ISSN 2520-4378

VOL 03 ZAMBIA’S JOURNAL ON PUBLIC HEALTH, DISEASE SURVEILLANCE, PREVENTION AND CONTROL ISSUE 12 DECEMBER 2019 The Health Press - Zambia is published by Zambia National Public Health Institute, Ministry of Health Zambia SINCE JAN 31, 2017. ADDRESS: PLOT 13, REEDBUCK ROAD, KABULONGA, LUSAKA. SPECIAL ISSUE

Editor-in-Chief: Ms Mazyanga L. Mazaba Managing Editor: Dr Raymond Hamoonga Editorial Team: Prof Paul Kelly Prof Seter Siziya Prof Mudenda Hangómbe Dr Jeremiah Banda Dr Alwyn Mwinga Dr Victor Mukonka Dr John S Moran Copy Editor: CompuScript Desktop Publisher: Omar Chanshi

Email: [email protected] Website: http://znphi.co.zm/thehealthpress/ Suggested Citation: [Author Surname, Initial].[Article title].Health Press Zambia Bull 2019; 03(10):[inclusive page numbers]. TABLE OF CONTENTS

FOREWORD and eye issues 1 Mazaba ML

EDITORIAL Eye Health In Zambia 2 Muma KIM,Mumbi WB

CASE REPORTS A Tooth for an Eye 3 Sanene V, Muma K I M

An Unusual Case of Proliferative Sickle Cell Retinopathy 6 Tembo C, Kasongole D

Bilateral Upper in a Day – Old Neonate 9 Fumpa JC, Muma KIM

Challenges In Managing CMV Retinitis – A Case Report From The University Teaching Hospitals Eye Hospital, Lusaka, Zambia 12 Patel V, Muma K I M , Kasongole D

Congenital Nasolacrimal Cutaneous Fistula 16 Mumbi W B, Ng’andweB, Hwang I P

Congenital Proptosis 18 Hamukali G, Muma K I M

Multiple Deep Corneal Foreign Bodies 20 Banda I J, Muma K I M

Devastating Effect of Suprachoroidal Haemorrhage 22 Lukavu M I, Muma K I M

External Ophthalmomyiasis (EOM) 24 Chipeta G N , Muma K I M CASE REPORTS High Myopia Mistaken for a Mental Illness 26 Chansa C, Muma K I M

Periocular Filariasis at Lusaka Eye Hospital – Zambia 28 Moonga A , MumaK I M.

Orbital Cysticercosis 30 Chansa M M, Misa F, Muma K I M

Phaces Syndrome 35 Mukupa DW, Nyaywa M, Misa F, Muma K I M

Proliferative Diabetic Retinopathy In A 16-Year-Old 40 Nyalazi JIM , Kasongole D, Muma KIM

Regression of Ocular Hodgkin’s Lymphoma in a 13-year-old 45 Kalukali C , Muma K I M

Simultaneous Occurrence of Trachoma Trichiasis, Ectropion and Facial Nerve Palsy 47 Siame A , Muma K I M

Subconjunctival Foreign Body Mistaken for a Scleral Tear 49 Preston M, Muma K I M

Trachoma Trichiasis (TT) in a Mentally Ill Patient. . 52 Ndalela N, Muma K I M

RESEARCH ARTICLES Rapid Assessment of Avoidable Blindness In Munchinga Province, Zambia 55 Mutati G, Mumbi W, Mboni C, Kayula C, Chisi S, Mwacalimba F, Nyalazi J, Mulenga P, Mashilipa E, Ndhlovu J , Maambo F , Kangwa T, Hampango M, Makupe A, Muma K I M.

Diabetic Retinopathy among patients attending University Teaching Hospitals Adult Hospital Medical Clinic in Lusaka 64 Patel V, Munachonga E M, Mutati G, Nyalazi J, Muma K I M

Cascading Screening for Diabetic Retinopathy at the University Teaching Hospitals: strategies to overcome barriers 73 Muma KIM, Nyalazi JIM, Mbewe C, KangwaT, Zulu G Chipalo – Mutati, G, Syakantu G,, Mwale C, Makupe A

Awareness and knowledge of glaucoma among eye patients attending the University Teaching Hospitals Eye Hospital 84 Muma K I M, Zulu G, Mumba – Malisawa T, Nyalazi J I M, Chinama – Musonda L, Syakantu G

EYE AND EYE ISSUES

Foreword By : ML Mazaba

Citation Style For This Article: Mazaba ML. . Eye and eye issuesDecember 2019. Health Press Zambia Bull. 2019; 3(12); pp 1-2.

Authors, reviewers, editors and readers,

Welcome to the first special issue of The Health Press Zambia. This issue captures interesting articles on various ophthalmological conditions affecting the Zambian population that were presented at the Zambia Ophthalmological Society Scientific Congress held in Lusaka, Zambia from 14th to 15th November 2019. Quoting a blog on Marvelotics, “Sight and vision are important because they allow us to connect with our surroundings, keep us safe, and help maintain the sharpness of our minds.” I cannot agree more with the blogger Victoria [1]. As much as many agree, eye diseases and vision disorders remain a major public health concern among populations globally but more-so in the underdeveloped regions of the world causing disability, suffering, and loss of productivity [2]. A large contributor to vision impairment is eye diseases, a number of which are treatable and chromic conditions such as diabetes. Low socio-economic status, lack of awareness, and limited access to eye care services have been attributed to the increasing risk of blindness. THP-Z invites you to learn more about the common eye diseases in Zambia and indeed the world over. Enjoy the read and hoping it may influence how you look at prevention and care of eye conditions. Remember that “Vision disability is one of the top 10 affects people’s ability to drive, read, disabilities among adults 18 years and older and the single most prevalent disabling condition among children.” [3]

Once again we invite you to submit your articles to THP-Z using the link https://mc.manuscriptcentral.com/thpz. 1. URL: https://marveloptics.com/blog/scholarship-program/the-importance-of-sight-and-vision-molly-blakely/ 2. Robert N. Kleinstein. Vision disorders in public health. Ann. Rev. Public Health. 1984. 5:36. 3. World Health Organisation. World Disability Report 2011. URL: https://www.who.int/disabilities/world_report/2011/ report.pdf

1 EYE HEALTH IN ZAMBIA

Editorial By : K I M Muma1,2,4 ,W B Mumbi3,4 1National Eye Health Coordination, Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka Zambia 2Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 3Lusaka Eye Hospital, Lusaka, Zambia 4University teaching Hospitals-Eye Hospital, Lusaka, Zambia EMAIL ADDRESS: Kangwa I. M. Muma:[email protected]

Citation Style For This Article: Muma KIM,Mumbi WB,. Eye Health In Zambia. Health Press Zambia Bull. 2019; 3(12); pp 2.

Since launching the Vision 2020, the Right section between eye health and legacy primary health care levels to address the to Sight in 2004, Zambia has developed goals 1 (reduce maternal and child illness- needs associated with eye conditions and and implemented two eye health strategic es and deaths by tackling conditions such vision impairment. This is the more rea- plans on various objectives and strate- as trachoma which tend to affect women son of taking eye health services to all the gies to eliminate avoidable blindness and and children largely), 3 (recruit 30,000 far-flung areas of the country by the year visual impairment. The current National health workers by 2021 which also is crit- 2021. Eye Health Strategic Plan (NEHSP) 2017- ical for enhanced eye health service de- 2021 is the third to be implemented and livery), 4 (implement the National Health Vision impairment has a negative impact it provides a five-year strategic direction Insurance Scheme and increase coverage on development, educational achieve- for eye health from 2017 to 2021, high- from 4% to 100% in order to increase eye ment, quality of life, social well-being and lighting the goals, objectives in the elimi- health care financing as well), 8 (train economic independence of individuals. In nation of avoidable blindness in Zambia. It 500 specialists by 2021 in order to have order to counter this, there has been an further provides a path and framework to ophthalmologists distributed to all parts enhancement of availability and accessi- guide the planning, delivery, management of the country among others) and 9 (halt bility of eye health care services, such as and implementation of quality eye health and reduce the incidence of non-com- cataract surgery, refraction services and services at community, district, provincial municable diseases in order to prevent provision of spectacles, including short- and national levels, in order to increase blindness from conditions such as cata- ages of trained health personnel, socio- eye health coverage across the country to ract, glaucoma and diabetic retinopathy). economic and cultural factors, inequities, at least 90% by the year 2021. The NEHSP The objectives and strategies in attaining and costs of services. In line with the Vi- draws its aspirations from the Nation- these intersections are embedded in the sion 2020 Right to Sight strategy, there al Health Strategic Plan (NHSP) 2017 – NEHSP. The national eye health service has been a deliberate effort to expand 2021, the 7th National Development Plan, coverage has increased to 81.5% in 2019 infrastructure, procure equipment and Sustainable Development Goal SDGs, the from 31.5% in 2011. consumables, embrace new technological Vision 2030 and the legacy goals. advances and human resources for eye health expansion. This progress has seen The prevalence of blindness in Zambia all eye health investigations and surgeries The Sustainable Development Goal 3 calls ranges from 2.2% to 4.4% which implies being performed within the country either on stakeholders to ensure healthy lives that there are 339,081 to 678,162 people at public or private facilities. It is envis- and promote well-being for all individuals who are either visually impaired or blind aged that the foundation that has been at all ages and recognising the important within a population of 16 954 051. The laid down provides good prospects of the intersections between eye health and oth- major causes of blindness include cata- eye health public facilities to be the trend er goals including Goal 1 (reducing pov- ract (53.2%), glaucoma (19.0%), tracho- setters in the country and the SADC re- erty through maintaining and restoring ma (5.7%), refractive errors (15.3%), cor- gion. To this end, two indicators for health sight), Goal 4 (ensure inclusive and equi- neal opacity (3.6%) and retinal disorders eye care are being used nationally which table quality education and promote life- including diabetic eye diseases (3.2%). are effective coverage of refractive error long learning opportunities for all), Goal 5 All these causes of vision impairment and effective coverage of cataract surgery. (achieve gender equality and empower all are preventable or addressable through women and girls), Goal 8 (promote sus- early detection and timely management, The fight against avoidable blindness tained, inclusive and sustainable econom- and that cost-effective interventions requires commitment of purpose of all ic growth, full and productive employment covering promotion, prevention, treat- stakeholders through forging strong part- and decent work for all), and Goal 10 (re- ment and rehabilitation. In line with the nerships and collaborations. It is by do- duced inequalities). government policy of delivering health ing such that we are going to attain the services through the primary health care much-desired Universal Eye Health Cov- As part of the transformation agenda, the approach, the majority of the eye health erage and integration across the continu- Ministry of Health equally calls for inter- services are being delivered through the um of eye health care. 2 A TOOTH FOR AN EYE Case Report By : *V Sanene1 , K I M Muma1,2 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusa- ka, Zambia 2University teaching Hospitals-Eye Hospital, Lusaka, Zambia

*E-mail Address: Viola Sanene: [email protected]

Citation Style For This Article: Sanene V, Muma K I M.A Tooth for an Eye . Health Press Zambia Bull. 2019; 3(12); pp 3-5.

ABSTRACT all scar tissue is removed. Then the inner with poor vision 6 months later. A female patient aged 30 years was mucosal lining of the cheek is transplant- On examination, there was an obvious brought to the University Teaching Hospi- ed onto a new surface of the eye [10]. A symblepharon in the right eye and OOKP tals - Eye Hospital (UTH-EH) complaining canine or premolar tooth and part of the in the left eye (fig.1). The visual acuity in of poor vision in both after suffering adjacent bone and ligaments are harvest- both eyes was hand movement (HM). On from Steven Johnson syndrome (SJS). ed. A bolt shaped structure is fashioned slit-lamp examination, the right eye had On examination, visual acuity was hand from the tooth-bone complex which is symblepharon of upper and lower movement (HM) in both eyes. The right fitted with a plastic optical cylinder [11]. and opacification of the . The left eye (RE) had adhesions (symblepharon) Stage 2 (about 4 months later) involves eye had a total permanent tarsorrhaphy of both upper and lower eyelids, haziness two separate procedures. The cheek mu- with Osteo-Odonto-Keratoprosthesis and cornea opacification, while left eye cosal lining over the eye is opened and the (OOKP). (LE) had a total permanent tarsorrhaphy inner contents of the eye are removed. Fundoscopy of the LE showed optic disc with Osteo-Odonto-Keratoprosthesis The tooth-bone-cylinder complex is har- cupping of about 0.9 cup disc ratio (CDR) (OOKP) at the centre. vested from the cheek and inserted into whereas fundoscopy was not possible to the eye; the mucosal cheek lining is placed perform in the RE due to the scarred cor- INTRODUCTION over the implant. At the end of the pro- nea. The intraocular pressures were 18 Corneal opacification is the second most cedure, light can now enter through the mmHg RE and was not measured in left common cause of blindness in the world plastic cylinder and the patient is able to eye. The patient was started on acetazol- affecting an estimated 10 million people see through this cylinder with good vision amide (Diamox) 500 mg stat then 250 [1]. Corneal blindness is far more preva- [12-14]. mg three times a day for three days. lent as a result of ocular surface disease The cornea is replaced by a polymethyl leading to corneal neo-vascularization methacrylate (PMMA) optical cylinder and scarring. The blindness due to cor- glued to a biological support (haptic) neal scarring can be managed in various made from human living tissue. Currently ways depending on the density of the scar available KPro (kerato- prosthesis) devic- [2]. The Osteo-Odonto-Keratoprosthesis es range from totally synthetic such as the (OOKP) is indicated for corneal lesions Boston KPro, to the totally biological tis- resulting from Steven Johnson Syndrome, sue engineered artificial cornea [15]. The trachoma, pemphigoid, trauma limited to OOKP combines both a synthetic optic the cornea and chemical burns [3]. with a biological haptic [16]. The OOKP is Figure 1. The left eye after osteo-odon- a true heterotopic auto graft made of liv- to-keratoprosthesis Benedetto Strampelli described the orig- ing long lasting human tissue. The patient consented to have this case inal technique of OOKP nearly fifty years report published. ago using the patient’s own tooth root and CASE SCENARIO alveolar bone as a vital support to an op- A female patient aged 30 years presented DISCUSSION tical cylinder. The OOKP also known as to the UTHs-EH complaining of poor vi- Osteo-Odonto-Keratoprosthesis is a vi- tooth in eye surgery is an auto graft used sion in both eyes. The patient gave a re- sion restoring surgical technique where for the treatment of severe corneal opac- port of having reacted to anti-tuberculosis the patient’s opaque cornea is replaced ities not suitable for corneal transplant drugs while in Zambia. After being diag- with an artificial device. In this case, the [4,5]. A Kerato-prosthesis is used to re- nosed with SJS in 2016, she sought medi- patient had end stage corneal blindness place damaged cornea [4,5]. cal advise in the United States of America and hence, OOKP was done on the left Falcinelli et al., 1986, modified this tech- (USA) where OOKP was conducted suc- eye as a way of restoring her vision [11]. nique in a stepwise fashion [6-9]. OOKP cessfully on the left eye and vision im- The optical device is made up of a PMMA is a 2-stage operation. Stage 1 of the sur- proved and was able to carry out normal (Polymethylmethacrylate) cylinder which gery involves 5 separate procedures. First activities. In May 2019, she noticed that acts as an artificial cornea. It is particular- the eye is opened up and the entire inner her vision was gradually decreasing. she ly resilient to a hostile environment such surface of the eyelids, corneal surface and later presented to UTHs - Eye Hospital as the dry keratinized eye. Patients are ad- 3 vised to quit smoking and practice mea- Giancarlo et al., (2005), described the Thorough patient preparation physically sures that will improve their oral hygiene long term anatomical and functional and psychologically is required in order so as to increase the chance of survival outcome in 181 cases and the results in- to have good results and to make patient of the buccal mucous membrane graft. In dicated that modified OOKP surgery can understand the importance of follow up this case the patient was neither smok- provide favourable anatomical and func- visits to the hospital in order to diagnose ing nor consuming alcohol. Therefore, the tion results, which are stable in the long and manage post-operative complica- buccal mucous membrane could survive term and retaining an intact OOKP was tions early. Good general health and oral longer [12-14]. The success rate of the 85% [9]. Just as in this case, the patient hygiene are important for this procedure OOKP surgery vary from different studies, retained good anatomical and functional to be successful. This technique demands Lui C, et al (1998) reported excellent long- of OOKP. Tan DT et al., 2008 treated 29 the involvement of both dental and oph- term retention of 85% in 18 years [3]. Ac- cases to restore sight with OOKP surgery thalmic surgeons to complete the proce- cording to Herold et al., (1999), 80% of and found excellent results without any dure [19]. OOKP patients achieved improvement of instability problems or extrusion [6]. The vision [16]. Lui C, et al., (2005), stated OOKP in this case report was very sta- Thus, it is necessary for both surgeons to that OOKP described by Falcinelli gives ble and there were no signs of extrusion. understand the finer details of the proce- the best long-term results for visual acuity Hughes et al., 2008, reported vitreo-ret- dure and its possible complications which of 75% with 6/12 or better and retention inal complications of the OOKP in a ret- can be avoided with adequate precautions of 85% for up to 18 years [15]. rospective review of 35 patients after a during surgery and its timely follow up of mean 57 months follow up which revealed the patients. Follow up visits is life-long in order to 9 vitreo-retinal complications in 8 pa- detect and treat complications which tients (23%) [18]. In this case, there were CONCLUSION include oral, oculoplastic, glaucoma, vit- no vitreo-retinal complications. Kumar Osteo-Odonto-Keratoprosthesis is the reo-retinal complications and extrusion et al., 2009, did a study to report diag- ocular surgical procedure of choice for of the devise [17]. Follow ups are done at nostic modalities and treatment options restoring sight in patients with end stage weekly interval for 1 month, then monthly for glaucoma in 15 eyes that underwent corneal scarring. Frequent follow up and for six months, then every 2 months for OOKP surgery and they concluded that good follow up plan for Osteo-Odon- six months, then every four months for visual field testing and optic disc assess- to-Keratoprosthesis is critical in order to stability of the prosthesis and intraocular ment with optic disc photographs seem to diagnose and treat complications as early pressure measurement. Once it is stable, be effective methods to monitor glauco- as possible so that restored vision is not follow up can be at longer intervals [10, ma and treatment strategies include oral lost. 11]. In this case the patient did not adhere medication (acetazolamide 500mg twice to follow up schedule and the doctors who a day) to lower intraocular pressure and performed the procedure did not forward cyclo-photocoagulation [19]. Due to inad- the report to the doctors of the patient’s equate follow up, the patient was not ful- residence for effective follow up. So, when ly evaluated for glaucoma and as a result the vision started deteriorating, the pa- she ended up with a CDR of 0.9 in the LE. tient could not be attended to promptly to establish what was causing that. There The OOKP is considered the only devise was also lack of communication between capable of offering long term visual re- the primary OOKP team and the patient habilitation in patients with end-stage which created a huge gap for follow up. ocular surface disease and severe tear Therefore, the vision was not good as deficiency (with or without eyelid defect expected or it could be that the patient based on the studies of cases that were could have fallen in the 15% of OOKP pa- done before [5]. tients reported not to have good vision by Lui et al., 2005.

4 LIST OF REFERENCES

1. ⦁ Whitcher JP, et al., World Health Organization J: corneal blindness a global perspective, 2001. 2. ⦁ Kansik J, J, et al., Clinical Ophthalmology, 7th edition. 2007; 7: 240-44. 3. ⦁ Liu C, Sciscio A, Smith G, Pagliarini S, Herold J. Indications and technique of modern Osteo-Odonto-Keratoprosthesis (OOKP) surgery. Eye News. 1998; 5:17-22. 4. ⦁ Dagher MH, Dohlman CH. The Boston Keraprosthesis in severe ocular trauma. Canadian J Ophthalmol. 2008; 43: 165-69. 5. ⦁ Strampelli B. Keratoprosthesis with osteodental tissue. American J Ophthalmic. 1963; 89: 1029-39. 6. ⦁ Tan DT, Tay AB, Theng JT, Lye KW, Parthasathy A, Por YM et al. Keratoprosthesis surgery for end- stage corneal blindness in Asian eyes. J Ophthalmol. 2008; 115:503-10. 7. ⦁ Tay AB, Tan DT, Lye KW, Theng J, Parthasarathy A, Por YM. Osteo-Odonto-Keratoprosthesis surgery: a combined ocular– oral procedure for ocular blindness. International J Oral maxillofac Surg. 2007; 36:807-13. 8. ⦁ Falcinelli G, Barogi G, Corazza E, Colliardo P. Oteo-odonto-cheratoprotesi: 10 ann di esperienze positive edinnovazzioni. Atti LXXIII Congress soc. Oftamologicaltaliana. 1993; 529-32. 9. ⦁ Falcinelli G. Missiroli A, Pettitti V, Pinna C. Osteo-Odonto-Keratoprosthesis up to date. Acta XXV ConcilliumOphthalmo logicum 1986. Rome. Kugler & Ghedini. 1987; 772-6. 10. ⦁ Falcinelli G, Barogi G, Taloni M. Osteo-Odonto-Keratoprosthesis: present experience and future prospects. Refractive Corneal Surg. 1993; 9: 193-4. 11. ⦁ Goma A, Comyn O, Lui C. Keratoprosthesis in clinical practice- a review. J clinical & Experimental Ophthalmology. 2010; 38: 211-24. 12. ⦁ Falcinelli G, Barogi G, Caselli M, Colliardo P, Taloni M. personal changes and innovations in Strampelli`s Osteosthesi so-Odonto-Keratoprosthesis. An InstBarraquet (Barc). 1999; 29:47-8. 13. ⦁ Falcinelli G, Falsini B,Taloni P, Colliardo M, Falcinelli G. Modified Osteo-Odonto- Keratoprosthesis for treatment of Corneal Blindness Long-term Anatomical and Functional Outcomes in 181 cases. Archives of Ophthalmol. 2005; 123:1319-29. 14. ⦁ Hille K, Grabner G, Lui C, Colliardo p, Falsinelli G.Taloni M et al. Standards for modified Osteo-Odonto-Keratoprosthesis (OOKP) surgery according trampelli and Falcinelli: the Rome-Vienna Protoccol. Cornea.2005; 24:895-908. 15. ⦁ Liu C, Paul B, Tandon R, Lee E, Fong K, Mavrikakis L et al. The Osteo-Odonto- Keratoprosthesis (OOKP). Seminars in Oph thalmol. 2005; 20: 113-28. 16. ⦁ Herold J, Scissio A, Smith G, Hull C. Modern Osteo-Odonto-Keratoprosthesis surgery. British J Ophthalmol. 1999; 83: 127- 8. 17. ⦁ Skelton VA, Henderson K, Lui c. Anaesthetic implications of Osteo-Odonto-Keratoprosthesis surgery. European J Anaes thesiol. 2000; 17:390-94. 18. ⦁ Hughes EH, Mokete B, Aintsworth G, Casswell AG, Eckstein MB, Zambarakji HJ et al. Vitreoretinal complications of Os teo-Odonto-Keratoprosthesis surgery. Retina. 2008; 28:1138-45. 19. ⦁ Kumar RS, Tan DT, Por YM, Oen FT, Hoh ST, Parthasarathy A et al. Glaucoma management in patients Osteo- Odonto-Ker atoprosthesis (OOKP). The Singapore OOKP study. J Glaucoma. 2009; 18: 354-60.

5 AN UNUSUAL CASE OF PROLIFERATIVE SICKLE CELL RETINOPATHY Case Report By : *C Tembo, D Kasongole 1Department of Surgery, School of Medicine, University of Zambia, Lusaka-Zambia 2University Teaching Hospitals - Eye Hospital, Lusaka-Zambia *E-mail Addresses: Chimozi Tembo: [email protected]

Citation Style For This Article: Tembo C, Kasongole D. An Unusual Case of Proliferative Sickle Cell Retinopathy. Health Press Zambia Bull. 2019; 3(12); pp 6-8.

ABSTRACT Teaching Hospital, Lusaka-Zambia involv- was advised that he needed surgery but Sickle cell haemoglobinopathies are a ing 94 patients, looking at the ocular man- was lost to follow-up. group of inherited disorders character- ifestations of sickle cell disease, found The patient had no history of hyperten- ized by quantitative or qualitative malfor- that ocular abnormalities were high with sion, diabetes mellitus, sickle cell disease, mations of haemoglobin (Hb). Diagnosis 69% of patients showing signs of ocular TB or retroviral disease. Family history of SCD is mainly by haemoglobin elec- manifestations. However, most were not was non-revealing. There was no history trophoresis. Ocular manifestations are causing visual impairment, with only 1% of alcohol intake or smoking. wide, encompassing anterior segment, of the patients being blind as a result of On examination, the general condition non-proliferative and proliferative reti- SCD [3]. was good. There was no pallor, jaundice or nopathy. Proliferative sickle cell retinop- Though PSCR can occur in patients with cyanosis. Visual acuity was hand motion athy (PSCR) represents a very serious sickle cell trait, it is very rare and in most (HM) and 6/18 not improving with pin- complication and may result in blindness cases there are other co-existing systemic hole in the right and left eye, respectively. if not diagnosed and treated early. PSCR disease such as diabetes or an inflamma- Intraocular pressure measured with Gold- rarely occurs in patients with sickle cell tory disorder or history of trauma. PSCR mann applanation was 20 mmHg in the trait, most times in association with an can be classified into five stages [4]. right eye and 18 mmHg in the LE. Slit lamp underlying systemic condition or ocular examination of the anterior segment ex- trauma. We present an unusual case of a Table 1: Proliferative Retinopathy amination was normal in both eyes. healthy young male with no history of sys- temic illness who presented with prolifer- ative sickle cell retinopathy in both eyes.

INTRODUCTION Sickle cell trait is thought of as a benign condition in comparison to Sickle cell disease (SCD). Sickling haemoglobinopa- thies are caused by one or more abnormal haemoglobins that induce red blood cells to adopt an anomalous shape under con- ditions of physiological stress such as hy- poxia and acidosis, with resultant vascular occlusion [1]. This results in distal tissue We present an unusual case of prolifera- Fundoscopy of the RE revealed pink disc ischemia and a host of related systemic tive sickle cell retinopathy in a young male with a CDR of 0.4. The blood vessels were and ocular complications. patient who presented with blurred vision sclerosed infero-temporally and the mac- SCD is most common among black Afri- in the left eye for 2 weeks who denied any ula showed a thick epiretinal membrane cans, due to its protective effect against history of sickle cell disease. (ERM) with retinal folds and old vitreous malaria. It also is found, with much less haemorrhage (VH). Fundoscopy of the LE frequency, in eastern Mediterranean and CASE SCENARIO revealed Pink disc with a CDR 0.4. Vessels Middle East populations. A 41-year-old male patient presented were Normal. There was subhyaloid hae- Ocular manifestations of SCD are wide. to UTHs - Eye Hospital complaining of morrhage (SHH) and Salmon patch was Ocular manifestations can be noted in the blurred vision in the Left Eye (LE) for 2 noted supero-temporally. anterior segment and in the posterior seg- weeks. He denied any history of trauma or At this point, an impression pf prolifera- ment in the form of nonproliferative and straining. tive sickle cell retinopathy both eyes with proliferative retinopathy [1]. There is an Past Ocular History revealed that he had epiretinal membrane right eye was made. inverse relationship between the severity been seen on two months earlier com- of systemic disease and the severity of plaining of loss of vision in the Right Eye The Full Blood Count (FBC)/ Differential retinopathy in homozygous SS individuals (RE) for 3 days of spontaneous onset and Count showed thrombocytopaenia while compared to compound heterozygous SC was diagnosed with vitreous haemor- all other parameters were normal. Urea/ subjects [2]. rhage of the RE. He had received intravit- Creatinine/LFTs were normal. Fasting An unpublished study in at the University real Bevacizumab (Avastin) in the RE and blood sugar was within normal limits and 6 so was the chest x-ray. Peripheral Blood Consultation was made to the haematol- Later he developed Hyphaema in the Smear showed red cell morphology of ogist in view of the thrombocytopaenia same eye with raised intraocular pressure. normocytic, normochromic. The white and blood film picture. Patient was coun- Anterior chamber washout was done. cell morphology was mild leukopenia and selled on the guarded visual prognosis. Current status, the RE is blind post en- no blasts were seen. On platelet morphol- Pan-retinal laser photocoagulation (PRP) dophthalmitis with neovascular glaucoma ogy, thrombocytopenia was noted on film. was done for both eyes in two (2) sittings, (NVG) while LE has resolving vitreous The sickling solubility test revealed Het- covering the superior and inferior retina. haemorrhage (VH) in proliferative sickle erozygous HbS and Haemoglobin electro- The patient was counselled and planned cell retinopathy (PSCR). phoresis AS. for surgery both eyes. He was planned for Fundus Fluorescein Angiogragraphy pars plan vitrectomy (PPV) plus mem- (FFA) was done with arm retina time of brane peeling (MP), endo-laser (EL) and 15 seconds. Fovea Avascular Zone (FAZ) fluid-air exchange (FAE). He had surgery appeared to be normal in both eyes. Ar- done on the RE from elsewhere. Unfor- eas of capillary non-perfusion (CNP) were tunately, he developed post-operative noted in both eyes with areas of leakage endophthalmitis. He received intravitreal only found in the LE. antibiotics at UTH Eye Hospital.

Figure 1: Fundus photos of the right eye showing vitreous haemorrhage taken in 2014

Figure 2: Fundus photo right eye showing epiretinal membrane and tractional retinal detachment taken 2019

Figure 3: Fundus Fluorescein Angiography showing areas of leakage in the right eye

7 DISCUSSION This is what was noticed with the case CONCLUSION SCD is the most common and the most under review. Bothe eyes ended up being Though rare Proliferative Sickle Cell Ret- severe haemoglobinopathy [5]. Though blind. PSCR occurs rarely in patients with inopathy (PSCR) can occur in patients sickle cell disease is prevalent in black Af- sickle cell trait. Most cases occur if there with sickle cell trait. There is need to elic- ricans, routine sickling test is not done in is an associated systemic condition such it precipitating factors for patients with most Zambian hospitals. The result is that as diabetes, hypertension or sarcoidosis sickle cell trait that present with retinop- very few sickle cell trait carriers know of or if there is history of ocular trauma [1,6]. athy. Both Sickle cell disease patients and their genetic condition. In this case there was no pointer to any those with sickle cell trait need regular Sickle retinopathy can have devastating co-morbidity systemic condition. While ophthalmological examination. consequences and may lead to severe vi- other blood tests were normal, he was sual impairment and blindness if left un- positive for sickle cell trait which was con- treated. firmed by haemoglobin electrophoresis.

LIST OF REFERENCES

1. Bowling, B., 2016. Kanski’s Clinical Ophthalmology, A Systematic Approach, Eighth. ed. Elsevier Limited, Sydney, Australia. 2. Bwalya, W.M. (2014) Ocular manifestations of sickle cell disease at the University Teaching Hospital, Lusaka, Zambia 3. de Melo, M.B., 2014. An eye on sickle cell retinopathy. Rev. Bras. Hematol. E Hemoter. 36, 319–321. https://doi.org/10.1016/j. bjhh.2014.07.020 4. Goldberg M.F. (1971) Classification and pathogenesis of proliferative sickle retinopathy. American Journal of Ophthalmology, 71 (3), pp. 649-665 5. Menaa, F., Khan, B.A., Uzair, B., Menaa, A., 2017. Sickle cell retinopathy: improving care with a multidisciplinary approach. J. Multidiscip. Healthc. 10, 335. https://doi.org/10.2147/JMDH.S90630 6. Jackson, H., Bentley, C.R., Hingorani, M., Atkinson, P., Aclimandos, W.A., Thompson, G.M., 1995. Sickle retinopathy in patients with sickle trait. Eye 9, 589–593. https://doi.org/10.1038/eye.1995.145

8 BILATERAL UPPER EYELID ECTROPION IN A DAY – OLD NEONATE

Case Report By : *J C. Fumpa1,2 and K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2Mukinge Mission Hospital, Kasempa, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*E-mail Addresses: Jairos C. Fumpa:[email protected]

Citation Style For This Article: Fumpa JC, Muma KIM.Bilateral Upper Eyelid Ectropion in a Day – Old Neonate. Health Press Zam- bia Bull. 2019; 3(12); pp 9-11.

ABSTRACT A one-day old neonate was brought to the solved as shown in figure 2 and the neo- Congenital eversion of the upper eyelids eye clinic at Lumwana District Hospital by nate was discharged. Subsequent follow (congenital ectropion) is a rare condition. the mother with complaints of swelling of up review at 2 weeks later on showed that Most of the cases are bilateral, but uni- both eyes and outward turning of eye lids the ectropion had completely resolved lateral cases also have been reported. It with reddening of both eyes since birth. with eyeballs noted to be normal and the does not seem to be caused by difficult Further history and relevant information neonate could fixate to light. labour through the birth passage. At Lum- was obtained from the attending mid-wife wana District Hospital, a day-old female who reported that, APGAR score was 9, neonate presented with ectropion on both born at term with birth weight of 3.1kgs, eyes at birth. The neonate was born at from a multiparous aged 37 years of age. term, by Spontaneous Vaginal Delivery The attending mid-wife further reported from a multiparous mother. Birth history that, the patient was delivered through was uneventful, although bilateral upper spontaneous vagina delivery and the preg- eyelid ectropion was immediately noted. nancy was uneventful. There was no his- The neonate was taken to the eye clinic tory of discharge from both eyes. Credé’s for further management. prophylaxis using Tetracycline Eye Oint- ment (TEO) was conducted by the mid- INTRODUCTION wife immediately after the neonate was Owing to the asymptomatic nature of born. Consent for photos and publication ectropion of eyelids refers to a condition was obtained from the mother. where the eyelids are turned outwards On examination, the general condition away from the [1]. This is a com- was good, afebrile (body temperature mon occurrence in the elderly although 370C), not pale, not jaundiced and had there are a number of causes such as no respiratory distress. There were no stroke, skin cancer, injury, scar tissue from other abnormalities noted in the neonate Figure 1: Clinical appearance of the pa- injuries or burns, growths on the eyelid systemically. Brisk reflex was present on tient’s eyes with ectropion (either cancerous or benign) birth defects both eyes. The cornea and the rest of the (due to genetic disorders such as Down anterior segment examination were found syndrome) Bell’s palsy (a condition that normal on both eyes. However both eyes damages the nerve that controls facial had ectropion with subconjunctival haem- muscles) or other types of facial paralysis orrhage and chemosis as shown in figure [1]. In the case of a new born baby, it is 1. more frequently associated with Down’s The neonate patient was admitted, and syndrome and ichthyosis [2]. the mother was reassured and counselled on the diagnosis and prognosis. Apart Congenital bilateral ectropion of the up- from bilateral ectropion and associated per eyelids is a rare, benign condition [3, findings, there was no evidence of any 4, and 5]. The eversion usually presents other abnormality on both eyeballs. The at birth and resolves spontaneously with- patient was treated conservatively. Tetra- in two weeks of birth [3, 4, 5]. Its etiology cycline eye ointment (TEO) and system- is unknown and several possible mecha- ic antibiotics were given as prophylactic nisms have been proposed, however it is management for subconjunctival haem- frequently associated with Down’s syn- orrhage and chemosis. To correct the ec- drome, ichthyosis, and newborns in the tropion, the eyelids were put in the correct black population [1, 2, 4]. position, TEO 1% applied then padded Figure 2: Clinical appearance of the pa- with wet gauze. tient’s eyes with resolved ectropion within CASE SCENARIO After 48 hours, the bilateral ectropion re- 48hrs 9 DISCUSSION ing absence of an effective lateral canthal applied and eyes padded, we recommend Congenital ectropion of the upper eyelid ligaments, lateral elongation of the eye- conservative treatment as opposed to is a rare abnormality that can threaten lid, hypotonia of the orbicularis, vertical surgical intervention. the cornea and vision if not treated early. shortening of the anterior lamella, and At Lumwana, the neonate who presented failure of the orbital septum to fuse with CONCLUSSION with bilateral ectropion of upper eyelids the levator aponeurosis [1-6]. Treatment Though congenital bilateral upper eyelid was treated conservatively as other caus- of congenital upper eyelid ectropion is ectropion is unusual, when it occurs, it es of congenital ectropion were ruled out. controversial. Surgical treatment options can be conservatively managed with full Congenital ectropion of the upper eyelids that can be employed in the management resolution within 2 weeks. Not all bilater- was first described by Adams in 1896 [3 of severe cases of congenital ectropion in- al ectropion of both upper eyelids at birth -5]. Later, Gilbert and co-workers de- clude tarsorraphy only [2-7], tarsorraphy can be associated with Down’s syndrome, scribed two more cases associated with with excision of redundant conjunctiva ichthyosis and other causes known. Down’s syndrome [6-7]. This rare condi- [5,7], fornix suture [3], full-thickness skin tion has been reported more frequently graft [1-5], full-thickness horizontal lid in black infants [1-8] associated with ich- shortening [2,6] and attachment of the thyosis [1-4] and in infants with trisomy orbital septum to the levator aponeurosis 21 [5]. Although the condition is generally [3]. bilateral and asymmetrical, some unilat- In this case under review, the patient did eral cases have been described [8]. The fulfill the conservative treatment parame- neonate in this case report had bilateral ters due to the absence of other congen- but asymmetrical ectropion. Down’s syn- ital abnormalities of the eyelids that may drome encompasses numerous ocular occur in Down’s syndrome. Therefore, a abnormalities like myopia, keratoconus, simple and conservative management nystagmus, epiblepharon, epicanthus, with lubricants / antibiotic ointment and convergent strabismus, cataracts, bleph- moist swabs were enough to prevent aroconjuctivitis with the epicanthal folds, desiccation of the exposed conjunctiva, and the typical mongoloid slant to the reduction of conjunctival edema and to eyelid fissures being the most obvious allow spontaneous inversion of the eyelid periocular findings [6]. None of these re- within 48 hours. The fact that, the child ported ocular abnormalities were found in responded to conservative treatment the neonate. Essentially this neonate was within 48 hours, the risk of amblyopia was normal. removed.

Although the pathophysiology of congen- Therefore, in the presented case where ital upper eyelid ectropion is unknown, the eyelids were repositioned mechani- multiple factors have been implied, includ- cally, eyelids taped down, eye ointment 10 LIST OF REFERENCES

1. Orbit, Eyelids and Lacrimal System, Section 7. Basic and Clinical Science Course, AAO, 2011-2012

2. Fasina O. (2013): Management of bilateral congenital upper eyelid eversion with severe chemosis. J Ophthalmic Vis Res. Apr;8 (2):175–178

3. Alvarez EV, Wakakura M, Alvarez EI. Surgical management of persistent congenital eversion of the upper eyelids. Ann Ophthalmol. 1988 Sep;20(9):353–4, 357

4. Surgical management of congenital upper-eyelid eversion.Loeffler M, Hornblass A Ophthalmic Surg. 1990 Jun; 21(6):435- 7

5. Maheshwari R, Maheshwari S. Congenital eversion of upper eyelids: case report and management. Indian J Ophthalmol. 2006 Sep;54(3):203–204

6. Suliman S, Michie C. A case of bilateral congenital eublepharon or ectropion. West Lond Med J. 2010;2(4):37–41

7. Omolase CO, Ogunleye OT, Omolase BO, Ogendengbe A. Conservative management of congenital eversion of the upper lid in a Nigerian child. Pak J Ophthalmol. 2012;28(4):222–223

8. Congenital bilateral ectropion in lamellar ichthyosis. Chakraborti C, Tripathi P, Bandopadhyay G, MazumderDB ,Oman J Ophthalmol. 2011 Jan; 4(1):35-6.

11 CHALLENGES IN MANAGING CMV RETINITIS – A CASE REPORT FROM THE UNIVERSITY TEACHING HOSPITALS-EYE HOSPITAL, LUSAKA Case Report By : *V Patel1, K I M Muma1,2 , D Kasongole1

1University Teaching Hospitals – Eye Hospital, Lusaka, Zambia 2Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University *EMAIL ADDRESS: Vrunda Patel: [email protected]

Citation Style For This Article: Patel V, Muma K I M , Kasongole D. Challenges In Managing CMV Retinitis – A Case Report From The University Teaching Hospitals Eye Hospital, Lusaka, Zambia. Health Press Zambia Bull. 2019; 3(12); pp 12-15.

ABSTRACT less than 50/µl. It also occurs as an op- of vascular sheathing, retinal necrosis Cytomegalovirus (CMV) retinitis is the portunistic infection in other immuno- with haemorrhages involving the posteri- most common cause of vision loss in pa- compromised states such as post organ or pole and mid periphery with disc and tients with acquired immunodeficiency transplant patients and those on chemo- macula oedema in both eyes, figs 1 and 2 syndrome (AIDS). CMV retinitis (CMVR) therapy [3]. With the widespread use of below. afflicted 25% to 42% of AIDS patients in anti-retroviral therapy, the incidence of A diagnosis of fulminant CMV retinitis the pre-highly active antiretroviral ther- CMV retinitis (CMVR) has reduced [4]. in both eyes was made. The patient was apy (HAART) era, with most vision loss The reduction in the incidence of CMVR planned for treatment with intravitre- due to macula-involving retinitis or retinal has resulted in less interaction of the dis- al ganciclovir of 2.5mg/0.1ml twice per detachment. Due to the reduction of the ease with eye health personnel and the week in each eye for three weeks which incidence of CMV retinitis, there is inad- reduced demand for the drugs that are she received diligently. The CD4 count equate supply of anti-CMV medications. used to treat it. The economic implica- was 98 cells/mm3 and the viral load was Ganciclovir may be the most cost-effec- tion of this is that the price of these drugs 53,262 copies/ml. Unfortunately, these tive drug for CMV management in other goes up because of reduced demand. In were done after the patient had com- parts of the world, but in Zambia the drug some instances, the drugs may not even menced treatment for CMVR. She had is very expensive and beyond the reach be stocked by the pharmaceutical compa- weekly fundus photos done. of most Zambians. A 27 year old female nies in which case they have to be sourced Due to the unavailability of oral val- presented with poor vision in both eyes from outside the country. The case pre- ganciclovir, the patient was put on week- for two months with gradual, painless sented highlights some of the challenges ly intravitreal ganciclovir injection as progression. She had been commenced faced with treating patients with CMV maintenance treatment. After a total of on Anti-Retroviral therapy for Human retinitis in our local setting. 12 injections in each eye, visual acuity Immunodeficiency Virus (HIV) infection improved to 6/18 in the right eye and re- two weeks prior to presentation. Present- CASE SUMMARY mained HM in the left eye. At this point ing visual acuity was hand movement in A female aged 27 years presented to the neovascularisation of the disc (NVD) in both eyes. Ocular examination revealed Eye Hospital of the University Teaching both eyes and a dispersed vitreous hae- mild anterior uveitis with widespread ar- Hospitals outpatient department with morrhage with tractional retinal detach- eas of retinal mid peripheral and posterior complaints of poor vision in both eyes. ment (TRD) in the left eye was noticed. pole vascular sheathing, retinal necrosis The problem started with gradual loss She received intravitreal bevacizumab with haemorrhages and macula oedema of vision in her left eye over the preced- 1.25mg/0.05mls in both eyes. She also in both eyes. A diagnosis of CMV retini- ing two months and then she had loss of had pan-retinal photocoagulation (PRP) tis was made in both eyes and the patient vision in the right eye two weeks prior to to the extent possible using laser indirect commenced on bi-weekly intravitreal presentation. It was not associated with ophthalmoscope in the left eye. ganciclovir injections followed by weekly pain. She had been using lubricating and After a total of 20 intravitreal ganciclo- maintenance injections. Visual acuity im- dexamethasone eye drops prescribed vir injections, 1 dose of intravitreal beva- proved only in the right eye to 6/12. She at another eye facility. She had no previ- cizumab in both eyes and PRP in the left developed neovascularisation of the disc ous history of ocular disorders. Medical eye, visual acuity was 6/12 in the right eye in both eyes and a tractional retinal de- history was significant for HIV infection and remained HM in the left eye. She had tachment in the left eye. for which she had been on antiretroviral regressed NVD in both eyes. The right eye treatment (ART) for two weeks. Baseline also had some disc pallor and sclerosed INTRODUCTION CD4 count results were not available. vessels while the left eye had TRD threat- Cytomegalovirus (CMV) is a ubiquitous On examination, her visual acuity was ening macula. Viral load had dropped to DNA virus that infects the majority of the hand movement (HM) in both eyes and 21,138 copies/mL. At this point in time, adult population [1]. It is the commonest IOP was 10mmHg in both eyes. Anteri- anti-CMV maintenance therapy was intraocular infection associated with Hu- or segment examination was significant stopped and ART continued. The patient man Immunodeficiency Virus (HIV) - af for mild anterior chamber reaction with awaits left eye pars plana vitrectomy with fecting an average of 25% of patients [2], 2+ cells. Vitreous was clear in both eyes. endolaser and silicon oil implant. particularly those with CD4 cell count Retinal exam showed widespread areas 12 Right eye Left eye Figure 1: Colour fundus photos at diagno- sis

Right eye

Figure 2: Colour fundus photos at end of Left eye intensive phase

Right eye Left eye

Figure 3: Colour fundus photos during maintenance phase 13 DISCUSSION therapy for those on ART [8]. cost of drugs, as well as the long course Patients with CMV retinitis present with Complications that may arise due to CMV of follow up. There is need to encourage painless, progressive loss of vision such retinitis include vitreous haemorrhage, people who are HIV positive to com- as the patient in this case presented with. retinal detachment, macula oedema, ret- mence ART treatment early in order to Sometimes floaters and visual field de- inal atrophy and optic neuropathy [7]. avoid such complications. fects may also be noted [5]. On retinal This patient had vitreous haemorrhage, exam, three main forms of CMV retinitis RD, and neovascularisation in both eyes. have been identified: fulminant (as in the These may lead to irreversible vision loss. case presented), perivascular and granu- This could be the likely fate of the left eye. lar [6]. The cause of poor vision in this patient in- A major component of the treatment cluded optic atrophy, macula atrophy and of patients with CMV retinitis involves retinal detachment. counselling in terms of compliance to For the case presented, the diagnosis of long term treatment and in advanced cas- CMV retinitis was made on presentation es on the guarded visual prognosis. This to the ophthalmologists. Primary care is so important to do because it involves physician did diagnose HIV and start injecting the ganciclovir into the eye for a ART. However, baseline immune status long time which the patient has to endure. by way of CD4 count was not done and This may be for 20 weeks or more. A mul- even the patient only managed to get one tidisciplinary treatment team involving result during the whole treatment course the ophthalmologist, low vision specialist, though it was repeatedly requested. At infectious disease specialist and counsel- least two HIV viral load results were avail- lors is vital to complete care. In the man- able showing reduced viraemia over time. agement of this patient all these people Use of intravenous ganciclovir or oral val- had a role to play which made managing ganciclovir was not possible in this patient the patient easier. Frequently, CMV retini- due the extremely high cost of such thera- tis is a clinical diagnosis though support- py that was not sustainable. This is a huge ive tests include presence of anti-CMV challenge in the Zambian setting because antibodies or CMV antigens in body fluids of limited availability of the drugs in the including ocular fluids [7]. This could not public and commercial pharmacies due of be done for this patient due to the poor the reduced utilisation of the same. The availability of serological tests. Serial fun- available drugs are very expensive due to dus photography is useful in monitoring low demand. Thus, treatment for this pa- response to treatment and progression of tient was limited to intravitreal ganciclovir the disease. This proved to be so for this and ART. Other patients are apprehensive patient as shown in figs 1, 2 and 3 above. about any invasive ocular treatment and Medical treatment for CMV retinitis in- thus refuse this treatment also. cludes local (intravitreal) and/or sys- Retinal surgery services are also not wide- temic antiviral therapy. Drugs such as ly available as yet in the public sector. As ganciclovir, valganciclovir, foscarnet, and a result, the patient has not yet had the cidofovir may be used. Disadvantage of surgery as at publication date. Low vision local ocular therapy include that there is services are also a challenge at present no protection of the other eye in case of due to lack of certain devices required for initial unilateral retinitis and that it does comprehensive low vision services. not treat concurrent systemic disease Despite the challenges, the patient man- either [7]. For bilateral disease system- aged to improve to 6/12 vision in one eye ic therapy is more useful. This was done that enabled her to move around inde- for this patient which proved useful. pendently by the last follow up. She was Treatment is given for a three-week long consistent with treatment and review ap- induction phase followed by a period of pointments which enabled the success. maintenance determined by the patient response and systemic immune recovery. CONCLUSION This patient received the induction regime Although there has been a success in as required and was given maintenance managing patients with HIV, there has for three months. ART also is key in the been a challenge with early detection of treatment of HIV patients with CMV ret- HIV-related conditions such as CMVR initis and also to prevent recurrence. This probably due to the reduced index of patient was already on ART. Generally, suspicion for the same. The successful CD4 count levels above 200 cells/µl may treatment of CMVR becomes difficult as be used to stop maintenance anti-CMV a result of the limited availability and high 14 LIST OF REFERENCES

1. Cytomegalovirus (CMV) Retinitis: Practice Essentials, Background, Pathophysiology. 2019 Feb 11 [cited 2019 May 19]; Available from: https://emedicine.medscape.com/article/1227228-overview 2. Rocha B. Ophthalmic Manifestations of HIV Infection. DJO [Internet]. 2004 Oct 29 [cited 2019 Jul 18];10(3). Available from: http://www.djo.harvard.edu/site.php?url=/physicians/oa/674 3. Shahnaz S, Choksi MT, Tan IJ. Bilateral Cytomegalovirus Retinitis in a Patient With Systemic Lupus Erythematosus and End-Stage Renal Disease. Mayo Clinic Proceedings. 2003 Nov 1;78(11):1412–5. 4. Kestelyn PG, Cunningham ET. HIV/AIDS and blindness. Bull World Health Organ. 2001;79(3):208–13. 5. Tsai JC, editor. Oxford American handbook of ophthalmology. Oxford ; New York: Oxford University Press; 2011. 742 p. (Oxford American handbooks). 6. Bowling B. Kanski’s Clinical ophthalmology, A Systematic Approach. 8th ed. Elsevier limited; 2016. 618–622 p. 7. Eong KGA, Beatty S, Charles SJ. Cytomegalovirus retinitis in patients with acquired immune deficiency syndrome. Post graduate Medical Journal. 1999 Oct 1;75(888):585–90. 8. Basic and clinical science course, section 12- Retina and vitreous, 2016-2017, American Academy of Ophthalmology

15 CONGENITAL NASOLACRIMAL CUTANEOUS FISTULA

Case Report By : *W B Mumbi1, B Ng’andwe2, I P Hwang3 1Eye Hospital, University Teaching Hospitals - Lusaka, Zambia. 2Faculty of Ophthalmology, Department of Surgery, School of Medicine, University of Zambia, Lusaka, Zambia 3California Clinic, California, United States of America *EMAIL ADDRESS: Willard B MumbI: [email protected] and [email protected]

Citation Style For This Article: Mumbi W B, Ng’andweB, Hwang I P. Congenital Nasolacrimal Cutaneous Fistula. Health Press Zambia Bull. 2019; 3(12); pp 16-17.

ABSTRACT la is reported globally to occur in one in months after the operation and we will Congenital lacrimal cutaneous fistula is a 2000 births with no sex predilection [2]. keep following up since some literature rare condition but a significant cause of Most are unilateral and are located infer- reports high recurrence rates with simple epiphora in children. Many cases might be onasal to the medial canthus. These fis- excision. asymptomatic and may require no treat- tulae may be asymptomatic and therefore ment however some might need surgical overlooked for some time after birth. In intervention owing to the high burden of some cases, it may be difficult to ascertain recurrent infections and epiphora associ- whether a fistula has been present since ated with the disease. Thus, this article re- birth and remained unnoticed or has aris- ports the first case of congenital lacrimal en later as a result of infection or surgical cutaneous fistula at the University Teach- intervention. Symptoms may be of tearing ing Hospitals – Eye Hospital (UTHs–EH) from the ostium of the fistula or from the in Lusaka, Zambia and its management eye or both depending on whether there is in a resource limited setting. A 3-year- also nasolacrimal obstruction. old female presented with a two months This article presents the first case of lac- history of epiphora and an opening on the rimal fistula in our setting and we present lower aspect of the medial canthus of the its management in a resource limited set- Fig 1: arrow showing a depression infero- left eye. The rest of the history was other- ting like ours. medially wise unremarkable. Physical examination revealed a prominent orifice noted on the inferomedial aspect of the medial can- CASE SUMMARY thal angle of the left eye and a negative A 3-year-old female presented to the ROPLAS sign. The opening was noted to UTHs–EH in Lusaka, Zambia with a 2 be discharging a watery discharge. The months history of an opening on the nasal rest of the anterior and posterior segment side of the left lower eyelid and watering examination was normal. Examination un- through that same opening. There was no der anaesthesia revealed a patent lower associated history of trauma and past oc- canaliculus as well as nasolacrimal path- ular history. Birth history and past medi- way. A simple excision(fistulectomy) and cal history were otherwise unremarkable. closure of the fistula was done success- The visual acuity was 6/6 in both eyes fully. The immediate postoperative peri- and the fundus was normal. od was uneventful. 1-week post-operative Adnexa Examination Fig 2: Immediate post operatively showing the child was noted to have developed an No facial asymmetry and no dysmorphic no tearing ocular infection which was successfully features. Fistula noted inferomedially on treated. Asymptomatic cases of lacrimal the left medial canthal angle as shown in fistula might be managed conservatively. fig 1. Simple surgical excision of lacrimal cu- taneous fistula may be sufficient to treat Management symptomatic cases. Intra-operatively, probing and irrigation was done in our patient which demon- INTRODUCTION strated a patent nasolacrimal pathway. Congenital lacrimal cutaneous fistula is The patient thus received a simple exci- a rare developmental condition in which sion and closure of the fistula, fig 2. a normally epithelized tract connects the Fig 3: One-week post operatively showing skin to the common canaliculus, lacrimal On week 1 review, the patient had pro- complete healing sac or nasolacrimal duct [1]. gressed well and was healing well (Fig The incidence of congenital lacrimal fistu- 3). The child remains asymptomatic 3 16 DISCUSSION The treatment of choice for a symptom- probing and irrigation was adequate to Congenital lacrimal fistulae are thought atic fistula is surgery, consisting of com- demonstrate patency of the nasolacrimal to arise due to an intrusion with the in- plete excision of the fistula, sometimes in apparatus. vagination, burial and subsequent tissue conjunction with nasolacrimal intubation Conclusion remodelling of the surface ectoderm that if there is associated distal nasolacrimal Congenital lacrimal cutaneous fistula can gives rise to the nasolacrimal pathway duct obstruction [1]. In the case under re- occur anywhere despite it being rare. In [3]. Most cases of lacrimal fistula are as- view the fistula was cut and sutured and longstanding cases surgical intervention ymptomatic and usually might not need there was no need to do a nasolacrimal may be the management of choice. any treatment apart from observation. intubation. This case was symptomatic and needed Establishing the patency of the naso- Consent surgical intervention which was conduct- lacrimal apparatus is important and can Consent to publish and use the images ed successfully. However, when the dis- be done through the dye disappearance was obtained from the mother of the pa- ease is coupled with obstruction of the test, probing and irrigation or dacryocys- tient nasolacrimal system, complications en- togram. This is because excisions done sue. Commonly this might lead to epiph- without correcting nasolacrimal obstruc- ora [4]. This patient had no nasolacrimal tions are bound to fail. In this case, obstruction which was confirmed during probing and syringing.

LIST OF REFERENCES

1. Birchansky, L.D., 1990. Management of Congenital Lacrimal Sac Fistula. Arch. Ophthalmol. 108, 388. https://doi. org/10.1001/archopht.1990.01070050086037 2. Chaung, J.Q., Sundar, G., Ali, M.J., 2016. Congenital lacrimal fistula: A major review. Orbit 35, 212–220. https://doi.org/10.1 080/01676830.2016.1176052 3. Missner, S.C., Kauffman, C.L., 2001. Congenital Lacrimal Sac Fistula: A Case Report and Review. 4. Sullivan J Timothy., Clarke P Michael., Morin J Donald., Pashby C Robert., 1992. The surgical management of congenital lacrimal fistulae. Australian and New Zealand Journal of Ophthalmology.

17 CONGENITAL PROPTOSIS

Case Report By : *G Hamukali1,2 , K I M Muma 1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2Mwami Mission Hospital, Chipata, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Given Hamukali: [email protected]

Citation Style For This Article: Hamukali G, Muma K I M .Congenital Proptosis . Health Press Zambia Bull. 2019; 3(12); pp 18-19.

ABSTRACT may affect the orbit, eyelids and conjunc- was reviewed a one month later the pro- This is a case report of a unilateral con- tiva [5, 6]. Lymphangiomas are common- had regressed. genital proptosis that presented at Chi- ly located behind the orbital septum and The mother of the patient gave consent to pata Central Hospital (CCH) of a female usually manifest with proptosis, as well as publish this case. neonate whose birth history was un- the pain caused by spontaneous intrale- eventful. At birth the neonate was given sional haemorrhage or upper respiratory DISCUSSION topical antibiotics and the parents were infection [7]. Lymphangiomas are relatively rare, be- sure it was going to resolve. Upon notic- nign, congenital malformations, which ing that the proptosis of the eye was not CASE SUMMARY may affect the conjunctiva, lids and or- regressing, the parents took the neonate A six day old female neonate from a rural bit of the eyes [5, 6]. Lymphangiomas back to the health facility in Malawi where village in Mchinji District of Malawi was are commonly located behind the orbital they were referred to CCH through Mwa- presented to CCH by the mother who was septum and usually manifest with propto- mi Mission Hospital. After examination concerned that the left eye protrusion was sis, as well as the pain caused by sponta- and investigations at CCH, a diagnosis of not regressing despite the treatment giv- neous intralesional haemorrhage or upper Lymphangioma was made for which the en and the assurance from medical per- respiratory infection [7]. In this case the neonate was successfully managed and sonnel. The mother reported that the eye lymphangioma was found to be behind discharged. was swollen and gradually increasing in the septum in the orbit. size and the neonate was unable to close In this article, we described a rare case of INTRODUCTION the left eye. proptosis with sudden onset and complete Proptosis is defined as the forward dis- The neonate was born via spontaneous regression, which led to no complications placement of the eyeball [1]. This condi- vaginal delivery with no complications. in a new-born referred to the neonatal tion could be induced by inflammatory, This neonate was a third child in the fam- ward of Chipata Central Hospital. Kasim vascular, infectious, cystic, neoplastic ily and the siblings were reported to be and Gendeh (2013) reported that neona- (benign and malignant), and traumatic health with normal eyes. General system- tal proptosis with post-orbital lymphan- factors [2]. ic evaluation was suggestive of respira- gioma is a rare malformation, which has tory distress and infected left eye. Visual been associated with severe causes in Unilateral proptosis has several differen- interest was positive especially to her previous studies. The rarity of such cases tial diagnoses, including microphthalmos right eye which had normal anterior and could be true because even at CCH such with a cyst, congenital cystic eyeball, posterior segment findings. Left eye find- cases are rarely attended. Solarte et al., and unilateral congenital glaucoma, der- ings included a mild proptosis, moderate 2010, reported a case of acute proptosis moid cyst of the orbit, neuroblastoma, chemosis, retracted eyelids, megalo-cor- in a 26-day infant caused by dural fistu- neurofibroma, nasofrontal or sphenoidal nea, dilated irregular and fixed pupil. The la, and the neonate was considered as the meningocele, orbital haematoma, hae- patient was admitted in a paediatric ward youngest case of acute proptosis to have mangioma, and lymphangioma [3]. Con- pending laboratory and radiology investi- been reported [9]. However, in this case genital proptosis is uncommon but may gations and consequent management. report the neonate was born with a pro- potentially be underreported. Differential Ultrasound showed a small cystic orbital ptosis which was steadily increasing in diagnosis of congenital proptosis includes mass suggestive of lymphangioma and size as was noted by the mother. congenital tumours (dermoid cyst, terato- the C-reactive protein (CRP) was positive. ma, retinoblastoma, rhabdomyosarcoma, Full Blood Count (RBC) confirmed sepsis In another study, Erickson and Tse, (2014) neuroblastoma, neurofibroma, myofibro- and systemic antimicrobial therapy was presented a case of gross proptosis at ma), vascular malformations, lymphangi- commenced. Ultrasound and laboratory birth as an uncommon manifestation omas, cysts, encephalocele/meningomy- investigations were repeated to monitor of various lesions, which were likely to elocele, bony abnormalities, abscesses, the progress of the condition. During the compromise vision and lead to deformi- and thyrotoxicosis [4]. 3 weeks of hospitalization, C- reactive ty or death [2]. Furthermore, a study by protein became negative and the orbital Paragache et al., 2004, described the Lymphangiomas are relatively rare, be- mass had regressed. The patient was then case of a one-month-old neonate with nign, congenital malformations, which discharged in good condition. The patient marked proptosis in the right eye. In this 18 case report, the neonate did not present Infections are often difficult to diagnose CONCLUSION with gross proptosis but enough to war- early with certainty, and quick tests such Lymphangiomas can present at birth and rant intensive investigations to confirm as measuring the blood level of a protein can be complicated with respiratory dis- the cause of proptosis. that responds to infection (called CRP) tress and sepsis which can effectively be are sometimes used to help make an ear- treated with antibiotics without any surgi- In the study by Ghosh et al., acute baso- lier diagnosis. A low C-reactive protein cal intervention. philic leukaemia was reported as a rare level is better than a high one, because it diagnosis in a seven-month-old male neo- indicates less inflammation in the body. nate who presented with a 3-week history No medical care has been proven effec- of bilateral proptosis. In a similar research, tive for lymphangiomas however, treat- Salihu et al., described a 15-year-old male ment for sepsis and respiratory distress patient with orbital lymphangioma who with antibiotics has seen some significant presented with symptoms such as sud- improvement. Lymphangioma is not re- den pain, proptosis, visual loss, restricted sponsive to radiation therapy or steroids. eye movements, diplopia, decreased visu- However, propranolol represents a poten- al acuity, compressive optic neuropathy, tial option, which may be of benefit even and subconjunctival haemorrhage. The for intractable diffuse lymphangiomatosis patient underwent surgical operation (or- [10]. Antibiotics are given for secondary bital decompression) unlike the patient in cellulitis as was the scenario in this case. this case.

Neonates, especially sick or preterm in- fants, are at risk of developing severe in- fections (such as bloodstream infections) during their stay on neonatal units.

LIST OF REFERENCES 1. Paragache G, Panda NK, Joshi K. Unilateral progressive proptosis in neonate. Indian J Otolaryngol Head Neck Surg. 2004; 56(1):35-6. 2. Erickson B P, Tse D T. Management of neonatal proptosis: a systematic review. Surv Ophthalmol. 2014;59(04):378–392. 3. Al-Salem AH. Lymphangiomas in infancy and childhood. Saudi Med J. 2004; 25(4):466-9. 4. Salihu N, Sylaj A. Orbital lymphangioma. Int J Case Rep Imag. 2014; 5(1):28–31. 5. Kasim KS, Gendeh BS. Case report: infantile orbital lymphangioma with a rare ENT presentation. J Rhinol Otol. 2013; 1(1):17-19. 6. Giugni AS, Mani S, Kannan S, Hatipoglu B. Exophthalmos: a forgotten clinical sign of cushing’s syndrome. Case Rep Endo crinol. 2013; 2013:1-3. 7. Mercandetti M. Exophthalmos fallow-up. Medscape. Available at: URL: http://emedicine.medscape.com /arti cle/1218575-followup; 2012. 8. Murthy R, Vemuganti GK, Honavar SG, Naik M, Reddy V. Extramedullary leukemia in children presenting with proptosis. J Hematol Oncol. 2009; 2:4-11. 9. Solarte CE, Levin AV, Armstrong D. Acute proptosis in a newborn infant: a presentation of infantile dural fistula. J AAPOS. 2010; 14(1):88-9. 10. Ozeki M, Fukao T, Kondo N. Propranolol for intractable diffuse lymphangiomatosis. N Engl J Med. 2011 Apr 7. 364(14):1380-2.

19 MULTIPLE DEEP CORNEAL FOREIGN BODIES

Case Report By : *I J. Banda1,2, K I. M. Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2Mpongwe Mission Hospital, Mpongwe, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Isaac J. Banda: [email protected]

Citation Style For This Article: Banda I J, Muma K I M. Multiple Deep Corneal Foreign Bodies. Health Press Zambia Bull. 2019; 3(10); pp 20-21.

ABSTRACT age group. The caterpillars in the Eastern lars. Avoidance of rubbing the affected Setae refer to stiff structures resembling Mediterranean region are found on red eye could be considered to prevent further a hair or a bristle, especially in an inver- pine trees on which they feed. These cat- penetration. Then seeking early medical tebrate. The caterpillar hairs are also re- erpillars are put in farms in order to limit attention to be considered immediately ferred to as caterpillar setae. These can their infestation in the red pine trees and eyes were exposed. have devastating effects on the eyes es- to be destroyed by a trained bug that eats pecially if they embedded themselves in them (the so called Calasoma sycopanta). CASE SUMMARY the deep cornea tissues. Literature revealed that workers lacked An 8-year-old female from the outskirts At Kitwe Teaching Hospital Eye Annex, protective wear as they were exposed to of Mpongwe District on the Copperbelt a very rare case of caterpillar setae em- caterpillar setae in caterpillar breeding Province of Zambia came to Kitwe Teach- bedded in deep corneal layers was en- farms resulting in setae ocular trauma. ing Hospital Eye Annex (KTHEA) with countered. An 8-year-old female patient The only well-known risk factor for intra- complaints of reduced vision, painful, presented with painful/pricky sensation, ocular penetration was found to be intra- pricky sensation, redness, photophobia lacrimation, red eye, photophobia and corneal caterpillar setae. and lacrimation in the RE for a day. The failure to open the right eye. Poor vision The first report of reactions caused by cat- patient further complained of having de- was noted in the Right Eye (RE). Slit Lamp erpillar setae was published by Schon in veloped eye problem while sleeping the examination revealed RE chemosis, hazy 1861 [5]. In 1904, Saemisch was the first night before she came to KTHEA. She was cornea and a lot of corneal foreign bodies to describe the granulomatous nodules referred to KTHEA as a case of Conjuncti- (FB). Multistaged surgical FB removal was found on the and conjunctiva caused vitis of unknown cause. performed and medical management was by vegetation or insect hairs as ophthal- On examination, general condition of instituted afterwards. Patient recovered mia nodosa [6]. Caterpillar setae ocular the patient was satisfactory apart from well after treatment. toxicity resulted from setae presence in reduced vision in the RE of 6/36, while the eye tissues which retain toxins [7,8]. LE vision was 6/6. The RE was tearing, INTRODUCTION The development of classification of oph- photophobic, had conjunctival injection, Multiple Deep Corneal FBs refer to more thalmia nodosa was initiated by Cadera et chemosis, caterpillar setae and corneal than 8 FBs on or in the cornea. Among the al., (1984) [9]. There are five classifica- clouding noted during examination. Other rare corneal FBs that can injure the cornea, tions which include: findings were corneal abrasions, caterpil- are caterpillar hairs (setae) which can get Type 1. An acute toxin reaction to hair lar setae on the tarsal conjunctiva and in embedded deep in the corneal layers [1]. (chemosis and inflammation) the deep cornea. The LE was normal. The caterpillar setae can cause severe Type 2. Chronic mechanical keratocon- A diagnosis of deep corneal caterpillar ocular tissue reactions that can lead to junctivitis caused by hair found in the bul- setae was made, and patient was admit- significant visual disturbance if interven- bar or palpebral conjunctiva with foreign ted for corneal FB removal under general tion is delayed [2]. The major treatment body sensation and corneal abrasions anaesthesia through a multistaged surgi- approach is surgical FB removal [3]. Type 3. Formation of conjunctival granu- cal corneal FBs removal process. All the The prevalence of FB corneal injury due to lomas due to subconjunctival or intracor- setae were successfully removed, and pa- caterpillar setae in Zambia is not known neal setae tient was commenced on topical steroid for there is nothing documented. Few cas- Type 4. Iritis secondary to hair penetra- and antibiotic treatment. es have been reported on from African tion of the anterior segment countries, but literature shows that there Type 5. Early or late vitreoretinal in- DISCUSSION are many cases in the Eastern Mediter- volvement due to penetration of the hair Classically, patients with caterpillar setae ranean countries where there are farms through the cornea, iris and or via corneal FB present with failure to open the that breed caterpillars [4]. Corneal FB transscleral route, vitritis, cystoid macular eye, painful, red eye, pricky sensation, lac- due to caterpillar setae was known to be oedema, papillitis or endophthalmitis may rimation, photophobia and FB sensation. an occupational disease for being com- occur. The severity of these ocular manifesta- mon among caterpillar farm workers, but The progression of such complications tions is mainly based on the number of currently it can occur in even non-cater- could be prevented by using protective caterpillar setae embedded in the cornea pillar farming communities and in any wear to people exposed to such caterpil- worsen due to rubbing the affected eye. 20 This action facilitates intraocular penetra- Health personnel should be aware of such CONCLUSION tion and the eye happened to be increas- manifestations of caterpillar setae trauma Caterpillar setae ocular trauma can occur ingly traumatised [1]. as there is no typical way of clinical pre- in Zambia. It is possible to remove all the Caterpillar setae on the cornea is a rare sentation. Intracorneal caterpillar setae caterpillar setae through a thorough and case but can occur anywhere in the world are very difficult to remove and a good well-planned surgical approach. and in any age group. The complications number of them can remain unremoved that arose from caterpillar setae in this [10]. Though caterpillar setae are difficult case were inflammation, chemosis, me- to remove, in this case the surgical remov- chanical conjunctivitis as it has been re- al was successful in two sittings and all ported in literature [9]. the caterpillar setae were removed. It is important that a careful history is taken from patients presenting with such signs to avoid misdiagnosis.

LIST OF REFERENCES 1. Fraser SG. Dowd TC, Bosanquet RC. Intraocular caterpillar hair (state): clinical course and management. Eye 1994;8:596- 598 2. Bishop JW, Morton MR. Caterpillar hair induced kerato-conjuctivitis . Am J Ophthalmol. 1967; 64:778-779. 3. Shibui H, kawashima, H Kamata K, Sasaki H, Inoda S, Shimizu H, Vitrectomy of caterpillar seta-induced endophthalmitis. Archophthalmol 1997; 115:555-6. 4. Corkey JA. Ophthalmianodosa due to caterpillar hair. Br J ophthalmol. 1955;39:301-306 5. Hered RW, Spauldng AG, sanitato jj, et al. ophthalmia nodosa caused by tarantula hair. Ophthalmology. 1988; 95:166-169. 6. Watts P, McPherson R, Hawkworth NR. Tarantula Keratouveitis. Cornea. 2000;19:393-394 7. Saemisch T. (1904). Ophthlmia nodosa. In graefe A, Saemisch T (eds.) handbuch der gesamten Augenheilkunde, 2nd ed. (pp 548-564). Leipzig: Engelmann. 8. Cadera W, Paachtma MA, Fountain JA. Ocular lesions caused by caterpillar hairs (opthalma nodosa) can J ophthalmol. 1984;19:40-44 9. Schon J. (1861). Bietragezur praktische Augenheikunde. Hamburg: Hoffman & Campe. P 183. 10. Sengupta S, Reddy PR, Gryasho J, et al. Risk factors for intraocular penetration of caterpillar hair in ophthalmia nodosa: a retrospective analysis. Indian journal of ophthalmology 2010;58:540-543

21 DEVASTATING EFFECT OF SUPRACHOROIDAL HAEMORRHAGE

Case Report By : *M I Lukavu1,2, K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2Eye Unit, Ndola Teaching Hospital, Ndola, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Metela L. Lukavu: [email protected]

Citation Style For This Article: Lukavu M I, Muma K I M. Devastating Effect of Suprachoroidal Haemorrhage. Health Press Zambia Bull. 2019; 3(12); pp 22-23.

ABSTRACT or vitrectomy [3-10]. SCH can also be as essary manoeuvres that would have saved Ndola Teaching Hospital’s eye unit had a result of type of anaesthesia employed the eye and possibly retain useful vision. a rare but vision threatening intraocular with retrobulbar anaesthesia having the The majority of patients encountering this surgery complication in a male patient greatest risk were as with general anaes- complication recover with useful vision aged 62 years. The patient developed su- thesia the risk for SCH is minimal. and the minority end up with blindness prachoroidal haemorrhage of the Left Eye Surgically the risk for SCH increases in case or complete loss of the eye [3, 4, 5]. Only (LE) intraoperatively. It was his second of posterior capsule rapture with vitreous a small proportion of patients complete- eye for cataract surgery as he had previ- loss, conversion from phacoemulsifica- ly lose the eye through evisceration such ously been operated on the right eye for tion to Extra Capsular Cataract Extraction as reported by Sharma et al.,1997, in India cataract. He had no systemic illness or (ECCE) and longer duration of intraocular where out of 6971 intraocular surgeries ocular disease and was not on any medi- surgery. Furthermore, post-operative risk done between 1988 and 1994, only 12 de- cation. The patient ended up with an evis- factors include hypotony and valsalva ma- veloped SCH demonstrating that SCH was ceration of the LE noeuvres (coughing and straining) [3-10]. extremely rare at a prevalence of 0.17% and only three (0.04%) cases could end INTRODUCTION CASE SUMMARY up with evisceration [3]. At NTH, of the Suprachoroidal haemorrhage (SCH) is A 62-year-old male patient presented thousands of intraocular surgeries that a rare but potentially devastating vision to the Ndola Teaching Hospital (NTH) have been performed over years, this was threatening complication of intraocular eye clinic for cataract surgery in the sec- the first encounter. This confirms the find- surgery [1,2]. It occurs due to rapture of ond eye which was the LE. The first cat- ings of Sharma et al. [3]. the long and short posterior ciliary arter- aract surgery in the RE was successful Intraoperative SCH is defined as a sud- ies [1,2] which leads to accumulation of with good visual outcome (visual acuity, den haemorrhagic swelling of the choroid blood within the potential space between 6/12). The patient had no abnormalities which develops at the time of surgery. It is the choroid and sclera. When it occurs, elicited from his past medical history as associated with expulsion of some or all an attempt can be made to control it. If well as his previous surgery and the rest of the intraocular contents. This is what successful, the guarded prognosis can be of the examinations were normal except happened in the case under study. Vari- reasonably improved and the patient can for the visual acuity of the left eye which ous studies have focused on identifying have useful vision and the globe saved was Hand Motion (HM). The basic tests patients at risk and reduction of risk fac- [3,4,7]. In most cases the, vision is lost such as blood sugar and Ultrasound were tors help to reduce the incidence [3-10]. completely and can end up with eviscer- normal. Patient had no systemic disease. Proper intraoperative and postoperative ation. Routine pre-operative medications were surgical management may be critical in The incidence of SCH tends to vary de- given. Local anaesthesia was adminis- saving the eye and having a good visual pending on the country, region and con- tered through a retrobulbar injection of outcome [6,7]. Some eyes can recover tinent. It is estimated that the incidence lignocaine 2% with adrenaline. While on from SCH with useful vision. Spaeth et of SCH in cataract surgery is currently the operating table, the patient suddenly al.,2007, have concluded from their study 0.03% with new techniques compared to developed Suprachoroidal Haemorrhage that occurrence of SCH does not in itself older techniques which was at 0.8%. Ma- (SCH) intraoperatively. The occurrence of lead to poor outcome. The prognostic fac- jority of SCH (50%) occurs after nucleus this complication was so rapid that there tors also include vitreous haemorrhage expression [8, 9, 10]. was no chance to perform the necessary and retinal break or detachment [10]. The Risk factors of SCH include advanced manoeuvres to save the eye. There was NTH patient did not have risk factors, but age, cardiovascular conditions, peripher- rapid extrusion of all intraocular contents presented the most rapid and devastating al vascular disease and certain medica- which lead to evisceration of the eye. progression of SCH. tions such as anticoagulants, antiplatelet In cases where there are risk factors, it is agents and cardiovascular drugs. Others DISCUSSION vital to have a high index of suspicion for include high myopia, , Glaucoma, Ndola Teaching Hospital eye unit had this expulsive SCH. Where SCH is suspected raised intraocular pressure pre-operative- rare and devastating experienced of SCH. intraoperatively, immediate rapid clo- ly and previous intraocular surgery, for The incidence happened so rapidly that sure of the wound is important especial- example, Penetrating Keratoplasty (PK) the eye could not be salvaged by the nec- ly when SCH progression is not so rapid. 22 Where there is a chance to control or stop In the case under discussion the progres- CONCLUSION the SCH, prolapsed intraocular contents sion of SCH was so rapid that there was Suprachoroidal haemorrhage though should be reposited as quickly as possible no room to control or stop it and it was rare can be devastating. The course of whilst maintaining the anatomical integri- not possible to achieve wound closure. suprachoroidal haemorrhage can be un- ty of the eye. If this is not possible, the eye Sclerotomy was also not possible to per- predictable and can lead to dramatic loss can be softened by performing posterior form. All the eye viscera rapidly sponta- of vision. Prompt recognition and appro- sclerotomy. neously extravasated and the eye ended priate management may limit its conse- up in evisceration. quences and provide a reasonable visual outcome.

LIST OF REFERENCES 1. Kanski J (2003) clinical Ophthalmology, a systemic approach, fifth edition, Butterworth Heinemann. 2. Sandford-smith, (2001), eye surgeries in hot climates, second edition. 3. Sharma t et al. ophthalmic surgery lasers (1997); 28/8; 640-641. 4. Desai P et al. National cataract surgery survey 1997-8: a report of the results of the clinical outcomes, Br J ophthalmology (1999); 8/12; 1336-1340 5. Ling R et al. Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, man agement, and outcomes, Br J Ophthalmology (2004); 88(4); 478-480 6. Reuben f et al 2018” management of suprachoroidal haemorrhage”, Singapore. 7. Barkar FA, Hussein A, Saad NM (2018)” Successful Surgical Management of Massive Suprachoroidal Haemorrhage”. 8. Lee S, et al (2015) “spontaneous resolution of massive expulsive suprachoroidal haemorrhage with good long-term visual outcome”. Korea. 9. Komal et al. (20117) “Idiopathic Bilateral suprachoroidal haemorrhage: A rare case presentation”, case report in ophthal mological medicine, vol.2017, Article ID 4234238, 3 pages, 2017. 10. Davison JA. et al. (1986) cataract refractive Surgeon; 12(6); 606-622.

23 EXTERNAL OPHTHALMOMYIASIS (EOM)

Case Report By : *G N Chipeta1,2, K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2Solwezi General Hospital, Solwezi, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia2University Teaching Hospitals - Eye hospital, Lusaka Zambia

*EMAIL ADDRESS: George N. Chipeta: [email protected]

Citation Style For This Article: Chipeta G N , MumaK I M.External Ophthalmomyiasis (EOM). Health Press Zambia Bull. 2019; 3(12); pp 24-26.

ABSTRACT cavity or sub retinal space [3]. The most showed a lot of conjunctival chemosis and Ophthalmomyaisis is an ocular condition damaging of the species, is the orbital slight bleeding from the previous surgical characterised by presence of live maggots myiasis where the fly larvae get their way wound which had been performed from in the ocular tissue. It occurs rarely espe- to the orbital structure and cause serious the health centre. The cornea and the rest cially where there is neglect in the man- damage to the surrounding tissues of the of the anterior segment examination were agement of bacterial ocular infection. It eye [3]. found normal. Fundus examination did not is believed to be a common condition in An existing open injury to the surround- reveal any larvae in the vitreous both eyes. under-developed world due to poor living ing skin of the eye may also pause as easy However, the lower eyelid of the left eye and hygiene standard. entry point to the internal eye structures. looked infected. This is a case in which a 16-year-old fe- Treatment of EOM constitutes mechani- After infiltrating the eyelid with 2% - lig male patient presented at the Solwezi cal removal of the fly larvae after applica- nocaine and instilling 1% lignocaine, the General Hospital Eye Clinic (SGHEC) with tion of a topical anaesthetic agent and use lower eyelid was gently pulled down and ocular foreign body sensation, lower eye- of topical antibiotic-steroidal combination on further exploration of the fornix con- lid swelling and tearing. She was referred [3]. The symptoms resolve immediately junctiva of the left eye, a single motile from a rural health centre with suspected after the removal of the larvae [3]. creamy white maggot was noticed with lower eyelid abscess for further manage- its head flicking back and forth. A few ment. An incision and drainage (I&D), CASE SCENARIO drops of 0.5% povidone iodine were ap- had previously been performed from the A sixteen (16) year old female patient pre- plied in the eye and the wound was thor- health centre but this did not resolve the sented to the eye clinic at Solwezi General oughly cleaned. A small incision was done suspected abscess. Hospital, with complaints of painful lamp, to expose the fly larvae from the fornix The patient’s visual acuity in both eyes tearing, redness and moving foreign ob- conjunctival tissue in the lower eyelid. Us- was normal (6/6). Exploration of the left ject in the lower eyelid of her left eye over ing the conjunctival forceps, the fly larva eye (LE) revealed a larva that was deeply a period of two (2) weeks. (measuring 3 mm) was carefully pulled seated in the tissues of the lower eyelid. A The patient did not have any history of out, put in saline and sent to the laborato- diagnosis of preseptal cellulitis secondary systemic or ocular illness. The mother re- ry for identification. to external ophthalmomyaisis (maggot ported that a few days earlier, the girl had The cornea and the rest of the anterior or larva in the eyelid) was made. The lar- sustained a small injury on the affected segment examination were found normal. va was carefully removed surgically. The eye after slipping over in the family goats’ Fundus examination did not reveal any fly patient’s condition improved within two house, but the wound quickly healed. A larvae in the vitreous or sub retinal spaces days of commencement of the topical and couple of days later, the patient began to both eyes. intravenous antibiotics. complain of irritation and painful swelling A diagnosis of external ophthalmomyaisis of the eyelid of same eye. She was treated in the lower eyelid of the left was made INTRODUCTION at the health centre for suspected eyelid and the patient was commenced on Gen- Myiasis is the infestation of humans and abscess where partial incision and drain- tamycin eye drops and intravenous anti- animals with live maggots (fly larvae) of age was performed in an effort to drain biotics in order to treat preseptal cellulitis certain flies [1]. Skin is the most com- out pus, but this did not help resolve the and prevent orbital cellulitis. Within five mon organ of infestation, but larvae have swelling in the eyelid. The patient then days the patient had improved tremen- sometimes been removed from the eyes, was referred to the hospital for further dously and was discharged on topical and ears, nose and urogenital although rarely management. Considering the fact that oral antibiotics. [2]. Ophthalmomyiasis is the infestation the patient was below age of 18 years, the of the orbital tissues with fly larvae (mag- mother consented for publication of the gots) is of three (3) types. In the External case report. DISCUSSION Ophthalmomyaisis (EOM) type fly lar- On examination, the general condi- Ophthalmomyiasis is an infestation of the vae are deposited on the eyelid or ocular tion was fair, febrile (body temperature orbital tissues with fly larvae (maggots) surface [3]. The second one is the inter- 38.60C), not pale, not jaundiced and of most commonly sheep and goat nasal nal type where fly larvae could penetrate had no respiratory distress. The visual botfly hominis of oestridae family (oes- the globe and can be seen in the vitreous acuity was 6/6 in both eyes. The left eye trus ovis) and Arthropoda of insecta class 24 [2,3]. The patient in this case report fell The causative maggots (fly larvae) for in central Europe and elsewhere, account- in the goat house and sustained injury on ophthalmomyaisis are usually small ing for 33% [6,7]. There have been no re- the left eye. It is possible that infection translucent or creamy white worms of ported cases from the sub- Saharan Africa could have come from the goat droppings about 3-5 mm length with brownish or [10,11], hence reporting this one. in the goat house. These fly larvae (mag- dark heads [4]. The larvae extracted from gots) are ejected in the milky fluid by a fe- the patient measured 3mm. The fly larva CONCLUSION male fly while it is in flight. Fly larvae can may have numerous hooks on its belly Ophthalmomyaisis is a rare condition in be deposited on or into the ocular surface which are used for crawling through tis- Zambia but may occur especially among of humans and be responsible for benign sue. When the larva infests the preseptal rural and animal rearing communities. external ophthalmomyaisis (EOM) [1-3]. tissue it can sometimes invade the orbital Patients who may present with lamps on On the contrary this was not benign as it cavity resulting into a lot of damage to the the eyelids or preseptal cellulitis coupled was symptomatic, and the patient com- globe [5-9]. In this scenario the globe was with conjunctival irritation and chemosis plained. Occurrences of ophthalmolmyai- not affected. of the eye should be carefully screened in sis are common in rural areas and animal Among 295 cases described world-wide order to rule out other conditions such as raising community areas [4]. The patient between 1918 and 2017 110 (37%) oc- the one in this case report. However, Oph- of interest was from a rural community curred in North Africa,57 (20%) in Mid- thalmyaisis is a treatable disease. and the family kept goats and sheep for dle-east and 31 (10%) in South-Asia. In their living. She could have picked the fly Europe EOMs are endemic in the Medi- larva from the goat house where she had terranean basin with sporadic cases fallen and sustained an eyelid injury.

25 LIST OF REFERENCES 1. Thakur K., Singh G and Chauhan S, A. ophthalmolmyaisis infection that occurred and was diagnosed and treated in a sin gle day: rare case report, Sood Oman Journal of Ophthalmology, 2(3)(2009),pp. 130-132, vidi.vini.vinci:external. 2. Smillie I., et al., Nasal and Ophthalmomyaisis: case report, J. laryngo otol, 124(8) (2010), PP.934-935. 3. Cameron J.A., et al., Conjunctival Ophthalmomyaisis caused by the sheep nasal botfly (oestrus ovis) AM journal of Oph thalmomyaisis 112 (3) (1991), pp. 331-334. 4. Pandey A. et al., External Ophthalmomyaisis caused by oestrus ovis a rare case report from India, Korean Journal of Para sitology 47 (10, (2009), pp.57-59. 5. Gregory A. R., et al., External Ophthalmomyaisis caused by the sheep botfly oestrus ovis in Northern Iraq Optom Vis. Science 81 (8) (2004, pp.584-590. 6. Abdellatif M. Z., et al., oestrus ovis as a cause of Red Eye in Aljbal Algharbi, Libya, Middle-East African Journal of Ophthal momyaisis 18 (4) (2011), pp. 305-308. 7. Dunbar J. et al, An outbreak of Human External Ophthalmomyaisis due to oestrus ovis in Southern Afghanistan,Clinical Infectious Diseases, 46 (11) (2008),pp. e124- e126. 8. Sreejith R.S. et al., Oestrus Ovis Ophthalmomyaisis with Keratits, Indian Journal Medical of Microbiology,28(4) (2010), pp. 399-402. 9. Jenzeri S. et al, Eternal Ophthalmomyaisis manifestation with Keratouveitis Internal Ophthalmomyaisis, 29 (6) (2009),pp. 533-535. 10. Maiotti J.M, Vacheret G. Conjuntival Myaisi a frequent Pathology in Corsica French Journal of Ophthalmomyasis ,1992 15: 679-682. 11. Papadopauslos. E. Chaligiannis I., Morgan ER, Epidemiology of oestrus ovis (Diptera: Oestridae) larva in Sheep and Goats in Greece, A small Research 2010; 89:51-56.

26 HIGH MYOPIA MISTAKEN FOR A MENTAL ILLNESS

Case Report By : *C Chansa1 and K I M Muma1,2 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Chipili Chansa: [email protected]

Citation Style For This Article: Chansa C, Muma K I M .High Myopia Mistaken for a Mental Illness. Health Press Zambia Bull. 2019; 3(12); pp 26-27.

ABSTRACT tients [5]. mental health assessment and examina- A 25-year-old female patient presented Reeves et al. 2000, reviewed the records tion was done, a provisional diagnosis of to the Chainama College Eye Clinic where of 64 patients with various conditions er- depressive disorder was made. Patient she was referred to by a psychiatrist for roneously admitted to psychiatric units was further referred to the eye clinic for full eye examination. The patient had been due to lack of thorough history and physi- ophthalmic evaluation. taken to psychiatric filter clinic by her par- cal examination [6]. Anxiety traits among On examination at the eye clinic, her vi- ents to seek help and counselling after young adults and other psychological ef- sual acuity was finger counting at 4 me- observing unusual behaviour. The patient fects as a result of high myopia may lead tres Right Eye (RE) and at 3 metres Left was reported to be isolating herself from to a person being mistaken to have a men- Eye (LE). On fundus examination, she everyone and had withdrawn from school. tal illness and yet not [7]. had a myopic/tessellated fundus, with no Examination revealed high Myopia which In the study by Dias et al., 2002, 469 new blood vessels on the retina, and the was corrected with spectacles at the facil- myopic patients reported moderate to macular was normal. Intraocular pressure ity. Patient’s behaviour changed dramati- high levels of self-esteem. At follow up was normal in both eyes at 17.5 mmHg. A cally, and psychiatric review showed that physical appearance, social acceptance, diagnosis of high myopia was made and she was actually not a psychiatric patient. behavioural conduct and general self-es- her vision was corrected with spectacles teem worth levels were noted to have of -10.50/-2.75 X 145 RE, and -14.0 DS INTRODUCTION been significantly affected [8]. Lagomasi- LE. Her vision improved to 6/12 in both High Myopia is defined as a condition in no et al., (1999) and Dias et al. (2002) re- eyes. The correction of her sight instantly which the spherical equivalent objective ported that children who experience more changed her behaviour and looked happy. refractive error is minus 5.00 Dioptres or visual problems tend to evaluate them- Her quality of life remarkably improved as higher in either eye [1]. It is a relatively selves less favourably in terms of their she went back to school and freely social- severe level of near sightedness that can physical appearance, school work, social ised with her peers and family members. be associated with significant eye health activities, and behavioural conduct as After six months reviews at both the men- complications [1]. The onset of high my- they were affected with low self-esteem tal filter clinic and eye clinic revealed that opia usually starts to develop after age of [9]. The identification of relationships be- she had no psychiatric symptoms nor was 10 years, but in other regions it can start tween a high levels of trait anxiety among she a mental patient; and that she had earlier or late in life [2]. The main form myopic young adults can help to define adapted well to her spectacle prescrip- of treatment in early stage high myopia is preventive actions aimed at protecting tion. prescription for glasses or contact lenses young patients from severe mental disor- The patient consented to having her case [3]. Global prevalence rates of high myo- ders [9]. published, but her names and location pia were estimated to affect 2.8 percent of withheld. the world population in 2010 [4]. Prelimi- CASE SCENARIO nary projections indicate that high myopia A sixteen (16) year old female patient will affect 10% of the world’s population preA 25-year-old female presented with DISCUSSION [3,4]. poor and blurred distance vision in both High myopia is a severe form of near The exact prevalence rates of high myopia eyes which she said to have experienced sightedness that can be associated with in Zambia are unknown but from Chain- for 9 years. She had briefly shared her significant eye health complications and ama Eye clinic outpatient records, these vision difficulties with her parents in the psychological effects [1]. In this case re- cases seem to be on the increase that is early stages, but the complaint was not port the patient under review presented from January 2017 to December 2017. taken seriously as there was no one else with severe visual impairment and strange Chainama eye clinic recorded 15 cases of in the family with similar problems. The behaviour. high myopia; whereas from January 2018 parents noted unusual behaviour of the According to Cohen et al., 2005, anxiety to December 2018, the cases increased to patient with decreasing vision. She with- traits among young adults and other psy- 22. drew from school, developed depressed chological effects as a result of high myo- High myopia can be visually and psycho- mood, and always wanted to isolate her- pia are not uncommon [7]. High myopia logically disabling and tends to affect the self. She was first taken to the mental is usually, personally and psychologically level of trait anxiety among young pa- filter clinic for attention where a detailed disabling and tends to affect the level of 26 trait anxiety among young patients [7,8]. Poor vision impacts upon nearly every CONCLUSION Such traits and other psychological ef- daily activity that people are used to un- High myopia resulting in blinding can lead fects if misunderstood may lead to a per- dertaking. It is easy for those with poor vi- to psychiatric condition. Early diagnosis son being mistaken to have mental illness sion to begin to feel isolated as their daily and treatment of high myopia in patients when in fact not; just as in the case under interaction with other people decreases presenting in psychiatric centres is an review. Caregivers or General Clinicians [7]. In this case the patient exhibited iso- effective intervention. Multidisciplinary may assume that a patient exhibiting lation from others. actions of the clinician’s skill both at the strange behaviour will always need psy- Preconceived assumptions regarding psy- mental and eye units played a very im- chiatric diagnosis, treatment, or admis- chiatric presentations and pitfalls of omis- portant role in arriving at the correct di- sions when not. In this case of a 25 years sion in the evaluation of patients with psy- agnosis and treatment. Hence the need to old high myopic female patient, she was chiatric symptoms allow medical mimics scale up community eye health awareness mistaken to be a mental patient simply to go undetected [8]. programmes in an integrated approach at based on the behaviour that those around all levels of health care. her observed; when in fact the changes in her behaviour was largely as a result Disclosure Statement of the psychological impact of her visual The authors have no conflicts of interest challenges.

LIST OF REFERENCES 1. The Impact of Myopia and High Myopia Report, Holden Vision Institute, 16-18 March 2015, P 10-11. 2. Community eye health Journal, volume 32,2019, PP 5-6 3. British Journal of ophthalmologists, 2016; 16:201 4. Holden B et al. Global prevalence of myopia, high myopia from 2000 to 2050. 5. Institute for control of eye myopia in children, 2008; 101-102. WHO, Institute, BHV (2016), the impact of myopia and high myopia. 6. Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med 2000; 18(4):391-393. 7. Cohen AL et al. Are language barriers associated with serious medical events? 2005; 116 8. Dias L, Manny RE, Hyman L, Fern k. The relationship between self-esteem and myopia. optom vis science.2002. 9. Lagomasino I, Daly R, Stoudemire A. Medical assessment of patients presenting with psychiatric symptoms in the emer gency setting. Psych Clin North Am 1999; 22(4):819-850.

27 PERIOCULAR FILARIASIS AT LUSAKA EYE HOSPITAL – ZAMBIA

Case Report By : *A Moonga1,2 , K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia. 2Lusaka Eye Hospital, Lusaka, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Moonga Argent. [email protected]

Citation Style For This Article: Moonga A , MumaK I M. Periocular Filariasis at Lusaka Eye Hospital – Zambia. Health Press Zam- bia Bull. 2019; 3(12); pp 28-29.

ABSTRACT mammals, but may also infect humans, veal the presence of subcutaneous nod- Human ocular infestation by a live filari- being considered a zoonotic agent. The ules. Heart ultrasound, abdominal ultra- al adult worm is a rare occurrence. These parasite’s most frequent localization in sound, and chest X-ray showed normal worms are caused by organisms such humans is in subcutaneous and ocular tis- relations. Based on clinical examination as Brugia malayi, Wuchereria bancrofti, sue (75.8%) [5,6], especially in the ocular and investigations, a diagnosis of subcu- Dirofilaria repens and many others. An area, which is accessible to mosquitoes taneous ocular parasitosis was made. unusual case of periocular filariasis was that act as vectors. Adult parasites are The parasite was surgically removed. A diagnosed at the Lusaka Eye Hospital in a found in subcutaneous tissues while the worm removed was white, translucent female patient aged 47 years. This was in larvae (known as microfilariae) are found and was measuring 8 cm. Surgery was a patient whose profession is to deal with in the blood of the infested animals. They successful and there were no post-surgi- animals. She presented with twitching are ingested by mosquitoes of genera Ae- cal complications. Further treatment was and feeling of movements on the eyelid. des, Anopheles, or Culex during the blood instituted with Diethylcarbamazine 50 Following clinical examination and labora- meal. The larvae grow and become infec- mg TID on days 1 and 2, then 100 mg TID tory investigations, diagnosis of periocu- tive inside the mosquito’s body. Infective on day 3 and 125mg TID on days 4 to 14. lar filariasis was confirmed. The treatment L3 larvae may be transferred to humans consisted of the surgical extraction of the through inoculation when the mosquitoes Declaration of patient consent parasite, antibiotics, steroidal anti-inflam- feed. The author certifies that consent was tak- matory and anthelminthic drugs. The in- en from the patient to publish her case. traoperative and postoperative evolution CASE SCENARIO The patients understand that their names of the case was favorable. A 47-year-old female patient, living in the and initials will not be published, and due USA who has frequent trips to Zambia efforts will be made to conceal their iden- INTRODUCTION and other African countries to carry out tity. The ocular manifestations of filariasis are research in animals such as dogs, cats, elephantiasis of the eyelids, iritis, retinal pigs, rabbits, presented at a private hospi- hemorrhages, or the presence of microfi- tal complaining of episodes of swelling of DISCUSSION laria in the lacrimal gland secretion [1]. In- the lower and upper eyelids of the left eye. The patient attended to at Lusaka Eye traocular infestation by the filarial worm is The patient could feel something moving Hospital had a rare presentation of extra- a rare occurrence in humans and most of in her eyelid for a period of 2 months be- ocular filariasis which did not give a lot of the published reports are from Southeast fore which she was asymptomatic. She challenges with the surgical management. Asia [2]. Entry into the anterior chamber was also complaining of twitching, dis- Microfilariae are more commonly known may be through ciliary vessels. Lymphatic comfort in the upper eyelid, generalized to cause intraocular filariasis than adult filariasis caused by Brugia malayi occurs body itchiness and episodes of fever. The worms [3]. W. bancrofti and B. malayi are in Southwest India, China, Indonesia, Ma- private hospital referred her to Lusaka Eye main causative organisms to cause uveitis laysia, Korea, Philippines, and Vietnam Hospital for further management. secondary to intraocular filariasis in the [3]. Brugian filariasis is mainly a rural dis- Ocular examination revealed a visual Indian subcontinent [4]. W. bancrofti is ease and is transmitted by mosquitoes of acuity of 6/6 in both eyes, normal intra- a helminth belonging to class nematodes. the genera Mansonia, Anopheles, and Ae- ocular pressure (14 mmHg in the right Man is the definitive host, the intermedi- des. Domestic animals like cats and dogs eye RE and 17 mmHg in the LE). A round ate host being species of Anopheles mos- may serve as reservoirs of infection [4]. formation containing a mobile thing in the quitoes. In this case report, the interaction During a blood meal, mosquitoes ingest subcutaneous tissue of the upper eyelid between the patient and domestic ani- microfilaria and they become infective was observed. Examination of the fundus mals predisposed her to mosquito bites in 10 days. Humans contract the disease of the eye revealed a well-defined disc through which the larvae could be trans- through repeated episodes of mosquito and macula and also normal blood ves- mitted to her easily. bite. sels without the presence of other larval Adult worms live in the lymphatic system, Dirofilaria repens (Spirurida, Onchocerci- forms. Ultrasound performed revealed a discharging live embryos (microfilaria) dae) is a nematode that parasitizes main- larva in the eyelid. into the bloodstream. Adult filarial worms ly dogs (Canis lupus familiaris) and other General clinical examination did not re- are thread-like structures that live in the 28 subcutaneous tissues and the lymphatic community, it is very important to always CONCLUSION system. They sexually reproduce micro- be on the lookout especially in patients Periocular and ocular filariasis is not com- filaria, the first larval stage. Microfilariae who could present from other parts of mon in our Zambian population but can are ingested by hematophagous arthro- the world. In this case the patient was not be seen in patients coming from outside pods, where they develop into infective a resident of Africa but the fact that she Zambia especially with the history of in- larvae that grow in the vertebrate host handled the definitive hosts of the para- teracting with animals such as cats and and mature into adult worms. The exact site, infestation could arise from there. It dogs. Accurate diagnosis and early treat- route of invasion of microfilariae into the is therefore very important to have a high ment bring out good outcome. eye is still unknown. They enter the eye index of suspicion, to take a good histo- probably through the long and short pos- ry and perform a thorough ocular exam- terior ciliary vessels, cerebrospinal fluid, ination in patients presenting with ocular or the optic nerve sheath [5]. swellings. In the same vein the patients Once a parasite is identified, it should be with uveitis of suspicious origin associ- removed live and intact to prevent inflam- ated with diseases like elephantiasis and mation, damage to the eye and anaphylax- having had serious contacts with domes- is. In the patient under discussion surgery tic animals must undergo thorough exam- was done cautiously in order to prevent ination to rule out ocular filariasis. any reactions. Ocular Filariasis though not commonly seen in the Zambian

LIST OF REFERENCES 1. Toussaint D, Danis P. Retinopathy in generalized loa-loa filariasis. A clinicopathological study. Arch Ophthalmol. 1965;74:470–6. [PubMed] [Google Scholar] 2. Sabesan S, Palaniyandi M, Das PK, Michael E. Mapping of lymphatic filariasis in India. Ann Trop Med Parasitol 2000;94:591-606. 3. Sabesan S, Raju KH, Subramanian S, Srivastava PK, Jambulingam P. Lymphatic filariasis transmission risk map of India, based on a geo-environmental risk model. Vector Borne Zoonotic Dis 2013;13:657-65. 4. Ganesh SK, Babu K, Krishnakumar S, Biswas J. Ocular filariasis due to Wuchereria bancrofti presenting as panuveitis: A case report. Ocul Immunol Inflamm 2003;11:145-8. 5. Arora Y, Das RN. Live male adult W. Bancrofti in the anterior chamber – A case report. Indian J Ophthalmol 1990;38:92-3. 6. Sven Poppert, Maike Hodapp, Andreas Krueger, Guido Hegasy, Wolf-Dirk Niesen, Winfried V. Kern, and Egbert Tannich (November 2009). “Dirofilaria repens Infection and Concomitant Meningoencephalitis”. Emerg. Infect. Dis. 15 (11): 1844–1846. doi:10.3201/eid1511.090936. PMC 2857255. PMID 19891881.

29 ORBITAL CYSTICERCOSIS

Case Report By : *M M. Chansa1, F Misa1 , K I M Muma2,3,4 1Department of Ophthalmology, Ndola Teaching Hospital, Ndola, Zambia. 2Ministry of Health, Lusaka, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia 4Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia *EMAIL ADDRESS: Mable M. Chansa: [email protected]

Citation Style For This Article: Chansa M M, Misa F, Muma K I M. Ornital Cysticercosis. Health Press Zambia Bull. 2019; 3(12); pp 30-34.

ABSTRACT seen however in the United States where one year prior. A sample was taken for A 47-year-old male presented to the intracerebral infection rarely occurs to- histopathology but the results were not Ophthalmology department at Ndo- gether with subcutaneous lesions [5]. followed up. Five months after excision, la Teaching Hospital with a discharging One of the challenges in Africa and inmost another growth was noticed in the same wound extending from the lower eyelid endemic countries, is the lack of aware- eye, which he opted to have removed with on the lateral aspect of the right eye and ness within communities as well as lack a blade at home, by a relative. A few days a melted cornea. He had a history of hav- of adequate reports and study findings on later, he started experiencing the pain and ing undergone a surgical procedure for a cysticercosis [6]. This can be attributed to discharge and presented to the eye de- conjunctival growth, 6 months prior to the lack of advanced diagnostic facilities partment a week later. There was also his- presentation. He was a known retroviral and technology that would allow prompt tory of having been on antiretroviral ther- disease patient with poor compliance to screening and identification of infected in- apy (ARVS) for the past seven years for antiretroviral medication. He also history dividuals [7] Few countries however, such Human Immunodeficiency Virus (HIV), of tuberculosis. Orbital cysticercosis was as South Africa, Zimbabwe, Madagascar with poor compliance to medication. An- diagnosed following clinical examination and other countries in Central, East and ti-tuberculosis medication had been com- and investigations and anti-helminthic West Africa have been able to produce pleted 7 months prior to presentation. therapy was instituted. scientific reports although data still- re mains limited [7]. Consent for the case On general examination, the patient was INTRODUCTION report publication was obtained from the ill looking and irritable but had normal Cysticercosis is a parasitic infection that patient. vital signs (blood pressure, pulse, tem- is caused by the larvae of Taenia Solium, In Zambia, the full countrywide extent, perature, respiratory rate), with palpable which is a pork tapeworm [1]. The infec- of the impact of cysticercosis in terms cervical lymph nodes. Ocular examination tion is acquired through ingestion of con- of prevalence, endemic areas as well as revealed visual acuity (VA) of perception taminated food and water transmitted socioeconomic effect is not fully appreci- of light (LP) for the right eye and 6/6 for through the faecal--oral route [1]. Neuro- ated. Several studies however, have been the left eye. Intraocular pressure (IOP) cysticercosis is a central nervous system carried out in Eastern province, tackling could not be taken in the right eye, but variant of the infection, responsible for aspects such as prevalence of cysticer- was 14.3mmHg in the left eye. The right causing seizures worldwide [1]. The infec- cosis in bovine as well as human hosts as eye had ecchymosis on the eyelids with a tion is postulated to cause twice as many well as effectiveness of control measures laceration extending from the lower eye- epilepsy occurrences compared to devel- for the prevention of spread of infection. lid to lateral canthus and past the margin. oped countries. Human cysticercosis prevalence has been There was also a foul smelling, purulent, In the United States and other areas with reported to range from 6-13% based on blood stained discharge covering the an- large immigrant populations, there has circulating antigen detection whereas bo- terior aspect of the eye. The cornea was been wide spread recognition of neu- vine cysticercosis prevalence was report- melted and the rest of the anterior seg- rocysticercosis as a common infection, ed to range from 8.2-64.2%, in Eastern ment structures could not be appreciated. not just in developing countries [2]. The province [8]. Extraocular motility was not well appreci- highest prevalence rates have been docu- ated due to the patient’s demeanour. The mented in South and Central America, Af- CASE SCENARIO left eye had normal anterior and posterior rica and Asia particularly in areas of poor A 47 year old male from Ndola city on the segment findings. sanitation and low socioeconomic status Copperbelt province of Zambia presented Differential diagnoses included right lid [3]. In Africa, it has been noted that Tae- to the eye department at Ndola Teaching laceration with corneal ulcer, osteomy- nia Solium is transmitted around most of Hospital complaining of a painful right eye elitis, orbital cellulitis and squamous the continent but not in the strictly Mus- with a discharging wound for one week. cell carcinoma of conjunctiva and eye- lim areas of North and sub-Saharan Afri- These symptoms were said to have begun lid. Full blood count, differential count, ca where pork is not consumed [4]. As in after he fell in the bathroom, whilst taking renal and liver function test results were Asia, concomitant localization of subcuta- a bath. There was also a history of having all within normal ranges. The CD4 count neous lesions with intracerebral infection had a growth on the white part of the eye was 65cells/uL. The skull x-ray showed is common in Africa. A different picture is (conjunctiva) excised from the same eye, a homogenous opacity in the right later- 30 al orbital region. Computed Tomography scan (CT scan) of the head showed small, numerous hypodense opacities scattered throughout the brain parenchyma, includ- ing the right orbital region; features con- sistent with cerebral, subarachnoid and right orbital cysticercosis. The patient was initiated on albendazole 400mg, orally, once a day for 3 days, praziquantel 2,600mg orally, once a day for 15 days with daily wound cleaning with povidone iodine three times a day. A week later, the patient was referred to the HIV/ AIDs specialists for further assessment, counselling and drug therapy re-assess- ment, and was recommenced on antiret- Figure 2: Right eye with melted cornea. roviral therapy (Tenofovir/Lamivudine/ Efavirenz). By the third review, the patient’s lacera- tion had healed and the discharge was no longer present. The patient however still had a melted cornea and a VA of LP in the right eye. A B-scan performed on the fourth visit indicated the absence of cysts in the posterior segment and orbit.

Figure 3: skull x-ray; Anterior-Posterior view showing homogenous opacification in the orbit-right eye.

Figure1: patient’s right eye with laceration wound, absence of lower lid lashes and chemosis.

Figure 4: CT-Scan of the head with numer- ous well circumscribed hypodense lesions in the brain.

31 DISCUSSION out in 1993 involving extrapolation of the diagnosing cysticercosis [19]. Serological Cysticercosis is a condition caused by the population at risk and adjusting for dis- tests such as Enzyme-linked immuno- tapeworm species Taenia Solium (main- ease other than seizures indicated that transfer blot (EITB) and enzyme linked ly), Taenia Saginata and Taenia Asiatica 400,000 people had symptomatic NCC in immunosorbent assay (ELISA) to detect [9]. It is commonly associated with a Lower Middle-Income Countries (LMICs) antibodies and co-agglutination were not low socio-economic status, in areas with [14]. This was deduced by estimating carried out as resources were unavailable. free-roaming pigs and low hygiene stan- mainly the active epilepsy, by subtract- Recent diagnostic advancements have dards. Despite the condition being gener- ing epilepsy rates in non-endemic regions seen the development of assays that are ally known to be caused by infected pork, from rates in endemic regions in Peru [14]. able to detect parasite antigens in serum it has been noted that cysticercosis is This information may not be applicable to and cerebral spinal fluid and can also be caused by re-infection, that is, ingestion all LMICs however, as differences do exist used to detect active infections. These as- of cysts passed out through stool. The in- in terms of individual country population says however, are best used in combina- fection obtained through direct ingestion and endemicity. Recent studies have how- tion with imaging. of infected, undercooked pork, water, fruit ever, through determination of active epi- In terms of treatment, larvicidal drugs and vegetables is referred to as taeniasis. lepsy rates from 0.6% to 1.8%, indicated such as albendazole and praziquantel are In the past, neurocysticercosis (NCC) that between 450, 000 and 1.35 million often used to kill the larvae[13]. Accord- was referred to as a neglected disease people in LMICs suffer epilepsy due to ing to WHO, there are currently no stan- together with echinococcosis but is now NCC [14, 15, 16]. The seizures are due to dard treatment guidelines for the man- recognised as a major neglected tropi- calcified granulomas which may develop agement of NCC. Proposals have however cal disease in the world[10]. This can be sporadic episodes of oedema, and in lat- been made. It has been noted, that the ef- attributed to the increase in cases being er stages, cause inflammatory responses ficacy of albendazole and praziquantel is diagnosed in tropical regions but without [17]. sub-optimal, with cure rates of 40 to 50% sufficient and accurate data on prevalence Orbital cysticercosis occurs in approxi- when the recommended dose is used [2]. rates and the full extent of the infection mately 4% of individuals with ocular cys- Therefore, there is need for more effec- [11]. Perhaps the absence of sensitization ticercosis. Despite occurring in the vitre- tive alternatives. The patient received al- and lack of knowledge within communi- ous, subretinal space and subconjunctiva, bendazole (400mg, once a day for three ties on the existence of the disease can the orbit is occasionally the site for cyst days) and praziquantel (2,600mg once also be considered as a contributing fac- lodgement [18]. a day for 15 days). Orbital cysts can be tor to why some cases are missed. With Ocular manifestations of NCC usual- treated conservatively with a 4-week reg- the prevalence of HIV/AIDs, cysticercosis ly worsen as the larvae increase in size imen of oral albendazole at 15 mg per kilo- is now a frequent opportunistic infection, and may lead to blindness in 3 to 5 years. gram per day [20]. responsible for focal brain lesions in pa- The parasites release toxins which cause The larvicidal drugs may cause an inflam- tients with HIV [12]. severe inflammatory reaction and even- matory response, occurring 2-5days after The patient presented with symptoms at tually lead to destruction of the ocular initiation of therapy and are therefore of- the age of 47. However, most literature structures [19]. This was noted in our ten combined with a corticosteroid to pre- states that individuals often present in the patient, who presented with a wound on vent this from occurring [21]. Rational use first and second decade of life. In a study the lower eyelid as well as corneal melt- of corticosteroids has also been linked to carried out in India to determine the clin- ing that is corneal ulceration and stromal a significant reduction in the occurrence ical manifestations, diagnosis, manage- dissolution. The presence of a profuse of seizures, though studies are still un- ment and outcome of orbital cysticerco- purulent discharge clinically indicated su- derway [22]. The patient however, did sis, the median age at presentation was perimposed bacterial infection although not receive any steroids in view of the low found to be 13 years [13]. pus swab examination did not identify CD4 count (64 cells/mm3), as a way of NCC commonly affects the brain paren- any growths on the media. The presence preventing further immunosuppression. chyma but can also be found in the ventri- of the discharge can also be attributed to In a study carried out in Latin America in cles, meninges, spinal cord, eye and sub- immunosuppression as a result of HIV/ 2006, in which 3 HIV positive individuals arachnoid spaces. Occurrence of these AIDs co-infection which pre-disposed the were treated for NCC, it was recommend- cysts in other sites has been associated patient to other infections. ed that the CD4 count be considered in with racemose cysts, which predispose Investigations carried out included imag- the diagnosis and treatment of NCC in to an even more complicated disease pro- ing studies such as computed tomography individuals with HIV/AIDs. It was further cess [4]. (CT), skull x-ray and ultrasonography (oc- recommended that a CD4 count of great- In the case of our patient, the cysts oc- ular B-Scan). The patient’s CT confirmed er than 200, with a definite or probable curred in the brain parenchyma and the the presence of cysts in the brain paren- chance of NCC occurring, should warrant orbit. The main symptom was presence of chyma as well as the right orbit-a feature the patient being considered for treat- a painful discharging wound on the right pathognomic with NCC. No cysts were ment of NCC [2]. lower eyelid, associated with poor vision. noted in the anterior segment, and the Surgical removal of orbital cysts has not Studies have however shown that most B-scan did not pick any cysts in the pos- been well documented but has been not- patients with NCC present with seizures terior segment. Imaging studies such as ed to be very successful for subconjunc- and NCC is considered to be the most high-resolution sonography, CT and mag- tival cysts. It is recommended that serial common cause of adult-onset epilepsy netic resonance (MRI) have been noted B-Scan, CT and MRI be carried out in or- in the United States [11]. A study carried to be most beneficial for identifying and der to monitor the resolution of the cysts. 32 Use of ventricular endoscopy to remove accessible ventricular cysts also results in reduced seizures and decreased morbidi- ty [17]. Despite the treatment interventions insti- tuted as well as the significant clinical im- provement noted on consequent review appointments, the patient’s vision re- mained perception of light in the right eye due to the already existing melted cornea

CONCLUSION This case highlights the possibility of the occurrence of orbital cysticercosis in the Zambian population. It can present in an unusual form, with a wound on the low- er eyelid as well as a melted cornea. The history could be for a longer duration like in this case, with a history of having had a conjunctival growth of one year prior to the presentation. Signs, symptoms and presentation of orbital cysticercosis are often non-specific and therefore require the clinician to have a high index of sus- picion, backed by thorough assessment in order to be able to diagnose it.

33 LIST OF REFERENCES 1. Garcia H.H. Gonzalez A.E. Evans C.A. Et al. (2003). Taenia Solium Cysticercosis. Laancet 2003 Aug 16;362 (983):547-56. 2. Sashank P. MacGregor R. Tebas B. (2006). Management of Potential Neurocysticercosis in Patients with HIV infection. Clinical Infectious Diseases 2006; 42:e30–4. 3. Schenone H.R. Ramirez A. Rojaz F. et al. (1982). Epidemiology of human cysticercosis in Latin America. Academic Press. New York. pp 25-38. 4. Estrada S.S et al. (2013). Neurocysticercosis. Hallazgos radiologicos. Radiologia. 2013;55:13-41. 5. Janeira L.F. (1988). Cerebral Cysticercosis. Postgraduate Medicine. 84:5, 71-76. DOI:101080/00325481.1988.11700435. 6. Assana E. Lightowlers W. Marshall et al. (2012). Taenia solium taeniosis/cysticercosis in Africa: Risk factors, epidemiolo gy and prospects for control using vaccination. Veterinary parasitology. 195. 10.1016/j.vetpar.2012.12.022. 7. Michel P. Callies P. Genin .C. Et al. (1992). Cysticercosis in Madagascar: diagnostic and therapeutic improvement. Da kar-Medical (Dakar) 37;191-197. 8. Mwape K.E. Blocher J. Wiefek J. Et al. (2015). Prevalence of Neurocysticercosis in People with Epilepsy in the Eastern Prov ince of Zambia. 9. Lesh E.J. Brady M.F. (2019). Tapeworm (Taenia Solium, Taenia Saginata, Diphyllobathrium, Cysticercosis, Neurocysticerco sis. StatPearls. Treasure Island (FL). StatPearls Publishing; 2019 Jan-. 10. Savioli L.S. Daumerie .D. (2010) First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases. Geneva: World Health Organisation 2010.1 2010.1. pp. 1–169. 11. Hotez P.J. Bottazzi M.E. Franco-Paredes C. Et al. (2008). The neglected tropical diseases of Latin America and the Carib bean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis 2: e300. doi:10.1371/journal.pntd.0000300. 12. Foyaca-Sibat. H. Ibañez-Valdés. (2003). - Intraventricular neurocysticercosis in HIV positive patients. Internet J. Neurol., 2(1)2003. 13. Rath S. Honaver S.G. Naik M. et al. (2009). Orbital Cysticercosis: Clinical Manifestations, Diagnosis, Management and Outcome. American Academy of Opthalmology Journal.https://doi.org/10.1016/j.ophtha.2009.07.030. 14. Bern C. Garcia H.H. Evans C. Et al. (1999). Magnitude of the disease burden from neurocysticercosis in a developing coun try. Clin Infect Dis 29:12031209. 15. Montano S.M, Villaran M.V. Ylquimiche L. Et al. (2005) Neurocysticercosis: association between seizures, serology, and brain CT in rural Peru. Neurology 65: 229–233. 16. Flisser A. Gyorkos T.W. (2007). Contribution of immunodiagnostic tests to epidemiological/intervention studies of cystic ercosis/taeniosis in Mexico. Parasite Immunol29: 637–649. 17. Nash T.E. Mahanty S. Garcia H.H (2013). Neurocysticercosis—More Than a Neglected Disease. PLoS. Negl Trop Dis 7(4): e1964. doi:10.1371/journal.pntd.0001964. 18. Bartholowmew R.S. Subretinal cysticercosis. Am J Ophthalmol. 1975;79:670‑3 19. Das S. Anterior orbital cysticercosis: A case presentation. Kerala J Ophthalmol 2017;29:2303. 20. Mahanty S. Paredes A. Marzal M. Et al. (2011) Sensitive in vitro system to assess morphological and biochemical effects of praziquantel and albendazole on Taenia solium cysts. Antimicrob Agents Chemother 55: 211–217. 21. Puri P. Grover A.K. (1998). Medical management of orbital myocysticercosis: A pilot study. Eye (Lond) 1998;12(Pt 5):795‑9. 22. Handali S. Klarman M. Gaspard A.N. Et al. (2010) Multiantigen print immunoassay for comparison of diagnostic antigens for Taenia solium cysticercosis and taeniasis. ClinVaccine Immunol 17: 68–72.9

34 PHACES SYNDROME

Case Report By : *W Mukupa1, M Nyaywa2, F Misa1 , K I M Muma3,4 1Department of Ophthalmology, Ndola Teaching Hospital, Ndola, Zambia. 2Arthur Davison Children’s Hospital, Ndola, Zambia. 3Ministry of Health, Lusaka, Zambia 4University Teaching Hospitals – Eye Hospital, Lusaka, Zambia *EMAIL ADDRESS: Wycliff Mukupa: [email protected]

Citation Style For This Article: Mukupa DW, Nyaywa M, Misa F, Muma K I M. Sphaces Syndrome. Health Press Zambia Bull. 2019; 3(12); pp 35-39.

ABSTRACT left side of the face and lower lip which in- A 1year 8 months old baby girl presented creased in size progressively. The patient to Arthur Davidson Children’s Hospital being a child, consent to have the case with a 4 month history of segmental hae- report published was obtained from the mangioma affecting the Left upper which mother. caused mechanical ptosis obstructing On examination, patient had a stable gen- the visual axis, with supraumbilical ra- eral condition, Visual acuity (VA) in both phe, sternal cleft defect and ventricular eyes was central, steady and maintained, septal defect. The clinical features were that is, the patient was able to fix and fol- consistent with PHACES syndrome. Three low moving targets. The intraocular pres- monthly doses of intralesional meth- sure was 11 mmHg and 12 mmHg in the yl-prednisolone were administered with right and left eyes respectively. The right complete regression of the haemangioma. eye had normal anterior and posterior segments. Left eye had a lesion, measur- INTRODUCTION ing about 6 by 4 cm, on the upper eyelid Infantile haemangioma (IH) is the most which was blanching with pressure. There common tumour in infancy. They oc- was mechanical ptosis on the affected eye cur in up to 2.6% of neonates and up to and smaller other lesions were noted on 12% of children by the first year [1,2,3]. lower lips also (figs 1 and 2). Systemic ex- A subgroup of patients with IH exhibit amination revealed a sternal cleft defor- Fig 1: Showing the child with a swollen left associated structural anomalies of the mity with a holosystolic murmur, and su- eye upper eyelid brain, cerebral vasculature, eyes, aorta, praumbilical raphe. Chest x-ray revealed and chest wall in the neurocutaneous dis- an enlarged cardiac shadow and a small order called PHACES syndrome. IH typi- ventricular septal defect (VSD) was noted cally present in 2 phases; a phase of rapid on echocardiogram. The ECG and abdom- proliferation which occur in the first year inal u/s were normal. The parameters on of life, followed by a slow gradual involu- Full blood count were within normal lim- tion over the next 5 to 7 or more years. IH its. Unfortunately, MRI or CT scan of the remain asymptomatic and can, therefore, brain and orbit were not done because the be managed by close observation. Indica- patient’s care-givers could not afford to tions for immediate management include; do the investigations due to the cost in- IH that might cause significant complica- volved. tions such as amblyopia, airway obstruc- A diagnosis of PHACES syndrome was tion, bleeding and ulceration, high output made based on above findings and cardiac failure [1]. multi-disciplinary approach was em- ployed in the management of the patient. CASE SCENARIO The teams involved were Ophthalmolo- A 1 year 8 months old girl with congeni- gy, Paediatric Surgery, General Paediat- Fig 2: Showing lesions on the lower lip tal sternal defect was referred from Roan rics, and Cardiology. Monthly doses of General Hospital to Arthur Davidson intralesional methylprednisolone were DISCUSSION Children’s’ Hospital for further manage- administered for 3 months. The outcome PHACES syndrome is a group of disorders ment. The patient was born at term via was complete resolution of the lesions as characterized by posterior fossa abnor- spontaneous vaginal delivery at the uni- shown in fig 3. malities, haemangioma, arterial lesions, versity Teaching Hospitals Women and cardiac abnormalities/coarctation of the New-born Hospital with no perinatal aorta [1,2,3]. complications. She presented with a 4/12 history of swelling on left upper eyelid, 35 distribution which partially corresponds disk anomaly, retinal vascular anomalies, to developmental facial prominences. Fa- optic nerve hypoplasia and atrophy, while cial haemangioma patterns have been de- anterior segment abnormalities include scribed into four segments: frontotempo- cataract, , conjunctival ral (S1), maxillary (S2), mandibular (S3) haemangioma, posterior embryotoxon, and frontonasal (S4) segments. The ma- Mittendorf dots, corneal opacity, sclero- jority of PHACE patients have haemangi- cornea, iris , iris heterochromia, oma involving the S1 segment regardless iris hypoplasia, and iris vessel hypertro- of other segment involvement. The facial phy. There can also be presence of mis- segmental involvement is also associat- cellaneous ocular abnormalities such as ed with clinical manifestation. Haeman- congenital glaucoma, , giomas located in the S1 & S4 segments proptosis, Horner syndrome, congenital are associated with structural brain, cere- 3rd or 4th nerve palsies, strabismus, and brovascular and ocular anomalies, while ptosis [10]. those located in the S3 segment are asso- Sternal defects and supraumbilical raphe ciated with sternal defects or supraumbil- were encountered in 43 patients with The first description of PHACE syndrome ical raphes. About 22% of patients pres- PHACES syndrome. Matry et al. report- with brain abnormalities was reported in ent with extracutaneous haemangioma ed three patients with subtle sternal pits 1978 by Pascual-Castoviejo [4] in 1996 with the most affected ones having only without underlying soft-tissue or bony while acronym PHACE was created by one extracutaneous manifestation to fulfil loss in a series of 14 patients with PHAC- Frieden et al in 1996; this gave the details a diagnosis of PHACE syndrome; the most ES syndrome. Our patient presented with of the most representative features of the common ones being CNS anomalies [1,7]. both sternal defect and supraumbilical syndrome [1]. The acronym has been ex- The first description of the association of defect [1]. panded to PHACES which includes supra- PHACE syndrome with brain abnormali- Observation remains the mainstay of umbilical raphe and sternal clefting ) [5]. ties was reported in 1978 by Pascual-Cas- treatment of capillary haemangiomas In 2009, a consensus to define the diag- troviejo. He reported that between 43% since most lesions regress on their own. nostic criteria for PHACES syndrome was and 90% of patients with PHACES have However, intervention is indicated in the arrived at. These criteria were divided into a CNS structural malformation.[8] Mal- following circumstances; occlusion of 2 categories that is PHACES syndrome or formations typically involve the posteri- the visual axis, optic nerve compression, possible PHACES syndrome. Major and or fossa, presenting as a Dandy-Walker severe proptosis, anisometropia, mac- minor criteria were determined for the complex, isolated cerebellar hemispher- eration and erosion of the epidermis, in- following organ systems: cardiovascular, ic hypoplasia, or a combination of the 2. fection, and cosmetic disfigurement [11]. cerebrovascular, ocular, structural brain, Dandy–Walker malformation is the most Obstruction of the visual axis in our case ocular, and ventral/midline.The diagnosis common associated developmental ab- was the reason why we had to intervene in of PHACES Syndrome requires the pres- normality [1,7]. order to prevent amblyopia. The manage- ence of a characteristic segmental hae- Vascular anomalies are the most frequent ment option can either be surgical ormed- mangioma greater than 5cm on the face malformation associated with cutaneous ical depending on the size and location of or scalp plus 1 major criterion or 2 minor haemangioma–vascular complex syn- the lesion. Medical management options criteria while possible PHACE requires drome. Absence of the internal carotid include; Steroids- topical, intralesional or the presence of a characteristic segmen- and/or vertebral arteries and persistence systemic, interferon alfa-2a therapy, Vin- tal haemangioma greater than 5cm on the of the trigeminal artery are the most com- cristine, Propranolol therapy or timolol scalp or face plus 1 minor criterion [6]. mon malformations [8]. Cardiac anom- therapy. Our patient responded well after Our patient presented with a haemangi- alies include; patent ductus arteriosus, administration of 3 doses of intralesional oma affecting the left upper eyelid about ventricular septal defects, arterial septal methyl-prednisolone [1,11]. 6x 4 cm in size, sternal cleft deformity, defects, pulmonary stenosis, tricuspid umbilical raphe and as small ventricular aortic valve, arterial enlargement, ven- CONCLUSION septal defect. Sternal cleft deformity and tricular hypertrophy, tetralogy of Fallot, Intralesional injection of corticosteroids umbilical raphe represented the major and patent foramen ovale. The case we has proven to be effective in the manage- criteria while ventricular septal defect the presented had a Ventricular septal defect ment of cutaneous infantile haemangio- minor criteria. Therefore, the presence which was confirmed by echocardiogram mas. In this case we highlighted the suc- of above features in our patient satisfied [1]. cessful management of a 1 year 8 months the criteria for diagnosis of PHACES syn- old girl who presented with a haemangi- drome. Approximately one-third of the PHACE(S) oma affecting the left eyelid and causing Haemangiomas in PHACES syndrome syndrome cases have eye involvements mechanical ptosis and had other features are more common in female with a fe- [6]. In a recent study on 23 cases of of PHACES syndrome. The haemangioma male: male ratio of 9:1 ratio for the latter PHACE(S) syndrome, 14% of the cas- was successfully treated with intralesion- [1]. They are typically bulky, plaque-like es showed ocular involvement [9]. The al steroid injections lesions involving several cervicofacial reported ocular manifestations of this segments, but without being confined by syndrome could be posterior segment ab- their boundaries. They have a segmental normalities which include morning glory 37 LIST OF REFERENCES 1. Sami N. Alsuwaidan. PHACES syndrome in association with airway haemangioma: First report from Saudi Arabia and literature review. Ann Thorac Med. 2012 Jan-Mar; 7(1): 44–47 2. Pornpun Sripornsawan, Thirachit C, Supika K. Successful Treatment of PHACE Syndrome with Oral Propranolol. 3. Reese V, et al. Association of facial haemangiomas with Dandy-Walkerand other posterior fossa malformations. J Pediatr. 1993. [PubMed] 4. Anita Rotter, Luciana Paula Samorano, Maria CecíliaRivitti-Machado, Zilda Najjar Prado Oliveira, Bernardo Gontijo. PHACE syndrome: clinical manifestations, diagnostic criteria, and management5 5. Nayak L, Nayak B, Sinha G, Khokhar. PHACE syndrome with lip haemangioma, microphthalmos and persistent fetal vascu lature. BMJ case Rep March 31 2016[PubMed] 6. Metry DW, Heyer G, Hess C, Garzon M, Haggstrom A, Frommelt P, et al. Consensus statement on diagnostic criteria for PHACE syndrome. Pediatrics 2009; 124:1447-56 7. V.S. Oza, E. Wang, A. Berenstein, M. Waner, D. Lefton, J. Wells and F. Blei. PHACES Association: A Neuroradiologic Review of 17 Patients. American Journal of Neuroradiology April 2008, 29 (4) 807-813 8. Pascual-Castroviejo I. Vascular and nonvascular intracranial malformations associated with external capillary haemangio mas. Neuroradiology. 1978;16:82–4. [PubMed] [Google Scholar] 9. Melnick L.E., Yan A.C., Licht D.J., Treat J.R., Castelo-Soccio L. PHACE syndrome: a retrospective review of 23 patients. Pediatr Dermatol. 2014;31:390-392. [PMC free article] [PubMed] [Google Scholar] 10. Assari R, et al. PHACE(S) syndrome: Report of a case with new ocular and systemic manifestations. J Curr Ophthalmol. 2016 Dec 27; 29(2): 136-138 11. Youssef JS. Quaraishi, HA, Cervicofacial haemangioma and its association with PHACE syndrome, Otolaryngol Head Neck Surg. 2003; 128:758-60. [PubMed]

39 PROLIFERATIVE DIABETIC RETINOPATHY IN A 16-YEAR-OLD

Case Report By : *JIM Nyalazi1,2 D Kasongole2, KIM Muma 1,2 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2University Teaching Hospital – Eye Hospital, Lusaka, Zambia

*EMAIL ADDRESS: Nyalazi I.M. Jessie: [email protected]

Citation Style For This Article: Nyalazi JIM , Kasongole D, Muma KIM. Proliferative Diabetic Retinopathy in a 16-year-old. Health Press Zambia Bull. 2019; 3(12); pp 40-44.

ABSTRACT years [1]. The risk of developing DR is not improve with the pinhole. Her weight Diabetic retinopathy (DR) is a common greater in patients who are diagnosed was 43.3 kgs, height – 1.6 m, which gave a blinding ocular complication of diabetes during or after puberty [5] and studies Body Mass Index (BMI) of 16.9 kg/m2. The mellitus (DM). Its manifestation depends demonstrate a higher incidence of DR in Blood Pressure (BP) was 120/70 mmHg. on a patient’s glycaemic control, duration late puberty than early puberty despite Retina examination in both eyes had dot of DM and the type of DM. It mostly af- similar durations of disease [6]. Some blot and flame shaped haemorrhages, fects patients with type 2 DM. Children adolescents lose vision due to macular cotton wool spots, hard exudates and new are almost never affected by DR. edema or, more commonly, PDR. Further- vessels elsewhere (NVEs). The Fasting The University Teaching Hospitals - Eye more, a number of adolescent patients Blood Sugar (FBS) was 16.3 mmol/l and Hospital (UTH-EH) had an unusual pre- rapidly develop progressive DR that leads renal function tests were all within normal sentation of Proliferative Diabetic Reti- to irreversible blindness unless it is de- range. Fundus Fluorescein Angiography nopathy (PDR) in a female patient aged 16 tected early and treated aggressively [7, (FFA) findings showed multiple areas of with Type 1 Diabetes Mellitus (T1D). The 8]. Therefore, early detection of DR and increasing fluorescence suggesting leak- patient was referred from Lewanika Gen- other blinding conditions through screen- age and confirming NVEs, (Figs 1 and 2). eral Hospital where Diabetic Retinopathy ing programmes is critical for preserving (DR) was elicited. The patient complained vision in patients with diabetes [7.8]. The patient underwent PRP I and PRP II of poor vision in both eyes for 2 months. in both eyes. The two were performed a On examination visual acuity (VA) was Treatment for PDR is by Pan Retinal Pho- week apart for each eye, (Figs 3 - 6). A 6/12 right eye (RE) and 6/18 left eye (LE). tocoagulation (PRP). However, having week after PRP II her vision improved to Funduscopy revealed neovascularisation been treated with PRP still renders patient 6/9 in both eyes. Subsequent review at elsewhere (NVE’s) in both eyes. A diag- at increased risk of reverting to new prolif- 3 months showed that her vision was re- nosis of PDR was made, and the patient erative disease, without the development stored to 6/6 in both eyes. The patient was managed with Pan-retinal photoco- of all the classical features of pre-prolif- was put-on long-term DR follow up plan. agulation (PRP). erative disease if DM is poorly controlled . [9]. Considering the fact that the patient was below 18 years, her mother consented to INTRODUCTION CASE SCENARIO the publication of the case including the Diabetes mellitus is the third most com- A 16-year-old female from Western Prov- pictures. mon chronic disease among children [1]. ince of Zambia presented to the UTH-EH The incidence and prevalence of T1D with complaints of poor distance vision in varies among different populations and both eyes for two months. She presented appears to be based upon several factors to Lewanika General Hospital (LGH) in including racial composition, age distribu- comatose state where she was diagnosed tion and geographic location. The Centers with Diabetic Ketoacidosis and a diagno- for Disease Control report that approx- sis of Type 1 DM was made. Treatment imately 1 in 400 American children has with insulin was initiated. When the pa- diabetes [2] and Lueder estimated that 1 tient’s condition was brought under con- of every 500 has T1D [3]. The rising prev- trol and became stable, she complained of alence of childhood type 1 and type 2 DM poor vision in both eyes following which possess a huge risk of visual impairment she was attended to at LGH Eye Unit and blindness due to DR which is an im- where she was subsequently referred to portant complication of DM [4]. the UTH-EH for DR management.

Diabetic retinopathy has been well de- On examination at UTH-EH, she appeared scribed in children. The majority of affect- appropriate for age and of good nutrition- ed patients do not develop vision-threat- al status. Visual Acuity (VA) was 6/12 RE ening retinopathy until after the teenage and 6/18 LE. The VA in both eyes could 40 41 42 DISCUSSION A number of adolescent patients devel- The American Academy of Ophthalmol- Diabetic retinopathy in children has been op rapidly progressive DR that leads to ogy (AAO) preferred practice pattern well described in the developed world irreversible blindness unless it is detected recommends the first examination “3-5 where as in the developing countries it early and treated aggressively [7, 8]. years after diagnosis” with yearly fol- is yet to be described properly. Initially Timely treatment with laser photo- low-up examinations [13]. The American the thinking was that DR could not occur coagulation can prevent visual loss in Diabetes Association (ADA) position in children, but it evidently occurs as vision-threatening retinopathy [11]. For- statement recommends the first eye demonstrated by Forlenza and Stewart, tunately, this PDR case was diagnosed at exam “within 3-5 years after diagnosis of 2013. Just as established by Forlenza and the right time and managed aggressively diabetes once the patient is age 10 years Stewart, this report confirms a DR case with LASER with good visual outcome. or older” with yearly follow-up examina- in a 16-year-old. It has been reported Treatment of affected adolescents is tions [14]. The newly published Canadian that the majority of affected patients do generally the same as for adults – focal or Ophthalmological Society (COS) guide- not develop vision threatening retinop- grid laser photocoagulation for macular lines recommend that screening for DR athy until after the teenage years. Some edema and pan-retinal photocoagulation should be initiated “5 years following adolescents lose vision due to macular (PRP) for PDR. Intravitreal injections of the diagnosis of diabetes” or at puberty edema or, more commonly PDR. In this anti-VEGF drugs have recently become with yearly follow-up examinations [15]. case report the patient was an adoles- the standard-of-care for adults, but In the Zambian situation the guidelines cent and a teenager with a huge risk neither anti-VEGF drugs nor intraocular are that every diabetic child who is ten of developing PDR which was the final corticosteroids have been used to treat years and above is subjected to annual diagnosis in the patient. From history this DR in children due to concerns regarding DR screening. However, the process of had developed rapidly and as reported ocular and systemic side effects [1]. In developing protocols is still under way. by other researchers such as Soffer et al. line with the treatment recommenda- (2003) and Maguire et al. (2006) [7, 8] tions for PDR in children, this case was CONCLUSION treated with PRP on time, adequately and This case report demonstrates that Treatable DR is extremely rare among successfully. diabetic retinopathy can occur in children paediatric Type 1 DM [10]. On the Following the increasing number of with diabetes mellitus regardless of the contrary, this case had vision threat- children with DR, a number of organisa- type of diabetes. Timely management ening DR within 2 months of diagnosis tions and institutions have come up with with LASER can help in maintaining or with T1D and her condition needed DR recommendations on follow up of DM restoring vision and preventing blindness. treatment. Moreover, DR can become patients for DR screening. The American Therefore, early detection of DR and oth- quite advanced before children recog- Academy of Pediatrics (AAP) recom- er blinding conditions through screening nize and report changes in vision, thus mends ophthalmologic examinations programs is critical for preserving vision further emphasizing the need for regular starting “3 to 5 years after diagnosis if in patients with diabetes screening programs [1]. The case under the patient is 9 years of age and above” discussion reported poor vision four days with annual follow-up examinations [12]. upon recovery from the comatose state during which she was first diagnosed of having T1D.

43 LIST OF REFERENCES 1. Forlenza G and Stewart MW, Diabetic Retinopathy in Children, 2013, Pediatric Endocrinology Reviews (PER) ● Volume 10 ⦁ No 2 ● January; P217-227 2. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services 3. Lueder GT, Silverstein J. Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus. Pediatrics 2005;116:270-273 4. Dabelea D, Mayer-Davis EJ, Saydah S, et al. SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009.2014;311:1778–86. 5. Kunin M, Tossavainen P, Hannula V, Lahti S, Hautala N, Falck A. (2011) Prevalence of retinopathy in Finnish children and adolescents with type 1 diabetes: a cross-sectional population-based retrospective study. Arch Dis Child 6. Kernell A, Dedorsson I, Johansson B, Wickstrom CP, Ludvingsson J, Tuvemo T, Neiderud J, Sjostrom K, Malmgren K, Kanulf P, Mellvig L, Gjotterberg M, Sule J, Persson LA, Larsson LI, Aman J, Dahlquist G. (1997) Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study. Diabetologia;40:307-310 7. Soffer B, Zhang Z, Miller K, Vogt BA, Shahinfar S. A double-blind, placebo-controlled, dose-response study of the effec tiveness and safety of lisinopril for children with hypertension. Am J Hypertension 2003;16(10):795-800 8. Maguire A, Cusumano JM, Craig ME, Donaghue KC. The case for biennial retinopathy screening in children and adoles cents: response to Stefansson. Diabetes Care 2006;29:178-179 9. Diabetic Retinopathy Screening training Module 5 Part 1 - Grading DR (2016) 10. Treatable Diabetic Retinopathy Is Extremely Rare Among Pediatric T1D Exchange Clinic Registry Participants Diabetes Care 2016;39:e218–e219 | DOI: 10.2337/dc16-1691 11. Early Treatment of Diabetic Retinopathy Study Research Group. Photocoagulation therapy for diabetic . JAMA. 1985;254:3086 12. American Academy of Pediatrics, (1998) Section on Endocrinology and Section on Ophthalmology. Screening for retinop `athy in the pediatric patient with type 1 diabetes mellitus. Pediatrics. 13. American Academy of Ophthalmology Retina Panel (2008), Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology 14. American Diabetes Association, (2002) Diabetic Retinopathy. Diabetes Care 15. Canadian Ophthalmological Society (2012), Diabetic Retinopathy Clinical Practice Guideline Expert Committee. Canadian Ophthalmological Society Evidence-Based Clinical Practice Guidelines for the Management of Diabetic Retinopathy. Can J Ophthalmol

44 REGRESSION OF OCULAR HODGKIN’S LYMPHOMA IN A 13-YEAR-OLD

Case Report By : *C Kalukali 1,2, K I M Muma 1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2Chongwe District Hospital, Chongwe, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia *EMAIL ADDRESS: Cecilia Kalukali: [email protected]

Citation Style For This Article: Kalukali C , Muma K I M. Regression of Ocular Hodgkin’s Lymphoma in a 13-year-old. Health Press Zambia Bull. 2019; 3(12); pp 45-46.

ABSTRACT lymphomas, approximately 15% of lym- HL was made and ocular treatment was An increasing number of cases of ocular phomas are classified as HL; the remain- initiated, and the child was referred to the non-Hodgkin’s lymphoma (HL) is being der are classified as Non-HL [9]. This rec- paediatric hospital where the excisional reported. While ocular involvement in ognizes >40 mature B cell neoplasms and biopsy of the inguinal lymph nodes was Hodgkin’s lymphoma is rare, it is a fre- <25 mature T and NH (natural killer) cell done. The histology results confirmed the quent affection in non-Hodgkin’s lympho- neoplasms [9]. HL diagnosis and the patient was com- mas (NHL). A 13-year-old boy presented This case report is about a 13- year-old menced on appropriate management. The to Chongwe District Hospital (CDH) with patient who presented with complaints child was followed up for a period of one pan uveitis. The patient presented with of low vision, watering eyes and photo- year and the HL resolved including the blurred vision in his Left Eye (LE), skin phobia. The patient had other systemic uveitis. Currently the child is on perma- rash and dry cough over a period of three infections in which after medical testing nent follow up with the children’s hospi- months. He had not sought any medi- was diagnosed with HL. This case report tal and the eye unit at CDH. Considering cal attention prior to his visit to eye unit. also examines the relationship between that the patient is under the age of 18, the Slit lamp examination revealed bilateral ocular findings and HL within the context mother consented for publication. non-granulomatous keratic precipitates of literature, and to raise awareness of this and flare. Physical examination revealed condition. DISCUSSION cervical and inguinal lymph nodes. His HL is usually seen in individuals aged laboratory work up including rheumatoid CASE SCENARIO 15-34 years and those over 55 years old factor and serum protein electrophore- A 13- year-old male patient presented [1]. The child reported in this case was 13 sis tests were all normal. A diagnosis of with skin rash, dry cough, and reduced years old demonstrating that HL can still pan uveitis was made and the patient was vision in his left eye for 3 months. There occur in children younger than 15 years. treated with topical and systemic steroids was history of the child being sickly of The incidence of pediatric HL tends to over a period of six months without im- more than 3 months, weight loss, no night rise as family size increases and socioeco- provement. The patient was counselled sweats and could not attend school due nomic status decreases; the opposite has and referred to a pediatrics hospital where to illness. This was the first presentation been reported with the adult form, which an excisional biopsy for inguinal lymph to the hospital and was not on any treat- is associated with high socioeconomic nodes confirmed Hodgkin’s lymphoma. ment. status in industrialized nations [10]. The Appropriate systemic treatment was giv- On general examination the child was ill child discussed in this report was the sixth en for Hodgkin’s lymphoma. looking, febrile, pale, slightly jaundiced, born and came from a poor socioeco- not cyanosed, had no finger clubbing and nomic status justifying the incidence oc- INTRODUCTION was not breathless. Head and neck exam- currence. Although HL is more prevalent Hodgkin’s lymphoma (HL) is a disease ination showed a buffalo face appearance. among males in all age groups, the nod- originating from lymphoid tissue and ac- Systemic examination revealed multiple ular sclerosis subtype is more common counts for less than 1% of all cancers [1]. cervical and inguinal lymphadenopathy among females [10]. This is consistent As lymph nodes are distributed through- bilaterally. On ocular examination, visual with what has been reported as the victim out the body, lymphomas may manifest acuity was 6/6 Right Eye (RE), 6/36 Left is male child. Unlike most other cancers, with involvement of various body parts Eye (LE), bilateral non-granulomatous HL can be cured through a combination of [2]. This can cause difficulties in diagno- keratic precipitates (KPs) and grade two medical management. Towler et al., 1999, sis as well as delayed treatment. Ocular flare. The KPs were more pronounced in reported achieving complete remission of involvement is more prevalent in non-HL the LE. Fundus examination was normal ocular inflammation with chemotherapy compared to HL [3]. A number of case re- in the RE, while macula edema and vitritis [8, 11] just as the child in this case was ports of ocular HL following the diagnosis were observed in the LE, though there was treated successfully. of systemic HL have been documented [4, no vitreous turbidity. His laboratory in- Ocular involvement in HL occurs by var- 5, 6]. Though rare, HL can initially present vestigations, which included rheumatoid ious mechanisms including direct lym- with ocular manifestations [7, 8]. Accord- factor, serum protein electrophoresis and phomatous or metastatic involvement of ing to 2016 revision of the World Health other tests were all normal. A diagnosis the choroid and the retina; paraneoplastic Organization (WHO) classification of of chronic posterior uveitis secondary to vasculitis; and iatrogenic complications 45 arising from HL treatment or immunosup- CONCLUSION pression [5-7, 12]. In this case, the child This case demonstrates the occurrence was not immunosuppressed and could of ocular Hodgkin’s Lymphoma despite it have been metastatic. These patients may being rare. It also highlights the fact that exhibit infiltration of the ocular structures, ocular Hodgkin’s Lymphoma can occur retinal periphlebitis, focal chorioretinitis, in younger age. Hodgkin’s Lymphoma is vitritis, papillary edema, exudative retinal treated with successful remission. detachment, soft exudates, retinal hem- orrhages, necrotizing retinitis, peripheral retinal exudates, and retinal white spots [3, 13]. The child under discussion exhib- ited with vitritis and macular edema just as described above. LIST OF REFERENCES 1. Knowles MD. Neoplastic hematopathology (2nd edition) New York 2. Young GA. Lymphoma at uncommon sites. Hematol oncol. 1999; 17:53-83. [PubMed] 3. Simsek HC, Akkoyun I, Yilmaz G Hematolojik Hastaliklarda Goz Bulgulari Retina-Vitreus. 2014; 22:85-92. 4. Mosteller MW, Margo CE, Hesse RJ. Hodgkin’s disease and granulomatous uveitis. Ann ophthalmol. 1985;17:787-790. [PubMed] 5. Primbs GB, Monsees WE, Irvine AR, Jr intraocular Hodgkin’s disease. Arch Ophthalmol. 1961; 66:477-482. [PubMed] 6. Brihaye-van Geertruyden M. Retinal lesions in Hodgkin’s disease. AMA Arch Opthalmol.1956; 56:94-99. [PubMed] 7. Barr CC, Joondeph HC. Retinal periphlebitis as the initial clinical finding in Hodgkin’s disease. Retina. 1983; 3:253-257. [PubMed] 8. Towler H, Lightman S. Posterior uveitis in Hodgkin’s disease. Aust NZJ Ophthalmol. 1999; 27:326-330. [PubMed] 9. Quintanilla‐Martinez Leticia, the 2016 updated WHO classification of lymphoid neoplasias, First published: 07 June 2017, https://doi.org/10.1002/hon.2399 10. Thomas RK, Re D, Zander T, Wolf J, Diehl V. Epidemiology etiology of Hodgkin’s lymphoma. Ann Oncol. 2002; 13: 147-156. [PubMed] 11. Seker M, Mengi A, Bilici A, Ustaaloglu BB, Kefeli U, Ozseker NI, Mayadagli A, Salepci T, Gumus M. Hodgkin lenfoma olgu larinin retrospektif degerlendirilmesi ve prognostic faktorlerin saptanmasi turk J Oncol. 2011; 26:108-114. 12. Sacks EL, Donaldson SS, Gordon J, and Dorfman RF. Epithelioid granulomas associated with Hodgkin’s disease: clinical correlation in 55 previously untreated patients. Cancer. 1978; 41:562-567. [PubMed] 13. Mateo-Montoya A, Bonnel S, Wolff B, Heron E, Sahel JA. White dots in the eye fundus revealing Hodgkin’s lymphoma. Eye (lond). 2010; 24:934-937. [PubMed]

46 SIMULTANEOUS OCCURRENCE OF TRACHOMA TRICHIASIS, ECTROPION AND FACIAL NERVE PALSY Case Report By : *A Siame1,2 , K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2Kasama General Hospital, Chongwe, Zambia 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia *EMAIL ADDRESS: Anthony siame: [email protected]

Citation Style For This Article: Siame A , Muma K I M. Simultaneous Occurrence of Trachoma Trichiasis, Ectropion and Facial Nerve Palsy. Health Press Zambia Bull. 2019; 3(10); pp 47-48.

ABSTRACT eye and 6/36 Left eye. The eyelashes All cases of trachoma trichiasis including A 55-year-old female patient presented were rubbing on the cornea and there was ectropion should be subjected to correc- at Kasama General Hospital’s Eye Clinic dryness of the eye. The conjucntiva was tive surgery of the eyelids. If left unat- with painful eyes, excessive tearing, for- injected and patient was in pain. The face tended to, these conditions can lead to eign body sensation and blurred vision in was drawn on the left side due to facial an impaired optical function of the ocular both eyes. After examination the patient nerve palsy on the right side (Fig 1). Di- surface through chronic irritation of the was diagnosed with Trachoma Trichiasis agnoses of Bilateral trachoma trichiasis conjunctiva and the cornea [4]. The pa- (TT), ectropion, exposure keratitis and (TT), Bilateral ectropion, Facial palsy af- tient discussed in this case report had a facial nerve palsy. Patient underwent si- fecting left side and Bilateral keratitis was rare presentation of trichiasis and ectro- multaneous multiple management involv- made. pion that complicated to keratitis [5,7]. ing Tarsal Plate Rotation (TPR), ectropion Surgical correction involved Tarsal plate It was determined that early intervention correction, physiotherapy and was treat- rotation and blepharoplasty. Medical was required in order to stabilise the tear ed for keratitis successfully. management with antibiotics and physio- film and to prevent recurrent corneal abra- therapy was initiated. sions, corneal ulceration, corneal opaci- INTRODUCTION Consent for publishing this case and pa- ties and eventually vascularization as well Normally, the upper and lower eyelids tient’s pictures was obtained from the pa- as scarring of the cornea and conjunctiva close tightly, protecting the eye from tient herself. as suggested by other researchers [6]. damage and preventing tear evaporation. If the edge of one eyelid turns inward (en- tropion), the eyelashes rub against the eye, which can lead to ulcer formation and scarring of the cornea. If the edge of one eyelid turns outward (ectropion), the two eyelids cannot meet properly, and tears are not spread over the eyeball [1]. These conditions are more common among old- er people due to increased tissue relax- ation with age, eye changes caused by infection, surgery, or injury and people who have blepharospasms. Ectropion may occur in people with facial nerve palsy [2]. These eyelid pathologies are charac- terised by common presentation such as redness, tearing, irritation of the eyes and altered balance of the anterior and poste- rior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical [3].

CASE SCENARIO A female patient aged 55years came to the eye clinic from Kasama village with complaints of tearing, eyelashes rubbing onto the cornea, pain, redness and poor vision for one year. The patient reported To address these multiple eye problems, history of epilation to relieve pain. On ex- a combination of Tarsal Plate Rotation amination visual acuity was 6/12 Right DISCUSSION (TPR) and blepharoplasty was conduct- 47 ed to correct and ectropion re- This demanded good planning and team- CONCLUSION spectively. Following surgery, there was work as other disciplines were involved. This case report shows that one can have improvement of the patient’s vision and multiple occurrence of ocular conditions the pain was no longer there. The caus- Keratitis was treated with tetracycline eye with atypical presentation. Management es of ectropion include Facial nerve pal- ointment and the patient equally respond- of such a combination of ocular condi- sy and involutional. Normally, these two ed well. Unfortunately, in literature there tions requires experience, collaboration causes occur independent of each other. was no information regarding manage- and skilfulness. Strangely this patient had both situations ment of such combination of conditions. occurring simultaneously. This posed a The management purely depended on ex- challenge in the management of such a perience and extensive consultation. combination of the two conditions. How- ever, this was skilfully excuted to the sat- isfaction of the patient. LIST OF REFERENCES 1. Matthew J. B. et al,British Medical Bulletin (2007) Vol 84,issue 1 pages 99-116 London, United Kingdom 2. James Garrity, MD, Entropion and Ectropion (2019); page1, Kenilworth, NJ, USA). 3. Minerva Chirurgica, Journal of Surgery (2013); page 1, University of Turin, Italy. 4. Mwale.c. et al, Ophthalmic epidemiology, Trachoma Prevalence in 67 Districts of Zambia (2018);2-3, Lusaka-Zambia 5. Michael giese, Northwest Eye Surgeon Insight Journal (2015) 1-4, Seattle, USA. 6. Stefanyszyn, M.A., Pathology of Entropion and Ectropion, presented at the Washington Hospital Centre Silver Jubilee Oculoplastic Symposium (March 25, 1983),2-4, Washington D.C. 7. Seunghyun Lee, Helen Lew, Department of Ophthalmology, Management of Facial nerve palsy patients, 2018;3-4, Seongnam, Korea.

48 SUBCONJUCTIVAL FOREIGN BODY MISTAKEN FOR A SCLERAL TEA

Case Report By : *M Preston1,2, K I M Muma1,3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2Mazabuka General Hospital, Mazabuka, Zambia. 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia *EMAIL ADDRESS: Preston Mubita:[email protected]

Citation Style For This Article: Preston M, Muma K I M, Subconjuctival Foreign Body Mistaken for a Scleral Tea. Health Press Zambia Bull. 2019; 3(12); pp 49-51.

ABSTRACT occasional specific damage. In the third through an eye injury can lead to substan- A 35-year-old, male factory employee place, organic material tends to set up a tial long-term costs, and impact on an in- with retained subconjuctival foreign body proliferative response characterized by dividual, their family and community in form of a glass particle in the left eye the formation of granulation tissue with (LE) presented at Mazabuka General the giant cells [4,5]. CASE SCENARIO Hospital Eye Unit with chronic painful red Foreign bodies on the conjunctival sur- A 35 year-old male factory worker from eye, photophobia and epiphora for two face are best recognized with slit-lamp Mazabuka district in Southern Province of months. On examination, his visual acuity examination. Foreign bodies can lodge in Zambia presented to Mazabuka General was 6/6 for the right eye (RE) and 6/9 for the inferior cul-de-sac or can be located Hospital eye unit complaining of chron- the LE. There was mild upper eyelid swell- on the conjunctival surface under the up- ic painful red eye with sentivity to light, ing and ecchymosis. The posterior seg- per eyelid [4]. It is imperative to evert the tearing, headache and blurred vision for ment of both the right and left eyes had upper eyelid to examine the superior tar- two months. normal findings. A clinical diagnosis of sal plate and eyelid margin in all patients He constantly got permission from work the left eye ocular trauma was made with with a history that suggests a foreign body to seek medical attention for his eye con- suspected scleral tear near the limbus at [4]. If several foreign bodies are suspect- dition of which he lost many man hours 9 O’clock position. Examination under ed double eversion of the eyelid with a from work. He had received medical at- local anaesthesia revealed a foreign body Desmarres retractor or a bent paperclip tention and treatment at several public which was later removed. The sclera was is advised to allow the examiner to effec- and private health centres with no im- found to be intact. tively search the entire arc of the superior provement. The pain remained the same cul-de-sac [4]. despite receiving different types of topical INTRODUCTION Usually the materials of extra ocular for- medication and oral pain killers. He also Eye trauma refers to damage caused by eign body are coal, dust, sand, iron parti- received traditional herbs and tattoos an injury to the eye [1]. Trauma may affect cles, glass, eye lashes, wood piece, husk without any improvement at all. He even- not only the eye, but the adnexa, including of seed and wings of insect among others. tually sought for help from local private adjacent tissue and bone structure [1,2]. The Intra Ocular Foreign Body (IOFB), optician where he was prescribed plono There are many different forms of trauma, which penetrate the eye and retained are photochromic spectacles. varying in severity from minor injury like minute chips of iron or steel, stone, glass, He could not recall any history of ocular eye foreign bodies to medical and surgical lead pellets, copper, spicules of wood to infection or trauma to the eye prior to the eye emergencies [1,2]. mention but a few [1,3]. onset of this problem. He could not recall An ocular foreign body is any abnormal Occupational eye injuries represent 63% any history of work related accidents pri- substance or object that is found on the of all occupational injuries. Workers in or to the onset of the pain. However, he eye, but does not belong to the eye [2,3]. construction, manufacturing and mining reported history of working under various The incidence of ocular foreign body is are particularly at risk. Fifty two percent departments, including factory mainte- high especially in the industrial towns. It (52%) of all occupational injuries in man- nance department where he was attached can occur at any age and in both genders. ufacturing are eye injuries [4]. Most oc- a week prior to the onset of his ordeal. He It affects the eye by mechanical effects, cupational eye injuries are foreign bodies was a constant user of safety glasses at by introduction of infection or by specific (FB) in the eye (71.5%) [4] . Up to 90% work and he reported that the company reaction [1-3]. of eye injuries are preventable with ef- was strict with the policy of safety attire The reaction of the eye to a retained for- fective interventions including education, at work stations. There was no history of eign body varies with the composition of professionals can play an important role known allergies in the family. particle [4]. The ocular reaction may be in promoting and prescribing eye injury On examination, his Visual acuity was of three types in the first place, inorgan- prevention strategies to help reduce this 6/6 on the RE and 6/9 on the LE. He had ic substances cause no specific reaction avoidable cause of vision loss. [4] photophobia and tearing in the LE with except for mechanical irritation and an Vision is intimately linked with one’s abil- subconjuctival haemorrhage. Slit lamp exudative and fibroblastic isolation of the ity to navigate the environment and can examination did not reveal any apparent foreign body [4,5]. Secondly, a chemical strongly affect our mental, physical and corneal or conjuctival foreign body or reaction may produce a nonspecific or economic well-being. Losing one’s vision lacerations and fluorescein staining was 49 negative. There was mild upper eyelid symptoms. He did not give any account of CONCLUSION swelling and ecchymosis. The posterior trauma prior to the onset of his ordeal. He This case report highlights the impor- segment of the LE had normal findings. recalls strict adherence to safety goggles tance of thorough ocular examination The RE was quiet with normal anterior at work. He did not notice at any point and good clinical acumen to avoid vision and posterior segment findings and his that a foreign particle had lodged in his threatening complications because of re- vital signs were normal. left eye neither did any of the staff who tained foreign bodies. Glass particles are A diagnosis of LE blunt ocular trauma was attended to him at various health centres, often challenging to identify and requires made with suspected scleral tear near the including our team at Mazabuka General skill to manage successfully. limbus at 9 O’clock position. After taking Hospital on first examination. written informed consent, this patient Glass particles and insect hairs are often was taken to theatre for further examina- difficult to see, but a careful search of the tion and possible suturing of the suspect- cul-de-sac with high magnification aids ed scleral tear. Under aseptic conditions in identification and removal. In case of the LE was given peribulbar injection as conjunctival foreign bodies there is need local anaesthesia while being mindful to search for signs of globe perforation of ocular pressure. The conjunctiva was [7,8] In this case, glass particle foreign separated from the sclera to expose the body embelded subconjunctivally on to source of the haemorrhage. A small piece the sclera surface, which presented as a of glass approximately 0.3 mm diameter small conjunctival growth and caused lo- was exposed and removed but the scleral cal inflammatory response. was intact. The scleral blood vessels were Eye injuries in the workplace are very cauterised and subconjuctival steroid an- common. More than 2,000 people injure tibiotic injection was given. Topical drugs, their eyes at work each day. About 1 in 10 eye pad and analgesics were given. The injuries require one or more missed work- patient was discharged the following day days to recover from. Of the total amount and reviewed after fourteen days. The of work-related injuries, 10-20 % will pain and haemorrhage had subsided sig- cause temporary or permanent vision loss nificantly and the patient was happy with [4]. Common causes for eye injuries are: this outcome. flying objects (bits of metal, glass), tools, Permission to publish this case was grant- particles, chemicals, Harmful radiation ed by the patient and any combination of these or other hazards. Many times these foreign parti- DISCUSSION cles are missed and intervention is only The subconjunctiva is a rare site for lodge- sought 24 to 72 hours later [5]. There are ment for ocular foreign body. Seventy five three things one can do to help prevent an percent (75%) of conjunctival foreign occupational eye injury; (1) know the eye bodies lodge on the conjunctiva surface safety dangers at work place (2) complete of the upper eye [4]. Conjunctiva foreign an eye hazard assessment (3) eliminate bodies of the eye are common and can hazards before starting work [4]. be removed with proper technique [4]. A The most recommended management of conjunctival foreign body should be sus- ocular foreign bodies is prevention by use pected if a patient present with a sensa- of safety eyewear protection which in- tion of something in the eye. Patients with cludes non-prescription and prescription a conjunctival foreign body often state safety glasses, goggles, face shields, hel- that their eye feels as if an irritating object mets and full-face respirators. The type (grit), sand, or glass is in the eye but that of safety eye protection one should wear they cannot localize exactly where the depends on the hazards at the workplace. sensation is [7,8]. The foreign body sen- Safety glasses with side protection (side sation is often worse upon blinking when shields) are recommended for particles, the foreign body is located on the con- flying objects, or dust areas. Goggles are junctival (inner) surface of the upper lid. recommended for chemicals. Special-pur- Corneal foreign bodies are easily detected pose safety glasses, goggles, face shields, as they are exposed clearly on the clear or helmets are designed for near task ra- cornea and because it is highly innervated diation (welding, lasers, or fibre optics) there is severe pain [7,8]. [4,5,]. In this patient, the signs of conjuctival for- Prompt referral to specialised emergen- eign body was not obvious as that of irri- cy centres is recommended once ocular tating eye object (grit) and sand sensation trauma is suspected or identified at first demostrating that ocular foreign bodies contact [6,8]. can lodge without eliciting clear signs and 50 LIST OF REFERENCES REFERENCES 1. Agarwal PK, Kumar H, Srivastava PK (1993) Unusual Orbital Foreign Bodies. Indian J Ophthalmol 41: 125-127. 2. Angra SK, Mohan M (1980) Intralenticular foreign bodies. Indian J Ophthalmol 28: 145-149. 3. Boyd BF (1997) Highlights of Ophthalmology 3:186 4. Bahrain Med Bull 2017; 39(2): 82 – 84- Occupational Eye Injury: The Neglected Role of Eye Protection Bahrain Medical Bulletin, Vol. 39, No. 2, June 2017 5. Khurana AK (2007) Ocular foreign body (4thEdn) pp: 409-412. 6. Mehrotra AS, Ignatius NK (1978) Retained intra ocular foreign body from bursting of the barrel of gun. Indian J Ophthal mol 26:17-18 7. Somashekar P. Biradar, A Study on Industrial Eye Injuries, Journal of Clinical and Diagnostic Research. - Arvind H.S 2011 October, Vol-5(5): 1076-108 8. Bahrain Med Bull 2017; 39(2): 82 – 84- Occupational Eye Injury: The Neglected Role of Eye Protection Bahrain Medical Bulletin, Vol. 39, No. 2, June 2017 9. Alstir K.O. Denniston, Philip L. Murry, Ocular Trauma, Oxford University Press 2014. 1108-1110 10. Khurana A K., Comprehensive Ophthalmology 6th Edition 2015, Jaypee Brothers Medical Publishers (P) Ltd

51 TRACHOMA TRICHIASIS (TT) IN A MENTALLY ILL PATIENT

Case Report By : *N Ndalela1, 2 and K I M Muma1, 3 1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 2Senanga General Hospital, Eye Department, Senanga, Zambia.. 3University Teaching Hospitals – Eye Hospital, Lusaka, Zambia *EMAIL ADDRESS: Ndalela Ndalela: [email protected]

Citation Style For This Article: Ndalela N, Muma K I M .Trachoma Trichiasis (TT) in a Mentally Ill Patient. Health Press Zambia Bull. 2019; 3(12); pp 52-54.

ABSTRACT to gain understanding that TT can occur Plasma Reaction (RPR) in order to rule out Trichiasis a medical term for abnormal- in either mentally ill or sound patients, other causes of mental illness. Both tests ly positioned eyelashes that grow back Tarsal Plate Rotation Surgery remains the were negative. toward the eye, touching the cornea or reliable option for Trachoma Trichiasis She received her trachoma surgery after conjunctiva. This can be caused by infec- Management in our Zambian setting [5]. sedation with Diazepam intravenously. tion, inflammation, autoimmune disor- Both eyes were operated in one sitting ders, congenital defects, eyelid agenesis CASE SCENARIO in order to avoid going through the same and trauma such as burns or eyelid injury. A 24-year-old female mentally ill patient challenges the next time. Local anaesthe- Trachomatous trichiasis is the result of presented to Senanga District Health TT sia (lignocaine 2% with Adrenaline) was multiple infections from childhood with Case management team with complaints then infiltrated in her eyelids. Posterior Chlamydia trachomatis, which causes re- of loss of vision, painful eyes, tearing, Lamellar Tarsal Plate Rotation (Trabut) current chronic inflammation in the tarsal headache, foreign body and pricking sen- was successfully performed. After sur- conjunctiva. This produces conjunctival sation in her eyes which had been there gery, tetracycline eye ointment was ap- scarring, entropion, trichiasis, and ulti- for more than eight years. The mental ill- plied in both eyes and thereafter padded mately blinding corneal opacification. It is ness had also been there for eight years. for 24 hours. Painkillers were given to her the leading cause of infectious blindness The patient was the eighth and last-born and the following day the eye pads were in the world. A 24-year-old female patient child. The patient had had the eye con- removed. On her first day post operatively, presented to Senanga’s Mata Rural Health dition for over 8 years for which she re- her visual acuity improved to hand move- Centre (RHC) where she was referred for ceived traditional medicines and all sorts ments. One week follow up was done and eye check up due to a chronic eye condi- of concoctions such as herbs mixed with her visual acuity was 6/36 in both eyes. tion she had. The patient was a confirmed fertilizer or sugar. Whenever she visited A week after surgery, the patient seemed psychiatric case. Examination revealed se- the nearest health facility situated 25 km oriented in time and place although she vere misdirected eyelashes, cornea opac- away, she was only given some unknown exhibited inappropriate behaviour and ities and tearing bilaterally. A diagnosis of eye ointments. Despite her being a known she was a bit cooperative and calm. The Trachoma Trichiasis was made. Despite psychiatric patient, she was not on any TPR surgery outcome was successful as the mental illness, Trachoma Trichiasis anti-psychotic treatment as access to a shown in figure 2 below. surgery was performed successfully, and psychiatric facility was a challenge to the the patient healed well. family. On account of being a mentally ill patient, INTRODUCTION her mother consented for her surgery and Trachoma is a disease of the eye caused use of her information in any medical/ by infection with the bacterium Chlamyd- clinical publication. ia trachomatis which leads to Trichiasis Though difficulty to handle due to her after a chronic phase [1]. Trachomatous mental state, her visual acuity was trichiasis (TT) is referred to as a cicatricial checked, and findings were; light percep- entropion of the upper eyelid which re- tion in both eyes. sults into inward turning of eyelashes rub- Other examination findings were; entropi- bing on the cornea causing constant pain on, turned in eye lashes touching the globe and light intolerance [2]. If Left untreated, (Figure 1), mucopurulent discharge, upper this condition can lead to corneal ulcer- tarsi scaring, cornea opacities in both ation resulting in corneal opacification eyes, hyper photosensitivity and failure to Fig1: Showing bilateral ectropion and and eventually visual impairment or blind- open her eyes. The face was dirty, and she house flies on the face ness [3]. TT can affect anyone regardless was generally in a poor state of hygiene. of their mental state. Mentally ill patients Her Blood Pressure was 110/70mmHg. tend to be uncooperative, restless, mobile, illogical and impulsive making it difficult Considering her mental status, she was to handle them [4]. While it is necessary subjected to retroviral test and Rapid 52 This patient was young and mentally ill. to be handled skilfully by the team to be She presented with all sorts of challenges sedated and for surgery to be done suc- as outlined above. She had to be sedated cessfully. Despite all these challenges, the for the surgery to take place. GA could patient was managed successfully with have been the best option, but the place some endurance. where surgeries were conducted from had no GA facilities. CONCLUSION Surgery to correct TT is a key component Trachomatous visual impairment and of all trachoma blindness control pro- blindness, which result from corneal grammes in endemic countries. There- opacification, have generally been thought fore, mental state of an individual should of as irreversible [7]. On the contrary, the not be a barrier to accessing TT surgery. patient recovered good sight of 6/36 in World Health Organization recommends both eyes after surgery. that TT surgery should be performed As a result of the unpredictability of when the opportunity arises. Fig 2: Showing successful outcome of TPR mentally ill patients a more individual- surgery at 2 weeks ized management approach with them is cardinal and their management needs DISCUSSION patience, tolerance and good clinical acu- Classically, the sequalae of trachoma tri- men [4, 8]. In this case, the patient had chiasis is visual impairment due to cornea to be sedated for the TPR surgery to be opacities [6]. The patients with TT who carried out. are mentally stable are easier and straight Patients with mental illness can have sig- forward to manage because of their being nificant and rapid mood and behavioural cooperative and heading to instructions. changes as well as sudden, volatile and This is a clear demonstration that illness- aggressive outbursts which can be both es can affect anybody without considering verbal and physical. Therefore, staff mem- mental status. Due to her mental state, it bers who interact with the patient are at is possible that she could have had se- risk of being victims of outburst [4, 9] vere Trachoma infection which could have hence proving difficulty to handle when complicated with TT at a tender age of conducting surgical management of TT. 24. Such people do not need sedation or Equally in this case, the patient was ag- general anaesthesia (GA) to undergo an gressive, uncooperative that she had operation.

53 LIST OF REFERENCES 1. World Health Organization (2012) Global WHO alliance for the elimination of blinding trachoma by 2020. Weekly Epide miological Record 87: 161–168. Pmid: 22574352 2. World Health Organization (2014) WHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013. Pmid: 25275153 3. Paul E, et al, (2006), https://www.cartercenter.org/documents/2302.pdf; Implementing the SAFE Strategy for Trachoma Control 4. Karen Appold (2016), hhtps://www.the-hospitalist.org>article;Experts Suggest Ways to Deal with Challenges Surround ing Care of Psychiatric Patients. The Hospitalist. 5. Baltussen R.M. et al, (2005), Cost-effectiveness of trachoma control in seven world regions. Ophthalmic Epidemiol; 12:91–101. [PubMed] 6. Bailey R., et al, (1999), The duration of human ocular Chlamydia trachomatis infection is age dependent. Epidemiol In fect.123:479–486. [PMC free article] 7. Barber K., Dabbs T. (1988), Morphological observations on patients with presumed trichiasis. Br J Ophthalmol. 1988; 72:17–22. [PMC free article] 8. Barry and Nilsson (2019), https://www.lexology.com>library: Challenges for Staff in Mental Health Wards. 9. Jo-Ann and Karen-Leigh (2014), https://www.researchgate.net>publicatiton>264393712; Challenges in Acute Care of People with Co-morbid Mental Illness. The Research Gate

54 RAPID ASSESSMENT OF AVOIDABLE BLINDNESS IN MUCHINGA PROVINCE, ZAMBIA Research Article By : *G Mutati1, W Mumbi1,5, C Mboni2, C Kayula2, S Chisi3, F Mwacalimba1, J Nyalazi1, P Mulenga2, E Mashilipa4, J Ndhlovu3, F Maambo5, T Kangwa1, M Hampango6,AMakupe7, K I M Muma1,7 . 1 University Teaching Hospitals Eye Hospital, Lusaka, Zambia 2Eye Department, Kitwe Teaching Hospital, Kitwe, Zambia 3Eye Department, Chipata Central Hospital, Chipata, Zambia 4 Eye Unit, Solwezi General Hospital, Solwezi, Zambia 5Eye Unit, Kabwe General Hospital, Kabwe, Zambia 6Eye Department, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia 7Ministry of Health, Ndeke House, Lusaka, Zambia EMAIL ADDRESS; [email protected] Citation Style For This Article: Mutati G MumbiW, Mbon C, KayulaC, ChisiS, Mwacalimba F, NyalaziJ, MulengaP, Mashilipa E, Ndhlovu J , Maambo F , Kangwa T, HampangoM, Makupe A, MumaK I M. Rapid Assesment Of Avoidable Blindness In Munchinga Province, Zambia. Health Press Zambia Bull. 2019; 3(12); pp 55-63.

ABSTRACT requiring expert assistance from epidemi- Aim: To determine the prevalence and Conclusion: The prevalence of blind- ologists or statisticians to produce reports causes of blindness and visual impair- ness and VI in persons aged 50 years [5]. It is for this reason that surveys have ment in Muchinga Province of Zambia us- and above was higher than estimated by been undertaken in only a few countries ing the RAAB methodology. WHO for Zambia. The majority of the and with only a few repeat surveys to de- Method: Ninety (90) clusters of 40 par- causes were avoidable, with cataract ac- termine the effect of the intervention pro- ticipants aged 50 years and older were counting for 53% of all cases of blindness. grammes implemented. Comprehensive randomly selected. Consenting subjects The data suggests that expansion of eye blindness surveys are therefore often not underwent enumeration to establish a care programmes to address avoidable feasible for planning and monitoring VI- demographic profile and thereafter a clin- causes of blindness is necessary in this SION 2020 programmes. Affordable and ical eye examination. Visual acuity (VA) area of Zambia. faster methodologies are required. was measured with a Tumbling ‘E’ chart. Key words: Rapid Assessment of Participants having a VA worse than 6/18 Avoidable Blindness, Cataract, Blindness, The rapid assessment of avoidable blind- were retested with a pinhole. If no im- Visual Impairment, Prevalence ness (RAAB) methodology has addressed provement in VA occurred, subjects un- . this need. The RAAB study methodology derwent clinical examination, including elicits information on the magnitude and a dilated fundus examination where nec- INTRODUCTION causes of blindness and vision impairment essary, to determine the cause of visual Globally, more than 82% of all blindness via reduced vision screening and ocular impairment. occurs in people ≥ 50 years old [1]. In Af- health screening of adults ≥ 50 years old. Results: A total number of 3,600 persons rica, the prevalence is 7.3 blind people per In addition, this methodology provides aged 50 years and above were sampled; million population [1]. These estimates information on the output and quality ≥ among these 3,502 (97.3%) were exam- are based on the World Health Organi- 50 years old. In addition, this methodol- ined. The age and sex-adjusted preva- zation (WHO) definition of blindness as ogy provides information on the output lence of bilateral blindness (presenting presenting visual acuity (VA) less than and quality of eye care services, barriers VA < 3/60) was 4.1% (95% Confidence 3/60 in the better eye and visual impair- to service, cataract surgical coverage and Interval [CI], 3.4-4.9%), and age and ment as VA less than 6/18 but at least other indicators of eye care services in the sex-adjusted prevalence of bilateral se- 3/60 in the better eye [2]. The study study area. Numerous RAAB studies have vere VI (VA of <6/60-3/60) was 3.1% area is in the Africa-E WHO sub-region been conducted in many countries around (95% CI, 2.4-3.8%). Avoidable causes [3]. Resnikoff et al. [4] posit an expect- the world [6,7,8,9,10,11,12,13]. The RAAB of blindness such as cataract, glaucoma ed Africa-E sub-regional prevalence of survey provides a needs assessment in and non-trachoma corneal scarring were bilateral blindness in individuals ≥ 50 the region under investigation so that a responsible for 89.8% of bilateral blind- years old of 9%. The implementation of focused district plan can be developed or ness and 86.1% of bilateral severe VI. Cat- the ‘VISION 2020: Right to Sight’ cam- adjusted accordingly. aract was the major cause of blindness paign has created global awareness of (53.0%); similarly, it was a major cause of the causes of avoidable blindness and the severe VI (63.5%). The cataract surgical need to provide evidence for eye health coverage in blind people adjusted for age needs and the impact of interventions to Muchinga Province and sex was low at 36.8% with significant guide future eye health strategies. This Muchinga Province is located in the gender difference of 45.8% for males and awareness has led to an expansion of ep- north-east of the country and borders 27.6% for females. The main barrier for idemiological investigations as baseline with Tanzania in the north, Malawi in the cataract surgery was inaccessibility of data became more important. However, east, and Eastern and Central Provinces the service (49.1%); this was followed by according to the International Centre for in the south. The province is located on lack of awareness of the available service Eye Health, ‘Blindness surveys are usually both sides of the Muchinga mountains (32.7%). lengthy, costly and complicated exercises, (Muchinga Escarpment), which serve as 55 a divide between the drainage basins of A list of all the villages and their popula- aged 50 years and above, there was no the Zambezi River (Indian Ocean) and tions in the respective wards was collect- need for segmentation and all the people the Congo River (Atlantic Ocean), mak- ed from the various districts and sent to of that age group were examined. In such ing it geographically a hard-to-reach area. the trainers who then used this to select cases, the cluster informer would inform It is one of the most sparsely populated the clusters. The sampling procedure em- the next village leader of the possibility of provinces in the country, with a popula- bedded in the RAAB software uses prob- the RAAB team including his area in the tion density of 8.1 persons per square kilo- ability proportional to the size of the pop- survey. metre and a population of 1,052,996 [14]. ulation methodology to randomly select Ethical approval The main rivers of the province are the Lu- villages automatically. The households Ethical approval for this study was grant- angwa River, a major left tributary of the within clusters were selected through ed by the University of Zambia Research Zambezi, the Chambeshi River, and a trib- compact segment sampling which in- and Ethics Committee and cleared by the utary of Lake Bangweulu in the drainage volved choosing a start point within the Ministry of Health. Permission to conduct basin of the Congo. The northern part of village and moving from house to house, the study was obtained from the Provin- the country receives the highest rainfall, enumerating all eligible residents (wheth- cial Medical Office and the respective dis- with an annual average ranging from 1,100 er at home at the time of visit or absent) trict medical offices. mm to over 1,400 mm. The main econom- until 40 eligible participants are enrolled. When the team reached the area in- ic activity for the province is agriculture, If any eligible participants were away from formed, (verbal) consent was obtained with livestock farming and the growing of home at the time of the visit, the survey from the participants after providing in- cereals, cassava and beans at subsistence team would return to the house at the end formation on the purpose, procedure and level [14]. of the day to meet with them. If they were the possible benefits of the study. still absent, a neighbour or friend would Participants were informed that partic- METHODS be asked for details on the individual’s vi- ipation was voluntary, and that all dis- A 16-year-old female from Western Pro- sual status. cussions and data collected from the viSample selection In order to facilitate the survey team’s study would be kept confidential, and The RAAB study area Muchinga Prov- work, the selected village was visited a day that findings will be anonymously report- ince. The total population in the area or two beforehand by the cluster informer. ed. Appropriate counselling, treatment was 1,052,996, with a mixture of urban, They worked with village leaders to pro- or referral for eye problems was provid- peri-urban and semi-rural areas [14]. The duce a sketch map of the ward showing ed to study participants. All subjects in estimated total population of the region major landmarks and the approximate the study were examined after informed surveyed was 322,601, with the popula- distribution of households in the village. consent and information documents were tion for each district as follows: Chama The cluster informer requested that local signed. All individuals requiring further 103,894, Chinsali 86,723, Isoka 72,189 leaders inform the residents of the visit of investigation for refractive correction, and Shiwang’andu 59,795 [15]. As in the the survey team and requested that resi- treatment of ocular disease or further in- rest of Zambia, the delivery of eye care dents of 50 years and above stay around vestigative procedures were referred to follows the district health model. Current their homes on the day of the survey. The the most appropriate and accessible eye eye health care infrastructure in the study village leader also appointed a guide to care facilities. Findings from the research area is found in a district hospital. Human work with the survey team on the day of were disseminated to the community in a resources for eye health in the area are their visit to introduce them to residents. feedback session to the community and ophthalmic nurses and clinical officers. its leaders at the end of the study. Primary community health workers in the Large villages were split into segments Training area refer to community health centres where each segment would include ap- The study was preceded by a training which also refer to the district hospitals. proximately 40 people aged 50 years and session and pilot study involving the enu- Sightsavers, a non-government organisa- above. One of the segments was chosen merators and clinical team to ensure the tion (NGO), supports eye health services at random in collaboration with the village ability of all individuals in the study to car- in the province through the seeing is be- leaders by drawing lots and all households ry out their respective roles. Kappa values lieving programme. within the segment were included in the were used as a measure of inter-observer A sample size adequate to demonstrate sample sequentially, until 40 people aged agreement between the clinical research a prevalence of blindness of 4.0% ±0.8% 50 years and above were identified, exam- team and a ‘gold standard’ team, with 0.6 with 95% confidence was calculated. ined, and their data entered on the data being an acceptable standard. All clini- This was increased for non-participation collection programme on the smartphone. cians satisfied this criterion. There were (10%) and design effect (1.5) resulting in If the segment had fewer than 40 people five survey teams, each consisting of an a size of 3,563 or 90 clusters of 40 partic- aged 50 years and above, then another ophthalmologist and an ophthalmic nurse ipants each (3,600 in total). The team de- segment was chosen at random and sam- or ophthalmic clinical officer, as well as a cided on clusters of size 40 rather than 50 pling continued. The sampling started at driver and a cluster informer who would due to the long distances between homes the edge of the village and all the house- work independently of the survey teams in the villages and the difficulties envis- holds were sampled sequentially until 40 to prepare the clusters for their visit aged in moving between the homes and people aged 50 years and above had been Clinical examination enrolling enough participants each day. examined. The standardised RAAB protocol was Enumeration and recruitment of study used in the clinical examination and in- participants If the village had fewer than 40 people volved the assessment of visual acuity 56 using a tumbling E optotype of 6/60 and and various degrees of vision loss. 2,315 people were blind, of whom 1,179 6/18 sizes. Subjects who failed testing on The survey was carried out over 6 weeks were females (50.1% female). the 6/60 optotype target were retested from October to November 2009. with a pinhole occluder. Blindness was classified as VA < 3/60 in the better eye RESULTS with available correction; severe visual Demographics of the sample impairment as VA between ≥ 3/60 and The total number of people examined was 6/60 in the better eye with available cor- 3,600 giving a response rate of 97.3%, rection; and moderate visual impairment of which 80 individuals (2.2%) were un- as VA between ≥ 6/60 and 6/18 in the available, 11 (0.3%) refused and 7 (0.2%) better eye with available correction. The were not capable of taking part in the sur- VA examination was followed by an ex- vey. Almost half of the people surveyed amination of the crystalline lens and the belonged to the 50-59 years age group. posterior segment with a direct ophthal- The age and gender composition of exam- moscope. Subjects presenting with VA < ined participants in relation to the popu- 6/18 and with no improvement with pin- lation in the survey area is summarised in hole were dilated using 0.5% tropicamide Table 1. solution, and a dilated ophthalmoscopy was performed to determine any posteri- or segment cause for vision impairment. All measurements were taken in full day- light with available correction. If the VA was <6/18 in either eye, then pinhole vision was also measured. If the vision improved to >6/18, then the con- dition was entered into the data as refrac- tive error.

The participant was then moved to a Females constituted 54.9% (1,921) of se- dark location - this was usually in their lected participants compared to 51.9% in homes, where the lens was assessed for the population. cataract formation. If there was no cat- Bilateral vision loss in the sample aract and the vision was still <6/18, the Of 166 people in the sample, 4.7% participants’ pupils were dilated with a (95%CI4.0-5.5%), were found to be bi- short-acting mydriatic for direct fundos- laterally blind (defined as VA worse than copy. The fundus was then examined and 3/60 in the better eye with available cor- the cause for vision loss recorded on the rection - see Table 2). The prevalence was RAAB application. similar between males and females, 4.6% and 4.8% respectively. A questionnaire on the barriers to cat- The prevalence of bilateral blindness, SVI aract surgery and surgical success was and VI is summarised in Table 2. administered to subjects presenting with cataracts or who had undergone cataract surgery respectively. Statistical analysis The specific RAAB software package de- veloped for the survey (Version 4.02) was used for data entry and standardised data analysis.4 Data were captured by double entry (to ensure reliability of data entry) and reports were generated daily to en- sure consistency within the data capture process. Automated analyses produced reports on the unadjusted prevalence of visual impairment, causes of visual im- Adjusting for differences in age and sex pairment, age- and gender-adjusted prev- between the sample and survey area pro- alence, and cataract surgical coverage. duced a prevalence of blindness of 4.1% Multiple logistic regression analysis was (95%CI3.3-4.9% - see Table 3). Extrap- conducted to determine associations be- olating this to the total population of the tween gender, age and education levels survey areas means that an estimated 57 dophakic people divided by the number who had operable cataract (i.e. the num- ber of aphakic/pseudophakic plus the number needing surgery). Ninety-two (92) eyes (1.3%, 95%CI 1.0-1.6) examined in the survey were found to be aphakic or pseudoaphakic. Age and sex adjustment imply this extrapolated to 1,360 eyes in the survey population (1.2%, 95%CI 0.9- Sample prevalence of severe VI (pre- Of eyes (approx. 4,059) were blind with 1.5%). Following adjustment for age and senting VA<6/60-3/60 in better eye) a cataract (cataract may not be the major sex, 37% of people with VA<3/60 who was 3.3% (95% CI2.6-4.0%), and 3.1% cause of blindness), table 5. Nine hundred required surgery were found to have re- (95%CI 2.4-3.8%) after adjustment for and eighty-three (983) people (1.7%, ceived it. Males were more likely to have age and sex. Adjusted prevalence of SVI 95%CI 1.2-2.3) in the survey area were received surgery than females (45.8% vs was 3.3% among males and 2.9% among estimated to be bilaterally blind with cat- 27.6%). females, which means an estimated 895 aract and 2,092 (3.7%, 95%CI 3.0-4.4) males and 837 females with bilater- were estimated to have one cataract blind Twenty eight percent (28%) of people al severe VI in the survey area. Sample eye, table 5. No major differences were with VA<6/60 who required surgery were prevalence of moderate VI (presenting observed between males and females. found to have received it, with VA<6/18-6/60 in better eye) was 10.2% (95%CI 8.8-11.5%) and 9.6% (95%CI 8.3-11.0%) after adjustment for age and sex. Adjusted prevalence of MVI was 9.9% among males and 9.4% among females which means an estimat- ed 2,678 males and 2,733 females in the survey area (50.5% female).

Causes of vision loss in the sample Cataract was the primary cause of bilat- eral blindness (53.0%), and bilateral se- vere VI (63.5%), and a major contributor to moderate VI (36.4%). Of the remain- der of blindness, glaucoma accounted for 14.5%, non-trachomatous cornea opac- ity was 10.2%, other posterior segment disease 7.2%, trachoma corneal opacity 6.0%, phthisis 3.0%, other globe/CNS abnormalities 3.0% and cataract surgical complications 3.0%. (Table 4).

Cataract blindness, surgical outcomes and cataract surgical coverage After adjustment for age and sex, it was estimated that 3.6% (95%CI 2.9-4.3%) o Cataract surgical coverage (CSC) was males more likely than female (36.7% vs reflected in the number of aphakic/pseu- 19.1%). 17.7% of people with VA<6/18 59 who required surgery were found to have they were regions with inadequate eye RAAB studies in the region, except in a received it with males more likely to have health service before interventions were RAAB conducted in South Malawi where received it than female (24.3% vs 12.2%). implemented. The response rate was the prevalence of blindness was higher in 97.2% which can be considered very high. males than females. Although the cluster informers working with local leaders knew the village The main causes of blindness in Muchin- ga were cataract, glaucoma and non-tra- chomatous cornea opacities. Similar causes have been observed in other RAAB surveys in the southern province of Zam- bia and Malawi. This result is consistent with the current trend that cataract is the most common cause of blindness world- wide. Our study found that unoperated cataract is also the major cause of severe VI and that uncorrected refractive er- ror is the primary cause of moderate VI. The finding of refractive error as the most common cause of VI could be due to the The CSC was 36.8% at visual acuity < boundaries and residents well, the re- myopic shift induced by age-related nu- 3/60 level; 28.8% at visual acuity < 6/60 sponse rate could have probably been clear sclerosis as reported by researchers level, and 17.7% at visual acuity < 6/18 higher had the survey not been conducted for RAAB in Kwazulu Natal [20]. In this level. Overall, CSC was greater amongst during harvest time. Normally because of study, avoidable causes were responsible males than females. the mountainous terrain, villagers would for 89.8% of blindness. The finding that camp at the farms away from the village most causes of blindness are avoidable Cataract surgical outcomes with avail- until harvesting was complete. A propor- justifies the initiative to address blindness able correction was relatively poor (Table tion (0.3%) refused examination and the in this area. The prevention of blindness 7). Exactly half of the eyes (50.0%) had scope of the study did not provide an ex- initiative in this area should include the a good outcome (can see 6/18), 17.0% planation for the reasons for refusal of the correction of refractive errors, which con- had borderline outcome (can see 6/60) clinical examination. tributed to 48% of moderate VI. and 33.0% had poor outcome (cannot see 6/60). Among eyes operated on in The survey found a high prevalence of The age and sex-adjusted cataract sur- the past three years, 58.1% of outcomes blindness (4.1%, 95%CI 3.4-4.9) com- gical coverage was low (37%) compared were good and 29.0% were poor. With pared to that obtained in Southern Zam- to studies from Malawi (44.6% unad- best correction. the proportion of good bia (2.3%) [16]. Results from other RAAB justed) [17], Kenya (78%) [21], Tanzania outcomes could rise to 63.8%, borderline surveys done in Malawi [17], Rwanda [18] (68.9%) [19] and Rwanda (47%) [18]. outcomes to 9.6% and poor outcomes and Tanzania [19] ranged from 1.8-3.3% Muchinga province has always depended would be 26.6%. Over half (61.3%) of (unadjusted) which was lower than what on sporadic eye camps conducted by oph- the poor outcomes were conducted in the was found in the study area. The preva- thalmologists from outside the province, government hospital. Of the 94 eyes that lence of blindness in Muchinga was pos- with the support of cooperating partners. received cataract surgery, all except three sibly higher than that of Southern Zambia The low CSC could be due to the absence had an intraocular lens (IOL) inserted. due to a number of reasons: Southern of a dedicated ophthalmic unit headed by Zambia’s demographic is an urban an ophthalmologist. The finding of a low cataract surgical coverage for females (25.5%) has also been noted in other ar- eas of Sub Saharan Africa [22].

WHO recommended that the grades of outcome for cataract surgery with an IOL are: good outcome VA >6/18 at 90%, borderline VA >6/60 at less than 5% and poor outcome of VA<6/60 at less than 5%. The high proportion of poor outcomes after cataract surgery in this survey could rural setting with the presence of active be due to a combination of factors, for in- DISCUSSION eye health services. The extrapolated stance there is no ophthalmologist to fol- This study was conducted to create base- number of blind people in the four dis- low up patients and therefore manage any line information on the prevalence and tricts of Muchinga was 2,315. The propor- complications. In this study, the majority causes of blindness in Muchinga region. tion of blind people was higher for females were attributed to poor patient selection These districts were selected because than males, a finding common to other and surgical complications. Most surger- 60 ies, although conducted in a hospital en- In our study, subjects with blindness ow- It is therefore evident that eye health ser- vironment, have a setting like that of an ing to bilateral cataracts (32.5%) did not vices are not available in Muchinga prov- eye camp where the screening of patients seek intervention because they were ‘un- ince and the result of this survey justifies preoperatively is inadequate; for instance, aware of treatment’. Sightsavers extending the services to conditions like glaucoma may be missed Muchinga province. as most patients present with dense cat- CONCLUSION Competing interests aract that obscures fundus view, and may he prevalence of blindness in Muchinga The authors declare that they have no fi- not have had any examination before the province of 4.1%. Although lower than the nancial or personal relationships which development of cataract. Secondly, biom- WHO projected for Africa, it remains high- may have inappropriately influenced them etry is not conducted pre-operatively and er than that obtained in the region. Cata- in writing this article. patients are offered a standard lens which ract is the commonest cause of blindness The study was funded by Sightsavers may not be appropriate for the patient. in Muchinga with refractive errors being Zambia and Ministry of Health, Zambia. the main cause of VI. Eye health services In our study, half of those that had not ac- are severely inadequate and inaccessible. cessed surgery for cataract reported that they were not able to access the service. Cataract surgical coverage is low and Studies have reported that major reasons there is an obvious gender imbalance in for low cataract surgical rates include the the accessibility of cataract service. Infor- following: low demand because of fear of mation/sensitisation on the availability of surgery, low demand from poor people services is also low. The quality of cata- because of high cost of surgery, low de- ract surgeries performed in the area is be- mand because of poor visual results, lack low the WHO recommendation. of eye surgeons (particularly in Africa), old age, no available services close to the community, and lack of awareness of available surgical services [23].

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63 DIABETIC RETINOPATHY AMONG PATIENTS ATTENDING UNIVERSITY TEACHING HOSPITALS ADULT HOSPITAL MEDICAL CLINIC IN LUSAKA Research Article By : *V Patel1, E M Munachonga1, G Mutati1,2, J Nyalazi2, K I M Muma1,2 1University of Zambia, School of Medicine, Lusaka 2University Teaching Hospitals - Eye hospital, Lusaka Zambia

*EMAIL ADDRESS: Dr Vrundaben Patel :[email protected]

Citation Style For This Article: Patel V, Munachonga E M, Mutati G, Nyalazi J, MumaK I M .Diabetic Retinopathy among patients attending University Teaching Hospitals Adult Hospital Medical Clinic in Lusaka. Health Press Zambia Bull. 2019; 3(12); pp 64-72.

ABSTRACT the knowledge that diabetes affects the of 52%, which was higher than average Purpose: eyes, only 55 (25.8%) had had a dilated from other studies [6]. In a Malawian co- Diabetic retinopathy (DR) is a blinding eye examination in the preceding twelve hort of patients from diabetic clinics, DR complication of diabetes mellitus and months. was the most common primary cause of a leading cause of visual impairment in vision loss (38.6%), followed by cata- people aged 20–64 years. Retinopathy Conclusion: ract (16.5%), and both DR and cataract develops overtime in all diabetics and A high prevalence of DR among patients (3.9%) [7]. Cleland et al. looked at a DR controlling the modifiable risk factors de- attending the adult medical diabetic clinic screening programme in Tanzania and of lays its onset and reduces progression. was found in this study, with only about the 3463 people analysed, DR was found This study was carried out to assess DR; a quarter of them having had dilated in 27.9% of people, maculopathy in 16.1%, its prevalence and associated clinical and eye examination in the preceding twelve Proliferative diabetic retinopathy (PDR) in demographic characteristics among pa- months. The study findings suggest that 2.8%, non-proliferative diabetic retinop- tients attending the UTHs-Adult Hospital better advocacy for retinopathy screen- athy (NPDR) in 25.1% [8]. In the capital medical clinic in Lusaka, Zambia ing and diabetes control needs to be im- city of Zambia – Lusaka, there was a lack Methods: plemented at the UTHs-Adult Hospital in of data on the level of retinopathy in di- This was a hospital-based cross-section- Lusaka. abetic patients and whether the patients al study carried out from 18th December, are having regular dilated eye examina- 2018 to 16th April, 2019 at the adult med- INTRODUCTION tion done by a health worker trained to ical diabetic clinic. Snellen visual acuity Diabetic retinopathy is a common micro- perform fundoscopy. This study aimed at (VA), blood pressure, weight and height vascular complication of diabetes melli- ascertaining what the prevalent severity were measured as well as relevant demo- tus (DM) [1] and also a leading cause of of DR was in patients at UTHs adult hos- graphic and medical information collect- visual impairment in people aged 20–64 pital medical clinic to determine if there ed. Retinal images were captured after years affecting 1 in 3 persons with dia- was as high a prevalence of DR at UTHs pupil dilatation and used for grading reti- betes ([2]. The International Agency for as seen in the Copperbelt. It also assessed nopathy using the International classifica- Prevention of Blindness (IAPB) reports risk factors that were associated with DR tion of DR scale. The worse eye was used that 75% of diabetes burden is in low to and whether diabetes patients were hav- to grade for DR. middle income countries and that DR is ing dilated fundoscopy regularly. Results: emerging among the top causes of vision A total of 213 participants were studied loss globally [3]. Risk factors for visu- METHODOLOGY with a female to male ratio of 2.3:1. The al impairment that have been identified This was a hospital-based cross section- median age was 53 years and majority from studies such as the Wisconsin Epi- al study carried from 18th December, (183=85.2%) had type 2 diabetes. Me- demiologic Study of Diabetic Retinopathy 2018 to 16th April, 2019 at the University dian duration of diabetes was five years. (WESDR) include poor glycaemic con- Teaching Hospitals (UTHs) in Lusaka. The Median glycated haemoglobin level was trol, hypertension, smoking and severity UTHs include the Adult and Emergency high at 8.1%. One hundred sixty-three of baseline retinopathy [4]. Controlling Hospital, Eye hospital, Cancer Diseases participants (76.5%) had normal VA and blood sugar levels reduces the annual in- Hospital, Children’s Hospital, and Women six (2.8%) were blind. cidence of DR but not the lifetime risk of and New Born Hospital. Participants were The prevalence of DR in this study was developing DR as it usually develops over DM patients recruited weekly into the 47.4%; 95% CI 40.8%-54.2% (101 par- time in all diabetes patients [2]. In most study from the Adult Hospital medical di- ticipants), with 8.9% (19 participants) cases of DR, an actual decrease in visual abetes clinic. Eye examination equipment having proliferative diabetic retinopathy. acuity is not noticed until progression to was set up in a designated room during Diabetic macula oedema was present in very advanced disease occurs [2]. This the clinic and information collected by 24 (11.3%; 95% CI 7.5%-16.1%). Dura- delays the presentation to any eye health ophthalmic personnel from the Eye Hos- tion of diabetes was the most significant care personnel [5]. pital and the principle investigator. The (p<0.0001) association found with reti- A study from the Copperbelt province sample size was 213 participants; calcu- nopathy. of Zambia based on a screening pro- lated using the prevalence formula for a Even though 104 participants (51.1%) had gramme found a prevalence rate of DR finite population. Inclusion criteria were 64 known DM patients who consented to was used; while Spearman coefficient take part in the study. Exclusion criteria was used for non-normally distributed included patients with ocular media not variables. In the final analysis to rule out clear for classifying fundus photos in both confounders, a multiple logistic regres- eyes and patients found to have retinal sion model was constructed using a cut co-morbidities, during fundus imaging, off of 20% for the variables. Age, HbA1c affecting the grading of DR. Every consec- and use of Anti-HTN medication were in- utive diabetic patient meeting inclusion cluded in the final analysis due to signif- criteria was included in the study. icant associations found in several other A researcher-administered questionnaire studies. The model helped identify factors for information regarding the demograph- that were associated with DR after adjust- ic characteristics of the patients, the rele- ing for baseline characteristics. A p-value vant diabetes medical and ocular history <0.05 was regarded as significant. and a section for the findings of blood pressure (BP), Body Mass Index (BMI), pin hole visual acuity (VA) and retinopa- thy grading was used for data collection. Other tools used included Snellen chart, pin hole, Digital Retinography System (DRS) fundus camera by Centervue, Ita- ly, Sphygmomanometer, weighing scale and height scale, and blood collection consumables. Patients were identified as they were waiting for the physician’s re- view and informed consent was obtained. Those found to have ocular media not clear enough to get gradable retinal im- ages in both eyes were excluded from the study and referred to a consultant oph- thalmologist at the eye hospital for further assessment and management. After mea- surement of VA, BP and BMI, the partic- ipants’ pupils were dilated with one drop of a mydriatic eye drop that had a com- bination of tropicamide 0.8% and phenyl- ephrine 5%. DRS fundus camera was used once the pupils were dilated to capture retinal images. Both colour and red-free retinal images were captured from both eyes and graded to assess the severity of retinopathy. The worse eye or the only eye with a gradable image was used in the analysis. The principle investigator read all retinal images and graded using the international classification of DR. One consultant ophthalmologist randomly re- viewed selected images to ensure quality and adherence to the international stan- dard and protocol for the study. Figure 1: Procedure flow chart Data was collected and entered in a Mi- crosoft Excel spread sheet. Analysis was done using STATA version 13.1. Continu- ous variables were tested for normality using Shapiro-Wilk test. The chi square and Mann-Whitney tests were used to compare no DR to DR depending on the type of variable. To determine the correla- tion between two normally distributed independent variables Pearson coefficient 65 RESULTS (p=0.030) and alcohol intake (p=0.002). In the multiple logistic regression analy- sis (table 3), duration of DM (p<0.0001), having diabetic foot (p=0.006) and alco- hol intake (p=0.005) were maintained as factors found to be statistically significant associations of DR.

For maculopathy, only duration of DM was found to be a statistically significant association (Odds ratio=1.10 with 95% CI 1.03-1.18).

higher than those who did not (52 years). Of the 213 study participants, 30 (14.8%) Univariate logistic regression analysis had type 1 DM and 183 (85.2%) had type revealed that those with tertiary level of 2 DM. The median duration of DM was 5 education (p=0.038), longer duration years (IQR = 2-10 years). The median du- of medical diabetes clinic attendance ration of attendance at UTHs adult hos- (p=0.009), and those with knowledge pital medical clinic was 3 years (IQR = 6 that diabetes has eye complications months to 7 years). (p=0.034) were more likely to have had a One hundred fifteen (54.5%) participants dilated eye examination in the preceding were taking insulin for DM control while 12 months. 80 (37.6%) were taking oral hypoglycae- mic medication. Twelve (5.6%) partici- pants were taking both insulin and oral Regarding knowledge about the ocular hypoglycaemics with 87 (40.8%) partic- complications of DM, 104 (51.2%) par- ipants also taking anti-hypertensive med- ticipants had some idea with poor vision ication. and blindness being the most common One hundred twenty four (58.2%) partic- responses. There was no statistically ipants did not report any complications significant difference in terms of gender arising from diabetes. However, 13 (6.1%) (p=0.203) nor education level (p=0.114) gave a history of diabetic foot, 67 (31.5%) in relation to knowledge about the ocular had peripheral neuropathy and 3 (1.4%) complications of DM. had kidney-related complications. Diabetic retinopathy and maculopathy Systolic BP measurements were nor- were classified using the ICO internation- mal in 117 (54.9%) participants, with 61 al classification of DR. DR was present in (28.6%) having stage 1 hypertension and 101 (47.4%; 95% CI 40.7% - 54.2%) par- 35 (16.4%) having stage 2 hypertension ticipants while 112 (52.6%; 95% CI 45.8% levels. Diastolic blood pressure measure- - 59.3%) participants had no DR. Eighty ments were normal in 142 (66.7%) par- two (38.5%; 95% CI 32.1% - 45.3%) ticipants, with 41 (19.2%) having stage 1 had NPDR and 19 (8.9%; 95% CI 5.7% - hypertension and 30 (14.1%) stage 2 hy- 13.6%) had PDR. 24 (11.3% with 95% CI pertension. The BMI was normal for 78 7.6% - 16.3%) participants had DME. No (37.7%) participants, 69 (33.3%) partici- participant had had previous laser treat- pants were overweight and 60 (29.0%) of ment for DR. the participants were obese. In the univariate analysis (table 2) the When asked if they had had a dilated eye factors significantly associated with DR examination in the preceding 12 months, included duration of DM (p=0.001), du- 55 (25.8%) responded positively. The ration of clinic 5 attendance (p=0.040), median age of participants who had the type of DM medication used (p=0.010), examination (58 years) was significantly DM related illnesses (p=0.001), BMI class 66 Figure 2: Distribution of DR among partic- ipants

Table 2: Univariate analysis of associa- tions of Diabetic retinopathy and macu- lopathy

67 Table 3: Multiple logistic regression analysis of risk factors associated with diabetic retinopathy

Glycated haemoglobin (HbA1c) findings showed a median value of 8.1%, with the lowest being 4.6% and highest 13%. The median HbA1c level increased with the severity of DR as shown in figure 2 below.

Figure 3: HbA1c levels in different grades of DR

Using the International Classification of Diseases 11 (ICD 11) VA was grad- ed, upon which classification of visual impairment and blindness was deter- mined. One hundred sixty three (76.5%) participants had normal visual acuity, 44 (20.7%) had visual impairment and 6 (2.8%) were blind

68 DISCUSSION trol in DM patients is advised to reduce is available to show intensive glycaemic This was a cross sectional study looking the overall morbidity associated cardio- control lowers risk of incidence and, to at the prevalence of DR and its associated vascular disease rather than to reduce a lesser extent, risk of progression of DR risk factors. Duration of DM, microvas- progression of DR [20]. in patients with younger-onset or type 1 cular complications and alcohol intake Retinopathy, nephropathy and neuropa- disease [27]. For older or type 2 patients, were found to be associated with DR. The thy are all microvascular complications of this is not so apparent [28]. prevalence of DR was found to be 47.42% DM and have been shown to be present (95% CI 40.75% - 54.18%) in this study. simultaneously in an individual. Three pa- A little more than half of the participants This result reaffirms the findings of the tients had nephropathy in this study and 2 (51.1%) in this study had some knowl- Copperbelt province study where preva- of these had NPDR while 1 had PDR. Hav- edge about diabetes affecting the eyes lence of DR was found to be 52% [6]. ing a DM-related complication was also though the knowledge was not specific The median age of participants in this found to be significantly associated with to retinopathy. Sadly, this knowledge gap study was 53 years (IQR=44 to 63 years) DR in this study (p<0.0001). was seen even among the participants which was consistent with many studies who had a positive medical background. looking at patients with both type 1 and The University Teaching Hospitals are ter- The most common responses were visual type 2 diabetes [6,9]. This study had a tiary level referral hospitals for the whole impairment and blindness. Other studies high ratio of female to male participants of Zambia. As such most of the DM pa- have shown a much higher percentage (2.3:1). Generally, females are more than tients seen are those that were poorly of diabetic patients with knowledge that males in study populations of type 2 DM controlled from local health centres or diabetes affects the eye; 75.62% from a or type 1 and 2 combined [10,11]. The have severe comorbidities. Type 1 DM pa- Saudi Arabian study and 89.0% from a number of smokers was very small in this tients require insulin for adequate glycae- Tanzanian study [29,30]. This highlights study and no association was found with mic control while for type 2 DM patients gaps in sensitisation and dissemination DR. Smoking is not an established known oral hypoglycaemic medication may be of information at the primary health care risk factor for DR, particularly type 2 DM, enough but about one third need insulin level as well as during specialized medical though it has been associated with DR in [21]. These two factors can explain the diabetic clinic visits in this setting. type 1 DM [12]. high number of participants using insulin Despite about half of participants know- In studies involving the adult population, in this study. Unadjusted p-value suggest- ing that diabetes affects vision, only type 2 DM is more prevalent than type 1 ed an association between medication 28.8% had had a dilated fundal eye exam- DM [13,14] and this was the case in this used and DR though this was not signifi- ination in the preceding twelve months. study too. The type of DM had no impact cant in the multiple analysis. Some stud- This low rate is consistent with other on DR in this study. Type 1 DM partici- ies report majority of participants taking studies- 28.8% in the study by Mumba et pants had a median duration of DM of 5 oral hypoglycaemics [6] while others re- al. in Tanzania [29]. Yearly eye screening years while for type 2 DM participants it port higher rate of insulin use, particularly for DR is the current recommended prac- was 5.5 years. in hospital patients [14,22]. tice for all diabetics, particularly those with no DR on initial screening [2]. This Among the participants, 40.85% were Strict glycaemic control has been shown could be a proxy indicator of physicians taking anti- hypertensive medication. to reduce the occurrence of DR as pre- eventually referring diabetic patients for Among those found to have stage 2 hy- sented in the UKPDS study where mean fundoscopy overtime though this could pertension level systolic and diastolic BP, HbA1c was 7.0% in the strict glycaemic also be attributed to patients developing less than 70% were taking anti-hyperten- control group and 7.9% in the convention- visual complaints. sive medication. However, no significant al group [23]. A systematic review looking association was found with any of these at HbA1c and DM showed significant as- As seen with other hospital-based stud- three BP parameters and DR in this study. sociation with DR at HbA1c levels of 5.8% ies, the prevalence of DR (47.42%) in This is comparable to findings from stud- to 7.3% and suggest a threshold of 6.5% this study was higher than findings from ies by Akpalu (2011) and by Rotimi et al., for diabetes-specific retinopathy [24]. In population-based studies. This value was (2003) from Africa [15,16]. However, this study, there was no statistically sig- closer to the 49% prevalence of DR found major epidemiological studies such as the nificant association between the overall in the study by Akpalu et al in Ghana [15] UKPDS have shown that strict control of median HbA1c level and DR. However, and the 52.0% in the Copperbelt province BP is associated with reduced risk of DR the box and whisker plot shown in figure of Zambia [6]. In contrast, DR was found and it’s progression though the effect 3 indicates the median HbA1c was pro- in only 27.9% in a population-based Tan- wears off with cessation of such control gressively higher from the ‘no DR’ to ‘PDR’ zanian study on enrolment into a screen- [17]. Other studies also show an associ- groups. The median for the ‘no DR group’ ing programme [8]. The systematic re- ation with stage 1 or 2 hypertension level (7.5%) was higher than that of the ‘no DR view by Burgess et al had a range of DR of blood pressure and DR [8,18]. Findings groups’ in other studies showing generally from 9.55% to 62.4%, with maculopathy from a review done by Do et el in 2015 poor glycaemic control in this study sam- ranging from 1.2% to 31.1% across East showed that strict hypertension control ple [18]. Other studies with similar sam- and Southern Africa [7]. Grading of DR had a modest effect in reducing the inci- ples of mostly type 2 DM patients also by means of retinal photographs (used dence of DR by 4 to 5 years but lack of did not find association between HbA1c in this study) as opposed to ophthalmo- effect on progression of DR over the same and DR [25,26]. Generally, when looking scopy has been found to produce higher time period [19]. Thus, hypertension con- at glycaemic control and DR, evidence frequency of DR detected [31]. 69 Final risk factor analysis revealed dura- CONCLUSION RECOMMENDATIONS tion of DM as the most important risk From this study, a high prevalence rate of From these findings, it is recommended factor for DR in this study. This is consis- DR at 47.42% (95% CI 40.75% - 54.18%) that more sensitisation programmes in tent with all studies done analysing risk was seen among patients attending the the primary health care facilities on need factors and it is known that all diabetics UTHs-Adult Hospital medical diabet- for regular retinal examinations in diabetic develop DR overtime [32]. Alcohol intake ic clinic in Lusaka. NPDR was present in patients are needed. Also, regular HbA1c and diabetic foot were also found to be 38.5% and PDR in 8.92% while 11.27% testing needs to be used as a means to associated with DR in our study; though (95% CI 7.46%-16.13%) had diabetic assess glycaemic control in patients at- the 95% confidence intervals were not macula oedema. Duration of diabetes was tending the medical diabetic clinic. This even and slightly wide suggesting less the most significant association found includes advocating for supportive labo- significance than indicated by the p-val- with retinopathy. Median HbA1c was 8% ratory services. Another recommendation ue. A UK primary-care based study did which showed poor average glycaemic is to scale up country wide DR screening find an association of alcohol intake with control among participants. Even though using retinal photography across Zambia. DR [33]. According to a meta-analysis 51.1% had the knowledge that diabetes This includes use of telemedicine for in- study in 2016 by Zhu et al., alcohol intake affects the eyes, only 25.82% had had a terpretation of images from areas with was not associated with increased risk of dilated eye examination in the preceding trained photographers but not trained im- DR, even in subgroup analysis of type of twelve months age graders or ophthalmologists. Further alcohol [34]. No African study was part studies are also needed with larger sam- of the meta-analysis though. In our study, ple sizes for a definite risk factor analysis no quantification of type and frequency of in both hospital-and community-based alcohol intake was done and this would settings in Lusaka. need to be further studied to explore any real association with DR.

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72 CASCADING SCREENING FOR DIABETIC RETINOPATHY AT THE UNIVERSITY TEACHING HOSPITALS: STRATEGIES TO OVERCOME BARRIERS Research Article By : *K I M Muma1,2,3, J I M Nyalazi2, C Mbewe2, T Kangwa2, G Zulu2, G Chipalo – Mutati2,3 , G Syakantu4 , C Mwale5, A Makupe6 11National Eye Health Coordination, Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia 2University Teaching Hospitals – Eye Hospital, Lusaka, Zambia 3Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 4School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia 5Provincial health office, Ministry of Health, Lusaka, Zambia 6Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia Citation Style For This Article: Muma KIM, Nyalazi JIM, Mbewe C, KangwaT, Zulu G Chipalo – Mutati, G, Syakantu G,, Mwale C, Makupe A. Cascading Screening for Diabetic Retinopathy at the University Teaching Hospitals: strategies to overcome barriers. Health Press Zambia Bull. 2019; 3(12); pp 73-83. ABSTRACT UTHs from January 2016 to June 2019 ic Retinopathy, Diabetic Retinopathy Objective: To develop a diabetic reti- of which nine hundred and ninety-three Screening, Prevalence nopathy strategy for early detection of (993) were screened at the UTHs – EH sight-threatening diabetic retinopathy in compared to 524 (34.5%) screened at the INTRODUCTION Zambia. UTHs – AH. Screening at UTHs – AH start- Background ed in 2018. For the years 2016 and 2017, Diabetes mellitus (DM), commonly Background: The Ministry of Health 36.9% (560/1517) participants were known as diabetes, is a group of metabol- (MoH), Zambia, embarked on a pro- screened compare to 43.2% (656/1517) ic disorders characterized by high blood gramme to scale up the initiative for Uni- in 2018 of which 50.6% (332/656) were sugar due to either the pancreas not pro- versal Health Coverage of services across screened at the UTHs – AH and 49.4% ducing enough insulin (TYPE 1), or the the continuum of health care throughout (324/656) at the UTHs – EH. Quar- cells of the body not responding properly the country. The University Teaching Hos- ters one and two of 2019 saw 63.8% to the insulin produced (TYPE 2) [1]. With pitals (UTHs) was tasked to play a pivotal (192/301) participants screened at UTHs the rise of a more sedentary lifestyle in role in this noble cause in line with MoH’s – AH compared to 36.2% (109/301) at both developed and developing countries, vision of bringing health as close to the the UTHs – EH. Overall, 57.2% (524/957) the global prevalence of DM is increasing family as possible. A National Diabetic participants were screened at the UTHs rapidly. Diabetes prevalence in Zambia Retinopathy Screening (DRS) programme – AH in 2018 and 2019 implying that the was reported at 6.2% in the population was commenced in 2012 in collaboration setting up of this service significantly in- aged 20 to 79 years [3]. with the Frimley Park Hospital of the Unit- creased the uptake of DRS by 57.2%, p ed Kingdom (UK). < 0.0001. There was an increase of the In the United States of America (USA) patients attended to by 63.7% from 102 and UK, diabetic retinopathy is an import- Methods: The DRS programme is based in quarters one and two in 2016 to 167 in ant cause of visual impairment and blind- on fundus camera screening using the the same quarters in 2019. The hosting of ness among adults aged 20–74 years [4]. UK protocol. This is both community and the DRS clinic by the medical clinic also About 50–73% of those with visual im- hospital based. The idea was to develop enhanced collaboration in the manage- pairment or blindness because of DR can strategies that would ensure the capture ment of DR between ophthalmologists be prevented by early detection and treat- of all diabetic patients in the country and and physicians at the UTHs. Nine hun- ment of risk factors, and by photocoagu- have them screened for diabetic retinop- dred and twenty-two (922) participants lation [5,6]. With timely laser treatment athy (DR). A national Diabetes Mellitus screened had DR making the prevalence and intravitreal anti-vascular endothelial (DM) register was also to be created of DR 60.8%. growth factor (VEGF) therapy, severe vi- where all the DM patients would be regis- sion loss from DR can be reduced by 90% tered and accounted for. The UTHs – Eye Conclusion: The 57% more DM patients [7,8,9]. Diabetic retinopathy is not only a Hospital (UTHs - EH) was to implement screened at the UTHs – AH demonstrat- blinding condition but also affects visual the programme at the University Teach- ed a huge need of following the DM pa- functions that affect performance of daily ing Hospitals (UTHs), in Lusaka Province tients to the medical clinic in order to activities like contrast sensitivity [10]. and oversee the roll out the national DRS increase the uptake and compliance to programme through the National Eye have DR screening. Thinking without the In the Copperbelt province of Zambia, a Health Coordination (NEHC) office. In box strategies including collaboration of population-based study on 2153 diabetic this endeavour, in 2018, the UTHs – EH all disciplines involved in the DM man- participants identified at various health introduced a weekly DRS screening clinic agement is vital in scaling up the DRS and centres and recruited in the DRS pro- at the medical clinic of the UTHs – Adult preventing blindness due to DR. The study gramme found some form of DR in 52% of Hospital (UTHs – AH) to increase the up- demonstrated the importance of creating participants and 36% had sight-threaten- take of DRS by all the DM patients attend- convenience for the patients and making ing DR [11]. The reported prevalence rate ing the diabetic clinic. the service not only relevant but readily was higher than most estimates from oth- available to the public. er studies; be it hospital-based or popula- Results: A total of 1517 DM patients had tion-based. Several classification systems both their eyes screened for DR at the Keywords: Diabetes Mellitus, Diabet- exist for grading severity of DR. In Zambia 73 the United Kingdom Diabetic Retinopathy African studies have shown low numbers Grading System (UKDRGS) using fundus of diabetic participants having routine eye photos is used (Table 1). In this study, the examinations. A study done in Tanzania UKDRGS was used [11]. looking at participants not being part of any screening programme for DR found Table 1: Grading of DR based on retinal that only 29% of participants had had an images eye examination in the previous year [12]. Similarly, in a South African study, 48.3% of participants had their last eye exam- ination more than a year and a half period [13]. However, in a Saudi Arabian study, about 95% of participants had regular eye examinations, much higher than in the Af- rican set up [14]. A multiple case study by Poore et al. (2014) evaluating DR screening pro- grammes in 2014 in Botswana, Ghana, Tanzania and Zambia noted a lack of local data in Africa on the scale of DR problem and that even in participants that were screened, uptake of referrals to the eye department was the main challenge [15].

Mild and moderate non-proliferative DR can be managed by good systemic glycae- mic control and regular ophthalmoscopy examinations. Severe Non-proliferative DR, proliferative DR and centre-involving macular oedema require urgent treatment to prevent vision loss. With the advent of retinal laser photocoagulation therapy and anti- Vascular Endothelial Growth Factor (VEGF) agents, DR and maculopathy can be treated to prevent blindness if detect- ed early enough [16]. Studies such as the Early Treatment of Diabetic Retinopathy Study (ETDRS) have shown that treat- ment with retinal laser photocoagulation can reduce the incidence of severe vision loss in participants with sight-threatening DR [17].

Diabetic Retinopathy Screening Timely screening and treatment for DR can prevent morbidity. As early DR is asymptomatic, the International Diabet- ic Foundation (IDF) guidelines recom- mend early detection of DR by means of DR screening which is very effective in the proper management of DR [19]. It is only through screening that diagnosis and treatment can be made at an early stage and prevent sight threatening DR [20]. The importance of eye screening programme is to reduce the risk of sight loss amongst people with diabetes by the prompt identification and effective treat- ment if necessary, of sight-threatening DR, at the appropriate stage during the disease process [21]. 74 rates of DM patients for DR [22]. athy grading was included. Other tools Feasible and efficacious methods for in- included a Snellen chart with pinhole, creasing screening follow-up rates include Several types of screening programmes Digital Retinography System (DRS, Cen- patient education, a streamlined referral have been designed throughout the world tervue, Italy) fundus camera and manual and scheduling process, and collaboration to meet the DR problem. We report on our Sphygmomanometer with local ophthalmologists and prima- active screening programme for diabetic ry care providers [18]. Diabetic patients eye disease and describe the sight and should be educated on the importance eye condition of the diabetic patients who Data collection procedure of regular eye examinations to detect have been involved in this programme. early retinopathy [18, 20]. Even with the PROCEDURE: control of retinopathy risk factors such as high blood pressure, high serum cho- METHODS Diabetic patients’ records were recruited lesterol, poor diabetic control, smoking, Study design to be included in the study at the adult obesity, and renal disease, regular ocular This was a retrospective study. hospital weekly medical clinic for diabetes examination is highly recommended [20]. Study duration and other endocrinology conditions. This is because long duration of the dis- January 2016 to June, 2019 Measurement of blood pressure, VA with ease is probably the most significant risk Study site pinhole to get the Best Corrected Visual factor for retinopathy [21]. Since diabetes The study was carried out at the Univer- Acuity (BCVA) was done. Ophthalmic is by nature a chronic ailment, most pa- sity Teaching Hospitals (UTHs) in Lusa- nurses from the Eye hospital trained in tients ultimately develop retinopathy in ka. The DM patients in this study were fundus imaging and DR grading were used the course of the disease. recruited weekly from the medical clinic as research assistants. Then the patients’ (clinic 5) of the Adult Hospital and the pupils were dilated with a mydriatic that Prevention of visual loss in DR has im- outpatient clinic at the Eye Hospital. had a combination of tropicamide 0.8% proved considerably during the last Study population and phenylephrine 5%. 1 eye drop was in- decade, especially in northern Europe All diabetes mellitus patients seen at the stilled in each eye and repeated as needed due to robust screening programmes in medical and eye clinics at the UTHs to achieve adequate pupillary dilatation. place [22]. Patient compliance with DR Inclusion criteria screening is not optimal, as shown by at- All patients with a diagnosis of diabetes DRS fundus camera was used to capture tendance rates ranging from 32 to 85% mellitus attending the medical clinic at retinal images on patients dilated with [24,25,26,27,28]. To increase DR screen- the UTHs – AH and UTHs – EH were el- mydriatically dilated pupils. Both colour ing attendance, insight into incentives igible for DR screening programme and and red-free retinal images were captured and barriers to retinopathy screening could participate. Fundus photographs from both eyes and graded to assess the is necessary. However, longer diabetes taken were graded in accordance with severity of retinopathy. The worse eye or duration, older age and diabetes-relat- the DR grading system used in the UK the eye with a gradable image was used ed visual problems are associated with National Health service (NHS). Visual in the analysis. The principle investigator screening compliance [28,29]. In the impairment data were collected from vi- read all retinal images and graded us- USA, financial barriers are also often re- sual acuity measurements recorded using ing the international classification of DR. ported [27,28,29,30]. Nevertheless, the Snellen chart. One ophthalmologist reviewed randomly main barrier for compliance was the pa- Exclusion criteria selected images to ensure quality and ad- tient’s belief that they do not have DR None was excluded herence to the international standard and [31]. Other factors were embarrassment Study sample protocol for the study. about poor glycaemic control and fear All diabetes mellitus patients seen at the of ophthalmological examination and medical clinic and the eye clinic who have Sight-threatening DR was defined as any treatment [32]. Many conclude that pa- not had it done and those due for their of the following: moderate pre-prolifera- tients’ lack of awareness (due to lack of annual DRS. For the study, no patient was tive retinopathy or worse (level 40–71 +); education/ information) is the main ob- recruited more than once. macular exudates in a circinate pattern stacle to attend a screening programme Sampling technique or within one disc diameter of the foveal [26,32,33,34,35]. In view of the major Every consecutive diabetic patient meet- centre or clinically significant macular oe- investments in screening and treatment ing inclusion criteria was included in the dema (level 3–4: sight-threatening macu- programmes, developing interventions study. lopathy); or other diabetes-related retinal to reduce non-compliance should be a Data collection instruments vascular disease: central or branch retinal priority [23]. another barrier is the mak- A researcher-administered questionnaire artery occlusion, central or branch retinal ing of appointments for eye screening at adapted from the current form used in vein occlusion. the eye facilities which be situated far screening programme at UTHs - Eye Hos- Data analysis from the medical clinic and could have a pital and Adult Hospital. The question- Data was collected and entered in Excel programme that is not aligned to favour naire contained information regarding the spread sheet. Analysis was then done immediate attention of the DM patients. demographic characteristics of the pa- using SPSS version 24. Continuous vari- There is also the barrier of travelling long tients, the relevant diabetic medical and ables were tested for normality using distances to go for eye check-up. These ocular history. A section for the findings of Shapiro-Wilk test. The chi square and barriers result in low uptake and follow-up blood pressure, visual acuity and retinop- Mann-Whitney tests were used to com- 75 pare no DR to DR depending on the type The University of Zambia Biomedical Re- terparts 63.7% (967/1517). Mean age of variable. To determine the correlation search Ethics Committee (UNZABREC) was 55. (SD 14.1), median age was 58 between two normally distributed inde- approved the study (reference number (SD14.1) and range was 66 years. Mean pendent variables Pearson coefficient 169-2019) and was carried out in com- reported duration of diagnosed diabetes was used; while Spearman coefficient pliance with the Helsinki Declaration was 4 years (SD 3.1), median was 5 years was used for non-normally distributed (2006). Further approval was obtained and range was 45 years. variables. In the final analysis to rule out from Ministry of Health of Zambia through confounders, a multiple logistic regres- the UTHs to use the data capture records. The clinical characteristics of the patients sion model was constructed using a cut Limitations of the study included in statistical analysis were: type off of 20% for the variables. Age, HbA1c This study was a retrospective one and 1 diabetes 10.5% (160/1517), type 2 di- (in some patients) and use of Anti-HTN some data could not be found. abetes 80.6% (1223/1517) and unspec- medication were included in the final ified diabetes 8.9% (134/1517). The fe- analysis due to significant associations males had more type 2 diabetes at 63.8% (780/1223) than their male counterparts, 36.2% (443/1223). However, there was no statistical difference between the fe- males and the males, p = 0.665; table 5. The type 2 diabetes patients had suf- fered more from hypertension 43.7% (534/1223) than the type 1 patients 25.0% (40/160) and this was statistically significant, p < 0.001; table 5.

Family history of diabetes was positive in 51.5% (781/1517) and 48.5% (736/1517) reported no family history of diabetes. Family history was statistically signifi- cantly different between the types 1 and 2 diabetic patients with 53.2% (649/1223) of type 2 diabetes having a positive family history compared to 40.5% (64/160) of the type 1 cohort; table 5. Of the 160 type 1 diabetes patients, 89.4% (143/160) were on insulin compared to 32.3% (395/1223) of the type 2 diabetes pa- tients. The majority 61.0% (746/1223) of the type 2 diabetes patients while 2.6% (32/1223) were on both oral hypoglycae- mics and insulin.

Diabetic retinopathy The prevalence of DR was graded based on the worst affected eye and the re- sults are shown in Table 6. Sixty point eight per cent (60.8% (922/1517)) of all DM patients (type 1, type 2 and type unspecified) showed evidence of DR. Forty one per cent of patients graded (41.0% (623/1517)) had sight threaten- ing DR. Five point seven per cent (5.7% (86/1517)) of all patients were graded as having proliferative DR which was distrib- RESULTS uted as 3.8% in type 1 diabetics (6/160) Demographic details compared to 5.8% (71/1223) of type 2 di- found in several other studies. The model A total of 1517 diabetic patients were abetics (p = <0.001). helped identify factors that were associ- screened from January 2016 to June 2019. ated with DR after adjusting for baseline Of the 1517 patients 93.8% had at least Prevalence of sight threatening DR was characteristics. A p-value <0.05 was re- one eye of gradable quality for statistical 31.3% (50/160) in type 1 diabetics com- garded as significant. analysis. The male patients represented pared to 43.1% (526/1517) of type 2 (p = Ethical considerations 36.3% (550/1517) and the female coun- <0.001). 76

77 78 DISCUSSION between ethnic, socioeconomic, and geo- olina, diabetes patients were seen for ini- The DR screening programme at the graphical groups nationally and in North tial eye examinations; retaining these pa- UTHs meets the World Health Organi- Carolina [39]. A North Carolina survey tients for their follow-up has been a bigger zation criteria for screening programmes, of people with diabetes showed that ap- challenge [18]. This difficulty in following which stipulates that early DR must be proximately 70% of non-Hispanic whites up with patients is not just a USA phe- recognized, acceptable treatment options and African Americans received eye ex- nomenon; a study by Keenum et al. based available and recognize DR as an import- aminations in the year before the survey, largely on an African American popula- ant public health concern [36]. Efforts compared to 61% of Native Americans tion in an urban setting, less than 30% to increase patient screening for DR and 52% of Hispanics [39]. The study of the study participants adhered to their should accompany efforts to increase did not investigate the details of possible recommended follow-up ophthalmic ex- patient education regarding the disease. disparities among the people seeking DR aminations [43]. These patients had ac- This is the practice currently at the UTHs. services. cess to a health care centre housing both Despite efforts to educate people about ophthalmology and primary care physi- DR in USA in 2012, the national survey Screening rates also vary by geographic cians in the same building that welcomed showed that 73% of adults aged 40 and location, with rural populations having patients, including those without insur- over with DR were unaware of their con- lower rates of screening, likely due to is- ance [43]. Poor compliance was more so dition [37]. At the UTHs only 25.7% of sues with access to care [40]. In this study in younger patients [43]. This is what was the participants were not aware of the 81.5% were from the urban setting and implemented at the UTHs where a one DR challenge. This was particularly so in 18.5% from the rural setting/high density stop DR screening clinic was created were patients with less severe DR, shorter di- areas. Diabetes patients with retinopathy patients were attended by the physicians abetes duration, and lack of a recent eye who have access to retinopathy screening and soon after that the ophthalmic team examination just as was reported in other at or near the office of their primary care took over and conducted a thorough DR studies [37]. This shows that eye health provider may more likely be screened out screening. This collaboration strategy led education and promotion must be an of convenience compared with those who to uptake increase of 57%. ongoing programme. Some studies have are referred to an eye health care special- The strategy also created convenience shown that follow-up rates increase most ist [41]. This tends to be the case in the for the patients to be attended to and pa- with education. A randomized, controlled hospital settings as well were we saw tients were not required to make appoint- study in 1999 showed that intensive edu- that uptake improved by 57% when the ments of being attended at a later date at cation to an intervention group increased screening was introduced at the medical the UTHs EH. follow-up appointment rates to about clinic. Other potential barriers to screen- 54%, from about 27% [38]. This should ing include financial difficulties and lan- The fact that this study minimized the ac- include the sensitisation and education guage differences [42]. This was not a cess barriers to immediate screening and of physicians and nurses dealing with barrier in our case. aided with scheduling follow-up, suggests DM patients in the medical departments. that additional barriers to DR screening This proved to be very crucial in improv- Improving screening rates for DR can im- can be overcome through more collab- ing uptake at the UTHs by setting up a prove focus for research and inform policy. oration with all the stakeholders dealing DR screening facility at the medical clinic. This can also help in enhancing interven- with DM. More research is needed to Health promotion was also critical in this tions utilized in different communities to elucidate factors involved in low uptake exercise which further improved the up- increase patient and provider awareness, and follow-up rates. Anecdotal data at the take of the DR screening services. collaboration with community-based pro- UTHs EH showed that only 25.0% of the grammes and disciplines, using electronic DM patients adhered to the recommend- Current DR screening guidelines recom- medical records and automatic remind- ed follow up plans. mend a retinal examination of at least ers, utilizing mobile diabetes clinics, and once per year in type 1 diabetics 5 years af- providing services in multiple languages CONCLUSION ter diagnosis whereas Type 2 diabetes pa- [42]. The University of North Carolina’s A one stop DR screening clinic is fun- tients should be examined immediately at management of diabetes patients is a damental in improving the uptake of DR the time of diagnosis and at least annually current example of a health care system services. Cascading screening for DR re- thereafter. More frequent examinations utilizing electronic medical records, au- quires effective strategies such collabora- are advised for patients with progressing tomatic reminders, and interdisciplinary tion between the physicians and the oph- retinopathy [10]. The retinal examination collaboration [18]. The UTHs have to in- thalmologists within the hospital setting. should be conducted by an ophthalmol- troduce electronic data capture and re- This strategy increased uptake and follow ogist, optometrist or a medical licentiate cords for easy access and to prevent loss up of DR patients at the UTHs by 57%. in ophthalmology (known as ophthalmic of records and to promote interdisciplin- This led to early detection of DR and early medical practitioner (OMP)) who should ary collaboration. This should be escalat- intervention in case of sight threatening look through a dilated pupil using the indi- ed to the whole country in order to cap- DR. Fundus photography improves DR rect or direct ophthalmoscope or slit lamp ture all DM patients and screen them for screening and retention because screen- biomicroscopy [10]. This is the practice at DR and later store data for planning and ing will be done by other medical person- the UTHs. research purposes. nel and ophthalmologists will grade the photos later and come up with manage- Disparities in screening rates exist In many locations around North Car- ment plans. 79 RECOMMENDATIONS compared to in-person screens. It is also One way of implementing tele-medicine Fundus photography telemedicine pro- cost-effective and generally well-liked by and tele-screening is by utilisation of the vides an alternative strategy for obtaining patients. System alerts can also be used in training hubs for the Levy Mwanawasa the retinal examination. This method in- letting primary care providers know when Medical University (LMMU). This will en- volves a trained photographer taking ret- eye examinations are due and when they hance both training and screening of DM inal images and sending them to a remote have been completed, giving them the op- patients for DR and the images will be an- trained reader (typically an ophthalmol- portunity to remind and counsel patients. alysed and interpreted from the DR centre ogist or DR graders) for interpretation. Putting up fundus photography across the at LMMU. Fundus photography telemedicine has country and training people to capture the Acknowledgments been shown to have acceptable sensitiv- images for transmission to the DR grading Potential conflicts of interest. All authors ity and specificity for screening of diabetic centre will prevent patients from travel- have no relevant conflicts of interest. retinopathy ling long distances to be screened.

80 LIST OF REFERENCES

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83 AWARENESS AND KNOWLEDGE OF GLAUCOMA AMONG EYE PATIENTS ATTENDING THE UNIVERSITY TEACHING HOSPITALS EYE HOSPITAL Research Article By : *K I M Muma 1,3, G Zulu1, T Mumba – Malisawa1, J I. M. Nyalazi1, L Chinama – Musonda2, G Syakantu3 1 University Teaching Hospitals Eye Hospital, Lusaka, Zambia 2Eye Department, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia 3School of Medicine and Health Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia *E-mail Addresses: Kangwa M. I. Muma: [email protected] and [email protected]

Citation Style For This Article: Muma K I M, Zulu G, Mumba – Malisawa T, Nyalazi J I M, Chinama – Musonda L, Syakantu G. Awareness and knowledge of glaucoma among eye patients attending the University Teaching Hospitals Eye Hospital. Health Press Zambia Bull. 2019; 3(10); pp 84-88.

ABSTRACT er levels of education and family history tives have been reported as an important Aim: To assess the awareness and knowl- of glaucoma. source of information regarding glauco- edge levels of glaucoma among eye pa- Conclusion: Awareness and knowledge ma [11]. However, a high awareness level tients attending the University Teaching about glaucoma was fairly good among does not indicate that the individual has Hospitals Eye Hospital. the eye patients attending the clinic at complete knowledge regarding glaucoma Background: Awareness and knowledge the University Teaching Hospitals Eye or enough understanding of the disease. on glaucoma can be vital in the fight Hospital. Participants with lower levels For example, several studies indicate that against blindness due to glaucoma. Spread of education were less aware and knew most individuals do not have an accurate of knowledge regarding some well-recog- less about glaucoma than their counter- understanding of this disease despite be- nized risk factors for glaucoma may en- parts with higher education levels. The ing aware of this disease [6-9]. Almost courage more awareness. For instance, a study findings stress the need for health 40% of the study participants had inade- risk factor such as a positive family history education and eye health promotion for quate knowledge of glaucoma [11]. of glaucoma, raises awareness because it effective prevention of blindness due to In describing the changing dynamics re- encourages a search for more information glaucoma. garding HIV infection patterns in Zambia, regarding the disease and its assessment. Keywords: Awareness, glaucoma, knowl- Michelo et al. (2006) argues that “life- Methods: This was a cross section study edge styles, cultural practices and communi- to assess the awareness and knowledge cation patterns may significantly differ levels of glaucoma. A total of 1714 partic- INTRODUCTION by educational attainment. However, ipants aged 18 to 98 years were recruited Owing to the asymptomatic nature of whenever change happens, it does most for the study. Respondents “having heard glaucomatous progression, glaucoma may probably begin with the higher educated of glaucoma” even before they were con- remain undetectable in most of the cases groups [12]. This could therefore explain tacted/recruited for the study were de- until it reaches an advanced stage [1]. This the lower risk levels of glaucoma seen fined as “aware” and respondents having finding highlights the high burden of dis- among higher educated groups. On the some understanding of the glaucoma dis- ease despite the existence of many effec- other hand, we are aware that there is no ease were defined as “knowledgeable”. tive treatments [1,2]. It is estimated that other study that has made this observa- Results: 1625 (94.8%) subjects complet- approximately 90% of glaucoma-related tion on the association of education and ed a questionnaire that assessed their blindness is preventable with proper early prevalence of POAG, thereby this study awareness and knowledge level of glau- treatment [3]. One of the most important endeavouring to do that coma. Overall 1,162 (71.5%; 95% CI: 70.7 and effective actions for early detection – 73.9) participants were aware of glauco- of glaucoma and its management may be MATERIALS AND METHODS ma and 899 (55.3%; 95% CI: 51.3 - 72.1) raising public awareness and knowledge Study area and population had some knowledge about glaucoma. levels regarding the disease. Different A cross sectional survey of 1,714 partic- Awareness of glaucoma was not statisti- levels of glaucoma awareness have been ipants aged 18 to 98 years old was con- cally significant in terms of age (P =0.43) reported in different populations [4-9]. ducted on POAG at the UTHs Eye Hos- and gender (P =0.87). Literate partic- Published studies from developing coun- pital in Lusaka, Zambia. The UTHs Eye ipants were four times more likely to be tries indicate low levels of awareness, [4- Hospital is the national referral eye hospi- aware and seven times more likely to be 6] while those from developed countries tal which provides ophthalmological sur- knowledgeable than illiterate participants suggests higher levels of awareness [7- gical and clinical services. The UTHs’ Eye (P value < 0.001). The level of education 9]. Spread of knowledge regarding some Hospital is estimated to cater for more had a significant association with both well-recognized risk factors for glaucoma than 21,000 clients annually for both rou- awareness and knowledge (p=0.001). In may encourage more awareness. These tine and morbidity driven health care. The addition, participants who were related or include a positive family history of glauco- clients that attend this clinic come from known to glaucoma patients were more ma, which is associated with higher glau- across the country and include both self- likely to be aware and knowledgeable than coma awareness [5,7,10]. This is because and system-referrals, representing all age other participants (Odds ratio: 4.11; 95% the presence of this risk factor encourages groups and all ethnic groups. CI: 2.12 – 5.45). Determinants of glauco- a search for more information regarding A systematic random sampling using ma awareness and knowledge were high- the disease and its assessment. The rela- 50% - time sampling was employed 84 which meant that of the 220 (on average) Table 1: Gender distribution of partici- in glaucoma was noted in 331 (20.4%; eye patients seen in the outpatient eye pants; N = 1625 95% CI: 17.9 - 25.8) of the respondents. clinic every month, 110 were to be picked to participate in the study. This translat- ed to a minimum 1320 participants to be recruited into the study for a period of twelve months. To cater for attrition and assuming a response rate of 80%, the sample size of the study pegged at 1,714 participants. Only 1625 (94.8%) eye pa- tients consented to study participation of which 309 had glaucoma. Five hundred and fifty-one (33.9%; 95% General awareness regarding glaucoma Most of the participants were females 871 CI: 28.1 - 38.3) responded that glaucoma among patients was assessed using the (53.6%) versus 754 (46.4%) male partic- could be treated and 625 (38.5%; 95% following broad questions: ipants (p=0.789), [Table 1]. The age range CI: 37.2 - 40.4) new that glaucomatous i.If they had previously heard of glaucoma of participants was 20 to 98 years with a eyes could become blind. Interestingly, ii.If they were aware of glaucoma running mean age being 51 years. 826 (50.8%; 95% CI: 44.7 – 56.7) of the in families respondents believed that glaucoma was iii.If they knew about the role of intra ocu- Table 2: Awareness of glaucoma; glau- the same as trachoma. lar pressure in causing glaucoma coma patients vs non-glaucoma patients One hundred and fifteen respondents iv.If the visual loss due to glaucoma is ir- N=1625 (7.1%; 95% CI: 3.9 - 10.4) considered that reversible or not and that it causes blind- screening could prevent glaucoma, but ness v.If they were aware of any treatment mo- dalities available for glaucoma. We defined “awareness” as having heard about the disease. Awareness was ac- cordingly classified. Having glaucoma knowledge was classified based on the other responses provided for the ques- tions above. Ethical statement The University of Zambia Biomedical Re- search Ethics Committee approved the Awareness was statistically different only 517 (31.8%; 95% CI: 27.9 – 36.1%) study (reference number 013-08-12). Fur- (p=0.033) between the glaucoma patient had undergone screening/consulted an ther approval was obtained from Ministry and the non-glaucoma one, Table 2. ophthalmologist in the previous year. of Health of Zambia through the UTH Source of information for 343 (21.1%; 95% A total of 1,162 (71.5%; 95% CI: 70.7 – CI: 17.4 – 24.7) participants was ‘word of RESULTS 73.9) participants were aware of glauco- mouth’ from family or friends. Another Of the 1,714 patients, 89 (5.2%) did not ma and 899 (55.3%; 95% CI: 51.3 - 72.1) 1,031 (63.4%; 95% CI: 59.1 - 68.3) par- accept to be in the study due to various had some knowledge about glaucoma ticipants had received information from reasons. Therefore, a total of 1,625 people (Tables 2 and 3). visiting hospitals, medical personnel, eye were screened giving a 94.8% response Awareness of glaucoma was not statisti- camps or other healthcare recourses. rate. cally significant in terms of age (P =0.43) Mass media was source of information and gender (P =0.87). Literate partic- for 251 (15.4%; 95% CI: 11.9 – 20.2) of the ipants were four times more likely to be participants. aware and seven times more likely to be No associations were found between knowledgeable than illiterate participants gender and awareness or knowledge of (P value < 0.001). The level of education glaucoma (p = 0.765) or age (p = 0.875). had a significant association with both 258 (76.3%; 95% CI: 72.1 – 79.3) partic- awareness and knowledge (p=0.001). In ipants were aware of glaucoma and the addition, participants who were related or same number (258) of participants had known to glaucoma patients were more some knowledge about glaucoma (Tables likely to be aware and knowledgeable than 1 and 2). There was a positive association other participants (Odds ratio: 4.11; 95% between glaucoma awareness and educa- CI: 2.12 – 5.45). tion level (p<0.0001). A total of 199 (12.2%; 95% CI: 10.4 - 17.5) participants understood the risk of famil- ial predisposition to glaucoma. Awareness about the irreversible nature of vision loss 85 DISCUSSION vey from Australia, 93% of 3,654 adult inheritance of glaucoma. Lack of aware- The study looked at awareness and study participants had awareness regard- ness regarding heritability of glaucoma has knowledge of glaucoma in patients with ing glaucoma [14]. been reported to vary from 21% to 68% glaucoma and those without glaucoma. Costa et al. (2006) and associates as- [11,23]. Deokule and associates found The process of behavior changes, which sessed and compared awareness re- that 41% of patients with glaucoma were culminates in action and maintenance, garding glaucoma in two groups of study aware of a risk for glaucoma in their family requires awareness and knowledge as its participants. One group consisted of high members, even though 45% of their fami- starting point [13]. Glaucoma is a highly level of educated American patients with ly members were not screened for glauco- prevalent ocular disease with a natural glaucoma, while the other comprised low ma [24]. Therefore, providing information course that ultimately leads to blindness level of educated Brazilian patients with to patients with glaucoma regarding the as compliance with treatment may im- glaucoma. The authors found significant heritability of glaucoma and necessity of prove with excellent patient knowledge differences between these two groups screening of their family members is cru- and awareness. It may also lead to aware- and concluded that differences in edu- cial. This would encourage patients to in- ness among the patients’ relatives and cational level lead to this disparity [21]. form their family members regarding the encourage them to participate in screen- In this study, the high number of partic- prognosis of glaucoma and their higher ing programmes. Low levels of aware- ipants with secondary and tertiary ed- chance of being affected by this blinding ness of glaucoma highlight the need for ucation may have led to the high rate of disease compared to the general popu- public education regarding this disease. glaucoma awareness. This correlates well lation. To achieve this, clinicians should It was discovered that knowledge regard- with national literacy levels which stands periodically ask their patients about the ing this condition was insufficient in both at over 60%.16 The findings of a study awareness of their relatives regarding the glaucoma patients and those without conducted by Gogate and colleagues from their diagnosis and whether their family glaucoma. Early diagnosis and institution India are consistent with this idea. In that members have participated in glaucoma of treatment can result in reduction of study, which found lower levels of glauco- screening examinations. The slightly low visual impairment and blindness, as the ma awareness, most study participants level of knowledge among the patients main predictor of eventual blindness is a were less educated [22]. Our results in- and non-patients highlights the impor- late presentation of the disease. dicate that level of education is the stron- tance of education for enhancing overall Awareness was defined as having heard gest explanatory variable for glaucoma knowledge of glaucoma. This knowledge about the disease. Our results indicate awareness. may encourage these individuals to seek that 89.0% of patients with glaucoma and In describing the changing dynamics re- glaucoma-screening examinations and 67.4% of those without glaucoma were garding HIV infection patterns in Zambia, help reduce the number of severe cases of aware of glaucoma. The most striking Michelo et al. (2006) argues that “life- this blinding condition. result from our study is that only 89.0% styles, cultural practices and communi- In a study from Germany, participants’ rel- of the cases (patients with) of glaucoma cation patterns may significantly differ by atives were the main sources of informa- were aware of the disease. The glauco- educational attainment. However, when- tion regarding glaucoma [25], while mass ma knowledge was high (64.5%) in our ever change happens, it does most proba- media was found to be the main source of study compared to studies from Australia bly begin with the higher educated groups information in a study from India [1]. In and India who respectively reported that [12]. Therefore, the lower risk levels of the current study, study participants de- 29% and 40.6% of the participants had glaucoma seen among higher educated clared that close acquaintances were their knowledge regarding glaucoma [14,15]. groups may be a stage of progression. On main source of information. Our observa- This difference with our study may be at- the other hand, we are aware that there is tions may be due to selection bias, as all tributed to the slightly high literacy rate in no other study that has made this obser- of our study participants were hospital re- the country which stands at 63.4% [16]. vation on the association of education and cruited. This should be considered when There are some differences in aware- prevalence of POAG, thereby calling for interpreting the results of our study. ness of glaucoma in different areas and additional observational studies on this There are inconsistent findings regard- nations. For instance, a study from Mel- factor. In addition, the glaucoma patients ing the relationship between gender and bourne, Australia, reported awareness of should also be encouraged to persuade awareness of glaucoma. In a few studies glaucoma in 76% of the general popula- their relatives to seek glaucoma-screen- from various countries, lack of glaucoma tion, while a population-based study from ing examinations. Certainly, this would awareness was associated with male gen- Nepal reported a very low (2.4%) level of lead to early diagnosis of the glaucoma in der [13,26], while the opposite has been glaucoma awareness [4,17]. In a study in the relatives. reported in other studies [4,27]. Other Barbados, 51% of participants with glau- Patients who were unaware of their diag- studies found no gender differences as- coma were unaware of their diagnosis nosis were most probably unaware of the sociated with knowledge or awareness of compared to our study where 53.6% were possibility of glaucoma being a heritable glaucoma [14,25,28]. This study equally aware of their diagnosis [18]. The 71.5% disease. In this study, only 199 of 1,625 found the same. observed level of glaucoma awareness in (12.2%) participants believed that a pos- this study is consistent with the data in itive family history was a risk factor for CONCLUSSIONS published reports from the United States, glaucoma. This may indicate the necessity The awareness and knowledge levels of which indicate that 70–93% of partici- of urgent action regarding patient knowl- glaucoma were fairly low. These findings pants attending eye clinics have heard edge of glaucoma and the need to provide suggest that there is a need for health about glaucoma [7,19,20]. In another sur- patients with useful information regarding education in this Zambia population to 86 increase their level of awareness and RECOMMENDATIONS As awareness about glaucoma can lead knowledge of glaucoma. Education level Community sensitization and education to early detection, a very important step was found to be a predictor of knowledge would be an effective and feasible public in preventing glaucoma-related blind- and awareness of glaucoma. Inadequate health strategy to enhance knowledge ness; [29] similarly educating masses knowledge in the general population may and awareness of glaucoma, especially will cardinal in improving awareness. Fur- be an important cause for failure to detect among individuals with a family history of thermore, there is a need to identify inter- glaucoma early and may result in blind- the disease. This approach may ultimately ventions that reinforce people’s attitude ness from the disease. reduce loss of vision due to glaucoma. above the perceived level of awareness about glaucoma and to devise strategies that can influence behavior to the risk of blindness from glaucoma.

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