Profile of primary childhood glaucoma at a child eye health tertiary facility in Malawi.

BACKGROUND: To describe the clinical characteristics and treatment of primary childhood glaucoma at Queen Elizabeth Central Hospital in Blantyre, Malawi. METHODS: A retrospective case notes review was undertaken of all medical records of patients aged less than 16 years with a diagnosis of primary glaucoma according to the Childhood Glaucoma Research Network Classification (CGRN) who presented from January 2016 to December 2018. The parameters extracted from the case files included age at presentation, sex, type of glaucoma, presenting complaints, laterality of ocular involvement, examination findings and the treatment modality instituted. The Mann-Whitney test was used to investigate factors associated with the intraocular pressure (IOP) in eyes that had a higher presenting IOP value compared to contralateral eyes. RESULTS: A total of 45 subjects (80 eyes) were identified, 42 with primary congenital glaucoma (PCG) and 3 with juvenile open angle glaucoma (JOAG). The mean age for the population was 2.6 years (S.D ± 3.7) and most of the patients were male, with a male-female ratio of 2:1. The majority of patients had bilateral disease (n = 35, 77.8%) with the commonest presenting complaint being a whitish appearance of the eye (57.5%). The eyes studied had a mean IOP of 30.1 mmHg (CI 27.4-32.9), a mean horizontal corneal diameter (HCD) of 13.6 mm (CI 13.1-14.2) and a mean cup-disc-ratio `(CDR) of 0.73 (CI 0.66-0.79). In addition, 62 eyes (77.5%) had corneal haze on examination. Most patients (n = 59, 73.8%) underwent a combined trabeculotomy - trabeculectomy surgery within the study period. The median presenting IOP was significantly higher with JOAG compared to PCG (P = 0.02). CONCLUSION: PCG was the most common primary childhood glaucoma at Queen Elizabeth Central Hospital and most patients presented with bilateral eye involvement. Most of the eyes had corneal haze and JOAG was associated with a higher presenting IOP compared to PCG. Further studies to investigate the outcomes of combined trabeculotomy - trabeculectomy surgery in primary childhood glaucoma in Malawi are recommended.

Establishing a Pediatric Ophthalmology Service in Malawi: Developments in Childhood Cataract Surgery.

PURPOSE: The purpose of this study is to report on the establishment of a Pediatric Ophthalmology Service for Malawi using childhood cataract surgery as a surrogate measure of its effectiveness. MATERIALS AND METHODS: A retrospective review of pediatric cataract surgery at Lions Sight First Eye Hospital, Blantyre, between 2011 and 2016. The paucity of comprehensive records allowed for the sampling of a maximum of 25 cases/year (n = 150) for comparison. Theatre records and population statistics were used to calculate childhood cataract surgical rates (CCSR). RESULTS: A total of 949 cataract operations were performed during the six years studied - 55.8% of these were boys. The number of operations per year remained generally stable. Of the 150 cases reviewed, the mean age at presentation was 6.01 years, with a trend toward a slightly younger age over the period. Over the years studied, the geographical distribution of referrals became more reflective of the population's distribution. Where the logarithm of the minimum angle of resolution (LogMAR) visions were available, these demonstrated a mean improvement from 2.008 (n = 43) preoperatively to 0.613 (n = 51) postoperatively. The mean follow-up was 106 days (0 days-3.25 years). Complication rates were low. The CCSR was 9.2/million population. CONCLUSIONS: A Pediatric Ophthalmology Service has been established in Malawi delivering safe, effective surgery on a country-wide scale for childhood cataract. Over the period studied, the age at presentation reduced, and there was an improvement in the geographical distribution of patients, likely due to an improvement in referral systems throughout Malawi.

Incremental cost-effectiveness of screening and laser treatment for diabetic retinopathy and macular edema in Malawi.

OBJECTIVE: To investigate the economic impact of introducing targeted screening and laser photocoagulation treatment for sight-threatening diabetic retinopathy and macular edema in a setting with no previous screening or laser treatment for diabetic retinopathy in sub-Saharan Africa. MATERIALS AND METHODS: A cohort Markov model was built to compare combined targeted screening and laser treatment for patients with sight-threatening diabetic retinopathy and macular edema against no intervention. Primary outcomes were incremental cost per quality-adjusted life year (QALY) gained and per disability-adjusted life year (DALY) averted. Primary data were collected on 357 participants from the Malawi Diabetic Retinopathy Study, a prospective, observational cohort study. Multiple scenarios were explored and a probabilistic sensitivity analysis was performed. RESULTS: In the base case (age: 50 years, service utilization rate: 80%), the cost of the intervention and the years of severe visual impairment averted per patient screened were $209 and 2.2 years respectively. Applying the World Health Organization threshold of cost-effectiveness for Malawi ($679), the base case was cost-effective when QALYs were used ($400 per QALY gained) but not when DALYs were used ($766 per DALY averted). The intervention was more cost-effective when it targeted younger patients (age: 30 years) and less cost-effective when the utilization rate was lowered to 50%. CONCLUSIONS: Annual photographic screening of diabetic patients attending medical diabetes clinics in Malawi, with the provision of laser treatment for those with sight-threatening diabetic retinopathy and macular edema, appears to be cost-effective in terms of QALYs gained, in our base case scenario. Cost-effectiveness improves if services are utilized more intensively and extended to younger patients.

Incidence and progression of diabetic retinopathy in Sub-Saharan Africa: A five year cohort study.

AIMS: To describe the incidence and progression of retinopathy in people with diabetes in Southern Malawi over 5 years. To document visual loss in a setting where laser treatment is not available. METHODS: Subjects from a cohort sampled from a hospital-based, primary-care diabetes clinic in 2007 were traced in 2012. Laser treatment was not available. Modified Wisconsin grading of retinopathy was performed using slit lamp biomicroscopy by a single ophthalmologist in 2007 and using four-field mydriatic fundus photographs at an accredited reading centre in 2012. Visual acuity was measured by Snellen chart in 2007 and by 'Early Treatment of Diabetic Retinopathy Study' chart in 2012. HbA1c, blood pressure, HIV status, urine albumin-creatinine ratio, haemoglobin and lipids were measured. RESULTS: Of 281 subjects recruited in 2007, 135 (48%) were traced and assessed, 15 were confirmed dead. At follow-up (median 5.3 years) ≥2 step retinopathy progression was observed in 48 subjects (36.4%; 95% CI 28.2-44.6). Incidence of sight threatening diabetic retinopathy for those with level 10 (no retinopathy) and level 20 (background) retinopathy at baseline, was 19.4% (11.3-27.4) and 81.3% (62.1-100), respectively. In multivariate analysis 2 step progression was associated with HbA1c (OR 1.2495%CI 1.04-1.48), and haemoglobin level (0.77, 0.62-0.98). 25 subjects (18.8%) lost ≥5 letters, 7 (5.3%) lost ≥15 letters. CONCLUSIONS: Progression to sight threatening diabetic retinopathy from no retinopathy and background retinopathy was approximately 5 and 3 times that reported in recent European studies, respectively. Incidence of visual loss was high in a location where treatment was not available.

First Prospective Cohort Study of Diabetic Retinopathy from Sub-Saharan Africa: High Incidence and Progression of Retinopathy and Relationship to Human Immunodeficiency Virus Infection.

PURPOSE: To describe the prevalence, incidence, and progression of retinopathy and to report associations with demographic, clinical, and biochemical variables in people with diabetes in Southern Malawi. DESIGN: Prospective cohort study. PARTICIPANTS: Subjects were systematically sampled from 2 primary care diabetes clinics. METHODS: We performed the first prospective cohort study of diabetic retinopathy from Sub-Saharan Africa over 24 months. Visual acuity, glycemic control, blood pressure, human immunodeficiency virus (HIV) status, urine albumin-to-creatinine ratio, hemoglobin, and lipids were assessed. Retinopathy was graded at an accredited reading center using modified Wisconsin grading of 4-field mydriatic photographs. MAIN OUTCOME MEASURES: Incidence of sight-threatening retinopathy and progression of retinopathy by 2 steps on the Liverpool Diabetic Eye Study Scale. RESULTS: A total of 357 subjects were recruited to the 24-month cohort study. At baseline, 13.4% of subjects were HIV positive and 15.1% were anemic. The 2-year incidence of sight-threatening diabetic retinopathy (STDR) for subjects with level 10 (no retinopathy), level 20 (background), and level 30 (preproliferative) retinopathy at baseline was 2.7% (95% confidence interval [CI], 0.1-5.3), 27.3% (95% CI, 16.4-38.2), and 25.0% (95% CI, 0-67.4), respectively. In a multivariate logistic analysis, 2-step progression of diabetic retinopathy was associated with glycosylated hemoglobin (odds ratio [OR], 1.27; 95% CI, 1.12-1.45), baseline grade of retinopathy (OR, 1.39; 95% CI, 1.02-1.91), and HIV infection (OR, 0.16; 95% CI, 0.03-0.78). At 2 years, 17 subjects (5.8%) lost ≥15 letters. CONCLUSIONS: Incidence of STDR was approximately 3 times that reported in recent European studies. The negative association of HIV infection with retinopathy progression is a new finding.

A cost analysis of pediatric cataract surgery at two child eye health tertiary facilities in Africa.

PURPOSE: To determine the direct cost of pediatric cataract surgery at two child eye health tertiary facilities (CEHTFs) in Africa. METHODS: The direct cost of pediatric cataract surgery was determined by reviewing data collected from two CEHTFs in Zambia and Malawi. Inventory, cost, and usage data of all durable medical equipment, consumable equipment, personnel, and medications were collected and the direct cost per child calculated. RESULTS: For cataract surgery and related treatment during 2011, the total cost per child was calculated to be $202 for Malawi and $277 for Zambia using figures derived from estimating labor cost allocation proportional to employee time devoted to pediatric cataract management. The one-time equipment cost totaled $178,121 for Malawi and $179,832 for Zambia. CONCLUSIONS: These cost estimates may serve as a basis for economic decisions aimed at improving access to care, management, and follow-up for children with cataract and provide useful insights for programs dedicated to promoting organizational and financial sustainability for CEHTFs in Africa.

Maternal and neonatal risk factors associated with vertical transmission of ophthalmia neonatorum in neonates receiving health care in Blantyre, Malawi.

CONTEXT: Neonatal conjunctivitis is associated with poor prenatal care worldwide. PURPOSE: Data on neonatal conjunctivitis is scarce in Malawi. This study describes risk factors associated with conjunctivitis in neonates born in a large tertiary care hospital in Blantyre, Malawi. MATERIALS AND METHODS: Medical records of a retrospective cohort of 231 neonates diagnosed with conjunctivitis from January 2006 to December 2009 at a large tertiary hospital in Malawi were reviewed. All subjects were clinically diagnosed with ophthalmia neonatorum. Data were collected on patient demographics and clinical features. The frequencies were calculated of various risk factors in neonates with ophthalmia neonatorum and their mothers as well as the treatments administered. RESULTS: Mean age of the mother was 23.45 years (range, 15-40 years), and the mean number of previous deliveries was 2.3 (range, 1-7) children. Nearly, 80% of mothers delivered preterm infants via spontaneous vaginal delivery. The mean birth weight of neonates was 2869.6 grams (1100-5000 grams). Among mothers, premature rupture of membranes was the leading risk factor (24%) followed by sepsis during labor (9%), and history of sexually transmitted infections (STI) (7%). Neonates presented with low Apgar scores (19%), fever (8%), and/or meconium aspiration (5%). Providers treated patients empirically with a varied combination of benzyl penicillin, gentamicin, tetracycline eye ointment, and saline eye wash. Tetracycline with a saline eyewash was used frequently (34%) compared with combinations of benzyl penicillin and gentamicin. CONCLUSIONS: Improving prenatal care to reduce sepsis, traumatic deliveries, and early diagnosis of STI with appropriate treatment may potentially reduce vertical transmission of neonatal conjunctivitis in this understudied population.

Diabetic retinopathy in sub-Saharan Africa: meeting the challenges of an emerging epidemic.

BACKGROUND: Sub-Saharan Africa faces an epidemic of diabetes. Diabetes causes significant morbidity including visual loss from diabetic retinopathy, which is largely preventable. In this resource-poor setting, health systems are poorly organized to deliver chronic care with multiple system involvement. The specific skills and resources needed to manage diabetic retinopathy are scarce. The costs of inaction for individuals, communities and countries are likely to be high. DISCUSSION: Screening for and treatment of diabetic retinopathy have been shown to be effective, and cost-effective, in resource-rich settings. In sub-Saharan Africa, clinical services for diabetes need to be expanded with the provision of effective, integrated care, including case-finding and management of diabetic retinopathy. This should be underpinned by a high quality evidence base accounting for differences in diabetes types, resources, patients and society in Africa. Research must address the epidemiology of diabetic retinopathy in Africa, strategies for disease detection and management with laser treatment, and include health economic analyses. Models of care tailored to the local geographic and social context are most likely to be cost effective, and should draw on experience and expertise from other continents. Research into diabetic retinopathy in Africa can drive the political agenda for service development and enable informed prioritization of available health funding at a national level. Effective interventions need to be implemented in the near future to avert a large burden of visual loss from diabetic retinopathy in the continent. SUMMARY: An increase in visual loss from diabetic retinopathy is inevitable as the diabetes epidemic emerges in sub-Saharan Africa. This could be minimized by the provision of case-finding and laser treatment, but how to do this most effectively in the regional context is not known. Research into the epidemiology, case-finding and laser treatment of diabetic retinopathy in sub-Saharan Africa will highlight a poorly met need, as well as guide the development of services for that need as it expands.

Causes of severe visual impairment and blindness in children in schools for the blind in eastern Africa: changes in the last 14 years.

PURPOSE: To determine the causes of severe visual impairment and blindness in children attending schools for the blind in Kenya, Malawi, Uganda, and Tanzania and to compare the findings with those of a 1994 study. METHODS: Children attending schools for the blind or annexes in 4 eastern African countries were examined. The major anatomical site of and underlying etiology of severe visual impairment and blindness was recorded using the standardized World Health Organization (WHO) reporting form. RESULTS: A total of 1062 children aged below 16 years were examined of whom 701 (65.2%) had severe visual impairment or blindness. The major anatomical sites of visual loss overall (% and 95% CI) were cornea scar/phthisis bulbi (19%,16.1-21.9), whole globe lesions (15.7%,13.0-18.4), retina (15.4 %, 12.7-18.1), lens related disorders (13.1%, 10.7-15.5), and optic nerve disorders (12.3%, 9.9-14.7). Corneal scar/phthisis was not distributed equally among the countries and was highest in Malawi, similar to findings in 1995. The major etiology of visual loss was childhood factors (29.9%) and an estimated 40% of severe visual impairment and blindness was due to potentially avoidable causes. CONCLUSION: The major causes of severe visual impairment and blindness overall have not changed appreciably since 1995. There are important differences among countries, however, and using overall estimates for planning may be misleading.

Cataract in children attending schools for the blind and resource centers in eastern Africa.

OBJECTIVE: The aim of this study was to describe results of a representative sample of children who have undergone cataract surgery in schools for the blind in 4 African countries. DESIGN: Cross-sectional study. PARTICIPANTS: Children enrolled at schools for the blind in Kenya, Malawi, Tanzania, and Uganda. METHODS: We used a population-proportional-to-size methodology to select a representative sample of schools for the blind and annexes and included all the children attending the selected schools. Trained teams using standardized examination methods and a modified World Health Organization form examined the children. The form was modified specifically to collect information on outcomes of cataract surgery. MAIN OUTCOME MEASURES: Operative status and postoperative visual acuity. RESULTS: Of 1062 children examined, 196 (18%) had undergone cataract surgery or had cataract as the major cause of visual impairment; 140 (71%) had bilateral surgery, 24 (12%) had unilateral surgery, and 32 (16%) had not had surgery. Of operated eyes, 118 (41%) had visual acuity > or =20/200. Intraocular lenses were implanted in 65% of the operated eyes. Eyes with intraocular lens were more likely to have better vision than those without (P for trend = 0.04). Amblyopia was the most common cause of poor visual acuity in children who had undergone cataract surgery. CONCLUSIONS: The number of children in the schools who receive cataract surgery has increased greatly since 1995. The high rate of amblyopia highlights the critical need for programs to find children earlier and to ensure adequate follow-up after surgery. Without such programs, the value of training pediatric surgeons will not be fully realized. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.