Diagnostic Correlation between General Practitioners and the Ophthalmologist in the Management of Eye Diseases

OBJECTIVES

To determine the accuracy of diagnosis of ophthalmic disorders as well as the adequacy of referral of patients with ophthalmic disorders for specialist eye care by the general practitioners (GP).

MATERIALS AND METHODS

This was a hospital-based descriptive study. Patients selected by systematic random sampling at the General Out-Patient Department (GOPD) of a tertiary hospital were evaluated by the ophthalmologist after they had been independently assessed by the General Practitioners. Diagnoses and referral decisions of the GP were compared with those of the ophthalmologist using Kappa Statistics.

RESULTS

A total of 382 patients were studied while 22 GPs participated in the study. Ocular disorders were found by the ophthalmologist in 112 (29.3%) patients while the remaining 270 (70.7%) were normal . Only 36 (32.1%) of those with ocular disorders had a diagnosis of ocular disorders by the General Practitioners. A correct diagnosis was made by the GPs for 18 (16.1%) patients (k=0.102, p =0.001); and the highest diagnostic agreement was obtained for conjunctivitis (k=0.464, P= 0.001). No patient with posterior segment disorder was diagnosed by the GPs. Majority (81%; k = 0.616, p=0.001) of referrals were in agreement with expected referral decision. However, 28 (25.0%) under-referrals and 16 (19.0%) over-referrals were noted.

CONCLUSION

About one-third of all the patients assessed had an ocular disorder, but the general practitioners detected these disorders only one-third of the time; a correct diagnosis of ocular disorders was made in only 16.1%, while no posterior segment disease was diagnosed. Wrong referral decisions were made in up to one-third of patients. Regular update courses for general practitioners on ophthalmic evaluation will help address these observed deficiencies.

Pterygium in Onitsha, Nigeria

Objective

To determine the pattern and risk factors of pterygium in adults at the Guinness Eye Centre Onitsha, Nigeria.

Materials and Methods

Consecutive adults aged ≥30 years with pterygium were studied. Each patient had comprehensive ocular examination including visual acuity, anterior segment, and adnexal assessment and fundoscopy. The pterygium was graded in terms of severity and type.

Results

A total of 156 patients with pterygium participated; 92 (59%) females versus 64 (41%) males (F:M =3:2). The age range was 30-65 years; mean: 43.9 ± 8.4 years. The majority of the study population (36.5%) was of the age group 40-49 years. The subjects were predominately traders 78 (50%) and 93 (59.6%) of the pterygium patients were outdoor workers. Bivariate analysis indicated that those involved in outdoor work were six times at greater risk of developing pterygium than indoor workers (P = 0.001; OR = 6.2). Out of the 156 pterygium patients seen, 107 (68.6%) of them complained of associated symptoms. Redness of the eye was the commonest symptom reported by 79 (50.9%) cases while 8 (5.1%) cases complained of burning sensation. There was a preponderance of nasal pterygia with temporal pterygia being the least. Blinding pterygium was seen in three eyes (1.3%).

Conclusion

Pterygium is a common disorder presenting at eye clinics. Outdoor workers are at a greater risk of developing pterygium. Thus, health education is of great importance.

The anterior chamber angle width in adults in a tertiary eye hospital in Nigeria

OBJECTIVE

The objective was to determine the anterior chamber angle width in adult Nigerian patients seen at the Guinness Eye Center Onitsha Nigeria.

MATERIALS AND METHODS

Consecutive new adult patients (aged ≥21 years) seen between March and July 2006 were the subjects of this study. Exclusion criteria included refusal to consent to the test, previous intraocular surgery that could distort the angle integrity and anterior segment pathology precluding the visualization of the angle. Each patient had visual acuity assessment, visual field analysis, ophthalmoscopy, intraocular pressure measurement, refraction, and gonioscopy. The angle grading was by the Shaffer method.

RESULTS

Of the 328 patients (648 eyes), aged 21-85 years (median age 59 years), 195 (59.5%) were females and patients older than 50 years constituted 64.9%. Gonioscopy showed that 245 eyes (37.8%) had wide open angles (grades III and IV); 227 (35.0%) had grade II angles; 176 (27.2%) had narrow angles (grade I or slit), 9 of which were deemed occludable. Of the 80 patients with chronic simple glaucoma, 20 (25%) had at least grade III angle; 34 (42.5%) had grade II angle; and 26 (32.5%) had grade I angle. Peripheral anterior synechiae were observed in three eyes. Compared with nonglaucomatous eyes, the angles of the glaucomatous eyes were significantly narrower (P <0.01). Similarly patients older than 50 years were more likely to have narrower angles (P < 0.001). However there was no significant difference between the angle width of male compared to female patients (P >0.05).

CONCLUSIONS

A little more than a third of adult patients seen in our hospital have wide open angles; a third of the glaucoma patients usually taken as open angle cases actually have very narrow angles some of which are occludable. A population-based study is therefore recommended to clearly define the epidemiologic characteristics of glaucoma including the anterior chamber width in different parts of Nigeria.

Incidence and risk factors for traditional eye medicine use among patients at a tertiary eye hospital in Nigeria

OBJECTIVE

To determine the incidence and risk factors for traditional eye medicine use among patients at the Guinness Eye Center Onitsha, Nigeria.

MATERIALS AND METHODS

Consecutive new adult ophthalmic patients seen at the Guinness Eye Center Onitsha between January and April 2007 were interviewed on the use of traditional eye medicines and the type of traditional eye medicine used.

RESULTS

Of the 500 patients interviewed, 66 (13.2%) had used traditional eye medicines (TEM). The 66 patients, aged 18-84, were made up of 32 males and 34 females. The commonly used TEM were liquid from plant leaves and roots and other concoctions of unknown origin. Conjunctivitis and cataract constituted 54.5% of the ocular problems; 15(22.7%) patients had visual impairment while 5(7.6%) other patients were blind. Risk factors for TEM use include age above 50 years (P<0.001); residence outside Onitsha metropolis (P<0.001) or ≥ 25 kilometres away from our hospital (P<0.02) and lack of any formal education (P<0.02). Decision to use TEM was not affected bygender (P>0.05); chronic nature (P>0.05) or painfulness of the ocular disease (P>0.05).

CONCLUSIONS

Traditional eye medicine is highly patronized by the people. Health education programmes with emphasis on safe eye care practices need be intensified in traditional healers and among the groups at risk.

Retrobulbar versus subconjunctival anesthesia for cataract surgery

OBJECTIVES

To compare the effectiveness, in terms of pain relief and akinesia of retrobulbar and subconjunctival an aesthesia during cataract surgery and also to compare the degree of postoperative ptosis associated with each technique.

MATERIALS AND METHODS

Consecutive adult patients undergoing cataract surgery between March and June 2008 at the Guinness Eye Center Onitsha, were randomized into retrobulbar and subconjunctival an aesthesia by simple random sampling. Patients' subjective perception of pain was graded into none, mild, moderate and severe; eyeball movement during surgery was graded into none, slight, moderate excessive. Two weeks after surgery, the palpebral fissure width was measured with the metre rule to determine the degree of post-operative ptosis.

RESULTS

Of the 90 patients studied, 55 (61.1%) patients had subconjunctival an anesthesia while 35(38.9%) had retrobulbar injection. In the retrobulbar injection group 25 (71.4%) patients had none or mild pains compared to 44 (80.0%) in the subconjunctival injection group; while 10 (28.6%) patients in the retrobulbar group experienced moderate to severe pains, 11 (20%) patients in the subconjunctival group had moderate pains and none experienced severe pains. But the difference in the degree of pain perception between the 2 groups is not statistically significant (χ2 = 0.01; df - 1; P>0.05 ). In the retrobulbar injection group, there was none or slight movement of the globe in 30 (85.7%) patients compared to 49 (89.1%) patients in the subconjunctival group. While 5 (14.3%) patients in the retrobulbar injection group had moderate globe movement, no patient in this group had excessive movement. In the subconjunctival injection group, 5 (9.1%) patients had moderate movement and 1 (1.8%) patient had excessive eyeball movement. The difference in the movement of the eyeball between the retrobulbar and the subconjunctival injections group was not significant (χ2 = 0.004; df - 1; P>0.05 ). In the retrobulbar injection group, the palpebral fissure width was within ≥ 10mm in 18 (51.0%) patients compared with 29 (53.0%) patients in the subconjunctival group. This difference was not statistically significant (χ2 = 0.0006; df - 1; P>0.05 ).

CONCLUSIONS

Both retrobulbar and subconjunctival an aesthetic techniques are effective and safe for cataract surgery although the pain experience may be slightly more for patients being operated upon under retrobulbar anaesthesia.

Age-related macular degeneration in Onitsha, Nigeria

OBJECTIVES

To determine the incidence, pattern and ocular morbidity associated with age-related macular degeneration (AMD) at the Guinness Eye Center Onitsha Nigeria.

MATERIALS AND METHODS

The case files of all new patients aged 50 years and above seen between January 1997 and December 2004 were reviewed. The files of patients with AMD were further studied. Information on age, gender, occupation, duration of symptoms, type of maculopathy, visual acuity, ocular and systemic co-morbidities were abstracted into a standard proforma and analyzed using the chi-square test, student t-test and confidence interval estimation.

RESULTS

Two hundred and fifty-six of 7966 (3.2%) new patients had AMD; M:F = 2:3; 60 -79 year age group constitute 70% of the cases. Non-neovascular AMD occurred in 210 (82%) patients with 182 (71.1%) having early AMD and 28 (10.9%) geographic atrophy. Neovascular AMD occurred in 46 (18%) patients. AMD was bilateral in 221 (86.3%) patients. Most patients presented late. Systemic co-morbidities were hypertension and diabetes; the main ocular co-morbidities were cataract and glaucoma. Thirty-four (13.3%) patients were bilaterally blind and 130 (50.8%) had bilateral visual impairment. Of the blind patients 13(38.3%) had neovascular AMD and 6 (17.7%) had geographic atrophy. This makes AMD the cause of blindness in 7.4% of the patients. An affected eye was more likely to have low vision than an unaffected eye (95%CI: 0.07, 0.21; P<0.05); persons aged 70 years and above were more likely to be blind (χ2 - 7.26, df -1; P<0.05); females were also more likely to be blind than males (t - 2.857, df - 8; P<0.05) and neovascular AMD significantly causes more blindness than the non-neovascular type (95% CI: 0.11, 0.37; P<0.05).

CONCLUSIONS

AMD was the main cause of blindness in 7.4% of the patients. Treatment facilities including low vision aids for AMD patients should be provided in eye hospitals in Nigeria. Health education of the public highlighting the risk factors for AMD should be mounted as part of Vision 2020 programme in Nigeria. A community based study is required to fully define the epidemiologic characteristics of AMD in Nigerians.

Intraocular pressure, retrobulbar anaesthesia and digital ocular massage

OBJECTIVES

To determine the degree of intraocular pressure (IOP) rise following retrobulbar anaesthetic injection as well as the optimal time required for the return of the IOP to the pre-injection level following ocular massage.

MATERIALS AND METHODS

Using the Perkins hand-held tonometer, the IOP of consecutive adult patients were measured in the operating room before local anaesthetic (3 ml of 2% xylocaine with or without adrenaline) injection; immediately after injection and every minute following ocular massage for the next 5 minutes.

RESULTS

Twenty-three eyes of 17 patients, aged 23-71 years, were studied. The mean (+/- SD) baseline (preinjection) IOP was 16.6 (+/- 6.8) mmHg. Immediately after the injection the IOP rose by 11.8-80% with a mean of 37.3 +/- 16.8% (95% CI: 30.4-44.2). By 3 minutes the IOP had returned to the pre-injection level. After 3 minutes the IOP had become lower than the pre-injection level (p < 0.05)

CONCLUSIONS

IOP rise following retrobulbar injection of 3 ml of local anesthetic varies from 11.8-80%. Digital ocular massage lowers the IOP to pre-injection level in 60.2% in 3 minutes; in 5 minutes it lowers the IOP to preinjection level in all eyes and to below pre-injection level 86%.

Medical students perception of undergraduate ophthalmology training in Nnamdi Azikiwe University Nnewi Campus

AIM

To determine the perception and aspiration of medical students towards ophthalmology.

METHOD

Information for the study was obtained through forced-choice questionnaire set to 102 medical students in 2000/2001 graduating class in Nnamdi Azikiwe University.

RESULTS

One hundred questionnaires were completed. As a specialty of choice ophthalmology ranked fourth {16.0%} as a first choice; second {21.0%} as a second choice and first {26.0%} as a third choice. Ninety-five of respondents found ophthalmology training useful.

CONCLUSION

This cohort of medical students considered ophthalmic training in this institution essential and adequate. Undergraduate ophthalmic course should ensure an understanding of the basic principles of ophthalmology and should be designed to motivate the interest and confidence of the medical students in the specialty. Training period should be at least 4 weeks. With appropriate training ophthalmology can attract reasonable interest as a choice for specification.

Leprosy control in the post leprosaria abolition years in Nigeria: reasons for default and irregular attendance at treatment centres

A questionnaire was administered to all patients with leprosy seen at the four leprosy clinics in Anambra State in a face to face interview. The questions covered, among other items, the clinic attendance behaviour and the single most important reason, monthly, for absenteeism in the preceding year. The total and individual frequencies of the reasons for absenteeism were determined for the various behavioural subgroups. The differences in frequencies and associations were analysed. Values of P < 0.05 were considered as significant. The results showed that 27 females and 26 males were interviewed. 39.6% of the patients were irregular attenders 735% were defaulters. Attendance at meetings (P < .001); work at home (P < 0.01) fear/shame/indignation (P < 0.05); no confidence in treatment (P < 0.025) were significant reasons for absenteeism among irregular attenders inter-current illnesses as reasons for absenteeism did not differ significantly between regular and irregular attendees. The association between clinic attendance behaviour and lesion location (revealed Vs concealed) was not statistically significant (X(2)0.3). The findings in this study indicate that in the post leprosaria abolition years, default and irregular clinic attendance by patients with leprosy are numerically large and may compound the problems of control programmes, and thus negate the realization of the global goal of intercepting leprosy transmission.