Primary care refers to clinical services delivered to people in the community by trained health professionals which could range from community or family physicians, community nurses, Community Health-care Workers (CHWs) and others (1, 2). In high-income countries, primary care set up is more catered for with family physicians providing care at this level of health care. However, in Low and Middle Income Countries (LMICs), nurses or community health care workers are mostly the first line in the Primary Healthcare Centres (PHCs) (2).

In 2019, the World Report on Vision (WRV) by the World Health Organization (WHO) called on countries to place renewed emphasis on integrating Primary Eye Care (PEC) services into primary healthcare (3). This recommendation aimed to address barriers to accessibility and affordability that hinder the delivery of basic eye health services in low- and middle-income countries (particularly in sub-Saharan Africa and South Asia) (3). The WHO Global Strategy on Human Resources for Health: Workforce 2030, adopted by the World Health Assembly in 2016, encourages countries to adopt a diverse, sustainable skills mix, harnessing the potential of CHWs in interprofessional primary care teams (4). The training of CHWs is geared towards service delivery targeted mostly towards preventive medicine interlaced with basic knowledge of maternal and child health services ranging from antenatal to immunisation services (1, 2, 4). They are also trained to attend to some uncomplicated endemic illnesses malaria and diarrhoeal diseases (1–4).

Glaucoma is the second leading cause of blindness (second to cataract) and the number one cause of irreversible blindness (5–7). Global prevalence studies have reported 64.3 million individuals were diagnosed with glaucoma worldwide in 2013 and it is projected to rise to 73 million by 2020 (8). Primary Open Angle Glaucoma (POAG) is the commonest type, with close to 60 million people affected in 2016 and is expected to rise to 65.5 million by 2020 (8). The life expectancy is increasing worldwide and with the growing number of older adult population, it is projected that 111.8 million people will have glaucoma in 2040 (8). Currently available treatments cannot reverse glaucomatous damage to the visual system; however, early diagnosis and treatment can prevent progression of the disease. In LMICs, up to 35% of patients present to the hospital blind in at least one eye (2, 9). In study (10) conducted in Ghana found nearly 24% of patients were blind in at least one eye at first presentation. Another study (11) in Tanzania, also reported 44.7% of patients presented with severe VF loss (< −20 dB), compared to 4.6% in England.

This study aims to assess the ability of community healthcare workers, without prior specialised ophthalmic training, to use portable diagnostic tools, in combination with a simple scoring system, to identify adults with possible glaucoma in the community, and to refer them appropriately for further evaluation and care in Abuja, Nigeria.

A total of 16 (15 females 1 male) CHWs were recruited and trained from 3 PHCs. Average age was 36 years (range; 22–52 years).

Table 5, Figure 2 presents the pre- and post-test scores of community health workers (CHWs) on knowledge of glaucoma. Pretest scores ranged from 0 to 45% across the eight items. Item 1 recorded the highest pretest score (45%), while items 2, 3, 6, and 7 had the lowest (≤5%). Post-test scores were higher across all items, ranging from 50 to 100%. Items 1, 5, 6, 7, and 8 recorded 100% scores, while items 2, 3, and 4 recorded 75, 50, and 80%, respectively (see Table 6).

This feasibility study explored the ability of CHWs without prior ophthalmic training to detect possible glaucoma using portable diagnostic devices in primary health care settings in Abuja, Nigeria. The findings demonstrated that CHWs could be trained within a short period to acquire both theoretical knowledge of glaucoma and practical competence in using devices such as the PEEK Acuity, iCare tonometer, Eyecatcher, and Remidio handheld fundus camera. The outcomes of this study provide important insights into the role of CHWs in expanding access to primary eye care and the potential of portable devices in facilitating early glaucoma detection in LMICs.

Baseline knowledge of glaucoma among CHWs was low, reflecting the inadequacy of eye health training in their routine curriculum. At pretest, only 40% of participants could define glaucoma correctly, and almost none could identify its risk factors, diagnostic investigations, or treatment options. These gaps in knowledge are consistent with previous reports from sub-Saharan Africa, where eye health is rarely integrated into community health worker training programmes, and awareness of glaucoma remains limited at both provider and community levels (8). The lack of awareness is concerning given the aggressive course of glaucoma in African populations and its contribution to irreversible blindness. Following training, knowledge improved substantially. All participants (100%) were able to define glaucoma correctly and to list the portable devices available for its detection. Furthermore, the proportion of CHWs able to identify risk factors, diagnostic investigations, and treatment modalities rose significantly, reflecting the effectiveness of the training intervention.

The training approach in this study, which combined lectures, demonstrations, and extensive hands-on sessions, proved particularly effective. Practical learning was essential, as CHWs are often more responsive to experiential methods than didactic lectures. By embedding opportunities for repeated practice, peer learning, and interactive demonstrations, the training created an environment where theoretical knowledge and technical skill developed in parallel. The use of pre- and post-tests, coupled with a structured practical evaluation, ensured that both cognitive understanding and operational competence were systematically assessed. This approach mirrors competency-based training frameworks advocated by WHO for strengthening CHW capacity in primary health care delivery (2).

While CHWs reported that the portable devices were generally easy to operate, difficulties were noted with specific tools, particularly the Remidio handheld fundus camera and, to a lesser extent, the iCare tonometer. Reported challenges included fatigue from prolonged use of the handheld fundus camera, difficulty focusing on the optic disc, and problems stabilising the tonometer during IOP measurement. These operational barriers highlight the importance of ergonomic considerations in device design, as well as the need for sufficient practice time during training to build user confidence and skill. Continuous training, ergonomic adjustments such as stabilisation stands, and refresher sessions could help mitigate these difficulties and enhance long-term usability.

Another challenge observed during training was the difficulty of detecting relative afferent pupillary defects (RAPD) in individuals with dark irises. Subtle pupillary responses are harder to detect in such cases, even for trained ophthalmologists. The use of high-quality instructional videos and repeated live demonstrations improved CHWs’ ability to recognise RAPD, but the limitation underscores the potential value of device-based solutions, such as infrared pupillometry, which can provide objective and quantitative assessments. Incorporating such technologies into portable diagnostic kits could further improve the accuracy and reliability of glaucoma detection in community settings.

The integration of glaucoma detection into primary care through CHWs has far-reaching implications for public health in sub-Saharan Africa. Glaucoma often presents late in this region, with many patients already blind in at least one eye at presentation. Studies in Ghana and Tanzania have shown that 24–45% of patients present with severe visual field loss at first consultation, compared to less than 5% in high-income countries such as England. This late presentation severely limits treatment options and increases the burden of irreversible blindness on individuals, families, and health systems.

Early identification and referral at the community level could therefore help reduce the proportion of late-stage glaucoma cases. By embedding glaucoma screening into routine primary care activities, CHWs could serve as the first line of defence against preventable blindness. This approach aligns with the WRV (2019), which emphasised the integration of primary eye care into primary health care systems, particularly in LMICs (3).

Portable devices are particularly well-suited to LMIC contexts due to their affordability, portability, and minimal maintenance requirements. Unlike traditional diagnostic tools that require specialised training, electricity, and hospital-based infrastructure, portable devices such as the iCare tonometer and Remidio handheld fundus camera can be used in rural or resource-limited settings. By equipping CHWs with these tools, eye health services can be decentralised and embedded into existing primary care systems without requiring large-scale infrastructural investments. This decentralisation is critical in Nigeria and other LMICs, where ophthalmologists are few and unevenly distributed, often concentrated in urban tertiary hospitals.

The use of CHWs in glaucoma detection is also consistent with the WHO Global Strategy on Human Resources for Health: Workforce 2030, which advocates for optimising the potential of CHWs within multidisciplinary primary care teams. By expanding their roles beyond maternal and child health, malaria, and infectious disease control, CHWs can contribute to the management of non-communicable eye diseases such as glaucoma, thereby enhancing the breadth and depth of primary care services.

A key strength of this study was its comprehensive training model, which emphasised progressive skill acquisition, competency-based assessment, and participant feedback. The structured design of the training ensured that CHWs were not only exposed to theoretical knowledge but also given ample opportunities to practise and refine their skills. The inclusion of pre- and post-tests allowed for objective measurement of knowledge gains, while the practical evaluation assessed operational competence. Together, these methods provided a robust assessment of the feasibility of training CHWs to use portable devices for glaucoma detection.

The study also demonstrated the practicality of deploying multiple portable devices simultaneously in routine primary care settings. This holistic approach reflects real-world service delivery more accurately than studies focusing on a single device. Moreover, the overwhelmingly positive feedback from CHWs suggests that training in eye health is both acceptable and engaging for this cadre of workers.

However, the study has limitations. The 3 day training period may not have been enough for participants to fully master device use and troubleshooting, and long term skill retention was not assessed. The small sample and purposive selection limit generalisability to other settings. The training did not include simple tests such as the oblique flashlight test or Van Herick’s technique for detecting angle closure glaucoma, and it did not cover the identification and referral of children with congenital or infantile onset glaucoma. The lack of a standardised national curriculum for CHW training in eye health also poses challenges for sustainable scale up.

Portable devices have the potential to significantly revolutionise eye care service delivery, especially in LMICs, due to their relatively low cost, ease of operation, and low maintenance requirements. The ability to train CHWs to effectively use these devices is a critical step toward addressing the challenge of accessibility and affordability in the prevention and early detection of blinding diseases such as glaucoma. In regions where specialised eye care is scarce or inaccessible, these portable devices provide an opportunity for primary healthcare providers to detect glaucoma at an early stage, refer patients for further treatment, and reduce the burden of preventable blindness. Training CHWs to use these devices could ultimately contribute to better eye health outcomes, alleviate the strain on specialised ophthalmic services, and improve the quality of life for individuals in underserved communities.