Impact of Coronavirus Disease 2019 on Intravitreal Antivascular Endothelial Growth Factor Injection Rates in Nigerians.

Aim: To quantify the impact of coronavirus disease 2019 (COVID-19) on the rate of intravitreal antivascular endothelial growth factor (VEGF) injections (IVI) in eye hospitals in Nigeria. Materials and Methods: A retrospective, observational, comparative study. The IVIs given 12 months before (pre-COVID) and 12 months after the first announcement of the COVID-19 lockdown (COVID) in Nigeria in four hospitals were used as the sample for this study. All eyes were treatment naïve. We determined the total number of all anti-VEGF injections, the number given for each indication, and the number of each type of the three anti-VEGFs given. A comparison of the presenting vision in IVI eyes between the two eras and the visual outcome of the IVI treatment was made. Data were analyzed using the SPSS version 22 to determine statistical significance. Results: Male/female ratio, pre-COVID 63.4%/36.6% and COVID 58.6%/41.4% (P = 0.123). Age, pre-COVID 61.3 (SD 12.9) 9-95 years and COVID 57.5 (SD 16.4) 0.15-95 years. There was a 15.3% (81 eyes) reduction in the number of eyes between pre-COVID and COVID eras (528 and 447 eyes, respectively). Likewise, the number of IVIs reduced by 26% (221 IVIs) from 850 pre-COVID to 629 COVID, P = 0.005. A comparison of the proportion of eyes in the four clinic locations between the two eras was not statistically significant (P = 0.148). The commonest indication was proliferative diabetic retinopathy in both eras, 208 versus 178 eyes (323 versus 226 IVIs). Bevacizumab, Ranibizumab, and Aflibercept were given in the following proportions 60.2%, 22.3%, and 17.4% (pre-COVID) versus 60.2%, 31.5%, and 8.3% (COVID), P = 0.000. Presenting visual acuity was >6/60 in 67.4% of eyes (pre-COVID) versus 59.4% of eyes (COVID), P = 0.039. Vision improved in 51.3% of eyes (pre-COVID) versus 47.7% (COVID); there was no significant difference in visual outcome comparing both eras, P = 0.972. Conclusion: COVID-19 significantly reduced the number of eyes and IVIs. Eyes had worse presenting visual acuity during the COVID era; however, treatment outcome was comparable between COVID and pre-COVID eras.

Visual outcome of treating proliferative sickle cell retinopathy in 108 eyes.

AIM: To report treatment methods and visual outcome of treating proliferative sickle cell retinopathy (PSCR). DESIGN: Retrospective interventional. METHODS: Review of PSCR eyes treated between 2017 to 2022. Patient demographics, fundus findings at presentation, genotype, PSCR stage, treatment used, and visual outcome were assessed. RESULTS: 108 eyes of 88 consecutive patients were studied. Male: Female 48:40. Mean age: 38.91 (SD:12.52) years. Genotype: sickle cell haemoglobin C (SC) 83 eyes (76.9%), sickle cell haemoglobin S (SS) 19 eyes (17.6%), and sickle cell trait (AS) 6 eyes (5.5%). PSCR stages: 3: 15 eyes (11.0%), 4: 74 eyes (67.0%), and 5: 19 eyes (22.0%). Treatment methods: Intravitreal Injection (IVI) of anti-vascular endothelial growth factor (VEGF) only (27 eyes,25%), scatter retinal laser photocoagulation (SRLP) only (7 eyes, 6.5%), Vitrectomy + SRLP (29 eyes, 26.9%), IVI + SRLP (25 eyes, 23.1%), and Vitrectomy + IVI + SRLP (20 eyes, 18.5%). The treatment used correlated with PSCR stage (p = 0.000). IVI only was mostly used to treat stage 4 (81.4%), and SRLP only was used for stages 3 (42.9%) and 5 (57.1%). IVI + SRLP treated eyes had the best pre- and post-treatment vision. Vitrectomy + SRLP treated eyes had the most improved vision. SRLP only had least visual improvement. Fundus findings correlated with visual outcome (p = 0.003); but stage of PSCR, genotype and treatment used had no correlation (P > 0.05). CONCLUSION: Several options effectively treat PSCR. Visual outcome improved or remained same in 90.7% of treated eyes. Randomized controlled trials will determine the optimum treatment for each distinct presentation of PSCR. Treatment guidelines and a disease classification system of prognostic value are unmet needs.

Prevalence and systemic associations of retinal vascular occlusions in Sub-Saharan Africa.

Background: Retinal vascular occlusions are a common cause of visual impairment. Studies on retinal vascular occlusions in sub-Saharan Africa (SSA) have primarily been retrospective and on retinal vein occlusion (RVO) only. The aim of this study, therefore, was to determine the prevalence and pattern of retinal vascular occlusions and their systemic associations in SSA. Materials and Methods: This was a hospital-based, cross-sectional study involving all new patients presenting at the general ophthalmic and specialty retina clinics in four hospitals in Nigeria over a 1 year period. All the patients underwent a comprehensive eye examination. The demographic and clinical data of patients with retinal vascular occlusions were entered into an excel sheet and analyzed using the Statistical Package for the Social Sciences (SPSS) software version 22.0. Statistical significance was indicated by P < 0.05. Results: A total of 8614 new patients were seen, and a diagnosis of retinal vascular occlusion was made in 90 eyes of 81 patients giving a disease prevalence of 0.9%. Eighty-one eyes of 72 (88.9%) patients had RVO, while 9 eyes of 9 (11.1%) patients had retinal artery occlusion (RAO). The mean age of patients with RVO and RAO was 59.5 years and 52.4 years, respectively. Increasing age, hypertension, and diabetes were the significant associations with retinal vascular occlusion with P < 0.0001. Conclusion: Retinal vascular occlusions are an increasing cause of retinal disease in SSA and tend to occur at an earlier age. They are associated with hypertension, diabetes, and increasing age. Further studies will, however, be required to establish the demographic and clinical profile of patients with RAO in the region.

Résumé Contexte: Les occlusions vasculaires rétiniennes sont une cause fréquente de la déficience visuelle. Les études sur les occlusions vasculaires rétiniennes en Afrique subsaharienne (SSA) ont été principalement rétrospectives et uniquemment sur l'occlusion veineuse rétinienne (RVO). Le but de cette étude était donc de determiner la prévalence et le schéma des occlusions vasculaires rétiniennes et leurs associations systémiques en Afrique subsaharienne. Matériels et méthodes: Il s'agissait d'une étude transversale hospitalière portant sur tous les nouveaux patients se présentant aux cliniques d'ophtalmologie générale et de rétine spécialisée dans quatre hôpitaux au Nigéria sur une période d'un an. Tous les patients ont subi un examen ophtalmologique complet. Les données démographiques et cliniques des patients avec des occlusions vasculaires rétiniennes ont été saisies dans une feuille excel et elles ont été analysées à l'aide du paquet statistique pour les sciences sociales (SPSS) logiciel version 22.0. La signification statistique était indiquée par P < 0,05. Résultats: Au total, 8614 nouveaux patients ont été vus et un diagnostic d'une occlusion vasculaire rétinienne a été réalisée dans 90 yeux de 81 patients donnant une prévalence de la maladie de 0,9 %. Quatre-vingt-un yeux de 72 (88,9 %) patients avaient RVO, tandis que 9 yeux de 9 (11,1%) patients avaient une occlusion de l'artère rétinienne (RAO). L'âge moyen des patients avec RVO et RAO était de 59,5 ans et 52,4 ans, respectivement. L'augmentation de l'âge, l'hypertension et le diabète étaient les associations significatives avec l'occlusion vasculaire rétinienne avec P < 0,0001. Conclusion: Les occlusions vasculaires rétiniennes sont une cause croissante de maladie rétinienne en Afrique subsaharienne et elles ont tendance à survenir à un âge plus précoce. Elles sont associées à l'hypertension, au diabète et à l'âge. D'autres études seront cependant nécessaires pour établir la démographie et le profil clinique des patients atteints de RAO dans la région. Mots-clés: Diabète, hypertension, occlusion artérielle rétinienne, occlusion veineuse rétinienne.

Outcome of peripapillary polypoidal choroidal vasculopathy treatment using combination therapy intravitreal ranibizumab and thermal retinal laser photocoagulation.

We present the case of a middle-aged female Nigerian diagnosed to have right eye peripapillary polypoidal choroidal vasculopathy (PCV). At presentation, her right eye Snellen visual acuity was 6/24+ (unaided) and 6/12 (aided) and the left eye was 6/9 (unaided) and 6/6 (aided). Fundus fluorescein angiography showed a hyperfluorescent peripapillary subretinal lesion associated with subretinal fluid demonstrated on spectral-domain optical coherence tomography. The PCV lesion was successfully treated using a combination of 3 monthly doses of intravitreal ranibizumab initially, followed by one session of focal thermal retinal laser photocoagulation. Her clinical state has remained stable after 5 years of follow-up, requiring no further treatment. This case demonstrates the effectiveness of combination therapy and can be a strategy for treating this PCV type. Successful treatment using this approach will reduce the burden of intravitreal anti-vascular endothelial growth factor, e.g., ranibizumab injections.

Résumé Nous présentons le cas d'une Nigériane d'âge moyen diagnostiquée comme ayant une vasculopathie choroïdienne polypoïdale (VPC) péripapillaire de l'œil droit. Lors de la présentation, son œil droit Snellen avait une acuité visuelle de 6/24+ (sans aide) et de 6/12 (aidé) et l'œil gauche était de 6/9 (sans aide) et 6/6 (aidé). L'angiographie à la fluorescéine du fond d'œil a montré une lésion sous-rétinienne péripapillaire hyperfluorescente associée au liquide sous-rétinien démontrée par tomographie par cohérence optique dans le domaine spectral. La lésion VPC a été traitée avec succès en utilisant une combinaison de 3 doses mensuelles de ranibizumab intravitréen initialement, suivie d'une séance de photocoagulation laser thermique rétinienne focale. Son état clinique est resté stable après 5 ans de suivi, ne nécessitant aucun traitement supplémentaire. Ce cas démontre l'efficacité de la thérapie combinée et peut être une stratégie pour traiter ce type de VPC. Un traitement efficace utilisant cette approche réduira le fardeau du facteur de croissance endothélial antivasculaire intravitréen, par exemple les injections de ranibizumab. Mots clés: Facteur de croissance endothéliale antivasculaire, thérapie combinée, vasculopathie choroïdienne polypoïdale, ranibizumab, laser rétinien Photocoagulation.

Neuroprotection for Nonarteritic Central Retinal Artery Occlusion: Lessons from Acute Ischemic Stroke.

Nonarteritic central retinal artery occlusion (NA-CRAO) is a variant of acute ischemic stroke (AIS) and is a cause of sudden severe loss of vision. There are guidelines by the American Heart Association and the American Stroke Association for the care of CRAO patients. This review explores the basis of retinal neuroprotection for CRAO and its potential for improving the outcome of NA-CRAO. Recently, there have been significant advances in research into the use of neuroprotection to treat retinal diseases, including retinal detachment, age-related macular degeneration, and inherited retinal diseases. Also, neuroprotective research in AIS has been extensive, and newer drugs tested, including Uric acid, Nerinetide, and Otaplimastat, with promising results. Progress in cerebral neuroprotection after AIS offers hope for retinal neuroprotection after CRAO; and a possibility of extrapolating research findings from AIS into CRAO. Combining neuroprotection and thrombolysis can extend the therapeutic window for NA-CRAO treatment and potentially improve outcomes. Experimented neuroprotection for CRAO includes Angiopoietin (Comp Ang1), KUS 121, Gene therapy (XIAP), and hypothermia. Efforts in the field of neuroprotection for NA-CRAO should focus on better imaging to delineate the penumbra after an acute episode of NA-CRAO (using a combination of high-definition optical coherence angiography and electrophysiology). Also, research should explore details of pathophysiologic mechanisms involved in NA-CRAO, allowing for further neuroprotective intervention, and closing the gap between preclinical and clinical neuroprotection.

Tractional Retinal Detachment: Prevalence and Causes in Nigerians.

Aim: To determine the causes of tractional retinal detachment (TRD) in Nigerians. Materials and Methods: A prospective, multicentre study evaluating eyes diagnosed to have TRD. History, clinical examination (including visual acuity, intraocular pressure measurement, anterior segment examination and dilated fundoscopy) and systemic evaluation (including previous diagnosis of diabetes, hypertension, sickle-cell disease and others) were performed in TRD eyes out of a cohort of retinal detachment eyes. Results: The prevalence of TRD of the 237 patients diagnosed with RD within a one-year study period was 25.7% (61 patients). Eighty eyes were diagnosed with TRD. Thirty-eight eyes of nineteen patients (31%) were bilateral, and 42 (69%) were unilateral. There were 38 male patients (62.3%) and 23 female patients (37.7%). The mean age was 52.3 ± 12.7 years (11-69 years). 88.5% of all TRD patients had an associated systemic disease, diabetes being the most common disease in 88.8% of them. Proliferative diabetic retinopathy was the most common cause of TRD (77.5%) and the most common cause of bilateral TRD. Both trauma and proliferative sickle-cell retinopathy occurred in 3.8% of the eyes. 68.8% of TRD eyes were blind at the presentation. However, the causes of TRD did not show any significant association with blindness (P = 0.819). Conclusion: Proliferative diabetic retinopathy poses a significant threat to vision, being the most common cause of TRD. Early detection and treatment of proliferative retinopathy in diabetes and sickle-cell disease, and trauma prevention will significantly reduce the burden of blindness due to TRD.

Exudative Retinal Detachment in Nigerians: Demographics and Causes.

Background: Exudative retinal detachment (ERD) is a rare type of retinal detachment (RD), and information on its causes and presentation in Nigerians and Black Africans is scarce. Aim: To report the prevalence, vision at presentation, and causes of ERD in a cohort of RD patients. Materials and Methods: A prospective, multicentre, hospital-based study. We examined consecutive eyes diagnosed with ERD in ophthalmic patients seen within 1 year in four ophthalmic hospitals in Nigeria. The patients had a complete eye examination, including visual acuity, intraocular pressure measurement, slit lamp examination of the anterior segment, dilated fundus examination, and other ancillary investigations. Statistical analysis was done using SPSS version 22.0. Results: Nine out of 237 patients were diagnosed with ERD, giving a hospital-based prevalence of 3.8% of RDs. The mean age of patients was 45.8 ± 21.6 years (6 months-80 years), male:female = 2:1. ERD was bilateral in one patient and unilateral in eight patients. There was no gender association (P = 0.84), but systemic disease was associated with a risk of ERD (P = 0.001). Five out of 9 (55.6%) patients had an associated systemic disease. The systemic diseases include two patients (40%) who had chronic renal failure, two patients (40%) who had systemic hypertension, and one patient (10%) who had lung cancer. Other ocular causes of ERD include post endophthalmitis, coats disease, and age-related macular degeneration in one eye each. 80 % of eyes were blind at presentation. Conclusion: ERD is a rare form of RD in Nigerians and is associated with systemic diseases. There are inflammatory, neoplastic, vascular, and degenerative causes of ERD. At presentation, most eyes are blind. Early presentation will be beneficial in salvaging vision. Also, awareness of the occurrence and causes of ERD should be created amongst eye care practitioners.

Clinical presentation and macular morphology in retinitis pigmentosa patients.

Background: Optical coherence tomography (OCT) is a noninvasive, frequently used imaging technology that enables detailed viewing of retina anatomy. It is used to monitor disease progression in retinitis pigmentosa (RP) eyes, including detecting changes in retinal thickness. Purpose: The purpose of the study is to determine the clinical presentation and macular morphology in RP eyes using OCT imaging. Methods: A retrospective review of case records and OCT scans in eyes diagnosed with RP in two ophthalmic clinics in Nigeria. Biodata, Snellen best-corrected visual acuity (BCVA), intraocular pressure (IOP), vertical cup-to-disc ratio (VCDR), and presence of maculopathy were determined. Data were analyzed using IBM SPSS version 22.0 (IBM Corp. Armonk, NY, USA). Results: Fifty-five eyes of 28 patients (18 males and 10 females), with a mean age of 47.16 ± 15.56 years (22-77 years), were studied. 40-49 years was the most frequent age group, 28.6%. Severe visual impairment occurred in 22% of eyes and myopia in 32%. Twenty-nine percent had undergone cataract surgery or had a significant cataract. The mean IOP was 11 mmHg, and the mean VCDR was 0.46. On OCT examination, macular atrophy was the most common finding in 74.5% of eyes, epiretinal membrane in 16.3%, cystoid macular edema in 7.3%, vitreomacular adhesion in 5.4%, and vitreomacular traction in 1.8%. There was no association between macular morphology, macular thickness, and BCVA (P = 0.155, P = 0.424). Conclusion: OCT provides information on macula structure in RP eyes. About 14.5% of eyes had a normal macula, while 85.5% had a maculopathy, confirming that RP eyes have a higher rate of maculopathy than non RP eyes. OCT evaluation of an RP eye should be a standard workup for the early detection of such maculopathy and monitoring for disease progression.

Résumé Contexte: La tomographie par cohérence optique (OCT) est une technologie d'imagerie non invasive fréquemment utilisée qui permet une visualisation détaillée de l'anatomie de la rétine. Elle est utilisée pour surveiller la progression de la maladie dans les yeux de la rétinite pigmentaire (RP), y compris la détection des changements dans l'épaisseur de la rétine. Objectif: Le but de l'étude était de déterminer la présentation clinique et la morphologie maculaire des yeux présentant une RP à l'aide de l'imagerie OCT. Méthodes: Une revue rétrospective des dossiers de cas et des scans OCT dans les yeux diagnostiqués de RP a été réalisée dans deux cliniques ophtalmologiques au Nigeria. Les données biographiques, la meilleure acuité visuelle corrigée de Snellen (MAVC), la pression intraoculaire (PIO), le rapport cup-sur-disc vertical (RCDV) et la présence de maculopathie ont été déterminés. Les données ont été analysées à l'aide d'IBM SPSS version 22.0 (IBM Corp. Armonk, NY, USA). Résultats: Cinquante-cinq yeux de 28 patients (18 hommes et 10 femmes), âgés en moyenne de 47,16 ± 15,56 ans (22­77 ans) ont été étudiés. Les 40 à 49 ans étaient la tranche d'âge la plus fréquente à 28,6 %. Une déficience visuelle sévère est survenue dans 22 % des yeux et une myopie dans 32 %. Vingt-neuf pour cent avaient subi une chirurgie de la cataracte ou avaient une cataracte importante. La PIO moyenne était de 11 mmHg et le RCDV moyen était de 0,46. À l'examen OCT, on retrouvait l'atrophie maculaire prédominante dans 74,5 % des yeux, la membrane épirétinienne (16,3 %), l'œdème maculaire cystoïde (7,3 %), l'adhérence vitréomaculaire (5,4 %) et la traction vitréomaculaire (1,8 %). Il n'y avait aucune association entre la morphologie maculaire, l'épaisseur maculaire et la MAVC (P = 0,155, P = 0,424). Conclusion: l'OCT fournit des informations sur la structure de la macula dans la RP. Environ 14,5% des yeux avaient une macula normale contre 85,5% avec maculopathie, confirmant ainsi que les yeux avec RP ont un taux de maculopathie plus élevé que les yeux sans RP. L'évaluation OCT d'un œil avec RP devrait être un bilan standard pour la détection précoce de maculopathie et la surveillance de la progression de la maladie. Mots-clés: Membrane épirétinienne, dystrophie rétinienne héréditaire, atrophie maculaire, œdème maculaire, tomographie par cohérence optique, rétinite pigmentaire.

Choroidal thickness and effect of sex and age in Africans.

Purpose: The purpose of the study is to evaluate choroidal thickness (CT) and the effect of age and gender in healthy Africans using enhanced depth imaging spectral-domain optical coherence tomography. Materials and Methods: In 172 eyes of 88 volunteers, the CT in the central subfoveal (CSF) area and at 2.5 mm superior, inferior, nasal, and temporal quadrants was measured. Four eyes were excluded due to poor image quality and image decentration. Simple linear regression was used to measure the effect of age on CT, and statistical analysis was done using IBM SPSS Statistics version 22. Results: The were 88 male and 84 female eyes, aged 30-80 years. The mean CT was CSF 265.44 ± 6.2 µm; inferior 256.19 ± 70.6 µm; superior 249.92 ± 76.2 µm; temporal 235.51 ± 70.3 µm; and nasal 199.53 ± 69.8 µm. The choroid was thickest in the CSF > Inferior > Superior > Temporal, and the nasal quadrant was thinnest in all age groups. There was a considerable decrease in the CSF with increasing age (P < 0.001). CT in males and females was similar since the difference in mean CSF CT between the genders was 2.085 µm (P = 0.858). Menopausal females had thinner CSF CT compared to premenopausal females (P < 0.001), but this was due to the aging effect. Conclusion: CT decreases significantly with increasing age but shows no gender difference in Africans. A comparison of CT studies from other ethnic nationalities shows some similarity with CT in Africans, suggesting that CT findings from other ethnic groups can be extrapolated to Africans.

Résumé Objectif: Évaluer l'épaisseur choroïdienne (CT) et l'effet de l'âge et du sexe chez les Africains noirs en bonne santé à l'aide de la tomographie par cohérence optique dans le domaine spectral (SD-OCT) par imagerie en profondeur améliorée (EDI). Matériel et méthodes: Dans 172 yeux de 88 volontaires, la tomodensitométrie dans la zone sous-fovéale centrale (LCR) et à 2,5 mm quadrants supérieur, inférieur, nasal et temporal a été mesurée. Quatre yeux ont été exclus en raison de la mauvaise qualité de l'image et de la décentration de l'image. Une régression linéaire simple a été utilisée pour mesurer l'effet de l'âge sur la TDM, et l'analyse statistique a été effectuée à l'aide de la version 22 d'IBM SPSS Statistics. Résultats: Il y avait quatre-vingt-huit yeux masculins et 84 yeux féminins, âgés de 30 à 80 ans. La TDM moyenne était de 265,44 ± 6,2 µm ; inférieure 256,19±70,6 µm; supérieur 249,92 ±76,2 µm; temporal 235,51 ±70,3 µm; et nasale 199,53 ±69,8 µm. La choroïde était la plus épaisse dans le LCR > inférieure > supérieure > temporal, et le quadrant nasal était le plus mince dans tous les groupes d'âge. Il y a eu une diminution considérable du LCR avec l'âge (p < 0,001). La TDM chez les hommes et les femmes était similaire puisque la différence de TDM moyenne du LCR entre les sexes était de 2,085 µm (p = 0,858). Les femmes ménopausées avaient une TDM du LCR plus mince que les femmes préménopausées (p<0,001), mais cela était dû à l'effet du vieillissement. Conclusion: CT diminue significativement avec l'âge, mais ne montre aucune différence entre les sexes chez les Africains noirs. Une comparaison des études CT d'autres nationalités ethniques montre une certaine similitude avec CT chez les Africains, ce qui suggère que les résultats CT d'autres groupes ethniques peuvent être extrapolés aux Africains noirs. Mots-clés: Africains, vieillissement, choroïde, épaisseur choroïdienne, tomographie par cohérence optique, rétine.

Secondary Macular Holes Post Pars Plana Vitrectomy.

Purpose: To report incidence, clinical presentation, and treatment outcome of full-thickness macular hole (FTMHs) diagnosed post pars plana vitrectomy. Methods: We retrospectively reviewed the demographics, best-corrected visual acuity (BCVA), indication for the primary vitrectomy, time to diagnose the secondary FTMH, optical coherence tomographic (OCT) appearance, and treatment outcome of FTMHs, occurring after vitrectomy performed between January 2019 and December 2020. Results: Six of 523 vitrectomized eyes developed FTMHs, an incidence of 1.1%. There were five females and one male, mean age of 56.5 years (range 37-85). The indication for primary vitrectomy was rhegmatogenous retinal detachment (RRD) in three eyes, one eye each for sub internal limiting membrane hemorrhage from a ruptured macroaneurysm, vitreous hemorrhage from polypoidal choroidal vasculopathy (PCV), and pre-insertion of Ahmed glaucoma drainage device (GDD). FTMHs occurred within one week to three months after vitrectomy (time from primary vitrectomy to the identification of the secondary MH was a mean of 1.03 months). Mean BCVA in all six MH eyes was log MAR 0.9 (Snellen: 6/54). Anatomical closure was achieved after one surgery in three eyes, two surgeries in 1 eye, after photodynamic therapy (PDT) in the PCV eye, and one patient declined surgery. The mean BCVA in the four surgically closed MH eyes improved marginally from log MAR 0.82 (Snellen: 6/38) to log MAR 0.72 (Snellen: 6/30), mean follow-up 7.6 months. Conclusion: Post-vitrectomy FTMH is rare, and RRD was the commonest indication for initial vitrectomy. We observed that all secondary MHs were closed successfully using the inverted internal limiting membrane (ILM) flap technique with limited improvement in vision. The visual outcome of these secondary MHs trails behind that of idiopathic MHs.

Burden and Presentation of Age-Related Macular Degeneration among Nigerians.

PURPOSE: Age-related macular degeneration (AMD) is a leading cause of visual impairment worldwide, and its prevalence may also be on the increase in Nigeria. The purpose of this study is to ascertain the burden and pattern of presentation of AMD in a developing country. METHODS: We conducted a multicenter, prospective study from January to December 2018. Biodata and history of systemic disease were obtained from consecutive patients presenting at four collaborating retina clinics and diagnosed with a retina disease after dilated fundus examination and ocular investigations such as fundus photography, fluorescein angiography, and optical coherence tomography. All eyes diagnosed to have wet and dry AMD were used for the study analysis. RESULTS: Out of 8614 patients, 156 eyes of 78 patients were diagnosed with AMD. The hospital-based prevalence for AMD was 0.91%. The mean age at presentation was 67.9 ± 9.2 years, ranging from 44 to 95 years. A majority (75.6%) of patients were between 60 and 79 years, 53.8% were females. Thirty-two eyes (20.5%) had wet AMD, while 124 eyes (79.5%) had dry AMD. Sixty-one eyes (39.1%) had moderate visual impairment (<6/18-6/60); 58 eyes (37.2%) had normal vision (6/18 and better); while 27 eyes (17.3%) were blind, and ten eyes (6.4%) had severe visual impairment. CONCLUSION: AMD contributes to the burden of visual impairment and blindness in the elderly Nigerian. In Nigeria, AMD occurs more in females and most common between the ages of 60 and 79. Dry AMD is four times more common than wet AMD. About 24% of eyes have severe visual impairment or blindness, while about a third each have a moderate visual impairment and normal vision. Increasing awareness of AMD among the at-risk population will be beneficial in achieving early diagnosis and treatment.

Vitrectomy and manipulation of intraocular and arterial pressures for the treatment of nonarteritic central retinal artery occlusion.

The purpose of this study is to describe a surgical technique and report the functional outcome of treating nonarteritic central retinal artery occlusion (CRAO) in 2 eyes of two consecutive male patients. Two males (A) and (B) presented 6 days and few hours, respectively, after symptom onset with the clinical features typical of CRAO, including sudden severe deterioration of vision to counting fingers and a cherry-red spot in the left and right fovea, respectively. While A had been on recent treatment for hypertension and hyperlipidemia, B had no significant medical history. Both patients underwent surgery, A, 9 days, and B, <15 h after symptom onset. Surgery involved a vitrectomy, lowering of intraocular pressure (<3 mmHg), and gradual increase of arterial pressure to 165/100 mmHg (through the slow injection of intravenous adrenaline). Intraoperatively, this resulted in immediate perfusion and visible dilation of the blood-filled central retinal artery (CRA) and retinal arteriolar network and dilatation of the central retinal vein. The final vision settled to 6/60 in A and 6/36+1 in B. Although preoperative macular infarction persisted in both eyes as demonstrated by optical coherence tomography angiography, both patients claim a convincing subjective visual benefit. The procedure appeared to have positively changed the natural history of the disease in both eyes. Vitrectomy with the manipulation of intraocular and arterial pressures significantly increases ocular perfusion along the entire CRA, which can dislodge CRA thrombo-emboli and has the potential to restore retinal perfusion and improve visual outcome if undertaken before irreversible retina damage. This is a relatively straightforward technique and should join the list of surgical techniques for treating CRAO.

Autologous Neurosensory Retinal Transplantation: A Report of Three Cases.

PURPOSE: To present the anatomical and functional outcomes of autologous surgical transplantation of a free neurosensory retinal graft in three cases of recurrent and chronic full thickness macular hole (MH). METHODS: A retrospective case series, reporting the profile, preoperative presentation, surgical technique, and postoperative outcome of three consecutive eyes of three patients who had autologous retina transplantation (ART) surgery for recurrent and chronic MHs, and had a minimum of six months follow-up. The technique involved excision of a free neurosensory graft after laser demarcation of the harvest site. The graft was slid under perfluorocarbon liquid (PFCL) into the MH. A five-day tamponade with PFCL was used to secure the graft within the MH and then exchanged with air. RESULTS: The patients were one female and two males aged 60, 44, and 67 years, respectively. All eyes had successful surgery. Postoperative vision improved from 6/36 to 6/18 in patient 1 and remained same as preoperative vision in the other two eyes. No eye lost vision postoperatively. The main complication of surgery was occurrence of retinal and vitreous hemorrhage in one eye (this did not appear to jeopardize the outcome) and retraction of graft tissue in two eyes. CONCLUSION: ART appears to be a safe and effective treatment for difficult MHs. Our results are comparable to previous studies. Short-term use of PFCL can be useful to secure the graft within the MH. Methods of improving visual function should be the focus of further research in this promising area.

Post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis treated with clear lens extraction in an African.

PURPOSE: To report the successful treatment of post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis managed with a clear lens extraction and posterior capsulectomy. OBSERVATION: A 34-year-old female African, known SC hemoglobinopathy patient, presented with bilateral blur in vision and floaters of a week duration; worse in her right eye. Her visual acuity was right eye 6/9 (20/30) and left eye 6/6 (20/20). Her anterior segment examination was normal in both eyes. On fundus examination, she had a right eye vitreous hemorrhage and bilateral active Sea-fan neovascular proliferation in the retina periphery. Following the administration of bilateral simultaneous intravitreal bevacizumab, she presented 4 days later with a right eye infective endophthalmitis. She suffered multiple recurrences despite adequate treatment, including a vitrectomy with silicone oil injection. Multiple microbiological assessment of intraocular extracts confirmed persistent Burkholderia cepacia infection. A wide ring-shaped opaque plaque was noticed on the posterior capsule of her clear lens. A decision was taken to perform a lensectomy and posterior capsulectomy. This resulted in immediate resolution of hypopyon and all intraocular inflammation. Vision improved from Hand Motion to 6/18 (20/60). CONCLUSION AND IMPORTANCE: This report suggests than in some cases of recurrent, difficult to treat, Burkholderia cepacia endophthalmitis, since the organism may have colonized the posterior lens capsule, the eye and vision can be salvaged by timely removal of a clear lens and capsulectomy. Clear lens removal has not been previously reported for treating recurrent Burkholderia cepacia endophthalmitis.

Natural History of a Large Bubble of Migratory Submacular Perfluorocarbon.

PURPOSE: To report the natural history of a large bubble of perfluorocarbon liquid (PFCL) in a parafoveal subretinal position which was monitored using optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). The bubble of PFCL was removed when it migrated to the subfoveal position; outcome after removal is also reported. OBSERVATION: A 62-year-old male, after repair of a giant retinal tear (GRT) detachment, regained Snellen acuity of 6/18 from preoperative vision of CF at 1 meter. A large bubble of subretinal PFCL was in the superior parafoveal area. For 18 months, the PFCL bubble was monitored using OCT and OCTA until it migrated into the subfoveal position after 22 months, coinciding with a decrease in vision to 6/36. Surgical removal of subfoveal PFCL was performed. This involved detachment of the foveomacular, epiretinal membrane (ERM) peel (complicated by iatrogenic macular hole (MH) formation), intravitreal injection of PFCL to displace subretinal PFCL to the periphery, creation of an inverted internal limiting membrane (ILM) flap to repair the MH and air exchange. Postoperative vision remained 6/36. His postoperative OCT showed significant loss of subfoveal outer retina. On OCTA, the superficial and deep vascular plexi and choriocapillaris appeared to be intact after the removal of the subfoveal PFCL. CONCLUSION AND IMPORTANCE: This report suggests that a large superior parafoveal bubble of PFCL may take as much as 18 months to migrate to the subfoveal position. Before this time, vision does not appear to be affected, though macular edema is present. Therefore, removal of the PFCL can be delayed until a convenient time for surgeon and patient. A large bubble of parafoveal PFCL ought to be removed before migrating to a subfoveal position and vision loss, since its removal will reduce the risk of outer retina loss.

Profile, Visual Presentation and Burden of Retinal Diseases Seen in Ophthalmic Clinics in Sub-Saharan Africa.

PURPOSE: To determine the burden of retinal diseases and the degree of visual impairment associated with each disease, amongst Nigerians. PATIENTS AND METHODS: This was a hospital-based multicenter, prospective, cross-sectional, non-comparative study conducted from January to December 2018. Data was obtained from consecutive patients with a retinal diagnosis presenting at the general ophthalmic and specialty retina clinics in four hospitals (three public, and one private teaching eye department) in Nigeria. Biodata, visual acuity and refraction, intraocular pressure, findings on dilated retinal examination, diagnosis and systemic diseases were noted. Degree of monocular and bilateral visual loss associated with each diagnosed retinal disease was summarized and p value was calculated using chi-square test. P < 0.05 was considered significant. RESULTS: Eight hundred seventy-six of 8614 patients had a retinal diagnosis; establishing a hospital-based retinal disease prevalence of 9.8%. Male:female ratio was 1.1:1. The mean age of study patients was 49.97 (standard deviation 17.64 years). Mean symptom duration was 21.63 months (standard deviation 41.94). The mean intraocular pressure was 13.87 mmHg. Forty-three different retinal diseases were diagnosed. The most common was retinal complications of diabetes, i.e., diabetic retinopathy (DR) alone, diabetic macular edema (DME) alone and a combination of DR and DME, which accounted for 13.7%, 5.6% and 9.3%, respectively (contributed 28.6% of the entire diagnosis). This was followed by retinal detachment (RD), in 219 eyes (15.4%), dry age-related macular degeneration (AMD) in 124 eyes (8.7%). Nearly half of the eyes were blind or severely visually impaired. Blindness occurred in 34.1% of eyes; severe visual impairment in 8.2% of eyes and 29.7% had normal vision. There were 469 patients who had systemic diseases. The common systemic diseases were hypertension in 169 patients (19.3% of the total number of patients), hypertension and diabetes in 156 patients (18%), and diabetes alone in 98 patients (11.1%). Sickle cell disease was present in 1.5%. CONCLUSION: There is need to invest in infrastructure, local training and development of systems for early detection and treatment of several retinal diseases in sub-Saharan Africa; DR and DME having the largest burden. Collaborative physician care and management of hypertension and diabetes could significantly reduce the burden of DR and DME.

Removal of adult subconjunctival Loa loa amongst urban dwellers in Nigeria.

Loiasis is a neglected tropical disease caused by infection with the filarial parasite Loa loa. It is a disease considered by many to be benign. Several reports of trans border importation of the Loa loa worm amongst immigrants and visitors from endemic regions of the world exist. In most cases an adult subconjunctival worm is removed from the patient. An interventional case series is reported and examines the practice of removal of subconjunctival adult Loa loa worms amongst urban dwellers in Nigeria. Four cases of ocular loiasis seen amongst urban dwellers in Nigeria exemplify the different presentations and removal methods of the subconjunctival adult worm. There were 2 males and 2 females aged 35years, 23years, 25years and 30years respectively. Each patient gave a history of having been raised in a rural community in childhood years, during which they were exposed to streams and muddy farm land; and then migrated to the urban community in later years. They all present with the finding of a subconjunctival adult worm, which was successfully removed and identified to be Loa loa. There are more urban dwellers in Nigeria who present with symptoms of foreign body sensation that may be related to the manifestation of a subconjunctival worm and are not recognized. This is because the emphasis on this disease has erstwhile been on the rural, village dwellers and not on urban dwellers. Eye care practitioners working in urban centers need to be aware of the possibility of this presentation, and be ready to remove any subconjunctival worm when it presents.

Human resource development for Vision 2020 in developing countries: a change from absolute numbers.

PURPOSE: To critically review the numbers, distribution, staff mix, and productivity of eye care workers (ECW) in Kwara State, north central Nigeria. METHODS: A cross-sectional descriptive survey of all ECW identified from all eye care facilities in July 2008 was carried out using a structured questionnaire. Output data on cataract surgery of each institution were also collected and data analyzed using SPSS 16. RESULTS: A total of 157 ECW comprising 8 ophthalmologists, 4 diplomates, 16 residents training ophthalmologists, 96 mid-level ophthalmic personnel (67 ophthalmic nurses, 3 optometrists, and 26 others), and 33 administrative and supporting staff were available to a population of 2.37 million. Ophthalmologist to population ratio was 1:300,000, optometrist 1:790,000, and ophthalmic nurses 1:35,000. Eighty percent of ECW and institutions are located in the state capital. There were no orthoptists, low vision specialists, counselors, or cataract finders, while optometrists, managers, and primary ECW were inadequate. The staff mix was 1 surgeon to 12 other ECW and an average of 182 cataract surgeries per surgeon per year. CONCLUSIONS: Emphasis should shift to team building and ensuring available workers perform optimally rather than meeting the absolute numbers of some cadre, which does not guarantee improved output. Issues of equitable distribution, appropriate staff mix, filling identified gaps in human resources, and addressing poor service uptake should be the focus to reach the goals of Vision 2020: The Right to Sight.