A mixed-methods study on evaluating an updated, francophone version of ETAT+ training in Madagascar.

Background: Madagascar needs major efforts to achieve the UN Sustainable Development Goals, despite the considerable reduction of child mortality during past years. In this context, implementation of emergency triage assessment and treatment (ETAT) plays an important role. In recent years, ETAT training activities rarely took place in Madagascar. To strengthen ETAT in Madagascar, a pilot training course was conducted in December 2019 at the University Hospital Mahajanga. Objectives: This study aims to evaluate if the ETAT+ pilot training content matches clinical needs in Madagascar and whether participants achieved their learning objectives. Methods: In this cross-sectional mixed-methods study, a 41-item questionnaire was used at the end of the ETAT+ training to evaluate their learning experience from the 12 participants (paediatricians, physicians, nurses and midwives). Six weeks after the training, guided interviews were conducted among five participants to describe how training content could be transferred into clinical practice in five health facilities. Results: Results suggest that this pilot project designed to contribute to the re-establishment of ETAT in Madagascar meets participants' needs and is adapted to clinical realities in terms of transmitted knowledge, skills and competencies. However, results also show that considerable multi-disciplinary efforts are needed to advance ETAT+ implementation in Madagascar. Conclusion: Implementation processes of ETAT training programmes need re-evaluation to assure their validity to contribute to quality of care improvements efficiently. Further operational research is required to evaluate sustainable, innovative implementation strategies adapted to contexts in Madagascar. Contributions of the study: This study aims to evaluate an updated Malagasy version of the Emergency Triage Assessment and Treatment Plus (ETAT+). The training met the participants' needs and was adapted to the clinical realities in Madagascar relating to transmitted knowledge, skills and competencies.

TOPIRAMATE-INDUCED BILATERAL ANGLE-CLOSURE GLAUCOMA. A CASE REPORT.

INTRODUCTION: Topamax (topiramate) is a drug used in the treatment of epilepsy or migraine. Its use may rarely be associated with the occurrence of secondary angle-closure glaucoma due to supraciliary effusion. Although the ocular finding resembles primary angle-closure glaucoma, bilateral infliction should always raise the suspicion that it is drug-induced glaucoma. CASE REPORT: The authors present a case of a 51-year-old patient on Topamax therapy with sudden vertigo, headache and blurred vision. Ophthalmic examination revealed bilateral angle-closure glaucoma, which was initially treated in the classical manner by administration of local antiglaucoma drugs and pilocarpine, followed by administration of osmotically active substances and laser iridotomy. Only the subsequent discontinuation of Topamax and the use of local cycloplegics and corticosteroids led to the release of the anterior segment angle closure and normalization of intraocular pressure. CONCLUSION: The indicating physician and ophthalmologist must be aware of the possible side effects of Topamax therapy to determine the correct diagnosis and to administer treatment appropriately.

PRE-RETINOPATHY OF TYPE 1 DIABETES IN THE CONTEXT OF FUNCTIONAL, STRUCTURAL AND MICROCIRCULATORY CHANGES IN THE MACULAR AREA.

AIM: The authors assessed the development of intraocular changes in type 1 diabetes (T1DM) from the onset of the disease leading to diabetic retinopathy (DR). The quote: “There must be an intermediate stage between the physiological intraocular finding and the diabetic retinopathy itself “, (prof. Jan Vavřinec). METHODS: A two-year study (2018 and 2019) was conducted at the Department of Ophthalmology of the Teaching Hospital Kralovske Vinohrady in Prague (Czech Republic). There were 54 patients aged 17-42 years, the detection of T1DM ranged between the 1st and 14th year of life, with a duration of 12-35 years. Individual patients were always examined simultaneously by three methods: CS (contrast sensitivity), SD-OCT (spectral domain optical coherence tomography) and OCT-A (optical coherence tomography-angiography). We examined 106 eyes once and in a comprehensive manner. RESULTS: We have shown that there is an intermediate stage between the physiological finding on the retina and DR, so-called diabetic pre-retinopathy (DpR). Subsequent redistribution of the observed into two DpR subgroups was derived from the size of the FAZ, either with its smaller area or with a larger area determining the microvascularity of the central area of the retina. The results of both other methods were assigned to these values. For SD-OCT, the depth of the fovea (the difference between the central retinal thickness and the total average retinal thickness) was determined, which was affected by the increased the macular cubature. In all patients it was on average 10.3 μm3. The retina in the central area was significantly strengthened compared to the healthy population at the level of significance p 0,001. We divided the actual DpR into an image: DpR1 in 26.5 % of eyes - condition with an average shallower fovea only by 21.5 μm below the level of the surrounding retina and an average narrower FAZ: 0.165 mm2 and with a more significant decrease in CS; DpR2 in 40.5 % of eyes - condition with average deeper fovea by 42 μm, i.e., more significantly and average larger FAZ: 0.325 mm2 with lower decrease of CS. At the same time, other changes in microvascularity were noted, such as disorders in the sense of non-perfusion in the central part of the retina of various degrees. This finding differed significantly from changes in already established (non-proliferative) NPDR in 36 % of eyes, when a significant decrease in CS with normal visual acuity was found 4/4 ETDRS. Statistical differences in CS between DpR1 and DpR2 and NPDR were determined - always p 0.001. The average depth of the fovea was NPDR: 29.5 μm. NPDR had the largest average FAZ: 0.56 mm2. Also significant were the most significant changes in non-perfusion and especially the presence of microaneurysms. CONCLUSIONS: These three non - invasive methods helped to monitor the dynamics of the development of ocular changes in T1DM of better quality than the determination of visual acuity and ophthalmoscopic examination. Increased retinal volume induced hypoxia of visual cells with subsequent dual autoregulatory mechanism conditioning two types of diabetic pre-retinopathy before the onset of DR.

CHANGES OF THE FOVEAL AVASCULAR ZONE AND MACULAR MICROVASCULATURE WITHIN THE FRAMEWORK OF OCT ANGIOGRAPHY EXAMINATION IN YOUNG PATIENTS WITH TYPE 1 DIABETES (PILOT STUDY).

AIM: Learn about the development and changes in foveal avascular zone (FAZ) and vascularity of retina in the surrounding zone, depending on the duration in young diabetic patients type 1 (T1DM). METHODS: As part of regular one-year examinations of young T1DM patients at the Eye Clinic of the University Hospital Královské Vinohrady in Prague (Czech Republic, EU) from January to December 2019, OCT angiography using the device Spectralis (Heidelberg Engineering) was included. Forty patients aged 18 to 30 years were examined, median 21 years. T1DM was diagnosed in childhood and lasted for more than 10 years. At the same time, a control group of forty individuals of similar age, without metabolic and other general disease was examined, normal visual acuity and physiological fundoscopic finding were obligatory. The FAZ size was evaluated in both groups (using built-in function "Draw Region"), also its shape, density decrease and change in character of vascularity of the retina was assessed. RESULTS: In the control group, the FAZ area ranged from 0.06 to 0.4 mm², with an average of 0.253 ± 0.092 mm² and a median of 0.27 mm². It was not affected by a fundamental change in its round shape and the surrounding capillary netting was regular and reasonably dense. In T1DM patients, the FAZ area was in a wider range, from 0.05 to 0.64 mm², an average of 0.300 ± 0.132 mm², and a median of 0.31 mm². The difference in FAZ across-the-board evaluation was statistically significant (p = 0, 009). Diabetic preretinopathy (DpR) was defined by the irregularity of the capillary density up to the manifestation of non-perfusion, in 61% of cases the size of the FAZ was changed. In diabetic retinopathy (DR) there was always an irregularity of the FAZ shape with its enlargement, manifestation of non-perfusion, capillary dilatation and rare microaneurysms. CONCLUSION: Changes in FAZ size corresponded to the stage of T1DM on the fundoscopic finding of the eye depending on its duration. The initial increased amount of foveal capillaries, which resulted in decreased FAZ area, was followed by a gradual decrease in capillaries and increased FAZ area, consistent with the manifestations of DpR. It was accompanied by a change in capillary density in macula to eventual non-perfusion. On the contrary, the increase in the FAZ area and its irregularity accompanied by non-perfusion of the capillary net and microaneurysms corresponded to the development of DR already.

[Contrast sensitivity and optic coherence tomography examinations in adolescent patients with diabetes type I preretinopathy (a pilot study)]. / Preretinopatie u mladistvých s diabetem 1. typu z pohledu vysetrení citlivosti na kontrast a koherencní tomografie (pilotní studie).

AIM: To evaluate the development of retinal changes in adolescent patients with diabetes type I (T1DM) with diseases duration more than 10 years, which started before 5 years of age. METHODS: The development of the findings on the posterior pole was followed up. The retinal functions were established by means of contrast sensitivity in four space frequencies: 3 cycles/degree (c/deg) (perimacular area), 6 c/deg and 12 c/deg (macular area), and, finally, 18 c/deg (foveola). The central retinal thickness, average retinal thickness of the specified quadrant of macular area, the foveolar depth of its own, and the volume of the perimacular area (perimacular cube volume) were measured by means of optical coherent tomography (OCT). MATERIAL: Altogether 20 patients with diabetes type I meeting the set criteria were examined, and their findings were compared with control group of healthy adolescent people. The values from the control group were used as our normative database. RESULTS: On the retina, there were found, during the diseases course lasting in average 13.3 years, changes of the macular area, especially tortuosity of macular final capillaries and pigmentation with disappearing of foveolar reflex, which, in 20 %, were followed by sporadic hard exsudates of the retina. Difference of the decreased values in adolescent patients, comparing to the control group, was recorded in contrast sensitivity in space frequencies of 3 c/deg (p 0.047) and 12 c/deg (p 0,0497), but statistically significant was the difference in space frequencies of 6 c/deg (p 0.0001) and 18 c/deg (p 0.0001). Using the OCT, no statistically significant difference was found in the central retinal thickness, but the values of foveolar depth in patients with diabetes type I were variable (p 0.0153); in four eyes it was much deeper, and in other four of them it was much shallower. Furthermore, there was higher the average thickness of the retina (p 0.0008) and the volume of the perimacular area (perimacular cube) (p 0,0001). CONCLUSION: The findings in eight eyes out of five patients with T1DM were evaluated as diabetic preretinopathy - pre-stage of beginning stage of diabetic retinopathy in central area of the retina from the functional and structural point of view of current pathological changes of contrast sensitivity and OCT. The findings of other three patients were rated as diabetic preretinopathy according to sporadic hard exsudates of the retina and OCT changes, but. until now, without contrast sensitivity changes. The one-year profile of glycated hemoglobin (HbA1c) was higher in patients with diabetic preretinopathy than without the eye involvement, but it was not statistically significant (p 0,0314).Key words: Contrast sensitivity (CS), Spectral Domain Optic Coherence Tomography (SD-OCT), diabetes mellitus type I (T1DM), diabetic preretinopathy (DpR), glycated hemoglobin (HbA1c).