Competency based ophthalmology training curriculum for undergraduate medical students in Zimbabwe.

Background: The establishment of a credible, defensible and acceptable "formal competency based ophthalmology training curriculum for undergraduate medical and dental students" is fundamental to program recognition, monitoring and evaluation. The University of Zimbabwe College of Health Sciences (UZ-CHS) has never had a formal ophthalmology training curriculum for medical graduates since its inception. This has cast doubts on the quality of medical graduates produced with regards to delivery of basic primary eye care in the community. Objective: The aim of this project was to develop a formal "competency based ophthalmology training curriculum" (CBOTC) for medical graduates in Zimbabwe. Design: Institution based (University of Zimbabwe College of Health Sciences and Parirenyatwa Group of Hospitals), cross-sectional analytic study. Methodology: A review of undergraduate medical training curriculum and literature was done to identify gaps in the ophthalmology training curriculum. A local needs assessment was conducted through interviews of major stake holders in the University of Zimbabwe College of Health Sciences and Parirenyatwa Group of Hospitals. Results: This project confirmed the lack of a formal ophthalmology training curriculum for medical graduates at the UZCHS, ad-hoc training of undergraduate ophthalmology and inconsistent student assessment in knowledge of and care of eye complaints. Cataract, glaucoma, refractive errors, ocular tumours, conjunctivitis, eye infection and eye injuries were suggested as priority conditions every student should learn during the rotation. A formal CBOTC for medical graduates based on identified needs and priority eye diseases has been developed in response. Conclusion: A CBOTC based on identified needs and focused on targeted diseases has been proposed geared towards producing medical graduates with the basic knowledge, skills and attitudes to deliver adequate primary eye care.

The prevalence, types and effects of traditional eye medicine use among newly presenting patients at Sekuru Kaguvi Hospital Eye Unit in Harare, Zimbabwe.

BACKGROUND: The use of Traditional Medicines (TM) is common practice world over. Traditional Eye Medicine (TEM) use may be associated with various ocular complications including blindness. A study on the prevalence of TEM use was carried out at Sekuru Kaguvi Hospital Eye Unit (SKHEU) in Harare, with emphasis on the types ofTEM used and associated ocular complications. OBJECTIVES: To evaluate the prevalence of TEM use among newly-presenting patients at SKHEU. To identify the ocular symptoms experienced by the new clinic-attendees who had used TEM for their current eye problem. To characterize the TEM used, in terms of type, source (provider) and routes of administration. To evaluate any association between TEM use and legal blindness at presentation, destructive eye procedures and other specific ocular complications among these patients. DESIGN: Hospital-based, cross-sectional analytic study. METHODS: All new patients attending one randomly selected clinic per week were recruited for the study over a period of eight months. The patients had a full clinical examination and data collected. RESULTS: The prevalence of TEM use among new patients at SKHEU was 61.5%. The initial ocular symptoms prior to the use of TEM were mainly those of ocular surface inflammation: tearing (77.4%), redness (74.9%), itchiness (71.6%) and pain (70.3%). The most common category of TEM used was plants and plant products. Most TEMs (92.4%) were administered as topical eye drops. In ninety-five percent of cases, the provider of TEM was not a formal traditional healer but rather relatives, friends and the patients self-medicated. The use of TEM was associated with specific ocular complications in 58.6% of cases. There were significant associations between use of TEM and corneal ulceration, corneal vascularisation, endophthalmitis, evisceration, exenteration and legal blindness at presentation. CONCLUSION: This study has shown that the use of TEM is common among new clinic-attendees at SKHEU and is associated with specific ocular complications.

Rhabdomyosarcoma of the orbit in a four months old infant in Zimbabwe: A case report.

Infants younger than one year of age with Rhabdomyosarcoma appear to have worse prognosis compared to older children due partly to high rates of local failure. We report a 4 months old infant with orbital rhabdomyosarcoma with poor outcome. Reluctance to use aggressive local control measures and suboptimal chemotherapy dosing are significant contributory factors. Call is made for need for more studies to determine appropriate local therapy in infants with rhabdomyosarcoma.

Patterns of Retinoblastoma in Zimbabwe: 2000-2009.

OBJECTIVE: To document the pattern of retinoblastoma in children in Zimbabwe for the period 2000-2009. DESIGN: Retrospective study. METHODS: Analysis of data from the Zimbabwe National Cancer registry and records of patients admitted to the Paediatric Oncology unit. Data collected from cancer registry were basis of diagnosis, age and gender. Data from the patients medical records included clinical presentation, time to diagnosis and treatment. SETTINGS: The Zimbabwe National Cancer Registry and Paediatric Oncology Unit at Parirenyatwa Tertiary Hospital. RESULTS: 196 patients with retinoblastoma were registered at the cancer registry over the study period. The diagnosis was confirmed histologically on 89% of the cases and in 7% the diagnosis was based on clinical grounds. The age ranged from less than one month to 7 years with median age of 24 months. Males were 111 (56%) with male:female ratio of 1.3:1. Forty three patients (84%) had unilateral and 8 (16%) bilateral disease. Medical records were retrieved from only 54 /196 cases (27.5%). The commonest clinical presentation was proptosis 35/54 (65%). Leucocoria was present in 14/54 (26%). Time interval between first symptoms and diagnosis ranged from less than one month to 24 months with mean duration of 7.7 months (SD = 6.9). Enucleation was performed on 33/ 54 (61%), exenteration on 20/54 (37%) chemotherapy was given to 34/54 (63%) and only 6/54 (11%) received radiotherapy. CONCLUSION: Retinoblastoma is the third commonest registered malignancy of childhood in Zimbabwe, characaterised by late presentation and poor access to therapy.

Bilateral HIV related ocular surface squamous neoplasia: a paradigm shift.

Four patients with bilateral ocular surface squamous neoplasia attended to at Sekuru Kaguvi Hospital Eye Unit are being presented to alert practitioners that OSSN is potentially a bilateral disease and its prevalence is likely to increase as the life expectancy of HIV infected patients is being positively affected by antiretroviral therapy. Reports on ocular diseases should be clear on laterality to avoid confusion between number of patients affected and number of eyes involved since the two cannot be used interchangeably.

Low level technology tool (LLTT) in screening for blindness: test qualities in the outpatients department of a tertiary eye unit using the Snellen chart.

OBJECTIVE: To validate the use of finger counting (low level technology tool) in screening for blindness in the outpatients department of a tertiary eye unit with the view of employing the test for screening illiterate people in hard to reach parts of the country where the conventional visual acuity charts are not available. DESIGN: Aperformance evaluation of counting fingers (LLTT) in screening for blindness against the standard test (Snellen chart). SETTING: Sekuru Kaguvi Eye Unit, Parirenyatwa Hospital, Zimbabwe. SUBJECTS: Patients presenting to the Eye Outpatient Department at Sekuru Kaguvi Eye Unit with various eye problems. MAIN OUTCOME MEASURE: Sensitivity of low level technology tool (LLTT) in identifying blind people. RESULTS: Sensitivity and specificity of LLTT in detecting blindness in all age groups combined was 100% and 88.5% respectively. Although sensitivity was not affected by patient age, specificity decreased with increasing age. The overall positive predictive value for the test was 53.3% and the prevalence of blindness among outpatient attendees was 11.6%. CONCLUSION: Finger counting is an effective tool that can be employed in screening for blindness in communities which are hard to reach, have low literacy rate and when conventional methods of testing visual acuity are not available.

Mortality in an ophthalmic ward at a tertiary eye unit in Zimbabwe.

OBJECTIVE: To review and determine the attributed causes of deaths among patients who died in Sekuru Kaguvi Hospital (SKH) Eye Unit Wards between August 1984 and October 2008 STUDY DESIGN: Retrospective study of completed BD12 forms and case records of inpatients who died betweenAugust 1984 and October 2008. SETTING: Sekuru Kaguvi Hospital Eye Unit, Parirenyatwa Group ofHospitals, Harare, Zimbabwe. RESULTS: Eighty three deaths occurred in the unit during the 24 year period, 51% were females and 33.7% were children below 13 years of age. Ninety three percent of deaths among children were attributed to neoplasias, while 22% of deaths among adults were attributed to infections. Non-ophthalmic causes of deaths were seen among adults. CONCLUSION: Malignancies are the commonest attributable causes of mortality in the Ophthalmic Wards at Sekuru Kaguvi Hospital Eye Unit. Resource mobilization is essential to improve Eye Care Services.

A historical perspective of registered cases of malignant ocular tumors in Zimbabwe (1990 to 1999). Is HIV infection a factor?

INTRODUCTION: Anecdotal and published reports suggest that ocular tumours are on the increase in Zimbabwe. OBJECTIVES: To determine the trends in incidence rates of common malignant ocular tumours registered with the Zimbabwe Cancer Registry during the last decade (1990 to 1999). DESIGN: Retrospective study. SETTING: Data were collected from the Zimbabwe National Cancer Registry, the Zimbabwe National Census 1992 and 2002 Reports, and patient records from hospitals. SUBJECTS: All cases of malignant ocular tumours registered with the Zimbabwe National Cancer Registry between 1 January 1990 and 31 December 1999. MAIN OUTCOME MEASURES: Age standardized annual incidence rates for registered cases of common ocular tumours. RESULTS: The age-adjusted annual incidence rates of squamous cell carcinoma of the conjunctiva had a more than 10-fold increase from 0.17 to 1.8 per 100,000 people during periods 1990 and 1999 respectively. Retinoblastoma dropped by more than half from 0.8 to 0.34 per 100,000 during the same period. The annual age standardised incidence rates for all ocular tumours showed a significant upward linear trend (chi2: 362.78, df=9 and p < 0.001). There was no significant gender difference in the distribution of these tumours amongst the study population. CONCLUSION: The increasing trend in the age-adjusted annual incidence rates of ocular surface squamous neoplasms could be attributed to the worsening HIV and AIDS pandemic in Zimbabwe or improved access/utilization of health services by the public.

Ocular surface squamous neoplasia (OSSN) and human immunodeficiency virus at Sekuru Kaguvi Eye Unit in Zimbabwe: the role of operational research studies in a resource poor environment?

OBJECTIVE: To determine the extent of association and relative risk of developing ocular surface squamous neoplasia (OSSN) among HIV positive patients seen in July 2004 at Sekuru Kaguvi Eye Unit, in Harare, Zimbabwe. DESIGN: Prospective study. SETTING: Sekuru Kaguvi Eye Unit. SUBJECTS: All patients who presented with conjunctival growths in July 2004. MAIN OUTCOME MEASURE: Relative risk. RESULTS: The relative risk of being HIV positive among patients with ocular surface squamous neoplasia was 3.6 with 95% CI 1.5 to 8.6. The mean CD4 cell count level was significantly lower among OSSN patients when compared to patients with non-ocular surface squamous neoplasia. RECOMMENDATIONS: 1. HIV related malignancies can be used as an indicator of when to commence patients on anti-retroviral (ARVs) when CD4 counts are not accessible; 2. Medical practitioners in resource-poor settings should conduct meaningful operational research as part and parcel of their routine clinical work using available resources, since funding is not readily available.

The trend of ocular surface squamous neoplasia among ocular surface tumour biopsies submitted for histology from Sekuru Kaguvi Eye Unit, Harare between 1996 and 2000.

OBJECTIVE: To determine the trend in the prevalence of ocular surface squamous neoplasia (OSSN) among ocular surface tumour biopsies submitted for histology from Sekuru Kaguvi Eye Unit (SKEU), Harare between January 1996 and August 2000. DESIGN: The study was a retrospective records review of patients who had biopsies of ocular surface tumours done during the study period. SETTING: National Referral Centre for eye patients (Sekuru Kaguvi Eye Unit), Parirenyatwa Hospital, Harare, Zimbabwe. SUBJECTS: A total of 1,587 records of patients who had ocular surface tumour biopsies performed were reviewed. MAIN OUTCOME MEASURE: Period prevalence of OSSN among ocular surface tumour biopsy specimens submitted for histology during the period under review. RESULTS: The median age of patients with OSSN was significantly different from the median age of patients with other conjunctival tumours: 35 years (interquartile range [IQR] 25 to 47 years) versus 51 years (IQR 25 to 60 years), p < 0.0005 respectively. Four hundred and thirty out of 615 (70%) patients with OSSN were females. The overall period prevalence of OSSN was 615 of the total of 1,587 (38.8%). The annual prevalence of OSSN among ocular surface tumour biopsy specimens was found to be on the increase and ranged from 33% (115) in 1996 and 57.9% (165) during the year 2000. The Chi-squared test for trend analysis showed a significant upward linear trend (x2 = 27.4, p < 0.004). Fifty three percent of the tumours were OSSN, 42% were pterygium and 5% were pyogenic granulomas of the conjunctiva. CONCLUSION: OSSN is the commonest tumour of the ocular surface whose primary site is the conjunctiva. Its prevalence in Zimbabwe is on the increase and it has a predilection for females over males. Further studies on the natural history, treatment and patient profile would pave a way to better quality of patient care and establish its association with HIV/AIDS.

The rate of and indications for enucleations at Sekuru Kaguvi Eye Unit in Harare: a comparative analysis.

OBJECTIVES: To determine the rate of and indications for enucleation at Sekuru Kaguvi Eye Unit (SKEU) in Zimbabwe and compare the findings with those from other tertiary eye care centres in the developing world. DESIGN: Descriptive retrospective cross sectional study. SETTING: Sekuru Kaguvi Eye Unit, Parirenyatwa Hospital, Harare, Zimbabwe. SUBJECTS: Records of patients who had undergone enucleation at Sekuru Kaguvi Eye Unit, between January 1988 to December 2000. MAIN OUTCOME MEASURES: Rate and indications of enucleations done at SKEU during the study period. RESULTS: Ocular tumours (64.2%) and ocular infections (26.4%) were the leading indications for enucleation and the crude incidence rate for enucleation at SKEU was 0.17% CONCLUSION: Indications for enucleation at the SKEU in Harare are similar to those experienced by other developing countries.

Orbital exenterations and squamous cell carcinoma of the conjunctiva at Sekuru Kaguvi Eye Unit, Zimbabwe.

OBJECTIVES: The aim of the audit was to determine the common orbital diseases necessitating orbital exenterations at Sekuru Kaguvi Hospital (SKH) between January and December 1999 and recommend ways of reducing the numbers of procedures done annually. DESIGN: Retrospective cross sectional study. SETTING: Department of Surgery, Parirenyatwa Hospital, University of Zimbabwe. SUBJECTS: 23 patients who underwent orbital exenterations at SKH over a one year period. MAIN OUTCOME MEASURE: The nature of orbital tumours requiring orbital exenteration in Zimbabwe. RESULTS: A total of 23 patients underwent orbital exenteration during the period under review. Of the 23 patients, 13 (56.5%) had squamous cell carcinoma (SCCA) of the conjunctiva with orbital extensions, 69% of the 13 patients were females and the mean age of these patients was 37.2 years (interquartile range 28, 48). CONCLUSIONS: People in tropical regions, where there is a high risk of squamous cell carcinoma of the conjunctiva in terms of increased predisposition to solar radiation, high prevalence of HIV and inadequate eye care services, should seek medical attention as soon as they notice a persistent conjunctival growth. Conjunctival tumours should be widely excised and material sent for histology to confirm diagnosis and clarity of excision margins. All patients diagnosed as having SCCA of the conjunctiva should be closely monitored to facilitate early detection of recurrences and institute appropriate treatment.

"A little reminder does no harm": case report.

A case of falsified non-accidental ocular injury of a 29 year old male is presented. The importance of an accurate history and appropriate investigations in the management of ocular injuries is highlighted to promote a high standard of health care delivery in Zimbabwe.

An extraordinary role for village community development workers in diagnosing blindness in the community.

OBJECTIVE: To determine the reliability of village community development workers in screening for blindness in the community and to suggest an extraordinary role for these cadres. DESIGN: Diagnostic study. SETTING: Chivi District, Zimbabwe. SUBJECTS: A simple random sample of 148 out of 886 people selected from notification forms. MAIN OUTCOME MEASURE: Sensitivity, specificity and predictive values. RESULTS: The screening method employed was found to have a sensitivity of 93% (95% CI), specificity of 32% (95% CI) and a predictive value for a positive result of 75%. CONCLUSION: The use of village community development workers to screen for blindness in the community has proved to be a reliable alternative when there is shortage of both ophthalmic trained personnel and funds.

A case of extreme myopia enrolled at a school for the blind.

A case of extreme myopia causing remedial blindness in a child enrolled at a school for the blind is presented. The need for training optometrists and creating posts for them at Central and Provincial Eye Units in the country has been highlighted. Selection guidelines for enrolling students at schools for the blind are essential if inappropriate admissions to these schools are to be curtailed.

Cataract surgery in Zimbabwe: the way forward.

The adoption of extracapsular cataract extraction and implant surgery as the standard method of managing senile cataracts in Zimbabwe has been hindered by several factors. These are; succumbing to pressure from promoters of intracapsular cataract surgery, inadequate human and material resources and the problems related to implementation. The problems with intracapsular cataract surgery and aphakic correction are well known. Practical methods of reducing the cost of extracapsular cataract extraction and implant surgery have been suggested. Considering the infrastructure and expertise currently available, coupled with the adoption of some of the cost cutting measures suggested, Zimbabwean ophthalmologists have the potential of providing high quality cataract surgery by international standards to the public without reservations.

Pseudo-exfoliation syndrome in Chivi District: a disease with no geographical or racial boundaries.

OBJECTIVE: To report on the high prevalence of pseudo-exfoliation syndrome and to suggest its possible link with glaucoma in Black Zimbabweans. DESIGN: Cross sectional. SETTING: Chivi District. SUBJECTS: A simple random sample of 148 blind people selected from a sampling frame of 886 blind people in Chivi district. MAIN OUTCOME MEASURES: Prevalence of pseudo-exfoliation syndrome. RESULTS: Pseudo-exfoliation was found among people between 55 and 90 years old. Of the sampled population 7.4% had PXS. Out of 17 eyes, cataracts were found in 12, glaucoma in eight, and spontaneous dislocated lenses in two. CONCLUSION: Pseudo-exfoliation is not rare in Chivi district and further research is needed to establish if it may be associated with glaucoma among Black Zimbabweans.