Chorioretinitis among Immigrant and Travellers. Comment on Mansour et al. Presumed Onchocerciasis Chorioretinitis Spilling over into North America, Europe and Middle East. Diagnostics 2023, 13, 3626.

We read, with interest, the paper by Mansour et al [...].

Spectrum of and Factors Associated with Eye Disorders among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Uganda.

Background: Ocular morbidities associated with rheumatoid arthritis (RA) have not received much attention in Africa, particularly in sub-Saharan Africa. They are among the commonest (40%) extra-articular organ involvement in RA. If undiagnosed, there is a potential risk of them causing visual impairment or blindness. There is no documented study in Uganda on the magnitude of eye disorders among RA patients. Aim: To determine the spectrum of eye disorders and associated factors among patients with RA attending Mulago National Referral Hospital. Methods: A hospital based cross-sectional study was conducted among adults with RA attending the rheumatology clinic between July 2021 and September 2021. Clinical and sociodemographic data were collected, and ophthalmologic examinations were performed on all consenting participants. Modified Poisson regression with robust standard error was used to determine factors associated with eye disorders. Results: Overall, 105 patients with RA were enrolled, of which, 53 (50.5%) had eye disorders. The commonest disorder (54.7%, n=29) was dry-eye syndrome. Factors that were significantly associated with eye disorders were age 36-55 years (aPR 1.56, p=0.015), duration of RA >5 years (aPR 1.81, p=0.001), use of hydroxychloroquine >5 years (aPR 1.77, p=0.041), dose of oral steroids >10 mg/day (aPR 1.49, p=0.034), and history of both diabetes and hypertension (aPR 1.87, p=0.014). Conclusion: The prevalence of eye disorders among patients with RA was high, with the commonest being dry-eye syndrome. We recommend that ocular examinations be performed on every patient at the time of RA diagnosis for early detection of eye disorders.

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.

Ocular complications and associated factors among traditional eye medicines users attending the eye clinic at Mulago national referral hospital, Uganda.

Background: Over the past decades there has been a phenomenal increase in the use of Traditional Eye medicines (TEM) worldwide and there are several factors that compel patients to use TEM. Objectives: We conducted a study to determine the types of traditional eye medicine, ocular complications, and associated factors among traditional eye medicine users at the Mulago National Referral Hospital (MNRH) eye clinic. Methods and Materials: A hospital-based cross-sectional study among TEM users at MNRH eye clinic from June to August 2021. Epi Data version 4.2 and STATA version 15 used for analysis. A modified Poisson regression with robust standard errors was used to determine the associated factors. Results: Overall, 182 TEM users (males:53.3%) were enrolled, with a mean age of 36±21SD years. The most frequently used type of TEM were plant products (47.8%). 70% of TEM users had ocular complications, the most frequent manifestation was conjunctivitis (53.9%). Ocular complications were significantly associated with living in the urban areas (p< 0.006) and participants who reported ease and availability of TEM (p < 0.001). Conclusion: Plant-based products were the most frequently used types of TEM, a large proportion of the TEM users were found with sight-threatening ocular complications.

Prevalence and risk factors for visual impairment among elderly patients attending the eye clinic at Mulago National Referral Hospital, Uganda: a cross-sectional study.

Background: The elderly have an increased risk of developing visual impairment (VI). Due to the increase in life expectancy of individuals in Sub-Saharan Africa, the population of the elderly is projected to increase. It is thus postulated that the prevalence of VI will increase which is currently unknown in Uganda. Objective: To determine the prevalence and risk factors for VI among the elderly at Mulago National Referral Hospital eye clinic in Uganda. Methods: This was a cross-sectional study carried out in 2020 with consecutive enrolment of patients aged 60 years and above. Obtaining history was followed by systemic and ocular examination. Statistical analysis was performed to determine the prevalence and factors associated with VI. Results: Of 346 elderly participants examined, 174 (50.3%) were males and median age was 67 (IQR 63-74). Prevalence of VI was 32.1%. Cataract was the leading cause of blindness 54.1%, followed by refractive error (21.6%), glaucoma (11.7%), and corneal opacities (5.4%). Age (adjusted Prevalence Ratio (aPR): 1.05, 95% CI (1.02, 1.06)), history of diabetes mellitus (aPR 1.46, 95%CI (1.04, 2.05)), history of hypertension (aPR 1.46, 95%CI (1.10, 1.93)), having completed primary level of education (aPR 0.74, 95%CI (0.55, 0.98)) and secondary level of education (aPR 0.47, 95%CI (0.30,0.73)), presence of a cataract at examination (aPR: 2.28, 95%CI (1.66, 3.13)) were statistically significantly associated with VI. Conclusion: In Mulago hospital, the prevalence of VI among the elderly is high with majority of the causes being correctable. We recommend that efforts towards early case identification of causes of VI among the elderly should be a priority.

High Prevalence of Glaucoma among Patients in an Onchocerciasis Endemic Area (Mahenge, Tanzania).

Onchocerciasis is known to cause skin lesions and blindness, but there is also epidemiological evidence that onchocerciasis is associated with epilepsy, including nodding syndrome. We carried out ocular exams in persons with epilepsy in Mahenge, an onchocerciasis endemic area with a high prevalence of epilepsy in Tanzania. We recruited 278 consecutive persons with epilepsy attending the epilepsy clinic at Mahenge hospital and satellite clinics in rural villages. They underwent a general physical and a detailed ocular examination and were tested for onchocerciasis Ov16 IgG4 antibodies. Glaucoma was defined by a raised intraocular pressure above 21 mmHg with evidence of typical glaucomatous disc changes in one or both eyes. Among the 278 participants, median age 27 (IQR 21-38) years, 55.4% were female; 151/210 (71.9%) (95% CI: 65.3-77.9) were Ov16 positive. The most frequent ophthalmic lesions were glaucoma (33.1%), vitreous opacities (6.5%) and cataracts (2.9%). In multivariate analysis, glaucoma (adjusted IRR = 1.46; 95% CI: 1.24-1.70) and age (adjusted IRR = 1.01; 95% CI: 1.01-1.02) were significantly associated with onchocerciasis. In conclusion, a high prevalence of glaucoma was observed among Ov16 positive persons with epilepsy. Persons with epilepsy with O. volvulus infection should undergo screening for glaucoma to prevent one of the causes of preventable blindness.

High COVID-19 Vaccine Acceptance among Eye Healthcare Workers in Uganda.

BACKGROUND: Protecting healthcare workers against COVID-19 disease is crucial, and COVID-19 vaccination is the most effective method to do so. Eye healthcare workers provide routine care in proximity, increasing infection risk, hence their need for full vaccination. This study determined COVID-19 vaccine acceptance and barriers to its uptake among eye healthcare workers practicing in Uganda. METHODS: This was a cross-sectional online and telephone survey based on the health belief model (HBM), conducted in June-August 2021. A modified Poisson regression model with robust standard errors was used to determine the factors associated with COVID-19 vaccine acceptance. RESULTS: In total, 300 (85%) of the 357 eye healthcare workers participated in the study with mean age 43 ± 8 years and 182 (60.7%) were men. Overall, 97.6% (95% CI: 95.9-99.4) had accepted and/or were willing to take the COVID-19 vaccine, 65.3% had received a shot of the COVID-19 vaccine, and 97 (32.3%) reported the intention to accept the vaccine when it became available. Among the HBM constructs, high perceived susceptibility and high perceived benefits were significantly associated with COVID-19 vaccine acceptance. CONCLUSIONS: The acceptance of the COVID-19 vaccine among eye healthcare workers in Uganda is very high. There is a dire need to make vaccines available to developing nations like Uganda.

Prevalence and predictors of ocular complications among children undergoing nephrotic syndrome treatment in a resource-limited setting.

BACKGROUND: Nephrotic syndrome is the most common glomerulopathy among children aged 2-18 years and high dose corticosteroids are the backbone of its management. Potentially blinding ocular complications often result from nephrotic syndrome and/or its treatment. We conducted a study to determine the prevalence and predictors of ocular complications among children undergoing nephrotic syndrome treatment at Mulago National Referral Hospital. METHODS: This was a cross-sectional study conducted for three [3] months at the pediatric renal unit of Mulago National Referral Hospital (MNRH). Data from a consecutive sample of 100 children was collected using a semi-structured questionnaire, entered into Epi-data 4.4.2 and exported to STATA 14 for analysis at univariate, bivariate and multivariate levels. A robust Poisson regression model was used to identify predictors of ocular complications. RESULTS: Out of 100 patients examined, 80(80%) had ocular complications. The median age was 10 (IQR: 7-12) and 52 (52%) were girls. The most frequent complications were hypertrichosis and refractive errors in 71% (95%CI 61.1-79.6) and 56% (95%CI 45.7-65.9) of the patients respectively. Age above 10 years was the predictor for ocular complications with a RR = 1.37 (95%CI:1.14-1.64) p = 0.001. CONCLUSIONS: We found a high prevalence of ocular complications among children with nephrotic syndrome in this tertiary hospital. The predictor of ocular complications was age greater than 10 years. We recommend that all children with nephrotic syndrome undergo a baseline ocular examination prior to commencement of treatment and be reviewed periodically by an ophthalmologist.

Intense Simulation-Based Surgical Education for Manual Small-Incision Cataract Surgery: The Ophthalmic Learning and Improvement Initiative in Cataract Surgery Randomized Clinical Trial in Kenya, Tanzania, Uganda, and Zimbabwe.

Importance: Cataracts account for 40% of cases of blindness globally, with surgery the only treatment. Objective: To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees. Design, Setting, and Participants: A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis. Interventions: The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period. Main Outcomes and Measures: The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period. Results: Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001). Conclusions and Relevance: This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety. Trial Registration: Pan-African Clinical Trial Registry, number PACTR201803002159198.

Prevalence, pattern and factors associated with ocular disorders in small-scale welders in Katwe, Kampala.

BACKGROUND: Welders are at an increased risk of eye disorders as a result of their occupation, leading to enormous vocational and economic consequences. With limited published studies among welders in low resource settings, we sought to determine the prevalence, pattern and factors associated with ocular disorders among small-scale welders in Katwe, Kampala. METHODS: In a field-based cross-sectional study, we recruited 343 small-scale welders. Simple random sampling was done to select the study participants. A pretested questionnaire was used to collect information on demographics, ocular, general history, systemic and ocular examination. The proportion of small-scale welders with ocular disorders (defined as any abnormal finding on eye examination) was determined. The bivariate and multivariate analyses were carried out, using logistic regression methods at a level of significance of 0.05. RESULTS: The mean age of the participants was 36 years (SD ± 12). The overall prevalence of ocular disorders was found to be 59.9%. The common ocular disorders included conjunctiva disorders (32%) and presbyopia (27%). There was a statistically significant relationship between females (OR = 4.279, P-value = 0.007), age 35 and above (OR = 4.244, P-value< 0.001), history of foreign body removal (OR = 1.677, P-value = 0.041), and ocular disorders. CONCLUSIONS: There is a high prevalence of ocular disorders among small-scale welders. Conjunctiva disorders, presbyopia and myopia were the commonest. Being female, age 35 and above and foreign body removal, were significantly associated with ocular disorders among welders. Policies should be put in place to ensure all welders use proper personal -protective equipment (welding helmets), and also receive regular eye checkup and health education.

Elevated inflammatory cytokines in aqueous cytokine profile in HIV-1 infected patients with cataracts in Uganda.

BACKGROUND: Cataracts occur earlier among HIV-infected adults and this is attributed to various intraocular inflammatory processes that result in early degeneration. In this study we purposed to investigate whether HIV infected individuals with cataracts develop heightened intraocular inflammatory processes compared to their HIV negative counterparts by determining the concentration of 8 cytokines in the aqueous humour of HIV-positive adults with cataracts and their HIV-negative counterparts. METHODS: A cross-sectional study was conducted among consecutive adults with cataracts that were operated in an ophthalmology surgical camp in western Uganda. We determined levels of Granulocyte macrophage stimulating factor (GM-CSF), interleukin 6 (IL-6), interleukin 8 (IL-8), tumour necrotic factor alpha (TNF-a), interferon gamma (IFN-g), interleukin 4 (IL-4), interleukin 2 (IL-2), and interleukin (IL-10) in the aqueous fluid using a multiplexed cytokine analysis. Data was entered in the SPSS version 10 and analyzed using STATA statistical software version 7.0. Categorical and continuous variables were compared using the χ2 test, Fisher's exact test and the Student's t-test. Bonferroni correction was used to cater for multiple comparison of p values for the various cytokines. RESULTS: The 50 adults that underwent cataract surgery were outdoor peasants with similar exposure hours to UV radiation. The HIV-positive patients were younger {median age 43 years (SD 11.741)} compared to the HIV -negative patients {median age 66.5 years (SD 21.4)}. The mean CD4+ T cell count of the HIV-positive patients was 161 cells /mm3, and 12(48%) had started anti-retroviral therapy (ART). Pro inflammatory cytokines, GM-CSF, IL-8 and IL-10 were significantly higher among HIV-positive individuals (p = 0.001, 0.030, < 0.001 respectively). HIV-positive individuals on ART also showed significantly higher levels of GM-CSF, IL-8 and IL - 10 (p = 0.002, 0.021, < 0.001 respectively). TNF-a and IL-4 were significantly higher among those with a CD4+ T cell count greater than 200cells/mm3 compared to those with CD4+ T cell count less than 200 cells/mm3 (p = 0.022, 0.032 respectively). CONCLUSION: Cataracts among HIV-positive adults were associated with higher intraocular inflammation relative to the healthy elderly individuals with cataracts. There is need to explore the potential role of intra-ocular anti-inflammatory agents in the management of cataracts among HIV positive patients.

CD4 T-cell activation and reduced regulatory T-cell populations are associated with early development of cataracts among HIV-infected adults in Uganda.

BACKGROUND: Cataracts contribute 12% of visual loss among HIV-infected adults in Uganda. Immuno-pathogenesis of cataracts may differ among HIV-infected individuals; thus the need for innovative therapeutic interventions among HIV-infected adults. METHODS: In a laboratory based case-control study, nested in a clinical/surgical community outreach camp, 50 adults with cataracts eligible for surgery were selected consecutively. HIV testing was done for individuals with unknown HIV sero-status. Peripheral Blood Mononuclear Cells (PBMC) were collected from all HIV-positive-adults-with-cataracts (cases) and HIV-negative-adults-with-cataracts (comparative group) and age-matched HIV-negative and HIV-positive-adults-without-cataracts (comparative group). Treg were measured as CD3+CD4+FoxP3+CD25+(Bright) and immune activation as CD3+CD4+CD38+HALDR+ using a Facs Canto II flowcytometer. Mann Whitney test was used to compare expression among the four groups. RESULTS: Of 50 adults operated for cataracts, 24 (48%) were female, 25 (50%) were HIV-positive. HIV-positive-individuals had cataracts earlier [median; Inter-quartile Range (IQR); 49 (44-53) years] than HIV-negative [70 (IQR 59-75) years]; p=0.0005. Treg were lower among individuals with cataracts irrespective of HIV status; p=0.001; but comparable among younger HIV-positive and elderly HIV-negative with cataracts; p=0.301. Immune activation levels were comparable among HIV-positive and HIV-negative individuals with cataracts. However, HIV-positive-individuals with cataracts expressed higher levels of immune activation than HIV-positive-individuals without cataracts; p=0.012 and HIV-negative-individuals-with-cataracts expressed higher levels of immune activation that HIV-negative-without-cataracts; p<0.0001. CONCLUSION: CD4 T-cell activation and reduced regulatory T-cell populations were associated with cataracts among adults aging with HIV. We recommend studies on clinical relevance of immune modulation in the prevention of early development of cataracts among adults aging with HIV in Africa.

The prevalence and causes of visual loss among HIV-infected individuals in Uganda.

AIM: To determine the prevalence of loss of visual acuity and to describe the ocular diseases associated with vision loss among HIV-infected individuals in Uganda.Methods: One thousand two hundred twelve HIV-positive individuals aged 18 years or older attending an HIV treatment site in Kampala,Uganda, were consecutively screened for loss of visual acuity using a Snellen chart. Those found to have a visual acuity of 6/9 or less in 1 or both eyes had a detailed ocular diagnostic evaluation.Results: One hundred thirty-six patients [11.2%; 95% confidence interval (CI): 9.49­13.13] had a visual acuity of 6/9 or less in at least 1 eye, with 74 (6.1%; 95% CI: 8.54­12.21) having bilaterally reduced presenting visual acuity. Eighty-eight (7.3%; 95% CI: 8.57­12.28)had a visual acuity of 6/18 or worse in at least 1 eye. Ocular diseases associated with reduced vision included cataract 16 (11.8%), optic nerve disease 20 (14.7%), refractive errors 35 (24.3%), and uveitis 44 (32.3%). Other diagnoses observed included diabetic retinopathy,maculopathies, corneal scars, glaucoma, and squamous cell carcinoma of the conjunctiva.Conclusions: Visual impairment and ocular disease affect a large proportion of HIV-infected individuals presenting for HIV care in Uganda. Most causes of vision loss were treatable or could have been prevented with appropriate ophthalmic and medical care.

Ocular immune reconstitution inflammatory syndromes.

PURPOSE OF REVIEW: The aim of this article is to review the current literature concerning immune reconstitution inflammatory syndrome in relation to the eye. The definition, epidemiology, pathophysiology, risk factors, clinical features, diagnosis and treatment are discussed. RECENT FINDINGS: Immune reconstitution inflammatory syndrome affecting the eye has been documented in association with cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy in a large number of patients. This syndrome is referred to as immune recovery uveitis, which is presumed to be mediated by recovery of immune responses specific to residual cytomegalovirus antigen located in the eye. In addition to improved immunity itself, risk factors include a low CD4 T count at the time of initiation of highly active antiretroviral therapy and involvement of a larger proportion of retina. Immune recovery uveitis is a major cause of visual loss and morbidity among patients with AIDS who are receiving highly active antiretroviral therapy. SUMMARY: Immune recovery uveitis is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy. Clear clinical definitions are required for ocular immune reconstitution inflammatory syndromes to avoid misclassification of other inflammatory conditions. A multidisciplinary approach is important in the diagnosis and management of immune recovery uveitis.