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Onchocerciasis in Ecuador: Ocular Findings in Onchocerca Volvulus Infected Individuals Br J Ophthalmol: First Published As 10.1136/Bjo.79.2.157 on 1 February 1995

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Onchocerciasis in Ecuador: Ocular Findings in Onchocerca Volvulus Infected Individuals Br J Ophthalmol: First Published As 10.1136/Bjo.79.2.157 on 1 February 1995 British Journal of Ophthalmology 1995; 79: 157-162 157 Onchocerciasis in Ecuador: ocular findings in Onchocerca volvulus infected individuals Br J Ophthalmol: first published as 10.1136/bjo.79.2.157 on 1 February 1995. Downloaded from P J Cooper, R Proaflo, C Beltran, M Anselmi, R H Guderian Abstract which is largely absent from the rain Little is known of the epidemiology and forest.7 clinical picture ofocular onchocerciasis in In the Americas, foci of disease have been South America. A survey of onchocercal described in Mexico, Guatemala, Colombia, eye disease was performed in the hyper- Venezuela, Brazil, and Ecuador. Earlier endemic area of a rain forest focus of reports from Guatemala58 and Venezuela9 onchocerciasis in Esmeraldas Province in indicated ocular pathology attributable to Ecuador. A total of 785 skin snip positive onchocerciasis. The absence of comprehensive individuals from black and Chachi reports on the current status of ocular Amerindian communities were examined. onchocerciasis in any of these foci has made it The blindness rate attributable to difficult to evaluate if blinding onchocerciasis onchocerciasis was 0.4%, and 8.2% were remains a major problem in these regions. visually impaired. Onchocercal ocular The epidemiology of the rain forest focus of lesions were seen in a high proportion of onchocerciasis in Esmeraldas Province of the study group: 33.6% had punctate Ecuador has been extensively studied.'0 keratitis, microfilariae in the anterior Current evidence suggests that the prevalence chamber and cornea were seen in 2890/o and intensity of infection and its geographical and 33.5% respectively, iridocyclitis was boundaries are expanding.11 12 This is because seen in 1.5%, optic atrophy in 5.1%, and of migration of infected individuals and the chorioretinopathy in 28.0%. Sclerosing presence of a highly efficient vector, Simulium keratitis was not seen. The prevalence of exiguum (Collins et al, unpublished observa- all ocular lesions increased with age. tions). Punctate keratitis was strongly associated There are no previous reports of the pattern with microfilarial counts in the cornea and of ocular onchocerciasis in Ecuador. This chorioretinopathy was correlated with paper describes the detailed ocular findings of infection intensities in the cornea and 785 Onchocerca volvulus infected individuals anterior chamber. Chachi Amerindians living in a hyperendemic area for onchocercia- http://bjo.bmj.com/ had higher anterior chamber microfilarial sis in Esmeraldas Province of Ecuador. counts and a greater prevalence of punc- tate keratitis than blacks though blacks had a greater prevalence of iridocyclitis Materials and methods and optic nerve disease. The pattern of ocular disease resembled rain forest STUDY POPULATION onchocerciasis in west Africa with few The study was performed in the hyperendemic on September 30, 2021 by guest. Protected copyright. severe ocular lesions in the anterior seg- area ofthe rain forest focus ofonchocerciasis in ment and all blinding lesions attributable the Santiago river basin of Esmeraldas to posterior segment disease. Province.10 The communities living in this area (BrJ Ophthalmol 1995; 79: 157-162) included both indigenous Amerindian (Chachi tribe) and black (of African descent) commu- nities. The ethnographic features ofthese com- Onchocerciasis is a major blinding disease in munities have been described elsewhere.13 the developing world. It is estimated that up to Patients were selected from 35 villages. The 18 million people are infected in Africa and single criterion for selection was a previously Central and South America.' Ofthese, approx- documented positive skin snip. Patients were imately one million are blind or suffer severe brought by canoe to a central examination cen- visual loss.2 tre for ocular assessment. The following infor- The clinical pattern of ocular onchocercia- mation was recorded for each patient: age, sex, sis differs from one geographical region to race, house location, and previous antifilarial Onchocerciasis another and sometimes between bioclimatic treatment. Control Programme, zones in the same region.3 For example, in Hospital Vozandes, west Africa, there are differences between rain Quito, Ecuador P J Cooper forest and savannah forms of ocular onchocer- PARASITOLOGICAL EXAMINATION R Proaflo ciasis. The prevalence of iritis, chorioretino- Skin biopsies were taken from both iliac crests C Beltran pathy, and optic atrophy is less in rain forest with a Stolz corneoscleral punch. The biopsies M Anselmi R H Guderian than in savannah areas.4-6 Blindness from were weighed and placed in micro well plates onchocerciasis is between 2-57 and 5 times6 in saline. The number of emergent microfilar- Correspondence to: more common Dr R H Guderian. in the savannah. Much of this iae were counted after 24 hours. The arith- excess is accounted for the advanced metic mean of the two was calculated for Accepted for publication by snips 20 September 1994 sclerosing keratitis found in the savannah each person. 158 Cooper, Proanio, Beltran, Anselmi, Guderian Table 1 Frequency distribution ofstudy population by age, sex, and race Age group (years) Br J Ophthalmol: first published as 10.1136/bjo.79.2.157 on 1 February 1995. Downloaded from 0-9 10-19 20-29 30-39 40-49 50+ Total Race Black 37 (12-9%/) 82 (28-60/) 44 (15-3%) 36 (12-5%) 41 (14-3%) 47 (16-4%) 287 (100%) Chachi 50 (10-00/) 145 (29-1%) 131 (26 3%) 67 (13-5%) 52 (10-4%) 53 (10-6%) 498 (100%) Sex Male 36 (8/3%) 150 (34.6%) 84 (19-4%) 60 (13-80/) 43 (9-9%) 61 (14-1%) 434 (100%) Female 51 (14-5%) 77 (21-9%) 91 (25/9%) 43 (12-3%) 50 (14-3%) 39 (11-1%) 351 (1000/%) Total 87 (11-1%) 227 (28/9%) 175 (22-30/) 103 (13-1%) 93 (11-9%) 100 (12-7%) 785 (100%) OPHTHALMIC EXAMINATION STATISTICAL ANALYSIS Uncorrected visual acuity was tested by illiter- Infection intensities of microfilariae in the skin ate E or literate Snellen charts at 6 metres in and anterior segment are expressed as the broad daylight. If either acuity was <6/12, it geometric mean number of microfilariae per was assessed with a pinhole. The following individual. Infection intensities are expressed as definitions for visual acuity were used: normal microfilariae per mg of skin. Comparison of acuity as 6/18 or better, visual impairment as proportions were analysed using x2 and of an acuity ofbetween 6/21 and 3/60, and blind- means using Student's t test. Spearman's rank ness as less than 3/60. Binocular visual impair- correlation coefficient was used to calculate the ment represents visual acuity in the better eye. correlation between two variables. Statistically Slit-lamp examination was conducted after significant findings by any of these three head down positioning of patients for 10 min- methods (p<0.05) were further analysed using utes using a Topcon slit-lamp. The numbers of multiple regression procedures to control for microfilariae in the anterior chamber were potential confounding factors. The regression counted. An arithmetic mean of counts from methods used were multiple logistic regression both eyes was calculated for each person. The for binary dependent variables and multiple following were also noted: the presence of live linear regression for continuous. dependent vari- and dead microfilariae and punctate opacities ables. The p values given in the text are those in the cornea, sclerosing keratitis, and cataract. obtained by the non-regression methods and Any other abnormality of the anterior chamber the results ofmultiple regression procedures are structures was recorded. Intraocular pressure only given where they do not confirm the find- measurements were performed on both eyes ings of these analyses (at p>0 05). Adjustment using a Goldmann applanation tonometer for age, sex, and race was performed by direct (Haag-Streit). Glaucoma was defined as an standardisation using the total population ofthe intraocular pressure greater than 25 mm Hg in hyperendemic area as standard. the presence of optic disc cupping or an intraocular pressure greater than 40 mm Hg in http://bjo.bmj.com/ the absence of disc cupping. After pupil dilata- Results tion with 1% tropicamide and 10% adrenaline, the ocular fundus was examined with a Keeler STUDY POPULATION indirect ophthalmoscope. The optic disc was A total of 785 persons aged 5 years or more examined for the presence of atrophy, papilli- (range 5-80, median 25) underwent parasito- tis, increased pigmentation, and sheathing of logical and ophthalmic examination. The age, the central retinal vessels. Abnormalities of the sex, and race distribution of this study sample on September 30, 2021 by guest. Protected copyright. retina and choroid were noted. Particular is shown in Table 1. There were no previous attention was paid to the presence of mottling histories of treatment with antifilarial drugs in or confluent atrophy of the retinal pigment the study population. epithelium (RPE) and chorioretinal scarring with pigment clumping, choriocapillary atro- phy, or both. SKIN INFECTION INTENSITY Ocular examinations were performed by two The overall intensity of infection by skin snip experienced ophthalmologists. No systematic test of interobserver variation was performed. 40 35 Table 2 Geometric mean microfilarial intensities in the 30 skin (MfS), anterior chamber (MfAC), and cornea (MfC) by race and sex 25 MfS MfAC MJC 2E 20 Race (mf/mg) (mf/eye) (mf/eye) C.)E 4)0 15 Black a,1 Male 22-7 0 4 0 4 10 Female 211 0-2 0-1 Total 22-0 0 3 0 3 Chachi 5 Male 32-0 1-0 0-6 Female 23-5 0 7 0 5 A Total 27-6 0-8 0 5 5-9 10-14 15-19 20-29 30-39 40-49 50+ Sex Age (years) Male 27-8 0-7 0 5 Female 22-7 0 5 0 4 Figure 1 Geometric mean microfilarial intensity in the Total 25-4 0-6 04 skin (MfS) by age.
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