Ocular manifestations in patients with Stevens-Johnson syndrome in Malawi-review of the literature illustrated by clinical cases.

PURPOSE: In Sub-Saharan Africa, manifestations of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are commonly seen in human immunodeficiency virus-infected patients receiving nevirapine-based antiretroviral therapy and/or cotrimoxazole. These patients often face severe ocular complications that lead to moderate to severe visual impairment or blindness. METHODS: Review of the current literature, illustrated by retrospective hospital-based case series: Eight patients at Lions Sight First Eye Hospital, Blantyre, Malawi with severe ocular complications like severe cicatrizing conjunctivitis with symblephara, corneal punctate erosions, corneal vascularization, and corneal ulceration are illustrated after the diagnosis of SJS/TEN. RESULTS: Light perception was reported in six (12 eyes) of them; two patients (4 eyes) had moderate visual impairment (6/36 and 6/18). In one patient, eye problems started after therapy with cotrimoxazole; in seven after therapy, with antiretroviral therapy. CONCLUSION: SJS/TEN in Sub Saharan Africa correlates significantly with moderate visual impairment up to blindness. Early recognition of eye complications and involvement of ophthalmologists in the acute stage, early treatment with local steroids, and close monitoring for up to 6 months after the acute phase are crucial. Severe ocular complications seem to be more severe in dark skin phototype.

Which colours are seen by the patient during cataract surgery? Results of an intraoperative interview.

PURPOSE: To discover what cataract patients see during phacoemulsification and if these light phenomena influence their anxiety levels during surgery. METHODS: In all, 200 patients were interviewed intraoperatively at the Eye Hospital, Petrisberg, Trier, Germany. The quality of the visual experiences was described and if these were pleasant, neutral or unpleasant. Systemic sedation was noted. RESULTS: Among 200 patients (209 eyes): 88 were men (91 eyes; 44%) and 112 were women (118 eyes; 56%). Median age (years): men (71), women (70). Mean operating time was 8 min. 49/209 (23%) were not anxious before and during surgery. 110/209 (52%) were more anxious before than during surgery, 50/209 (24%) were still anxious during surgery, 27/209 (13%) got sedation with midazolam (1-5 mg). Colours in descending order seen: blue, red, pink, yellow, green, purple, turquois, and orange. The most dominant colour combination was red/blue. Structures were seen by 162/209 (78%). Most (61%) intraoperative visual experiences were pleasant, 38% were neutral, and 1% found them transiently unpleasant. Three patients felt blinded by the light of the operating microscope. CONCLUSIONS: The experience of colours and other light phenomena was pleasant for most patients during phacoemulsification under topical anaesthesia. They occur spontaneously when the patient is fixating on the operating light. They are not dependent on the individual or environment. Sedation only in 13%. Direct questioning for visual sensations by the operating surgeon may lead to less need for sedation and lead to less side effects for elderly and multimorbidity people postoperatively. The surgeon can use this knowledge to reassure patients during surgery.

Refractive errors, visual impairment, and the use of low-vision devices in albinism in Malawi.

BACKGROUND: This study focuses on the refractive implications of albinism in Malawi, which is mostly associated with the burden of visual impairment. The main goal was to describe the refractive errors and to analyze whether patients with albinism in Malawi, Sub-Saharan Africa, benefit from refraction. METHODS: Age, sex, refractive data, uncorrected and best-corrected visual acuity (UCVA, BCVA), colour vision, contrast sensitivity, and the prescription of sunglasses and low vision devices were collected for a group of 120 albino individuals with oculocutaneous albinism (OCA). Refractive errors were evaluated objectively and subjectively by retinoscopy, and followed by cycloplegic refraction to reconfirm the results. Best-corrected visual acuity (BCVA) was also assessed binocularly. RESULTS: One hundred and twenty albino subjects were examined, ranging in age from 4 to 25 years (median 12 years), 71 (59 %) boys and 49 (41 %) girls. All exhibited horizontal pendular nystagmus. Mean visual acuity improved from 0.98 (0.33) logMAR to 0.77 (0.15) logMAR after refraction (p < 0.001). The best improvement of VA was achieved in patients with mild to moderate myopia. Patients with albinism who were hyperopic more than +1.5 D hardly improved from refraction. With the rule (WTR) astigmatism was more present (37.5 %) than against the rule (ATR) astigmatism (3.8 %). Patients with astigmatism less than 1.5 D improved in 15/32 of cases (47 %) by 2 lines or more. Patients with astigmatism equal to or more than 1.5 D in any axis improved in 26/54 of cases (48 %) by 2 lines or more. CONCLUSIONS: Refraction improves visual acuity of children with oculocutaneous albinism in a Sub-Saharan African population in Malawi. The mean improvement was 2 logMAR units.

[Retinoblastoma in Malawi: why are admissions too late?]. / Retinoblastom in Malawi : Warum zu späte Einweisung?

BACKGROUND: A total of 82 % of stationary admissions with the diagnosis of retinoblastoma (2009-2011) to the tertiary ophthalmology unit in Blantyre, Malawi (n = 58) presented with advanced stage disease. PATIENTS AND METHODS: In another study in 2012 we sought to identify why children mostly presented in advanced stages of disease and whether the delay was unique to children with cancer. In-depth interviews (IDI) were conducted at the hospital with 40 parents or guardians of children with retinoblastoma, congenital cataract, congenital glaucoma and corneal perforation (10 each). RESULTS: Most delays and delayed admissions occurred at the family (27.5 %, 11 out of 40) and primary health centre levels (30.0 %, 12 out of 40). Lack of money for transport caused delays (15.0 %, 6 out of 40) at all care levels. In contrast, children with painful conditions presented to a health facility within 24 h of onset without any complaints about lack of money for transport. CONCLUSION: Education about retinoblastoma and other non-painful eye diseases could be improved by a poster campaign to both parents and professionals at all medical healthcare levels. Transport for such cases between the various healthcare centers should be provided free of charge. There is room for improvement in initial diagnosis, referral and management within the healthcare service in the tertiary sector.

[Visual experiences during cataract surgery under topical anesthesia]. / Visuelle Erlebnisse unter Kataraktchirurgie in topischer Anästhesie.

BACKGROUND: Cataract patients observe structures, colors and movements during surgery. Is there any pattern to their visual experiences? METHODS: From 2005 to 2011 a total of 20,000 phacoemulsification procedures were performed using topical anesthesia. From these patients we received 45 pictures which had been painted to reflect intraoperative their visual impressions so that approximately 1 out of 500 of the patients painted a picture. A further 98 patients were questioned postoperatively about their intraoperative visual impressions and were shown the 45 pictures. They described their own visual experiences and any similarities with the 45 pictures were documented. RESULTS: All patients were awake and cooperative during surgery. Afterwards they described their visual experiences whereby 36 patients saw mainly blue, 32 red/pink and 27 saw yellow colors. Out of the 45 pictures 30 (67%) were identified as being similar to their own visual images and 10 patients could not describe any postoperative visual phenomena. CONCLUSION: Patients notice optical phenomena during cataract surgery under topical anesthesia with eye drops. Visual images are often similar among patients. The surgeon can use this knowledge to explain these experiences while talking to the patient intraoperatively. This may reassure patients during surgery.

Barriers to uptake of free pediatric cataract surgery in Malawi.

PURPOSE: To examine the demographic, sociocultural and socioeconomic factors that prevent families of cataract blind children from accepting free pediatric cataract surgery in Malawi. METHODS: A total 58 parents of 62 children were recruited into the study. Of these, 53 parents partook in in-depth interviews and focus group discussions after the children were screened and the parents offered free cataract surgery. Overall, 37 parents accepted (acceptors) and 16 parents did not accept (non-acceptors) cataract surgery. All interviews were transcribed and iteratively analyzed. Household economic status was quantified using the Progress out of Poverty Index for Malawi. RESULTS: Acceptors were better off economically (p = 0.13). Understanding of cataract, its causing blindness and impairment, as well as treatment options, by the decision makers in the families was poor. Decision-making involved a complex array of aspects needing consideration before accepting, of which distance to the health facility was a frequently mentioned barrier. Non-acceptors were more likely to come from twice the distance compared to acceptors (p = 0.0098). Non-acceptors were more likely to be peasant (subsistence) farmers than acceptors (p = 0.048). Non-acceptors were more likely to live in a house made of mud bricks with a roof of grass thatch (p = 0.001). There was no significant difference in acceptance rate between educated and non-educated mothers (p = 0.11). Intensive counseling as provided in this project increased the likelihood of accepting surgery. CONCLUSION: Economic hardship and long distances to health facilities decrease acceptance even of free pediatric cataract surgical services, highlighting that just providing surgery free of cost may not be sufficient for the most economically disadvantaged in rural Africa.

[Pediatric cataract surgery in Malawi]. / Chirurgie der kindlichen Katarakt in Malawi.

PURPOSE: The aim of this study was to evaluate the postoperative refractive status after pediatric cataract surgery with age-determined intraocular lens (IOL) implantation in children (age 0-8 years) in Malawi. MATERIALS AND METHODS: Hospital-based retrospective study from January to June 2011 analyzing age, sex, origin, type of cataract surgery, IOL power and postoperative refractive status. In the absence of biometry, IOL powers were chosen according to the child's age and IOL availability. RESULTS: A total of 58 eyes from 33 children were surgically treated of which 25 (76%) were bilateral and 8 (24%) unilateral. Best refractive outcome was achieved with a 25 diopter (D) IOL implanted in children 5-8 years old. None of the children aged 1-7 years achieved the previously calculated target refraction. Results showed a marked myopic variability. The range of postoperative refraction was from - 15 D to + 12.5 D and a large number of children (n=11, 33%) did not attend for follow-up. CONCLUSION: Implanting IOLs according to age groups is not a suitable surgical strategy even in resource-poor settings. Refractive outcomes were too variable with a marked myopic shift. Biometry and keratometry are required in order to undertake pediatric cataract surgery. Developing regional pediatric centres should be a focus of the VISION 2020 initiative.

[Visual impairment and blindness in children in a Malawian school for the blind]. / Sehbehinderung und Blindheit bei Kindern in einer malawischen Blindenschule.

PURPOSE: The aim of this study was to determine the anatomic sites of severe visual impairment and blindness in children in an integrated school for the blind in Malawi, and to compare the results with those of previous Malawian blind school studies. METHODS: Children attending an integrated school for the blind in Malawi were examined in September 2011 using the standard WHO/PBL eye examination record for children with blindness and low vision. Visual acuity [VA] of the better eye was classified using the standardised WHO reporting form. RESULTS: Fifty-five pupils aged 6 to 19 years were examined, 39 (71 %) males, and 16 (29 %) females. Thirty eight (69%) were blind [BL], 8 (15 %) were severely visually impaired [SVI], 8 (15 %) visually impaired [VI], and 1 (1.8 %) was not visually impaired [NVI]. The major anatomic sites of visual loss were optic nerve (16 %) and retina (16 %), followed by lens/cataract (15 %), cornea (11 %) and lesions of the whole globe (11 %), uveal pathologies (6 %) and cortical blindness (2 %). The exact aetiology of VI or BL could not be determined in most children. Albinism accounted for 13 % (7/55) of the visual impairments. 24 % of the cases were considered to be potentially avoidable: refractive amblyopia among pseudophakic patients and corneal scaring. CONCLUSIONS: Optic atrophy, retinal diseases (mostly albinism) and cataracts were the major causes of severe visual impairment and blindness in children in an integrated school for the blind in Malawi. Corneal scarring was now the fourth cause of visual impairment, compared to being the commonest cause 35 years ago. Congenital cataract and its postoperative outcome were the commonest remedial causes of visual impairment.

[Resident training in ophthalmology: can the German system learn from the Malawian one?]. / Weiterbildung zum Facharzt für Augenheilkunde: Kann das deutsche vom malawischen System lernen?

BACKGROUND: Training regulations in Germany and Malawi are compared. One German "Facharztausbildungsordnung" was compared with the syllabus of the Malawian Master of Medicine Degree in Ophthalmology. Germany nowadays has got 7000 ophthalmologists, Malawi nine; population in Germany 80 million, in Malawi 14 million. METHODS: We present a written comparison underlined with one illustrative table. RESULTS: Modalities in resident training are very different. Training period: Germany 60 months, Malawi 48 months. Training manner: In Germany mostly theoretical private studies at hospitals and in private practices. Practical advice comes from senior residents, specialists and consultants. It is qualitywise and quantitatively very different within the country. The Malawian syllabus is very structured according to teaching in theory and practice. There are 250 hours of regular teaching each year. Lecturers are especially paid for teaching from outside the country. Training aim in Germany is mainly a medical ophthalmologist whereas in Malawi it is an ophthalmic surgeon. Exams: Germans take part in an oral exam of 30 minutes after 60 months training. Malawian residents take exams every two years: written, oral, practical. Furthermore they are supposed to take part in exams of the ICO (International Council of Ophthalmology) - until now with 100% success for the first attempts. CONCLUSION: German residents have lots of academic freedom during their training. It is non-uniform. Training aim in Germany is mainly a medical ophthalmologist whereas in Malawi it is an ophthalmic surgeon. The Malawian postgraduate training is uniform with scheduled instructions. That is why quality among candidates can be better compared.

[Rapidly progressing unilateral proptosis in a 6-year-old girl]. / Rasch fortschreitende unilaterale Proptosis bei einem 6-jährigen Mädchen.

This report describes the case of a 6-year-old girl who presented with painless swelling of the right orbit since 4 weeks and moderate proptosis. Tests revealed visual acuity RE 6/6, LE 6/6, normal intraocular pressure (IOP), anterior and posterior segments normal. Ultrasound examination showed multiple lesions in the spleen, normal liver, no abdominal mass and enlarged abdominal lymph nodes. Fine-needle aspirate results were not available at the time of clinical decision-making. In Malawi the treatment for all stages of Burkitt's lymphoma is intravenous cyclophosphamide (40 mg/kg on day 1 and oral cyclophosphamide 60 mg/kg on days 8, 18 and 28). Intrathecal hydrocortisone (12.5 mg) and methotrexate (12.5 mg) are given with each treatment cycle.

[Comparison of the iCare tonometer with the Goldmann tonometer in Malawi]. / Vergleich des iCare-Tonometers mit dem Goldmann-Tonometer in Malawi.

BACKGROUND: The risk for glaucoma is 4-5 times higher in patients from sub-Saharan Africa. Thus, especially in developing countries an easy and effective method for assessing the intraocular pressure (IOP) is needed. METHODOLOGY: In this hospital-based survey 150 eyes were divided into 3 groups concerning the IOP (group I < 16 mmHg, group II 16-23 mmHg and group III > 23 mmHg) and underwent examination with ultrasound pachymetry followed by iCare tonometry (ICT) and Goldmann applanation tonometry (GAT). Agreement of the measurements by two tonometers was assessed with the Bland-Altman method and the influence of the central corneal thickness (CCT) on the ICT measurements was determined. RESULTS: The mean difference between the IOD measured with GAT and ICT was 0.84 ± 2.63 mmHg. The differences were similar in all three groups (0.77-0.97 mmHg), however, the standard deviation in group III (4.04 mmHg) was greater than in groups I (1.98 mmHg) and II (1.79 mmHg). The mean CCT was 513.51 ± 36.22 µm. CONCLUSIONS: The agreement of measurements by GAT and ICT was good for lower IOP values but less accurate in patients with higher IOP values (group III). A dependency of the CCT on the ICT measurements was observed. In comparison to other countries the lowest CCTs were found in Malawian patients.

Minimal cross-infection risk through Icare rebound tonometer probes: a useful tool for IOP-screenings in developing countries.

AIMS: Recently, a new rebound tonometer has been introduced into the market, which might be useful for glaucoma screenings in developing countries. Disposable probes, that are potentially reusable, are recommended by the manufacturer. Our study aimed to address the question of microbial transmission risks if the probes are reused. METHODS: IOP measurements were obtained from 100 healthy eyes. The used probes were inoculated on broth and culture media. In addition, 10 probes were analyzed using environmental scanning electron microscopy in saturated hydrogen-steam atmosphere after usage and wipe disinfection technique with Sekusept 4% solution or Isopropanol 70%. RESULTS: No bacterial or fungal growth could be detected in any of the inoculated agar plates or broth tubes. No microorganisms, clumps of cells, or single intact epithelium cells were detected in any of the probes using environmental scanning electron microscopy. Cell debris was detected on seven probes; three probes were completely free of any residual cell elements. CONCLUSION: Transmission of possibly infective material through reused probes is significantly less than for reusable Goldmann probes if the same sterilization protocols are applied. Re-usage of the probes appears safe and is helpful in avoiding unnecessary costs.

[Global blindness]. / Globale Blindheit.

Worldwide there are 37 million people who are completely blind and another 112 million whose sight is severely restricted. Of all blind people throughout the world, 85% live in developing countries. In three quarters of cases, blindness could be prevented or treated. The VISION 2020 campaign is dedicated to halving the number of people suffering from the diseases leading to blindness by means of disease control, training of specialist ophthalmic staff and development of appropriate infrastructures. More effort is needed if these goals are to be met. German ophthalmologists engaged in conservative and surgical treatments who join in and support VISION 2020 will be welcomed.

Antibiotic resistance pattern and visual outcome in experimentally-induced Staphylococcus epidermidis endophthalmitis in a rabbit model.

OBJECTIVE: To study whether the clinical outcome of Staphylococcus epidermidis-induced endophthalmitis in rabbits is related to the antibiotic resistance pattern of the infecting strain. DESIGN: Experimental animal study. PARTICIPANTS: The right eyes of 36 New Zealand white albino rabbits were inoculated with strains of S. epidermidis that displayed various patterns of antibiotic resistance. METHODS: There were 12 rabbits in each of three study groups: fully antibiotic susceptible (FS), partially antibiotic resistant (PR), and multiresistant (MR). Five days after inoculation, the eyes were enucleated and prepared for histologic studies. MAIN OUTCOME MEASURES: Comparisons among the three groups were made based on electroretinographic (ERG) findings, histologic evaluation by a masked observer, and clinical examination. RESULTS: Electroretinographic findings on all rabbits were made by an unmasked observer. At 30 hours after inoculation, the ERG was diminished to 65% of normal for group FS, compared with a flat ERG waveform for groups PR (P < 0.05) and MR (P < 0.05). The ERG waveform was flat for all three groups at 72 hours after inoculation. Histologic evaluation by use of a histologic score revealed that the degree of inflammation and destruction of the retina was less for group FS (n = 10) compared with groups PR (n = 8) and MR (n = 8). Clinical examination revealed that there was a trend of less ocular inflammation for group FS compared with groups PR and MR. CONCLUSIONS: In a rabbit model of S. epidermidis-induced endophthalmitis, antibiotic-susceptible strains caused less inflammation and destruction of the infected retina than did antibiotic-resistant strains.

[Hallermann-Streiff syndrome: should spontaneous resorption of the lens opacity be awaited?]. / Hallermann-Streiff-Syndrom: Sollte die Spontanresorption der getrübten Linse abgewartet werden?

BACKGROUND: As the lens may become absorbed spontaneously extraction of the congenital cataract in the Hallermann-Streiff syndrome is controversial. PATIENT: A male newborn with Hallermann-Streiff syndrome was referred to the eye clinic because of a bilateral mature cataract. The risks of an operation seemed too serious because the eyes were extremely microphthalmic (a-p diameter approx. 10.5 mm). Instead, it was decided to await spontaneous lens absorption which then occurred slowly and completely between the beginning of the 2nd and the end of the 3rd year of life without considerable inflammatory responses. In the meantime, the child has a good orientation and is able to paint and to discriminate colours without optic correction. CONCLUSIONS: The critical investigation of the literature reveals that the frequency of spontaneous lens absorption in the Hallermann-Streiff syndrome is probably (widely) underestimated. It can be estimated with up to 50% (or even more) if patients which were operated on are excluded and if untreated patients are followed up till the end of the 5th year of life. Functional results seem to be quite similar for treated and untreated eyes. Therefore we would recommend to await the spontaneous lens absorption in the Hallermann-Steiff syndrome especially when the cataract is combined with considerable microphthalmia.