Afekhide Ernest Omoti

Richter syndrome: a review of clinical, ocular, neurological and other manifestations

Richter syndrome describes the development of high‐grade non‐Hodgkin lymphoma (NHL) or Hodgkin lymphoma in patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Richter transformation occurs in 3·3 to 10·6% of patients with CLL. The large cell lymphoma clone occurs by transformation of the original CLL clone in the majority of patients, and as a separate and independent neoplasm in fewer cases. Richter transformation may be triggered by viral infections, such as Epstein‐Barr virus infection, which are common in immunosuppressed patients. Trisomy 12 and chromosome 11 abnormalities, as well as multiple genetic defects, have been described in patients with Richter syndrome. These abnormalities may cause CLL cells to proliferate and, by facilitating the acquisition of new genetic abnormalities, to transform into Richter syndrome cells. Presenting features typically include a rapid clinical deterioration with fever in the absence of infection, progressive lymph node enlargement, and an elevation in serum lactate dehydrogenase. Extranodal Richter syndrome has also been reported to occur in the central nervous system, eye, gastrointestinal system, nose, skin, face, bone and bronchus. The therapeutic options include cytoreductive therapy consisting of chemotherapy and immunotherapy, followed by allogeneic stem cell transplantation as postremission therapy.

Bilateral Total Loss of Vision Following Eclampsia – A Case Report

Visual loss following eclampsia is usually reported to be a result of retinopathy, exudative retinal detachment or cortical blindness. This paper reports the case of a 31-year-old para 5 + 0 housewife who developed bilateral visual loss following eclampsia and presented to the ophthalmologist four weeks later with a vision of light perception in both eyes. Examination showed evidence of hypertensive retinopathy. Convinced that the ocular findings were not responsible for such marked visual loss, she was commenced on systemic, topical and sub-conjunctival injection of steroids, acetazolamide and multivitamins. Her vision improved progressively to 6/6 right eye and 6/9 left eye after three weeks. Obstetricians are advised to refer cases of visual loss following eclampsia promptly to the ophthalmologist who should in turn manage aggressively with systemic, topical and sub-conjunctival steroids.

Ocular disorders in adult leukemia patients in Nigeria

Context: Leukemias may present with, or be associated with ocular disorders. Aims: To determine the rates of ophthalmic disorders in adult patients with leukemia. Settings and Design: A prospective study of ocular disorders in adult patients with leukemia at the University of Benin Teaching Hospital, Benin City, Nigeria, between July 2004 and June 2008 was conducted. Methods and Materials: The patients were interviewed and examined by the authors and the ocular findings were recorded. Statistical analysis was performed using Instat GraphPad™ v2.05a statistical package software. The means, standard deviation, and the Kruskal-Wallis non parametric test were performed. Results: Forty-seven patients with leukemias were seen. Nineteen patients (40.4%) had CLL, 14(29.8%) had CML, 9(19.1%) had AML and 5(10.6%) had ALL. Seven patients (14.9%) had ocular disorders due to leukemia. The ocular disorders due to the leukemia were proptosis in two patients (4.3%), retinopathy in one patient (2.1%), conjunctival infiltration in one patient (2.1%), periorbital edema in one patient (2.1%), retinal detachment in one patient (2.1%), and subconjunctival hemorrhage in one patient (2.1%). There was no significant difference in rate of the ocular disorders in the various types of leukemia (Kruskal-Wallis KW= 4.019; corrected for ties. P=0.2595). One patient (2.1%) was blind from bilateral exudative retinal detachment while 1 patient (2.1%) had monocular blindness from mature cataract. Conclusions: Ophthalmic disorders that are potentially blinding occur in leukemias. Ophthalmic evaluation is needed in these patients for early identification and treatment of blinding conditions.

Vascular risk factors for open angle glaucoma in african eyes.

Context: The exact patho physiological mechanizm of optic nerve damage in glaucoma is not fully understood. Aim: To assess the vascular risk factors in open angle glaucoma in African eyes. Settings and Design: Prospective multicenter hospital-based study in Edo State, Nigeria. Materials and Methods: Three hundred and twenty-two glaucoma patients and 184 control subjects were included in the study comprising 200 male glaucoma patients (62.11%) and 122 females (37.89%). A cohort of consecutive patients with a diagnosis of primary open angle glaucoma and age and sex matched control subjects were included in this prospective, cross-sectional, and multicenter hospital-based study conducted during the period January-June 2008. Blood pressure (BP), pulse and intraocular pressure findings were recorded and mean BP, pulse and perfusion pressure for each eye calculated. Statistical Analysis Used: Mean, standard deviations, 95% confidence intervals, Welchs t test, and Fishers exact test were calculated. Results: The mean IOP in the 644 eyes of the 322 glaucoma patients was 22.65 mmHg (SD plus/minus 11.06). The systolic blood pressure (P < 0.0001), diastolic blood pressure (P < 0.0001), mean arterial blood pressure (P < 0.0001), pulse pressure (P < 0.01), systolic perfusion pressure (P < 0.01) were all significantly higher in glaucoma patients than in control. Conclusions: Higher systolic, diastolic, mean arterial BP and pulse pressure was found in Black African patients with open angle glaucoma.

Pharmacological strategies for the management of cancer pain in developing countries

Pain associated with cancer is often under treated especially in the developing countries where there are problems of poor economy, poor purchasing power of the citizens, absence of effective national health insurance schemes, poor manpower, fake adulterated and expired drugs, poor drug storage conditions; adverse temperature conditions combined with poor power supply which may affect drug efficacy. There is also poor understanding of the physiopharmacology of cancer pain management by health care providers. Assessment of the severity of the pain by location, oncological type, as well as psychosocial, emotional and environmental factors are necessary. The pain often occurs from malignancy, from procedures done to diagnose, stage and treat the malignancy, and from the toxicities of therapy used in treating the cancer. The first priority of treatment is to control pain rapidly and completely, as judged by the patient. The second priority is to prevent recurrence of pain. Analgesic drugs are given ‘by the ladder,’ ‘by the clock’ and ‘by the appropriate route’ using the analgesic ladder guideline proposed by the World Health Organization (WHO). The pharmacological aspects of various drugs used in the management of cancer pain are discussed.

An unusual case of marble intraocular foreign body

This report presents a case of marble intraocular foreign body that developed toxic complications during surgery. The patient is a 25 years old male who presented to the University of Benin Teaching Hospital with a history of trauma to the right eye while cutting marble. He was examined, had an ocular ultrasound scan and subsequently had an extracapsular cataract extraction. His visual acuity in the right eye was light perception. There was an entry point on the cornea, the lens was opaque, there was vitreous haemorrhage and the intraocular foreign body was localized in the posterior part of the posterior segment by ultrasound scan. He had extracapsular cataract extraction. During anterior capsulotomy, the cornea suddenly and rapidly became cloudy with a brownish tinge and the corneal epithelium started desquamating.Marble on its own may not be toxic but the other chemicals including cement, used in the processing of the marble were responsible for this delayed toxicity. Ultrasound scan is valuable in localisation of intraocular foreign bodies.

Presenting visual acuities in a referral eye center in an oil-producing area of Nigeria

Objectives: To determine the pattern of presenting visual acuities at an eye center in the Niger Delta region of Nigeria. Study Design: Retrospective chart review Methods: A retrospective review of patient records attending a private referral eye center providing services for company patients and the general public in the region. Information was obtained from computerized medical records of 6533 patients who attended the center for various eye concerns in a 5-year period (January 1998 to December 2002). Results: A total of 6533 patients were seen in this 5-year period of which 2472 (37.8%) were company patients and 4061 (62.2%). were private patients. There were 3879 males (59.4%) and 2654 females (40.6%). A visual acuity of 6/6 or better was seen in 50.8% of the patients. In 76.6% of patients, a visual acuity of 6/18 or better was recorded. There were 21.4% of patients in the low vision group. Bilateral blindness occurred in 2.1% of patients. Monocular blindness occurred in 3.7% of patients. Low vision occurred in 16.9% of company patients and 24.1% of private patients. Bilateral blindness occurred in 0.9% of company patients and 2.7% of private patients, while monocular blindness occurred in 1.2% of company patients and 5.2% of private patients. The main ocular problems were refractive error, glaucoma, conjunctivitis, headaches, ocular trauma, retina and related pathologies, cataract, uveitis, pterygium and corneal problems. Conclusion: The incidence of low vision and blindness is high in the oil-producing area of the Niger Delta region of Nigeria. Low vision and blindness were more common in private patients than in company patients.

Infertility and migraine in midwest Niger-Delta region.

The editorial on infertility and Womens Reproductive Health in Africa 1 in the African Journal of Reproductive Health Vol. 3. No. 1 (May) 1999 refers. The importance of the issues raised are becoming more and more relevant in our experience practicing ophthalmology in Warri town - the major urban centre in mid-west Niger Delta region of Nigeria. Amongst other things, the article pointed out that infertility exists in Africa including Nigeria, which has more than 800,000 couples with fertility problems. That high birth rate in the continent does not automatically translate to high fertility rate and that the high birth rate does not mean there is no problem with infertility. The article also enumerated the effect of infertility on reproductive health including prevalence and transmission of HIV/AIDS infection, the short and long-term consequences and the way forward including specific community based intervention programmes and intrgraation into other women health programmes. In our practice in the Niger Delta we have noticed some other cause and effect of infertility we wish to share with you and your readership. Infertility is the failure of a couple who desire pregnancy to conceive after one year of regular unprotected sexual intercourse. The prevalence is about 25%. There is natural decline in fertility that comes with aging. The decline accelerates after age 30. In women over the age of 35, it is prudent to begin an evaluation of the couple after only 6 months of failing to conceive 2 . Infertility is responsible for migraine headaches in a large number of women we are treating in our centre. Three quarters of migraine sufferers are women. 2 Women with fertility problems have twice more migraine and that the onset is 5 years earlier in women with fertility problems. 2 Endometrosis, a common cause of infertility has a prevalence of 5% in women of reproductive age and over 38% of endometrosis patients have migraine 3 . In our practice environment, migraine and infertility are seen to have other relationship. Infertility in the family causes the male (most times) to engage in extra marital affairs in quest for children. Having children has a high premium in the Niger Delta region like other parts of Nigeria 4 . The extra marital affairs on its own merit causes marital disharmony and emotional stress that triggers migraine attacks. The unprotected sex by the husband who wants children causes fear in the woman that she could be infected with HIV by her husband and this genuine fear triggers further attack of migraine. More women are marrying late in our practice environment. The reasons include more women working in all sectors of the economy because of harsh economic environment, higher educa-tion pursuit by women, high bride price and high rate of unemployment for would-be-husbands. The late marriage and the natural decline in fertility that comes with aging are pushing more women into infertility in addition to the numerous reasons enumerated in your article. Also in our practice environment which is largely an oil economy with other support services as banks etc; we have very highly educated corporate and very financially empowered or capable women between the ages of 30 and 40+ years who have attack of migraine headaches because of infertility related issues unsolicited for, advanced singleness. They have problems getting husbands because of their fairly advanced ages or because of their economic empowerment (many men have complex and are uncomfortable when the difference is very clear). With the knowledge that their age bracket is associated with decline in fetility 2 , they are anxious and worried as to when they will get married; at what age they will have children and then the problems of infertility when they get married. The above is similar to the findings of Kishi et al 5 who reported that fecundity studies such as time to pregnancy and infertility prolonged time is a major cause for anxiety in Japanese women with similar situation such as: more women pursuing higher education, late marriage and more population working. These experiences are making Ophthal-mologists play more role in counseling their female patients with migraine and this also adds to the call you made in your article for panoramic evaluation of infertility and its socio economic effects and to tackle it comprehensively.

Ocular disorders in stroke patients in a tertiary hospital in Nigeria.

BACKGROUND Stroke is a medical emergency of public health importance which affects the physical, mental, and emotional well-being of its victims. Management and rehabilitation are cumbersome for patients and caregivers. Ocular involvement and visual loss could further increase the burden of care. AIM To determine the prevalence of ocular disorders in patients with stroke in a Tertiary Hospital in Nigeria. MATERIALS AND METHODS A descriptive hospital-based study was performed on all consenting and conscious adult patients aged 18 years and above with a diagnosis of stroke made within 1-year who were admitted to the stroke ward or attended the stroke clinic of the Neurology Unit in the Department of Medicine, University of Benin Teaching Hospital, Benin City from October 2013 to December 2013. RESULTS A total of 170 eyes of 85 patients were studied with a mean age of 66.08 years ± 10.99; range 43-88 years. There was a male: female ratio of 2.6:1. Ocular abnormalities were documented in 95.5% of the patients. A presenting visual acuity of ≥6/18 was found in 66.7%. Mild ptosis and exotropia were seen in 2.9% and 0.6% of the eyes respectively. Intraocular pressure was between 10-21 mmHg in 87.7% eyes while 11.8% eyes had afferent pupillary defects. Cataract was seen in 71.8% eyes and optic nerve head changes in 48.8% eyes which includes temporal disc pallor and glaucomatous optic neuropathy in 29.4% and 14.2% eyes, respectively. Abnormalities found in the retina include retinal hemorrhages in 10.6% eyes, cotton wool spots in 2.4% eyes, and hard exudates in 7.8% eyes. Retinal vascular abnormalities were documented in 32.4% eyes. Visual complaints following stroke were documented in 9.6% of the patients. CONCLUSION Ocular abnormalities are present in patients with stroke, mostly due to predisposing risk factors for stroke, and age-related changes. Routine ophthalmic evaluation is suggested in the management of patients with cerebrovascular accident in our environment for better quality of care.

Clinical Features and Risk Factors of Patients with Presumed Ocular Toxoplasmosis

Purpose: To determine the clinical features and risk factors of presumed ocular toxoplasmosis (POT) in patients affected with the condition at Irrua, Nigeria. Methods: The study included 69 patients with POT, and 69 age and sex matched subjects who served as the control group. Data was obtained using interviewer administered questionnaires. Examination included measurement of visual acuity (VA), intraocular pressure (IOP), slit lamp examination, gonioscopy and dilated fundus examination. Results: Mean age of cases and control subjects was 57.16 ± 18.69 and 56.09 ± 16.01 years respectively. The peak age group in patients with POT was 60 years and above. The most common presenting complaint was blurred vision occurring in 100% of cases. Drinking unfiltered water in 58 (84.1%) patients was the most common risk factor. Other risk factors included post cataract surgery status in 32 (46.4%) subjects, ingestion of poorly cooked meat in 30 (43.5%) cases and exposure to cats in 9 (13.0%) patients. All risk factors were more common in POT patients (P < 0.05). Out of 69 patients, 62 (89.9%) had unilateral while 7 (10.1%) had bilateral involvement. Out of 76 eyes with uveitis, 53 (69.7%) were blind. Active disease was significantly more common with increasing age (P < 0.05). Conclusion: Patients with POT were rather old and some risk factors were modifiable, therefore health education for preventing the transmission of toxoplasmosis and provision of sanitary water may help reduce the incidence of ocular toxoplasmosis.