Drs. George and Vijaya's description of the education system in India makes apparent that the wrong questions are being asked regarding manpower needs in less developed regions. Rather than doctors, ophthalmologists, or ophthalmic surgeons per capita, the focus needs to shift to the number of well-trained ophthalmologists and ophthalmic surgeons per capita. Patients with disease are often undiagnosed or incorrectly managed in large part because doctors complete training programs without using a slit lamp or operating microscope and receive minimal exposure to an adequate number of patients. This effect is magnified in subspecialties such as glaucoma, where practitioners lack the necessary skills to perform tonometry, gonioscopy, fundsocopy, and perimetry.

Many fellowships in India require a remediation period of months so that fellows can learn the basic skills that were not taught during their residency. Last year, I met an attending who had recently completed his residency after having performed only three cataract surgeries at a government hospital in India. In comparison, residents at a neighboring private charity hospital perform at least 1,000 cases using modern techniques over the course of their training.

We must collaborate with our Indian colleages and help raise the standards of education to eliminate needless blindess. To this end, we need to help them establish the equivalent of a residency review committee to ensure all residents have the proper didactic and practical training and a board examination to determine a minimal level of competence. Guideliness and educational materials are already available from various online sources such as www.gonioscopy.org and the International Council of Ophthalmology (http://www.icoph.org) Although these resources are available, there is often little or no incentive to implement them.

—Alan L. Robin, MD, section editor

Ophthalmic training in India is conducted in various settings, from medical colleges to independent ophthalmic hospitals. In 2011, there were approximately 1,285 residency openings. Of these, 331 were 2-year diploma programs in ophthalmology run by the Medical Council of India, 687 were 3-year master of surgery (MD) programs, and 267 were 3-year Diplomate of the National Board (DNB) residency programs.1 Also available are 2-year bridging courses that a diploma holder can pursue to upgrade his or her skills to the DNB level.

A survey of postgraduate training schools in India, which included medical colleges and other accredited institutions, found that approximately 832 residents (771 in the masters program and 61 in the DNB program) are trained each year.2 The survey also found that some medical schools did not have functional slit lamps, indirect ophthalmoscopes, or operating microscopes and that DNB programs had at least one of each. Among the medical schools surveyed, 25% had no applanation tonometers, 34% had no Nd:YAG lasers, and 45% had no Goldmann perimeters. It is unlikely that automated perimeters were available.

The survey also determined that the mean new outpatient load was approximately 31,000 cases per year but could be as low as 778 cases per year. Approximately 30% of training centers had an annual outpatient load of less than 15,000 cases per year (50 cases per day for 300 working days). The mean number of glaucoma surgeries performed in the hospital annually was 74, with a range from two to 115 per year. As a result of low case loads and a lack of basic medical equipment, many residency programs are unable to provide adequate training in ophthalmology, let alone glaucoma care to patients.

Medical schools appeared to be worse equipped than most DNB centers, according to the survey. The provision of hardware alone, however, may not solve the problem. Thomas et al found that upgrading equipment in medical colleges did not substantially improve resident training.3 In fact, residents were not being trained in modern examination or surgical techniques, and they did not feel sufficiently confident to practice independently upon completion of their training.

RAMIFICATIONS

Not adequately training residents to detect and manage glaucoma is a missed opportunity for improving glaucoma management in India. More than 90% of glaucoma cases are undetected, and a rapidly aging population and increasing life expectancy will only exacerbate the problem.4 In both the Chennai Glaucoma Study and the Andhra Pradesh Eye Disease Survey, a significant proportion of patients found to have angle-closure glaucoma were being treated for open-angle glaucoma.5,6 In the Aravind Comprehensive Eye Survey, half of the patients with newly detected glaucoma had previously been examined by an eye care professional.7

INTENSIVE TRAINING: ONE PATH TO IMPROVEMENT

Courses and fellowships ranging from 1-week observerships to 24-month formal fellowships that offer varying levels of hands-on experience in glaucoma are available. The Glaucoma India Education Program run by the Glaucoma Society of India attempts to familiarize general ophthalmologists and trainees with the basic requirements for glaucoma assessment through didactic lectures delivered by experienced physicians in small towns and cities across the country.

Tejwani et al reported the impact of an intensive, hands-on, 4-week supervised training program in ophthalmic clinical evaluation for ophthalmology residents and private practitioners.8 The attendees were from different parts of India as well as from Ghana, Vietnam, Bangladesh, Sri Lanka, Saudi Arabia, and Paraguay; 57% were trainee residents at various stages of training, and 43% were ophthalmologists with 1 to 15 years' experience. The participants completed a questionnaire before and again after training to assess their skills in multiple areas, and each question was graded on a scale of 0 to 4.

Before training, the mean score was less than 1 (never done or occasionally done) for four-mirror gonioscopy, less than 2 (done but not comfortable) for applanation tonometry, 1.32 for interpretation of Humphrey visual fields (Carl Zeiss Meditec, Inc.), and 2.11 for assessment of the disc with a 78.00/90.00 D lens. After training, the scores for gonioscopy (3.52), applanation tonometry (3.65), and disc assessment (3.25) increased to greater than 3 (comfortable), and that for visual field analysis increased to 2.83. Although these are self-reported scores, they highlight how a well-structured intensive program may significantly improve clinical skills.

OTHER POSSIBILITIES

The sheer volume of individuals who have glaucoma or who are at risk for the disease (40 million persons) cannot be tackled by the few trained glaucoma specialists in the country or by the 700 members of the Glaucoma Society of India.8 Most care will continue to be provided by general ophthalmologists.

Systemic changes in residency training are urgently needed in order to appropriately manage glaucoma in the long term. In the short term, bridging courses for general ophthalmologists could help improve the quality of care for patients. The introduction of mandatory continuing medical education credits in some states might also help improve standards of care. Finally, support from either the government or industry for intensive training programs at recognized centers, which are open to all residents across the country, could rapidly improve the caliber of ophthalmic training.

Section Editor Alan L. Robin, MD, is an associate professor of ophthalmology at the Wilmer Eye Institute and an associate professor of international health at the Bloomberg School of Public Health, both at Johns Hopkins University in Baltimore. Dr. Robin may be reached at (410) 377-2422; arobin@glaucomaexpert.com

Ronnie George, DO, DNB, MS, is a senior consultant at the Sri Jadhavbai Nathmal Singhvee Glaucoma Services and director of research for the Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India. He acknowledged no financial interest in the products or companies mentioned herein. Dr. George may be reached at +91 44 28271616; drrg@snmail.org.

Lingam Vijaya, DO, MS, is director of the Sri Jadhavbai Nathmal Singhvee Glaucoma Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Vijaya may be reached at +91 44 28271616; drlv@snmail.org.

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