Clinical characteristics and aetiology of uveitis in a viral haemorrhagic fever zone.

BACKGROUND/OBJECTIVES: Studies on uveitis in Sierra Leone were conducted prior to the Ebola Virus Disease epidemic of 2013-16, which was associated with uveitis in 20% of survivors. They did not include imaging or investigation of tuberculosis and used laboratory services outside the country. We performed a cross-sectional study on patients presenting with uveitis to establish their clinical characteristics and identify the impact of in-country laboratory diagnoses. METHODS: We invited uveitis cases presenting to Eye Clinics in Sierra Leone from March to September 2022 to participate in the study. They underwent a diagnostic work-up, including fundus and ocular coherence tomography imaging. Active uveitis cases underwent further investigations including serology and immunological tests for syphilis, tuberculosis, herpetic viruses and HIV and chest radiographs. RESULTS: We recruited 128 patients. The median age was 34 (IQR 19) years and there was an equal gender split. Panuveitis was the predominant anatomical uveitis type (n = 51, 40%), followed by posterior uveitis (n = 36, 28%). Bilateral disease affected 40 patients (31%). Active uveitis was identified in 75 (59%) cases. ICD 11 definition of blindness with VA < 3/60 occurred in 55 (33%) uveitis eyes. Aetiology of uveitis from clinical and laboratory assessment demonstrated that most cases were of undifferentiated aetiology (n = 66, 52%), followed by toxoplasmosis (n = 46, 36%). Trauma contributed to eight (6%) cases, syphilis to 5 (4%) cases and Ebola to 2 (2%). CONCLUSIONS: Uveitis was associated with high levels of visual impairment. Posterior and panuveitis contributed to the highest proportion of uveitis cases. Laboratory studies helped differentiate syphilis as a significant aetiology of uveitis.

Clinical Characteristics and Aetiology of Uveitis in a Viral Haemorrhagic Fever Zone.

Background/Objectives: Studies on uveitis in Sierra Leone were conducted prior to the Ebola Virus Disease epidemic of 2013-16, which was associated with uveitis in 20% of survivors. They did not include imaging or investigation of tuberculosis and used laboratory services outside the country. We performed a cross-sectional study on patients presenting with uveitis to establish their clinical characteristics and identify the impact of in-country laboratory diagnoses. Methods: We invited uveitis cases presenting to Eye Clinics in Sierra Leone from March to September 2022 to participate in the study. They underwent a diagnostic work-up, including fundus and ocular coherence tomography imaging. Active uveitis cases underwent further investigations including serology and immunological tests for syphilis, tuberculosis and herpetic viruses and HIV, and chest radiographs. Results: We recruited 128 patients. The mean age was 36 ± 14 years and there was an equal gender split. Panuveitis was the predominant anatomical uveitis type (n=51, 40%), followed by posterior uveitis (n=36, 28%). Bilateral disease affected 40 patients (31%). Active uveitis was identified in 75 (59%) cases. ICD 11 definition of blindness with VA<3/60 occurred in 55 (33%) uveitis eyes. Aetiology of uveitis from clinical and laboratory assessment demonstrated that most cases were of undifferentiated aetiology (n=66, 52%), followed by toxoplasmosis (n=46, 36%). Trauma contributed to eight (6%) cases, syphilis to 5 (4%) cases and Ebola to 2 (2%). Conclusions: Uveitis was associated with high levels of visual impairment. Posterior and panuveitis contributed to the highest proportion of uveitis cases. Laboratory studies helped differentiate syphilis as a significant aetiology of uveitis.

Effect of bimedial recession on near-distance disparity in esotropia.

BACKGROUND: Esotropia may be associated with a difference in the deviation at near and distance fixation termed near-distance disparity (NDD). Convention suggests patients with NDD may benefit more from bilateral medial rectus recessions (BMR) as opposed to a unilateral recession/resection (RR). The aim of this study is to establish the effect of BMR for the treatment of esotropia on both the near and distance deviation and NDD. METHODS: Retrospective patient records search from 2011 to 2021. INCLUSION CRITERIA: comitant esotropia, first surgery, equal and normal vision with free alternation. EXCLUSION CRITERIA: incomitant, neurological or restrictive strabismus, previous surgery, clinically significant amblyopia. RESULTS: 49 patients met the inclusion criteria. 19 patients were female; the average age was 17 years. Following surgery, the average near deviation reduced from 39PD base out (BO) to 11PD BO. The average distance deviation reduced from 33PD to 9PD. Average preoperative NDD was 12 PD. NDD resolved in 15 out of 18 patients with NDD (83%). The average PD gain per mm of recession was 2.7 for near and 2.2 for distance. CONCLUSIONS: BMR is an effective surgical treatment for esotropia and has a greater effect on near deviation than distance. It is also an effective and simple technique for lesser degrees of NDD. BMR has several advantages over RR: no tissue loss, readily reversible, the scars are easier to hide and it avoids potential motility limitations due to leash effects following resection.

Factors associated with adherence to treatment in patients with open angle glaucoma in Sierra Leone, West Africa: patient demographics and questionnaire.

BACKGROUND: Glaucoma is a significant cause of blindness worldwide. It is more common, presents earlier and is more aggressive in those of African descent. Non-adherence and poor knowledge of glaucoma is a significant barrier to treatment and has been associated with low health literacy. We aim to establish the factors contributing to late presentation, treatment non-adherence and disease progression in glaucoma patients in Sierra Leone. This will help better understand the challenges eye services face, highlight fields requiring development in patient-clinician interaction and identify areas or specific vulnerable patient groups in which resources should be focused. METHODS: Prospective, consecutive recruitment of 120 patients with POAG attending the Lowell and Ruth Gess Eye Hospital and the Connaught Government Teaching Hospital, Freetown, Sierra Leone between February and April 2020. Data were collected from 3 sources: (1) review of clinical notes since first attendance, (2) semi-structured interviews and (3) assessment of study participant's drop instillation technique using a structured checklist. Descriptive statistics was performed for demographic data and other relevant data points. Logistic regression was used for analysis of target variables. RESULTS: The average age was 62 years with more males (52.6%). Agricultural workers and informal street traders represented 13.2% of participants' occupation. 25.8% of participants had no formal school, and 47.4% had either a degree or a diploma. This is out of proportion with the general population and may represent a hidden demographic of glaucoma patients. Drop instillation technique was successful in 52% of study participants. Notable responses to the questionnaire were 30% of patients did not know the name of their eye condition and 22% had no knowledge of glaucoma. CONCLUSION: Investment in a wide-ranging and robust screening programme and public health campaigns targeting these vulnerable groups and high-risk individuals, for example with a positive family history, alongside improved patient education and staff training is required to improve glaucoma care. Support from government, international organisations and the private sector is required to reduce the economic burden of blindness in Sierra Leone.

Aqueous misdirection syndrome following ab interno gelatin stent can be managed successfully with anterior vitrectomy approach.

INTRODUCTION: Minimally invasive glaucoma surgery (MIGS) is a relatively new surgical technique available to glaucoma surgeons. The ab interno gelatin XEN stent (XEN®45, Allergan Inc., CA, USA) drains aqueous into the subconjunctival space and is theoretically less invasive than trabeculectomy and therefore carries less risk. Aqueous misdirection syndrome (AMS) is a rare but well-recognised complication of any intraocular surgery. Only four cases have been reported following XEN stents but their management and outcome was not discussed. We present a case of AMS following XEN implantation including management and outcome. CASE PRESENTATION: A 78 year old lady with an axial length of 21.27 mm and a previous episode of acute angle closure glaucoma was treated with laser peripheral iridectomy and, later, clear crystalline lens extraction. However, she continued to have high intraocular pressure (IOP) and a shallow anterior chamber. Despite medical therapy, she developed worsening glaucoma.She had XEN implantation to her right eye with no intraoperative complication. Unfortunately, she developed signs of AMS. Medical and laser zonulohyaloidectomy failed to resolve the condition. She then had surgical iriodozonulohyaloidectomy and anterior vitrectomy which resolved the AMS. DISCUSSION: Management of AMS has been well documented. However, incidence following novel surgical techniques, such as XEN implantation, is not well reported. We have shown that AMS following XEN can be successfully treated using an anterior approach.

A novel unbalanced translocation between the short arms of chromosomes 6 and 16 in a newborn girl: Clinical features and management.

The reporting of previously undescribed genetic mutations and resulting clinical phenotypes guides management and enables a more accurate prognosis for clinicians treating newborns with similar features. Previous cases of 6p deletions and 16p duplications have been described as separate entities. This patient presents with both and has a unique phenotype.

Commercial Slit Lamp Anterior Segment Photography versus Digital Compact Camera Mounted on a Standard Slit Lamp with an Adapter.

PURPOSE: To compare slit lamp mounted anterior segment cameras (SLCs) versus digital compact camera (DCC) with slit-lamp adaptor when used by an inexperienced technician. METHODS: In this cross sectional study, where posterior capsule opacification (PCO) was used as a comparator, patients were consented for one photograph with SLC and two with DCC (DCC1 and DCC2), with a slit lamp adaptor. An inexperienced clinic technician, who took all the photographs and masked the images, recruited one eye of each patient. Images were graded for PCO using EPCO 2000 software by two independent masked graders. Repeatability between DCC1 and DCC2, and limits-of-agreement between SLC and DCC1 mounted on slit-lamp with an adaptor were assessed. Coefficient-of-repeatability and Bland-Altmann plots were analyzed. RESULTS: Seventy-two patients (eyes) were recruited in the study. First 9 patients (eyes) were excluded due to unsatisfactory image quality from both the systems. Mean evaluation of posterior capsule opacification (EPCO) score for SLC was 2.28 (95% CI: 2.09-2.45), for DCC1 was 2.28 (95% CI: 2.11-2.45), and for the DCC2 was 2.11 (95% CI: 2.11-2.45). There was no significant difference in EPCO scores between SLC vs. DCC1 (p = 0.98) and between DCC1 and DCC2 (p = 0.97). Coefficient of repeatability between DCC images was 0.42, and the coefficient of repeatability between DCC and SLC was 0.58. CONCLUSIONS: DCC on slit lamp with an adaptor is comparable to a SLC. There is an initial learning curve, which is similar for both for an inexperienced person. This opens up the possibility for low cost anterior segment imaging in the clinical, research, and teaching settings.

A Systematic Review of Patient-Reported Outcomes for Surgically Amenable Epiphora.

PURPOSE: In evaluating epiphora and its management, the bottom line for all stakeholders is whether an intervention confers any real benefit on quality of life. A review was conducted to identify and appraise patient-reported outcome measures (PROMs) in surgically amenable epiphora. METHODS: A systematic search was conducted of studies relating to surgical intervention for epiphora. Patient-reported outcome measures were identified and assessed against standard criteria. RESULTS: Of 30,544 identified articles, 227 were eligible for data extraction. Of these, 69% reported a PROM as the primary outcome. PROMs identified included single-item symptom scores (48% of primary outcome PROMs), single-item reports of improvement (30%), the Glasgow Benefit Inventory (3%), Lacrimal Symptom Questionnaire (0.5%), Nasolacrimal Duct Obstruction Symptom Score (0.5%), Ocular Surface Disease Index (0.5%), Visual Function Questionnaire-25, the Short Form-36 Health Survey, and 3 other symptom scores. None were developed through consultation with the target population, and there was inadequate testing of content validity. The strengths and limitations of each PROM are presented, with regard to interpretation, responsiveness, reliability, and validity. DISCUSSION: The importance of robust and psychometrically sound PROMs is essential if the under-reporting of quality of life improvement in patients treated for epiphora is to change. Recommendations for the use of each identified PROM are discussed. CONCLUSIONS: Several PROMs have been used in the recent literature to evaluate patients undergoing surgery to treat epiphora. Assessed against standard criteria, no PROM has proven to be both psychometrically robust and clinically meaningful for use in this population. Future PROM development should be guided by this standard framework.

Trends in ophthalmology journals: a five-year bibliometric analysis (2009-2013).

AIM: To explore the trends in the ophthalmic literature over a 5-year period in relation to country, research expenditure and demographics. METHODS: Articles published between 2009 and 2013 by the 20highest-contributing countries in the 20 top-ranked ophthalmology journals were identified by their country of affiliation. The number of articles published and mean impact factor were measured per country for each year and trends explored using regression analysis with 5-year and 10-year forecasts calculated. Data on research expenditure was collected and tested for correlation with the number of articles and mean impact factor. RESULTS: The analysis included 19 338 articles. The USA, UK and Europe accounted for 60.2% of articles published, with the USA contributing 7388 articles (34.0%). The USA also demonstrated the highest mean impact factor (3.5). Research expenditure was significantly correlated with both research output (r=0.86, P<0.001) and scholarly impact (r=0.42, P<0.001). China (P<0.01), Korea (P<0.01) and India (P<0.02) demonstrated a significant growth in research output over the study period. The research contribution of these three countries combined is forecasted to overtake that of Europe within ten years, with China expected to be the second-largest contributor within five years. These countries were also among those demonstrating the greatest growth in research expenditure. CONCLUSION: While the USA and European countries are major contributors of ophthalmic research, the productivity of some Asian countries is growing impressively. The contribution of China, Korea and India is forecasted to outweigh that of Europe by 2023. Research expenditure is highly correlated with research productivity and these trends reflect the differing economic priorities across the world.

Are You Missing an Entropion? The Test of Induced Entropion 2.

PURPOSE: Entropion is the inward turning of the eyelid. The most common type of entropion is involutional, a combination of eyelid laxity, lower eyelid retractor weakness, and orbicularis oculi override. Unfortunately, the condition can be intermittent and remain undiagnosed, leading to ocular surface damage. In suspected cases, clinicians can use provocation techniques to elicit the condition. These include the forced closure of the eyelids, the tetracaine provocation test, and the test of induced entropion (TIE). The authors present an alternative diagnostic test: the TIE-2. METHODS: The TIE-2 test is performed by asking the patient to look down while the examiner holds the upper eyelid open and high to prevent downward movement. The patient is then asked to close their eyelids as tightly as possible. An entropion will then be induced. To illustrate the technique, the authors present 2 patients seen in the oculoplastics clinic with symptoms and signs suggestive of intermittent entropion, in whom conventional provocation tests were unsuccessful. RESULTS: In both cases, conventional methods did not provoke an entropion. However, the TIE-2 test successfully induced an entropion, leading to the correct diagnosis and appropriate management. CONCLUSION: When there is suspicion of intermittent entropion that is not revealed with existing provocation tests, the TIE-2 is a simple and useful diagnostic tool.

Frontal sinus mucocoele: a rare cause of ptosis.

A 73-year-old man, with no medical history of note, presented with a 4-week history of an isolated left-sided ptosis and associated periorbital and retro-orbital discomfort. His pupils were spared, his eye movements were not restricted and he was not proptosed. A prompt CT orbits and head scan revealed a large left frontal sinus mucocoele that had eroded into the left orbit. The patient had successful endoscopic sinus surgery under the ear, nose and throat team and 1 month later was seen in ophthalmology clinic. His ptosis and discomfort had fully resolved and he had no neurological sequelae from the surgery.