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Momoh RO, Bunce C, Oko-oboh GA, Gilbert CE. Advanced glaucoma at presentation is associated with poor follow-up among glaucoma patients attending a tertiary eye facility in Southern Nigeria. Ophthalmic Epidemiol 2018; 25:266-272. [DOI: 10.1080/09286586.2018.1424345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Rita Omoso Momoh
- Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Catey Bunce
- Department of Primary Care & Public Health, Kings College London, London, United Kingdom
| | | | - Clare E. Gilbert
- London School of Hygiene & Tropical Medicine, International Centre for Eye Health (ICEH), London, United Kingdom
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Baboolal SO, Smit DP. South African Eye Study (SAES): ethnic differences in central corneal thickness and intraocular pressure. Eye (Lond) 2018; 32:749-756. [PMID: 29328064 DOI: 10.1038/eye.2017.291] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/26/2017] [Indexed: 11/09/2022] Open
Abstract
PurposeGlaucoma is the leading cause of irreversible blindness worldwide. South Africa has a diverse population but there is a lack of published ethnic specific normative data. The purpose of the study is to determine the distribution of intraocular pressure (IOP) and central corneal thickness (CCT) values in a multi-ethnic South African population and to determine additional systemic and ocular factors that influence IOP and CCT.Patients and methodsThis cross-sectional study included a total of 402 participants with 706 eyes aged 18-94 years. Participants underwent a standardized interviewer-administered questionnaire for risk factor assessment followed by a full ophthalmic examination. The averages of six IOP readings were measured with an Icare PRO tonometer and CCT was measured with a Pentacam.ResultsThe mean CCT readings in the African, Mixed ethnicity, and Caucasian participants were 514.77±31.86, 531.77±35.17, and 549.97±30.51 μm (P<0.001). The mean IOP in the African, Mixed ethnicity, and Caucasian participants were 15.51±2.49, 15.09±2.12, and 15.13±2.53 mm Hg (P=0.07). Africans had significantly higher IOP than Mixed ethnicity (P=0.034) and Caucasians (P=0.011). Hypertensives had a higher IOP (P=0.03). Age and pseudophakia were associated with a lower IOP (P<0.001) and higher CCT (P<0.001). There was a strongly positive correlation between CCT and IOP (β=0.021; P<0.001).ConclusionsIn the South African Eye Study (SAES), Africans had the thinnest corneas and highest IOP followed by Mixed ethnicity and Caucasians. Including systemic and ocular factors that influence IOP specific to each population and ethnic group, will lead to a more accurate clinical risk stratification in glaucoma management.
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Affiliation(s)
- S O Baboolal
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - D P Smit
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Can Adapted Motivational Interviewing Improve Uptake of Surgical or Laser Treatment for Glaucoma in Nigeria: Randomized Controlled Trial. J Glaucoma 2017; 26:822-828. [PMID: 28857945 DOI: 10.1097/ijg.0000000000000729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess whether adapted motivational interviewing (MI) has any impact on the proportion of participants who subsequently underwent surgery or laser treatment for glaucoma. MATERIALS AND METHODS A single site randomized controlled trial in Bauchi, Nigeria. Participants were new patients with a confirmed diagnosis of primary open-angle glaucoma in 1 or both eyes, where surgery or laser was recommended. Intervention was a session of MI adapted for glaucoma and the local context, using an interview guide based on local qualitative research. Participants were randomly allocated to intervention or usual care. Usual care was routine explanation by an ophthalmologist and an educational pamphlet. After the interview, a 12-item Working Alliance Inventory questionnaire was administered to patient-interviewer pairs to assess the collaborative relationship. RESULTS Two hundred seventy-six glaucoma patients participated; 70% males. One hundred thirty-five (49%) were assigned to adapted MI and 141 to usual care. All received the intervention as allocated. Uptake (ie, the proportion who underwent treatment) of laser or surgery in the MI group was 52% compared with 45% in the usual care group (risk difference 7.2%; 95% confidence interval, -4.5% to 18.9%). Mean Working Alliance Inventory scores were 68.0 for interviewers and 68.5 for participants with a combined reliability coefficient of 93.9% (ie, high internal consistency and reliability). CONCLUSIONS We observed only a small increase in the uptake of surgery or laser with MI compared with usual care which was not statistically significant. Although only 1 in 2 patients accepted surgery or laser in this trial, this is a much higher proportion than in other studies.
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Kizor-Akaraiwe NN, Monye HI, Okeke S. Awareness and knowledge about glaucoma and proportion of people with glaucoma in an urban outreach programme in Southeast Nigeria. BMJ Open Ophthalmol 2017; 1:e000018. [PMID: 29354697 PMCID: PMC5721634 DOI: 10.1136/bmjophth-2016-000018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 01/17/2017] [Accepted: 02/17/2017] [Indexed: 12/04/2022] Open
Abstract
Aim The aim of this study was to determine the level of awareness and knowledge of glaucoma and the proportion of people with glaucoma among participants of a 1-day urban eye outreach programme. Methods The study was a cross-sectional survey. Data, collected by means of a structured questionnaire, included participants' demographic details, and awareness, knowledge and ocular status as regards glaucoma. Publicity for the outreach was created through the mass media (radio stations and television), churches, handbills, posters and different hospital staff. Data analysis was by Statistical Package for Social SciencesV.20.0. Associations between participants' demographic and other details were tested using Pearson's χ2 test, and a p value of <0.05 was considered significant. Results Four hundred and seventy-eight (93.2%) of the 513 people in attendance were eligible and consented to participate. Awareness, knowledge and proportion of people with glaucoma in the study population were 65.5%, 36.8% and 14.5%, respectively. Awareness was significantly associated with attainment of some formal education, awareness of a positive family history, and having had an eye check prior to the outreach. The mass media was the most common information source. Good knowledge level was significantly associated with higher educational attainment and occupation, whereas proportion of people with glaucoma was significantly associated with increasing age. Conclusion Improving awareness with suitable content for the target population through effective means such as the mass media may be a veritable first step in combating blindness from glaucoma.
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Affiliation(s)
- Nkiru N Kizor-Akaraiwe
- Department of Ophthalmology, College of Medicine, Enugu State University of Science and Technology, Enugu, Nigeria.,Enugu State University of Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Henrietta I Monye
- Department of Ophthalmology, University College Hospital, Ibadan, Nigeria
| | - Suhanya Okeke
- Department of Ophthalmology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
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Kyari F, Nolan W, Gilbert C. Ophthalmologists' practice patterns and challenges in achieving optimal management for glaucoma in Nigeria: results from a nationwide survey. BMJ Open 2016; 6:e012230. [PMID: 27729348 PMCID: PMC5073544 DOI: 10.1136/bmjopen-2016-012230] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE OF THE STUDY Glaucoma, a chronic non-communicable disease, and leading cause of irreversible blindness worldwide is a public health problem in Nigeria, with a prevalence of 5.02% in people aged ≥40 years. The purpose of this nationwide survey was to assess Nigerian ophthalmologists' practice patterns and their constraints in managing glaucoma. STUDY DESIGN Ophthalmologists were sent a semistructured questionnaire on how they manage glaucoma, their training in glaucoma care, where they practice, their access to equipment for diagnosis and treatment, whether they use protocols and the challenges they face in managing patients with glaucoma. RESULTS 153/250 ophthalmologists in 80 centres completed questionnaires. Although 79% felt their training was excellent or good, 46% needed more training in glaucoma diagnosis and surgery. All had ophthalmoscopes, 93% had access to applanation tonometers, 81% to visual field analysers and 29% to laser machines (in 19 centres). 3 ophthalmologists had only ophthalmoscopes and schiøtz tonometers. For 85%, a glaucomatous optic disc was the most important feature that would prompt glaucoma work-up. Only 56% routinely performed gonioscopy and 61% used slit-lamp stereoscopic biomicroscopy for disc assessment. Trabeculectomy (with/without antimetabolites) was the only glaucoma surgery performed with one mention of canaloplasty. Poor compliance with medical treatment (78%) and low acceptance of surgery (71%) were their greatest challenges. CONCLUSIONS This study indicates that a systems-oriented approach is required to enhance ophthalmologist's capability for glaucoma care. Strategies to improve glaucoma management include strengthening poorly equipped centres including provision of lasers and training, and improving patients' awareness and education on glaucoma.
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Affiliation(s)
- Fatima Kyari
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, International Centre for Eye Health, London, UK
- Department of Ophthalmology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | | | - Clare Gilbert
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, International Centre for Eye Health, London, UK
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Abdull MM, Gilbert CC, Evans J. Primary open angle glaucoma in northern Nigeria: stage at presentation and acceptance of treatment. BMC Ophthalmol 2015; 15:111. [PMID: 26296993 PMCID: PMC4546340 DOI: 10.1186/s12886-015-0097-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/31/2015] [Indexed: 11/16/2022] Open
Abstract
Background To determine the stage of primary open angle glaucoma at presentation at a tertiary eye unit, to assess patient’s knowledge of glaucoma and acceptance and subsequent adherence to treatment. Method Information collected prospectively on new glaucoma patients aged 30 or more years included distance from residence and what they knew about glaucoma and its treatment. Treatment offered took account of disease severity and socioeconomic factors. Reasons for not accepting surgery were recorded. At follow up intraocular pressure (IOP) was measured and adherence to medication assessed verbally. Four categories of severity were defined based on visual acuity and visual fields defects in the worse eye. Results 131 patients were recruited (mean age 52.8 years; 62 % male). Most attended because of symptoms (70 %). Mean IOP in affected eyes was 31.9+/-SD 12.4 and mean vertical cup:disc ratio was 0.8. 99 eyes (47 %) had a visual acuity of light perception or worse. Risk factors for advanced/end-stage disease were age >50 years, living >10 km from the hospital, some awareness of glaucoma, not being literate, being unemployed and presenting with symptoms. In multivariable analysis older age and poor knowledge of glaucoma remained independent risk factors. 75 were offered trabeculectomy: five agreed but only one underwent surgery. Reasons for rejecting surgery were fear (37 %), preferred medical treatment (27 %) and cost (15 %). 32/85 (24 %) participants started on topical medication attended follow up. 72 % reported excellent compliance but only 56 % of glaucomatous eyes had IOPs less than 21mmHg. Conclusions To prevent glaucoma blindness strategies are required which promote earlier detection, with counselling to promote acceptance of and adherence to treatment.
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Affiliation(s)
- Mohammed M Abdull
- Ophthalmology Department, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Bauchi State, Nigeria. .,International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
| | - Clare C Gilbert
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
| | - Jennifer Evans
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
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Jackson DJ, Razai MS, Falama R, Mongwa M, Mutapanduwa M, Baemisi C, Josiah E, Nkomazana O, Lehasa A, Brealey E, White AJ, Jankowski D, Kerr-Muir MG, Martin KR, Ngondi JM. The clinical characteristics of patients with glaucoma presenting to Botswana healthcare facilities: an observational study. BMJ Open 2014; 4:e005965. [PMID: 25472657 PMCID: PMC4256541 DOI: 10.1136/bmjopen-2014-005965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aimed to establish the clinical characteristics of patients with glaucoma attending eye care facilities in Botswana, and management of glaucoma among patients who received care in these facilities. The study also aimed to calculate the number of new diagnoses of glaucoma within the glaucoma service. DESIGN A prospective, hospital-based, observational study. SETTING A multicentre study was undertaken in government-run eye departments in Botswana from June to August 2012. PARTICIPANTS All patients with a diagnosis of glaucoma attending clinics at seven study sites were invited to participate. OUTCOME MEASURES Examination findings, diagnosis and management were extracted from individual patient-held medical charts. Sociodemographic characteristics, patient knowledge and understanding of glaucoma were assessed through face-to-face interviews. In addition, details of outpatient attendances for 2011 were collected from 21 government-run hospitals. RESULTS The majority of the 366 patients interviewed had a diagnosis of primary glaucoma (86.6%). The diagnoses were mainly made by ophthalmologists (48.6%) and ophthalmic nurses (44.0%). Many patients (38.5%) had been symptomatic for over 6 months before visiting an eye clinic. The mean presenting intraocular pressure was 28.2 mm Hg (SD 11.9 mm Hg). Most follow-up patients (79.2%) had not received surgery, however, many (89.5%) would accept surgery. Only 11.5% of participants had heard of glaucoma prior to diagnosis. Many participants (35.9%) did not understand glaucoma after being diagnosed. The majority (94.9%) of living first-degree relatives had never been examined. The number of newly diagnosed glaucoma cases for 2011 in the south of the country was 14.1/100,000; 95% CI (12.0 to 16.5), in the north it was 16.2/100,000; 95% CI (13.8 to 19.0). CONCLUSIONS Glaucoma is a significant burden that presents challenges to ophthalmic services in Botswana. Many patients have limited understanding of the condition and poor access to services. There is a need to develop a treatment infrastructure to include safe surgery and a reliable supply of effective medication.
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Affiliation(s)
- Daniel J Jackson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Mohammad S Razai
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Rosemary Falama
- University of Botswana School of Medicine, Gaborone, Botswana
| | | | | | - Chao Baemisi
- University of Botswana School of Medicine, Gaborone, Botswana
| | | | | | | | - Evelyn Brealey
- Addenbrooke's Abroad, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew J White
- Cambridge NIHR Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | | | | | - Keith R Martin
- Cambridge NIHR Biomedical Research Centre, University of Cambridge, Cambridge, UK
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Öztürker ZK, Öztürker C, Bayraktar S, Altan C, Yilmaz OF. Does the use of preoperative antiglaucoma medications influence trabeculectomy success? J Ocul Pharmacol Ther 2014; 30:554-8. [PMID: 24918962 DOI: 10.1089/jop.2014.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To investigate the influence of preoperative antiglaucoma medications on trabeculectomy outcome. METHODS Two hundred fifteen eyes, which underwent primary trabeculectomy, were retrospectively analyzed. The average follow-up was 39.8±30.3 months. The only cases of primary open-angle glaucoma, with or without pseudoexfoliation (PXF), were included. "Complete success" was defined as intraocular pressure (IOP) <18 mmHg without glaucoma medications, whereas relative success was defined as the same IOP target with medications. The influence of the preoperatively used glaucoma medications on surgical success was analyzed by univariate Pearson correlation and multivariate (ordinal) regression analysis. RESULTS There were 118 male (54.9%) and 97 female (45.1%) patients with a mean age of 66.9±9.3 years. PXF glaucoma (PXFG) was present in 93 eyes (43.3%). In 33 patients (15.3%), diabetes mellitus (DM) was present. Complete success was achieved in 116 eyes (54%), relative success in 81 eyes (37.6%), and failure in 18 eyes (8.4%). Neither the total number nor the duration of glaucoma medications used before trabeculectomy was found to have any statistically significant influence on surgical success. In statistical analysis, a combination of topical beta-blocker and carbonic anhydrase inhibitor (BB+CAI) used before surgery was found to be associated with statistically better outcome, whereas the preoperative use of topical beta-blockers alone could have a negative influence on success. PXF was shown to be independently associated with trabeculectomy outcome on multivariate regression analysis. CONCLUSION The glaucoma medications used preoperatively were not found to have any statistically significant negative influence on the trabeculectomy outcome and use of the combined BB+CAI preparation could have a positive influence, whereas the use of topical beta-blockers alone could have a negative influence on success, although not statistically significant. The presence of PXF was independently associated with a better surgical outcome.
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Adekoya BJ, Shah SP, Onakoya AO, Ayanniyi AA. Glaucoma in southwest Nigeria: clinical presentation, family history and perceptions. Int Ophthalmol 2014; 34:1027-36. [PMID: 24442760 DOI: 10.1007/s10792-014-9903-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 01/04/2014] [Indexed: 10/25/2022]
Abstract
Knowledge of the presentation pattern of glaucoma helps in providing more understanding of the disease, leading to better control. The aim of this study was to determine the presentation pattern among newly diagnosed glaucoma patients in Lagos, Nigeria. This was a multicenter cross-sectional survey of newly diagnosed glaucoma patients, recruited over a four-week period. Socio-demographic characteristics, presenting history, awareness and perception on glaucoma, and basic examination findings were obtained. A total of 208 patients, including 90 (43.2 %) females with a mean age of 53.9 years were recruited. One hundred and forty-three (68.7 %) were self-referred patients with a mean duration of symptoms of 2.6 years. Fifty-five (26.4 %) patients gave a history of glaucoma in at least one family member. Ninety-five patients (45.7 %) were aware that glaucoma can cause visual loss, but 69 (72.6 %) out of these believed the visual loss is reversible. Seventy (33.7 %) patients had been previously diagnosed with glaucoma elsewhere. From the 208 patients, 35.5 % had visual impairment (presenting visual acuity [VA] of <6/18 in the better eye), while 15.5 % were blind (presenting VA in better eye <3/60). Lack of glaucoma awareness, positive family history and illiteracy were associated with late presentation of glaucoma. Late presentation is still a major concern among glaucoma patients in Southwest Nigeria, and there is a need to intensify present efforts aimed at increasing public awareness, emphasising the irreversible nature of the disease, as well as encouraging at-risk groups such as first-degree relatives to go for screening.
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Affiliation(s)
- Bola J Adekoya
- Department of Surgery, Lagos State University College of Medicine (LASUCOM), Ikeja, Lagos, Nigeria,
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Kyari F, Abdull MM, Bastawrous A, Gilbert CE, Faal H. Epidemiology of glaucoma in sub-saharan Africa: prevalence, incidence and risk factors. Middle East Afr J Ophthalmol 2013; 20:111-25. [PMID: 23741130 PMCID: PMC3669488 DOI: 10.4103/0974-9233.110605] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
PURPOSE The purpose of this study is to review the epidemiology of different types of glaucoma relevant to Sub-Saharan Africa (SSA) and to discuss the evidence regarding the risk factors for onset and progression of glaucoma, including risk factors for glaucoma blindness. METHODS Electronic databases (PubMed, MedLine, African Journals Online- AJOL) were searched using the full text, Medical Subject Headings (MeSH) terms, author(s) and title to identify publications since 1982 in the following areas: population-based glaucoma prevalence and incidence studies in SSA and in African-derived black populations outside Africa; population-based prevalence and incidence of blindness and visual impairment studies in SSA including rapid assessment methods, which elucidate the glaucoma-specific blindness prevalence; studies of risk factors for glaucoma; and publications that discussed public health approaches for the control of glaucoma in Africa. RESULTS Studies highlighted that glaucoma in SSA is a public health problem and predominantly open-angle glaucoma. It is the second-leading cause of blindness, has a high prevalence, an early onset and progresses more rapidly than in Caucasians. These factors are further compounded by poor awareness and low knowledge about glaucoma even by persons affected by the condition. CONCLUSION Glaucoma care needs to be given high priority in Vision 2020 programs in Africa. Many questions remain unanswered and there is a need for further research in glaucoma in SSA in all aspects especially epidemiology and clinical care and outcomes involving randomized controlled trials. Genetic and genome-wide association studies may aid identification of high-risk groups. Social sciences and qualitative studies, health economics and health systems research will also enhance public health approaches for the prevention of blindness due to glaucoma.
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Affiliation(s)
- Fatima Kyari
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Ophthalmology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Mohammed M. Abdull
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
| | - Andrew Bastawrous
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare E. Gilbert
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Hannah Faal
- Africa Vision Research Institute, Durban, South Africa
- Calabar Institute of Tropical Disease Research and Prevention, University of Calabar Teaching Hospital, Nigeria
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Soatiana JE, Kpoghoumou MA, Kalembo FW, Huyi Zhen H. Outcomes of Trabeculectomy in Africa. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojoph.2013.33019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Dean WH, Courtright P, Cook C. Does Training Clinic Nurses to Test Pinhole Visual Acuity as a Screen for Glaucoma Increase Glaucoma Referrals to Eye Care Professionals? A Pilot Study in Malawi. Ophthalmic Epidemiol 2012; 19:293-6. [DOI: 10.3109/09286586.2012.712193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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