Ophthalmology training in sub-Saharan Africa: a scoping review.

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.

Survey of ophthalmologists-in-training in Eastern, Central and Southern Africa: A regional focus on ophthalmic surgical education.

Background: There are 2.7 ophthalmologists per million population in sub-Saharan Africa, and a need to train more. We sought to analyse current surgical training practice and experience of ophthalmologists to inform planning of training in Eastern, Central and Southern Africa. Methods: This was a cross-sectional survey. Potential participants included all current trainee and recent graduate ophthalmologists in the Eastern, Central and Southern African region. A link to a web-based questionnaire was sent to all heads of eye departments and training programme directors of ophthalmology training institutions in Eastern, Central and Southern Africa, who forwarded to all their trainees and recent graduates. Main outcome measures were quantitative and qualitative survey responses. Results: Responses were obtained from 124 (52%) trainees in the region. Overall level of satisfaction with ophthalmology training programmes was rated as 'somewhat satisfied' or 'very satisfied' by 72%. Most frequent intended career choice was general ophthalmology, with >75% planning to work in their home country post-graduation. A quarter stated a desire to mainly work in private practice. Only 28% of junior (first and second year) trainees felt surgically confident in manual small incision cataract surgery (SICS); this increased to 84% among senior trainees and recent graduates. The median number of cataract surgeries performed by junior trainees was zero. 57% of senior trainees were confident in performing an anterior vitrectomy. Only 29% of senior trainees and 64% of recent graduates were confident in trabeculectomy. The mean number of cataract procedures performed by senior trainees was 84 SICS (median 58) and 101 phacoemulsification (median 0). Conclusion: Satisfaction with post-graduate ophthalmology training in the region was fair. Most junior trainees experience limited cataract surgical training in the first two years. Focused efforts on certain aspects of surgical education should be made to ensure adequate opportunities are offered earlier on in ophthalmology training.

Developing clinical cancer genetics services in resource-limited countries: the case of retinoblastoma in Kenya.

BACKGROUND/AIMS: Clinical cancer genetics is an integral part of cancer control and management, yet its development as an essential medical service has been hindered in many low-and-middle-income countries. We report our experiences in developing a clinical cancer genetics service for retinoblastoma in Kenya. METHODS: A genetics task force was created from within the membership of the existing Kenyan National Retinoblastoma Strategy group. The task force engaged in multiple in-person and telephone discussions, delineating experiences, opinions and suggestions for an evidence-based, culturally sensitive retinoblastoma genetics service. Discussions were recorded and thematically categorized to develop a strategy for the design and implementation of a national retinoblastoma clinical genetics service. RESULTS: Discussion among the retinoblastoma genetics task force supported the development of a comprehensive genetics service that rests on 3 pillars: (1) patient and family counseling, (2) community involvement, and (3) medical education. CONCLUSIONS: A coordinated national retinoblastoma genetics task force led to the creation of a unique and relevant approach to delivering comprehensive and accurate genetic care to Kenyan retinoblastoma patients. The task force aims to stimulate innovative approaches in cancer genetics research, education and knowledge translation, taking advantage of unique opportunities offered in the African context.

The epidemiology of low vision and blindness associated with trichiasis in southern Sudan.

BACKGROUND: We investigated vision status associated with trachomatous trichiasis (TT) and explored age-sex patterns of low vision and blindness associated with trichiasis in Mankien district of southern Sudan where trachoma prevention and trichiasis surgery were absent. METHODS: A population based survey was undertaken and eligible persons underwent eye examination. Visual acuity (VA) was tested using Snellen E chart and persons with TT identified. Vision status was defined using the WHO categories of visual impairment based on presenting VA: normal vision (VA > or = 6/18 in better eye); low vision (VA < 6/18 but > or = 3/60 in better eye); and blindness (VA < 3/60 in better eye). An ordinal logistic regression model was fitted and age/sex specific distribution of vision status predicted. RESULTS: Overall 341/3,567 persons examined had any TT. Analysis was based on 319 persons, 22 persons were excluded: 20 had both TT and cataract; and 2 had missing VA data. Of the 319 persons: 158(49.5%) had trichiasis-related corneal opacity (CO); bilateral TT and bilateral CO were found in 251(78.7%) and 110 (34.5%), respectively; 146 (45.8%) had low vision or blindness; the ratio of low vision to blindness was 3.2:1; and no sex differences were observed. In our model the predicted distribution of vision status was: normal vision, 53.9% (95% CI 50.9-56.9); low vision, 35.3% (95% CI 33.3-37.2); and blindness, 10.9% (95% CI 9.7-12.0). CONCLUSION: We have reported severe trichiasis and high prevalence of vision loss among persons with trichiasis. Our survey showed that almost 1 in 20 of the entire population suffered low vision or blindness associated with trachoma. The need for trichiasis surgery, trachoma prevention services, and rehabilitation of the blind is acute.

Prevalence of risk factors and severity of active trachoma in southern Sudan: an ordinal analysis.

We aimed to investigate prevalence of potential risk factors, and associations between risk factors and active trachoma in southern Sudan. Surveys were undertaken in ten sites and children aged 1-9 years examined for trachoma. Risk factors were assessed through interviews and observations. Using ordinal logistic regression, associations between severity of active trachoma and risk factors were explored. Trachomatous inflammation-intense (TI) was considered more severe than trachomatous inflammation-follicular (TF). A total of 7,418 children were included in the analysis. Risk factors and prevalences were unclean face, 52.3%; face washed less than twice daily, 50.8%; water collection > 30 minutes, 38.1%; absence of latrines, 95.4%; garbage disposal within 20 m, 74.4%; cattle ownership, 69.2%; and flies, 83.3%. After adjusting for age and sex, unclean face, less frequent face washing, cattle ownership, and increasing fly density were found to be independently associated with severity of active trachoma. Our study suggests that facial hygiene and environmental sanitation are priority trachoma-control interventions in southern Sudan.

Prevalence and causes of blindness and low vision in southern Sudan.

BACKGROUND: Blindness and low vision are thought to be common in southern Sudan. However, the magnitude and geographical distribution are largely unknown. We aimed to estimate the prevalence of blindness and low vision, identify the main causes of blindness and low vision, and estimate targets for blindness prevention programs in Mankien payam (district), southern Sudan. METHODS AND FINDINGS: A cross-sectional survey of the population aged 5 y and above was conducted in May 2005 using a two-stage cluster random sampling with probability proportional to size. The Snellen E chart was used to test visual acuity, and participants also underwent basic eye examination. Vision status was defined using World Health Organization categories of visual impairment based on presenting visual acuity (VA). A total of 2,954 persons were enumerated and 2,499 (84.6%) examined. Prevalence of blindness (presenting VA of less than 3/60 in the better eye) was 4.1% (95% confidence interval [CI], 3.4-4.8); prevalence of low vision (presenting VA of at least 3/60 but less than 6/18 [corrected] in the better eye) was 7.7% (95% CI, 6.7-8.7); whereas prevalence of monocular visual impairment (presenting VA of at least 6/18 [corrected] in better eye and VA of less than 6/18 [corrected] in other eye) was 4.4% (95% CI, 3.6-5.3). The main causes of blindness were considered to be cataract (41.2%) and trachoma (35.3%), whereas low vision was mainly caused by trachoma (58.1%) and cataract (29.3%). It is estimated that in Mankien payam 1,154 persons aged 5 y and above (lower and upper bounds = 782-1,799) are blind, and 2,291 persons (lower and upper bounds = 1,820-2,898) have low vision. CONCLUSIONS: Blindness is a serious public health problem in Mankien, and there is urgent need to implement comprehensive blindness prevention programs. Further surveys are essential to confirm these tragic findings and estimate prevalence of blindness and low vision in the entire region of southern Sudan in order to facilitate planning of VISION 2020 objectives.

Blinding trachoma in postconflict southern Sudan.

BACKGROUND: Trachoma is a leading cause of preventable blindness. Reports from eye surgery camps and anecdotal data indicated that blinding trachoma is a serious cause of visual impairment in Mankien payam (district) of southern Sudan. We conducted this study to estimate the prevalence of trachoma, estimate targets for interventions, and establish a baseline for monitoring and evaluation. METHODS AND FINDINGS: A population-based cross-sectional survey was conducted in May 2005. A two-stage cluster random sampling with probability proportional to size was used to select the sample population. Participants were examined for trachoma by experienced graders using the World Health Organization simplified grading scheme. A total of 3,567 persons were examined (89.7% of those enumerated) of whom 2,017 were children aged less than 15 y and 1,550 were aged 15 y and above. Prevalence of signs of active trachoma in children aged 1-9 y was: trachomatous inflammation-follicular (TF) = 57.5% (95% confidence interval [CI], 54.5%-60.4%); trachomatous inflammation-intense (TI) = 39.8% (95% CI, 36.3%-43.5%); and TF and/or TI (active trachoma) = 63.3% (95% CI, 60.1%-66.4%). Prevalence of trachomatous trichiasis was 9.6% (95% CI, 8.4%-10.9%) in all ages, 2.3% (95% CI, 1.6%-3.2%) in children aged under 15 y, and 19.2% (95% CI, 17.0%-21.7%) in adults. Men were equally affected by trichiasis as women: odds ratio = 1.09 (95% CI, 0.81%-1.47%). It is estimated that there are up to 5,344 persons requiring trichiasis surgery in Mankien payam. CONCLUSIONS: Trachoma is a serious public health problem in Mankien, and the high prevalence of trichiasis in children underscores the severity of blinding trachoma. There is an urgent need to implement the surgery, antibiotics, facial cleanliness, and environmental change (SAFE) strategy for trachoma control in Mankien payam, and the end of the 21-y civil war affords an opportunity to do this.

The epidemiology of trachoma in Eastern Equatoria and Upper Nile States, southern Sudan.

OBJECTIVE: Limited surveys and anecdotal data indicate that trachoma is endemic in the states of Eastern Equatoria and Upper Nile in southern Sudan. However, its magnitude and geographical distribution are largely unknown. We conducted surveys to ascertain the prevalence and geographical distribution of trachoma, and to identify targets for control interventions. METHODS: Population-based cross-sectional surveys were conducted in nine sites in southern Sudan between September 2001 and June 2004. Two-stage random cluster sampling with probability proportional to size was used to select the sample. Trachoma grading was done using the WHO simplified grading system. FINDINGS: A total of 17 016 persons were examined, a response rate of 86.1% of the enumerated population. Prevalence of signs of active trachoma in children aged 1-9 years was: TF=53.7% (95% confidence interval (CI)=52.1-55.3); TI=42.7% (95% CI=41.2-44.2); TF and/or TI=64.1% (95% CI=62.5-65.5). Prevalence of trichiasis (TT) in children aged less than 15 years was 1.2% (95% CI=0.9-1.4), while TT prevalence in persons aged 15 years and above was 9.2% (95% CI=8.6-9.9). Women were more likely to have trichiasis compared to men (odds ratio (OR)=1.57; 95% CI=1.34-1.84). Tentative extrapolation to the states of Eastern Equatoria and Upper Nile estimates that there is a backlog of 178,250 (lower and upper bounds=156,027-205,995) persons requiring surgery and the entire population, estimated to be over 3.9 million, is in need of the SAFE strategy to control blinding trachoma. CONCLUSION: Trachoma is a public health problem in all nine of the study sites surveyed. The unusually high prevalence of active trachoma and TT in children points to the severity of the problem. There is urgent need to implement trachoma control interventions in trachoma endemic regions of southern Sudan.