Trachoma in Western Equatoria State, Southern Sudan: Implications for National Control

Baseline data on trachoma prevalence is a prerequisite for intervention. Prior to the present study, all surveys in Southern Sudan reported trachoma prevalences that exceeded the threshold for large-scale intervention. This gave rise to the notion that the disease may be endemic throughout the country. The present study was conducted under the auspices of the National Program for Integrated Control of Neglected Tropical Diseases, to verify whether prevalences in two counties west of the Nile exceeded the WHO recommended intervention threshold for mass drug administration (MDA) of antibiotic treatment. The results show that trachoma prevalence at county level was below this threshold. However, prevalences in some communities within the county were above the threshold, meaning that they should be targeted with MDA of antibiotics, as well as with other interventions such as trichiasis surgery, health promotion and improved water and sanitation. This finding reminds us of the need for geographical targeting of resources, both for surveys and subsequent intervention. Current resources are insufficient to conduct population-based prevalence surveys for trachoma throughout Southern Sudan. Further surveys should thus be conducted in areas where collection of additional information will be most informative. We propose that a combination of risk-mapping and rapid assessments is used to identify such areas

Simulation-based surgical education for glaucoma versus conventional training alone: the GLAucoma Simulated Surgery (GLASS) trial. A multicentre, multicountry, randomised controlled, investigator-masked educational intervention efficacy trial in Kenya, South Africa, Tanzania, Uganda and Zimbabwe.

BACKGROUND/AIM: Glaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma. METHODS: We designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months. RESULTS: Twenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, p<0.001). At 1 year, the mean surgical competency score of the intervention arm participants was 28.6 (71.5%), compared with 11.6 (29.0%) for the control (difference 17.0, 95% CI 14.8 to 19.4, p<0.001). CONCLUSION: These results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery. TRIAL REGISTRATION NUMBER: PACTR201803002159198

Improving patient compliance with diabetic retinopathy screening and treatment

Diabetic retinopathy is one of the many complications of diabetes. Because there are no symptoms initially, patients will not realise that they have the condition until it is at a proliferative stage or they develop macular oedema, when their vision becomes affected. Unfortunately, vision that has been lost may never be regained

A qualitative study in the United Kingdom of factors influencing attendance by patients with diabetes at ophthalmic outpatient clinics.

INTRODUCTION: Many diabetics do not have regular eye examinations, although it is known that early diagnosis and treatment of sight-threatening retinopathy reduces the risk of blindness. The barriers that prevent diabetics from attending eye clinics are poorly understood. PURPOSE: To determine what factors may influence diabetic patients' attendance at eye clinics. METHODS: A qualitative survey of both patients and eye care providers was undertaken in a rural district general hospital and in an urban tertiary teaching hospital. Methods employed included semi-structured interviews, focus groups and non-participatory observations. All interviews and discussions were recorded and transcribed. The transcripts were then analyzed to detect emerging themes. Data collection continued until no new themes emerged. RESULTS: Lack of awareness was seen as the greatest barrier by both patients and providers. Patients were aware that diabetes could affect the eye, but not that it could lead to blindness, nor that severe retinopathy could be asymptomatic. Patients reported that fundus images used for screening were a valuable educational resource. Fear, particularly of laser treatment, and guilt, about poor control causing retinopathy, deterred patients from attending. Both patients and providers recognized that regular attendance was inconvenient; however, providers underestimated the difficulties patients faced in obtaining time off work to attend clinics. CONCLUSION: Providing more complete information about diabetic retinopathy, and making eye clinic attendance more convenient for patients, may increase the number of diabetics who have regular eye examinations

Management of common eye conditions in a primary health care setting: A guide for South Sudan health workers

South Sudan has a huge burden of blindness with an estimated prevalence in excess of 1.5% and it is a common reason for patients attending a primary care facility [1]. Seventy five percent of this blindness can be prevented or treated by properly trained middle cadre eye health worker working with simple diagnostic tools in a primary health care setting or by referring to secondary care in a timely manner. In addition to the common causes of visual loss South Sudan suffers with the burden of two infectious diseases, Trachoma predominantly to the East of the Nile and Onchocerciasis to the West of the Nile [2]. It is therefore crucial that the following simple measures are applied at a community level to prevent eye disease and avert blindness

The Impact of Simulation-based Trabeculectomy Training on Resident Core Surgical Skill Competency.

PRECIS: Simulation-based surgical education shows a positive, immediate and sustained impact on core surgical skill competency in trabeculectomy amongst resident ophthalmologists. PURPOSE: To measure the impact of trabeculectomy surgical simulation training on core surgical skill competency in resident ophthalmologists. METHODS: This is a post-hoc analysis of the GLAucoma Simulated Surgery (GLASS) trial, which is a multi-center, multi-national randomized controlled trial. Resident ophthalmologists from six training centers in sub-Saharan Africa (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) were recruited according to the inclusion criteria of having performed zero surgical trabeculectomies and assisted in less than five. Participants were randomly assigned to intervention and control arms using allocation concealment. The intervention was a one-week intensive trabeculectomy surgical simulation course. Outcome measures were mean surgical competency scores in eight key trabeculectomy surgical skills (scleral incision, scleral flap, releasable suturing, conjunctival suturing, sclerostomy, tissue handling, fluidity and speed), using a validated scoring tool. RESULTS: Forty-nine residents were included in the intention-to-treat analysis. Baseline characteristics were balanced between arms. Median baseline surgical competency scores were 2.88/16 (IQR 1.75-4.17) and 3.25/16 (IQR 1.83-4.75) in the intervention and control arms respectively. At primary intervention, median scores increased to 11.67/16 (IQR 9.58-12.63) and this effect was maintained at three months and one year (P=0.0001). Maximum competency scores at primary intervention were achieved in the core trabeculectomy skills of releasable suturing (n=17, 74%), scleral flap formation (n=16, 70%) and scleral incision (n=15, 65%) compared to scores at baseline. CONCLUSION: This study demonstrates the positive impact of intensive simulation-based surgical education on core trabeculectomy skill development. The rapid and sustained effect of resident skill acquisition pose strong arguments for its formal integration into ophthalmic surgical education