Impact of COVID-19 on ophthalmic surgical procedures in sub-Saharan Africa: a multicentre study.

BACKGROUND: The COVID-19 pandemic had a profound impact on healthcare and ophthalmology services globally. Numerous studies amongst various medical and surgical specialties showed a reduction in patient attendance and surgical procedures performed. Prior published ophthalmic literature focused on specific types of procedures and were usually single centre. The current study attempts to quantify the impact on a larger scale, namely that of sub-Saharan Africa, and to include all ophthalmic subspecialties. METHODS: This is a retrospective analysis of the surgical records from 17 ophthalmology centres in seven countries located in East, Central, West and Southern Africa. The date of declaration of the first lockdown was used as the beginning of the pandemic and the pivot point to compare theatre records one year prior to the pandemic and the first year of the pandemic. We examined the total number of surgical procedures over the two year period and categorized them according to ophthalmic subspecialty and type of procedure performed. We then compared the pre-pandemic and pandemic surgical numbers over the two year period. RESULTS: There were 26,357 ophthalmic surgical procedures performed with a significant decrease in the first year of the pandemic (n = 8942) compared to the year prior to the pandemic (n = 17,415). The number of surgical procedures performed was lower in the first year of the pandemic compared to the year prior to the pandemic by 49% [Incidence rate ratio (IRR) 0.51, 95% CI 0.41-0.64), 27% (0.73, 0.55-0.99), 46% (0.54, 0.30-0.99), 40% (0.60, 0.39-0.92) and 59% (0.41, 0.29-0.57) in sub-Saharan Africa (4 regions combined), West, Central, East and Southern Africa, respectively]. The number of surgical procedures in the different sub-specialty categories in sub-Saharan Africa (4 regions combined) was significantly lower in the first year of the pandemic compared to the year prior to the pandemic, except for glaucoma (IRR 0.72, 95% CI 0.52-1.01), oncology (0.71, 0.48-1.05), trauma (0.90, 0.63-1.28) and vitreoretinal (0.67, 0.42-1.08) categories. CONCLUSION: This study provides insight into the impact of the COVID-19 pandemic in multiple regions and countries on the African continent. The identification of which surgical subspecialty was most affected by the COVID-19 pandemic in each region allows for better planning and resource allocation to address these backlogs.

Determinants of participation in glaucoma genomic research in South East Nigeria: A cross-sectional analytical study.

BACKGROUND: Genomic research advances the understanding of human health and disease. It also drives both the discovery of salient genetic association(s) as well as targeted screening, diagnostic and therapeutic strategies. Human subject participation is crucial for the success of genomic research. METHODS: This is a cross sectional analytical study conducted at two tertiary centers in Enugu Southeast Nigeria. Semi structured questionnaires were administered to eligible consenting participants. Data on their demographics, willingness to participate in genomic research and motivation for participation were obtained. Data was analyzed using Stata version 17 and summarized using median, frequencies and interquartile range(IQR). Associations between covariates were evaluated with Chi square test and multivariable logistic regression. RESULTS: Among 228 glaucoma subjects who participated in our study,119(52.2%) were female and 109(47.8%) were male. The median age was 64 years(IQR = 50-76). Although 219 (96.0%) participants expressed willingness to participate in a glaucoma genetic study, only 27(11.9%) of them will be willing to participate if there will not be feedback of results to participants (χ2 = 18.59, P<0.001). No participant expressed willingness to submit ocular tissue samples. Majority (96.2%) of subjects will not participate if the intended research required submission of body samples after death. Desire to know more about glaucoma (63%) was the most common reason for participation. In a multivariable logistic model, subjects between 61-90 years (p = 0.004, OR = 7.2) were 7 times more likely to express willingness to participate in glaucoma genetic research after adjusting for other covariates when compared to subjects aged 41-60 years. Other covariates did not influence participants' willingness. CONCLUSION: Glaucoma subjects are more likely to be willing to participate in genetic research, if they would receive feedback of results. Willingness to participate in genetic research is significantly associated with age. LIMITATIONS: We did not evaluate the salient options for feedback of results to participants in our study.

Glaucoma Treatment Patterns in Sub-Saharan Africa.

PRCIS: Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma. Laser therapy was underutilized where they were available. Physicians were more likely to recommend surgery in severe glaucoma, laser therapy in mild glaucoma, while recommendation of medical therapy did not depend on glaucoma severity. PURPOSE: To characterize treatment patterns for newly diagnosed glaucoma in sub-Saharan Africa (SSA). METHODS: This was a multicenter cross-sectional study of adults newly diagnosed with glaucoma at 27 eye care centers in 10 African countries. In addition to demographic and clinical data, physician treatment recommendations (medication, laser, surgery, or no treatment) were recorded. Statistical analyses were performed using STATA version 14.0. RESULTS: Data from 1201 patients were analyzed. Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma (69.4%), with laser (13.2%), surgery (14.9%), and no treatment (2.5%) recommended to the remaining patients. All sites had medical therapy available and most (25/27, 92.6%) could provide surgical treatment; only 16/27 (59.3%) sites offered laser, and at these sites, 30.8% of eyes were recommended to undergo primary laser procedures. As glaucoma severity increased, the laser was recommended less, surgery more, and medications unchanged. Patient acceptance of medical therapy was 99.1%, laser 88.3%, and surgery 69.3%. CONCLUSIONS: Medical therapy for first-line glaucoma management is preferred by most physicians in SSA (69%). Laser therapy may be underutilized at centers where it is available. These findings underscore the need for comparative studies of glaucoma treatments in SSA to inform the development of evidence-based treatment guidelines and of programs to reduce glaucoma blindness in SSA. Strategic approaches to glaucoma therapy in SSA must address the question of whether medical therapy is the most optimal first-line approach in this setting.

Pattern of eye diseases in adults at the general outpatient clinic of a Tertiary Hospital in Nigeria.

Objective: To determine the pattern of eye diseases at the general outpatient department (GOPD) of a Nigerian tertiary hospital. Materials and Methods: Patients selected by systematic random sampling at the GOPD of a Nigerian tertiary hospital were studied. Information on sociodemographics and ocular complaints were obtained using interviewer-administered questionnaire. Ocular examination included visual acuity measurement and anterior and posterior segments examinations. Data analysis was with Statistical Package for the Social Sciences. Results: Three hundred and eighty-two patients, comprising 124 (32.5%) males and 258 (67.5%) females, aged between 18 and 86 years, mean 44.8 ± 15.4 years, were studied; 112 (29.3%) had eye diseases but only 88 (78.6%) patients complained of ocular disorder(s). Common complaints were poor vision 53 (60.4%), red eye and grittiness 15 (17.0%) each. Common eye diseases were lens 52 (13.6%) and conjunctiva 46 (12.0%) disorders. Attaining higher education was protective against eye diseases (P < 0.05). Conclusion: Nearly a third of patients at the GOPD have eye diseases. Therefore, primary eye care should be integrated into the GOPD service with provision of relevant manpower and facilities for care of the ophthalmic patients.

Résumé Objectif: Pour déterminer le schéma des maladies oculaires au service général de consultation externe d'un hôpital tertiaire nigérian. Matériels et Méthodes: Des malades sélectionnés par échantillonnages aléatoires systématiques au service ambulatoire général, d'un hôpital tertiaire au nigérian on été étudies. Les informations sur les données sociodémographiques et les plaintes oculaires ont été obtenues à l'aide d'un questionnaire lors d un interview. L'examen oculaire comprenait la mesure de l'acuité visuelle et de l'examen des segments antérieur et postérieur. L'analyse données a été effectuée par le progiciel des sciences sociales. Résultats: Trois cent quatre-vingt-deux malades, comprenant 124(32,5%) hommes et 258 (67,5%) femmes, âges entre 18 et 86 ans, moyenne 44,8 ± 15,4 ans, ont été étudiés ; 112 (29,3%) avaient des maladies oculaires mais seulement 88 (78,6%) malades se plaignaient de trouble(s) oculaire(s). Les plaintes les plus courantes étaient une mauvaise vision 53 (60,4%), les yeux rouges et la sécheresse oculaire 15(17,0%) chacun. les maladies oculaires courants étaient les troubles du cristallin 52(13,6%) et la conjonctive 46 (12,0%). le fait d'avoir fait des études supérieures ont protégé contre les maladies oculaires courant (P<0.05). Conclusion: Près d'un tiers des malades de la service ambulatoire général, Nigérian ont des maladies oculaires. Par conséquent, les soins oculaires primaires doivent être intégrés dans le service ambulatoire généra avec la fourniture de la main-d'œuvre et des installations nécessaires pour les soins a les malades d'ophtalmiques. Mots-clés: Maladies oculaires, troubles oculaire, service ambulatoire général, Nigérian.

Eye Health-seeking Behaviour of Traders in Rural Nigeria.

Aim: The aim of this article was to determine the healthcare provider first sought, reasons for the choice, and symptom duration before hospital presentation among traders in rural Nigeria. Materials and Methods: This was a cross-sectional study of traders at a rural Nigerian market, selected by systematic random sampling. A structured questionnaire was used to obtain information on sociodemographics, eye disease symptoms, eye care provider first sought, and reasons for choice. The analysis was carried out with Statistical Package for Social Sciences using descriptive and inferential statistics with an alpha level at 0.05. Results: Of the 177 traders, 88 (49.7%) were males and 89 (50.3%) were females. The mean age was 46.5 ± 13.75 years (range 19-72). Of the 83 traders who had ocular symptoms 23 (27.7%) never sought any care. The eye care providers first sought were patent medicine vendors 22 (26.5%), orthodox hospital 17 (20.5%), eye glass vendors 3 (3.6%), and traditional healers 3 (3.6%). The median symptom duration before presentation to an eye health facility was 83 days. Reasons for not seeking orthodox eye care first included cost 33 (39.8%), 'ailment not serious' 22 (26.5%), and advice from friends 7 (8.4%). Females were more likely to seek orthodox care (χ2=4.22, P=0.04), whereas males were more likely to feel that their ailment was not serious. Traders aged >50 years were less likely to seek any care for eye ailment (χ2 =8.41, P=0.04). Conclusion: Traders with eye disorders seek care late and most first seek care outside the orthodox hospital. Cost and feeling that ailment was not serious are barriers to seeking orthodox eye care. Eye health education and cost reduction would improve uptake of orthodox eye care services.

Clinical Characteristics and Stage at Presentation of Glaucoma Patients in Sub-Saharan Africa.

PRCIS: The initial presentation of glaucoma varies meaningfully across SSA. A comprehensive strategy with regional customization based on local differences is needed to reduce glaucoma blindness in SSA. PURPOSE: To explore regional variations in the presentation of newly diagnosed glaucoma in Sub Saharan Africa (SSA). METHODOLOGY: This was a multicenter, cross-sectional study in which newly diagnosed, consecutive, glaucoma patients aged older than or equal to 18 years were recruited from 27 eye clinics in 10 countries throughout SSA. Demographic and ophthalmic examination data were collected. Glaucoma severity was based on optic nerve head and visual field assessment. Statistical analyses were performed using STATA version 14.0. RESULTS: Among 1214 enrolled patients with newly diagnosed glaucoma from Western, Eastern, and Southern Africa, the overall mean (SD) age was 59.9 (17.1) years. More than half of all patients (716/1178; 60.8%) presented with severe glaucoma in the worse eye, and one-third (36.9%) had severe glaucoma in both eyes. Primary open angle glaucoma was the commonest form of glaucoma in all regions (77.4%). A family history of blindness (260/1204, 21.6%) was common. Patients from Western Africa had lower mean presenting intraocular pressure (26.4 [11.1] mm Hg, P <0.001), but had worse glaucoma in the better eye based on mean cup-disc ratio (0.8; P <0.001) and mean visual field mean deviation [10.4 (8.4)] dB, P =0.016) compared with other regions. Exfoliation glaucoma was more common in Eastern Africa (30/170=17.7%, P <0.001) compared with other regions. CONCLUSION: The initial presentation of glaucoma varies meaningfully across SSA. A comprehensive strategy with regional customization based on local differences is needed to reduce glaucoma blindness in SSA.

Glaucoma care and follow-up in sub-Saharan Africa: Is there a need for modification of counselling practices to improve awareness, knowledge and treatment acceptance profiles? A prospective cross-sectional study.

BACKGROUND: Blindness from glaucoma is prevalent in parts of Africa. Lack of awareness, late diagnosis, poor acceptance and compliance to treatment as well as unorthodox care practices are among many contributing factors. Strategies that improve glaucoma awareness and treatment acceptance are required to resolve this trend. PURPOSE: To evaluate the influence of counselling on glaucoma awareness, willingness to accept glaucoma surgery and eye care practices among primary open-angle glaucoma patients on medical treatment. METHODS: A prospective cross-sectional interviewer-administered questionnaire-based study evaluating the demographics, glaucoma awareness, acceptance of operative care and use of traditional eye medications among patients with primary open-angle glaucoma on medical treatment followed up over a 12-month period. RESULTS: A total of 120 eligible participants were recruited. Glaucoma awareness and basic knowledge were 93.3 and 12%, respectively. Educational attainment and positive family history were associated with glaucoma awareness (p = 0.027 and p = 0.042, respectively). Seventy-five (62.5%) participants accepted glaucoma surgery as a treatment option. However, the duration of medical treatment was inversely related to the acceptance of glaucoma surgery (odds ratio = - 0.390, p = 0.009). Twelve (10.5%) participants use traditional eye medication for their current eye problem. CONCLUSION: Glaucoma counselling should be performed with a content template that delivers all relevant information to patients and caregivers. This will bridge gaps in knowledge and improve the early presentation, acceptance of glaucoma surgery and eye care practices.

Association of Genetic Variants With Primary Open-Angle Glaucoma Among Individuals With African Ancestry.

Importance: Primary open-angle glaucoma presents with increased prevalence and a higher degree of clinical severity in populations of African ancestry compared with European or Asian ancestry. Despite this, individuals of African ancestry remain understudied in genomic research for blinding disorders. Objectives: To perform a genome-wide association study (GWAS) of African ancestry populations and evaluate potential mechanisms of pathogenesis for loci associated with primary open-angle glaucoma. Design, Settings, and Participants: A 2-stage GWAS with a discovery data set of 2320 individuals with primary open-angle glaucoma and 2121 control individuals without primary open-angle glaucoma. The validation stage included an additional 6937 affected individuals and 14 917 unaffected individuals using multicenter clinic- and population-based participant recruitment approaches. Study participants were recruited from Ghana, Nigeria, South Africa, the United States, Tanzania, Britain, Cameroon, Saudi Arabia, Brazil, the Democratic Republic of the Congo, Morocco, Peru, and Mali from 2003 to 2018. Individuals with primary open-angle glaucoma had open iridocorneal angles and displayed glaucomatous optic neuropathy with visual field defects. Elevated intraocular pressure was not included in the case definition. Control individuals had no elevated intraocular pressure and no signs of glaucoma. Exposures: Genetic variants associated with primary open-angle glaucoma. Main Outcomes and Measures: Presence of primary open-angle glaucoma. Genome-wide significance was defined as P < 5 × 10-8 in the discovery stage and in the meta-analysis of combined discovery and validation data. Results: A total of 2320 individuals with primary open-angle glaucoma (mean [interquartile range] age, 64.6 [56-74] years; 1055 [45.5%] women) and 2121 individuals without primary open-angle glaucoma (mean [interquartile range] age, 63.4 [55-71] years; 1025 [48.3%] women) were included in the discovery GWAS. The GWAS discovery meta-analysis demonstrated association of variants at amyloid-ß A4 precursor protein-binding family B member 2 (APBB2; chromosome 4, rs59892895T>C) with primary open-angle glaucoma (odds ratio [OR], 1.32 [95% CI, 1.20-1.46]; P = 2 × 10-8). The association was validated in an analysis of an additional 6937 affected individuals and 14 917 unaffected individuals (OR, 1.15 [95% CI, 1.09-1.21]; P < .001). Each copy of the rs59892895*C risk allele was associated with increased risk of primary open-angle glaucoma when all data were included in a meta-analysis (OR, 1.19 [95% CI, 1.14-1.25]; P = 4 × 10-13). The rs59892895*C risk allele was present at appreciable frequency only in African ancestry populations. In contrast, the rs59892895*C risk allele had a frequency of less than 0.1% in individuals of European or Asian ancestry. Conclusions and Relevance: In this genome-wide association study, variants at the APBB2 locus demonstrated differential association with primary open-angle glaucoma by ancestry. If validated in additional populations this finding may have implications for risk assessment and therapeutic strategies.

Follow-up and adherence to glaucoma care by newly diagnosed glaucoma patients in enugu, nigeria.

PURPOSE: To determine uptake, adherence and influencing factors to follow-up care by newly diagnosed glaucoma patients from free eye screening exercise. METHODS: The study was a cross-sectional survey of newly diagnosed glaucoma patients during free eye screenings carried out in March and October, 2016 in Enugu, Nigeria. Data on participants were analyzed after a minimum of 6 months from the screening for uptake and adherence to follow-up care. Qualifying patients had questionnaires administered to them by phone interview. Information requested regards awareness, knowledge on diagnosis as well as reasons for non-uptake and non-adherence. RESULTS: 182 newly diagnosed glaucoma patients were included of which 121 (66.5%) were males, with median age of 50years.About 164 (90.1%) had at least a primary education. There were more self- employed persons 59 (32.4%) compared to other occupations. Uptake of follow up care was 17.6% (32/182). Adherence rate was 25% (8/32). Major reasons for non-uptake were lack of funds 54.9% (n = 50/91), distance 11% (n = 10/91) and receiving care from other facilities 11.0% (n = 10/91). Others include discourteous staff behavior and lack of information on diagnosis. Similarly, major reasons for non-adherence were lack of funds 44.4% (n = 8/18) and distance 22.2% (n = 4/18). Knowledge and prior awareness of glaucoma were found to be significantly associated with uptake of follow up care (p = 0.020). CONCLUSION: Uptake and adherence to follow-up was found to be low in this study population mainly attributed to cost, distance and poor knowledge of glaucoma natural history. Reviewing cost/out of pocket expenditure, providing care closer to patients, adequate education of staff and patients may significantly improve uptake of care after initial diagnosis.

The Rationale for Selective Laser Trabeculoplasty in Africa.

Glaucoma is the leading cause of irreversible blindness in Africa. The condition is treatable but not curable. There are numerous obstacles to glaucoma care in Africa, including availability, accessibility and affordability of treatments, as well as medication nonadherence among patients. Medical therapy is costly relative to the average income in Africa and it requires daily self-dosing by patients. Surgery is of limited availability in many regions in Africa, and a high proportion of patients refuse surgery because it is expensive. Selective laser trabeculoplasty (SLT) proves to be a favorable alternative to medical or surgical care, as it is highly effective and safe in people of African descent, more cost-effective than medical therapy, quick and easy to perform, and portable. The procedure also requires no postoperative care, thus obviates the issue of nonadherence. In uncontrolled studies, SLT has a high response rate and it lowers intraocular pressure by 30% to 40%, which exceeds the goal in international guidelines for initial therapies. The African Glaucoma Consortium (AGC), a member-driven stakeholder collective, has been formed in part to develop the infrastructure for continent-wide improvements in glaucoma care. It embraces SLT as a potential key tool in their development plans. The mission of AGC includes improving clinical care by educating existing and new health care professionals to expand the provider network, by conducting trials to identify optimal care strategies for glaucoma in Africa, and by facilitating the development of an integrated network of Centers of Excellence to bring SLT and other crucial glaucoma therapies to communities throughout Africa.

Awareness and knowledge about glaucoma and proportion of people with glaucoma in an urban outreach programme in Southeast Nigeria.

AIM: The aim of this study was to determine the level of awareness and knowledge of glaucoma and the proportion of people with glaucoma among participants of a 1-day urban eye outreach programme. METHODS: The study was a cross-sectional survey. Data, collected by means of a structured questionnaire, included participants' demographic details, and awareness, knowledge and ocular status as regards glaucoma. Publicity for the outreach was created through the mass media (radio stations and television), churches, handbills, posters and different hospital staff. Data analysis was by Statistical Package for Social SciencesV.20.0. Associations between participants' demographic and other details were tested using Pearson's χ2 test, and a p value of <0.05 was considered significant. RESULTS: Four hundred and seventy-eight (93.2%) of the 513 people in attendance were eligible and consented to participate. Awareness, knowledge and proportion of people with glaucoma in the study population were 65.5%, 36.8% and 14.5%, respectively. Awareness was significantly associated with attainment of some formal education, awareness of a positive family history, and having had an eye check prior to the outreach. The mass media was the most common information source. Good knowledge level was significantly associated with higher educational attainment and occupation, whereas proportion of people with glaucoma was significantly associated with increasing age. CONCLUSION: Improving awareness with suitable content for the target population through effective means such as the mass media may be a veritable first step in combating blindness from glaucoma.

Prevalence, Awareness and Determinants of Diabetic Retinopathy in a Screening Centre in Nigeria.

There is a global rise in the prevalence of diabetes and this has led to a rise in the consequences of diabetes such as diabetic retinopathy (DR). The current study aims to determine the prevalence, awareness and determinants of DR among diabetics who attended a screening centre in Enugu, south-eastern Nigeria. A descriptive cross-sectional study was carried out among consenting diabetic patients who visited the centre. An interviewer-administered questionnaire was used to gather information on demographic details, the knowledge of the participants on effects of diabetes on the eye and previous care they had received for their eyes. Each participant underwent eye examination which included posterior segment examination with slit lamp biomicroscopy with +90DS lens after pupil dilation. A total of 80 eligible participants were examined. The prevalence of any DR among the participants was 32.1 % (95 % CI 20.6-43.5) whereas prevalence of proliferative diabetic retinopathy, PDR was 6.4 % and diabetic macular oedema, DME was 31.3 %. Age at onset of diabetes and duration of diabetes were the most determinant factors associated with DR (p = 0.039 and p = 0.000 respectively). Only ten (12.5 %) participants had undergone at least one specific eye examination to check for DR since they were diagnosed with diabetes. The major reason for not having had a prior screening is 'no one referred me for it' (31 participants, 44.3 %). DR is emerging as an important cause of blindness and severe visual impairment. Adequate screening programme and treatment protocol need to be set up for this population even in developing countries to prevent blindness.