Ophthalmologists' Perspective on Barriers to Cataract Surgery and Surgical Productivity in Ethiopia, Ghana, and Zambia: A Descriptive, Mixed-Methods Survey.

PURPOSE: While progress was made towards the Vision 2020: The Right to Sight goals, Ethiopia, Ghana, and Zambia fell short of the recommended cataract surgical rate (CSR) on a national level. Post-operative cataract surgical outcomes are also lower compared to other regions. This study aimed to describe perceived barriers to cataract surgical uptake, factors related to surgeon surgical productivity, and surgical offerings in each of these countries. METHODS: An online survey was sent to ophthalmologists practicing in Ethiopia, Ghana, and Zambia. Responses were collected between June 25, 2021 and January 30, 2022. RESULTS: Responses were received from 122 ophthalmologists from Ethiopia, Ghana, and Zambia. The estimated participation rate was 47% (122/257). Distance to cataract surgical centres, lack of surgical centres, and lack of surgical equipment were among the top 10 most agreed upon barriers by respondents within each country. Many respondents reported that current financial reimbursement does not incentivise maximum productivity in themselves (56%, 68/122) or their staff (61%, 74/122). Surgeons proposed several ways to improve productivity incentives. Private practice was perceived to have the best reimbursement incentives (77%, 94/122), whereas government hospitals were least agreed upon (4%, 5/122). Discrepancies in timely post-operative refraction and eyeglasses disbursement were reported. CONCLUSIONS: Overcoming the identified barriers, improving surgeon productivity, and addressing identified deficits in cataract care will likely reduce the backlog of cataract blindness while ensuring increasingly improved patient outcomes.

Technical capacities needed to implement the WHO's primary eye care package for Africa: results of a Delphi process.

OBJECTIVE: The aim of the study was to establish the technical capacities needed to deliver the WHO African Region's primary eye care package in primary healthcare facilities. DESIGN: A two-round Delphi exercise was used to obtain expert consensus on the technical complexity of each component of the package and the technical capacities needed to deliver them using Gericke's framework of technical feasibility. The panel comprised nine eyecare experts in primary eyecare in sub-Saharan Africa. In each round panel members used a 4-point Likert scale to indicate their level of agreement. Consensus was predefined as ≥70% agreement on each statement. For round 1, statements on technical complexity were identified through a literature search of primary eyecare in sub-Saharan Africa from January 1980 to April 2018. Statements for which consensus was achieved were included in round 2, and the technical capacities were agreed. RESULTS: Technical complexity statements were classified into four broad categories: intervention characteristics, delivery characteristics, government capacity requirements and usage characteristics. 34 of the 38 (89%) statements on health promotion and 40 of the 43 (93%) statements on facility case management were considered necessary technical capacities for implementation. CONCLUSION: This study establishes the technical capacities needed to implement the WHO Africa Office primary eye care package, which may be generalisable to countries in sub-Saharan Africa.

Orbital Apex Syndrome: a rare complication of herpes zoster ophthalmicus in a Ghanaian woman living with HIV.

Herpes Zoster Ophthalmicus (HZO) usually affects the immunocompromised and aged. It results from the reactivation of latent varicella zoster infection in the trigeminal ganglia. Orbital apex syndrome (OAS) is a rare sequela of the disease and tends to be disfiguring and vision-threatening if not addressed. We report on a 43-year-old Ghanaian female living with Human Immunodeficiency Virus infection and on highly active antiretroviral therapy who presented with a 2-month history of a healed vesicular rash left side of the forehead and a droopy left upper eyelid. On examination, she had complete ptosis, visual acuity in the left eye was 6/36, and restricted mobility in all directions of gaze. On anterior segment examination using a slit lamp biomicroscope, the left eye had mild cornea oedema with keratic precipitates and relative afferent pupillary defect (RAPD). Intraocular pressure and posterior segment of the right eye were normal. Computed tomography (CT) Scan of the head was taken to rule out other causes of OAS. Patient was treated with oral acyclovir 400mg five times daily for 30 days, topical steroids and oral prednisolone 60mg daily for 30 days which was tapered. Ptosis improved significantly with mild supraduction and infraduction deficit. Visual acuity improved to 6/12 and all keratic precipitates cleared. The patient, however, developed a corneal scar from a possible neurotrophic ulcer after defaulting treatment for 11 months. OAS , as a rare sequalae of HZO, responds well to oral acyclovir and steroids. Prompt diagnosis and appropriate treatment, even at late presentation, yield positive outcomes. Funding: None declared.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach.

BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Trachoma control in Southern Zambia--an international team project employing the SAFE strategy.

PURPOSE: To determine the prevalence of trachoma and to measure the impact of the SAFE strategy (World Health Organization GET 2020 strategy) for treating trachoma in the Gwembe District of Southern Zambia. DESIGN: This is an observational study of the introduction of the SAFE strategy employing a collaborative approach and its impact on trachoma in the area. PARTICIPANTS: Three thousand eight hundred ninety two persons in communities at 26 well sites in the Gwembe district of Southern Zambia were included in this study. METHODS: New, clean water wells were drilled under local supervision for each of 26 identified villages. All people living in villages near the wells were screened for trachoma and then treated with antibiotic if required. Education on personal and environmental hygiene was provided by trained volunteers. Patients affected by trichiasis and corneal scarring received surgery, locally if possible. Attempts to control fly populations by cleaning villages, penning livestock, and digging latrines were undertaken. This was performed under advisement and consultation with local villagers and government officials. Data was collected on variables normally associated with trachoma and others relating to demographics, water quality, environment and hygiene. MAIN OUTCOME MEASURES: Prevalence of trachoma in the area at two years post introduction of SAFE strategy. RESULTS: The overall prevalence of trachoma in the area was 47% in 2001; however, the prevalence was 55% among children under 10 years. At two years post intervention, the overall prevalence of trachoma reduced to 7.6%, and decreased to 10.6% in children under 10 years, and 5.9% among adults. CONCLUSIONS: Continued monitoring and risk factors will need to continue to be addressed in order to sustain this trachoma control project in this area of Zambia.