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.

A randomized, open-label study of the tolerability and efficacy of one or three daily doses of ivermectin plus diethylcarbamazine and albendazole (IDA) versus one dose of ivermectin plus albendazole (IA) for treatment of onchocerciasis.

BACKGROUND: Onchocerciasis ("river blindness") has been targeted for elimination. New treatments that kill or permanently sterilize female worms could accelerate this process. Prior studies have shown that triple drug treatment with ivermectin plus diethylcarbamazine and albendazole (IDA) leads to prolonged clearance of microfilaremia in persons with lymphatic filariasis. We now report results from a randomized clinical trial that compared the tolerability and efficacy of IDA vs. a comparator treatment (ivermectin plus albendazole, IA) in persons with onchocerciasis. METHODS AND FINDINGS: The study was performed in the Volta region of Ghana. Persons with microfiladermia and palpable subcutaneous nodules were pre-treated with two oral doses of ivermectin (150 µg/kg) separated by at least 6 months prior to treatment with either a single oral dose of ivermectin 150 µg/kg plus albendazole 400 mg (IA), a single oral dose of IDA (IDA1, IA plus diethylcarbamazine (DEC. 6 mg/kg) or three consecutive daily doses of IDA (IDA3). These treatments were tolerated equally well. While adverse events were common (approximately 30% overall), no severe or serious treatment-emergent adverse events were observed. Skin microfilariae were absent or present with very low densities after all three treatments through 18 months, at which time nodules were excised for histological assessment. Nodule histology was evaluated by two independent assessors who were masked regarding participant infection status or treatment assignment. Significantly lower percentages of female worms were alive and fertile in nodules recovered from study participants after IDA1 (40/261, 15.3%) and IDA3 (34/281, 12.1%) than after IA (41/180, 22.8%). This corresponds to a 40% reduction in the percentage of female worms that were alive and fertile after IDA treatments relative to results observed after the IA comparator treatment (P = 0.004). Percentages of female worms that were alive (a secondary outcome of the study) were also lower after IDA treatments (301/574, 52.4%) than after IA (127/198, 64.1%) (P = 0.004). Importantly, some comparisons (including the reduced % of fertile female worms after IDA1 vs IA treatment, which was the primary endpoint for the study) were not statistically significant when results were adjusted for intraclass correlation of worm fertility and viability for worms recovered from individual study participants. CONCLUSIONS: Results from this pilot study suggest that IDA was well tolerated after ivermectin pretreatment. They also suggest that IDA was more effective than the comparator treatment IA for killing or sterilizing female O. volvulus worms. No other short-course oral treatment for onchocerciasis has been demonstrated to have macrofilaricidal activity. However, this first study was too small to provide conclusive results. Therefore, additional studies will be needed to confirm these promising findings. TRIAL REGISTRATION: The study is registered at Cinicaltrials.gov under the number NCT04188301.

New Research Aims to Optimize Therapy Against Onchocerciasis.

Onchocerciasis is a parasitic disease that is the second most common cause of infectious blindness in the world, affecting 25 million people, mostly in sub-saharan Africa. Mass drug administration (MDA) with ivermectin has been the mainstay of a successful international effort to reduce the burden of vision loss. Despite improvements in infection rates and blindness through MDA with ivermectin, adult worms are not killed or permanently sterilized by this drug and can live for greater than 10 years. Therefore, new treatments for onchocerciasis are critical to accelerating the rate of elimination of this blinding disease. Here we discuss an ongoing study of a new treatment for onchocerciasis.

A Reevaluation of the Tolerability and Effects of Single-Dose Ivermectin Treatment on Onchocerca volvulus Microfilariae in the Skin and Eyes in Eastern Ghana.

Mass administration of ivermectin (IVM) has significantly reduced onchocerciasis prevalence, intensity, and morbidity in most endemic areas. Most IVM clinical trials were performed long ago in persons with high-intensity infections that are uncommon in West Africa today. This cohort treatment study recruited participants from a hypoendemic area in eastern Ghana to reevaluate the efficacy and tolerability of IVM with a special focus on the kinetics of microfilaria (Mf) clearance. Mf in the skin and anterior chambers (AC) were assessed by skin snip and slit lamp examinations at baseline and at 3 and 6 months after treatment with IVM 150 µg/kg. Most participants (184-231, 79.7%) enrolled were treatment-naïve. The baseline geometric mean skin Mf count was 12.67/mg (range 3-86). Although persons with MfAC at baseline (64/231, 27%) had significantly higher skin Mf counts than people without MfAC, 7 of 39 (15%) of persons with skin Mf counts in the range of 3-5 Mf/mg had MfAC. Skin Mf were detected in 14% (31/218) and 45% (96/216) of participants 3 and 6 months after IVM treatment, respectively. MfAC were detected in 12 of 212 (5.7%) study participants at 6 months. 81% (187 of 231) of participants experienced 439 adverse events within 7 days after treatment; all adverse events were mild (96.1%) or moderate. This study has provided new data on the kinetics of Mf in the skin and eyes after IVM treatment of persons with light to moderate intensity Onchocerca volvulus infections that are common in Africa at this time.

Outer retina reconstruction following inverted internal limiting membrane flap technique for large macular holes.

PURPOSE: The aim of this study is to investigate the outer retina reconstruction using postoperative spectral domain optical coherence tomography (SD OCT) in large diameter macular holes (MHs) treated with the inverted internal limiting membrane (ILM) flap technique. METHODS: A retrospective study of 14 consecutive eyes that had vitrectomy and inverted ILM flap technique for MHs with a base diameter of 400 µ or greater. Preoperative and postoperative SD OCT images were assessed for MH closure and for outer retina presence; represented by the external limiting membrane (ELM) and ellipsoid zone (EZ), in the subfoveal and parafoveal areas. RESULTS: The average MH base diameter was 963 µ. Postoperative SD-OCT revealed an absence of the outer retina in six eyes, a continuous (regular) presence of the outer retina in four eyes, and a discontinuous (interrupted) presence in four eyes. There was an inverse relationship between MH size and presence or absence of ELM and EZ. A larger MH base diameter size was associated with a higher probability of an absent ELM and EZ (P = 0.04). Eyes in which an outer retina was present postoperatively achieved 6/18 and better vision compared to eyes without (P = 0.08). CONCLUSION: The outer retina in some large MHs treated with ILM flap technique can undergo reconstitution and remodeling which improves over time. The average size for MHs with complete reconstitution was 652 µ, 855 µ for those with interrupted reconstitution, and 1242 µ for eyes with no outer retina reconstruction. This suggests that MHs having a size within the limit of the no outer retina reconstitution MH group may be candidates for other surgical techniques in which postoperative outer retina presence is expected.

Inverted Internal Limiting Membrane Technique Maintains Macular Hole Closure in Retinal Detachment Following Macular Hole Repair.

Recent advances in macular hole surgery have significantly improved the rates of anatomical success. One important advance is the dye-assisted peeling of the internal limiting membrane (ILM) around the hole. In large holes (<400 µ), sometimes, ILM peeling alone is not enough to achieve closure, and this may be improved by inverting part of the peeled membrane and using it to cover the macular hole or inverting and tucking the ILM flap into the hole. In this case report, a patient with large full-thickness macular hole underwent a hole repair with an inverted ILM flap technique. The eye developed a subsequent retinal detachment with large collection of subretinal fluid beneath the repaired hole, but the hole remained intact, suggesting that the adhesive forces binding an inverted flap to the edges of a repaired macular hole appear to be strong enough to maintain structural integrity of the closed hole even in the presence of a macula-involving retinal detachment with large subretinal fluid collection.

Comparison of primary open angle glaucoma patients in rural and urban Ghana.

PURPOSE: To compare the clinical features of glaucoma patients who present at a rural hospital in North Eastern Ghana and an urban hospital in the capital city of Accra. METHODS: This is a multi-center retrospective case series involving records of newly diagnosed glaucoma patients with emphasis on primary open angle glaucoma (POAG). Information collected included basic demographic data, intraocular pressures and optic disc measurements. RESULTS: A total of 949 patients (437 rural; 512 urban; 1868 eyes) were included. Rural vs. urban comparisons, respectively: mean age, 53.2 ± 16.3 vs. 54.5 ± 16.4 years; male: female ratio, 3:2 vs. 1:1; POAG, 78.1% vs. 50.6%; POAG suspect, 10.3% vs. 41.9%; IOP, 39.2 ± 7.1 vs. 31.8 ± 7.3 mmHg; bilateral blindness, 34.1% vs. 17.5%; uniocular blindness, 52.2% vs. 32.9%. Females at the rural hospital were twice as likely to present blind in at least one eye (OR 2.04, CI 1.36 - 3.07, p < 0.001). CONCLUSIONS: Patients with POAG at the rural hospital present with more advanced disease characteristics.

Comparison of moderate and advanced glaucoma patients in Ghana.

PURPOSE: To compare moderate and advanced glaucoma patients in Ghana. METHODS: A retrospective cross-sectional study of 164 patients with primary open-angle glaucoma (POAG) were separated into moderate and advanced glaucoma groups. Definitions of moderate and advanced POAG were derived from International Geographical and Epidemiologic Ophthalmology criteria and included clinical assessment of optic disc atrophy and Humphrey automated perimetry. Data were collected at the patient's first visit prior to initiation of therapy. Eligible POAG patients included those ≥30 years old with reliable Humphrey visual field (HVF) results, no past POAG diagnosis, treatment, or evidence of a secondary cause for glaucoma. Main outcome measures included comparisons of intraocular pressure (IOP), cup-to-disk ratio (CDR), best corrected visual acuity (VA), age, Humphrey mean deviation (MD), and pattern standard deviation (PSD). RESULTS: Of 164 charts reviewed, 90 (54.9%) advanced and 74 (45.1%) moderate POAG patients were compared. Mean age was 59.36 versus 55.53 years, respectively. Significant differences in IOP, CDR, CDR asymmetry, and HVF results were described. IOP > 30 mmHg was associated with CDR > 0.7 and MD greater than -12 dB in both eyes. CONCLUSION: Significant differences were found between IOP, CDR, MD and PSD values. HVF is predictive of pretreated IOP, CDR, and severity of POAG and it is strongly encouraged as part of the standard glaucoma work up in all Ghanaian patients.