Presentation of children with advanced retinoblastoma for treatment in Ghana: the caretakers' perspectives.

BACKGROUND: Retinoblastoma, the commonest childhood malignant intraocular tumour, is diagnosed late, with less than 50% survival in developing countries, including Ghana. OBJECTIVES: To determine, from caretakers' perspective, contributing factors to late presentation of children with retinoblastoma. METHODS: A cross-sectional study involving questionnaire administration to consenting caretakers of consecutive children diagnosed with advanced retinoblastoma at the Eye Unit, Korle-Bu Teaching Hospital, Accra, Ghana, from September 2008-June 2011. Clinical diagnosis was confirmed by CT scan or ultrasonography. Ethical approval was granted by University of Ghana Medical School. RESULTS: Forty caretakers aged 22-58 years (mean = 32.8 ± 7.8yrs) were interviewed. Twenty-four (60%) were females, 36(90%) were parents. Thirty-two (80%) had at least primary level of education. Initial symptoms noticed by caretakers were: white spot 35(87.5%), redness 3(7.5%), proptosis 1(2.5%) and squint 1(2.5%). Thirty-five caretakers (87.5%) sought prior treatment between 1-24 months (median=1month) and 7(37%) beyond 3months, mainly from health/eye centres 34(85%). Six caretakers (15.4%) knew their children had cancer, 11(27.5%) had heard about retinoblastoma, but only 2(5.0%) knew treatment existed. Thirty-two caretakers (80%) would accept enucleation with prosthesis and 17(42.5%) without it. Cost: 8(20% respondents) and lack of awareness of prognosis of retinoblastoma 12(30% respondents) were stated as important factors though they did not prove significant. Caretakers' level of education, occupation and gender had no significant association with knowledge about retinoblastoma, awareness of treatment or cure, acceptance of enucleation with or without prosthesis, nor awareness of prognosis without treatment, p>0.05. CONCLUSION: Low awareness of the cause, treatment and prognosis of retinoblastoma exists among caretakers of children with advanced retinoblastoma. This may contribute to the late stage of the disease presentation.

Prevalence of refractive error and other eye diseases in schoolchildren in the Greater Accra region of Ghana.

PURPOSE: To determine the prevalence of refractive error and other eye diseases in schoolchildren in the Greater Accra region of Ghana. METHODS: Research assistants tested visual acuity (VA) using a Snellen chart in students randomly selected from 24 schools (i.e., 8 metropolitan, 8 urban, and 8 rural). An ophthalmologist examined students with VA of 6/12 or worse in either eye and students with other eye problems. RESULTS: Nine hundred fifty-seven students aged 6 to 22 years were screened: 67 had myopia with VA of 6/12 or worse in the better eye, 3 were unilaterally blind (2 from squint or amblyopia, 1 from a hypoplastic disk), and 4 had unilateral low vision from macular scars. Other eye diseases observed were congenital glaucoma (1), vernal conjunctivitis (2), and infective conjunctivitis (6). The prevalence of refractive error reducing vision to at least 6/12 was 7.0%. The prevalence of squint and amblyopia was 0.2%. CONCLUSION: The most common eye defect in the students was refractive error. Squint and amblyopia were rare.

Mean intraocular pressure in Ghanaians.

Intraocular pressure (IOP) was measured in 600 Ghanaians by applanation. They were aged 16 to 77 years with a mean age of 36 years and standard deviation of 12.91. Nineteen subjects (3%) were found to have glaucoma. Five hundred and forty-five qualified for analysis of IOP in non-glaucomatous eyes. The IOP in the latter ranged from 5 to 28 mmHg with a mean of 15.5, median 16, and standard deviation 3.70. The graph of mean IOP is slightly skewed to the right. The 95% confidence interval for mean intraocular pressure for the population is 15.3 to 15.7. The graph of IOP by age showed a slight drop in IOP after the 50-55 year age group. There was no significant difference between mean IOP in males and females (t statistic = 0.17, p > 0.5).

Ocular tumours and problems in management: a Ghanaian experience.

Fifty eight cases of ocular tumours and forty cases of Burkitt's lymphoma with ocular involvement from the Eye and Burkitt's units of the Korle-Bu Teaching Hospital were reviewed. The tumours formed 0.1% of all the new cases seen at the Eye Clinic. Two thirds of tumours that presented at the Eye Clinic occurred in children below the age of 12 years. The three most commonly occurring tumours were retinoblastomas (50%), dermoid cysts (15.5%) and assorted conjunctival tumours (10.3%). The only secondary tumour encountered was orbital squamous cell carcinoma with the primary site in the maxillary antrum. Misconceptions and socioeconomic problems contributed immensely to late diagnosis, difficulties with management, and poor prognosis for both vision and life. Ocular involvement occurred in 40(16%) out of 248 cases of Burkitt's lymphoma from the Burkitt's Unit.

Visual loss in urban and rural chronic glaucoma patients in Ghana.

The visual acuity of newly diagnosed glaucoma patients in a rural and an urban area were compared in a hospital-based cross-sectional study in Ghana. Age at presentation was strikingly higher in the rural group due to local factors which result in a difference-in-age structure of the rural and urban population. The crude relative frequency of bilateral blindness was significantly higher for rural than urban. However, with age adjusted relative frequencies for bilateral blindness there was no significant difference between rural and urban patients. There was significant difference between them for those aged 51-71 when blindness in one or both eyes were considered together. There was more consistent blindness in the rural community: the difference was attributed to local factors such as better access to eye care in the urban group.

Traditional methods of treatment of cataract seen at Korle-Bu Teaching Hospital.

Fourteen eyes in eleven patients treated by the traditional methods for cataract were evaluated. Three different methods of treatment were classified from the cases: intracapsular (the traditional couching), extracapsular, and zonulysis. The operations were carried out on the left eye in 64%, bilateral in 27%, and right in 9%. Complications noted were uveitis, glaucoma, lens in pupil, posterior capsule opacification, cystoid macular oedema (CMO) but infection was conspicuously absent. Some of the results were good. With those that did not appear acceptable and could be further improved patients either received partial management or did not bother. Pain was the worrying symptom. These results of the traditional methods are not desirable but until intra-ocular lens implantation is widely practised in Ghana traditional methods are likely to compete with orthodox methods to a variable degree.

Intraocular pressure asymmetry-Topcon Computerised Tonometer CT-20.

The Topcon Computerised Tonometer CT-20, a non-contact tonometer (NCT), was used to measure intraocular pressure (IOP) in mmHg in 1,226 subjects above the age of 30 years with no ocular pathology. The mean IOP was 14.41 mmHg and the standard deviation 3.43. The mean IOP far was higher in female (14.60) than male (14.22). This gender difference in the mean IOP was significant; t stat = 2.69, P < 0.5. Right IOP exceeded left IOP and this was highly significant in both male (t stat 4.03) and female (t stat 5.64) p < 0.01. This IOP asymmetry approximates a normal distribution. The mean of the differences (right-left IOP) and standard deviation for all subjects were 0.57 and 2.26 respectively. The range for the differences was- 10 to 10 mmHg. Asymmetry was greater in females than males (t stat = 2.05, p < 0.05). Knowledge of these statistics will help in decisions concerning glaucoma screening with NCT.

Evaluation of Greenbaum's anaesthetic technique using lignocaine with adrenaline.

The Greenbaum's technique of parabulbar anaesthesia was used to deliver 2% lignocaine with 1:200,000 adrenaline in 44 patients undergoing anterior segment types of procedures. These consisted of 22 intracapsular cataract extraction, 7 extracapsular cataract extraction and lens implant, 1 lens aspiration, 6 trabeculectomies, 1 combined trabeculectomy and extracapsular cataract extraction, 2 prolapsed iris, 2 corneal laceration, 2 hyphaema evacuation, and 1 retinal cryopexy. Three children and 41 adults were included in the study. Onset of anaesthesia was rapid and effective. Though akinesia was not always complete the surgery was always manageable. Almost all the patients had painless surgery. With this method there is virtually no risk of serious complications that may be encountered in retrobulbar and peribulbar anaesthesia such as retrobulbar haemorrhage, globe penetration and perforation, optic nerve damage, and injection into the subarachnoid space. This method is simple, safe, and effective.

Dermis-fat grafts and enucleation in Ghanaian children: 5 years' experience.

BACKGROUND: Enucleation in young children often results in retarded orbital growth ipsilaterally. The need for an implant that will naturally grow with the child, like Dermis-fat Graft (DFG), for managing the anophthalmia has been of interest over the years. OBJECTIVE: To evaluate the use of DFG as an implant for volume replacement post-enucleation. STUDY DESIGN: A prospective non-comparative case series involving 18 consecutive children who had DFG either primarily or secondarily in conjunction with enucleation for intraocular pathologies, from December 2007 to September 2012, at the ophthalmology unit, Korle-Bu. Data from patients who had a minimum of three months follow up(FUP) were analysed. OUTCOME MEASURES: Complete covering of DFG with healthy conjunctiva, increase in volume of DFG, and presence or absence of complications. RESULTS: Fifteen patients were analysed, aged nine months to ten years (mean (SD), 3.7±2.7years). Eight (53.3%) were females. Thirteen (86.7%) DFGs were secondary and 2(13.3%) primary. Indications for enucleation were intraocular retinoblastoma (n=10, 66.7%), unexplained retinal detachment mimicking retinoblastoma (n=3,20.0%), anterior staphyloma (n=1,6.7%) and medulloepithelioma (n=1,6.7%). Fourteen (93.3%) patients showed increase in volume of DFG. Time for Conjunctival reepithelialisation of the dermal surface was four to fourteen weeks (mean/median=5.5/4.0). Complications encountered were infection (n=1,6.7%), infection with necrosis (n=1,6.7%), melanosis /keratinization (n=2, 13.3%) and cysts(n=2,13.3%). The patients were followed up for 3 to 54 months (mean/median 20.13 /16.00). CONCLUSION: DFG for management of post-enucleation anophthalmia in Ghanaian children showed 93.3% success.

Epidemiology and recurrence rate of pterygium post excision in Ghanaians.

OBJECTIVES: To determine the epidemiology and recurrence rate of pterygium after excision using bare sclera technique. DESIGN: Prospective non-comparative study. SETTING: Ophthalmology unit, Korle-Bu Teaching Hospital, Accra, Ghana. METHODS: The study involved 60 consecutive patients with primary apterygial from July 1998 to December 2000 who had bare sclera excision after informed consent. They were post-operatively followed up for 30-months. RESULTS: Thirty-five patients (58%) were females. The patients' ages ranged from 17-75 years, mean (±12.6). Overall recurrence was 22(37%). The main complications encountered include were granuloma 20 %(n=12), restriction in medial rectus muscle motility 2(3%), persistent vascularisation at excision site 2(3%) and adherence leucoma with uveitis 1(2%). No significant association was found between recurrence and pterygium morphology, calcification, allergy and occupation (indoor or outdoor). CONCLUSION: The recurrence rate after pterygium excision using bare sclera technique in Ghanaians is high (37%).

Combined trabeculotomy and trabeculectomy: outcome for primary congenital glaucoma in a West African population.

PURPOSE: To evaluate the surgical outcome of combined trabeculotomy-trabeculectomy in Ghanaian children with primary congenital glaucoma. MATERIALS AND METHODS: A retrospective case series involving 19 eyes of 12 consecutive children with primary congenital glaucoma who had primary trabeculotomy-trabeculectomy from 12 August 2004 to 30 June 2008, at the Korle-Bu Teaching Hospital, Ghana. Main outcome measures were preoperative and postoperative intraocular pressures, corneal diameter, corneal clarity, bleb characteristics, duration of follow-up, surgical success, and complications. RESULTS: A total of 19 eyes of 12 patients met the inclusion criteria. Six of the patients were males. Mean age at diagnosis was 4.4 (range 2-8) months. Mean age at surgery was 5.9 months (range 3-16). Eight (67%) infants had bilateral disease. Mean duration of follow-up was 13.1 (range 5-38) months. The preoperative mean horizontal corneal diameter was 13.4 ± 1.1(range 12-16) mm. Complete success (intraocular pressure <21 mm Hg) was obtained in 15 (79%) eyes. The probability of success was 94.4, 83.3, 66.7, 44.4, 38.9, 33.3, and 13.3% at 3, 6, 9, 12, 15, 18, and 21 months, respectively (Kaplan-Meier analysis). All eyes had corneal oedema preoperatively. Seventeen eyes (90%) had clear cornea at their last follow-up. Mean preoperative and postoperative intraocular pressures were 30.3 ± 8.8 and 18.1 ± 6.8 mm Hg respectively (P<0.001, t-test). Twelve (63%) eyes had well-functioning blebs at the last follow-up. One eye (5%) developed seclusio pupillae and cataract postoperatively. CONCLUSION: The overall success for combined trabeculotomy-trabeculectomy in Ghanaian children with primary congenital glaucoma was 79%. The probability of success reduced from more than 66% in the first 9 months postoperatively to below 45% after that.

Presentation of retinoblastoma at a paediatric eye clinic in ghana.

BACKGROUND: Retinobalstoma, the commonest childhood malignant intraocular tumour, is usually diagnosed early with over 90% survival rate in developed countries. In developing countries, the diagnosis is late resulting in less than 50% survival. OBJECTIVE: To determine retinoblastoma stages at presentation and patients' outcomes. DESIGN: Retrospective case series. METHODS: The clinical and histopathological records of children with retinoblastoma seen from May 2004 to December 2005 were studied. Data was analysed for mode of presentation, laterality, clinical staging using Reese-Ellsworth (R-E) classification, histopathological high risk features (HHRF) for metastasis, and patient outcome. SETTING: Ophthalmology Unit, Korle-Bu Teaching Hospital, Ghana. RESULTS: Twenty-three patients presented with retinoblastoma over the period. Males were 12(52.2%). The age range from 1 to 84 months, mean 36.3(±22.15) and median (36 months). Nineteen (82.6%) had unilateral and 4(17.4%) bilateral disease. The common clinical presentations were leukocoria in 20(87.0%), proptosis 8(34.8%), strabismus 5(21.7%) and red eye 5(21.7%). The clinical features were commensurate with R-E stage V in 20(87.0%) patients, 2(8.7%) with orbital recurrence and 1(4.3%) with post-enucleation anophthalmos. HHRFs were present in 9(75%) enucleated eyes with invasion of optic nerve as the commonest site (7/9). The patients were followed up for 1 day to 19 months. Eight abandoned treatment, 2 were discharged for palliative treatment, 2 out of 5 with metastasis died and 6 had no metastases at their last visit. Common sites for metastasis were the bone marrow, brain and orbit. CONCLUSION: Majority of the patients presented with advanced disease manifesting as leukocoria, proptosis, RE stages V disease and poor outcome.

Causes of childhood visual impairment and unmet low-vision care in blind school students in Ghana.

The purpose of this study was to determine the causes of childhood visual impairment and blindness in students of a school for blind children, to determine how many students had some residual vision, and to evaluate any unmet low-vision care. A survey of students in the blind school was conducted in two parts in May-June and then October 2003. The sample consisted of 201 students who became blind before the age of 16. Information was obtained from student interviews, doctors' referral notes and ophthalmic examination of all students who consented. Students with residual vision had low-vision assessments. These investigations were supplemented with active participation of the investigators in Parent-Teacher Association meetings and focus group discussions with parents. One hundred and ninety-nine students consented and were recruited, whereas two declined. Ninety-six became visually impaired within their first year of life and 33 by the age of 5 years. Pathology of the cornea and then the lens were the commonest causes of blindness. One hundred and eight students were totally blind, whereas 87 (43.7%) had some residual vision and formed the target for the second part of the study. Fifty-one out of 77 of this target group who turned up for low-vision examination had useful residual vision by the World Health Organisation (WHO) low-vision examination chart. Spectacle magnifiers aided two students to read normal print at N5 and N8, respectively. Different visual aids would help enhance the residual vision in some of the others. Emotional trauma was apparent in parents and teachers. Children who became blind later in life remained in shock for a longer time and adapted less well to their visual impairment. Visual impairment in the population is not uncommon. Some causes are preventable. There is a significant unmet need for low-vision care, particularly amongst children in Ghana, and perhaps many countries in the West Africa subregion. It is hoped that the findings from this study will help spur sustained interventions.

Evaluation of risk factors for advanced glaucoma in Ghanaian patients.

PURPOSE: This study was to determine factors associated with individuals presenting late with advanced glaucomatous optic nerve damage. METHODS: A case-control study recruiting 123 patients with early features of primary open angle glaucoma (control) and 93 patients with advanced glaucoma (cases) was carried out for risk-factor analysis. Exposures of interest included those already established as major risk factors for glaucoma. These were initial intraocular pressure (IOP), age, and family history. In addition, occupation, ethnic origin, history of diagnosis of diabetes mellitus, hypertension, sickle cell disease, and previous eye examination were of interest. RESULTS: Univariate analysis showed that initial IOP>31 mmHg, age of > 60 years, absence of family history of glaucoma, occupational grouping, ethnicity, and male sex were associated with advanced glaucoma at presentation. Adjusted odds ratio or by multiple logistic regression model showed that initial IOP>31 mmHg in a patient was more likely to present with advanced glaucoma (OR 2.66, 95% confidence interval (CI) 1.45, 4.91; P-value 0.0017) than lower pressures. Patients aged 60-69 years (OR 2.53, 95% CI 1.01, 6.31; P-value 0.0473) and 70-90 years (OR 5.16, 95% CI 1.97, 13.51; P-value 0.0008) were more likely to present with advanced glaucoma than younger ones CONCLUSIONS: Subjects with initial IOP>31 mmHg were nearly three times more likely to present with advanced glaucoma than those with IOP<32 mmHg. Subjects over the age of 60 years were more than two times likely to present with advanced glaucoma than younger subjects.

Prevalence of glaucoma in an African population.

PURPOSE: To determine the prevalence of primary open-angle glaucoma (POAG) in a Ghanaian population aged 30 years and above and to describe any ethnic variations in glaucoma prevalence in this population. METHOD: A cross-sectional prevalence survey for POAG was carried out on residents of 30 years and above in the Akwapim-South district of Ghana. The principal investigator examined all glaucoma suspects and those diagnosed as glaucoma in the initial screening to determine all definite cases of POAG. All cases had intraocular pressure measurements. Glaucoma cases and suspects and some normal subjects had fundus biomicroscopy with 78 D Volk lens, and Humphrey FDT N-30 visual fields plotted. RESULTS: A total of 1843 people aged 30 years were screened from the population. The standardized age-specific prevalence was 7.7% (30 years and above) and 8.5% (40 years and above). The best-fit trend line for prevalence/age relationship was exponential. No gender or ethnic difference in prevalence was found. CONCLUSIONS: The prevalence of POAG in this population is high and comparable to those in black populations in Barbados and St. Lucia