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.

Dry eye disease among Glaucoma patients on topical hypotensive medications, in a tertiary hospital, Ethiopia.

BACKGROUND: Dry eye disease is a multifactorial disease; causing various ocular symptoms with potential damage to the ocular surface. Applying hypotensive eye drops are presumed to initiate or exacerbate existing dry eye disease. The purpose of this study was to determine the frequency of signs and symptoms and severity of dry eye disease among glaucoma patients on topical hypotensive medications and controls. METHODS: A cross-sectional comparative study, involving 320 glaucoma patients and controls. Ocular Surface Disease Index (OSDI) symptoms score and Schirmer, tear breakup time and corneal staining tests were used to assess dry eye disease. Data was analyzed using SPSS version 24 software; p-value less than 0.05 was considered as statistically significant. RESULTS: Among the 160 study glaucoma patients, the mean duration of topical hypotensive medication use was 5.2 ± 5.21 years (range, 4 months - 32 years). Mild to severe level of OSDI score was found in 122 (76%) glaucoma patients and in 137 (86%) controls (p = 0.033). Mild to sever abnormal clinical tests in the glaucoma patients and control, respectively, were 106 (66%) vs 80 (50%) corneal staining (p = 0.045), 79 (49%) vs 72 (45%) TBUT (p = 0.021), and 91 (57%) vs 83 (52%) Schirmer test (p = 0.242). Test results at the level of sever: 2 (1%) vs 0 (0%) corneal staining, 50 (31%) vs 39 (24%) TBUT and 65 (41%) vs 60 (38%) Schirmer test in the glaucoma patents and controls, respectively. Corneal staining and TBUT had correlation with the number of drugs (p = 0.004 and 0.031, respectively), and more relationship of the two tests with total number of drops applied per day (p = 0.01 and p <  0.001, respectively). Patients on pilocarpine and timolol had more corneal staining and lower TBUT [(p = 0.011 and p <  0.001) and (p = 0.04 and 0.012), respectively]. CONCLUSIONS: The study has identified glaucoma patients to be more affected by dry eye disease than non-glaucoma patients, and presence of significantly lower TBUT and higher corneal staining in the glaucoma patients on multidrops and multidose per day. We recommend consideration of evaluation and management of DED for glaucoma patients on multidrops and multidose hypotensive medications.

Efficacy and Safety of Selective Laser Trabeculoplasty among Ethiopian Glaucoma Patients.

BACKGROUND: Selective laser trabeculoplasty (SLT) is a safe and effective treatment modality for lowering intraocular pressure (IOP). PURPOSE: To determine the efficacy and safety of SLT among Ethiopian patients with primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PXG), and ocular hypertension (OHT). METHOD: A prospective, nonrandomized interventional study was conducted at Menelik II Hospital, Ethiopia. Patients on antiglaucoma medication with uncontrolled IOP and those patients treated for the first time with 360 degrees of SLT were included. Success was defined as an IOP lowering of > 20% from baseline without repeat treatment. RESULT: A total of 95 eyes of 61 patients with a diagnosis of OAG and OHT were enrolled. The diagnosis was POAG in 55 (57.9%) eyes, PXG in 22 (23.2%) eyes, and OHT in 18 (18.9%) eyes. Seventy (73.7%) eyes were on medications, and 25 (26.3%) eyes were treated with laser as primary therapy. The mean (SD) baseline IOP and medication were 24.3 ± 2.5 mmHg and 1.29 ± 1.01, respectively. The one-year mean (SD) IOP reduction was 6.7 ± 4.2 mmHg and medication reduction was 0.26 ± 1.34. The overall IOP reduction at 12 months was 27.6%, and the success rate was 60%. The mean IOP (SD) reduction for patients who were treated for the first time with laser and on antiglaucoma medication was 6.5 ± 3.1 mmHg and 6.8 ± 2.8 mmHg, respectively. Post-SLT, patients experienced transient ocular pain, brow ache, headache, and/or blurring of vision in 31.6%, anterior chamber reaction in 36.8%, and IOP spike ≥ 6 mmHg in 11.6%. CONCLUSION: SLT is an effective and safe treatment modality for OHT, POAG, and PXG among Ethiopian patients either as a first-line treatment or as an adjunct to topical glaucoma treatment.

The Relationship Between Melanin and Glaucoma: A Case-control Study.

PRéCIS:: In a case-control study, skin pigmentation was not statistically significantly different when comparing glaucoma patients to those without glaucoma. PURPOSE: Darker skin color has been implicated as a risk factor for glaucoma based on previous studies' subjective assessments of skin pigmentation. This study used objective measurements to determine whether cutaneous pigmentation is a risk factor for glaucoma. METHODS: This case-control study was conducted at Menelik II Tertiary Referral Hospital in Addis Ababa, Ethiopia. Patients aged 40 years or older from the glaucoma clinic who were being scheduled for trabeculectomy were enrolled as cases and age-matched patients without glaucoma from other clinics at Menelik II Tertiary Referral Hospital were enrolled as controls. A Dermacatch device was used to capture melanin measurements in triplicate from the inner arm of each participant. The exposure variable of interest was the median of the triplicate skin melanin measurements, in arbitrary units. The outcome of interest was presence of glaucoma. RESULTS: Agreement between the triplicate inner arm melanin measurements was high, with an intraclass correlation of 0.99 (95% confidence interval, 0.98-0.99). Mean melanin values were 704 units (SD 94) in 76 cases and 694 units (SD 93) in 152 controls. Melanin was not statistically significantly associated with glaucoma after adjusting for sex and season of measurement (ie, dry vs. rainy), with an odds ratio of 1.15 (95% confidence interval, 0.59-2.24) per 100 units of inner arm melanin. CONCLUSION: This study failed to find a significant association between skin pigmentation and glaucoma using an objective and reproducible assessment of pigmentation.

Results From the First Teleglaucoma Pilot Project in Addis Ababa, Ethiopia.

PRECIS: A teleglaucoma case-finding model was utilized in Ethiopia using a high-risk case identification approach. An overall 7.9% of patients had definite glaucoma, and 13.8% were glaucoma suspects. Most cases could be managed medically. BACKGROUND: This study was carried out to analyze disease prevalence and clinical referral pathways for high-risk patients assessed through a hospital-based teleglaucoma case-finding program. METHODS: Patients over the age of 35 years were referred from outpatient diabetic and hypertensive clinics. Through a teleglaucoma consultation, a glaucoma specialist provided remote diagnosis and management recommendations. Patient referral pathways were analyzed. Part way through the program, frontline ophthalmic nurses and optometrists were empowered to refer patients to be seen by general ophthalmologists within a week if patients met high-risk criteria. Qualitative stakeholder feedback was also obtained. RESULTS: A total of 1002 patients (53% female) were assessed with a mean age of 51.0±11.7 years. The prevalence of glaucoma and glaucoma suspects was 7.9% (79 cases) and 13.8% (138 cases), respectively. Retinopathy was found in 9.1%, with hypertensive retinopathy (2.7%) and diabetic retinopathy (2.5%) representing the majority of cases. Age-related macular degeneration was present in 1.5% and cataract in 16%. An overall 63% of cases were without organic eye disease. 35% of patients were referred to a general ophthalmologist, 0.7% to a glaucoma specialist (for surgery), 1.5% to a retina specialist, and 17.7% to an optometrist for further care. Qualitative analysis revealed that stakeholders felt the value of teleglaucoma would be in triaging patients requiring more urgent management and in identifying disease at an earlier stage. CONCLUSIONS: There is a high prevalence of glaucoma in Ethiopian patients assessed through this teleglaucoma program. This model and study have also demonstrated various principles behind telemedicine, such as the development of an intelligent triage system, case-finding for a variety of diseases, and consideration of optimal patient flow/referral pathways.

Level of adherence to ocular hypotensive agents and its determinant factors among glaucoma patients in Menelik II Referral Hospital, Ethiopia.

BACKGROUND: Good adherence to ocular hypotensive agents is important to control intraocular pressure and hence to prevent progressive glaucomatous optic nerve head damage. Periodic investigation of adherence is crucial in glaucoma treatment. The purpose of this study was to assess level of adherence to ocular hypotensive agents and to identify factors affecting adherence among glaucoma patients at a tertiary public eye care center. METHODS: The study was a hospital-based cross-sectional study that was conducted in Menelik II Referral Hospital from June 1, 2015 to July 31, 2015. A systematic random sampling technique was used to select 359 study participants from the source population. The study patients were interviewed and their medical charts were reviewed using a pretested structured questionnaire. Adherence was assessed using Morisky Medication Adherence Scale - 8 and adherence determinant factors were identified using multivariate binary logistic regression analysis. The association was declared statistically significant at p < 0.05. RESULTS: Among the 359 study glaucoma patients, 42.6 % were adherent to their prescribed hypotensive agents. Higher educational level (AOR = 4.60, 95 % CI: 1.01-21.03, p < 0.049), being self - employed (AOR = 6.14, 95 % CI: 1.37-27.50, p < 0.018) and taking lesser frequency of drops (AOR = 2.89, 95 % CI: 1.25-6.66, p < 0.013) were significantly associated with adherence, whereas being a farmer (AOR = 0.07, 95 % CI: 0.01-0.75, p < 0.028), having very low monthly family income (AOR = 0.22, 95 % CI: 0.06-0.77, p < 0.019) and self - purchasing of medications (AOR = 0.30, 95 % CI: 0.10-0.93, p < 0.036) were significantly associated with non-adherence. CONCLUSIONS: The study has identified the adherence level to the prescribed ocular hypotensive agents to be sub-optimal and is influenced by different factors among glaucoma patients of the public tertiary center. We recommend glaucoma care providers to pay due attention on the importance of adherence.

The spectrum of glaucoma presentation at Menelik II Hospital, Addis Ababa.

BACKGROUND: Glaucoma is a major cause of blindness in Africa. However, many do not know if they have the disease until late. OBJECTIVE: The aim of this study was to describe the type and severity of glaucoma at presentation METHODS: A hospital based prospective review of 602 glaucoma patients was conducted over 18 month period ending in 2009. A special registry captured Socio demographic and clinical data at the glaucoma clinic of Menelik II Hospital in Addis Ababa. The vertical cup disc ratio (CDR) of the optic nerve head provided the bases to stage, the severity of glaucoma. RESULTS: Large portion of the total reviewed patients were men, 401 (66.6%) or above the age of 40 years, 484 (80.4%). The mean intraocular pressure was 28.5 and 30.6 in the right and left eye in mmHg. The leading subtypes of glaucoma, accounting 64.3% (n = 387), were Primary Open Angle Glaucoma, 227 (37.7%) and Pseudo exfoliation glaucoma, 160 (26.6%). At presentation, 260 (44%) and 109 (18%)) were unilaterally and bilaterally blind (vision < 3/60) respectively. Bilateral glaucoma was found in 464 (77%) and 366 (61%) presented with advanced stage (CDR > or = 9.0). Cases with advanced stage were likely to present with blindness [Odds Ratio (OR) -6.2 95% CI (3-8-10.1) and 6.9 95% CI (4.2-11.3)] or high Intraocular pressure >30mmHg [OR=3.4, 95% CI (2.2 -5.2) and 2.8, 95% CI (1.4-3.4)] in the respective right and left eyes. The stage, had no statistically significant association with age, sex, residence or type of glaucoma (Chi2 test, p > 0.05). CONCLUSIONS: A large proportion of patients still arrive at glaucoma clinic with a very late stage of open angle glaucoma. Intervention strategies are requiredfor early detection and treatment of glaucoma in Ethiopia.

Liposarcoma presenting as a recurrent eyelid tumor.

Liposarcoma of the head and neck is rarely reported Orbital and eye lid involvement has been found to be extremely rare. A 25 year old male patient from Harar presented with left eyelid mass of two years duration and diagnosed to have liposarcoma by incisional biopsy. Despite the difficulty in obtaining wide surgical margins, the small tumor size at presentation and the apparent predominance of well-differentiated type means that the prognosis for orbital liposarcoma was generally good. The epidemiological, clinical feature and histological findings are discussed. It is recommended to consider liposarcoma as a differential diagnosis of orbital mass lesions.