International travel to obtain medical treatment for primary retinoblastoma: A global cohort study.

Early diagnosis and treatment of retinoblastoma (Rb), the most common intraocular malignancy, can save both the child's life and vision. However, access to services and hence chances for survival and preserving the eye and its vision vary widely across the globe. Some families have to, or make a choice to, leave their home country to seek planned medical treatment abroad. We aimed to investigate how frequently this cross-border travel occurs and the factors associated with it. A total of 278 Rb centres in 153 countries were recruited to participate in a global cross-sectional analysis of newly diagnosed Rb patients in 2017. Number and proportions of children who travelled from their home country for treatment were analysed by country, continent, socioeconomic stratum and clinical and demographic features. The cohort included 4351 new patients of whom 223 [5.1%, 95% confidence interval 4.5-5.8] were taken across country borders for planned medical treatment. Independently significant predictors of travelling across borders included: being from a country with a smaller population, being from a country classified as low socioeconomic status, having bilateral Rb and having intraocular disease without extraocular spread. The factors that determine international travel for Rb treatment are complex and deserve further investigation. We may need to rethink the way services are delivered in the light of the threat of severe curtailment of international travel from pandemics like corona virus disease 2019.

Cataract surgery outcomes in bangladeshi children.

PURPOSE: To measure visual acuity (VA) outcomes, complication rates, and the social impact of cataract surgery in a cohort who underwent surgery as children in Bangladesh. DESIGN: Case series. PARTICIPANTS: A total of 471 of 850 children from 6 Bangladeshi districts who had been identified as cataract blind using key informants (KIs) between 2004 and 2009 during the Bangladesh Childhood Cataract Campaign (BCCC) together with all those children not included in the BCCC database but in the Child Sight Foundation (CSF) database who had been identified as cataract blind. METHODS: The subjects and families were contacted again by KIs and transported to local examination centers, where parents and subjects were administered a questionnaire and subjects underwent full ocular examination. Where operative data were available (15%), they were analyzed in conjunction with questionnaire and examination findings. Statistical analysis was performed using SPSS Statistics (IBM, Armonk, NY). MAIN OUTCOME MEASURES: Presenting and best-corrected visual acuities (BCVAs), cause(s) of poor outcome, postoperative refraction, and school attendance. RESULTS: A total of 407 of the participants had undergone bilateral surgery as children, with a mean follow-up of 8.8 years. The mean age at examination was 16 years (range, 5-28 years; standard deviation [SD], 4.6 years); 63% of those examined were male; 22% had a binocular presenting VA of >20/60; and 53% were severely visually impaired or blind (VA <20/200). After refraction, 33% had VA >20/60 in their better eye and 33% had VA <20/200. Factors that predicted poor VA in multivariate logistic regression analysis were nystagmus (P < 0.001), longer delay in presentation (P < 0.001), and magnitude of absolute spherical equivalent refractive error (P<0.001). Some 50% had nystagmus, and 69% of those currently aged ≤16 years were attending school. Better acuity was associated with school attendance (P < 0.001), whereas gender was not. CONCLUSIONS: Approximately one third of all participants had a BCVA of ≥20/60 in their better eye. Amblyopia and nystagmus limited visual outcome, indicating the need for earlier detection and treatment. This is the first study to show the link between pediatric cataract outcome and access to education, a millennium development goal.

Outcomes of goniotomy for primary congenital glaucoma in East Africa.

OBJECTIVE: To evaluate the effectiveness of goniotomy to treat primary congenital glaucoma in an east African population. DESIGN: A retrospective series using case records. For patients who underwent goniotomies in both eyes, only the first was analyzed. PARTICIPANTS: Forty-seven children undergoing goniotomy (47/80 operated eyes analyzed). Thirty-six children (77%) were male. Mean age was 19 months (range 1-204 months, standard deviation [SD] = 35). INTERVENTION: First goniotomy was performed from the temporal side. Repeat surgery, if necessary, was performed via nasal side approach and 100% ethanol-soaked cotton-tipped swabs were used to clear the corneal epithelium when necessary for angle visualization. MAIN OUTCOME MEASURES: Postoperative intraocular pressure (IOP) <21 mmHg was considered success. Potential risk factors for failure were analyzed. Quantitative visual acuities were measured with Cardiff acuity cards and Lea tests in older children. RESULTS: A total of 36 of 47 children (77%) returned for follow-up. Mean follow-up interval was 12 months (range, 1-62 months; SD = 15). A total of 28 of 47 children (60%) had >3 months of follow-up, and 11 children had >1 year of follow-up. A total of 12 of 47 eyes (26%) required repeat goniotomy. Three of these required further trabeculectomy with mitomycin C, 1 of which required eventual enucleation after failure to control IOP, enlargement, and pain. A total of 11 of 28 children (39%) with >3 months follow-up required repeat surgery. A total of 24 of 28 children (86%) with follow-up intervals of at least 3 months achieved postoperative IOPs of <21 mmHg. Mean IOPs decreased (t = 6.1, P < 0.0005) from 23.4 mmHg (SD = 5.3 mmHg) to 14.4 mmHg (SD = 7.6 mmHg). Only 1 predictor of failure to achieve successful control of IOP was identified: female gender (relative risk = 5.3, 95% confidence interval, 1.1-26.3). Corneas were clear in 4 of 47 eyes (8.5%) preoperatively and 32 of 41 eyes (78%) postoperatively. Of 25 children with preoperative and postoperative acuities measured, 22 (88%) recorded improvement. CONCLUSIONS: Preliminary results of goniotomy in an African population with advanced disease and late presentation are reasonably encouraging. Overall results are comparable with historical drainage procedures, with the advantage of preserving conjunctiva. Further studies are justified.

Outcomes of bilateral cataract surgery in Tanzanian children.

OBJECTIVE: To investigate outcomes of bilateral pediatric cataract surgery in east Africa. DESIGN: Retrospective interventional case series. PARTICIPANTS: Two hundred forty-three children who underwent bilateral cataract surgery at the Comprehensive Community-Based Rehabilitation for Tanzania Disability Hospital between 2001 and 2004. METHODS: Demographic, surgical, preoperative, and postoperative clinical characteristics obtained from patient records were entered into a database (Microsoft Excel; Microsoft, Redmond, WA), and statistical analysis was conducted using SPSS software for Windows (SPSS, Inc., Chicago, IL). MAIN OUTCOME MEASURES: Postoperative visual acuities and factors affecting them and postoperative refraction results. RESULTS: Intraocular lenses were inserted in the first eyes of 232 children (149 Alcon AcrySof [Alcon Laboratories, Fort Worth, TX], 83 polymethyl methacrylate [PMMA]). Fifty-eight (62%) of 94 patients with final follow-up acuities recorded in both eyes achieved 20/60 or better in their better eye and 13 (13%) of 94 patients were blind. Of the various predictors of good visual outcome identified for children or eyes, only absence of preoperative blindness (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.0-18.0; P<0.0005) remained significant in a multivariate logistic regression model. One hundred nine (51%) of 212 refracted first eyes had early postoperative refractive error spherical equivalent magnitudes of 2 diopters (D) or more. Ninety-nine (47%) of 212 eyes had initial postoperative cylinders of 3 D or more, dropping to 30 (18%) of 164 of those who had later follow-up refraction. Presence of biometric data was not associated with smaller postoperative refractive errors. Eyes with AcrySof lenses were less likely (OR, 2.5; 95% CI, 1.04-6.06) to have more than 3 D of astigmatism at latest follow-up. AcrySof lenses also were more likely (OR, 2.1; 95% CI, 1.2-3.7) to be fixated in the bag than PMMA lenses. Acute fibrinous uveitis occurred in 30 cases (12%), and transient corneal haze occurred in 20 cases (8%). Twenty-seven (11%) had chronic complications, 69 (28%) underwent a further general anesthetic procedure, and 9 (4%) underwent yytrium-aluminum-garnet capsulotomy. CONCLUSIONS: Preoperative blindness was the strongest predictor of poor postoperative visual outcome; the use of AcrySof lenses as opposed to PMMA lenses made in-the-bag fixation more likely and also reduced postoperative astigmatism.

The long-term natural history of trachomatous trichiasis in the Gambia.

PURPOSE: Trachoma is the leading infectious cause of blindness. However, there are few data on the natural history of trachomatous trichiasis to guide program planning or that investigate its pathogenesis. METHODS: A cohort of Gambians with trichiasis in one or both eyes who had declined surgery was observed. Clinical examinations were performed at baseline and 4 years later. Conjunctival swab samples were collected for Chlamydia trachomatis PCR and bacteriology. RESULTS: One hundred fifty-four people were examined at baseline and 4 years later (241 nonsurgical eyes). At baseline 124 (52%) eyes had major trichiasis (5+ lashes), 75 (31%) minor trichiasis (1-4 lashes), and 42 (17%) no trichiasis. By 4 years, trichiasis had developed in 12 (29%) of 42 previously unaffected eyes. Minor trichiasis progressed to major in 28 (37%) of 75 eyes. New corneal opacification more commonly developed in eyes that had major (10%) compared to minor (5%) trichiasis at baseline. Bacterial infection was common (23%), becoming more frequent with increasing trichiasis. C. trachomatis infection was rare (1%). Conjunctival inflammation was common (29%) and was associated with progressive trichiasis and corneal opacification. CONCLUSIONS: Trichiasis progressed in the long-term in this environment, despite a low prevalence of C. trachomatis. Blinding corneal opacification develops infrequently, unless major trichiasis is present. Epilation and early surgery need to be formally compared for the management of minor trichiasis. The pathologic correlates and promoters of conjunctival inflammation need to be investigated.

Operational evaluation of the use of photographs for grading active trachoma.

We evaluated the reliability of photographs to verify field diagnoses of active trachoma. We examined 956 residents of a trachoma-endemic village for signs of trachoma using the World Health Organization simplified grading system. Two photographs of the right eye of 948 persons were independently graded (masked to field assessment) by the field examiner and two other experienced graders. There was only moderate agreement between field assessment and the subsequent photographic evaluations by the three graders. When we counted ungradable photographs as disagreements, mean kappa scores for the signs trachomatous inflammation (follicular [TF]) and trachomatous inflammation (intense [TI]) were 0.44 and 0.51, respectively. There was also only fair-to-moderate agreement between the three assessments (by different examiners) of the photographs. Either the signs TF and TI themselves are not as reliable as previously believed, or photographs should be used for their diagnosis only when reliability testing demonstrates better agreement than found here.

Longitudinal study of trachomatous trichiasis in The Gambia: barriers to acceptance of surgery.

PURPOSE: Investigation of compliance with surgery for trachomatous trichiasis has become a priority of the World Health Organization. This study was conducted to investigate attitudes toward trichiasis and its treatment and to determine the rate of surgical uptake in The Gambia. METHODS: A 1-year longitudinal study was performed in 190 subjects with trichiasis. Persons with major trichiasis (involving five lashes or more) were referred for surgery, and those with minor trichiasis were advised to epilate. Outcome measures included attitudes toward trichiasis and its treatment, reported barriers to surgical uptake, acceptance rates for surgery, and factors affecting acceptance. RESULTS: Twenty-three percent (95% confidence interval [CI] 16.5%-30.6%) of subjects with major trichiasis attended for surgery during the year. Degree of ignorance about surgery, symptoms impeding work, and a multiple income source for the head of household predicted attendance. Reported lack of time predicted nonattendance. Sixty-eight percent of patients who had undergone surgery were trichiasis free at last follow-up. CONCLUSIONS: Poor attendance for surgery remains a problem in The Gambia. Barriers include ignorance and lack of time and money. Health education and surgical delivery strategies are needed to overcome these barriers. Regular audit of surgical results is necessary, with retraining where indicated.

Off-axis digital flash photography: a common cause of artefact leukocoria in children.

Leukocoria, a presenting sign in several significant pediatric ocular conditions, can be artefactually produced by off-axis flash photography in healthy eyes. The authors demonstrate the conditions needed to produce this phenomenon, which is more commonly seen in children due to their larger-sized pupils, photogenicity, and frequent off-axis shots.