Assessing the barriers and facilitators of access to diabetic retinopathy screening in sub- Saharan Africa: a literature review.

Diabetic retinopathy (DR) is the leading cause of blindness in working age adults. An increase in visual loss has been projected for sub-Saharan Africa (SSA) with the diabetes epidemic in the region. Screening is a cost-effective way to reduce this scourge, but adequate services are scarce. This review aims to evaluate the evidence on barriers and facilitators of access to DR screening with a view to making evidence-based recommendations for the development of effective and sustainable programmes in SSA. A systematic literature search of Africa-Wide Information, Embase, Cochrane library, Global Health, and Medline databases was done using diabetic retinopathy, screening, and Sub-Saharan Africa as concepts. Google Scholar was also searched to identify relevant literature. Studies were included if they were done in SSA and reported on barriers and/or facilitators of access to DR screening. The database search yielded 616 papers and google scholar yielded 9223 papers. Of these, 54 papers were assessed for eligibility and 18 met the inclusion criteria. These were appraised with appropriate checklists. Fourteen themes were synthesised. Most were supply challenges affecting all dimensions of access and the six components of the health systems building blocks. Several studies had poor methodologies, and this has implications for the evidence provided. The findings of this review show a weakness in the health systems suggesting this is the major indirect barrier to DR screening in SSA. Measures to strengthen the health system for DR screening is strongly recommended.

Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems.

BACKGROUND: Over two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper. METHODS: This was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02. RESULTS: There are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in < 10% of the facilities. The services delivered focussed on maternal and child health, with low attendance by adults aged over 50 years with over 50% of facilities reporting ≤10 attendances per year per 1000 catchment population. No facility reported data on patients with eye conditions in their patient registers. CONCLUSION: A policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.

Human resource and governance challenges in the delivery of primary eye care: a mixed methods feasibility study in Nigeria.

BACKGROUND: To increase access to eye care, the World Health Organization's Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria. METHODS: Design: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization's health system framework. RESULTS: A clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages. CONCLUSION: Our study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

Case series of retinopathy of prematurity blindness in Nigeria: A wakeup call to policy makers, hospitals, ophthalmologists and paediatricians.

BACKGROUND STATEMENT: Inadequate retinopathy of prematurity (ROP) screening coverage portends a high risk for increasing the cases of ROP blindness. This study aims to report the clinical profile of pre-term babies who developed ROP blindness, highlight the usefulness in determining screening criteria and the role of private hospitals in ROP blindness prevention. CASE SERIES REPORT: Online Google form and telephone survey was conducted from May to December 2020 among paediatric ophthalmologists who provided the clinical details of ROP blind children seen between 2016 and 2020. The main outcome measured included type of the hospital of birth, gestational age, birth weight, ROP Screening and treatment, and blinding ROP Stage among children born premature. The SPSS-IBM version 26 was used for the analysis. Eighteen children blind from ROP with an equal male-to-female ratio were reported. Mean gestational age was 28.4 ± 2.2 weeks (range 26 - 34 weeks, median was 28.0 weeks). Mean birth weight was 1173.7 ± 317.9 grams (range 776 - 2100 grams, median 1125 grams). Six (33.3%) babies were born in private hospitals between 28 and 32 weeks. Sixteen (88.9%) children never had ROP screening. Fifteen (83.3%) were blind in both eyes. Six (33.3%) had Stage IVb and 12 (66.7%) Stage V. CONCLUSION: About 90% of the babies who became blind did not undergo ROP screening. It is crucial that all babies born at 34 weeks or earlier and have birth weight of < 1500 grams in public/private hospitals be screened for ROP to prevent this avoidable blindness in Nigeria.

Refractive Error and Visual Impairment Among School Children: Result of a South-Eastern Nigerian Regional Survey.

PURPOSE: To determine the prevalence refractive errors and causes of visual impairment in school children in the south-eastern region of Nigeria. METHODS: School-based cross-sectional samples of children 5 to 15 of age in both urban and rural areas were profiled through cluster sampling. The main outcome measures were presenting, uncorrected, and best-corrected visual acuity using the Refractive Error in School-age Children (RESC) protocol. RESULTS: A total of 5723 children were examined during the study period comprising 2686 (46.9%) males and 3037 (53.1%) females; (M:F ratio 0.9:1) and aged 10.49±2.74SD of mean (range, 5 to 15 years). The age group 12 to <13 accounted for the highest 776 (13.6%) number of the study participants. The uncorrected visual acuity (VA) of <20/40 (6/12) was seen in 188 (3.4%) of the study participants while the presenting and best-corrected visual acuity of <20/40 (6/12) were noted in 182 (3.4%) children and 14 (0.2%) children, respectively. Refractive error was the principal cause of visual impairment. CONCLUSION: Prevalence of refractive error is low. Myopia is the principal cause of refractive error occurring more in females and in urban schools. The main cause of visual impairment is refractive error, and most children that need spectacle correction did not have them. Program to identify children with refractive error in addition to providing free or affordable optical services remains the key to preventing visual impairment from refractive error particularly in resource-poor settings.

Nasal loop myopexy as a primary procedure to correct exotropia hypotropia complex in high myopia.

PURPOSE: To evaluate success of nasal loop myopexy as a primary procedure in correcting the ocular deviation in primary position when combined with recession and resection procedure (R&R) in exotropia hypotropia complex in high myopia and to explore the probable cause for deviation. CASE REPORTS: We present a case series of three adult males with exotropia hypotropia complex and high myopia with large angle exotropia and hypotropia, with deflection of the courses of superior and medial recti seen intraoperatively. We performed a conventional recession and resection procedure, which was combined with a nasal loop myopexy between the superior rectus (SR) and medial rectus (MR) in the same session, under local anesthesia, to correct the deflected course of SR and MR; with the aim of correcting the deviation in primary position and improving ocular motility, mainly elevation in abduction. RESULTS: We present a case series of three adult males with exotropia hypotropia complex, who were operated between March 2017 and October 2017. In all the three cases described above, it was noted that the preoperative exotropia and hypotropia improved following the combination of nasal loop myopexy with a conventional recession and resection procedure, as shown by improvement in ocular deviation in the primary position (measured by prism bar cover test, PBCT). First patient improved from 50 prism exotropia with 16 prism hypotropia to 5 prisms exophoria and 6 prisms hypotropia in left eye. Second patient improved from 45 prism right exotropia and 10 prism hypotropia to 10 prisms exotropia and 6 prism hypotropia. Third patient improved from 40 prism left exotropia and 20 prisms hypotropia to 10 prism esotropia and 5 prisms hypotropia. Ocular motility showed no restriction following surgery in any of the gazes. Limitation of elevation in abduction, caused due to SR deflection, improved due to repositioning of SR and MR in their anatomical positions in all the cases. In the first patient elevation in abduction improved from -4 to -1; in the second and third patients, it improved from -2 to 0. None of the three adult patients experienced any side effects following the procedure. CONCLUSION: The combination of recession and resection procedures with nasal loop myopexy was found to be effective in correcting the ocular deviation and limitation to elevation in abduction by correcting the deflected course of superior rectus and medial rectus to result in an effective improvement of elevation in abduction. One case had an overcorrection of exotropia. There were no other major complications.

Spectrum of Eye Disorders Seen in a Pediatric Eye Clinic South East Nigeria.

PURPOSE: This study aims to determine the prevalence, pattern, and time of presentation for the ocular disorders seen among children attending a pediatric eye clinic in Nigeria. MATERIALS AND METHODS: A retrospective chart review of all first-time patients at a pediatric eye clinic, within 2005-2007 was carried out. Data on cohort demographics, duration of illness before the presentation, and types of ocular disorders were collected and analyzed. Statistical significance was indicated by P < 0.05. RESULTS: A total of 335 cases were reviewed, comprising 171 males and 164 females. The majority of children were in the 10-14 age group (31.94%). Allergies (40.72%) were the most common ocular disorder followed by refractive errors (22.16%), trauma (7.98%), and inflammation/infections (7.98%). Among others, ocular disorders seen in decreasing frequency were ocular motility imbalance (5.41%), tumors (1.28%), and ptosis (0.77%). Least common was juvenile glaucoma (0.51%). Majority (42.09%) presented more than 1 year after onset of illness while only 16.2% presented within 1 month of their illness. CONCLUSION: Most common causes of ocular disorder in this study were allergy, refractive error, and trauma. Majority of the children presented late, and most of the disorders can result in visual impairment/blindness if not treated early. This emphasizes the need for appropriate health education to avert most cases of childhood blindness/visual impairment.

Prevalence, Awareness and Determinants of Diabetic Retinopathy in a Screening Centre in Nigeria.

There is a global rise in the prevalence of diabetes and this has led to a rise in the consequences of diabetes such as diabetic retinopathy (DR). The current study aims to determine the prevalence, awareness and determinants of DR among diabetics who attended a screening centre in Enugu, south-eastern Nigeria. A descriptive cross-sectional study was carried out among consenting diabetic patients who visited the centre. An interviewer-administered questionnaire was used to gather information on demographic details, the knowledge of the participants on effects of diabetes on the eye and previous care they had received for their eyes. Each participant underwent eye examination which included posterior segment examination with slit lamp biomicroscopy with +90DS lens after pupil dilation. A total of 80 eligible participants were examined. The prevalence of any DR among the participants was 32.1 % (95 % CI 20.6-43.5) whereas prevalence of proliferative diabetic retinopathy, PDR was 6.4 % and diabetic macular oedema, DME was 31.3 %. Age at onset of diabetes and duration of diabetes were the most determinant factors associated with DR (p = 0.039 and p = 0.000 respectively). Only ten (12.5 %) participants had undergone at least one specific eye examination to check for DR since they were diagnosed with diabetes. The major reason for not having had a prior screening is 'no one referred me for it' (31 participants, 44.3 %). DR is emerging as an important cause of blindness and severe visual impairment. Adequate screening programme and treatment protocol need to be set up for this population even in developing countries to prevent blindness.

Assessing the knowledge and skills in clinical ophthalmology of medical interns: survey results from enugu, South-eastern Nigeria.

PURPOSE: To compare the skills and knowledge of clinical ophthalmology among medical interns in Enugu, Nigeria, to the recommendations of the International Council of Ophthalmology (ICO). MATERIALS AND METHODS: A questionnaire-based cross-sectional survey was conducted of Medical Interns attending the University of Nigeria Teaching Hospital and Enugu State University Teaching Hospital, from April 2010 to June 2010. Data on cohort demographics, undergraduate ophthalmology exposure, clinical skills and diagnostic competencies were collected and analyzed. Statistical significance was indicated by P < 0.05. RESULTS: The cohort comprised 81 males and 48 females (sex ratio = 1.7 : 1), aged 21-35 years (mean: 26.8 ± 2.4 years). The gender difference was significant (P < 0.05). The response rate was 88.7%. The duration of undergraduate ophthalmology exposure ranged from 1 to 4 weeks. Exposure was often adequate in cornea/external eye (95.3%), lens/cataract (95.3%) and glaucoma (92.2%); but not in vitreo-retinal disease (47.3%), neuro-ophthalmology (45.7%) and refractive surgery (0.0). The majority were competent at visual acuity testing (97.7%) and visual field examination (93.0%). There was lower competency at anterior chamber assessment (49.6%) and slit-lamp examination (39.5%). The majority could confidently diagnose conjunctivitis (96.1%) and cataract (90.7%), but not strabismus (42.6%) or macular degeneration (20.2%). CONCLUSIONS: Medical interns in Enugu displayed gaps in their undergraduate ophthalmology exposure, clinical knowledge and skills. This has implications for stakeholders in medical education and eye care delivery. Review of the curriculum, provision of training resources and compliance with ICO guidelines could address the deficiencies.