Outcomes of goniotomy for primary congenital glaucoma in East Africa.

OBJECTIVE: To evaluate the effectiveness of goniotomy to treat primary congenital glaucoma in an east African population. DESIGN: A retrospective series using case records. For patients who underwent goniotomies in both eyes, only the first was analyzed. PARTICIPANTS: Forty-seven children undergoing goniotomy (47/80 operated eyes analyzed). Thirty-six children (77%) were male. Mean age was 19 months (range 1-204 months, standard deviation [SD] = 35). INTERVENTION: First goniotomy was performed from the temporal side. Repeat surgery, if necessary, was performed via nasal side approach and 100% ethanol-soaked cotton-tipped swabs were used to clear the corneal epithelium when necessary for angle visualization. MAIN OUTCOME MEASURES: Postoperative intraocular pressure (IOP) <21 mmHg was considered success. Potential risk factors for failure were analyzed. Quantitative visual acuities were measured with Cardiff acuity cards and Lea tests in older children. RESULTS: A total of 36 of 47 children (77%) returned for follow-up. Mean follow-up interval was 12 months (range, 1-62 months; SD = 15). A total of 28 of 47 children (60%) had >3 months of follow-up, and 11 children had >1 year of follow-up. A total of 12 of 47 eyes (26%) required repeat goniotomy. Three of these required further trabeculectomy with mitomycin C, 1 of which required eventual enucleation after failure to control IOP, enlargement, and pain. A total of 11 of 28 children (39%) with >3 months follow-up required repeat surgery. A total of 24 of 28 children (86%) with follow-up intervals of at least 3 months achieved postoperative IOPs of <21 mmHg. Mean IOPs decreased (t = 6.1, P < 0.0005) from 23.4 mmHg (SD = 5.3 mmHg) to 14.4 mmHg (SD = 7.6 mmHg). Only 1 predictor of failure to achieve successful control of IOP was identified: female gender (relative risk = 5.3, 95% confidence interval, 1.1-26.3). Corneas were clear in 4 of 47 eyes (8.5%) preoperatively and 32 of 41 eyes (78%) postoperatively. Of 25 children with preoperative and postoperative acuities measured, 22 (88%) recorded improvement. CONCLUSIONS: Preliminary results of goniotomy in an African population with advanced disease and late presentation are reasonably encouraging. Overall results are comparable with historical drainage procedures, with the advantage of preserving conjunctiva. Further studies are justified.

Presentation, surgery and 1-year outcomes of childhood cataract surgery in Tanzania.

BACKGROUND: Recent reports have suggested a significant change in the causes of blindness in children in low-income countries cataract becoming the leading cause. We aimed to investigate the presentations and surgical outcomes in children with cataract operated at different ages in Tanzania. METHODS: We conducted a prospective study of 228 children aged ≤192 months at three tertiary centres, 177 with bilateral cataracts and prospectively followed them for 1-year postsurgery. We collected demographic, surgical, preoperative and postoperative clinical characteristics using the standard childhood cataract surgical assessment questionnaire. Families were encouraged to return for follow-up by phone with travel reimbursement where necessary. RESULTS: Preoperatively, 76% bilateral children were blind in the better eye. 86% of children were followed up at 1 year and 54% bilateral children achieved visual acuity of 0.48 logMAR or better in the better eye and 5% were blind. 33% of unilateral children achieved visual acuity of 0.48 logMAR or better and 17% were blind. Preoperative blindness (adjusted OR (AOR) 14.65; 95% CI 2.21 to 97.20), preoperative nystagmus/strabismus (AOR 9.22; 95% CI 2.66 to 31.97) and aphakia (AOR, 5.32; 95% CI 1.05 to 26.97) predicted poor visual outcome in bilateral cases. 9% of 342 refracted eyes had initial postoperative cylinder of 1.5 D or more, as did a similar proportion (11%) of 315 eyes refracted 1 year after surgery. Acute fibrinous uveitis occurred in 41 (12%) eyes. CONCLUSION: Three-quarters of children were blind preoperatively whereas over half had good vision 1-year postoperatively. Preoperative blindness, nystagmus/strabismus and aphakia predicted poor visual outcome, suggesting that cataract density determines density of amblyopia.

Why are children brought late for cataract surgery? Qualitative findings from Tanzania.

PURPOSE: Worldwide, at least 190,000 children are blind due to cataract. Although, surgical intervention is the treatment of choice, in most developing countries the number of children with cataract being brought to hospital for surgery has been few in number, considerably less than the burden of disease in the community. Furthermore, long delay in presentation is a major deterrent to improved visual outcome and compromises the future quality of life of children and their families. The main objective of this qualitative study was to provide a better understanding of surgical delay in the care of children with congenital or developmental cataract. METHODS: We conducted 117 semi-structured interviews with parents or guardians of children admitted for cataract surgery at a tertiary hospital in northern Tanzania. RESULTS: We identified several factors influencing the treatment-seeking behaviors of parents and guardians, including gender relations within the household, local health beliefs about cataract and cataract surgery and the ability of health care professionals in primary and secondary care settings to adequately inform parents and guardians about cataract and cataract surgery. CONCLUSIONS: Practical, short and medium term avenues must be explored to reduce delays of presentation. Public education, training of health workers and counseling efforts in the communities may be necessary to enable children to access services in a timely fashion.