Managing a patient with open-angle glaucoma: a case study.

How would a panel of experts manage the case presentation of Mr AA

Primary open angle glaucoma in northern Nigeria: stage at presentation and acceptance of treatment.

BACKGROUND: To determine the stage of primary open angle glaucoma at presentation at a tertiary eye unit, to assess patient's knowledge of glaucoma and acceptance and subsequent adherence to treatment. METHOD: Information collected prospectively on new glaucoma patients aged 30 or more years included distance from residence and what they knew about glaucoma and its treatment. Treatment offered took account of disease severity and socioeconomic factors. Reasons for not accepting surgery were recorded. At follow up intraocular pressure (IOP) was measured and adherence to medication assessed verbally. Four categories of severity were defined based on visual acuity and visual fields defects in the worse eye. RESULTS: 131 patients were recruited (mean age 52.8 years; 62% male). Most attended because of symptoms (70%). Mean IOP in affected eyes was 31.9+/-SD 12.4 and mean vertical cup:disc ratio was 0.8. 99 eyes (47%) had a visual acuity of light perception or worse. Risk factors for advanced/end-stage disease were age >50 years, living >10 km from the hospital, some awareness of glaucoma, not being literate, being unemployed and presenting with symptoms. In multivariable analysis older age and poor knowledge of glaucoma remained independent risk factors. 75 were offered trabeculectomy: five agreed but only one underwent surgery. Reasons for rejecting surgery were fear (37%), preferred medical treatment (27 %) and cost (15 %). 32/85 (24 %) participants started on topical medication attended follow up. 72% reported excellent compliance but only 56% of glaucomatous eyes had IOPs less than 21 mmHg. CONCLUSIONS: To prevent glaucoma blindness strategies are required which promote earlier detection, with counselling to promote acceptance of and adherence to treatment

The basics of good postoperative care after glaucoma surgery.

Glaucoma patients are treated by lowering the intraocular pressure (IOP) to a level that it is not harmful to the optic nerve. This prevents or delays loss of vision. Lowering of the IOP can be achieved through use of eye medication, surgery or laser procedures. The most common glaucoma surgery is trabeculectomy

Coverage of hospital-based cataract surgery and barriers to the uptake of surgery among cataract blind persons in nigeria: the Nigeria National Blindness and Visual Impairment Survey.

PURPOSE: To determine cataract surgical coverage, and barriers to modern cataract surgery in Nigeria. METHODS: Multistage stratified cluster random sampling was used to identify a nationally representative sample of 15,027 persons aged 40+ years. All underwent visual acuity testing, frequency doubling technology visual field testing, autorefraction, and measurement of best corrected vision if <6/12 in one or both eyes. An ophthalmologist examined the anterior segment and fundus through an undilated pupil for all participants. Participants were examined by a second ophthalmologist using a slit lamp and dilated fundus examination using a 90 diopter condensing lens if vision was <6/12 in one or both eyes, there were optic disc changes suggestive of glaucoma, and 1 in 7 participants regardless of findings. All those who had undergone cataract surgery were asked where and when this had taken place. Individuals who were severely visually impaired or blind from unoperated cataract were asked to explain why they had not undergone surgery. RESULTS: A total of 13,591 participants were examined (response rate 89.9%). Prevalence of cataract surgery was 1.6% (95% confidence interval 1.4-1.8), significantly higher among those aged ≥70 years. Cataract surgical coverage (persons) in Nigeria was 38.3%. Coverage was 1.7 times higher among males than females. Coverage was only 9.1% among women in the South-South geopolitical zone. Over one third of those who were cataract blind said they could not afford surgery (36%). CONCLUSIONS: Cataract surgical coverage in Nigeria was among the lowest in the world. Urgent initiatives are necessary to improve surgical output and access to surgery

Epidemiology of glaucoma in sub-saharan Africa: prevalence, incidence and risk factors.

PURPOSE: The purpose of this study is to review the epidemiology of different types of glaucoma relevant to Sub-Saharan Africa (SSA) and to discuss the evidence regarding the risk factors for onset and progression of glaucoma, including risk factors for glaucoma blindness. METHODS: Electronic databases (PubMed, MedLine, African Journals Online- AJOL) were searched using the full text, Medical Subject Headings (MeSH) terms, author(s) and title to identify publications since 1982 in the following areas: population-based glaucoma prevalence and incidence studies in SSA and in African-derived black populations outside Africa; population-based prevalence and incidence of blindness and visual impairment studies in SSA including rapid assessment methods, which elucidate the glaucoma-specific blindness prevalence; studies of risk factors for glaucoma; and publications that discussed public health approaches for the control of glaucoma in Africa. RESULTS: Studies highlighted that glaucoma in SSA is a public health problem and predominantly open-angle glaucoma. It is the second-leading cause of blindness, has a high prevalence, an early onset and progresses more rapidly than in Caucasians. These factors are further compounded by poor awareness and low knowledge about glaucoma even by persons affected by the condition. CONCLUSION: Glaucoma care needs to be given high priority in Vision 2020 programs in Africa. Many questions remain unanswered and there is a need for further research in glaucoma in SSA in all aspects especially epidemiology and clinical care and outcomes involving randomized controlled trials. Genetic and genome-wide association studies may aid identification of high-risk groups. Social sciences and qualitative studies, health economics and health systems research will also enhance public health approaches for the prevention of blindness due to glaucoma

Risk factors for open-angle glaucoma in Nigeria: results from the Nigeria National Blindness and Visual Impairment Survey.

BACKGROUND: The glaucoma-specific blindness prevalence in Nigeria (0.7 %, 95 % CI 0.6-0.9 %) among those aged ≥40 years is one of the highest ever reported. This study determined the risk factors for open-angle glaucoma (OAG) in adults examined in the Nigeria National Blindness and Visual Impairment Survey. METHODS: A nationally representative sample of 13,591 people aged ≥40 years in 305 clusters in Nigeria were examined (response rate 90.4 %) between January 2005 to June 2007. Everyone had logMAR visual acuity measurement, Frequency Doubling Technology (FDT) visual field testing, autorefraction, A-scan biometry and optic disc assessment. Full ocular examination (n = 6397), included Goldmann applanation tonometry. Values for defining glaucoma using International Society of Geographical and Epidemiological Ophthalmology criteria were derived from the study population. Disc images were graded by Moorfields Eye Hospital Reading Centre. Socio-demographic factors (age, gender, ethnicity, literacy and place of residence), ocular parameters (intraocular pressure [IOP], axial length and mean ocular perfusion pressure [MOPP]) and systemic parameters (blood pressure, blood glucose and body mass index [BMI]) were assessed for association with OAG. RESULTS: Thirteen thousand eighty-one (96 %) of 13,591 participants had vertical cup:disc ratio measured in at least one eye. 682 eyes of 462 participants were classified as OAG, with 12,738 controls. In univariate analyses the following were associated with OAG: increasing age, male gender, Igbo and Yoruba ethnic groups, illiteracy, longer axial length, higher IOP, lower MOPP, greater severity of hypertension and low BMI (underweight). In multivariate analysis, increasing age (odds ratio [OR] 1.04, 95 % CI 1.03-1.05), higher IOP (OR 1.22, 95 % CI 1.18-1.25) and Igbo ethnicity (OR 1.73, 95 % CI 1.18-2.56) were independent risk factors for OAG. CONCLUSION: Case detection strategies for OAG should be improved for those aged ≥40 years and for ethnic groups most at risk as a public health intervention

Adapted motivational interviewing to improve the uptake of treatment for glaucoma in Nigeria: study protocol for a randomized controlled trial.

BACKGROUND: Glaucoma is a chronic eye disease associated with irreversible visual loss. In Africa, glaucoma patients often present late, with very advanced disease. One-off procedures, such as laser or surgery, are recommended in Africa because of lack of or poor adherence to medical treatment. However, acceptance of surgery is usually extremely low. To prevent blindness, adherence to treatment needs to improve, using acceptable, replicable and cost-effective interventions. After reviewing the literature and interviewing patients in Bauchi (Nigeria) motivational interviewing (MI) was selected as the intervention for this trial, with adaptation for glaucoma (MIG). MI is designed to strengthen personal motivation for, and commitment to a specific goal by eliciting and exploring a person's reasons for change within an atmosphere of acceptance and compassion. The aim of this study is to assess whether MIG increases the uptake of laser or surgery amongst glaucoma patients where this is the recommended treatment. The hypothesis is that MIG increases the uptake of treatment. This will be the first trial of MI in Africa. METHODS: This is a hospital based, single centre, randomized controlled trial of MIG plus an information sheet on glaucoma and its treatment (the latter being "standard care") compared with standard care alone for glaucoma patients where the treatment recommended is surgery or laser.Those eligible for the trial are adults aged 17 years and above who live within 200 km of Bauchi with advanced glaucoma where the examining ophthalmologist recommends surgery or laser. After obtaining written informed consent, participants will be randomly allocated to MIG plus standard care, or standard care alone. Motivational interviewing will be delivered in Hausa or English by one of two MIG trained personnel. One hundred and fifty participants will be recruited to each arm. The primary outcome is the proportion of participants undergoing laser or surgery within two months of the date given to re attend for the procedure. MIG quality will be assessed using the validated MI treatment integrity scale. DISCUSSION: Motivational interviewing may be an important tool to increase the acceptance of treatment for glaucoma. The approach is potentially scalable and may be useful for other chronic conditions in Africa. TRIAL REGISTRATION: ISRCTN79330571 (Controlled-Trials.com)

Causes of blindness and visual impairment in Nigeria: the Nigeria national blindness and visual impairment survey.

PURPOSE: Determine causes of blindness and visual impairment among adults aged >or=40 years. METHODS: Multistage, stratified, cluster random sampling with probability proportional to size procedures were used to identify a nationally representative sample of 15,027 persons >or=40 years of age. Distance vision was measured with a reduced logMAR tumbling E-chart. Clinical examination included a basic eye examination of all subjects and a more detailed examination of those who had presenting vision or=40 years who were enumerated, 13,599 (89.9%) were examined. In 84%, blindness was avoidable. Uncorrected refractive errors were responsible for 57.1% of moderate (40% over the next decade

Prevalence of blindness and visual impairment in Nigeria: the National Blindness and Visual Impairment Study.

PURPOSE: To determine the prevalence of blindness and visual impairment among adults aged > or = 40 years in Nigeria. METHODS: Multistage, stratified, cluster random sampling with probability proportional to size procedures was used to identify a cross-sectional nationally representative sample of 15,027 persons > or = 40 years of age from all 36 states in Nigeria and the Federal Capital Territory. Distance visual acuity (VA) was measured with a reduced logMAR tumbling-E chart at 4 and 1 m. Presenting and best corrected visual acuities were recorded. Autorefraction was performed in all examined adults. Clinical evaluations included examination under dilation for those with presenting vision or = 40 years were enumerated and 13,599 (89.9%) examined. Prevalence of blindness ( or = 40 years have moderate to severe visual impairment or blindness ( or = 40 years in Nigeria. Significant differences exist between the geopolitical zones and emphasis should be on ensuring eye services across Nigeria, which means that planning at the regional level is necessary