A systematic review of network meta-analyses among patients with nonvalvular atrial fibrillation: A comparison of efficacy and safety following treatment with direct oral anticoagulants.

BACKGROUND: Direct oral anticoagulants (DOACs) are indicated for the prevention of stroke and systemic embolism (SE) in patients with nonvalvular atrial fibrillation. While no head-to-head randomized controlled trials (RCTs) exist that evaluate the efficacy and safety of DOACs, network meta-analyses (NMAs) based mainly on RCTs for each DOAC and using various methodologies have been published. This systematic literature review summarizes the evidence on stroke/SE bleeding events, mortality, and other adverse events from NMAs that reported indirect comparisons of DOACs. METHODS: Searches were conducted in PubMed, Embase, and the Cochrane Database of Systematic Reviews to identify NMAs published between January 2010 and March 2017 that compared vitamin K antagonists or DOACs using RCT data. Comparisons on stroke/SE and major bleeding (MB), as well as secondary outcomes, for DOAC versus DOAC comparisons were extracted and summarized using apixaban as the reference. RESULTS: Twenty-two NMAs were included in the final summary: All assessed MB; 15 assessed stroke/SE. No statistically significant differences were observed for apixaban compared with any DOAC in the 15 NMAs that assessed stroke/SE. Apixaban was associated with a lower risk for MB compared with rivaroxaban in 16 of 20 NMAs and dabigatran 150 mg in 13 of 16 NMAs. Four of 6 NMAs showed lower risk for GI bleeding for apixaban compared with rivaroxaban and dabigatran 150 mg; however, this outcome was not assessed by most NMAs. CONCLUSION: This systematic literature review of NMAs showed varying levels of bleeding risk among DOACs, with apixaban generally having a lower risk than rivaroxaban and dabigatran 150 mg.

LONG TERM OUTCOMES OF AUGMENTED TRABECULECTOMY WITH 5-FLUOROURACIL IN NIGERIA.

BACKGROUND: Glaucoma in sub-Saharan Africa has been described as a surgical disease because of the high cost of medical treatment, poor compliance and unavailability of medications. AIM: This study reports the long-term outcomes and complication rates following trabeculectomy with 5-fluorouracil in a case series of Nigerians. DESIGN OF STUDY: This was a retrospective, observational, non-comparative case series. SETTING: University College Hospital, Ibadan, Nigeria. METHODOLOGY: Each patient had complete ophthalmic evaluation. The post-operative intraocular pressure (IOP), visual acuity outcomes and post operative complications were assessed. The World Glaucoma Association consensus on surgical outcome was used to evaluate surgical outcome. RESULTS: Of the 292 patients who presented with glaucoma during this period, a total of 47 eyes of 31 patients (10.6%) had trabeculectomy with 5-FU. The mean presenting intraocular pressure (IOP) was 31.8±12.2mmHg. At three years post-operatively, 48.5% achieved complete success without medications while 90.9% achieved success with or without medications at an IOP cut off of ≤21mmHg. At the same time point of 3 years and an IOP cut off of ≤15mmHg, 63.6% achieved success with or without medications. At a mean post-operative period of 43± 19.6 months, (range 12-86 months), mean IOP had reduced from a preoperative mean of 31.8±12.2mmHg to 15.4±4.7mmHg (P<0.001). CONCLUSION: Trabeculectomy with 5-Fluorouracil is effective in the long term in reducing IOP with minimal complications in this population of Nigerians.

Risk factors for pterygium recurrence after surgical excision with combined conjunctival autograft (CAG) and intraoperative antimetabolite use.

BACKGROUND: To identify the determinants of recurrence following primary pterygium excision combined with conjunctival autograft (CAG) and intraoperative use of Mitomycin C (MMC) or 5-Fluorouracil (5-FU). METHODS: A randomized controlled clinical trial comparing 5-FU (50 mg/ml) plus CAG versus MMC (0.01%) plus CAG in preventing recurrence of primary pterygium following excision. RESULTS: A total of 80 eyes of 80 subjects were studied, with 46 eyes in the 5-FU group and 34 eyes in the MMC group. The mean age was 50.7 +/- 13.1 years with a male: female ratio of 0.95:1. Mean follow up period was 35.2 +/- 29.1 weeks. The overall recurrence rate was 10%, with a rate of 8.7% in the 5-FU group and 11.8% in the MMC group. The mean age of the patients who had a recurrence was 38.1 +/- 13.3 years compared to 52.1 +/- 12.4 years in those without a recurrence (p = 0.003). The median size of the pterygium in patients who had a recurrence was 3.2mm, while the median size in patients who did not have a recurrence was 3.0mm (p = 0.8). Five (12.8%) males had a recurrence compared to three (7.3%) females (p = 0.48); while 10.5% of fleshy pterygia recurred compared to none (0%) of the non-fleshy pterygia (p = 1.00). CONCLUSION: Younger age remains a risk factor for recurrence when both CAG and antimetabolites are combined in the treatment of pterygium, while the effect of gender, size and morphology of the pterygium may be diminished by such combination.

Outcome of trabeculectomy with 5-fluorouracil using releasable suture technique in a Nigerian Tertiary Hospital.

BACKGROUND: Trabeculectomy has undergone a series of modifications in recent times most of which are aimed at improving the efficacy of the procedure while reducing complications. The use of releasable sutures is one of such modifications. OBJECTIVE: To assess the efficacy and complications associated with the use of releasable sutures and 5-Fluorouracil(5-FU) in trabeculectomy among indigenous African patients with primary open angle glaucoma. METHODS: This was a chart review of 22 eyes of 17 patients diagnosed with primary open angle glaucoma. All the eyes included in the review had trabeculectomy with 5-Fluorouracil using releasable suture technique with postoperative clinic follow- up visit for a minimum period of 72 weeks. Information sought included patient's demographics, preoperative antiglaucoma medications, pre- and post- operative intraocular pressure, and associated complications. RESULTS: There were 17(13 M, 4 F) patients with 22 eye surgeries. Their mean age was 49.8 ± 9.3 years. The mean preoperative intraocular pressure was 27.7 ± 5.9 mmHg. The intraocular pressure on the first post-operative day was 10.6 ± 11.1 mmHg. The mean pressure before the removal of the releasable suture was 14.1 ± 10.8 mmHg and after removal was 6.0 ± 7.2 mmHg, (p > 0.0001). The mean intraocular pressure at 72 weeks of follow up was 16.9 ±5.6 mmHg. A qualified success rate of 81.8% was achieved in terms of intraocular pressure control. There were two eyes complicated by blebitis and an eye complicated by malignant glaucoma. CONCLUSION: The use of releasable suture in trabeculectomy helped in maintaining the intraocular pressure at a lower level in the early postoperative period and in reducing postoperative shallowing of the anterior chamber. The procedure appears to be associated with some sight- threatening complications such as endophthalmitis.

Visual outcome after cataract surgery at the university college hospital, ibadan.

AIM: The aim of this study was to determine the visual outcome of patients who had cataract surgery in the University College Hospital Ibadan. METHODOLOGY: This is an observational descriptive, longitudinal study of consecutive patients undergoing cataract surgery at the University College Hospital conducted between May and October 2007. A total of 184 patients who presented to the hospital and met the inclusion criteria were recruited into the study. Patients were examined preoperatively, 1st day postoperatively and 8th week postoperatively. RESULTS: The mean age was 66.5 years; and the male to female ratio was 1.2:1. Preoperatively, 137 patients (74.5%) were blind in the operated eye, while 39 patients (23.6%) were blind in both eyes at presentation. At 1st day postoperatively, 87 patients (47.3%) had pinhole visual acuity of 6/6-6/18. Best corrected vision after refraction eight weeks postoperatively showed that 127 patients out of 161 patients (78.8%) had good vision while 28 patients (17.4%) had borderline vision, and six patients (3.8%) had severe visual impairment after refraction. The number of bilaterally blind patients also reduced from 39 (23.6%) to one (0.6%). Uncorrected refractive error was the commonest cause of poor vision prior to refraction. Glaucoma was the commonest ocular co-morbidity accounting for poor vision in 9.1% of patients eight weeks after cataract surgery. CONCLUSION: This study demonstrates that good results can be obtained with cataract surgery and intraocular lens implantation in the developing world. More attention should be directed towards ensuring that successful outcomes are indeed being realized by continued monitoring of postoperative visual outcomes and prompt refraction for all patients.

Visual Outcome after Cataract Surgery at the University College Hospital; Ibadan

Aim: The aim of this study was to determine the visual outcome of patients who had cataract surgery in the University College Hospital Ibadan. Methodology: This is an observational descriptive; longitudinal study of consecutive patients undergoing cataract surgery at the University College Hospital conducted between May and October 2007. A total of 184 patients who presented to the hospital and met the inclusion criteria were recruited into the study. Patients were examined preoperatively; 1st day postoperatively and 8th week postoperatively. Results: The mean age was 66.5 years; and the male to female ratio was 1.2:1. Preoperatively; 137 patients (74.5) were blind in the operated eye; while 39 patients (23.6) were blind in both eyes at presentation. At 1st day postoperatively; 87 patients (47.3) had pinhole visual acuity of 6/6-6/18. Best corrected vision after refraction eight weeks postoperatively showed that 127 patients out of 161 patients (78.8) had good vision while 28 patients (17.4) had borderline vision; and six patients (3.8) had severe visual impairment after refraction. The number of bilaterally blind patients also reduced from 39 (23.6) to one (0.6). Uncorrected refractive error was the commonest cause of poor vision prior to refraction. Glaucoma was the commonest ocular co-morbidity accounting for poor vision in 9.1of patients eight weeks after cataract surgery. Conclusion: This study demonstrates that good results can be obtained with cataract surgery and intraocular lens implantation in the developing world. More attention should be directed towards ensuring that successful outcomes are indeed being realized by continued monitoring of postoperative visual outcomes and prompt refraction for all patients

Perception and attitude of people toward onchocerciasis (river blindness) in South Western Nigeria.

BACKGROUND: Onchocerciasis (river blindness) is a major cause of bilateral blindness with devastating socioeconomic consequences. Since Nigeria is the most heavily onchocerciasis endemic country in the world, the information on people's knowledge about this disease is significant. This could influence their response to current preventive measures of the African Programme for Onchocerciasis Control. AIM: This study was designed to estimate the level of knowledge and attitudes of rural/semi-urban communities in Ife North Local Government Area of Osun State toward onchocerciasis. MATERIALS AND METHODS: Cluster random sampling was used to select 500 adults for the study. Semi-structured questionnaires were administered to subjects. Data on knowledge of the local name, cause, mode of transmission, manifestation, severity, treatment, and prevention of onchocerciasis were collected and analysed. Statistical analysis included frequency distribution of the responses and a Chi-square test for comparison of variables with the P value for statistical significance set at 0.05. RESULTS: Onchocerciasis was well known by its local name among 458 (91.6%) of the respondents. Only seven (1.4%) knew that it affects both the eyes and skin. The cause was commonly attributed to impure blood by 114 (22.8%), whereas transmission was thought to be through fomites by 161 (32.2%). Only 12 (2.4%) respondents attributed the disease to blackfly bites. The level of education and the association of onchocerciasis with a river were significantly associated (P = 0.001). Subcutaneous nodules were felt to contain water (85.4%), baby worms (3.2%), and fat (0.6%). There was a negative attitude toward sufferers of the disease. CONCLUSION: Adequate information transfer in simple local dialect by trained personnel to the communities at risk of onchocerciasis is essential for better uptake of all aspects of the onchocerciasis control programme.

Survey of blindness and low vision in Egbedore, South-Western Nigeria.

BACKGROUND: Developing efficient and cost-effective eye care programmes for communities in Nigeria has been hampered by inadequate and inaccurate data on blindness and low vision. OBJECTIVE: To determine the prevalence and causes of blindness and low vision among adults 50 years and older in South-Western Nigeria in order to develop viable eye care programme for the community. METHODS: Twenty clusters of 60 subjects of age 50 years and older were selected by systematic random cluster sampling. Information was collected and ocular examinations were conducted on each consenting subject. Data were recorded in specially designed questionnaire and analysed using descriptive statistical methods. RESULTS: Out of the 1200 subjects enrolled for the study, 1183(98.6%) were interviewed and examined. Seventy five (6.3%)) of the 1183 subjects were bilaterally blind and 223(18.9%) had bilateral low vision according to WHO definition of blindness and low vision. Blindness was about 1.6 times commoner in men than women. Cataract, glaucoma and posterior segment disorders were major causes of bilateral blindness. Bilateral low vision was mainly due to cataract, refractive errors and posterior segment disorders. CONCLUSION: The prevalence of blindness and low vision in this study population was high. The main causes are avoidable. Elimination of avoidable blindness and low vision calls for attention and commitment from government and eye care workers in South Western Nigeria.

The dangers of bunk beds to the eye - a case report and preventive measures.

This is to illustrate the case of a 14 year old male student of a secondary school who fell off the top of an unguarded bunk bed in his hostel while sleeping and sustained a fracture of the left orbital margin, severe periorbital echymosis and conjunctivitis. He was managed conservatively. Two weeks post injury; the swelling resolved. At 2 months post injury, he improved tremendously and his visual acuity in the affected eye was 6/6. The swelling resolved and his anterior and posterior segments were normal. The patient was lucky to have had an intact eyeball. If it had been a penetrating eye injury, it could have been disastrous. Blinding eye injuries may be irreversible.Unguarded bunk beds may be dangerous to the eye. A recommendation of minimal standard for bunk-beds for children or no bunks at all in schools is suggested.

Visual impairment from age-related cataract among an indigenous African population.

AIM: To determine the magnitude of visual impairment (VI) resulting from lens opacity/cataract among a rural population in southwestern Nigeria. METHOD: A population-based cross-sectional survey using a multistage sampling method to select subjects >or=50 years. Participants with pinhole visual acuity of

Visual outcome of cataract surgery in University College Hospital, Ibadan Nigeria.

BACKGROUND: Cataract is a leading cause of avoidable blindness, while cataract surgery is the commonest major surgical procedure worldwide. OBJECTIVE: To evaluate the visual outcome and causes of poor vision in patients who had cataract extraction at a major hospital in Nigeria. METHODS: A retrospective study of the case notes of patients who had cataract extraction in the Eye Clinic of University College Hospital, Ibadan between July and Dec. 2004 was done. The visual outcome was analyzed using the WHO categorization of visual outcome and those with poor visual outcome evaluated for the cause of such poor outcome. RESULTS: Forty-seven (40.2%) of the eyes had good outcome before refraction and the number increased to 80 (67.8%) after correcting for postoperative refractive error. The highest single cause of poor visual outcome was uncorrected refractive error, 32 (47%) eyes. Other causes included posterior capsule opacification 7 (18.4%) eyes, preexisting ocular co-morbidity such as glaucoma, optic atrophy and maculopathy 6 (15.9%) eyes. CONCLUSIONS: This review showed that uncorrected refractive error and posterior capsular opacification were the major causes of poor visual outcome after cataract surgery. Preoperative biometry for all patients, meticulous intra operative cortical clean up, adoption of the cataract surgery outcome tally sheet and better patient selection will help improve the outcome of our cataract surgeries.

Post-operative complication of trabeculectomy in Ibadan, Nigeria: outcome of 1-year follow-up.

OBJECTIVE: To describe the post-operative complications reported in patients who had trabeculectomy with and without antimetabolite in UCH, Ibadan between 1999 and 2003 and the success rate achieved in term of the post-operative intraocular pressure (IOP). METHODS: A retrospective study of the records of glaucoma patients who had trabeculectomy between 1999 and 2003 and had follow-up in UCH Ibadan eye clinic for a minimum of 1 year was carried out. RESULTS: Seventy-six out of 171 eyes that had trabeculectomy during the period were reviewed. Mean age of patients was 49.4 years. The mean preoperative IOP was 31.8 mm Hg. Success rate of 79.4% was achieved in term of IOP control at a year of follow-up. The most frequent early post-operative complication was shallow AC (13 eyes; 17.1%) while late complication was elevated IOP (21 eyes; 27.6%). Others were encapsulated bleb 7.9% and hyphema 3.9%. There was no significant difference in the complication rate in those who had intraoperative antimetabolite (5-fluorouracil) when compared with those operated without antimetabolite. CONCLUSION: Guarded filtration surgery is effective in controlling IOP. Most of the complications noted were transient and not visually threatening.

The effect of timolol maleate on tear film break-up time in Nigerians.

The aim of this study was to evaluate the effect of Timolol maleate on tear film break-up time in a Nigerian population. 192 eyes of 96 subjects were examined in a hospital based case-control study after being administered pre-coded questionnaires. The mean tear film break-up time was measured. There was significant difference (t = 10.164, P < 0.001) in the mean break-up time of cases (10.45 secs) and controls (30.18 secs). Half of the cases had some ocular discomfort with the instillation of Timolol maleate, a significant number of them having just been commenced on the medication (chi2 = 8.889, P = 0.003). Long-term instillation of Timolol maleate impairs tear film stability. The ocular discomfort experienced by patients on Timolol may contribute to poor drug compliance observed in patients on chronic drug therapy. Regular screening of patients on Timolol maleate for tear film instability and dry eyes is important and drug manufacturers should explore the possibility of incorporating artificial tears in Timolol maleate preparation.

Combined central retinal artery and vein occlusion complicating orbital cellulitis.

Orbital Cellulitis is a dreaded ophthalmologic disease. It may destroy vision and the eye and may even become life threatening. Often visual loss is the result of exposure and subsequent destruction of ocular tissue commonly the cornea and the uvea. We report a case of combined central retinal artery and vein occlusion complicating orbital cellulitis in a 35 year old patient who was 37 weeks pregnant resulting in loss of vision in the affected eye. There have been few case reports of this type of complication of orbital cellulitis.

Pterygium treatment using 5-FU as adjuvant treatment compared to conjunctiva autograft.

BACKGROUND: The use of conjunctiva autograft, adjunct antimetabolite therapy has been shown to be effective in preventing pterygium recurrence. OBJECTIVE: To compare 5 fluorouracil (5-FU) to conjunctival autograft in the treatment of large, fleshy pterygium. METHODS: A randomised controlled prospective study of outcome of pterygium treatment using 5-FU as adjuvant treatment compared to conjunctiva autograft. Thirty-five eyes with large pterygium treated with bare sclera conjunctival excision plus 5-FU were compared with 33 eyes treated with excision and conjunctival autograft alone. RESULTS: Post-operative pterygium recurrence was observed in four (11.4%) eyes treated with 5-FU and 4 (12.1%) eyes treated with conjunctiva autograft (P>0.05). The post-operative complications included, granuloma formation 11.4% for 5-FU and 3.0% for autograft and conjunctival discharge 5.7% for 5-FU group only. CONCLUSION: 5-FU is marginally superior to conjunctival autograft in the prevention of pterygium recurrence but neither gives a more desirable single digit recurrence rate. Randomised studies combining both conjunctival autograft and 5-FU in pterygium treatment is advocated to further explore their effect.

Conjunctival hyperaemia and other ocular adverse effects on healthy African subjects after single dosing with 0.004% Travoprost.

Conjunctival hyperaemia and ocular adverse effects induced by a single dose of 0.004% travoprost in healthy subjects were evaluated. A randomized, double-blind cross-over placebo controlled study was done. Conjunctival hyperaemia was evaluated clinically at 12, 24, 36 and 72 hours after dosing and volunteers reported all ocular adverse effects. 15 out of 20 subjects (70%) dosed with travoprost compared with 2 out of 20 (10%) dosed with placebo developed clinically moderate hyperaemia. However, significant difference in hyperaemia in the two groups occurred only at 24 hours (P < 0.048). The hyperaemia cleared by 72 hours. Travoprost may cause significantly short-term conjunctival hyperaemia even after a single dose in the eyes of healthy African subjects.

Visual standards in commercial driving.

OBJECTIVES: The study was carried out to review the ocular factors involved in road traffic accidents (RTA) in order to reduce associated injuries and possibly suggest a standard for driving. MATERIALS AND METHODS: The study was carried out in the eye clinic of Ladoke Akintola University of Technology Teaching Hospital, Osogbo between May and June 2004. A stratified random sample technique was used to select 99 drivers (198 eyes) from 6 motor park units. Information obtained included age, sex, past history of road traffic accident (RTA), visual acuity and field, colour vision and ability to read number plate tests. RESULTS: Six drivers (6.1%) were visually impaired. There were 5 cases of monocular blindness. Twenty (20.20%) drivers had accidents in the past, 24(24.24%) could not read number plate at 20.5meters, 6 (6.1%) were colour blind while 36 had visual field loss within 120 degrees horizontally. All the six drivers that had visual field loss encroaching within 20 degrees of fixation had accidents in the past. CONCLUSION: This study has shown that there is need to improve on the standard of vision testing before licenses are issued or renewed. Where visual acuity alone is used, it must be done properly by testing one eye at a time. However, a comprehensive eye test using a battery of tests comprising visual acuity, colour vision, visual field and number plate test at 20.5 meters before first issue of driving license and at renewals will be better. Drivers with visual impairment or inability to read number plate test at 20.5 meters should be disqualified from driving commercial vehicles. Drivers with monocular blindness or visual field loss encroaching within 20 degrees of fixation must also not be allowed to drive commercial vehicles. However, further large scale studies will be necessary in order to prove all these propositions scientifically.

Corneal diameters in infants born in two hospitals in Ibadan, Nigeria.

OBJECTIVES: To measure the horizontal corneal diameters in infants at birth and compare with values reported in other studies. DESIGN: A cross-sectional hospital based study. SUBJECTS: All the healthy infants born within the period of one month in these hospitals were eligible for enrolment into the study. Horizontal corneal diameter measurements were performed with indirect caliper in both eyes of each of the 342 healthy full term infants and 25 preterm healthy infants born in these two hospitals. These results were evaluated according to the age of the infants RESULTS: The corneal diameter in term infants was found to range from 9.00 mm to 12.50 mm during the first week of life with a mean of 10.26 mm (SD +/-0.59 mm, n = 64). This is higher than what was reported for Caucasian infants (P < 0.01). Mean horizontal corneal diameter in all male infants aged 1-238 days was 11.06 mm (SD 0.75 mm, n = 187), slightly higher than 10.93 mm (SD 0.22 mm, n = 154) in all females, though this difference was not statistically significant. Horizontal corneal diameter increased progressively with age, from a mean value (SD) of 10.26 mm (0.72) to a mean value (SD) of 12.0 mm at 34 weeks of age. There was no significant difference in the mean corneal diameter of the right and left cornea. A few infants had corneal diameters of 12.50 mm and had no congenital glaucoma. Mean corneal diameter in preterm infants less than 37 weeks of gestation was 8.90 mm at birth (SD 1.25 mm, n = 25). CONCLUSION: The horizontal diameter increased with age from birth to the 34 weeks of age. Changes after this period were not studied. The values obtained in these African infants were slightly higher than those reported from other populations.

Neovascular glaucoma in a Nigerian African population.

OBJECTIVE: To determine the ocular and systemic factors associated with neovascular glaucoma (NVG) in an African population. DESIGN: Hospital based cross sectional study. SETTING: Eye clinic, Department of Ophthalmology, University College Hospital, Ibadan, Nigeria. SUBJECTS: Sixty one consecutive patients with clinical diagnosis of NVG seen between January 1995 and December 1999 had a complete ocular evaluation. RESULTS: Among the 61 subjects studied with an identifiable aetiological factor presumably causing neovascular glaucoma, 82% had associated posterior segment diseases producing ischaemia. These were retinal venous obstruction (78.7%), retinal arterial occlusion (1.6%). Those with no identifiable vaso-occlusive disease had couching (11.5%), aphakia with vitreous loss (3.3%) and chronic uveitis (1.6%). Systemic arterial hypertension was present in 62.3% while diabetes mellitus was present in only 8.3% of the subjects studied. Chronic uveitis and penetrating eye injury were infrequently diagnosed. Chronic open angle glaucoma was present in the other eye of 37.7% of subjects. Neovascular glaucoma was unilateral in 95.1% of subjects. 84.4% of affected eyes were blind on presentation. Males outnumbered females among subjects with NVG above 40 years, while females outnumbered males in the subjects below 40 years of age. Eyes of that were couched constitute a significant proportion of subjects with neovascular glaucoma. CONCLUSION: Medical conditions such as systemic hypertension, diabetes and ocular conditions like retinal vein, retinal artery occlusion, couching and glaucoma were associated with NVG. Most of these ocular and systemic associations should be identified early and treated to prevent neovascular glaucoma in the other eye of the subject.