Retinopathy of prematurity in Rwanda: a prospective multi-centre study following introduction of screening and treatment services.

OBJECTIVES: To investigate risk factors for retinopathy of prematurity (ROP) in a newly established ROP screening and management programme in Rwanda, Africa. METHODS: In this multi-centre prospective study 795/2222 (36%) babies fulfilled the inclusion criteria (gestational age (GA) < 35 weeks or birth weight (BW) < 1800 g or unstable clinical course), 424 (53%) of whom were screened for ROP. 270 died before the first screening. ROP and treatment-warranted ROP were classified using the revised International Classification of ROP (2005). Data on maternal and perinatal risk factors were collected from daily neonatal notes. RESULTS: 31 babies (7.3%, CI 5.0-10.2) developed any ROP, 13 of whom (41.9%, CI 24.5-60.9) required treatment. ROP was seen in six neonates with GA > 30 weeks and BW > 1500 g, one of whom required treatment. In univariate analysis the following were associated with any ROP: increasing number of days on supplemental oxygen (OR 2.1, CI 1.5-3.0, P < 0.001), low GA (OR 3.4, CI 1.8-6.4, P < 0.001), low BW (OR 2.3, CI 1.5-3.4, P < 0.001), at least one episode of hyperglycaemia ≥ 150 mg/dl (OR 6.6, CI 2.0-21.5, P < 0.001), blood transfusion (OR 3.5, CI 1.6-7.4, P < 0.001) or sepsis (OR 3.2, CI 1.2-8.6, P = 0.01). In multivariate analysis longer exposure to supplemental oxygen (OR 2.1, CI 1.2-3.6, P = 0.01) and hyperglycaemia (OR 3.5, CI 1.0-12.4, P = 0.05) remained significant. CONCLUSIONS: ROP has become an emerging health problem in Rwanda, requiring programmes for screening and treatment. ROP screening is indicated beyond the 2013 American Academy guidelines. Improved quality of neonatal care, particularly oxygen delivery and monitoring is needed.

Correction: Retinopathy of prematurity in Rwanda: a prospective multi-centre study following introduction of screening and treatment services.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.In the original Article, Erwin Van Kerschaver was erroneously attributed an affiliation. This has been corrected in the XML,HTML and PDF versions of this Article.

Glaucoma Surgery Outcome in Rwanda.

PURPOSE: To assess long-term intraocular pressure (IOP) outcome after adult trabeculectomy surgery in Central Africa. PATIENTS AND METHODS: All adult glaucoma patients who underwent trabeculectomy surgery in the Kabgayi Eye Unit, Rwanda between August 2003 and March 2008 were invited for a follow-up visit. Surgical and clinical data were collected from medical records. At the study visit, best-corrected visual acuity was measured and Goldmann applanation tonometry and biomicroscopy were done. Good IOP outcome was defined as both an IOP<21 mm Hg and achieving ≥30% reduction from the preoperative IOP. Considering first operated eyes, univariate and multivariate logistic regression was used to investigate risk factors for failure. RESULTS: Of 163 individuals operated 3 had died, 118 (74%) participated. Preoperatively, the mean IOP was 31 mm Hg (SD=11; range, 12 to 60). At the time of the follow-up study visit the mean postoperative IOP was 13 mm Hg (SD=5; range, 4 to 35). Good IOP outcome was achieved in 132 eyes (84%). Univariate analysis suggested a protective effect against failure of use of antimetabolites [odds ratio (OR)=0.39; 95% confidence interval (CI), 0.14-1.11; P=0.07] and a decrease in success with length of follow-up (OR=3.57; 95% CI, 1.09-12.50; P=0.03). The latter remained borderline significant with multivariate analysis. Seven eyes went from previously better vision (at least hand movements) down to perception of light or no perception of light after trabeculectomy. Particularly a flat anterior chamber in the first postoperative week (OR=0.07; 95% CI, 0.01-0.49; P<0.001) and late hypotony (OR=0.04; 95% CI, 0.002-0.99; P=0.004) were significant risk factors for severe visual loss. CONCLUSIONS: Trabeculectomy with antimetabolites is one of the best available options for glaucoma management in Africa. However, the IOP control reduced at a follow-up duration beyond 2 years, highlighting the importance of regular long-term follow-up.

Noninvasive intraocular pressure monitoring: current insights.

Glaucoma is the second leading cause of blindness worldwide and intraocular pressure (IOP) is currently its only modifiable risk factor. Peak IOP has for a long time been considered as a major contributor to glaucoma progression, but its effects may depend not only on its magnitude, but also on its time course. The IOP is nowadays considered to be a dynamic parameter with a circadian rhythm and spontaneous changes. The current practice of punctual measuring the IOP during office hours is therefore a suboptimal approach, which does not take into account the natural fluctuation of IOP. Because of its static nature a single IOP measurement in sitting position fails to document the true range of an individual's IOP, peak IOP, or variation throughout the day. Phasing means monitoring a patient's IOP during the daytime or over a 24-hour period. This can provide additional information in the management of glaucoma patients. This review focuses on the current insight of non-invasive IOP monitoring as a method of obtaining more complete IOP profiles. Invasive techniques using an implantable sensor are beyond the scope of this review.

Skin diseases among schoolchildren in Ghana, Gabon, and Rwanda.

OBJECTIVES: Skin diseases, especially skin infections, among schoolchildren in Africa can be a major health problem. The objective of this study was to determine the prevalences of skin diseases among children in rural and urban schools in three different African countries and to study the influence of socioeconomic level. METHODS: Cross-sectional, population-based studies were performed in Ghana, Gabon, and Rwanda. Point prevalences of skin diseases were estimated on the basis of physical examination by at least one dermatologist. RESULTS: A total of 4839 schoolchildren were seen. The overall prevalence of schoolchildren with any skin disease was high and amounted to 34.6% and 42.0% in two Ghanaian studies, 45.8% in Gabon, and 26.7% in Rwanda. In children with skin diseases, skin infections represented the greatest proportion of disease, accounting for 14.7% and 17.6% of skin disease in the Ghanaian studies, and 27.7% and 22.7% in Gabon and Rwanda, respectively. Diseases with the highest prevalence were tinea capitis and bacterial skin infections, especially in rural areas and in schools serving children living at lower socioeconomic levels. CONCLUSIONS: The prevalences of skin diseases among African schoolchildren were high. Skin infections such as tinea capitis and pyoderma predominated.

Vernal keratoconjunctivitis: an update.

Vernal keratoconjunctivitis (VKC) is a bilateral, usually seasonally recurrent, allergic inflammation of the conjunctiva, characterised by limbal gelatinous hypertrophy and/or upper tarsal giant conjunctival papillae. Although rare in temperate regions, it represents an important cause of hospital referral in many parts of Africa and Asia. Clinical and immunohistochemical studies suggest that IgE-dependent (type I allergic) and IgE-independent (type IV allergic) mechanisms are involved in the immunopathogenesis of VKC, in which various inflammatory cells, including different T cell subpopulations play an active role via a cascade of chemical mediators. Endocrine, genetic, neurogenic, environmental and socioeconomic risk factors have been identified. However, its aetiology and pathophysiology remain unclear. The clinical course of this disease is usually benign and self-limiting, but a minority of patients will face very debilitating and sight threatening complications. Topical corticosteroids are often used during flare-ups in combination with mast cell stabilizers as maintenance treatment for VKC. However this management is unsatisfactory in controlling severe cases and avoiding recurrences. Non-steroidal immune modulators such as ciclosporin A and tacrolimus are promising alternatives, but tolerance to these agents needs to be improved and production costs reduced. The purpose of this review is to give an update on its epidemiology, immunopathogenesis and management.

Vernal keratoconjunctivitis in school children in Rwanda: clinical presentation, impact on school attendance, and access to medical care.

OBJECTIVE: We sought to describe the clinical presentation, effect on visual acuity, impact on school attendance, and access to appropriate eye care in children with vernal keratoconjunctivitis (VKC) in Rwanda (Central Africa). DESIGN: Case-control study nested within a cross-sectional survey. PARTICIPANTS: We examined 3041 children; 121 had VKC. METHODS: Primary schools were randomly selected and children were interviewed using a questionnaire on VKC-related symptoms. Data on health-seeking behavior and school attendance were recorded. Children received a full eye examination, including visual acuity using a LogMar E Chart. MAIN OUTCOME MEASURES: Description of the clinical findings, unaided visual acuity, prior attendance for medical eye care, and the impact of VKC on school attendance. RESULTS: Of the 121 children with VKC, 119 (98.4%) had only limbal disease. Ocular itching (n = 101; 83.5%) was the predominant symptom and this was seasonal in 66 children (65.4%), constant but with variable intensity in 18 (17.8%), and constant with constant intensity in 17 children (16.8%). Children with VKC were >6 times more likely to have corneal astigmatism >2 diopters in their worse eye (odds ratio [OR], 6.31; 95% confidence interval [CI], 3.26-12.26; P<0.001) than controls. Eight affected eyes had astigmatism >4 diopters or irregular astigmatism incompatible with autokeratometry. Although 4 eyes (1.7%) had uncorrected low vision from VKC-induced corneal astigmatism or keratoconus, only 1 child was visually impaired in both eyes. School nonattendance for an ocular reason during the last 3 months was 5 times more likely in children with VKC (n = 44; 36.4%) than among those without (n = 297; 10.2%; OR, 5.04; 95% CI, 3.40-7.47; P < 0.001). Repeating a school year or having ever dropped out of school was not more common among children with VKC than those without. Medical eye care had been sought by 54 (44.6%) children with VKC. CONCLUSIONS: This survey of prevalence and treatment of VKC in an African community adds to the argument for better primary eye care, including a safe topical medication. Long-term follow-up of this cohort is required to ascertain the overall risk of sight-threatening complications.

24-hour intraocular pressure fluctuation monitoring using an ocular telemetry Sensor: tolerability and functionality in healthy subjects.

PURPOSE: To evaluate the tolerability, comfort, and reliability of the signal transmission of an ocular Sensor used for 24-hour intraocular pressure fluctuation monitoring in humans. PATIENTS AND METHODS: In this uncontrolled open trial involving 10 healthy volunteers, an 8.7-mm radius prototype ocular telemetry Sensor (SENSIMED Triggerfish, Lausanne, Switzerland) and an orbital bandage containing a loop antenna were applied and connected to a portable recorder after full eye examination. Best-corrected visual acuity and position, surface wetting ability, and mobility of the Sensor were assessed after 5 and 30 minutes, 4, 12, and 24 hours. Subjective wearing comfort was scored and activities documented in a logbook. After Sensor removal, a full eye examination was repeated and the recorded signal analyzed. RESULTS: The comfort score was high and did not fluctuate significantly over time. The mobility of the Sensor was limited across follow-up visits and its surface wetting ability remained good. Best-corrected visual acuity was significantly reduced during Sensor wear and immediately after its removal (from 1.07 before, to 0.85 after, P value 0.008). Three subjects developed a mild, transient corneal abrasion. In all but 1 participant, we obtained usable data of a telemetric signal recording with sufficient sensitivity to depict ocular pulsation. CONCLUSIONS: This 24-hour trial has encouraging results on the tolerability and functionality of the ocular telemetric Sensor for intraocular pressure fluctuation monitoring. Further studies with different Sensor radii conducted on a larger study population are needed to improve comfort, precision, and interpretation of the telemetric signal.

Topical ciclosporin in the treatment of vernal keratoconjunctivitis in Rwanda, Central Africa: a prospective, randomised, double-masked, controlled clinical trial.

AIM: To compare the short-term efficiency and safety of topical ciclosporin A (CsA) 2% with dexamethasone 0.1% in the treatment of predominantly limbal vernal keratoconjunctivitis (VKC) in Rwanda, Central Africa. METHODS: Consecutive patients with VKC were randomised in a prospective, double-masked, clinical trial to receive either topical CsA 2% dissolved in olive oil vehicle or dexamethasone 0.1% drops for 4 weeks. Both groups then received sodium chromoglycate 2% drops for maintenance therapy for a further 4 weeks. The primary outcome was the reduction in composite score for VKC-related symptoms and signs at 4 weeks. Secondary outcomes included side effects, best-corrected visual acuity, comfort rating of the trial drops during 4 weeks' test medication and relapse rate thereafter. RESULTS: The 366 participants recruited had the limbal (91.5%) or mixed form of VKC. At the end of the 4-week treatment period, the composite score had decreased significantly (p<0.001) from baseline without any significant difference between CsA and dexamethasone (p=0.20). There were no severe adverse reactions, but CsA drops caused more stinging than the oil placebo and dexamethasone (p<0.001). In both treatment groups, the visual acuity had improved at 4 weeks compared with baseline (p<0.001) with no significant difference between the treatment arms. The relapse rate following cessation of the trial treatments was similar (p=0.84) in both groups. CONCLUSION: There is no significant difference between the efficiency of topical CsA 2% and dexamethasone 0.1% for the management of acute VKC in Central Africa, but tolerance needs to be improved.