Central corneal thickness in newly diagnosed glaucoma patients in South West Ethiopia: a cross-sectional study.

BACKGROUND: Reports of central corneal thickness (CCT) among glaucoma patients, particularly for pseudoexfoliative glaucoma (PXG) and Primary Angle Closure Glaucoma (PACG) are scarce in the Sub-Saharan African (SSA) population. The aim of this study is to evaluate CCT in black patients with newly diagnosed glaucoma and ocular hypertension (OHT) in South West Ethiopia. METHODS: This was a prospective study undertaken with an ultrasonic pachymeter from June 2014 to February 2015 in Jimma University Specialized Hospital. Patients aged 18 years and older newly diagnosed with glaucoma or OHT were included. RESULTS: A total of 162 eyes of 162 subjects were included. Hundred and fifty five subjects were glaucomatous: (67 PXG, 42 Primary Open Angle Glaucoma (POAG), 28 PACG, 14 Normal Tension Glaucoma (NTG), 5 Juvenile Open Angle Glaucoma (JOAG) and 6 (OHT). The mean age was 59.3 ± 12.8 years. For the whole sample, CCT was 518.67 (±39.97) µm. OHT group had significantly greater CCT (576.33 ± 49.32 µm) than the glaucomatous groups (p = 0.004). POAG (506.69 ± 35.08 µm) and NTG (510.79 ± 44.37 µm) groups had thinner CCT than PXG (520.48 ± 38.95 µm), PACG (524.00 ± 37.16 µm), and JOAG (518.00 ± 30.82 µm) groups, but this was not statistically significant (p = 0. 296). There was a statistically significant decline of CCT with advanced age (P = 0.02). There wasn't significant difference of average CCT between the ethnic groups (P = 0.3) and gender (P = 0.064). CONCLUSION: The mean CCT of Ethiopian glaucoma patients is thinner than Caucasians and similar to those reported from previous studies in Sub Saharan Africa. OHT patients had thicker CCT; there was no statistically significant difference observed in average CCT amongst glaucoma subtypes.

Glaucoma Treatment Patterns in Sub-Saharan Africa.

PRCIS: Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma. Laser therapy was underutilized where they were available. Physicians were more likely to recommend surgery in severe glaucoma, laser therapy in mild glaucoma, while recommendation of medical therapy did not depend on glaucoma severity. PURPOSE: To characterize treatment patterns for newly diagnosed glaucoma in sub-Saharan Africa (SSA). METHODS: This was a multicenter cross-sectional study of adults newly diagnosed with glaucoma at 27 eye care centers in 10 African countries. In addition to demographic and clinical data, physician treatment recommendations (medication, laser, surgery, or no treatment) were recorded. Statistical analyses were performed using STATA version 14.0. RESULTS: Data from 1201 patients were analyzed. Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma (69.4%), with laser (13.2%), surgery (14.9%), and no treatment (2.5%) recommended to the remaining patients. All sites had medical therapy available and most (25/27, 92.6%) could provide surgical treatment; only 16/27 (59.3%) sites offered laser, and at these sites, 30.8% of eyes were recommended to undergo primary laser procedures. As glaucoma severity increased, the laser was recommended less, surgery more, and medications unchanged. Patient acceptance of medical therapy was 99.1%, laser 88.3%, and surgery 69.3%. CONCLUSIONS: Medical therapy for first-line glaucoma management is preferred by most physicians in SSA (69%). Laser therapy may be underutilized at centers where it is available. These findings underscore the need for comparative studies of glaucoma treatments in SSA to inform the development of evidence-based treatment guidelines and of programs to reduce glaucoma blindness in SSA. Strategic approaches to glaucoma therapy in SSA must address the question of whether medical therapy is the most optimal first-line approach in this setting.

Assessment of Risk Factors for Advanced Open Angle Glaucoma Presentation among Patients Visiting Jimma University Medical Center, Jimma, Ethiopia.

Background: Glaucoma is the predominant cause of irreversible blindness, particularly the late presentation. The purpose of this study is to identify the risk factors associated with late presentation in Jimma University Medical Center. Methods: A case-control study was done among patients newly diagnosed to have open angle glaucoma (of any type) at Jimma University Medical Center from July 2014 - January 2019. Cases were patients/eyes diagnosed to have any type of open angle glaucoma with advanced glaucomatous disc features, whereas controls were patients diagnosed with early and moderate stages of glaucoma. Results: There were 205 (116 cases and 89 controls) participants. The mean age of the participants at the time of diagnosis was 58.3±13.4yrs. Family history of blindness, presenting IOP, type of glaucoma and age were independently associated with late presentation. Patients with family history of blindness had late advanced glaucoma five times higher than those with no family history of blindness. The presence of late glaucoma among patients with presenting intra ocular pressure < 30mmHg is lower than those having ≥30mmHg (Adjusted Odds Ratio= 0.136). Primary open-angle glaucoma patients were less likely to present with advanced glaucoma than pseudoexfoliative glaucoma patients (Adjusted Odds Ratio=0.39). The chance of presenting with late glaucoma was increased by 3.4% for every one year increment of age. Conclusions: Presence of family history of blindness, high presenting intraocular pressure, pseudoexfoliative glaucoma and old age are risk factors for late presentation of glaucoma.

Clinical Characteristics and Stage at Presentation of Glaucoma Patients in Sub-Saharan Africa.

PRCIS: The initial presentation of glaucoma varies meaningfully across SSA. A comprehensive strategy with regional customization based on local differences is needed to reduce glaucoma blindness in SSA. PURPOSE: To explore regional variations in the presentation of newly diagnosed glaucoma in Sub Saharan Africa (SSA). METHODOLOGY: This was a multicenter, cross-sectional study in which newly diagnosed, consecutive, glaucoma patients aged older than or equal to 18 years were recruited from 27 eye clinics in 10 countries throughout SSA. Demographic and ophthalmic examination data were collected. Glaucoma severity was based on optic nerve head and visual field assessment. Statistical analyses were performed using STATA version 14.0. RESULTS: Among 1214 enrolled patients with newly diagnosed glaucoma from Western, Eastern, and Southern Africa, the overall mean (SD) age was 59.9 (17.1) years. More than half of all patients (716/1178; 60.8%) presented with severe glaucoma in the worse eye, and one-third (36.9%) had severe glaucoma in both eyes. Primary open angle glaucoma was the commonest form of glaucoma in all regions (77.4%). A family history of blindness (260/1204, 21.6%) was common. Patients from Western Africa had lower mean presenting intraocular pressure (26.4 [11.1] mm Hg, P <0.001), but had worse glaucoma in the better eye based on mean cup-disc ratio (0.8; P <0.001) and mean visual field mean deviation [10.4 (8.4)] dB, P =0.016) compared with other regions. Exfoliation glaucoma was more common in Eastern Africa (30/170=17.7%, P <0.001) compared with other regions. CONCLUSION: The initial presentation of glaucoma varies meaningfully across SSA. A comprehensive strategy with regional customization based on local differences is needed to reduce glaucoma blindness in SSA.

Ocular Biometry and Intra Ocular Lens Power among Cataract Patients in Rural Eastern Ethiopia.

BACKGROUND: The objective of the study was to report on the main parameters of ocular biometry and Intraocular lens (IOL)power of patients attending a cataract surgical campaign in Eastern Ethiopia. METHODS: The study was a cross-sectional study on 765 eyes which were eligible for cataract surgery during a mass cataract surgical campaign conducted from April 04 to April 10, 2018 at Bisidimo Hospital, Eastern Ethiopia. Ocular biometric parameters were measured by automated keratorefractometer and Sonomed A-Scan (Model 300AP) using contact applanation method. Multiple linear regression analysis was done to determine association of ocular biometry components with socio demography of the study subjects. RESULTS: The mean corneal curvature and anterior chamber depth (ACD, measured from corneal epithelium to lens) were found to be 7.61 mm and 2.88mm respectively. The mean axial length was estimated to be 22.98 mm. The mean refractive power of IOL was calculated to be 19.34D. The mean axial length in females was shorter than that of males by 0.24 (P - value = 0.01). The mean ACD in males was also larger than that of females by 0.1 (P - value = 0.001). CONCLUSION: This study provided a larger population based normative data on ocular biometry in Ethiopia. The female sex was a strong predictor of small axial length. Increasing age had no effect on axial length but was found to be a stronger predictor of shallow ACD.

Prevalence and Pattern of Ocular Morbidity among School Children in Southern Ethiopia.

BACKGROUND: Visual health is linked to school achievement, quality of life and productivity. But eye screening in school children is not routinely done in most Ethiopian schools. This study was done to determine prevalence and pattern of ocular morbidity among school children in Roman Dega-Kedida, Southern Ethiopia. METHOD: This was a cross-sectional study. All children aged 16 years or less, attending the school during the study period were included. Data entry and statistical analyses were performed using SPSS Version 16. A P - value of < 0.05 was considered statistically significant. RESULT: A total of 778 children participated in this study. The female to male ratio was 1.06:1. The mean age was 11.34(±2.31) years. A total of 201 (25.8%) children had ocular morbidities. The most common was trachoma found in 85(10.9%). Of these, 49(56.5%) had active trachoma, while 37(43.5%) had either trachoma scar or trachomatous trichiasis. Allergic conjunctivitis was found in 49(6.3%), refractive error in 37(4.8%), and xerophthalmia in 17(2.2%) children. Visual impairment in one or both eyes was found in 41(5.3%) children. Thirty-two children (4.1%) had bilateral Visual impairment of which 6(18.8%) had moderate to severe visual impairment. The cause of visual impairment was refractive error in 37(90.2%), corneal opacity in 3(7.3%) and cataract in 1(2.4%) child. CONCLUSION: Most of the ocular diseases observed were either preventable or treatable. Health education to the community and establishing regular school screening program is recommended.

Barriers to Cataract Surgery Utilization Among Cataract Patients Attending Surgical Outreach Sites in Ethiopia: A Dual Center Study.

BACKGROUND: Cataract is the leading cause of avoidable blindness globally and in Africa. Various barriers limit access of cataract blind individuals to cataract surgery. This study aimed to determine the barriers to cataract surgery utilization among cataract blind patients presenting to campaign sites in Ethiopia. METHODS: An institution-based cross-sectional design study was conducted to select 209 patients. The study was conducted from July to August 2020. A structured questionnaire was used to collect socio-demographic data and barriers for not having cataract surgery. Physical examination such as visual acuity, slit lamp bio microscopy and direct ophthalmoscopy was done for all participants. Epi Info 7 was used for data entry and Statistical Package for Social Science/SPSS version 23 was used for analysis after data were exported. Descriptive methods were employed for analysis. RESULTS: A total of 209 subjects were recruited in the study with a mean age of 64.2 (±14.6) years, with a range of 32-99 years. From the total study subjects, 53% were males and 40.2% were over 66 years old. Upon presentation to the campaign site, 33% of study subjects had visual acuity of operable eye under blindness category and half of the study subjects (50.2%) had mature cataract. The most reported barriers were waiting until cataract becomes mature (18.7%), fear of surgery complications (16.7%), far from eye health institution (16.4%) and lack of income/cost for surgery (11.5%). CONCLUSION: Recognizing the severity and the blindness burden of cataract in Ethiopia, creating public awareness, establishing eye health institutions, increasing the number of eye health professionals, increasing the quantity and the quality of cataract campaigns to alleviate these barriers are of paramount importance at the country level.

Glaucoma Awareness and Knowledge Among Ethiopians in a Tertiary Eye Care Center.

INTRODUCTION: Glaucoma outcomes are closely associated with patients' awareness of the disease. However, little is known about glaucoma awareness and knowledge in Addis Ababa, a densely populated and ethnolinguistically diverse capital city in Ethiopia, the second largest country in Africa. METHODS: We performed a cross-sectional survey in the ophthalmology waiting room at St. Paul's Hospital, a tertiary care center in Addis Ababa. Respondents included patients, patient family members, and non-clinical staff. Participants were asked if they had read or heard about glaucoma to gauge basic awareness of the disease; those with awareness were asked to take a quiz to measure their objective glaucoma knowledge. We performed multivariable regression to identify factors associated with glaucoma awareness, quiz performance, and self-rated ability to use eye drops. RESULTS: Of 298 respondents, 145 (48.7%) were female, and the average age was 44.9 ± 17.2 years. A majority (167; 56.0%) had primary school or less than primary school education. Only 131 (44.0%) had basic glaucoma awareness. Of these, 95 (72.5%) knew that glaucoma causes permanent vision loss, 103 (78.6%) knew glaucoma is often asymptomatic in early stages, 62 (47.3%) identified elevated intraocular pressure as a glaucoma risk factor, and 124 (94.7%) knew glaucoma was treatable. A majority of this subset (126; 96.2%) said they would be willing to use medicated eye drops, and 130 (99.2%) indicated a willingness to undergo surgery if recommended. Education level was independently associated with glaucoma awareness (p < 0.001) and glaucoma quiz performance (p = 0.03). CONCLUSION: In a population sample from an ophthalmology waiting room in Addis Ababa, glaucoma awareness was poor and most strongly associated with education level. Educational interventions at public health and provider-patient levels are warranted. Our results suggest high receptiveness to both medical and surgical treatment.

Amsler grid test for detection of advanced glaucoma in Ethiopia.

OBJECTIVE: This study was done to determine the validity of amsler grid test black on white (BOW), as well as white on black (WOB) for identifying central visual field (VF) defects in patients with advanced glaucoma. DESIGN: Prospective study. PARTICIPANTS: We prospectively included 100 consecutive eyes of 88 adult patients with advanced glaucoma and 100 eyes of 100 normal individuals. We used a lottery method to choose the side of the eye for the control groups. METHODS: All participants had reliable Humphrey 10-2 Swedish Interactive Threshold Algorithm (SITA) standard VF. Both the BOW and WOB amsler grid tests were done for each group. Sensitivity, specificity, and positive and negative predictive values of the amsler grid scotoma area were calculated with the 10-2 VF as the reference standard. RESULTS: The mean ± standard deviation (SD) of age and the 10-2 VF mean deviation (MD) of advanced glaucoma eyes were 59.8 ± 11.8 (range 34-84) years and -19.94 ± 9.8(range -34.98--0.52) respectively. Among 108 eyes with normal 10-2 VF test, 103 had a normal BOW amsler grid test and 5 had an abnormal BOW test. Among 92 eyes with an abnormal 10-2 VF test, 74 had an abnormal and 18 had normal BOW amsler grid test. Sensitivity, specificity, and positive and negative predictive values of the BOW amsler grid test were 80.4%, 95.4%, 93% and 85.1% respectively whereas that of the WOB amsler grid test were 71.7%, 95.4%, 93% and 72.8% respectively. CONCLUSION: The sensitivity and specificity of both BOW and WOB amsler grid tests were high in detecting VF defects in advanced glaucoma.

Ocular Biometry and Their Correlations with Ocular and Anthropometric Measurements Among Ethiopian Adults.

PURPOSE: To determine the average values of ocular biometry dimensions and investigate their inter-correlations and their association with anthropometric measurements among Ethiopian adults with healthy eyes. METHODS: A cross-sectional study was undertaken from June 2018 to July 2019. A total of 400 eyes of 200 subjects were included in the study. Univariable and multivariable linear regression were used to determine the association of demographic variables (age and sex) and anthropometric parameters (height, weight and BMI) with ocular biometric indices. RESULTS: The mean age was 40.31±11.39 with a range from 18 to 69 years. The mean (SD) of horizontal corneal diameter, average corneal refractive power, anterior chamber depth (ACD), lens thickness (LT) and axial length (AL) were 11.45 (0.89) mm, 43.94 (9.78) diopter, 2.91 (0.43) mm, 4.29 (0.55) mm and 22.96 (0.82) mm, respectively. Age had a negative correlation with ACD (r= -0.196, p= <0.001) and positive correlation with lens thickness (r= 0.324, p<0.001). Height had a positive correlation with ACD (r=0.114, p=0.023) and LT (r= 0.206, p=<0.001) while negative correlation with LT (r=-0.129, p=0.01). In the multivariate linear regression, age (-0.009 (-0.013, -0.05), p-value <0.001) and sex (0.104 (0.01, 0.198), p-value=0.03) had a significant association with ACD and only gender (0.478 (0.302, 0.654), p-value <0.001) had a statistically significant association with lens thickness. CONCLUSION: This study determined the normative values for ocular biometric parameters among Ethiopian adults for the first time. Age, gender and height were associated with biometric indices. AL was significantly positively correlated with ACD and negatively correlated with LT. There was a negative correlation between LT and both AL and ACD.

Proportion of Glaucoma among Voluntary People Coming for Glaucoma Screening Program at Jimma University Department of Ophthalmology, Jimma, Ethiopia.

BACKGROUND: Glaucoma is the second leading cause of blindness worldwide. Glaucoma screening has been controversial, and much of the controversy has centered on the value of mass or community screening. METHODS: The aim of this study was to determine the proportion of glaucoma among volunteer adults who were screened in Jimma University Department of Ophthalmology. A cross-sectional study was conducted among 459 volunteer residents of Jimma town and surrounding areas. The study subjects were aged 40 years and above, who came for community screening program after media announcement during the four consecutive weekends of November 2014. Comprehensive eye examination was done including best corrected visual acuity, intra-ocular pressure measurement, stereoscopic optic nerve evaluation, angle structure evaluation and visual field testing. Three diagnostic criteria for glaucoma were employed for all cases. RESULTS: Of all adults who came for screening, 47(10.24%) were diagnosed to have glaucoma, 59(12.85%) were glaucoma suspects, and 8(1.74%) had ocular hypertension. The proportion of glaucoma increased with increasing age, (P value= 0.001 (99%CI)). Primary open angle glaucoma was the most common form (42.55%) of all new cases while 4.4% of all screened adults were followed by normal tension glaucoma (29.79%), pseudoexfoliative glaucoma (19.15%), and primary angle closure glaucoma (6.38%) Around 5.7% of all glaucoma cases were found to be blind. CONCLUSION: The proportion of glaucoma in this community screening program in Southwest Ethiopia was 10.24% with primary open angle glaucoma being the commonest subtype. Glaucoma community screening should be promoted for early diagnosis and intervention to prevent irreversible blindness.

Results From the First Teleglaucoma Pilot Project in Addis Ababa, Ethiopia.

PRECIS: A teleglaucoma case-finding model was utilized in Ethiopia using a high-risk case identification approach. An overall 7.9% of patients had definite glaucoma, and 13.8% were glaucoma suspects. Most cases could be managed medically. BACKGROUND: This study was carried out to analyze disease prevalence and clinical referral pathways for high-risk patients assessed through a hospital-based teleglaucoma case-finding program. METHODS: Patients over the age of 35 years were referred from outpatient diabetic and hypertensive clinics. Through a teleglaucoma consultation, a glaucoma specialist provided remote diagnosis and management recommendations. Patient referral pathways were analyzed. Part way through the program, frontline ophthalmic nurses and optometrists were empowered to refer patients to be seen by general ophthalmologists within a week if patients met high-risk criteria. Qualitative stakeholder feedback was also obtained. RESULTS: A total of 1002 patients (53% female) were assessed with a mean age of 51.0±11.7 years. The prevalence of glaucoma and glaucoma suspects was 7.9% (79 cases) and 13.8% (138 cases), respectively. Retinopathy was found in 9.1%, with hypertensive retinopathy (2.7%) and diabetic retinopathy (2.5%) representing the majority of cases. Age-related macular degeneration was present in 1.5% and cataract in 16%. An overall 63% of cases were without organic eye disease. 35% of patients were referred to a general ophthalmologist, 0.7% to a glaucoma specialist (for surgery), 1.5% to a retina specialist, and 17.7% to an optometrist for further care. Qualitative analysis revealed that stakeholders felt the value of teleglaucoma would be in triaging patients requiring more urgent management and in identifying disease at an earlier stage. CONCLUSIONS: There is a high prevalence of glaucoma in Ethiopian patients assessed through this teleglaucoma program. This model and study have also demonstrated various principles behind telemedicine, such as the development of an intelligent triage system, case-finding for a variety of diseases, and consideration of optimal patient flow/referral pathways.

The Ahmed Glaucoma Valve in Refractory Glaucoma: Experiences in Southwest Ethiopia.

BACKGROUND: The management of refractory glaucoma is a challenging task for any glaucoma surgeon. This study is aimed to evaluate the efficacy of Ahmed Glaucoma Valve implantation in refractory glaucomas in South-West Ethiopia. METHODS: A retrospective review was conducted on the charts of consecutive patients treated with Ahmed glaucoma valve implantation at Jimma University Specialized Hospital between August 2012 and August 2014. Success was defined as Intraocular Pressure (IOP) less than 22 mm Hg and greater than 5mm Hg at 6 months, with at least 30% reduction from baseline, without medical therapy (complete success) or either with or without medication (qualified successes). RESULTS: A total of 12 eyes of 11 patients were included. The mean age of patients was 40.7 (SD= 19.0) years; 63.6% of them were males. The main types of glaucoma were pseudoexfoliative (3 eyes), uveitic (2 eyes), chronic angle closure (2 eyes) and Juvenile Open Angle (JOAG) (2 eyes). The mean IOP was reduced from preoperative level (32.75±7.14 mmHg) to (15.75 ±4.35 mmHg) at six postoperative months, (P<0.001); 66.7% eyes had complete successes while 83.3% had qualified success. Intra-operative complications were encountered in 2(16.7%) eyes, while 5/12 (41.7%) eyes had post-operative complications-hypotony (one with choroidal effusion) and progression of cataract in 2 eyes each. Hypertensive phase was diagnosed in 2(16.7%) eyes. CONCLUSION: The Ahmed glaucoma valve implant appears to be effective and relatively safe for treating complicated glaucomas with success rate comparable with those reported from other studies. KEYWORDS: Ahmed glaucoma valve, refractory glaucoma, complications, Ethiopia.

Adherence to topical glaucoma medications in Ethiopian patients.

PURPOSE: Successful outcomes of medical treatment for glaucoma require proper and daily use of medication to prevent disease progression. The aim of this study was to determine the adherence to anti-glaucoma medications and factors associated with non-adherence among patients with ocular hypertension (OHT) or glaucoma at Jimma University Specialized Hospital, Ethiopia. MATERIALS AND METHODS: A hospital based cross sectional study was conducted on 200 consecutive patients from July to November 2010 at Jimma University Hospital in Southwest Ethiopia. Patients with OHT or glaucoma who were taking topical anti-glaucoma medications for more than six months were included. The study subjects were interviewed and their medical records were reviewed. Non-adherence to glaucoma therapy (NAGT) was defined as self-reported on missed medications or missed appointments, or a physician noting poor adherence. A P < 0.05 was statistically significant. RESULT: Overall, 135 (67.5%) patients were non adherent to glaucoma therapy. Non adherence was associated with older age (P = 0.04), advanced stage of glaucoma (P = 0.01), longer frequency of follow up (P = 0.00) and financial problem (P = 0.000). Sex (P = 0.53), level of education (P = 0.09), and marital status (P = 0.77) were not statistically significantly associated with non-adherence to anti-glaucoma drug treatment. CONCLUSION: A relatively high proportion of patients were not adhering to the medications regimen for glaucoma. Older age, advanced glaucoma, lengthier frequency of follow-up and financial hardship were associated with non-adherence. Eye care providers should be aware of the problem of non-adherence to topical medications.

Advanced glaucoma: management pearls.

A significant proportion of glaucoma patients present late, particularly in the developing world, and unfortunately, in an advanced stage of the disease. They are at imminent danger of losing remaining vision, and may also be afflicted with various socioeconomic and health challenges. The encounter with such a patient is typically characterized by anxiety/fear and sometimes hopelessness from the patient's perspective. The physician may also feel that they are in a difficult position managing the patient's disease. When dealing with such cases, we suggest a holistic, individualized approach taking into account the 'biopsychosociospiritual' (BPSS) profile of each patient. The BPSS model takes into account relevant ocular as well as systemic biology (factors such as the mechanism of glaucoma, level of intraocular pressure [IOP], rate of progression, life expectancy, general health), psychological considerations (e.g., fear, depression), socio-economic factors and spiritual/cultural values and beliefs before being able to decide with the patient and their care partner(s) what treatment goals should be and how they can best be approached. Treatment for advanced glaucoma can be highly effective, and patients and their care partners should be informed that aggressive IOP lowering to the low teens or even single digits offers the best chance of protecting remaining vision. This can be achieved safely and effectively in most cases with trabeculectomy (including an antimetabolite), and in some cases with medical and/or laser therapy. Vision rehabilitation and psychosocial support should also be considered in order to optimize remaining vision, replace fear with hope as appropriate, and thus improve the overall quality of life.