Off-axis digital flash photography: a common cause of artefact leukocoria in children.

Leukocoria, a presenting sign in several significant pediatric ocular conditions, can be artefactually produced by off-axis flash photography in healthy eyes. The authors demonstrate the conditions needed to produce this phenomenon, which is more commonly seen in children due to their larger-sized pupils, photogenicity, and frequent off-axis shots

Longitudinal study of trachomatous trichiasis in The Gambia: barriers to acceptance of surgery.

PURPOSE: Investigation of compliance with surgery for trachomatous trichiasis has become a priority of the World Health Organization. This study was conducted to investigate attitudes toward trichiasis and its treatment and to determine the rate of surgical uptake in The Gambia. METHODS: A 1-year longitudinal study was performed in 190 subjects with trichiasis. Persons with major trichiasis (involving five lashes or more) were referred for surgery, and those with minor trichiasis were advised to epilate. Outcome measures included attitudes toward trichiasis and its treatment, reported barriers to surgical uptake, acceptance rates for surgery, and factors affecting acceptance. RESULTS: Twenty-three percent (95% confidence interval [CI] 16.5%-30.6%) of subjects with major trichiasis attended for surgery during the year. Degree of ignorance about surgery, symptoms impeding work, and a multiple income source for the head of household predicted attendance. Reported lack of time predicted nonattendance. Sixty-eight percent of patients who had undergone surgery were trichiasis free at last follow-up. CONCLUSIONS: Poor attendance for surgery remains a problem in The Gambia. Barriers include ignorance and lack of time and money. Health education and surgical delivery strategies are needed to overcome these barriers. Regular audit of surgical results is necessary, with retraining where indicated

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

How to manage a patient with glaucoma in Africa

IntroductionHow to manage a patient with glaucoma in Africa? The simple answer is: having made the diagnosis by optic disc assessment and intraocular pressure measurements (visual field tests are usually unavailable and unnecessary), perform trabeculectomy surgery using a technique broadly similar to that described by Ian Murdoch in this issue. This article discusses the reasons for this relatively universal management principle. The focus of this article is primary open-angle glaucoma, which affects the large majority of glaucoma patients across the continent. Some brief principles concerning management of other types of glaucoma in Africa are included at the end

Outcomes of bilateral cataract surgery in Tanzanian children.

OBJECTIVE: To investigate outcomes of bilateral pediatric cataract surgery in east Africa. DESIGN: Retrospective interventional case series. PARTICIPANTS: Two hundred forty-three children who underwent bilateral cataract surgery at the Comprehensive Community-Based Rehabilitation for Tanzania Disability Hospital between 2001 and 2004. METHODS: Demographic, surgical, preoperative, and postoperative clinical characteristics obtained from patient records were entered into a database (Microsoft Excel; Microsoft, Redmond, WA), and statistical analysis was conducted using SPSS software for Windows (SPSS, Inc., Chicago, IL). MAIN OUTCOME MEASURES: Postoperative visual acuities and factors affecting them and postoperative refraction results. RESULTS: Intraocular lenses were inserted in the first eyes of 232 children (149 Alcon AcrySof [Alcon Laboratories, Fort Worth, TX], 83 polymethyl methacrylate [PMMA]). Fifty-eight (62%) of 94 patients with final follow-up acuities recorded in both eyes achieved 20/60 or better in their better eye and 13 (13%) of 94 patients were blind. Of the various predictors of good visual outcome identified for children or eyes, only absence of preoperative blindness (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.0-18.0; P<0.0005) remained significant in a multivariate logistic regression model. One hundred nine (51%) of 212 refracted first eyes had early postoperative refractive error spherical equivalent magnitudes of 2 diopters (D) or more. Ninety-nine (47%) of 212 eyes had initial postoperative cylinders of 3 D or more, dropping to 30 (18%) of 164 of those who had later follow-up refraction. Presence of biometric data was not associated with smaller postoperative refractive errors. Eyes with AcrySof lenses were less likely (OR, 2.5; 95% CI, 1.04-6.06) to have more than 3 D of astigmatism at latest follow-up. AcrySof lenses also were more likely (OR, 2.1; 95% CI, 1.2-3.7) to be fixated in the bag than PMMA lenses. Acute fibrinous uveitis occurred in 30 cases (12%), and transient corneal haze occurred in 20 cases (8%). Twenty-seven (11%) had chronic complications, 69 (28%) underwent a further general anesthetic procedure, and 9 (4%) underwent yytrium-aluminum-garnet capsulotomy. CONCLUSIONS: Preoperative blindness was the strongest predictor of poor postoperative visual outcome; the use of AcrySof lenses as opposed to PMMA lenses made in-the-bag fixation more likely and also reduced postoperative astigmatism

The long-term natural history of trachomatous trichiasis in the Gambia.

PURPOSE: Trachoma is the leading infectious cause of blindness. However, there are few data on the natural history of trachomatous trichiasis to guide program planning or that investigate its pathogenesis. METHODS: A cohort of Gambians with trichiasis in one or both eyes who had declined surgery was observed. Clinical examinations were performed at baseline and 4 years later. Conjunctival swab samples were collected for Chlamydia trachomatis PCR and bacteriology. RESULTS: One hundred fifty-four people were examined at baseline and 4 years later (241 nonsurgical eyes). At baseline 124 (52%) eyes had major trichiasis (5+ lashes), 75 (31%) minor trichiasis (1-4 lashes), and 42 (17%) no trichiasis. By 4 years, trichiasis had developed in 12 (29%) of 42 previously unaffected eyes. Minor trichiasis progressed to major in 28 (37%) of 75 eyes. New corneal opacification more commonly developed in eyes that had major (10%) compared to minor (5%) trichiasis at baseline. Bacterial infection was common (23%), becoming more frequent with increasing trichiasis. C. trachomatis infection was rare (1%). Conjunctival inflammation was common (29%) and was associated with progressive trichiasis and corneal opacification. CONCLUSIONS: Trichiasis progressed in the long-term in this environment, despite a low prevalence of C. trachomatis. Blinding corneal opacification develops infrequently, unless major trichiasis is present. Epilation and early surgery need to be formally compared for the management of minor trichiasis. The pathologic correlates and promoters of conjunctival inflammation need to be investigated

Cataract surgery outcomes in bangladeshi children.

PURPOSE: To measure visual acuity (VA) outcomes, complication rates, and the social impact of cataract surgery in a cohort who underwent surgery as children in Bangladesh. DESIGN: Case series. PARTICIPANTS: A total of 471 of 850 children from 6 Bangladeshi districts who had been identified as cataract blind using key informants (KIs) between 2004 and 2009 during the Bangladesh Childhood Cataract Campaign (BCCC) together with all those children not included in the BCCC database but in the Child Sight Foundation (CSF) database who had been identified as cataract blind. METHODS: The subjects and families were contacted again by KIs and transported to local examination centers, where parents and subjects were administered a questionnaire and subjects underwent full ocular examination. Where operative data were available (15%), they were analyzed in conjunction with questionnaire and examination findings. Statistical analysis was performed using SPSS Statistics (IBM, Armonk, NY). MAIN OUTCOME MEASURES: Presenting and best-corrected visual acuities (BCVAs), cause(s) of poor outcome, postoperative refraction, and school attendance. RESULTS: A total of 407 of the participants had undergone bilateral surgery as children, with a mean follow-up of 8.8 years. The mean age at examination was 16 years (range, 5-28 years; standard deviation [SD], 4.6 years); 63% of those examined were male; 22% had a binocular presenting VA of >20/60; and 53% were severely visually impaired or blind (VA 20/60 in their better eye and 33% had VA <20/200. Factors that predicted poor VA in multivariate logistic regression analysis were nystagmus (P < 0.001), longer delay in presentation (P < 0.001), and magnitude of absolute spherical equivalent refractive error (P<0.001). Some 50% had nystagmus, and 69% of those currently aged ≤16 years were attending school. Better acuity was associated with school attendance (P < 0.001), whereas gender was not. CONCLUSIONS: Approximately one third of all participants had a BCVA of ≥20/60 in their better eye. Amblyopia and nystagmus limited visual outcome, indicating the need for earlier detection and treatment. This is the first study to show the link between pediatric cataract outcome and access to education, a millennium development goal

Operational evaluation of the use of photographs for grading active trachoma.

We evaluated the reliability of photographs to verify field diagnoses of active trachoma. We examined 956 residents of a trachoma-endemic village for signs of trachoma using the World Health Organization simplified grading system. Two photographs of the right eye of 948 persons were independently graded (masked to field assessment) by the field examiner and two other experienced graders. There was only moderate agreement between field assessment and the subsequent photographic evaluations by the three graders. When we counted ungradable photographs as disagreements, mean kappa scores for the signs trachomatous inflammation (follicular [TF]) and trachomatous inflammation (intense [TI]) were 0.44 and 0.51, respectively. There was also only fair-to-moderate agreement between the three assessments (by different examiners) of the photographs. Either the signs TF and TI themselves are not as reliable as previously believed, or photographs should be used for their diagnosis only when reliability testing demonstrates better agreement than found here