A Non-Inferiority Study of Combination of Latanoprost and Timolol Formulation to Their Separate Use in Drug-Naive Primary Open Angle Glaucoma and Ocular Hypertension Nigerian Patients. {RCT 93803536 (Nigeria Clinical Trial Registry)}

BACKGROUND

Control of intraocular pressure continues to be the mainstay of the management of primary open-angle glaucoma. It is also one of the key factors to consider in the diagnosis and risk of conversion of ocular hypertension to glaucoma (POAG). Medical management of IOP control is central to the treatment of POAG especially in resource-poor countries.

AIM

This study aimed to demonstrate the non-inferiority of a fixed combination of front-line drugs in the medical management of glaucoma (latanoprost and timolol) compared to concomitant use of the same drugs.

METHODOLOGY

It was a double-blind, randomized clinical trial (RCT) in which 116 sequentially consenting participants 40 years and above were recruited and randomized to receive either a fixed combination (group A) or a concomitant combination of latanoprost and timolol (group B). The study was carried out across two tertiary centers in southwest Nigeria.

RESULTS

One hundred and fifteen (115) patients were analysed, 58 in group A and 57 in group B. The mean age of participants was 57.9 (± 11.5) years. There were 51 (44.3%) females. Primary open-angle glaucoma (POAG) was the diagnosis in 88 (76.5%) of the participants. No statistically significant difference between the two groups at recruitment. Mean IOP reduction from baseline to day 28 was -17.30 ± 7.8 (95% CI: -15.37 to -19.15), and -14.59 ± 6.1 (95% CI: -12.98 to -16.19) for groups A and B. Group A thus had a 54.97% IOP reduction from baseline values while group B had 51.81% (p = 0.770). The mean intergroup difference (MeD) in IOP reduction (µA - µB) between the two groups on day 28 was 2.05 ± 5.74 (95% CI: 0.6 - 1.61) p=0.04.

CONCLUSION

The study was able to demonstrate a noninferiority relationship between the fixed combination dosage form of latanoprost and timolol as compared to the concomitant dosage forms.

PREVALENCE AND PATTERN OF PRESBYOPIA IN A RURAL NIGERIAN COMMUNITY

BACKGROUND

Presbyopia is an age related loss of accommodation that results in the inability to focus at near distances. Few population-based studies exist on the prevalence of presbyopia among people living in developing countries.

AIM

To determine the prevalence of presbyopia, presbyopia correction coverage and identify barriers to spectacle usage in individuals aged 35years and above.

DESIGN

Cross sectional descriptive survey.

SETTING

Esie, a rural community in Kwara State, Nigeria.

MATERIALS AND METHODS

Four hundred and four subjects with best corrected distance vision ≥20/60 were enrolled into the study by a multistage sampling procedure. Distance and near vision testing and near refraction (for those with presenting near VA < N8 at 40cm) were carried out. Interviewer administered structured questionnaires were used to collect subjects' information.

RESULTS

Three hundred and thirty five subjects were included while 24 subjects were not available for examination and 45 subjects excluded based on the visual acuity cut off point. The age range was 35 to 100 years, with a mean age of 57±12.1years. The prevalence of presbyopia was 59.7%. Presbyopia correction coverage was 46.5%. Increasing age was found to be significantly associated with presbyopia, while gender, occupation and educational level were not. Skilled workers, retired persons and those with at least a secondary education were more likely to have glasses than others. The commonest barrier to obtaining near vision glasses was lack of money.

CONCLUSION

Presbyopia is a major burden and cause of ocular morbidity in this rural community. Cost is the commonest barrier to obtaining near vision spectacles. Increasing the availability of affordable spectacles will go a long way to overcome this.

CHALLENGES IN THE MANAGEMENT OF GLAUCOMA IN A DEVELOPING COUNTRY; A QUALITATIVE STUDY OF PROVIDERS' PERSPECTIVES

BACKGROUND

Glaucoma management is challenging to patients as well as to the eye care providers. The study is aimed at describing the challenges faced by providers using qualitative methods.

METHODS

In-depth interviews were conducted with selected Ophthalmologists and resident doctors in ophthalmology at centres offering medical and surgical glaucoma services in Lagos state, Nigeria, according to established qualitative methods. This was done using semi-structured, open ended questions to explore the providers' perspective on glaucoma burden, challenges in the management, surgery for glaucoma, acceptance of glaucoma surgery by patients, and recommendations for improving glaucoma services. The discussions were recorded with the aid of a micro-cassette recorder. Familiarisation was done to identify key ideas in the data, then, the main themes and sub-themes were identified. Quotes that reflect the themes and sub-themes were then identified in the data.

RESULTS

In-depth interviews were conducted with a total of 11 ophthalmologists and resident doctors in training. Majority were of the opinion that glaucoma is a significant burden constituting about 35% of outpatient visits. Identified patient related challenges include; late presentation, lack of glaucoma awareness, delay in referral from optometrists, and poor compliance with medications. Shortages in needed equipment were also identified. Availability, affordability and counterfeiting of drugs were the major challenges related to medical treatment. Majority of the participants agreed that surgery should be offered to the patients as soon as the diagnosis of glaucoma is made. However, continuous monitoring of the patient on medical treatment is another line of option for them in early cases; if they are convinced the patients will be compliant. Some respondents considered the current number of glaucoma surgeries as adequate, while some think otherwise. Reasons put forward for reluctance to offer glaucoma surgery include; late presentation, lack of patient satisfaction, complications of surgery, and negative publicity.

CONCLUSION

Even though the challenges in the management of glaucoma in developing countries are many, they are not insurmountable. There is need for concerted and integrated efforts involving all cadres of eye care practitioners, patients, institutions and governments to address this important eye disease. Improved awareness, provision of adequate equipment, availability and affordability of medications, need for training and retraining of eye care providers are all important measures that can lead to better management of the glaucoma patient.

Blindness and scalp haematoma in a child following a snakebite

BACKGROUND

Snake envenomation is a major public health problem of the Savannah regions of West Africa. Ocular manifestations of snakebites are rare with few reports documenting blindness as a complication.

OBJECTIVE

To highlight an unusual manifestation of snake bites and its attendant problems.

METHODS

A report of scalp haematoma and blindness in a 10 year old child presenting 2 weeks after a snake bite (presumably carpet viper) is a rare manifestation. Local swelling, epistaxis, bilateral proptosis, exposure keratopathy and use of traditional eye medications were associated findings. Anti-venom though administered late saved the child's life but blindness could not be reversed.

RESULTS

Ocular ultrasonography revealed layered retrobulbar collection in the left eye, presumably due to hemorrhage. The skull x-ray showed a soft tissue swelling and aspirate from scalp swelling was bloody. Cranial Computed Tomography (CT) scan done late detected no abnormalities.

CONCLUSION

Snakebite is associated with lifelong morbidity. Ocular manifestations must be treated as emergency. This case highlights the effect of ignorance and poverty in a setting of a common medical emergency leading to blindness and reduced quality of life.

Poor cataract surgical output: eye care workers perspective in north central Nigeria

BACKGROUND

Cataract remains a disease of priority being the leading cause of blindness globally. Although surgically curable, cataract surgical output has remained low in Nigeria, Kwara state inclusive. A study was carried out to investigate the perception of eye care workers (ECW) on low surgical output and their adjudged reasons; this has hitherto not being evaluated.

MATERIALS AND METHODS

A cross-sectional quantitative survey with the aid of pretested structured questionnaire of all ECW and qualitative survey using in-depth interview on selected workers in Kwara State, Nigeria was done.

RESULTS

A total of 142 out of the 157 ECWs (90.5%) working in the 14 surgical eye centers in the state were interviewed with a mean age of 40.37 years, SD ± 8.67. There were 94 (66.2%) females, with a female to male ratio of 2:1. 91 (64.1%) participants were of the opinion that the numbers of cataract surgeries in the state were inadequate. Hospital-based and human resource efficiency-related issues such as long clinic waiting time, multiple paying and procedural sites, poor staff mix, and gaps in available human resource were the major reasons given for low cataract output. Others reasons were high cost and fear of surgery, distance of eye clinics from patients.

CONCLUSIONS

Regular operational researches, proper deployment, and efficient use of human and material resources in addition to subsidized cost and appropriate health education to allay fear of surgery are steps that could enhance cataract surgical output.

Managing glaucoma in Lagos State, Nigeria - availability of Human resources and equipment

AIMS AND OBJECTIVES

There is a paucity of data onthe human resourcesand ophthalmic equipmentavailable for the diagnosis and management of glaucoma in Nigeria. This study is aimed at describing the ophthalmic human resources, as well as available and functioning equipment used in diagnosing and managing glaucoma in Lagos State, Nigeria.

MATERIALS AND METHODS

This was a prospective multicentre cross sectional study.Data on human resources and equipmentavailable were collected from all government tertiaryand secondary health institutions in the state. One large-practice private eye hospital in the state was included for comparative purposes.

RESULTS

The average number of ophthalmologists per hospital was 1.3 and 4.5 in the secondary and tertiary centres respectively, with overall ophthalmologists to population ratio of 1:400,000, and ophthalmic nurses to population ratio of 1:150,000. There were only 2 full time low vision therapists and 3 equipment technicians. Only the private hospital had a dedicated patient counsellor and an eye unit manager. 64% of ophthalmic equipment in the government sector were functioning compared with 100% in the private centre. Overall, equipment to population ratios were; slit lamp=1:517,000, 78/90D lens=1:1,487,000, tonometer=1:660,000, visual field analyser=1:2,380,000, and pachymeter=1:5,950,000.

CONCLUSIONS

Current population ratios for ophthalmologists and ophthalmic nurses in the state meets vision 2020 recommendations, but there are shortages of other key human resources such as equipment technicians, low vision therapists and patient counsellors. In addition, equipment required for the management of glaucoma wereinadequate, not available or not functioning. Findings from this study suggest that there is an urgent need for increased government funding to glaucoma services in Lagos State.

Minimising cornea scarring from the use of harmful traditional eye remedies in developing countries

Corneal scarring is the fourth largest cause of blindness globally, and a much more prominent factor in developing countries. Blindness from corneal scarring is largely a preventable phenomenon, and is capable of causing significant morbidity that can last for a lifetime. A significant proportion of these cases are caused by the use of harmful traditional eye medicines/remedies, and are used and prescribed by friends, relatives and traditional healers, with widespread use especially in developing countries. Use of traditional remedies can also cause harm indirectly by causing delays before seeking medical treatment. Reducing corneal scarring from the use of harmful traditional medicine is through a combination of approaches with the key strategies being community diagnosis, education, participation, and intervention, with provision of basic eye care integrated into the primary health care of the community. Collaboration with traditional healers in the community is also another approach that has been found to be useful.

Minimising corneal scarring from the use of harmful traditional eye remedies in developing countries

Corneal scarring is the fourth largest cause of blindness globally, and a much more prominent factor in developing countries. Blindness from corneal scarring is largely a preventable phenomenon, and is capable of causing significant morbidity that can last for a lifetime. A significant proportion of these cases are caused by the use of harmful traditional eye medicines/remedies, and are used and prescribed by friends, relatives and traditional healers, with widespread use especially in developing countries. Use of traditional remedies can also cause harm indirectly by causing delays before seeking medical treatment. Reducing corneal scarring from the use of harmful traditional medicine is through a combination of approaches with the key strategies being community diagnosis, education, participation, and intervention, with provision of basic eye care integrated into the primary health care of the community. Collaboration with traditional healers in the community is also another approach that has been found to be useful.

Visual function survey of commercial intercity vehicle drivers in Ilorin, Nigeria

OBJECTIVE

To determine the prevalence of visual impairment among commercial intercity vehicle drivers (CIVDs) in Ilorin, Nigeria.

DESIGN

A cross-sectional descriptive study.

PARTICIPANTS

Among the estimated 450 drivers operating in 5 motor parks for CIVDs in Ilorin, 399 drivers participated in the study.

METHODS

A structured questionnaire was administered at the motor parks to consecutive and consenting drivers, and basic ocular examinations were done.

RESULTS

Using the Federal Road Safety Commission's requirement for commercial drivers in Nigeria, the prevalence of drivers with inadequate visual acuity (VA) was determined to be 11.5%, and 3.3% had monocular blindness. The prevalence of abnormal colour vision and visual field loss was 4.3% and 5.5%, respectively. There was no statistically significant relationship between visual impairment (VA and visual fields) and involvement in road traffic accidents (p > 0.05). Uncorrected refractive error, cataract, and glaucoma were the commonest causes of visual defects. Three hundred thirty-seven drivers (84.5%) did not have their eyes tested at first licensing and 370 drivers (92.7%) did not have testing at least once during renewals.

CONCLUSIONS

A significant number of CIVDs in Ilorin are operating with VA that is far below the expected for their class of licence, and another unacceptably high percentage did not undergo any form of ocular examination prior to obtaining their driving licence. There is a need for renewed efforts to enforce a compulsory basic ocular examination for all prospective commercial drivers, and to ensure that the visual requirement for driving is met.

Primary sinonasal tuberculosis in a Nigerian woman presenting with epistaxis and proptosis: a case report

Tuberculosis is the second leading cause of death worldwide after human immunodeficiency virus/AIDS and is especially prevalent in developing countries. We report a case of primary sinonasal tuberculosis without pulmonary involvement, which is rare, in a 27-year old female Nigerian fish farmer. She had a 3-year history of right-eye proptosis, bilateral nasal masses, and epistaxis. Cranial computed tomography suggested an extensive sinonaso-orbital neoplastic lesion. We performed a right external frontoethmoidectomy. Histologically, the excised nasal polyps revealed tuberculosis. Six months of antituberculosis therapy provided satisfactory improvement. Sinonasal tuberculosis, despite its rarity, should be added to the differential diagnosis of nasal and paranasal sinus disorders, and histologic evaluation remains the hallmark of diagnosis. Therapy with a short-duration, multidrug combination, rather than the longer-duration treatment regimen hitherto used, could be quite valuable, especially in the setting of a developing country with poor patient compliance.

Chemical eye injuries: presentation and management difficulties

BACKGROUND/PURPOSE

To review the pattern of presentation and management difficulty of patients with ocular chemical bums.

METHOD

Retrospective study of all patients with ocular burns seen over 8-year period (March 1998-April 2006) in the eye clinic as well as the plastic and reconstructive surgery unit of our hospital. Case files were retrieved and relevant information extracted and analyzed.

RESULTS

There were a total of 23 patients (n=33 eyes) seen in the period under review consisting of 19 males and 4 females. The age ranged from 6-52 years with mean age of 31.87years. The chemical injuries were accidental in 73.9% of the cases and of these 76.5% were work related. The remaining 26.1% resulting from assault were bilateral and led to blindness in all the patients. Main injurious agents were acid and alkali.

CONCLUSION

Major cause of chemical injury was work related; although blindness and disability occurred more in the cases of assault. Occupational health issues need a revisit, preparedness of health institutions to take adequate care of people with ocular burns is presently poor.

HIV seropositivity and related eye diseases in Uith, Ilorin

INTRODUCTION

HIV is assuming an alarming pandemic worldwide and presently in Nigeria it is a source of concern to all and sundry.

AIM

To review the demography of cases positive for HIV in the eye clinic over a 5-year period and to identify ocular diseases that have high predictive value for HIV.

METHODS

A retrospective study of all the patients that were screened for HIV in the eye clinic over a 5-year period was done. Screening was by ELISA method with confirmation by Western blot test.

RESULTS

A total of 60 patients were screened and 26 (43.3%) of them were HIV positive. The male to female ratio of HIV positive patients was 1:1. All the seropositive patients were between the ages of 20-49 years and about a third were students from the higher institutions. Half of the patients were single. Diagnoses with high predictive values were Herpes Zoster Ophthalmicus (62%), Steven Johnson syndrome (50%), HIV retinopathy (75%), Bilateral Unresolving Toxoplasmosis (42%). The common presentations however are Herpes Zoster Ophthalmicus (HZO) and unresolving bilateral Uveitis.

CONCLUSION

HIV and ocular involvement is increasing in Ilorin. The high-risk groups among patients presenting to the hospital are students of higher institutions and Soldiers. Diseases of high predictive indices are Herpes zoster Ophthalmicus, Steven Johnson's syndrome, HIV retinopathy.

Permanent hypoparathyroidism developing post-thyroidectomy

A case of permanent hypocalcaemia following a subtotal thyroidectomy for a simple multinodular goiter in a 35 year -- old married teacher is presented. This further confirms the need for utmost precaution during thyroid surgery to prevent the damage or inadvertent removal of the parathyroid glands and its consequential complications. It also throws more light on the problem faced in the management of hypocalcaemia vis a vis patient compliance and availability of proper medications in this environment.