Editorial Glaucoma – Management and Diagnostic Challenges in Africa

Abstract

Glaucoma remains one of the leading causes of irreversible blindness globally¹ and poses a significant public health challenge in Africa², with a reported prevalence of 4.4%³. The disease disproportionately affects populations of African ancestry, who are known to have higher prevalence, earlier onset, more aggressive disease progression, and poorer visual outcomes compared with other ethnic groups^3-5. Despite advances in ophthalmic screening, diagnostic technology and therapeutic interventions worldwide, significant barriers continue to impede accessible, quality and cost-effective glaucoma services across the African continent. Common barriers include health system strengthening capacity, infrastructure and equipment gaps, direct and indirect costs, shortage of human resources for eye health, poor physical access and distance to services, diagnostic accuracy bias, lack of local guidelines, gender and socioeconomic inequities, ^{6, 7}. These bottlenecks contribute to suboptimal glaucoma detection and management throughout the continent.

Primary open-angle glaucoma (POAG) is the most common form of glaucoma in Africa^{5, 8-10} and frequently presents at advanced stages¹¹. Many patients remain asymptomatic and undiagnosed until substantial optic nerve damage and visual field loss have already occurred^{10, 12}. The asymptomatic nature of early glaucoma, combined with limited public awareness and inadequate health promotion and screening programs, and poor socioeconomic status contributes to delayed presentation and irreversible blindness¹³. In many African communities, eye diseases are often only recognized when central vision and quality of life become severely impaired, by which time treatment options become less effective.

Diagnostic challenges remain profound. Comprehensive glaucoma evaluation requires specialized equipment such as slit lamps, gonioscopy and indirect lenses, pachymeters, optical coherence tomography (OCT), and automated perimetry. However, many healthcare facilities in low-resource African settings lack access to such technologies¹⁴. Many studies have identified elevated IOP as a strong risk factor for POAG^{15, 16}. In rural areas especially, diagnosis may rely largely on intraocular pressure measurements and direct ophthalmoscopy, both of which have limited sensitivity for early disease detection. Furthermore, normal-tension glaucoma cases may easily be missed when excessive emphasis is placed on elevated IOP¹⁷. In addition, fluctuations in intraocular pressure (IOP) may play an important role in the management and progression of glaucoma¹⁸.

Visual field and optical coherence tomography (OCT) testing, which are central to functional and structural glaucoma assessment, respectively, presents additional difficulties. This is because the diagnosis of glaucoma may have clinically significant depressive symptoms¹⁹. As a result, qualitative assessments of glaucoma visual field-testing challenges maybe related to sustained concentration, test-related anxiety, doubts about the testing process, and physical discomfort. Addressing patient concerns and anxiety related to visual field testing is essential, with particular emphasis on allowing patient-initiated breaks to mitigate concentration difficulties and physical discomfort during the procedure²⁰.

Moreover, OCT normative databases are predominantly derived from European, Asian, or North American populations, raising concerns about their applicability in African patients where neuroretina ring, retinal nerve fibre and ganglion cell inner retina layers characteristics may differ^{21, 22}. Monitoring structural and functional glaucoma progression is important for timely treatment in early disease²³.

Human resource for eye health limitations also contribute significantly to diagnostic delays. While the number of ophthalmologists has grown^{24, 25}, glaucoma subspecialists continue to be largely based in urban healthcare facilities, creating disparities in access to advanced glaucoma care for patients in rural and underserved areas^{7, 26}. Despite carrying a substantial burden of eye disease, sub-Saharan Africa has three ophthalmologists per million population, highlighting a significant human resource gap²⁵. In addition, the distribution of eye care personnel across sub-Saharan Africa remains inadequate for the growing burden of visual impairement^{14, 24}. Consequently, tertiary eye centres are often overwhelmed, while rural populations remain underserved.

Management of glaucoma in Africa is equally challenging. Medical therapy is frequently limited by poor affordability and accessibility, frequent drug stock outs, and inadequate insurance coverage. Prostaglandin analogues, although highly effective, are often too expensive for long-term use in low-income populations. In addition, Rho kinase (ROCK) inhibitors may not be readily available in many health facilities on the continent, necessitating alternative management. Poor adherence to therapy is common and may result from medication side effects, limited understanding of the chronic nature of glaucoma, and socioeconomic constraints^27-29. Although laser therapy is available in certain centres, its adoption and utilization remain limited³⁰. Furthermore, patients may discontinue treatment once symptoms improve or when financial resources become strained. Given the high prevalence of glaucoma and the predominantly low-income populations across sub-Saharan Africa, optimal management strategies should emphasize early screening and timely detection, coupled with reliable, long-term treatment options that are minimally dependent on patient adherence and compliance².

Surgical intervention, particularly trabeculectomy, remains an important treatment modality in Africa because of poor adherence to chronic medical therapy. Evidence suggests that early surgical management of Primary Congenital Glaucoma, undertaken within the first days to weeks of life, substantially improves prognosis and reduces the risk of irreversible visual impairment³¹. However, surgical outcomes may be compromised by late presentation, aggressive wound healing responses, limited postoperative follow-up, and shortages of antifibrotic agents such as mitomycin-C. Fear of surgery and cultural misconceptions further reduce surgical acceptance in some communities³². Furthermore, the increasing introduction of minimally invasive glaucoma surgery (MIGS) offers promise but remains financially inaccessible in many low-resource environments^{33, 34}.

Childhood glaucoma poses unique diagnostic and management challenges, particularly in low-resource settings. Delayed presentation, limited access to specialized pediatric ophthalmology services, and the frequent need for examinations under anesthesia contribute to difficulties in achieving timely diagnosis and effective treatment. Therefore, increasing disease awareness, promoting early diagnosis, and ensuring timely treatment are essential for reducing the risk of long-term visual impairment^{35, 36}. Furthermore, the lifelong nature of the disease necessitates sustained monitoring and repeated interventions^{37, 38}, yet long-term follow-up is often compromised by healthcare access barriers and socioeconomic constraints. Consequently, affected children are at increased risk of irreversible visual impairment, which can adversely affect educational attainment, psychosocial development, and overall quality of life during critical developmental years³⁹

Nevertheless, important opportunities exist to improve glaucoma care in Africa. Strengthening public awareness campaigns, integrating glaucoma screening into primary healthcare systems, and promoting opportunistic screening of people at risk could facilitate earlier diagnosis. Teleophthalmology and artificial intelligence-assisted diagnostics may help bridge gaps in specialist availability, especially in remote regions^40-42. Furthermore, increasing local training opportunities for ophthalmologists, glaucoma specialists and midlevel cadres, and expanding access to affordable diagnostic technologies are essential steps towards sustainable and high impact glaucoma services.

Research focused specifically on African populations must also be prioritized. There remains a critical need for population-based epidemiological studies, genetic research^{3, 43}, and normative imaging databases relevant to African eyes²¹. Locally generated evidence will be vital in developing context-appropriate diagnostic criteria and treatment strategies.

Glaucoma in Africa is not merely an ophthalmic condition; it is a significant public health challenge with substantial socioeconomic consequences. Blindness from glaucoma affects productivity, independence, and quality of life, often placing additional burdens on already strained healthcare systems and families. Childhood glaucoma represents a significant economic challenge, with costs peaking in the first year after presentation due to the need for comprehensive diagnostic assessments, surgical treatment, and close postoperative monitoring⁴⁴. Reducing the burden of glaucoma blindness across Africa will require coordinated efforts involving governments, civil society, nongovernmental organisations, healthcare and academic institutions, professional societies, researchers, and international partners.

Early detection, equitable access to affordable treatment, investment in healthcare infrastructure and equipment, and sustained research initiatives remain central to addressing the growing glaucoma burden in Africa. Without urgent and coordinated action, glaucoma will continue to contribute significantly to preventable irreversible blindness across the continent.