Interventions for trachoma trichiasis.

BACKGROUND: Trachoma is the leading infectious cause of blindness. The World Health Organization (WHO) recommends eliminating trachomatous blindness through the SAFE strategy: Surgery for trichiasis, Antibiotic treatment, Facial cleanliness and Environmental hygiene. This is an update of a Cochrane review first published in 2003, and previously updated in 2006. OBJECTIVES: To assess the effects of interventions for trachomatous trichiasis for people living in endemic settings. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2015), EMBASE (January 1980 to May 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 May 2015. We searched the reference lists of included studies to identify further potentially relevant studies. We also contacted authors for details of other relevant studies. SELECTION CRITERIA: We included randomised trials of any intervention intended to treat trachomatous trichiasis. DATA COLLECTION AND ANALYSIS: Three review authors independently selected and assessed the trials, including the risk of bias. We contacted trial authors for missing data when necessary. Our primary outcome was post-operative trichiasis which was defined as any lash touching the globe at three months, one year or two years after surgery. MAIN RESULTS: Thirteen studies met the inclusion criteria with 8586 participants. Most of the studies were conducted in sub-Saharan Africa. The majority of the studies were of a low or unclear risk of bias.Five studies compared different surgical interventions. Most surgical interventions were performed by non-physician technicians. These trials suggest the most effective surgery is full-thickness incision of the tarsal plate and rotation of the terminal tarsal strip. Pooled data from two studies suggested that the bilamellar rotation was more effective than unilamellar rotation (OR 0.29, 95% CI 0.16 to 0.50). Use of a lid clamp reduced lid contour abnormalities (OR 0.65, 95% CI 0.44 to 0.98) and granuloma formation (OR 0.67, 95% CI 0.46 to 0.97). Absorbable sutures gave comparable outcomes to silk sutures (OR 0.90, 95% CI 0.68 to 1.20) and were associated with less frequent granuloma formation (OR 0.63, 95% CI 0.40 to 0.99). Epilation was less effective at preventing eyelashes from touching the globe than surgery for mild trichiasis, but had comparable results for vision and corneal change. Peri-operative azithromycin reduced post-operative trichiasis; however, the estimate of effect was imprecise and compatible with no effect or increased trichiasis (OR 0.85, 95% CI 0.63 to 1.14; 1954 eyes; 3 studies). Community-based surgery when compared to health centres increased uptake with comparable outcomes. Surgery performed by ophthalmologists and integrated eye care workers was comparable. Adverse events were typically infrequent or mild and included rare postoperative infections, eyelid contour abnormalities and conjunctival granulomas. AUTHORS' CONCLUSIONS: No trials were designed to evaluate whether the interventions for trichiasis prevent blindness as an outcome; however, several found modest improvement in vision following intervention. Certain interventions have been shown to be more effective at eliminating trichiasis. Full-thickness incision of the tarsal plate and rotation of the lash-bearing lid margin was found to be the best technique and is preferably delivered in the community. Surgery may be carried out by an ophthalmologist or a trained ophthalmic assistant. Surgery performed with silk or absorbable sutures gave comparable results. Post-operative azithromycin was found to improve outcomes where overall recurrence was low

Comparisons of diabetic retinopathy events associated with glucose‐lowering drugs in patients with type 2 diabetes mellitus: A network meta‐analysis

Aim To assess the comparative effects of glucose‐lowering drugs (GLDs) on the risk of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM). Methods We systematically searched Cochrane Central Register of Controlled Trials, PUBMED and EMBASE from inception to January 17, 2017 to identify randomized controlled trials (RCTs) that reported DR events among T2DM patients receiving any GLD. Random‐effects pairwise and network meta‐analyses were performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs). Results A total of 37 independent RCTs with 1806 DR events among 100 928 patients with T2DM were included. The mean duration of diabetes was 8.7 years and mean baseline HbA1c was 8.2% (SD, 0.5%). Our network meta‐analysis found that DPP‐4i (OR, 1.20; 95% CI, 0.87‐1.65), GLP‐1RA (OR, 1.19; 95% CI, 0.94‐1.52) and SGLT2 inhibitors (OR, 0.79; 95% CI, 0.49‐1.28) were not associated with a higher risk of DR than placebo; however, a significantly increased risk of DR was associated with DPP‐4i in the pairwise meta‐analysis (OR, 1.27; 95% CI, 1.05‐1.53). Sulfonylureas, on the other hand, were associated with a significantly increased risk of DR compared to placebo (OR, 1.67; 95% CI, 1.01‐2.76). Conclusions Current evidence indicates that the association between DPP‐4i, GLP‐1RA or SGLT2 inhibitors and risk of DR remains uncertain in patients with T2DM. Some evidence suggests that sulfonylureas may be associated with increased risk of DR. However, given that DR events were not systematically assessed, these effects should be explored further in large‐scale, well‐designed studies

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery

Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection

Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine.

IMPORTANCE: The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care. OBJECTIVE: To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings. MAIN OUTCOMES AND MEASURES: The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings. RESULTS: A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7% having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1% of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7% of the other ocular findings were cataract. CONCLUSIONS AND RELEVANCE: In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated

Questioning a South African hypertension threshold of 150 mm Hg – Authors' reply

We are grateful for the opportunity to respond to Schutte and colleagues. We agree with Schutte and colleagues that the systolic blood pressure (SBP) measurements presented in our study could contain error. However, of the potential sources of measurement error they note (whitecoat effects [+2·5 mm Hg], averaging measurements from two different waves [+3·8 mm Hg], and supine measurements [+3–10 mm Hg]), only the white-coat effects potentially applies to our study. Although we average measurements from 2 different years, we assign the resulting SBP to the last year of data. Therefore, any bias would result in SBP measurements that are conservative, rather than inflated by 3.5 mm Hg. SBP in the National Income Dynamics Survey is also measured in a sitting, not supine, position; however, Schutte and colleagues correctly identified our reporting error, and we have requested a formal correction. On balance, any measurement error is likely to be much smaller than Schutte and colleagues assert and would not change our main study conclusions

Saliva urea nitrogen dipsticks to predict acute kidney injury in Malawian trauma patients

Background: Many low-resource settings have limited access to serum creatinine tests necessary for kidney disease identification. Among Malawian patients who are hospitalized after trauma, we evaluated the use of point-of-care saliva urea nitrogen (SUN) dipsticks to predict acute kidney injury (AKI). Methods: In a nested prospective cohort study, we enrolled hospitalized acute trauma patients aged ≥6 months to evaluate AKI (defined by KDIGO criteria) and the test characteristics of SUN to predict AKI. Results: Among 335 participants (approximately three-quarters able to expectorate and 34% aged ≤18 years), 12.5% (n = 42) developed AKI. At a SUN threshold of ≥40 mg/dL, a positive dipstick test was specific (99.3%) but insensitive (14.3%) in predicting AKI, with a positive predictive value of 75% and negative predictive value of 89%. At this threshold, 2.4% of participants were dipstick-positive (SUN+), and 75% of those had AKI. Reducing the SUN threshold to ≥30 mg/dL increased participants who were SUN+ to 5.0% (n = 16) but also increased the false positive rate and missed 79% (n = 33) of AKI cases. Stratified results showed better performance among adults than children and similar results when comparing participants who could and could not expectorate. There was moderate correlation between categorized BUN values and SUN (r = 0.53) but less agreement (weighted kappa 0.27; 95% CI 0.17–0.37). Conclusions: SUN dipstick testing has good specificity and negative predictive value for ruling out AKI, but poor sensitivity. We found similar results among those who could or could not expectorate a saliva sample

Definitions and Standardization of a New Grading Scheme for Eyelid Contour Abnormalities after Trichiasis Surgery

Approximately 8 million individuals worldwide suffer from trichiasis, a condition characterized by in-turned lashes that rub against the eye. Trichiasis is caused by repeated or prolonged ocular infection with Chlamydia trachomatis. Surgery is available to correct in-turned lashes. In most programmatic and research settings, the primary determinant of surgical success is whether or not lashes are touching the globe post-operatively. However, other surgical outcomes such as the contour of the eyelid are also important. Yet, no standard method for evaluating and reporting this outcome has been defined. In this study, we developed and tested a grading system for evaluating the severity of eyelid contour abnormalities after surgery using photographs of eyelids six weeks post-operatively. We found good agreement across photograph graders and also between field and photograph grades. This system should be useful in helping to standardize reporting of this outcome

Pre-operative trichiatic eyelash pattern predicts post-operative trachomatous trichiasis.

IMPORTANCE: Trichiasis surgery programs globally have faced high rates of poor surgical outcomes. Identifying correctable risk factors for improving long-term outcomes is essential for countries targeting elimination of trachoma as a public health problem. OBJECTIVE: To determine whether the location of trichiatic eyelashes prior to surgery influences development of post-operative trichiasis (PTT) within two years after surgery. DESIGN: Secondary data analysis of four randomized clinical trials evaluating methods to improve trichiasis surgery outcomes. These include the Surgery for Trichiasis, Antibiotics for Recurrence (STAR) trial, Partnership for Rapid Elimination of Trachoma (PRET-Surgery), absorbable versus silk sutures trial, and epilation versus surgery for minor trichiasis trial. SETTING: Primary trials were conducted in rural areas of Ethiopia and Tanzania. INTERVENTIONS OR EXPOSURES: Trichiasis surgery performed with either the bilamellar tarsal rotation procedure or posterior lamellar rotation procedure. MAIN OUTCOMES: Prevalence of PTT within two years after surgery, location of trichiatic eyelashes pre-operatively and post-operatively. RESULTS: 6,747 eyelids that underwent first-time trichiasis surgery were included. PTT rates varied by study, ranging from 10-40%. PTT was less severe (based on number of trichiatic eyelashes) than initial trichiasis for 72% of those developing PTT, and only 2% of eyelids were worse at follow up than pre-operatively. Eyelids with central only-trichiasis pre-operatively had lower rates of PTT than eyelids with peripheral only trichiasis in each of the three trials that included severe TT cases. 10% of eyelids with peripheral trichiasis pre-operatively that develop PTT have central TT post-operatively. CONCLUSIONS AND RELEVANCE: Pre-operative central trichiasis is less likely than peripheral trichiasis to be associated with subsequent PTT. Regardless of type of surgery, surgeon skill levels, or pre-operative trichiasis severity, the presence of peripheral trichiasis pre-operatively is associated with higher rates of PTT. Making an incision that extends the length of the eyelid and adequately rotating the nasal and temporal aspects of the eyelid when suturing may help to minimize the chance of developing peripheral PTT. TRIAL REGISTRATION: ClinicalTrials.gov PRET: NCT00886015; Suture: NCT005228560; Epilation: NCT00522912

Visual findings in children exposed to Zika in utero in Nicaragua

Knowledge regarding the frequency of ocular abnormalities and abnormal visual function in children exposed to Zika virus (ZIKV) in utero but born without congenital Zika syndrome (CZS) is limited. We hypothesized that children exposed to ZIKV in utero born without CZS may have visual impairments in early childhood. We performed ophthalmic examination between 16 and 21 months of age and neurodevelopment assessment at 24 months of age with the Mullen Scales of Early Learning test (MSEL) on children enrolled in a cohort born to women pregnant during and shortly after the ZIKV epidemic in Nicaragua (2016–2017). ZIKV exposure status was defined based on maternal and infant serological testing. Visual impairment was defined as abnormal if the child had an abnormal ophthalmic exam and/or low visual reception score in the MSEL assessment. Of 124 children included in the analysis, 24 (19.4%) were classified as ZIKV-exposed and 100 (80.6%) unexposed according to maternal or cord blood serology. Ophthalmic examination showed that visual acuity did not differ significantly between groups, thus, 17.4% of ZIKV-exposed and 5.2% of unexposed had abnormal visual function (p = 0.07) and 12.5% of the ZIKV-exposed and 2% of the unexposed had abnormal contrast testing (p = 0.05). Low MSEL visual reception score was 3.2-fold higher in ZIKV-exposed than unexposed children, but not statistically significant (OR 3.2, CI: 0.8–14.0; p = 0.10). Visual impairment (a composite measure of visual function or low MESL visual reception score) was present in more ZIKV-exposed than in unexposed children (OR 3.7, CI: 1.2, 11.0; p = 0.02). However, the limited sample size warrants future investigations to fully assess the impact of in utero ZIKV exposure on ocular structures and visual function in early childhood, even in apparently healthy children

Multiple cardiovascular risk factor care in 55 low- and middle-income countries:A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009–2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40–69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8–66.4]) than those with hypertension only (47.4% [45.3–49.6]) or diabetes only (46.7% [44.1–49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8–41.8] using antihypertensive and 42.3% [95% CI: 39.4–45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1–27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4–18.8]), followed by diabetes (13.3% [10.7–15.8]) and hypertension-diabetes (6.6% [5.4–7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors