Outcome of retinoblastoma in east Africa.

We estimated the proportion of patients reaching a pediatric ophthalmology unit (Comprehensive Community Based Rehabilitation for Tanzania Disability Hospital, CCBRT) or an oncology unit (ORCI) in east Africa and investigated presentation, histology, and treatment outcomes of patients with retinoblastoma. A 5-year retrospective study identified 91 patients, representing approximately 18% of the nationwide total. Mean lag time was 10 months (standard deviation (SD) = 17) and mean follow-up was 8 months (SD = 11, range 0-40, n = 91). Thirty months disease-free survival probability was 0.23 (standard error = 0.07). Outcomes for retinoblastoma in Africa remain poor. The data presented here suggest strategies for improving the outcomes, including encouraging earlier presentation and establishment of multi-disciplinary treatment centers.

Long term outcome of trichiasis surgery in the Gambia.

BACKGROUND: Trichiasis surgery is believed to reduce the risk of losing vision from trachoma. There are limited data on the long term outcome of surgery and its effect on vision and corneal opacification. Similarly, the determinants of failure are not well understood. METHODS: A cohort of people in the Gambia who had undergone surgery for trachomatous trichiasis 3-4 years earlier was re-assessed. They were examined clinically and the conjunctiva was sampled for Chlamydia trachomatis polymerase chain reaction (PCR) and general bacterial culture. RESULTS: In total, 141/162 people were re-examined. Recurrent trichiasis was found in 89/214 (41.6%) operated eyes and 52 (24.3%) eyes had five or more lashes touching the globe. Corneal opacification improved in 36 of 78 previously affected eyes. There was a general deterioration in visual acuity between surgery and follow up, which was greater if new corneal opacification developed or trichiasis returned. Recurrent trichiasis was associated with severe conjunctival inflammation and bacterial infection. C trachomatis was detected in only one individual. CONCLUSIONS: Recurrent trichiasis following surgery is a common potentially sight threatening problem. Some improvement in the cornea can occur following surgery and the rate of visual loss tended to be less in those without recurrent trichiasis. The role of conjunctival inflammation and bacterial infection needs to be investigated further. Follow up of patients is advised to identify individuals needing additional surgical treatment.

Primary open-angle glaucoma presentation at a tertiary unit in Africa: intraocular pressure levels and visual status.

AIM: To investigate the presentation of POAG at a tertiary referral hospital in East Africa, including intraocular pressures, visual status and management decisions. METHODS: Retrospective review of first-time presenters with POAG over a 6-month period. RESULTS: Of the 298 patients identified, mean age 57 years (n = 296, range = 14-88, SD = 14), 213 (72%) male, 122 (41%) had normal vision (using WHO better eye acuity criteria: visual impairment < 6/18, blind < 3/60) at presentation, 87 (30%) had visual impairment and 86 (29%) were blind. The mean presenting IOP was 32 mmHg (SD = 11) and 70% of the patients had a cup:disc ratio of 0.8 or worse in the better eye. Longer disease duration (OR = 1.20, 95% CI 1.04-1.39) and higher mean IOP (OR = 1.06, 95% CI 1.02-1.10) were associated with visual impairment or blindness. Intraocular pressure showed a negative linear correlation with presenting logMAR acuity (R(2) = 0.115, SE = 1.30, p < 0.0005). The mean IOP in eyes that had undergone trabeculectomy (19 mmHg, SD = 8, n = 17) was significantly (p < 0.0005) lower than that in eyes that had not (34 mmHg, SD = 12, n = 274). The referral rate for trabeculectomy was 158/275 (57%). Male sex (OR = 2.17, 95% CI 1.0-4.72), higher mean IOP (OR = 1.09, 95% CI 1.05-1.14) and not being blind (OR = 26.47, 95% CI 9.90-70.78) were associated with surgical referral. Of the 158 patients, 76 (48%) accepted surgery. CONCLUSIONS: A high proportion of patients presenting to our unit with POAG are visually impaired or blind and the higher their presenting IOP the poorer their visual acuity. Previous trabeculectomy was associated with lower IOPs and protection from visual impairment and blindness. Further training of clinic staff towards early surgical referral and investigation of gender barriers is required.

An ultrasound based classification of periocular haemangiomas.

AIMS: To propose a classification system for periocular haemangiomas based on ultrasound evaluation. METHODS: Retrospective review of ultrasound images from children seen in the authors' unit with periocular haemangiomas. Static ultrasound images from 50 patients with periocular haemangiomas were reviewed as identified from a computerised database. Each haemangioma ultrasound image was classified into three categories: (1) preseptal only; (2) preseptal + extraconal; (3) preseptal + extraconal + intraconal. These were compared with the categories given to each patient at first presentation after dynamic scanning. RESULTS: Classification was possible from the static images in 44 (88%) cases. Of those classified 20 (45%) were preseptal only; 17 (39%) were preseptal + extraconal, and seven (16%) had an additional intraconal component. The classification in all 44 cases was the same as that given at the time of presentation. In the small number of cases which went to surgery or had neuroimaging, the ultrasound classification was confirmed. CONCLUSIONS: Ultrasound classification was not difficult to perform and no child needed sedation or general anaesthesia for this exam. Ultrasound anatomical classification is an important first step in determining appropriate treatment of periocular haemangiomas. The authors present what they believe to be the first such classification.

Longitudinal study of trachomatous trichiasis in the Gambia.

AIM: Investigation of the natural history of trachomatous trichiasis in the Gambia and of the outcome of self epilation and surgery for the condition. METHODS: A 1 year longitudinal study of 190 subjects with trichiasis was performed. Major trichiasis cases (five lashes or more) were referred for surgery and minor trichiasis cases were advised to epilate. Outcome measures included progression of trichiasis and corneal scarring; attendance for and results of surgery. RESULTS: 34 of 148 (23%, 95% CI 16 to 31) subjects with major trichiasis attended for surgery over the year. Progression from minor to major trichiasis occurred in 18 of 55 subjects (33%, 95% CI 21 to 47). Progression of corneal scarring occurred in 60 of 167 patients (36%, 95% CI 29 to 44). Clinically active trachoma and conjunctival bacterial isolation predicted progression of corneal opacity. Surgery was successful in 39 of 54 (72%) eyes. CONCLUSIONS: Despite the overall decline in trachoma in the Gambia, patients with both minor and major trichiasis remain at risk of developing corneal opacity. Active trachomatous inflammation and additional infection with bacteria may accelerate this process. Antibiotic treatment for trichiasis patients (in addition to surgery) should be investigated. Surgery for minor trichiasis may be indicated. Regular audit of surgical results is necessary with retraining where needed.

Azithromycin for the treatment and control of trachoma.

Trachoma, a recurrent follicular conjunctivitis caused by Chlamydia trachomatis, is the leading cause of preventable blindness worldwide. Efforts to control this disease have met with limited success. This failure is due in part to the limitations of conventional antibiotic treatment, a prolonged course of topical tetracycline. Azithromycin, an azalide antibiotic, is effective against chlamydial infections when given as a single oral dose. Recent research from Africa has shown azithromycin to be as effective as tetracycline in the treatment of trachoma. Under operational conditions azithromycin proved to be more effective. This success is attributed to a much-improved compliance with treatment. Community-wide mass treatment with azithromycin is advocated as a means of controlling trachoma in endemic countries. Questions still remain over the use of azithromycin for this purpose. The frequency and target population of mass distribution campaigns need to be defined. A few countries are beneficiaries of a philanthropic donation by the manufacturer of azithromycin, Pfizer Inc. However, in the absence of a drug donation programme the cost-effectiveness of this measure is unclear.

Combined cataract and trabeculectomy surgery for advanced glaucoma in East Africa; visual and intra-ocular pressure outcomes.

AIM: To investigate visual and intra-ocular pressure (IOP) outcomes of combined cataract and glaucoma surgery at a high-volume centre in East Africa carried out over a 1-year period (2006). METHODS: A retrospective analysis of patient records. RESULTS: A total of 163 patients were identified. Mean age was 67 years (SD 11, range 21-86 years) and 113 (69%) were men. Presenting visual acuity in the operated eye was 6/60 or worse in 135/163 (93%) and was <3/60 in 76 of 163 (47%) patients. Mean presenting IOP was 28 mm Hg (SD 9, range 12-60). Pre-operative cup disc ratios were 0.8 or worse in 131 of 163 (85%) patients. Phacotrabeculectomy (PT) was carried out in 130 (80%) cases, small incision cataract surgery trabeculectomy (SICST) in 10 (6.1%) cases, and extra-capsular cataract extraction trabeculectomy (ECCET) in 23 (14.1%) cases. In all, 107 (66%) attended for follow-up (mean interval 104 days, range: 6-390 years, SD 88) and at follow-up 75 (70%) patients had improved visual acuity pre-operatively. Pre-operative cup disc ratio of 0.9 or greater predicted failure to improve VA at follow-up (OR 4.0 95% confidence interval (CI) 1.30-12.1). Fifty-nine (62% (95%CI 52-71%)) patients had follow-up IOPs of 6-15 mm Hg and 82 (85% (95% CI 78-92%)) had follow-up IOPs of 6-20 mm Hg. CONCLUSION: Combined surgery produces visual benefit for most patients with similar pressure control to pure trabeculectomy and is therefore a useful option in practises where follow-up may be doubtful.

Optic neuropathy endemic in secondary school children in Dar es Salaam, Tanzania.

AIM: To investigate the prevalence and causes of optic neuropathy, reported as epidemic in 1997, among secondary school students in Dar es Salaam, Tanzania. PATIENTS AND METHODS: First year students (n = 10,892) from 63 secondary schools located within 30 km from the base hospital were interviewed and had a visual acuity (VA) screening test. Students failing the 6/12-line in either eye were defined as having "poor eyesight" and referred to the base hospital where an optometrist re-tested VA and refracted them. An ophthalmologist examined students with VA of 6/12 or worse in either eye and visual impairment was defined as VA of worse than 6/12 with best correction. Associations between optic neuropathy, socioeconomic status and educational results were investigated. RESULTS: Students' ages ranged from 12 to 22 (mean 15.2) years; 50.6% were male. The prevalence of optic neuropathy was 0.3 (SD 0.051)%. The condition affected older students and was associated with the family having fewer economic possessions (car, computer, television). Optic neuropathy accounted for 19/33 (58%) of bilateral visual impairment cases. No effect of the disease on educational performance was identified. CONCLUSION: Optic neuropathy remains a significant problem in this population and can now be termed endemic rather than epidemic. Further research into its causes is required.

Use of cataract services in eastern Africa--a study from Tanzania.

PURPOSE: To establish the proportion of patients who are blind or have low vision prior to undergoing cataract surgery at tertiary referral centers in Tanzania. To assess which patient groups presenting for cataract surgery are more likely to be blind or visually impaired. METHODS: Using pre-existing computerized audit systems we gathered data on pre-operative visual status, age, gender and presentation mode (walk-in or outreach) for 3765 patients undergoing 4258 cataract operations at 2 hospitals in Tanzania. Visual status was defined based on vision in the better eye. RESULTS: 32% of operations were performed on blind patients, 37% on patients with low vision and 31% on normally sighted patients. Predictors of blindness at presentation were: female sex (OR 1.15; 95% CI 1.00-1.32); referral from a rural outreach program (OR 1.75; 95% CI 1.51-2.02) and older age (OR 1.02; 95% CI 1.01-1.02). CONCLUSIONS: It is not only the blind who present to cataract services in Tanzania. The demand for surgery amongst patients who or are normally sighted represents a positive move towards prevention, and not only cure of cataract blindness in Tanzania. However, it also highlights the need to target those left blind from cataract in order to deliver services to those most in need. Cataract programs targeting patients in rural areas and older patients are likely to increase the number of blind patients benefiting from cataract services.

How should blindness in children be managed?

BACKGROUND: In all, 1.4 million children are estimated to be blind worldwide and only 6.5% of these are thought to come from the more affluent countries. The focus of this paper is therefore the developing world and Africa in particular, where evidence suggests that congenital cataract is becoming the leading cause of childhood blindness. METHODS: A review of the literature on management of congenital cataract was combined with original data from the author's experience in east Africa. CONCLUSIONS: Health service structure, surgical technique, health education, and community screening to promote early referral, good surgical follow-up, and training of multidisciplinary teams based at specialist children's eye centres are all essential components for effective strategies to control childhood blindness due to congenital cataract.

Ocular and systemic side effects of brimonidine 0.2% eye drops (Alphagan) in children.

INTRODUCTION: Brimonidine 0.2% (Alphagan) is a topical alpha-2 agonist widely used as an antihypertensive. There have been occasional reports of systemic adverse effects in children including apparent central nervous system depression. There are few data available on the overall safety of brimonidine 0.2% in children. METHODS: Computerised pharmacy records were used to identify all children who had been prescribed brimonidine 0.2% in our eye department between August 1999 and June 2001, and their notes were reviewed. RESULTS: In all, 23 patients were identified from pharmacy records and 22 sets of notes were recovered and reviewed. The mean age at commencement of treatment was 8 years (range 0-14 years). In all, 10 (46%) were treated in one eye and 12 (54%) in both. Brimonidine 0.2% was taken for a mean 14 months (range 1 day-75 months). A total of 14 (64%) patients were already taking a topical beta-blocker when brimonidine 0.2% was commenced and a further four (18%) were being treated with another topical hypotensive agent. Of the 22 patients, six (27%) had to stop brimonidine 0.2% because of adverse side effects (two because of local irritation/allergy, two because of tiredness, and two because of fainting attacks). DISCUSSION: Many topical hypotensive agents are not licensed for use in children and few safety data are available. In this study, 18% of children had systemic adverse effects sufficient to necessitate stopping the drug. It is possible that educational impairment may have passed unnoticed in others. Larger studies are required to investigate this further.

Reliability of telemedicine for diagnosing and managing eye problems in accident and emergency departments.

OBJECTIVES: To assess the accuracy and efficiency of telemedicine in diagnosing and managing eye problems presenting to accident and emergency departments. DESIGN: A controlled trial with a face-to-face and telemedicine phases, each involving 40 patients undergoing two consecutive consultations. In the face-to-face phase, both consultations were in person; in the telemedicine phase, observer 1 used videoconferencing technology at 384 kbit/s (separate nonslit lamp-torchlight and slit lamp examinations) and observer 2 saw the patient face to face. Setting The accident and emergency department at Moorfields Eye Hospital.Participants In total, 80 consenting new patients presenting to the department. MAIN OUTCOME MEASURES: (1) Agreement levels between the two observers for each phase (judged by an independent masked investigator), (2) length of consultation, and (3) number of unnecessary recalls. RESULTS: Agreement rates were as follows. Face-to-face phase: total agreement (30/40=75%), trivial disagreement (8/40=20%), clinically important disagreement (2/40=5%). Telemedicine phase (torchlight): complete agreement (16/40=40%), trivial disagreement (20/40=50%), clinically important disagreement (4/40=10%). Telemedicine phase (slit lamp): total agreement (23/40=58%), trivial disagreement (15/40=37%), clinically important disagreement (2/40=5%). Agreement levels in the telemedicine phase with torchlight examination were significantly lower (chi(2)=10.07, P=0.007) for any disagreement. Telemedicine consultations erred on the side of clinical caution and were no slower than face-to-face consultations (mean 6 min for observer 1 in both phases). Recalls were more likely (chi(2)=5.16, P=0.02) after telemedicine consultations with torchlight only (9/40) compared with face-to-face consultations (2/40). Although there were more significant disagreements using the telemedicine, in each case the telemedicine diagnosis and management erred on the side of safety; hence, no patient would have suffered by wrong management because of the consultation using telemedicine. CONCLUSIONS: Telemedicine was found to be an accurate, safe, and efficient method of diagnosing and managing these patients, especially if slit lamp images were used. Advice using telemedicine erred on the side of caution, which resulted in more recalls.

Non-trachomatous corneal opacities in the Gambia--aetiology and visual burden.

AIMS: National blindness surveys conducted in the Gambia in 1986 and 1996 showed an increase in blindness and visual impairment from non-trachomatous opacity. This study aimed to investigate the aetiology of these opacities and to assess the resulting visual burden. METHODS: A population-based, randomised blindness survey was conducted in the Gambia in 1996. Patients with visual impairment or blindness were examined by an ophthalmologist with a slit lamp. Causes of corneal opacity were determined as accurately as possible by clinical history and examination. RESULTS: A total of 154 patients with non trachomatous corneal opacity were examined of whom 39 had bilateral opacities and 115, unilateral. Causes included corneal infection, measles/vitamin A deficiency, harmful traditional practices and trauma (unilateral scarring). Overall, corneal pathology alone was responsible for bilateral visual impairment or blindness in 19 (12%) patients and unilateral visual impairment or blindness in 88 (57%) patients. Those patients with bilateral visual impairment or blindness (mean age 59, SD) were older (P= 0.003) than others (mean age 44, SD = 20). The use of harmful traditional eye practices was associated with bilateral corneal blindness or visual impairment (RR = 2.63, 95% CI 1.11-6.21, P = 0.04). Although none of the corneal scars reported here were attributed to trachoma, in patients over the age of 45, the prevalence of trachomatous conjunctival scarring in this group was 38.8% compared to 19.4% of the whole nationwide sample. DISCUSSION: Strategies for the prevention (including the quest for cheaper anti-microbial drugs and co-operation with traditional healers) and surgical treatment of these corneal opacities are discussed.