Squamous cell carcinoma of the conjunctiva

Squamous cell carcinoma of the conjunctiva is the end-stage of a spectrum of disease referred to as ocular surface squamous neoplasia (OSSN). OSSN is a malignant disease of the eyes that can lead to loss of vision and, in severe cases, death. The main risk factors for both are exposure to solar ultraviolet radiation outdoors, HIV/AIDS, human papilloma virus and allergic conjunctivitis. The limbal epithelial cells appear to be the progenitors of this disease

Ovarian hyperstimulation syndrome (OHSS): case report

There has been a rapid increase in the number of couples receiving treatment for infertility with Assisted Reproductive Technology (ART) in recent years. While there is robust evidence supporting the efficacy and safety of ART, it is important to be aware of the risks, the most serious of which is OHSS. A case of OHSS, a rare complication of COS, which is potentially fatal, is presented. Patient with secondary infertility (Para 0 + 1), who had had IVF - COS followed by oocyte retrieval and subsequent embryo transfer. She presented at Accident and Emergency Unit, Nairobi Hospital, with dyspnea, chest pain, abdominal pain and distension. A diagnosis of OHSS withpulmonary thromboembolism was made. She was admitted to Intensive care unit(ICU). She was managed with oxygen by mask, intravenous fluids, anticoagulant and albumen in Intensive Care Unit with fully recovery.The case study presents her clinical manifestations, investigation, progress, management, outcome and preventive measures

Beckwith-Wiedemann Syndrome in assisted reproductive techniques: Case report

Assisted Reproductive Techniques (ART) is a crucial treatment for infertile couples and is frequently common. ART entails  manipulation of oocyte and sperm in a laboratory: in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).The key  objective of ART is to yield superior quality embryos that are competent for implantation with good perinatal outcome. In spite of widespread acceptability of ART, concerns have been raised on the long-term safety of removal and manipulation of the gametes and embryos. High incidence of imprinting disorders like Beckwith-Wiedemann syndrome (BWS) have been noted in babies conceived after ART. The case report discusses BWS encountered after conception with ART and a review of other imprinting disorders associated with ART

Epidemiology and Management of Ocular Surface Squamous Neoplasia in Kenya

Introduction Ocular surface squamous neoplasia (OSSN) is a spectrum of disease that ranges from noninvasive intra-epithelial dysplasia of the conjunctival and cornea (CCIN), through to invasive squamous cell carcinoma (SCC). It often presents with unilateral tumours on the eyeball. The tumours may cause blindness, disfigurement and even death. In East Africa, OSSN is relatively common and aggressive, affecting younger adults and proportionally more women than in other parts of the world. The management of OSSN is challenging for various reasons. Its risk factors are not clearly understood. Studies have implicated HIV, human papilloma virus (HPV) and solar radiation however about 30% of cases are HIV-negative while some studies have implicated HPV and others found no association. The importance of vitamin A for a healthy ocular surface is known, yet its role in OSSN has not been studied. Early diagnosis relies on the clinical impression yet OSSN appears similar to other conjunctival tumours and histopathology services are generally unavailable in Africa. Surgery is the mainstay of treatment but recurrence is an issue. There is no trial evidence for the various treatments used in HIV-infected persons. This project was an integrated set of studies to improve our understanding of the epidemiology and management of OSSN in Kenya. Methods We conducted three systematic reviews on the epidemiology of OSSN in Africa, the pathophysiology of OSSN and updated a Cochrane review on the interventions for OSSN in HIV-infected individuals. Working in four eye care centres in Kenya between July 2012 and July 2015, we conducted the following six studies: (i) clinical assessment of a series of patients with conjunctival lesions to describe OSSN to determine how OSSN may differ clinically from benign lesions, (ii) evaluated vital staining with a special dye called Toluidine Blue (ToB) for making the diagnosis of OSSN, (iii) developed a diagnostic algorithm based on clinical features and vital staining, (iv) conducted a large case-control study to investigate risk factors that may contribute to the development of OSSN, (v) investigated the care-seeking journey of OSSN patients to assess referral pathway and treatment delay, and finally, (vi) conducted a randomised placebo-controlled trial of 5-Fluorouracil (5FU) chemotherapy eyedrops given after surgery to investigate if this can reduce recurrence of the lesions. Results Meta-analysis of data from cancer registries worldwide showed that Africa has the highest incidence of OSSN in the world with a peak at latitude 160 South and males and females are equally affected, unlike other continents where male disease predominates. Here the agestandardized rate in cases/year /100,000 population (95%CI) is 1.38 (1.00–3.75) and 1.18 (1.08–3.43) in males and females, respectively (p=0.853). Incidence rises with increasing exposure to direct sunlight (2–4 h, OR = 1.7, 95% CI: 1.2–2.4 and ≥5 h OR = 1.8, 95% CI: 1.1–3.1) and outdoor occupations (OR = 1.7, 95% CI: 1.1–2.6). Fixed-effect meta-analysis shows a strong association with HIV (6 studies: OR = 6.17, 95% CI: 4.83–7.89) but not cigarette smoking (2 studies: OR = 1.40, 95% CI: 0.94–2.09). HPV shows heterogeneous association (random effects meta-analysis of 7 studies: OR = 2.64, 95% CI: 1.27–5.49). The pathophysiology review concluded that limbal epithelial stem cells are the likely progenitor cells of OSSN. UV radiation probably causes DNA damage via pyrimidine dimers (involving the p53 tumour suppressor gene), photo-immunosuppression and reactivates latent HPV. HPV E6 inhibits p53 gene allowing DNA-damaged cells past the G1-S checkpoint of the cell cycle. HPV E7 inhibits the retinoblastoma (pRB) gene anti-transcription at G1 so infected cells continue replicating. HIV, photo-immunosuppression and vitamin A deficiency may impair tumour surveillance. The Cochrane review found no trials for the interventions used in OSSN in HIV-infected populations. There was one trial in Australia that found topical Mitomycin C (MMC) effective. The results from case series reviewed were difficult to compare. They reported a wide variety of combinations of surgery and adjuvant treatment used during surgery or post operatively; varying doses of adjuvant agents used; different inclusion criteria of patients and recurrences reported at varying periods after treatment. Surgery with adjuvant 5FU or MMC was often associated with recurrences of 11% to 67% about 30 months later. We enrolled 496 adults with any conjunctival lesions requiring excision and 131 controls. OSSN was themost common lesion diagnosed in 187 (38%). Patients with OSSN were slightly older (mean [SD] age, 41 [11.6] vs 38 [10.9] years; p =0.002) and tended to have lower levels of education than patients with benign lesions (p = 0.001). Females predominated (67% of OSSN vs 64% of benign lesions; p = 0.65). HIV infection was common among patients with OSSN (74%). Although some clinical signs were more frequent in OSSN, all OSSN signs were also observed in benign lesions. OSSN and benign conjunctival lesions have overlapping phenotypes and cannot always be reliably distinguished on clinical grounds. The positive predictive value of clinical appearance in identifying OSSN was 54%. Inter-observer agreement was modest (κ= 0.1-0.4). Any blue colour on vital staining with ToB 0.05% had a sensitivity of 92%, specificity of 31%, positive predictive value of 41%, and negative predictive value of 88% for OSSN. Interobserver agreement was substantial for staining (k=0.8) and moderate for overall diagnosis (OSSN or benign) (κ =0.4). Use of ToB caused mild discomfort in 88 (21%) patients; mild superficial punctate keratopathy seen in 7 (1.7%) and no histological evidence of corneal toxicity was observed. ToB had a high rate of false positives (69%). We developed a simple probability-tree clinical algorithm that shows the probability of OSSN with various combinations of clinical features. A multivariable regression model found 8 features strongly associated with OSSN; prior excision, corneal involvement, feeder vessels, dark blue ToB staining, papillary or gelatinous tumour surface, severe inflammation, antiretroviral therapy and temporal or circumlimbal tumours. Using a cut-off of any 3 of these features, the sensitivity was 89%, specificity 50%, and 65%of lesions were correctly classified. This specificity was higher than any blue ToB staining (31%) but lower than clinical photoexamination (60%). A total of 131 cases were frequency-matched to 131 controls by age, sex and eye center. Risk factors for OSSN were HIV infection without antiretroviral therapy (ART) use (OR=48.30; 95%CI 7.53-309.90) and with ART use (OR=19.02; 95%CI 6.55-55.26), longer duration of exposure to the sun in the main occupation (6.9 hrs/day vs. 4.6 hrs/day, OR=1.23; 95%CI 1.08-1.39) and a history of allergic conjunctivitis (OR=80.20; 95%CI 8.62-746.29). Wearing hats was protective (OR=0.21; 95%CI 0.07-0.63). We studied the care-seeking journey followed by 158 new OSSN patients. About half (88/158, [56%]) presented directly to the study centres while the rest were referred. Indirect presenters sought care earlier than direct presenters (median 2.0 months vs 5.5 months) and travelled a shorter distance to the first health facility (median 20km vs 30km) but had surgery later (median 12.5 months vs 5.5 months). Visits beyond the first health facility for indirect presenters markedly increased delay (median 7.3, 29.0, 37.9, and 32.0 months for 1-4 facilities, respectively). Delay was associated with number of health facilities visited (adjusted ordered OR=9.12; 95%CI 2.83-29.4, p<0.001) and being female (adjusted ordered OR=2.42; 95%CI 1.32-4.44, p=0.004). In the randomized placebo-controlled trial we randomly allocated 49 participants to 5FU and 49 to placebo. Four participants were lost to follow-up. Treatment with 5FU was associated with fewer OSSN recurrences: there were 5/47 (10·6%) recurrences in the 5FU arm and 17/47 (36·2%) in the placebo arm (odds ratio 0·21; 95%CI 0·07-0·63, p=0·01). There was little effect from adjusting for passive smoking and antiretroviral therapy imbalance (adjOR=0·23; 95%CI 0·07-0·75, p=0·02). Adverse effects were transient, mild and more frequent with 5FU: ocular discomfort (43 [88%] vs 36 [73%]), epiphora (24 [49%] vs 5 [10%]), and eyelid skin inflammation (7 [14%] vs 0). Conclusions The clinical impression alone is unreliable for distinguishing OSSN from benign lesions. Toluidine Blue (ToB) staining is less specific and predictive than clinical examination by an Ophthalmologist. However, ToB may be a useful tool for other health care workers, with less ophthalmic training who might be involved in screening patients for the disease, as when there is no staining the disease is unlikely to be malignant. An algorithm that combines clinical features and ToB staining improves the specificity to 50%, is reasonably accurate (65%) for distinguishing OSSN from non-OSSN and shows the probability of disease with various combinations of clinical features. This algorithm cannot replace histopathology. Measures to prevent and control HIV, prevent sun exposure such as wearing hats, and control allergic conjunctivitis are recommended. Referral introduces significant delay before patients receive definitive treatment for OSSN. Women were more likely to experience delay. Despite regular contact with the health system for those with known HIV infection, delays occurred. Training in recognition and referral of OSSN cases, particularly in the HIV service, might lead to shorter delays before presentation. Post-operative topical 5FU substantially reduced recurrence of OSSN, was well-tolerated, and its use recommended in this context

Surgery for post-vitrectomy cataract

BACKGROUND: Cataract formation or acceleration can occur after intraocular surgery, especially following vitrectomy, a surgical technique for removing the vitreous which is used in the treatment of disorders that affect the posterior segment of the eye. The underlying problem that led to vitrectomy may limit the benefit from cataract surgery. OBJECTIVES: The objective of this review was to evaluate the effectiveness and safety of surgery for post-vitrectomy cataract with respect to visual acuity, quality of life, and other outcomes. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE in-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily Update, Ovid OLDMEDLINE (January 1946 to May 2013), EMBASE (January 1980 to May 2013, Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2013), PubMed (January 1946 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.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 22 May 2013. SELECTION CRITERIA: We planned to include randomized and quasi-randomized controlled trials comparing cataract surgery with no surgery in adult patients who developed cataract following vitrectomy. DATA COLLECTION AND ANALYSIS: Two authors screened the search results independently according to the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We found no randomized or quasi-randomized controlled trials comparing cataract surgery with no cataract surgery for patients who developed cataracts following vitrectomy surgery. AUTHORS\u27 CONCLUSIONS: There is no evidence from randomized or quasi-randomized controlled trials on which to base clinical recommendations for surgery for post-vitrectomy cataract. There is a clear need for randomized controlled trials to address this evidence gap. Such trials should stratify participants by their age, the retinal disorder leading to vitrectomy, and the status of the underlying disease process in the contralateral eye. Outcomes assessed in such trials may include gain of vision on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale, quality of life, and adverse events such as posterior capsular rupture. Both short-term (six-month) and long-term (one-year or two-year) outcomes should be examined

Heterotopic pregnancy in an assisted reproduction conception; case report and literature review

Infertility management by assisted reproduction techniques has had rapid increase. While there is robust evidence supporting the efficacy and safety of assisted reproduction technique (ART), complications are encountered. Heterotopic pregnancy, defined as the presence of both an intrauterine and an ectopic gestation, is a rare eventuality of early pregnancy. A 42 years old patient (Para 0+1) with a diagnosis of secondary infertility is presented; she had In Vitro fertilization (IVF) with egg donation. Two weeks after the IVF, a positive serum Beta Human Chorionic Gonadotropin confirmed the pregnancy and she continued with intake of progestins for luteal phase support. At 7 weeks gestation she presented at a local hospital with acute pelvic pain. A diagnosis of heterotopic pregnancy was made after transvaginal showed right slow leaking ectopic pregnancy andintrauterine missed abortion. Laparoscopic surgery, right salpingectomy and manual vacuum aspiration were performed with good subsequent recovery. The case presented, discusses the aetiology, clinical presentation, diagnosis and management of heterotopic pregnancy

Day care laparoscopic surgery in gynaecology at a dedicated unit in Nairobi, Kenya

Objective: To evaluate and audit the outcomes of Gynaecological Day care Laparoscopic Surgery inNairobi,KenyaDesign: Retrospective case analysisSetting: The International Centre for Minimal Access Surgery, NairobiSubjects: one thousand three hundred and seventy nine patients undergoing Laparoscopic SurgeryResults: Between January 2011 to December 2015 a total of 1,379 Laparoscopic procedures were undertaken during the reporting period of which 1,121 ( 88.5 % ) were done as day procedures. In total 137 patients ( 9.9 % ) spent one night at ICMAS, 21 ( 1.5 % ) were transferred to a Major Hospital and 41 patients (2.9 %) underwent conversion to Laparotomy. There were two Hospital re-admissions (0.14 % ) and one complication ( 0.07% ), a bladder injury was encountered.Conclusions: Daycare surgery is a continually evolving speciality being competently performed by several units by various disciplines world over , including Kenya. In recent years the complexity of the procedures has increased with a wider range of patients being considered for challenging surgeries including those presenting with acute conditions. Our experiences have been favourable

Ocular rhinosporidiosis mimicking conjunctival squamous papilloma in Kenya - a case report.

BACKGROUND: Ocular rhinosporidiosis is a chronic granulomatous infection caused by a newly classified organism that is neither a fungus nor bacterium. It often presents as a benign conjunctival tumour but may mimic other ocular conditions. It is most often described in India. In Africa cases have been reported from South Africa, Kenya, Tanzania, Malawi, Uganda, Congo and Ivory Coast. CASE PRESENTATION: A 54 year old man was seen in Kenya with a lesion that resembled a conjunctival papilloma. We report resemblance to conjunctival papilloma and the result of vital staining with 0.05% Toluidine Blue. CONCLUSION: Ocular rhinosporidiosis occurs in East Africa. It may resemble conjunctival squamous papilloma. Vital staining with 0.05% Toluidine blue dye did not distinguish the two lesions well

Infection with high-risk genotypes of human papillomavirus and cervical cytological findings among kidney transplant recipients in Kenya: a single centre experience

Background: High-risk human papillomavirus (hrHPV) infection is linked with uterine cervix premalignant lesions and invasive carcinomaof the uterine cervix. Methods: Descriptive cross sectional study carried out among female kidney transplant (KTx) recipients in Kenyatta National Hospital, Nairobi-Kenya. We studied the risk factors for acquisition of hrHPV, examined cervical cytology and assayed for 14 hrHPV DNA using Cervista® HPV HR test and Cervista® MTA (Hologic®) automated platforms. Results: The 14-hrHPV genotypes assayed were 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 and the prevalence rate was 31.25 % (10/32). Abnormal cervical cytology was noted in 4/32 (12.5%) and included low-grade squamous intraepithelial lesion (2/32), atypical squamous cells of undetermined significance (1/32) and atypical glandular cells (1/32). The average age was 41.9 years with mean age at first coitus being 20.4 years. Majority of the women 20(62.5%) were married while 8(25%) were single. About 18(56.3%) had only one sexual partner. About 20% of women were nulliparous and 4(12.5%) had a parity of five. Duration since transplantation ranged between 1-21 years. Conclusions: The burden of hrHPV and abnormal cervical cytology in our study seemed lower than that reported elsewhere andeven in general population. This study may form basis for further studies about HPV infections and carcinoma of the uterine cervixamong the kidney allograft recipients in our setting. Keywords:&nbsp;Cervical carcinoma; kidney transplant recipients; high risk Human Papillomavirus

Topical fluorouracil after surgery for ocular surface squamous neoplasia in Kenya: a randomised, double-blind, placebo-controlled trial

BACKGROUND: Ocular surface squamous neoplasia (OSSN) is an aggressive eye tumour particularly affecting people with HIV in Africa. Primary treatment is surgical excision; however, tumour recurrence is common. We assessed the effect of fluorouracil 1% eye drops after surgery on recurrence. METHODS: We did this multicentre, randomised, placebo-controlled trial in four centres in Kenya. We enrolled patients with histologically proven OSSN aged at least 18 years. After standard surgical excision, participants were randomly allocated to receive either topical fluorouracil 1% or placebo four times a day for 4 weeks. Randomisation was stratified by surgeon, and participants and trial personnel were masked to assignment. Patients were followed up at 1 month, 3 months, 6 months, and 12 months. The primary outcome was clinical recurrence (supported by histological assessment where available) by 1 year, and analysed by intention to treat. The sample size was recalculated because events were more common than anticipated, and trial enrolment was stopped early. The trial was registered with Pan-African Clinical Trials Registry (PACTR201207000396219). FINDINGS: Between August, 2012, and July, 2014, we assigned 49 participants to fluorouracil and 49 to placebo. Four participants were lost to follow-up. Recurrences occurred in five (11%) of 47 patients in the fluorouracil group and 17 (36%) of 47 in the placebo group (odds ratio 0·21, 95% CI 0·07–0·63; p=0·01). Adjusting for passive smoking and antiretroviral therapy had little effect (odds ratio 0·23; 95% CI 0·07–0·75; p=0·02). Adverse effects occurred more commonly in the fluorouracil group, although they were transient and mild. Ocular discomfort occurred in 43 of 49 patients in the fluorouracil group versus 36 of 49 in the placebo group, epiphora occurred in 24 versus five, and eyelid skin inflammation occurred in seven versus none. INTERPRETATION: Topical fluorouracil after surgery substantially reduced recurrence of OSSN, was well-tolerated, and its use recommended