Impact of COVID-19 on ophthalmic surgical procedures in sub-Saharan Africa: a multicentre study.

BACKGROUND: The COVID-19 pandemic had a profound impact on healthcare and ophthalmology services globally. Numerous studies amongst various medical and surgical specialties showed a reduction in patient attendance and surgical procedures performed. Prior published ophthalmic literature focused on specific types of procedures and were usually single centre. The current study attempts to quantify the impact on a larger scale, namely that of sub-Saharan Africa, and to include all ophthalmic subspecialties. METHODS: This is a retrospective analysis of the surgical records from 17 ophthalmology centres in seven countries located in East, Central, West and Southern Africa. The date of declaration of the first lockdown was used as the beginning of the pandemic and the pivot point to compare theatre records one year prior to the pandemic and the first year of the pandemic. We examined the total number of surgical procedures over the two year period and categorized them according to ophthalmic subspecialty and type of procedure performed. We then compared the pre-pandemic and pandemic surgical numbers over the two year period. RESULTS: There were 26,357 ophthalmic surgical procedures performed with a significant decrease in the first year of the pandemic (n = 8942) compared to the year prior to the pandemic (n = 17,415). The number of surgical procedures performed was lower in the first year of the pandemic compared to the year prior to the pandemic by 49% [Incidence rate ratio (IRR) 0.51, 95% CI 0.41-0.64), 27% (0.73, 0.55-0.99), 46% (0.54, 0.30-0.99), 40% (0.60, 0.39-0.92) and 59% (0.41, 0.29-0.57) in sub-Saharan Africa (4 regions combined), West, Central, East and Southern Africa, respectively]. The number of surgical procedures in the different sub-specialty categories in sub-Saharan Africa (4 regions combined) was significantly lower in the first year of the pandemic compared to the year prior to the pandemic, except for glaucoma (IRR 0.72, 95% CI 0.52-1.01), oncology (0.71, 0.48-1.05), trauma (0.90, 0.63-1.28) and vitreoretinal (0.67, 0.42-1.08) categories. CONCLUSION: This study provides insight into the impact of the COVID-19 pandemic in multiple regions and countries on the African continent. The identification of which surgical subspecialty was most affected by the COVID-19 pandemic in each region allows for better planning and resource allocation to address these backlogs.

Optic neuritis: A South African hospital-based prospective study protocol.

BACKGROUND: Optic neuritis is a relatively common disease with an estimated lifetime risk of 0.6 per 1000; the estimated prevalence is 1-5 per 100 000/year. It occurs because of inflammation of the optic nerve from a variety of causes. The diagnosis of the disorder is established clinically and current literature is predominantly based on white patients from high-income countries. Optic neuritis presents differently in black patients compared to white patients. This study aims to assess the presentation and outcome of optic neuritis patients in a South African setting. METHODS: This is a prospective, hospital-based cohort study that will enrol patients with optic neuritis presenting to either the neurology department at Chris Hani Baragwanath Academic Hospital or the ophthalmology department at St John Eye Hospital, both in Johannesburg, South Africa. The specific aetiologies, clinical presentation and radiological findings will be studied, and the patient's course over one year will be documented in three-monthly follow-up visits. A specific group of patients with Neuromyelitis Optica Spectrum Disorders (NMOSD) and Myelin Oligodendrocyte Glycoprotein Associated Disorders (MOGAD) optic neuritis will be followed up for 5 years at yearly intervals. DISCUSSION: This study represents one of the few cohort studies in Sub-Saharan Africa that seeks to investigate optic neuritis. Our hope is that it will lead to better insights regarding the presentation, course and outcome of this condition. We will also analyse the data with a view of developing a predictive model for good visual outcome.

Response to botulinum neurotoxin injections in large-angle infantile esotropia: a post hoc analysis.

PURPOSE: To determine the anticipated reduction of baseline angle of esotropia and identify predictors of change following botulinum neurotoxin (BNT) injections in large-angle infantile esotropia. METHODS: This was a prospective, longitudinal study of children <10 years of age diagnosed with infantile esotropia of >30Δ and given either 1, 2, or 3 BNT injections. Post-injection change from baseline deviation was recorded, and predictors of reduction were analyzed. For this study, children were further divided into subgroups based on initial deviation of ≤60Δ (group 1) and >60Δ (group 2). The outcomes of subsequent surgeries in failed cases were analyzed. RESULTS: A total of 117 children were included, 55 in group 1 and 62 in group 2. Mean age was 30.3 ± 18.8 months. Mean baseline deviation was 62.5Δ ± 13.1Δ: 51.4Δ ± 8.4Δ in group 1 and 73Δ ± 7.5Δ in group 2. The mean number of injections was 2.2 ± 0.7. Success was achieved in 25.6% of patients (33.4% in group 1; 16.2% in group 2). The mean percentage reduction of deviation after BNT injection was 55.2% ± 26%, larger in group 1 than in group 2 (61.3% vs 51.1% [P = 0.001]). Five children reverted to baseline deviation. In multivariate analysis, adjusting for number of injections, younger age and larger baseline deviation were significant independent predictors of a larger absolute amount of reduction (P = 0.02, and 0.002, resp.). Thirty-two children had subsequent surgery; 22 were followed for a minimum of 6 months, and 20 were aligned within 10Δ of orthotropia. CONCLUSIONS: In large-angle esotropia there was a reduction of approximately 50% of baseline deviation, with greater relative reduction for smaller baseline deviations; the absolute change in angle was greater in younger children. Alignment after subsequent surgery appeared to remain stable and surgery required less recession than would have been needed for the original angle of esotropia.

Tubercular Uveitis in Uveitis Cases in a High TB and HIV Setting: A Prospective Cohort Study.

Purpose: The diagnosis of tubercular uveitis (TBU) is difficult. The lack of a diagnostic gold standard has contributed to challenges in determining the true prevalence and clinical predictors of TBU. We aimed to determine the proportion of TBU cases in adults with uveitis and to examine clinical features associated with TBU. Methods: A prospective cohort study of adult uveitis cases after exclusion of other specific etiologies. The diagnosis of TBU was based on a composite reference of: any clinical signs of uveitis; exclusion of other causes of uveitis; and positive QuantiFERON-Gold test, tuberculin skin test, and/or ocular TB polymerase chain reaction. Results: Of 79 cases analyzed, 49 (62%) had TBU. Female sex (P = 0.001) and chronic uveitis (P = 0.006) cases were more common in the TBU group than the non-TBU group whereas diffuse choroiditis (P = 0.010) and HIV-positive (P = 0.001) cases were less common. Choroidal granulomas (P = 0.176) and serpiginous-like choroiditis (P = 0.292) were more common in TBU group, albeit not significantly. On univariate analysis, female sex (odds ratio, 5.1; P = 0.002), negative HIV status (odds ratio, 0.2; P = 0.001), and chronic uveitis (odds ratio, 4.1; P = 0.008) were associated with TBU. A negative HIV test was associated with TBU on multivariate analysis (P = 0.049). Conclusions: A high proportion of cases had TBU. Our study did not significantly confirm some of the clinical features associated with TBU reported in other studies. Translational Relevance: Our study highlights the difficulties in determining the proportion and clinical predictors of TBU, especially in the absence of a gold standard diagnostic test.

Global prevalence and clinical outcomes of tubercular uveitis: a systematic review and meta-analysis.

Tubercular uveitis (TBU) is an inflammation/infection of the eye secondary to Mycobacterium tuberculosis infection. The difficulty in making the diagnosis has resulted in variable prevalence and clinical response rates. We aimed to determine the global prevalence of TBU in uveitis patients stratified by TB high-burden countries (HBCs) and non-HBCs and by geographic regions and the clinical response of TBU to antitubercular treatment We performed a systematic review and meta-analysis of TBU studies published in PubMed, Scopus and EMBASE, up to June 30, 2020. A random effects model was used for all meta-analyses. Of 5,018 articles identified, 70 prevalence studies (65,607 uveitis and 3,166 TBU cases) and 18 clinical outcome studies (1,570 TBU cases; 1,304 responded to anti-tubercular therapy [ATT]) were analyzed. The overall weighted prevalence of TBU was 4.0% (95% CI, 3-5); in TB HBCs it was 7.0% (95% CI, 5-11), non-HBCs 3.0% (95% CI, 2-4), and sub-Saharan Africa 11.0% (95% CI, 8-15). The overall weighted clinical response was 82.0% (95% CI, 75-89). Despite the difficulty in diagnosing TBU, the prevalence is expectantly higher in HBCs, and sub-Saharan Africa and the clinical outcome is poor. Standardization of diagnostic criteria and ATT is warranted in future cohort studies.

Cost comparison between botulinum neurotoxin and surgery in the treatment of infantile esotropia in a tertiary public hospital.

OBJECTIVE: To compare the cost implications of botulinum neurotoxin (BNT) injection to surgery in infantile esotropia (IE) in a public/government funded hospital. METHODS AND ANALYSIS: A simple costing comparison was undertaken for a randomised clinical trial in IE. Patients were randomised to receive either BNT or standard surgery. The participants in the BNT arm were further subdivided into subgroups based on their age in months and degree of esotropia in prism dioptres (PD) at presentation: G1 ≤60 PD/24 months, G2 ≤24 months/>60 PD, G3 >24 months/≤60 PD, G4 >24 months/>60 PD. The costs were calculated for each arm from primary treatment to eventual satisfactory outcome defined as orthophoria or microtropia (≤10 PD). A bottom-up costing analysis was done for single and multiple procedures for each arm. Comprehensive variable costs as well as fixed costs were calculated at each point of intervention and expressed in local currency ZAR (US$1=ZAR15.00). Costing was analysed for surgery and BNT subgroups (based on clinical success). RESULTS: There were 101 patients enrolled in the trial. 54 in the BNT arm and 47 in the surgery arm. Cost for single surgery and single BNT was ZAR 7743.04 and 1713.14, respectively. A favourable clinical outcome was achieved in 72% of surgery arm and 37% of BNT arm. The mean cost for eventual favourable outcome in BNT arm was ZAR9158.08 and in surgery arm ZAR9124.27 (p=0.26). Mean cost in G1 was ZAR6328.45, in G2 ZAR7197.45, in G3 ZAR11891.93 and G4 ZAR12882.44 (p=0.018). CONCLUSION: BNT has a cost-benefit in IE and is a viable option in the primary treatment of IE in resource constrained regions. Clinical outcomes and economic benefit in smaller angle of esotropia and younger patients are comparable to surgery.

Treatment Outcome of Tubercular Uveitis in a High TB and HIV Setting: A Prospective Cohort Study.

PURPOSE: To determine the time to resolution of inflammation in tubercular uveitis (TBU) cases on standard anti-tubercular treatment. Sub-analysis of time to resolution according to HIV status was also performed. PATIENTS AND METHODS: A prospective cohort study of presumed idiopathic uveitis cases >18 years underwent the tuberculin skin test, QuantiFERON-TB Gold test, and ocular tuberculosis (TB) polymerase chain reaction test. Adult TBU cases were treated with standard anti-tubercular therapy (and corticosteroids) for 9 months. Cases were followed-up for resolution of inflammation at 1.5, 3, 6, 9, 12 and 15 months post-diagnosis. Outcome measure was resolution of inflammation on ≤10 mg oral prednisone per day. RESULTS: Seventy-nine presumed idiopathic uveitis cases were enrolled in the study, 49 (62%) were diagnosed with TBU. The mean (SD) age of TBU cases at diagnosis was 41.8 (13.4) years. Using a multilevel mixed effects model, resolution was achieved at 6 months in the TBU cases (OR = 1.21; 95% CI, 1.03-1.41; P = 0.017). Using generalized estimating equations, resolution was also achieved at 6 months in the TBU cases (OR = 1.21; 95% CI, 1.05-1.39; P = 0.008). The HIV-positive cases (OR = 1.62; 95% CI, 1.13-2.31; P = 0.008) and the HIV-negative cases (OR = 1.25; 95% CI, 1.06-1.48; P = 0.009) achieved resolution at 9 months. CONCLUSION: Resolution of inflammation in TBU cases on anti-tubercular treatment with corticosteroids was achieved at 6 months and maintained throughout the study. Our study suggests a minimum of 6 months treatment is required for significant resolution. Resolution of inflammation in HIV-positive and HIV-negative TBU cases needs to be further explored.

Neurological and growth outcomes in South African children with congenital cytomegalovirus: A cohort study.

OBJECTIVES: To assess neurological sequelae and growth in the first 12 months of life in a cohort of congenital cytomegalovirus (cCMV) infected infants compared to cCMV uninfected infants. STUDY DESIGN: This was a prospective matched cohort study conducted in Soweto, South Africa where forty-six confirmed cCMV cases were matched on HIV-exposure, gender and gestational age (±two weeks) to 84 cCMV-uninfected controls in a 1:2 ratio. Cases and controls were followed up until 12 months of age to assess anthropometry, hearing and neurodevelopmental outcomes. RESULTS: Thirty-four (73.9%) cCMV cases and 74 (88.1%) controls, completed all assessments at 12 months age. At 12 months, one cCMV case had died, none of the children in either group had SNHL and neurodevelopmental delay was present in a similar percentage of cCMV cases (n = 2; 6%) and controls (n = 1, 4%; OR 1.09, 95% CI 0.04-27.84, p = 0.958). Anthropometry did not differ between cases and controls overall throughout the follow up period. HIV-exposed cases had smaller head circumference for age at 6 and 12 months when compared with HIV-exposed controls. CONCLUSION: By 12 months of age, there was no evidence of a difference in neurological sequelae between cCMV infected South African children and cCMV uninfected children in this study. Further follow-up is warranted to detect late-onset hearing loss and neurodevelopmental delay beyond 12 months of age.

A 20-Year Retrospective Review of Retinoblastoma at Two Tertiary Academic Hospitals in Johannesburg, South Africa.

AIM: This paper presents a 20-year review of retinoblastoma in Johannesburg, South Africa, aiming to better characterize the disease in this sub-Saharan setting. METHODS: The study represents a retrospective case series of retinoblastoma patients presenting to Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital between January 1, 1992, and December 31, 2011. RESULTS: The total number of cases identified was 282, with 245 meeting the study inclusion criteria. Retinoblastoma comprised 6.9% of the total pediatric oncology presentations; 65.3% were unilateral, 34.3% bilateral, and 0.4% trilateral. The overall male-to-female ratio was 1.08. The mean age at presentation overall was 32.6 months (median 28.0), in the unilateral group 39.4 months (median 33.0), and in the bilateral group 19.7 months (median 17.0). The mean delay to presentation overall was 7.0 months (median 4.0). The most frequent presenting symptoms were leukocoria (37.1%) and proptosis (34.7%). The distribution of disease stages at presentation (International Retinoblastoma Staging System) was 1.6% stage 0, 24.1% stage I, 27.8% stage II, 16.3% stage III, and 25.3% stage IV. 26.5% defaulted care. The 5-year Kaplan-Meier survival estimate was 57.7% overall. CONCLUSION: This study shows that delayed presentation and refusal of therapy remains a significant barrier to effective treatment in this African setting.