participants were included in the study as they were able to completely fill the questionnaire. The age of the patients in the study ranged from 18-80 years. There were 125 (43.1%) males and 165 (56.9%) females in the study. The female to male ratio was 1.3:1. Results of study have been tabulated in (Table/Fig 1). In the present study, six aspects in view of knowledge about their diseases were considered in the questionnaire, only 88 (30.34%) patients were educated about the nature and progression of glaucoma. About 65 (22.41%) patients were educated about the correct method of instillation of eye drops and 221 (76.20%) were aware that timing of instillation of eye drops has a role to play. About 211 (72.76%) confirmed that knowledge about glaucoma was given to them by the ophthalmologist. Regarding the correct method of instillation of eye drops, punctal occlusion was explained by the treating doctor to 40 (13.79%). About 25 (8.62%) had information regarding assisted instillation of AGM. Approximately 70.4% patients (62 patients out of 88 patients, who were educated about their disease) understood about glaucoma when they were informed by doctor or staff. 89.24% patients (58 subjects out of 65 patients, who were explained about correct method of instillation) had understanding about importance of correct method and appropriate timing of instillation of eye drops. Rest of the subjects neither did understand nor bothered to ask again.

In the study, 179 (61.72%) patients visited the treating ophthalmologist on advised dates. In the present study, out of 221 patients who were explained about the importance of timing of instillation of eye drops, 154 (69.68%) patients were instilling eye drops as advised. Out of those 40 patients in knowledge, who were educated about punctal occlusion, 13 (32.5%) were not performing it while instilling the antiglaucoma eye drops and 9 (22.5%) performed punctal occlusion each time. In present study, 22 patients (7.59%) missed their antiglaucoma eye drops once a week.

Out of total 290 patients, only 40 (13.79%) were asked to demonstrate the correct method of instillation of drops on subsequent visit to their ophthalmologist. On discussing about the method of instillation of AGM, it was found that 218 (75.17%) were self-administering drops, 50 (17.24%) were assisted by some care giver for instilling eye drops and rest 22 (7.59%) were instilling eye drops sometimes by themselves and sometimes by assisted method, depending on availability of helper. In the study, 24 patients got their IOP checked every month, 163 patients three monthly; 47 patients six monthly and 12 patients yearly, respectively. The study showed that 44 patients were getting IOP checked at random interval as per their convenience. On observing the patients while instilling eye drop in dedicated examination room, various difficulties faced by patients in instilling eye drops in decreasing order included extra drop expression in 73% , eye-tip touch in 61%, dose forgetfulness in 43%, difficult targeting in 34%, difficult squeezing in 29% and difficult capping in 19% patients.

Five questions were included in questionnaire to find out the practice methodology of ophthalmologist in diagnosing and treating glaucoma. About 244 (84.14%) patients noticed that, there was a television installed in waiting area of their ophthalmologist’s clinic. However, out of those 244 subjects, only 20 (8.2%) patients stated that educative video about eye diseases were played on television. The investigations which were used to make diagnosis of glaucoma as seen in patient’s records in the study included IOP in 100% patients, slit lamp examination in 100%, fundus examination in 87%, Optical Coherence Tomography (OCT) in 77%, perimetry in 32% and gonioscopy in 10% patients, respectively. Only 23% patients (67 patients) were told about the importance of family screening. Family screening was missed in 223 (76.90%) of the cases in present study. In the present study, 53 (18.28%) patients were informed about their systemic illness and its relation to occurrence of glaucoma and its control. Nearly 237 (81.72%) patients in present study were not being paid attention to related co-morbid systemic illness.

Discussion

Various treatment modalities are available for the treatment of glaucoma; topical AGM being the first line therapy, followed by laser or surgical treatment in specific cases (16). With the effective use of medical therapy, vision loss in patients with glaucoma can be prevented (17). The three important constituents of a successful topical pharmacotherapy are adherence, persistence and correct administration of eye drops by the patients (18). However, this is possible only, if the patient is inclined towards treatment. Patient motivation is possible through proper education, which requires a good counselling from the healthcare provider. Thus, it is important to reconsider the loop hole at each level in our day to day clinical glaucoma practice.

In present study, only 30.34% patients were educated about glaucoma, which was low as compared to one of the study where 98% of the patients had knowledge about the disease (19). The reason for high prevalence in referred study was because the patients were dealt by glaucoma specialist, who naturally emphasises more on the disease as compared to patients treated by comprehensive ophthalmologist in present study. India is a country, where glaucoma is treated by general ophthalmologist as much as by glaucoma specialists. In the present study, out of those who were educated about the disease 89.24% understood what condition they were dealing, but 10.76% till failed to understand in the first visit. Thus, it indicates that the patients should be reinforced and educated about the disease on every visit or atleast frequently, if time constraints are there due to high patient load.

The patient compliance increases, if he/she understands the silent nature of disease progression. In present study, mostly the treating ophthalmologist educated the patient about the disease, the importance of the correct method and appropriate timing of instillation of eye drops. In few cases, trained staff imparted the knowledge. Educating and motivating the glaucoma patients to instil timely eye drops is a very crucial but on the other hand very tedious task. It involves cooperation and judicious time of treating doctor. As there is more patient load on the doctor, so meticulously training their staff to spend time with the patient, explaining them disease nature and course is also a good alternative for the doctor. This will reduce burden and thus, enhancing the efficiency of the doctor, without compromising the purpose to bridge the education and motivation gap.

In present study, punctal occlusion was informed to only 13.79% patients. Out of those informed only 22.5% (9 patients) performed it every time. Large proportion (13 not performing punctal occlusion at all and 18 sometimes doing punctal occlusion) despite being informed didn’t practice it. Similar observation was seen in study by Gupta R et al., which concluded that nearly out of 10 people were not able to instill the eye drop correctly (20). Punctal occlusion causes the drug to remain for a longer duration in the eye. So, its effect lasts longer thus reducing IOP effectively. Also, the drug does not reach systemic circulation, thereby reducing side-effects. In some studies, correct method of instillation of eye drop was not explained to the patients (21),(22). Studies suggest that there should be more education of eye drop instillation technique (20),(23). Compliance is better ensured, if they are told about side-effects beforehand as few patients discontinue eye drop because of side-effects like hyperaemia and grittiness (24).

In the present study, 75% patients were administering eye drops by themselves. Common issues reported by patients in the study included extra drop expression, difficult targeting, difficult squeezing, eye tip touch, difficult capping and forgetting doses. Similar problems have been addressed in other studies too (25),(26). Touching the eye and lid with the tip of bottle is a problem, as it may be a source of contamination of bottle (27),(28),(29). Cost of AGM is an important hindrance in long-term compliance. Moreover, proper usage of drops may be pocket friendly to the patient. To minimise all these difficulties, patients should be demonstrated about the correct method of instilling eye drops. For proper implementation of this practice, patient should be reinforced by asking to demonstrate the method at every subsequent visit (30).

A few percent, 8.62% of subjects had knowledge about assisted eye drop instillation in present study. Glaucoma, once diagnosed puts a physical, mental, financial and social burden too. Based on patient’s age, visual status, general health, cognition and comprehensive level, the concept of assisted instillation of eye drop has been widely recommended and followed (31). Therefore, family members should be motivated to support the patient in dealing with the disease. Accompanying attendant should be encouraged during counselling sessions to assist in instillation of eye drops. Large number of studies has shown faulty practice of self instillation of eye drop (20),(25),(32),(33). While many patients claiming to have no difficulty in instilling drops are often unaware of faulty techniques (25). A study has clearly stated that 10% glaucomatous blindness was due to poor compliance (34). Faulty instillation of eye drops may result in failure to reach target IOP. This therapeutic under-effect leads to addition of add-on eye drops. It adds up to the local and systemic side-effects as well as cost of treatment (35). Thus, present study highlighted the importance of repeated demonstration of method of instillation of topical AGM at each visit.

Other important determinant of compliance of AGM included skipping of drop. The frequency of missing eye drops was variable in the present study. These have been reported in previous studies also (19),(27). Poor compliance results in therapeutic failure. In present study, 61.7% patients visited ophthalmologist on the dates advised for follow-up, thus estimating the compliance of patient. Proper counselling, education and reinforcement at every visit are crucial for ensuring regular and timely follow-ups.

Education could be spread by newspapers, radio, or educative videos (36). It has been observed in present study as well as day to day OPD visits in various clinics that most of the setups had television (TV). It generally displays entertainment videos for time pass of waiting patients. Educative videos about eye diseases should be encouraged in OPD through television sets. A lot of myths can be eliminated through education especially in our society and country where myths are readily and powerfully accepted.

There are many subsets of investigations which are performed in glaucoma patients. IOP measurement, slit lamp examination and dilated fundus examination were one in almost all the cases in which glaucoma is suspected. As illustrated in the present study, gonioscopy had been done in 10% patients only. Gonioscopy should be done in all suspected and established glaucoma cases. It is a helpful tool in diagnosing secondary glaucoma such as following blunt trauma which is often missed during routine glaucoma work-up due to incomplete history. Performing gonioscopy requires good expertise on part of clinician and is not patient friendly. Thus, it is easily skipped during examination for making diagnosis by general ophthalmologist. Though basic and essential, yet its importance is fading off in clinical practice. Gonioscopy as an OPD procedure should not be underestimated (37).

Glaucoma is a disease that runs in families (6). First degree relatives are most commonly affected (7). Open angle glaucoma is more common, so majority of patients are asymptomatic. Therefore, hidden cases need to be identified to decrease the burden of disease. Thus, family screening plays a very pivotal role in this regard. However, it missed in 77% of the cases in present study.

Systemic control of associated illnesses is an underestimated but a key for proper control of IOP. The risk factors contributing to glaucoma include hypertension, diabetes mellitus, cardiovascular disease, migraine, obstructive sleep apnoea, etc., (6),(7),(8),(9),(10). So, not only treating the eye, but treating the whole body is also an essential prerequisite for controlling optic neuropathy in glaucoma. Most of the cases, nearly 81.72% patients in present study were not being paid attention, to related co-morbid systemic illness. Thus, special emphasis is to be made in controlling those relatable factors that influence the management of glaucoma.

Limitation(s)

Patient’s compliance to drops was assessed using a questionnaire, so the response was subjective. In addition, bias may have been introduced as patient tends to be more cautious, while instilling drops in presence of a doctor in the examination room. Education level of the patient was not taken into account, which might have a role to play in the better understanding and compliance towards AGM and disease as a whole.

Conclusion

In the present study only 30.34% patients were educated about the nature and progression of glaucoma. About 70.45% patients understood about glaucoma, when they were informed by doctor or staff, 69.68% patients were instilling eye drops as advised. Only 23.10% patients were told about the importance of family screening. Proper method and timely instillation of drops is crucial to achieve target IOP, minimising side-effects, retarding optic neuropathy and reducing the cost of treatment.

Prospectively an extensive assessment of comprehensive ophthalmologist’s and ophthalmologist practicing glaucoma as a speciality can be done regarding the knowledge and attitude of the disease, which will surely be beneficial to bring out shortcomings in the practice.

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DOI and Others

DOI: 10.7860/JCDR/2022/59381.17024

Date of Submission: Jul 29, 2022
Date of Peer Review: Aug 24, 2022
Date of Acceptance: Oct 12, 2022
Date of Publishing: Nov 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 05, 2022
• Manual Googling: Oct 10, 2022
• iThenticate Software: Oct 11, 2022 (4%)

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