Photographic grading to evaluate facial cleanliness and trachoma among children in Amhara region, Ethiopia.

BACKGROUND: Promotion of facial cleanliness is recommended for the elimination of blinding trachoma, largely because of observational studies that have found an association between various measures of facial uncleanliness and trachoma. However, when a field grader assesses both facial cleanliness and trachoma, associations may be biased. Assessment of photographs of the face and conjunctiva by masked graders may provide a less biased estimate of the relationship between facial cleanliness and trachoma. METHODS: Face photographs, conjunctival photographs, and conjunctival swabs were obtained on a random sample of 0-9-year-old children from each of 40 communities in Amhara region, Ethiopia. Face photographs were assessed for the presence of seven measures of an unclean face (i.e., wet nasal discharge, dry nasal discharge, wet ocular discharge, dry ocular discharge, food, dust/dirt, and flies) by three independent masked photo-graders. Conjunctival photographs were similarly graded in a masked fashion for signs of clinically active trachoma. Conjunctival swabs were processed for Chlamydia trachomatis DNA. RESULTS: Of 2073 children with complete data, 808 (39%) had evidence of clinically active trachoma, 150 (7%) had evidence of ocular chlamydia infection, and 2524 (91%) had at least one measure of an unclean face. Dry ocular discharge had the strongest association with clinically active trachoma (age- and sex-adjusted prevalence ratio [PR] 1.4, 95% CI 1.2-1.6) and ocular chlamydia infection (PR 1.9, 95%CI 1.3-2.9), although significant associations were observed between each of the measures of facial uncleanliness and trachoma. CONCLUSIONS: Masked assessment of face and conjunctival photographs confirmed prior observational studies that have noted associations between various measures of facial uncleanliness and trachoma. The causal relationship between facial uncleanliness and trachoma is unclear since many features used to measure facial cleanliness (e.g., ocular discharge, nasal discharge, and flies) could be consequences of antecedent ocular chlamydia infection. TRIAL REGISTRATION: NCT02754583, clinicaltrials.gov.

The Impact of Simulation-Based Trabeculectomy Training on Resident Core Surgical Skill Competency.

PRCIS: Simulation-based surgical education shows a positive, immediate, and sustained impact on core surgical skill competency in trabeculectomy among resident ophthalmologists in training. PURPOSE: To measure the impact of trabeculectomy, surgical simulation training on core surgical skill competency in resident ophthalmologists. MATERIALS AND METHODS: This is a post hoc analysis of the GLAucoma Simulated Surgery trial, which is a multicenter, multinational randomized controlled trial. Resident ophthalmologists from 6 training centers in sub-Saharan Africa (in Kenya, Uganda, Tanzania, Zimbabwe, and South Africa) were recruited according to the inclusion criteria of having performed zero surgical trabeculectomies and assisted in <5. Participants were randomly assigned to intervention and control arms using allocation concealment. The intervention was a 1-week intensive trabeculectomy surgical simulation course. Outcome measures were mean surgical competency scores in 8 key trabeculectomy surgical skills (scleral incision, scleral flap, releasable suturing, conjunctival suturing, sclerostomy, tissue handling, fluidity, and speed), using a validated scoring tool. RESULTS: Forty-nine residents were included in the intention-to-treat analysis. Baseline characteristics were balanced between arms. Median baseline surgical competency scores were 2.88/16 [interquartile range (IQR): 1.75-4.17] and 3.25/16 (IQR: 1.83-4.75) in the intervention and control arms, respectively. At primary intervention, median scores increased to 11.67/16 (IQR: 9.58-12.63) and this effect was maintained at 3 months and 1 year ( P =0.0001). Maximum competency scores at primary intervention were achieved in the core trabeculectomy skills of releasable suturing (n=17, 74%), scleral flap formation (n=16, 70%), and scleral incision (n=15, 65%) compared with scores at baseline. CONCLUSIONS: This study demonstrates the positive impact of intensive simulation-based surgical education on core trabeculectomy skill development. The rapid and sustained effect of resident skill acquisition pose strong arguments for its formal integration into ophthalmic surgical education.

Photographic grading for trachoma diagnosis within trachoma impact surveys in Amhara region, Ethiopia.

BACKGROUND: As countries reach the trachoma elimination threshold and cases of trachomatous inflammation follicular (TF) become rare, it becomes difficult to train survey graders to recognize clinical signs. We assess the use of photography as a grading tool, the efficiency of an in-country grading center and the comparability of field and photographic grading. METHODS: During January-February 2017 surveys in Amhara, Ethiopia, field graders assessed TF, trachomatous inflammation intense (TI) and trachomatous scarring (TS). Photographs were taken from each conjunctiva and later graded at the Gondar Grading Center (GGC) at the University of Gondar in Amhara. Two trained ophthalmology residents graded each set of photographs and a third grader provided an adjudicating grade when needed. RESULTS: A total of 4953 photographs of 2477 conjunctivae from 1241 participants in 10 communities were graded over 5 d at the GGC. Six examined participants were not photographed. Agreement between field and photographic grades were for TF: percent agreement (PA) 96.7%, κ=0.70 (95% confidence interval [CI] 0.64 to 0.77; for TI: PA 94.7%, κ=0.32 (95% CI 0.20 to 0.43); and for TS: PA 83.5%, κ=0.22 (95% CI 0.15 to 0.29). CONCLUSIONS: Conjunctival photography may be a solution for programs near the elimination threshold where there are few available community cases for training field graders.

Simulation-based surgical education for glaucoma versus conventional training alone: the GLAucoma Simulated Surgery (GLASS) trial. A multicentre, multicountry, randomised controlled, investigator-masked educational intervention efficacy trial in Kenya, South Africa, Tanzania, Uganda and Zimbabwe.

BACKGROUND/AIM: Glaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma. METHODS: We designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months. RESULTS: Twenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, p<0.001). At 1 year, the mean surgical competency score of the intervention arm participants was 28.6 (71.5%), compared with 11.6 (29.0%) for the control (difference 17.0, 95% CI 14.8 to 19.4, p<0.001). CONCLUSION: These results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery. TRIAL REGISTRATION NUMBER: PACTR201803002159198.

Refractive Outcome of Cataract Surgery Done at University of Gondar Tertiary Eye Care and Training Center, North West Ethiopia.

PURPOSE: According to World Health Organization (WHO), cataract is the leading cause of blindness and visual impairment throughout the world. Post-operative refractive error is one of the commonest reasons for poor visual outcome after cataract surgery especially in developing countries where the standard modern biometry equipments are not available. The objective of this study was to assess the refractive outcome of cataract surgery done at University of Gondar (UoG) Tertiary Eye Care and Training Center, North West Ethiopia. METHODS: A descriptive cross-sectional study was done on 66 patients who had undergone manual small incision cataract surgery (MSICS) and fulfilled the inclusion criteria at UoG Tertiary Eye Care and Training Center from July 15 2019 to October 15 2019. RESULTS: From 90 post-operatively refracted eyes, 58 (64.4%) eyes achieved a target refraction of ±1.00 Diopter (D). The right and left eyes achieved mean post-operative refraction SE of -0.073±1.45D and -0.93±1.70 D, respectively. But only 54 (60%) eyes were implanted with the calculated IOL power and for the remaining 40% the calculated IOL was not available at the store. And the target (Good) post-operative uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) was achieved in 66.7% and 82.2% eyes, respectively. CONCLUSION: The post-operative refractive outcome after cataract surgery at the center is low. For over one-third of operated eyes, the calculated IOL was not implanted due to the absence of the required IOL power at the store and, therefore, a wide range of IOL power should be available at the center.

Awareness of Glaucoma and Associated Factors Among Adults in Gish Abay Town, Northwest Ethiopia.

PURPOSE: The purpose of this study was to determine the awareness of glaucoma and associated factors among adults living in Gish Abay town, Northwest Ethiopia. METHODS: A population-based cross-sectional study was conducted on 594 adults who were selected using systematic random sampling from April to May 2018. Data were entered into Epi Info version 7 and were analyzed by SPSS version 23. Binary and multivariable logistic regression was used to determine factors associated with awareness. Variables with P-value < 0.05 were considered statistically significant. RESULTS: The proportion of awareness of glaucoma was 24.4% [95% CI; 21.0, 28.1]. It was positively associated with educational status, primary education [AOR: 3.15; 1.72, 5.77], secondary education [AOR; 3.11: 1.66, 5.84], college and above [AOR; 6.10; 2.80, 13.27], history of eye examination [AOR: 6.52; 3.46, 12.25], income level >2000 Ethiopian birr [4.65; 2.59, 8.37] and history of chronic diseases [AOR; 2.93: 1.25, 6.85]. CONCLUSION: The status of glaucoma awareness in Gish Abay town can be said to be low as compared to studies. Higher educational status, eye examination, history of chronic diseases and better income level were significantly associated with awareness of glaucoma.

Knowledge of glaucoma and associated factors among adults in Gish Abay town, Northwest Ethiopia.

BACKGROUND: Glaucoma is a global public health problem and it is the leading cause of irreversible blindness worldwide. Even though public knowledge of glaucoma is a key for early case identification and prevention of blindness, it is unknown in the study area, making provision of interventions difficult. Therefore, this study was intended to assess knowledge of glaucoma and associated factors among adults in Gish Abay town, Northwest Ethiopia, 2018. METHODS: A Community based cross - sectional design study with systematic random sampling technique was used to select 630 adults. The study was conducted from April to May, 2018. Data was entered into Epi Info version 7 and was analysed by Statistical Package for Social Sciences version 23. Binary logistic regression model and adjusted odds ratio with 95% confidence level was used to identify the significant factors associated with knowledge of glaucoma. Variables with P-value ≤0.05 was considered statistically significant. RESULTS: About 594 adults were participated with a response rate of 94%. Above half of (52%) the participants were females with median age of 28 years. The proportion of good knowledge was demonstrated in 16.8% [95% CI; 14.0, 19.9]. Educational status: primary education [AOR; 2.89: 1.41, 5.90], secondary education [AOR; 3.03: 1.47, 6.24] college and above [AOR; 5.18: 2.21, 12.13], history of eye examination [AOR; 6.52: 3.37, 12.63]; family history of glaucoma [AOR; 12.08: 4.13, 35.30] and higher income level [AOR; 3.11: 1.55, 6.25] were positively associated with good knowledge of glaucoma. CONCLUSIONS: The proportion of good knowledge of glaucoma was low. Higher educational status, positive family history of glaucoma, eye examination and higher income level were significantly associated with knowledge of glaucoma.

Ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) for trabeculectomy.

BACKGROUND/AIMS: To develop, test and determine whether a surgical-competency assessment tool for simulated glaucoma surgery is valid. METHODS: The trabeculectomy ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) was assessed for face and content validity with a large international group of expert eye surgeons. Cohorts of novice and competent surgeons were invited to perform anonymised simulation trabeculectomy surgery, which was marked using the Sim-OSSCAR in a masked fashion by a panel of four expert surgeons. Construct validity was assessed using a Wilcoxon rank-sum test. Krippendorff's alpha was calculated for interobserver reliability. RESULTS: For the Sim-OSSCAR for trabeculectomy, 58 of 67 surgeons (86.6%) either agreed or strongly agreed that the Sim-OSSCAR is an appropriate way to assess trainees' surgical skill. Face validity was rated as 4.04 (out of 5.00). Fifty-seven of 71 surgeons (80.3%) either agreed or strongly agreed that the Sim-OSSCAR contents represented the surgical technique of surgical trabeculectomy. Content validity was rated as 4.00. Wilcoxon rank-sum test showed that competent surgeons perform better than novices (p=0.02). Interobserver reliability was rated >0.60 (Krippendorff's alpha) in 19 of 20 steps of the Sim-OSSCAR. CONCLUSION: The Sim-OSSCAR for trabeculectomy, a newly developed and validated assessment tool for simulation glaucoma surgery, has validity and reliability. It has the potential to play a useful role in ophthalmic surgical education.

Hospital based surveillance of congenital rubella syndrome cases in the pre-vaccine era in Amhara Regional State, Ethiopia: A base line information for the country.

BACKGROUND: Rubella virus infection in early pregnancy lead to serious multi-organ birth defects known as congenital rubella syndrome (CRS). The incidence of CRS varies in different populations and the highest burden is found in developing countries in which rubella vaccination is not included in their national immunization programs. In Ethiopia, there is scarcity of data about congenital rubella syndrome. Therefore, the aim of this study was to determine the burden of CRS-related birth defects and its incidence in the pre-vaccine era in Amhara Regional State, Ethiopia. MATERIALS AND METHODS: A cross sectional study was conducted in Dessie, Felege-Hiwot and University of Gondar Referral Hospitals, from December 2015 to August 2017. After getting informed assent from each parent/guardian, blood was collected from infants < 1 year of age for laboratory determination of anti-rubella virus antibodies. Their socio-demographic data and clinical information compatible with congenital rubella syndrome were collected using WHO guideline. RESULTS: During the study period, a total of 50 infants suspected for congenital rubella syndrome were included in the study. All infants suspected for CRS were tested against rubella specific IgM and IgG [for infants ≥ 6 months of age] antibodies using ELISA method. Of these, 9/50 (18%) and 4/14 (28.6%) of them were laboratory confirmed and potential CRS cases, respectively. In the present study, the most common laboratory confirmed defect was ocular manifestations 6 (66.7%) followed by heart related problems 5 (55.6%). In the present study, most of the laboratory confirmed cases (66.7%) were reported among 1-5 months of age infants. In addition, 5 (55.6%) of the infants with laboratory confirmed CRS cases were male and 6 (66.7%) of them were from urban settings. In this study, the incidence of CRS was 0.4 per 1000 live births. CONCLUSION: In this study, nearly one fifth of the infants had laboratory confirmed congenital rubella syndrome and most of them had multiple rubella associated congenital defects at a time. Most of these congenital anomalies were reported among infants ≥ 1 month of age. Based on our result, the incidence of the CRS was line with the global incidence of the CRS in the pre-vaccine era. Therefore, establishing strong rubella/CRS surveillance system as well as introducing the rubella containing vaccine in the national immunization program might be important to reduce the burden of rubella and CRS in the country.

Bilateral Orbital Pseudotumor in a 3-Year-Old Child: A Case Report.

Orbital pseudotumor is a rare, idiopathic, inflammatory process within the orbit. Early diagnosis is essential to prevent corneal, retinal and extraocular muscle damage. This article describes the presentation and clinical course of a 3-year-old male with bilateral orbital pseudotumor.

Active trachoma two years after three rounds of azithromycin mass treatment in Cheha District Gurage Zone, Southern Ethiopia.

BACKGROUND: Azithromycin mass distribution was given to residents of Gurage zone Cheha district in 2004, 2005 and 2006 for three consecutive years with more than 90% coverage. The effect of treatment in the study community was not yet determined. The present study was therefore designed to assess the effect of azithromycin on the prevalence of active trachoma two years after three rounds of mass treatment of the community at Cheha district, Gurage zone. METHODS: A multistage stratified cluster random survey was employed to determine the prevalence of active trachoma among children aged 1 to 9. Selected children were examined for trachoma using the simplified WHO grading system and their households were assessed for trachoma risk factors. RESULTS: This survey demonstrated that the prevalence of active trachoma in the study community was 22.8% (95% CI 18.24% - 27.36%) that was lower than that of Southern Nations, Nationalities, and People's Regional prevalence (33.2%) in 2006. Only 27.6% (95% CI 25.7% - 30.1%) of the study population had a safe and clean water supply, whereas 42.7% (95% CI 39.8% - 46.2%) of the visited households had simple pit latrines. CONCLUSION: This survey demonstrated that despite repeated mass oral azithromycin distributions, the prevalence of active trachoma was still high. Therefore, the other components of the SAFE strategy such as fly control program, improving the water sources, measures to improve face washing and construction of utilizable latrines that are being implemented through the health extension package have to be integrated with mass azithromycin treatment to eliminate active trachoma in the district.

Chldren's rights and corporal punishment in Assendabo town and the surrounding area, South West Ethiopia.

Corporal punishment of children has been used as a disciplinary measure to modify undesirable behavior of children worldwide. This study was conducted with the aim of determining the knowledge, attitudes and the extent that corporal punishment is practiced in the study area. A cross-sectional study was conducted among the residents of Assendabo town and its surroundings area form January 8-12, 2003. A total of 368 residents with at least one child living with them were selected and interviewed using a structured questionnaire. Data were analyzed using SPSS for windows version 11.0. The study revealed 310 (87.6%) of the parents employed child corporal punishment as a method of disciplining out of which nearly half of them claimed their action was for the ultimate benefit of their children. Only 12 (3.5%) of the parents reported infliction of trauma while punishing their children. There was no significant parental difference both in attitude and practice of child corporal punishment. Family income is found to affect both attitude and practice of corporal punishment. From this study it is concluded that the knowledge about the existence of a legal framework which protects a child from any form of abuse is low. The attitude towards avoidance of child corporal punishment is unfavorable and there is a high prevalence of child corporal punishment practiced.