Covadonga Bascaran

Changing patterns of cataract services in North-West Nigeria: 2005-2016.

Purpose This study was conducted to assess the impact of the eye care programme on cataract blindness and cataract surgical services in Sokoto, Nigeria over a 12 year period 2005–2016. Methods Data from the 2005 population based cross-sectional study of blindness in Sokoto state was re-analysed to obtain baseline estimates of the prevalence of cataract blindness and cataract surgical coverage for persons 50 years and over in Wurno health zone. A population based survey of a representative sample of persons 50 years and over in Wurno health zone was conducted in July 2016. Data on eye health workforce, infrastructure and cataract surgical services between 2005 and 2016 were analysed from relevant documents. Results In 2005 the unadjusted prevalence of bilateral cataract blindness (<3/60) in people 50 years and over in Wurno health zone was 5.6% (95% CI: 3.1, 10.1). By 2016 this had fallen to 2.1% (95% CI 1.5%, 2.7%), with the age-sex adjusted prevalence being 1.9% (95% CI 1.3%, 2.5%). The CSC for persons with visual acuity <3/60, <6/60, <6/18 for Wurno health zone was 9.1%, 7.1% and 5.5% respectively in 2005 and this had increased to 67.3%, 62.1% and 34.7% respectively in 2016. The CSR in Sokoto state increased from 272 (1005 operations) in 2006, to 596 (2799 operations) in 2014. In the 2005 survey, couching (a procedure used by traditional practitioners to dislocate the lens into the vitreous cavity) accounted for 87.5% of all cataract interventions, compared to 45.8% in the 2016 survey participants. In 2016 18% of eyes having a cataract operation with IOL implantation had a presenting visual acuity of <6/60 (poor outcome) with the main causes being postoperative complications (53%) and uncorrected refractive error (29%). Conclusion Between 2005 and 2016 there was a doubling in cataract surgical rate, a 7 times increase in cataract surgical coverage (<3/60), and a decrease in cataract blindness and the proportion of eyes being couched. However, there remains a high prevalence of un-operated cataract in 2016 indicating a need to further improve access to affordable and good quality cataract surgical services.

Analysis of an international collaboration for capacity building of human resources for eye care: case study of the college-college VISION 2020 LINK

BackgroundThere is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term.Case presentationThe VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links.MethodsAn exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis.ResultsThe findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge.ConclusionThe study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks.

Outcome of trachoma lid surgeries in Jigawa state, Nigeria

Abstract Background: Following the implementation of the SAFE strategy in Jigawa state, ophthalmic nurses trained as lid surgeons perform trichiasis surgery in the state. This study aimed to determine the early outcome of these surgeries with the specific objectives to determine the recurrence rate of trichiasis; the incidence of eyelid contour abnormality and incidence of eyelid closure defects 3–6 months postoperatively. Methods: A retrospective cohort study of patients operated for the first time between December 2012 and April 2013 in four zones in Jigawa state. Zones were selected based on the location of the most active surgeons. Patients were examined with torchlight for presence of recurrent trichiasis (TT recurrence), eyelid contour abnormality (ECA) and eyelid closure defects (ECD). Results: 133 eyes of 77 patients were examined; incidences recorded were TT recurrence 17.29% (95% CI 11.29–24.80%), ECA 18.93% (95% CI 12.64–26.67%) and ECD 5.3% (95% CI 2.15–10.62%). Incidence of poor outcome varied with zone and was associated with female sex, duration of symptoms >1 year preoperatively, bilaterally operated eyes, and paid surgery. Conclusion: The incidence of poor outcome measures was high across all zones evaluated. The risk factors associated with poorer outcome include late presentation, female sex, Bilateral surgery, and paid surgery.

Human resources for refraction services in Central Nepal

Uncorrected refractive error is a public health problem globally and in Nepal. Planning of refraction services is hampered by a paucity of data. This study was conducted to determine availability and distribution of human resources for refraction, their efficiency, the type and extent of their training; the current service provision of refraction services and the unmet need in human resources for refraction in Central Nepal.

Trends in cataract surgical rate and resource utilisation in Egypt

ABSTRACT Purpose: To describe cataract services in Egypt and explore resources and practices in public and private sectors. Methods: The study was conducted between June and August 2015. All facilities in the country providing cataract services were contacted to obtain information on surgeries performed in 2014. Hospitals performing eye surgery in Quena, Sharkia, and Fayoum regions were visited and a questionnaire on resources for cataract surgery was completed. Results: Cataract surgery was offered in the public sector by 64 government and 16 university teaching hospitals and in the private sector by 101 hospitals. Over 90% of all facilities in the country contacted participated in the study. In 2014, the national cataract surgical rate (CSR) was 3674 varying in governorates from 7579 in Ismailia to 402 in Suez. The private sector performed 70% of cataract surgeries. Analysis of three regions showed an 11.7% increase in cataract output between 2010 and 2014. The average number of cataract surgeries per unit in 2014 was 2272 in private, 1633 in university, and 824 in government hospitals. Private hospitals had 60% of human resources for eye care. Phacoemulsification was the surgical technique in 85.6% of private, 72.1% of university, and 41% of government hospitals. Reasons explaining the differences in output between public and private sectors were the lack of trainers, supervisors, and incentives. Conclusion: The private sector provides most of the cataract services in Egypt, resulting in inadequate services for the poor. There is a 15-fold variation in CSR between the best and least served regions. The public sector could increase cataract output by improving training, supervision, and incentives.

Spectacle Compliance and Its Determinants in a School Vision Screening Pilot in Botswana

ABSTRACT Purpose: The effectiveness of school eye health programmes relies on many factors, including compliance with spectacle wear. The objectives of this study were to determine spectacle compliance in a school vision screening pilot programme in Botswana, and investigate factors predictive of compliance. Methods: The study was an observational, cross-sectional follow-up of a pilot school screening programme. Unannounced compliance checks were completed after 3–4 months in a convenience sample of 19 schools. Sex, age, school level, visual acuity, and refractive error were analysed using logistic regression to investigate factors predictive of compliance. Findings: Compliance data were recorded for 193/286 (67.5%) children; 62.2% were female and the median age was 15 years (interquartile range 12–17 years). 60.1% of the sample were compliant with spectacle wear. Girls were more likely to be compliant than boys (adjusted odds ratio (aOR) = 2.32, 95% confidence interval (CI) 1.03–5.27). Children at primary and junior secondary school were more likely to be complaint than senior secondary school children (aOR = 16.96, 95% CI 5.60–51.39; and aOR = 3.39, 95% CI 1.39–8.22, respectively). Children with binocular uncorrected visual acuity (UCVA) of 6/7.5 to 6/12 were 2.76 (95% CI1.05–7.23) times more likely to be compliant than children with binocular UCVA of 6/6. Conclusion: Compliance was higher in Botswana than previous African studies; however, improvement in this area would increase the effectiveness of the programme. Further investigation into barriers to spectacle wear affecting boys and older children is warranted. A prescribing protocol to avoid low prescriptions – especially where binocular UCVA is 6/6 – is desirable.

Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs

BackgroundThe use of clinical practice guidelines envisages augmenting quality and best practice in clinical outcomes. Generic guidelines that are not adapted for local use often fail to produce these outcomes. Adaptation is a systematic and rigorous process that should maintain the quality and validity of the guideline, while making it more usable by the targeted users. Diverse skills are required for the task of adaptation. Although adapting a guideline is not a guarantee that it will be implemented, adaptation may improve acceptance and adherence to its recommendations.MethodsWe describe the process used to adapt clinical guidelines for diabetic retinopathy in Kenya, using validated tools and manuals. A technical working group consisting of volunteers provided leadership.ResultsThe process was intensive and required more time than anticipated. Flexibility in the process and concurrent health system activities contributed to the success of the adaptation. The outputs from the adaptation include the guidelines in different formats, point of care instruments, as well as tools for training, monitoring, quality assurance and patient education.ConclusionGuideline adaptation is applicable and feasible at the national level in Kenya. However, it is labor- and time -intensive. It presents a valuable opportunity to develop several additional outputs that are useful at the point of care.

Effectiveness of peer support to increase uptake of retinal examination for diabetic retinopathy: study protocol for the DURE pragmatic cluster randomized clinical trial in Kirinyaga, Kenya

BackgroundAll patients with diabetes are at risk of developing diabetic retinopathy (DR), a progressive and potentially blinding condition. Early treatment of DR prevents visual impairment and blindness. The natural history of DR is that it is asymptomatic until the advanced stages, thus annual retinal examination is recommended for early detection. Previous studies show that the uptake of regular retinal examination among people living with diabetes (PLWD) is low. In the Uptake of Retinal Examination in Diabetes (DURE) study, we will investigate the effectiveness of a complex intervention delivered within diabetes support groups to increase uptake of retinal examination.MethodsThe DURE study will be a two-arm pragmatic cluster randomized clinical trial in Kirinyaga County, Kenya. Diabetes support groups will be randomly assigned to either the intervention or usual care conditions in a 1:1 ratio. The participants will be 700 PLWD who are members of support groups in Kirinyaga. To reduce contamination, the unit of randomization will be the support group. Peer supporters in the intervention arm will receive training to deliver the intervention. The intervention will include monthly group education on DR and individual member reminders to take the eye examination. The effectiveness of this intervention plus usual care will be compared to usual care practices alone. Participant data will be collected at baseline. The primary outcome is the proportion of PLWD who take up the eye examination at six months. Secondary outcomes include the characteristics of participants and peer supporters associated with uptake of eye examination for DR. Intention-to-treat analysis will be used to evaluate the primary and secondary outcomes.DiscussionEye care programs need evidence of the effectiveness of peer supporter-led health education to improve attendance to retinal screening for the early detection of DR in an African setting. Given that the intervention combines standardization and flexibility, it has the potential to be adopted in other settings and to inform policies to promote DR screening.Trial registrationPan African Clinical Trial Registry PACTR201707002430195, registered 25 July 2017, www.pactr.org

A tool for planning retinoblastoma services in sub‐Saharan Africa

Cancer care remains inadequate in low‐middle income countries (LMICs). Children with cancer have 80% chance of surviving in high‐income countries compared to 20% in LMICs. Retinoblastoma (RB), an aggressive eye cancer of childhood and top childhood cancer in sub‐Saharan Africa (SSA), has a low survival rate, due to a delay in diagnosis and abandonment of treatment. The purpose of this study is to provide a tool for planning human resources required to manage RB in SSA.

An assessment of trichiasis surgery workforce in Jigawa State, Nigeria

Abstract Purpose: To compare the trichiasis surgery workforce in Jigawa state with the World Health Organization recommendations for surgical technique, training and equipment supply; and to explore the self-reported challenges faced by the lid surgeons in the recruitment and management of trichiasis patients. Methodology: All available trichiasis surgeons in the state were given questionnaires to complete with information about their training, management of trichiasis, difficulties faced in their practice, surgical equipment; and perceived barriers to uptake of trichiasis surgery. Results: Fifteen surgeons evaluated, all were males with a mean age of 43.7 years (±8.6 years), with an average of three surgeons per zone. Nine of the surgeons could perform both BLTR and Trabut operation, four could do only Trabut while two did only BLTR. All had formal training and certification, except two who trained on the job. Only surgeons whose first training was at least 8 years prior to the study had been retrained. There was an average of 1.66 (±1.17) complete trichiasis surgery instrument sets per centre. Eight (53.33%) surgeons were satisfied with the number and quality of surgical sets. Self reported challenges faced by the surgeons were postoperative infection from poor hygiene, poor compliance with postoperative medications, lack of acceptance of surgery by patients, difficulty in accessing remote areas and sub-standard drugs. Conclusion: Staff training and instrument supply fall short of the recommended for trichiasis surgeons. The challenges faced by TT surgeons in Jigawa are similar to those experienced by TT surgeons in other resource poor settings.