John Szetu

Diabetic eye disease among adults in Fiji with self-reported diabetes

Background:  To characterize diabetic eye disease and its management among adults aged ≥40 years with self‐reported diabetes in Fiji.

Towards standards of outcome quality: a protocol for the surgical treatment of cataract in developing countries

routinely above 1.0 DS – arguably does not fulfil the obligations of surgical aftercare. Consistently poor outcomes are not tolerated in developed countries. Surgeon training, professional bodies, educated consumers, indemnity issues, funding providers, legislative constraints, preferred practice guidelines, and a free and active media probably all contribute to this. In developing countries, however, there is seldom such scrutiny. Some surgeons mistakenly equate this with a tolerance of lesser standards and an attitude that patients are lucky to be receiving any treatment, whatever the outcome. The evidence is that cataract surgical service provider self-regulation frequently does not work in developing countries. Until the health and medical milieux mature in these countries, to the point that there are similar protective mechanisms as occur in developed countries, there is a need to find other means of patient protection. The first of these might be for the local ministry of health to strengthen its capacity to undertake more effective workforce monitoring and control. With this, visiting surgical teams would be less inclined and able to bypass, as frequently occurs now, those responsible for health outcomes in the community. The ministry would also be better able to engage with local surgeons in its employ. The second might be to require surgeons to adopt ‘essential practice requirements’ for the interventions they perform, such as cataract surgery in adults. In the absence of a strong local evidence base, these protocols should be grounded in collective experience. Although they should be amenable to consultative change, adherence to them should be compulsory, avoiding ‘circumstances’ as the justification for any expediency with any outcome. Later, as health care and its delivery advance and resources are more plentiful, the essential requirements may be replaced with evidence-based preferred practice guidelines, which allow practitioner discretion and are more responsive to individual patient need. Third, monitoring of activity and outcomes should be mandatory to ensure that protocols are used and standards are met. 7,8,10 In the case of cataract surgery, this may be done manually or otherwise, and should involve both the practitioner and the health ministry. For the sake of illustration and presentation, these three elements have been combined into a single protocol for cataract surgery in adults (Appendix I). Realizing that local circumstances may require some variation, and that not all of the elements may be enacted immediately, four ministries of health in the Pacific region are currently considering its adoption. The authors commend this approach to ministries of health, surgeons and others interested in finding solutions to the problem of securing quality health outcomes in developing countries.

Diabetic eye disease among adults in Fiji with previously undiagnosed diabetes

Background:  To determine the prevalence and severity of diabetic eye disease among adults aged ≥40 years with unrecognized diabetes in Fiji.

Evaluation of the first 5 years of a national eye health programme in Vanuatu

Purpose:  To evaluate against its objectives the achievements of the first 5 years of a national eye health programme in Vanuatu.

Population-based study of self-reported ocular trauma in Fiji.

Background:  To characterize causes, risk factors and outcomes for ocular trauma among adults aged ≥40 years in Fiji.

Cataract and its surgery in Fiji

Background:  To characterize cataract and its surgery among adults aged ≥40 years in Fiji.

Ocular trauma in the Solomon Islands.

Following eye trauma in Papua New Guinea, there is frequently a poor visual outcome with 60% having a visual acuity of less than 6/60 in the injured eye. The factors predisposing the Solomon Islanders to poor visual outcome after eye trauma also exist elsewhere in the Pacific. There is often a delay in obtaining ophthalmic care: primary surgical repair for penetrating trauma and the timely application of intensive appropriate topical ocular antibiotics. The reasons for this delay include a lack of community eye health awareness (with patients often presenting when the vision has deteriorated), long distances on foot or by canoe to primary healthcare centres, inconsistent and expensive transport systems and lack of appropriate medication at many primary, district and even provincial clinics. Also there is a common fear of hospitals and faith in traditional health workers (THWs). After eye injuries, most patients admit to self-medicating with substances such as the skin of the betel nut, freshly squeezed plant juice or breast milk. Breast milk, although initially sterile is sticky, attracts flies and provides a media for microbial growth. Others consult THWs, believing their ‘kastom meresin’ is more effective. However, traditional eye medicines have an unknown content, concentration, pH and are non-sterile. Other factors that may predispose the eye to infection are the faecal contamination of the ocean surrounding most coastal villages, compromised personal hygiene due to the shortage of running water and the humid climate promoting fungal infection. Thylefors argued that in the developing world superficial corneal injury, which occurs as a result of agricultural work, often leads to rapidly progressive corneal ulceration and subsequent visual loss and has been overlooked as a worldwide cause of monocular blindness. Corneal opacity secondary to trauma has been termed the ‘silent epidemic’ and corneal opacity is the source of 39–70% of monocular blindness worldwide. Indeed a report by the World Health Organization in 2002 lists corneal opacity as the second major cause of blindness in Tonga. However, Tonga and Vanuatu were the only two countries with available data from the Pacific from 1991 and 1989, respectively. Considering the importance of corneal scarring, there are few studies evaluating the aetiological factors predisposing a population to corneal infection secondary to trauma. Upadhyay et al. reported in Nepal if trivial corneal abrasions were treated within 18 h of injury with 1% chloramphenicol 96% healed without developing an ulcer. However, 28.6% developed a corneal ulcer if the treatment was delayed 25–48 h. Furthermore, as public health programmes have become more effective in reducing the prevalence of the traditional causes of corneal blindness, such as trachoma, keratomalacia and leprosy, ocular trauma has become relatively more important. Moreover, there have been no studies in the Pacific to determine if diabetes has an influence on the incidence of infection, or causes delay in healing after ocular trauma. From previous studies the importance of early intervention in ocular trauma seems to be crucial. Therefore the role of the priOcular trauma in the Solomon Islands

Sight-threatening Diabetic Retinopathy at Presentation to Screening Services in Fiji

Abstract Purpose: To report the spectrum of retinopathy at first presentation to photoscreening services, to determine the proportion of patients that present with sight-threatening diabetic retinopathy (STDR), and to raise awareness of the burden of diabetic eye disease in Fiji. Methods: This retrospective observational cohort study used data from the initial visit of all new patients presenting to the diabetes retinal screening service at the Pacific Eye Institute in Fiji over the 3-month period between July and September 2012. Patients were assessed using a detailed questionnaire regarding diabetes type, duration of disease, medications, complications and co-morbidities, and blood sugar control. Patients subsequently underwent non-mydriatic fundus photography according to Pacific diabetes retinal screening guidelines. Images were graded at the time of acquisition, and data were entered onto a computerized database. For the purposes of this study, information regarding retinopathy grading, visual acuity and patient demographics was used. Results: A total of 522 new patients were screened over the 3-month period. STDR was observed in 27% of patients, with 15% observed to have bilateral STDR. Diabetes control was generally poor. Blindness and visual impairment were observed in 2.7% and 6.7% of the cohort, respectively. Conclusion: Severe and advanced diabetic retinopathy was present in this population presenting to screening. This was observed 4 years after the formal expansion of the screening services and reflects the high prevalence of diabetes in the population. The need for increased public awareness and greater resource allocation into diabetes and its complications is emphasized.

The association of diabetes and BMI among Melanesian and Indian Fijians aged ≥ 40 years

The present study examines the association of diabetes with BMI (kg/m(2)) in Asian-Indian and Melanesian Fijian populations sharing a common environment. A population-based survey was used to investigate the risk of diabetes (defined by glycosylated Hb concentration ≥ 6·5 % among participants who denied previous diagnosis of the disease by a medical practitioner) by sex, ethnicity and strata of BMI in a series of age-adjusted logistic regression models. Ethnicity and BMI interactions were compared using WHO and empirically derived BMI cut-off points. Indians had a greater risk (BMI and age adjusted) of undetected diabetes than Melanesians in both males (OR 2·99, 95 % CI 1·73, 5·17; P < 0·001) and females (OR 2·26, 95 % CI 1·56, 3·28; P < 0·001). BMI ≥ 25 to < 30 and ≥ 30 kg/m(2) conferred a higher risk of diabetes compared with a BMI ≥ 18·5 to < 25 kg/m(2). Risk was higher for males with a BMI ≥ 25 to < 30 kg/m(2) (OR 2·35, 95 % CI 1·24, 4·46; P = 0·007) and BMI ≥ 30 kg/m(2) (OR 6·08, 95 % CI 3·06, 12·07; P < 0·001) than for females with the same BMI (OR 1·85, 95 % CI 1·11, 3·08; P = 0·027 and OR 2·10, 95 % CI 1·28, 3·44; P = 0·002, respectively). However, the threshold that appeared to differentiate higher risk varied by ethnicity and sex. For Melanesians, BMI thresholds suggested were 25 kg/m(2) for males and 32 kg/m(2) for females. For Indo-Fijians, these were 24 and 22 kg/m(2) for males and females, respectively. Disaggregating by ethnicity and sex, and applying specific evidence-based thresholds, may render BMI a more discriminating tool for assessing the risk of developing diabetes among Fiji adults.

Diabetic retinopathy in a hospital eye clinic population in Honiara, Solomon Islands.

Background:  To determine the presence, severity and context of diabetic retinopathy among diabetic adults using hospital eye clinic services in Honiara, Solomon Islands.