The official journal of the Ophthalmological Society of South Africa
WINTER 2024 | Vol 19 • No 3
TRABECULECTOMY: A REVIEW OF PREOPERATIVE RISK FACTORS FOR BLEB FAILURE
D Heale, C Tinley, L Camras, J Fischer, D McClunan
A RETROSPECTIVE CHART REVIEW OF ORBITAL CELLULITIS CASES THAT PRESENTED TO INKOSI ALBERT LUTHULI CENTRAL HOSPITAL (IALCH) OVER A PERIOD OF 5 YEARS
A Narayan, C-H Kruse, M Du Bruyn
SPECTRUM OF GLAUCOMATOUS DISEASE AT CHARLOTTE MAXEKE JOHANNESBURG
ACADEMIC HOSPITAL: A RETROSPECTIVE CLINICAL AUDIT
I Walters, S Williams
EARLY POSTOPERATIVE INTRAOCULAR PRESSURE ELEVATION FOLLOWING TRAINEE
CATARACT SURGERY AT A TERTIARY TRAINING HOSPITAL IN JOHANNESBURG
E Jansen, R Höllhumer
A CASE OF TRILATERAL RETINOBLASTOMA INITIALLY PRESENTING UNILATERALLY IN AN INFANT EVOLVING TO A DIAGNOSIS OF GERMLINE RETINOBLASTOMA: DIAGNOSTIC DILEMMAS AND THERAPEUTIC CHALLENGES IN THE PRESENCE OF PINEAL GLAND CYSTS.
N Narainswam, N Freeman, T Seobi, H Mustak
SA Ophthalmology Journal
The official journal of the Ophthalmological Society of South Africa ISSN: 2218-8304
Editor-in-Chief
Prof Nagib du Toit journaleditor@ossa.co.za
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Professors: Colin Cook, Nagib du Toit, Priscilla Makunyane, Aubrey Makgotloe, Hamzah Mustak, Christopher Tinley, Linda Visser, Susan Williams
Doctors:
Eric Albrecht, Hassan Alli, Naseer Ally, Stephen Cook, Leonard Heydenrych, Roland Hollhumer, Mpopi Lenake, Stephen Manyeruke, James Rice, Tshilidzi van der Lecq
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Contents
COVER PIC: Image reconstruction demonstrating critical neural and vascular structures in close proximity to the tract.
4 FROM THE EDITOR
Looking back, seeing ahead: The decade that redefined ophthalmology
N Ally
6 GUIDELINES FOR AUTHORS
8 REVIEW ARTICLE
Trabeculectomy: A review of preoperative risk factors for bleb failure
D Heale, C Tinley, L Camras, J Fischer, D McClunan
15 ORIGINAL STUDY
A retrospective chart review of orbital cellulitis cases that presented to Inkosi Albert Luthuli Central Hospital (IALCH) over a period of 5 years
A Narayan, C-H Kruse, M Du Bruyn
22 ORIGINAL STUDY
Spectrum of glaucomatous disease at Charlotte Maxeke Johannesburg
Academic Hospital: A retrospective clinical audit
I Walters, S Williams
29 ORIGINAL STUDY
Early postoperative intraocular pressure elevation following trainee cataract surgery at a tertiary training hospital in Johannesburg
E Jansen, R Hӧllhumer
34 CASE REPORT
A case of trilateral retinoblastoma initially presenting unilaterally in an infant evolving to a diagnosis of germline retinoblastoma: diagnostic dilemmas and therapeutic challenges in the presence of pineal gland cysts
N Narainswam, N Freeman, T Seobi, H Mustak
Looking back, seeing ahead: The decade that redefined ophthalmology
Welcome to the Winter issue of the SAOJ. As with previous issues, publications from registrar MMeds have contributed a significant proportion of the articles published in the journal. While this may seem to be quite onerous on registrars and academic departments, in general, it’s worth noting that the ophthalmology landscape has shifted massively over the past decade.
Internationally, fewer people are pursuing the path of being a general ophthalmologist, with sub specialisation and fellowships already the norm. I don’t think anyone would argue that the general ophthalmologist has become obsolete as services that are too sub specialised, can become problematic with patient management since no one sees the ‘big picture’. Conversely, having a specific subset of ophthalmologists who are subspecialised is particularly helpful when it comes to patient management especially of complex and rare pathologies.
Ophthalmology in South Africa has seen a shift towards this type of practice as well, with more registrars pursuing fellowships both locally and internationally. Since the fellowship landscape is extremely competitive, and varied in terms of what each fellowship has to offer, a potential applicant needs to be as competitive as possible. This helps to ensure placement in a good fellowship programme that will equip one with the necessary skills and experience to work confidently in that subspecialty.
Gone are the days when one can turn up with just a logbook and a smile and hope to secure a fellowship. One must have, not one, but numerous publications to be considered and shortlisted for an interview.
The SAOJ has provided a journal which is both Google Scholar indexed and DHET accredited. It has provided a platform by which registrars are able to delve into the peer review process for the first time.
Thankfully, we as South African ophthalmologists have two things going for us. Firstly, we have excellent registrar training (especially surgical training) with exposure to a wide variety of pathology. From the unfortunate severity of retinoblastoma, various orbital tumours, as well as the full spectrum of cataracts, there is scarcely an entity that a South African trained ophthalmologist has not seen. Our surgical training also provides an excellent basis from which we can acquire and refine subspecialist skills. There are registrar training programmes in Europe that do not offer phacoemulsification training as part of the programme. Manual Small Incision Cataract surgery/ Extracapsular Cataract extraction is also an indispensable tool to have in one’s arsenal that we often take for granted. Secondly, from a research perspective, there is no shortage of research topics. This means that, not only registrars, but ophthalmologists in general, are able to explore interesting, worthwhile research within their clinics quite easily.
Returning to the present issue, we have a few interesting articles from various institutions. The first is a retrospective cohort study of orbital cellulitis from Inkosi Albert Luthuli Hospital. Diseases with underlying infective aetiologies are more common in our country and the continent, and this study looks at an important disease entity. We also have a retrospective study on a cohort of
glaucoma patients at Charlotte Maxeke Johannesburg Academic Hospital. As we know, glaucoma in Africa is a major priority for eyecare services and this study reinforces what we know already regarding the disease. Keeping with the theme of glaucoma, we have a review article assessing risk factors for bleb failure. Glaucoma filtration surgery is required especially when disease progression is severe, and bleb failure is an important concern in our population. In addition to the above, we have a prospective cohort study that investigates the post-operative intraocular pressure changes in patients undergoing cataract surgery performed by registrars in Johannesburg. To round this issue off, we have an interesting case report of a child who developed trilateral retinoblastoma and was managed at Red Cross Children’s Hospital. The mix of publications touches on important eye health issues for ophthalmologists in this country and we hope that you find this issue informative and stimulating.
Dr Naseer Ally FCOphth (SA), ChM (Edinburgh), MMed MBBCh Consultant Ophthalmologist, St John Eye Hospital: Vitreo-retinal lead Assistant Editor, South African Ophthalmology Journal
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South African Ophthalmology Journal guidelines for authors
The SA Ophthalmology Journal is a peerreviewed scientific journal and the official mouthpiece of the Ophthalmological Society of South Africa. It appears on a quarterly basis.
1. The South African Ophthalmology Journal invites review articles, original studies and case reports for submission. Articles should be the original, unpublished work of the stated author. All materials submitted for publication must be submitted exclusively for publication in this journal. Written permission from the author or copyright holder must be submitted with previously published figures, tables or articles. Authors are solely responsible for the factual accuracy of their work.
2. A cover sheet is to be submitted with each manuscript. It should contain the title of the manuscript, the names of all authors in the correct sequence, their academic status and affiliations. The ORCID ID number for each author should be supplied (https:// orcid.org/). The corresponding author should include his/her name, address, phone and email address.
3. Articles should be between 2 000 and 3 000 words in length. A 200-word abstract should state the main conclusions and clinical relevance of the article. Use the headings Background, Methods, Results and Conclusion. Five keywords are to be supplied at the end of the abstract.
4. Authors should declare any interests, financial or otherwise, regarding the publication of their article, under the headings of Funding and Conflict of interest. If none, this should be stated. An ethics statement regarding patient consent and/ or Ethics Board approval should be included. Authors should also indicate whether the submission forms part of an ‘MMed dissertation by publication’ by stating so clearly on the title page.
5. All articles are to be in English and are to
follow the Vancouver style of referencing. References should be numbered consecutively in the order that they are first mentioned in the text and listed at the end in numerical order of appearance. Identify references in the text by Arabic numerals in superscript after punctuation, e.g. … trial.13
6. The following format should be used for references:
Articles: Kaplan FS, August CS, Dalinka MK. Bone densitometry observation of osteoporosis in response to bone marrow transplantation. Clin Orthop 1993;294:173-78. Chapter in a book: Young W. Neurophysiology of spinal cord injury. In: Errico TJ, Bauer RD, Waugh T (eds). Spinal Trauma. Philadelphia: JB Lippincott; 1991: 377-94.
7. Tables should carry Roman numerals, I, II etc., and illustrations Arabic numbers 1, 2 etc.
8. Abbreviations and acronyms should be defined on first use and kept to a minimum.
9. All figures, tables and photographs should also be submitted electronically. Each figure must have a separate self-explanatory legend. The illustrations, tables and graphs should not be embedded in the text file, but should be provided as separate individual graphic files, and clearly identified. Photographs should be saved as a 300 dpi JPEG file. Graphs and algorithms, which need to be editable, should be saved as MS Word documents or in PowerPoint. Tables should be saved either in MS Word or in a PowerPoint document. Photographs and X-rays need to be suitably anonymised. Permission should be obtained for the use of patient photographs.
10. Articles are to be submitted by email to the Editor-in-Chief, Prof Nagib du Toit at the following email address: journaleditor@ ossa.co.za The text should be in MS Word. Pages should be numbered consecutively in the following order wherever possible: Title page, abstract, introduction, materials
and methods, results, discussion, acknowledgements, tables and illustrations, references.
11. The Editor reserves the right to shorten and stylise any material accepted for publication.
12. For all accepted articles, authors will be requested to provide five (5) multiple choice CPD questions related to their paper.
13. Authors need to disclose whether they used artificial intelligence (AI)-assisted technologies (such as Large Language Models, chatbots, or image creators) in the production of submitted work. Authors who use such technology should describe, in both the cover letter and the submitted work, how they used it. Authors should not list AI and AI-assisted technologies as an author or co-author, nor cite AI. Chatbots (such as ChatGPT) should not be listed as authors because they cannot be responsible for the accuracy, integrity, and originality of the work. Authors should carefully review and edit the result because AI can generate authoritative-sounding output that can be incorrect, incomplete, or biased and all plagiarism that may have been produced by the AI, should be excluded.
All rights reserved. Copyright subsists in the Author of this work. No part of this article or included photographs may be reproduced, published, performed, broadcast, transmitted or adapted in any form or by any electronic, mechanical or other means without the written permission of the copyright holder. This article is published by New Media, a division of Media24 (Pty) Ltd with consent of the Author. Any unauthorised reproduction, publishing, or adaption of this work will constitute copyright infringement and render the doer liable under both civil and criminal law.
Trabeculectomy: A review of preoperative risk factors for bleb failure
C Tinley FRCOphth(London), Associate Professor (UCT), Paediatric Ophthalmologist Orcid ID: https://orcid.org/0000-0001-5817-7122
L Camras BS Biomedical engineering, PhD Biomedical engineering (Duke University), Chief Scientific Officer at Alievio. Department of Biomedical Engineering, Duke University Orcid ID: https://orcid.org/
J Fischer PhD Biomechanical engineering, BEng (Megatronics) MEng (Biomedical), Head of Engineering Liqid Medical ORCID ID: https://orcid.org/0000-0002-5634-6428
D McClunan MBChB(SU), DipOphth(SA), MMed(UCT), FCOphth(SA) ORCID ID: https://orcid.org/ 0000-0003-3308-8865
Corresponding author: Dr D Heale, email: dougheale@me.com
Abstract
Background: Trabeculectomy is a procedure which allows for alternative aqueous humour drainage to a sub-tenon space called a bleb. The procedure is used in the management of glaucoma to decrease intraocular pressure. While trabeculectomy can be an effective treatment for glaucoma, several risk factors exist which may increase the risk for treatment failure.
Aim: This review is aimed at providing an overview of the literature on known risk factors for trabeculectomy failures, and to establish whether there are currently any comprehensive preoperative scoring systems that may aid the clinician in making a more informed management decision.
Methods: A literature review was conducted to determine the preoperative risk factors for trabeculectomy bleb failure. PubMed and Google Scholar were searched using the key words: trabeculectomy, risk factors and outcomes. Additional studies were identified through propagation.
Results: Eleven papers are included in this review. One study attempts to categorise certain risk factors into a grading system for a preoperative risk assessment. However, the factors deemed clinically significant according to their own retrospective cohort
Introduction
Glaucoma is the principal cause of irreversible blindness, with an estimated prevalence of 3.5% in the population aged 40 to 80. The control of intraocular pressure (IOP) remains the crucial factor in preaventing visual field loss.1 In the last 20 years, there have been a variety of new surgical devices and techniques developed for the lowering of IOP. However, despite the recent advances in filtration surgery, trabeculectomy remains the gold standard for subconjunctival blebforming surgery and the management of uncontrolled glaucoma.1
First described by Cairns in 1968 , the trabeculectomy procedure aims to create a subconjunctival bleb through a sclerostomy
study omit potential other significant risk factors found in the literature from the scoring system. No comprehensive risk scoring system looking at a larger range of previously determined statistically significant risk factors could be found.
Conclusions: Several risk factors have repeatedly been deemed clinically significant for treatment failure in the setting of trabeculectomy surgery. There exists no comprehensive risk stratification system for risk of treatment failure. Such a classification system would be useful for patient selection, counselling, and management.
Competing interests: The author declares that he has no financial or personal relationship that may have inappropriately influenced him in writing this article.
Author contribution: The author is the primary author of the written publication.
Funding: The author received no financial support for the research, authorship, or publication of this article.
and partial-thickness flap. This procedure allows for the controlled efflux of aqueous humour from the anterior chamber into the sub-tenon space, creating a bleb. The procedure aims to lower IOP to a level at which the progression of axonal loss associated with glaucoma may be slowed or halted, limiting the potential for further visual field loss and blindness. 3,4 The relationship between the aqueous flow rate and the resistance to aqueous outflow through the bleb wall are two factors most commonly responsible for determining the final IOP.4 When the outflow of aqueous is insufficient to maintain adequate IOP control, then treatment failure occurs.4 Several risk factors have been deemed
statistically significant in the risk of treatment failure in trabeculectomy: patients younger than 40;3,5,6 African descent;7–9 diabetes;6,10 a raised preoperative IOP;3,11,12 subtype of glaucoma including uveitic and pseudoexfoliative glaucoma;3,12,13 number and duration of hypotensive medications used at the time of surgery3,14 and a history of previous ophthalmic surgery. 3,5,13 Khaimi and Reyes4 suggest that most of these risk factors point towards a similar aetiological agent for surgical failure as they all influence the healing process at the site of the bleb, resulting in increased inflammatory response and eventually bleb wall scarring caused by episcleral-conjunctival fibrosis.4 Adjuvant therapies such as anti-fibroblastic
agents, including Mitomycin-C (MMC), have been shown to reduce the risk of bleb scarring, thereby increasing the success rate of trabeculectomy surgery in high-risk cases.1,15 Tube shunt implantation has been found to have a lower failure rate in patients who have undergone previous filtration surgery when compared to trabeculectomy. Tube shunt devices may, therefore, be a preferred treatment option for patients at increased risk for treatment failure.16,17 Various new non-bleb-forming glaucoma devices have been developed that do not utilise the subconjunctival aqueous drainage pathway.18 These devices may therefore be a preferred treatment option for patients who are at high risk for bleb failure in general.
There remains a need for a comprehensive scoring system, which can guide surgeons on which patients are at higher risk for bleb filtration failure and may be better suited to surgical treatments incorporating higher doses of MMC, tube shunt surgery, or other types of surgery where bleb creation is avoided altogether.15,16,18
Methods
The methodology consisted of a pair of research questions that were used
to define inclusion criteria with which relevant studies were identified. A literature search was then conducted, and the identified studies were subjected to an inclusion screening procedure against the inclusion criteria.
Research questions
The research questions investigated in the review were the following:
1. What are the preoperative risk factors associated with trabeculectomy failure?
2. Are there any existing preoperative scoring systems based on risk factors for trabeculectomy failure?
Inclusion criteria
Only papers available in English were included in the study. Publication types included systematic reviews, randomised control trials, cohort, and case series. Peer reviewed articles, as well as dissertations and books were included. The time frame for the article search was between 2000 and 2022. Only studies on adults over the age of 19 were included as risk factors for paediatric and congenital glaucoma are not comparable with adult-onset glaucoma. Patients must have undergone
Table II: The demographic breakdown of the included studies.
Glaucoma type (%)
trabeculectomy with consideration of potential preoperative risk factors. Where relevant, studies needed clear definitions of complete success, qualified success, and failure of filtration surgery.
Literature search
A database search of Google Scholar and PubMed was used for the literature review. The search phrases used are described in Table I. The search phrases were developed using the following key words: trabeculectomy, risk factors and outcomes.
Table I. The search phrases used in the literature search.
Database Search phrase
Results Google Scholar allintitle: trabeculectomy Risk Factors outcomes
24 papers PubMed ((trabeculectomy [Title]) AND (risk factors [Title])) AND (outcomes) 27 papers
Inclusion screening
The search found a total of 51 studies. Fourteen duplicates were removed,
18 studies were removed through title screening, four studies were removed through abstract screening and six were
removed through full-text screening. The remaining nine studies were included in the review.
Propagation
Two additional studies were found through backward propagation. A total of
Table III: A summary of the results listed according to the statistical method utilised in each study. Risk factors marked in bold were found to be significant.
HR = Hazard Ratio; * = p < 0.05; d = p > 0.05; O = Not documented; ‡ = Age < 40; † = Age >60; ç = Age per decade; § = Non-white vs White; ¶ n= Non-diabetic vs Diabetic Trab = Trabeculectomy; POAG = Primary Open Angle Glaucoma; XG = Exfoliative Glaucoma; UG = Uveitic Glaucoma; 20 Glauc = Secondary Glaucoma; Cat = Cataract
Table IV: The risk factors considered in the candidate studies. Risk factors marked with an “o” were considered. The risk factors marked with a bold “X” were significant.
Study
AGIS 9 Ederer et al8 o
AGIS 11 Dally et al6
Ehrnrooth et al12
Emerick et al14
Hugkulstone et al10
Issa de Fendi et al15 o
Iwao et al13 o
Landers et al3 X
Law et al5 X o
Musch et al19 o
Scott et al7 o X
Sugimoto et al20 o
11 studies were included in the results of the study.
Data extraction
The following data points were extracted from each of the studies:
The trabeculectomy risk factors considered: age, ethnicity, diabetes, number of medications, duration of medication use, secondary glaucoma, preoperative IOP and previous glaucoma surgery.
The risk factors for trabeculectomy bleb failure that were significant. The extracted data points are given in Table I and Table II
Results
The demographic breakdown of each study is given in Table II. The listed results according to the statistical method utilised in each study are given in Table III. The extracted data points from each study are given in Table IV.
Issa De Fendi et al.15 was the only study identified in the review that attempted to develop a risk group category for trabeculectomy failure rate. The authors confirm this by stating: “This is the first study to combine different prognostic factors creating a prognostic risk group with an addictive effect to find a high-risk patient for surgical failure.”15
The same authors15 attempted to assess the role of significant risk factors and develop a risk group category related to trabeculectomy failure. Through a retrospective cohort analysis of glaucoma patients managed with MMC assisted trabeculectomy, the authors demonstrated the statistical significance of the following risk factors:15
Type of glaucoma
Previous ophthalmic surgery
Glaucoma medication used for longer than three years
Four glaucoma medications used before a trabeculectomy.
Using these four statistically significant risk factors, the authors identified three risk group categories: low, medium and high risk for surgical failure at three years postoperatively. The study reports that for low risk (zero risk factors) the incidence of freedom from surgical failure was 93%; medium risk (one to two risk factors) was 83%; and high risk (three to four risk factors) was 37%. These findings suggest that the positive surgical outcomes are related to risk factors and that a risk classification for trabeculectomy is feasible. This study is limited by its retrospective design, risk of bias for historical cohorts, and possible inter-surgeon variability.15
Cassin et al. 21 suggested that the relative risk attributable to each preoperative risk factor is not completely understood, with an uncertainty as to which factors may be cumulative in their risk for bleb filtration failure. 21
Several influential risk factors, such as ethnicity 15 and diabetes are not accounted for in the risk group categorisation develop by Issa De Fendi.15 Further investigation of these and other risk factors are required to develop a holistic understanding of the factors that influence the success of trabeculectomy surgery.
Discussion
This section provides discussion of pertinent risk factors associated with the success of trabeculectomy surgery identified in Table II Each risk factor is discussed in a separate section that investigates the aetiological factors that may contribute to surgical failure and the significance of the risk factor to surgical failure.
Age
Younger age has been referenced as a risk factor for surgical failure in trabeculectomy surgery. 3,6 This has been attributed to a more aggressive healing response in younger patients. 3,6,15 Landers 3 suggested that a thicker Tenon’s capsule may play a role in this response3, while FernandezVigo22 found a negative correlation between age and Tenon’s capsule thickness. 22 In addition, it is believed that younger patients may have more active fibroblasts and inflammatory cells than older patients. 5,22 While Issa de Fendi15 failed to show a statistically significant correlation between age under 40 and surgical failure, the authors believe this to be due to the identification of other risk factors within the subject population, such as number of glaucoma medications at time of surgery.15
Feiner 11 found a clinically significant correlation between the younger age of the patient and a higher preoperative IOP. A higher preoperative IOP has been associated with an increased risk of filtration surgical failure, discussed later in the review article.11,19
Law5 found that in repeat trabeculectomies, older age was the most significant factor in determining surgical success. These findings further illustrate the importance of the inflammatory response in causing bleb filtration failure, as it is postulated that older patients have reduced numbers of fibroblasts and inflammatory mediators present in the conjunctiva. 5
Ethnicity
A limitation of several studies has been the racial demographic of patients included in the patient population undergoing trabeculectomy. 3,15 This omission has resulted in race often being excluded from the statistical analysis of potential risk factors for surgical failure. Although African descent has been cited as a potential risk factor 6 , the results were often not significant, such as in the Advanced Glaucoma Intervention (AGIS) 11 Study6 which reported a 60% higher risk of surgical failure in patients of African descent ( p < .05) 6 as well as the AGIS 9 study 8 which showed African American patients have a 79% higher risk of failure compared with Caucasian patients in initial trabeculectomy ( p < .05). 8 In addition, Scott et al 7 reported significantly lower success rates in African American patients compared to patients not of African descent (76% vs 87% at one year, p < .05) in trabeculectomies with the use of adjunctive MMC’ 7 which is consistent with the AGIS 11 Study.6 However, it does not correspond with the adjusted AGIS analysis, which showed no significant effect. This lack of an effect is further corroborated by Sturmer 23 and Broadway, 24 which showed ethnicity to have no significant effect.6 Nagar,9 however, showed that when comparing patients of Afro-Caribbean descent with European descent, the former had poorer surgical outcomes, particularly for trabeculectomy and suggested that non-penetrating filtration surgery may be more effective in the AfroCaribbean population. In addition, it was noted that patients of Afro-Caribbean descent have higher preoperative IOP, which as discussed later in the review article has been suggested to be an independent risk factor for filtration surgical failure. The study concludes by stating that further, more powerful studies are necessary to assess surgical outcomes in the Afro-Caribbean population.9
Diabetes
Another risk factor which is suggested to increase the risk of trabeculectomy failure is diabetes. Although the evidence is limited, the AGIS: 11 study 6 reports that there was an almost three times higher risk for surgical failure in the diabetic compared to non-diabetic patient population (Hazard Ratio 2.86, p < .05). This study is supported by Hugkulstone,10 who reported results in agreement with that of the AGIS 11 study,6 showing success rates in the non-diabetic and diabetic groups of
83% and 61%, ( p < .05), respectively).10 Issa de Fendi15 authors did not assess diabetes as a risk factor for surgical failure in their paper. Furthermore, Landers 3 found no significant relationship between diabetes and risk of trabeculectomy failure.
Secondary glaucoma
Landers 3 and Issa de Fendi15 suggest that secondary glaucoma may lead to a higher rate of surgical failure for several reasons according to the type of secondary glaucoma. Most studies12,15 seem to group the secondary glaucoma subtypes together as one risk group in order to assess for statistical significance. Issa de Fendi15 assesses several secondary glaucoma subtypes but does not specifically discuss the various subtypes in the study, presenting the statistical significance of the subtypes as a group (secondary glaucoma Hazard Ratio 7.5, p < .05).
Landers,3 however, identifies two main subtypes associated with an increased risk of surgical failure. Firstly, uveitic glaucoma is presented as a known risk factor. The same authors 3 suggest this is secondary to a higher concentration of conjunctival inflammatory mediators, fibroblasts, macrophages, and lymphocytes, which may increase the associated healing response of the surrounding tissue. This is corroborated by more recent studies such as Iwao13 that found that trabeculectomy with MMC was less effective in maintaining IOP reduction in uveitic glaucomatous eyes when compared with primary open angle glaucoma. The same study found that uveitic eyes with previous cataract surgery (Relative Risk = 2.96, p < .05) and granulomatous uveitis (Relative Risk = 3.81 p < .05) were at particular risk for surgical failure. Secondly, pseudoexfoliative glaucoma has been found to have a higher rate of filtration surgical failure, higher IOP spikes and a more rapid rate of progression. 3 Ehrnooth12 reported similar results, finding that exfoliative glaucoma and early postoperative IOP larger than 30 mmHg increased the likelihood of surgical failure.
Preoperative intraocular pressure (IOP)
A high IOP at the time of diagnosis has been cited as a risk factor for filtration surgery failure. 3,12,19 Landers 3 found statistical significance for a preoperative IOP of > 30 mmHg at diagnosis, with the risk shown to increase as the IOP increased (IOP 30-34 mmHg: Hazard Ratio 5.2, p < .05; IOP > 40 mmHg: Hazard Ratio 8.8, p < .05). Issa de Fendi15 did not include
IOP at diagnosis as a risk factor in the scoring system as the study failed to find statistical significance.
Feiner 11 suggested a higher preoperative IOP was associated with a higher IOP at nine years of follow up after trabeculectomy, further suggesting that IOP at diagnosis may be a clinically important risk factor for filtration surgical failure.11,19 This may be further corroborated by the findings of Ehrnrooth12 who showed that early postoperative pressures of more than 30 mmHg decreased the possibility of complete surgical success. Sugimoto20 showed that a high preoperative pressure more than 30 mmHg was a risk factor for surgical success.
Previous ophthalmic surgery
Issa de Fendi15 found previous ophthalmic surgery to be a statistically significant risk factor for surgical failure. 3,15 This was attributed to an increase in postoperative subconjunctival fibrosis. The same authors found a similarly statistically significance of the risk factor as previous studies such as Landers 3 who found previous intracapsular cataract excision to be statistically significant. 3,15 This is further corroborated by Law5 who found repeat trabeculectomy with MMC to have lower success rates compared to initial trabeculectomy with MMC (41% vs 61%; p < .05). The study also suggests that the conjunctival disruption from previous ophthalmic surgery may result in a higher number of activated fibroblasts and inflammatory cells thereby leading to failure of the filtration mechanism.
Sugimoto20 found that the third trabeculectomy was significantly less successful than the first and second surgeries, further corroborating the above evidence. The percentage of eyes fulfilling the complete success criteria in the first, second and third trabeculectomy groups were 91%, 94% and 83% at one year, and 72%, 72% and 51% at five years.
Number of IOP lowering medications
The number of topical IOP lowering medications in use at the time of surgery has been cited as an additional risk factor.14,15 Emerick 14 suggested that the association between the increased risk of failure of the bleb filtration mechanism and the increased number of glaucoma medications is due to the increased exposure of the ocular surface to the preservative Benzalkonium Chloride. 3,14,15 Emerick 14 suggested that the preservative results in a predisposition for healing of
the filtration bleb through an increase in the number of inflammatory mediators and immune cells such as macrophages, lymphocytes and fibroblasts. Issa de Fendi15 found a statistically significant risk for the number of preoperative IOP lowering medications. Furthermore, Landers 3 found that two or more glaucoma medications were a risk for filtration surgical failure at 20 years.
Emerick 14 suggested that the best patient for trabeculectomy has a normal tear film, healthy non-inflamed conjunctiva and a normal aqueous composition. This is not the case for most patients undergoing filtration surgery who have often been on several IOP lowering medications for several years prior to surgical intervention. The same authors found that fewer medications resulted in the most favourable outcomes for filtration surgery. In addition, it is concluded that when eyedrops are used, preservative-free medication is a better alternative, further suggesting Benzalkonium Chloride as a potential cause of an increased inflammatory response within the conjunctiva.14
Duration of IOP lowering medications
The duration of exposure to IOP lowering medications has been citied as an additional risk factor for trabeculectomy failure.14,15 Emerick 14 found that shorter duration of topical medication exposure resulted in the most favourable outcomes for filtration surgery. This is secondary to decreased ocular surface exposure to the preservative Benzalkonium Chloride. Issa de Fendi15 found that the risk of trabeculectomy failure is further complicated by the duration of use of IOP lowering medications, with a statistically significant risk for duration of topical medication use. Landers 3 was, however, unable to show a significant risk for the duration of medication use at 20 years.
Analysis of data
The studies included use different definitions of success and differing statistical methods to analyse results.6 This makes comparing data between studies difficult and may affect the interpretation of conclusions regarding the risk factors for bleb failure in trabeculectomy. In order to mitigate this, a more detailed meta-analysis of the data would be required, involving an adjusted analysis of the results from the included studies according to a set definition of success within standardised statistical criteria for inclusion. The set
definition of success could be adjusted according to the World Glaucoma Association Guidelines for each study and the results then compared and interpreted.
Conclusion
The risk factors for trabeculectomy failure are centred around an increased inflammatory response in the conjunctiva and surrounding tissue. This is secondary to an increased concentration of inflammatory mediators such as macrophages, lymphocytes and fibroblasts,15 which results in an overall increase in the healing response and eventual bleb wall scarring secondary to episcleral-conjunctival fibrosis, culminating in failure of the surgical bleb and resultant increase in IOP. This leads to a risk of progression of glaucomatous changes in the affected eye. 3,15,21
With the variety of surgical devices and techniques developed in the last two decades in the treatment of glaucoma,1 comprehensive preoperative risk stratification guidelines for trabeculectomy may prove a useful tool in the management decision-making process – particularly when one factors in the heightened risk of failure with repeat filtration surgery. 5,25
Issa de Fendi15 is the only study identified in this review that attempted to risk stratify patients according to preoperative risk factors for trabeculectomy failure.15 However, the study uses only four risk factors in the scoring system determined to be clinically significant by their retrospective cohort design, which as mentioned earlier has several limitations.15
Issa de Fendi15 does not include various other risk factors in the suggested risk scoring system which have previously been found by other studies to be clinically significant in the failure rate of trabeculectomies. These limitations of the current literature demonstrate the potential of developing a more complete risk stratification score based on a comprehensive literary review.
A limitation to the above suggestion would be the various criteria used to determine the definition of success within each study, however, potential adjustment of individual study results could be achieved through a standardised definition of success such as the World Glaucoma Association Guidelines or the AGIS Adjusted analysis.6
As various new glaucoma devices and techniques continue to be developed, a comprehensive risk stratification score for patients potentially needing to undergo filtration surgery may become increasingly important in guiding management decisions
in glaucoma, particularly when these alternative devices may be a preferred treatment option for patients at high risk for bleb failure.
References
1. Koike KJ, Chang PT. Trabeculectomy: A Brief History and Review of Current Trends. Ophthalmol. Clin. 2018;58(3):117-133.
2. Cairns JE. Trabeculectomy Preliminary report of a new method. Am J Ophthalmol. 1968;66(4):673-679. doi:10.1016/0002-9394(68)91288-9.
3. Landers J, Martin K, Sarkies N, Bourne R, Watson P. A twenty-year follow-up study of trabeculectomy: Risk factors and outcomes. Ophthalmology. 2012;119(4):694-702. doi:10.1016/2011.09.043.
4. Khaimi MAM, Reyes MM. Filtering Surgery in the Management of Glaucoma. Ento Key. Ophthalmology. 2021. 60: 1-5.
5. Law SK, Shih K, Tran DH, Coleman AL, Caprioli J. Long-term Outcomes of Repeat vs Initial Trabeculectomy in Open-Angle Glaucoma. Am J Ophthalmol. 2009;148(5). doi: 10.1016/j. ajo.2009.05.032.
6. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 11. Risk Factors for Failure of Trabeculectomy and Argon Laser Trabeculoplasty. Am J Ophthalmol; 2002. 134(4):481-498. doi: 10.1016/ S0002-9394(02)01658-6.
7. Scott IU, Greenfield DS, Schiffman J, et al. Outcomes of Primary Trabeculectomy with the Use of Adjunctive Mitomycin. Arch Ophthalmol. 1998; 116:86-291.
8. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 9. Comparison of Glaucoma Outcomes in Black and White Patients Within Treatment Groups. Am J Ophthalmol; 2001;132(3):311-320.
9. Nagar A, Maghsoudlou P, Wormald R, Barton K. Differences in the Surgical Outcomes of Glaucoma Surgery in Patients of African Caribbean Descent. Curr Eye Res. 2022. 47(12):1567-1577 doi:10.1080/02713683.2022.2126 859.
10. Hugkulstone CE, Smith LF, Vernon SA. Trabeculectomy in diabetic patients with glaucoma. Eye; 1993; 7:502-506.
11. Feiner L, Piltz-Seymour JR. Collaborative Initial Glaucoma Treatment Study: A Summary of Results to Date. Curr Opin Ophthalmol. 2003; 14:106–111.
12. Ehrnrooth P, Lehto I, Puska P, Laatikainen L. Long-term outcome of trabeculectomy in terms of intraocular pressure. Acta Ophthalmol. Scand. 2002: 80: 267–271.
13. Iwao K, Inatani M, Seto T, et al. Long-term outcomes, and prognostic factors for trabeculectomy with mitomycin c in eyes with uveitic glaucoma: A retrospective
14. Emerick GT. Improving the success of filtration surgery. Glaucoma Today. 2004; 35-38.
15. Issa De Fendi L, Cena De Oliveira T, Bigheti Pereira C, Pereira Bigheti C, Viani GA. Additive effect of risk factors for trabeculectomy failure in glaucoma patients: A risk-group from a cohort study. J Glaucoma. 2016;25(10): 879883. doi: 10.1097/IJG.0490.
16. Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC. Postoperative complications in the tube versus trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol. 2012;153(5):814. doi: 10.1016/j.ajo.2011.10.024.
17. Gross RL. Glaucoma filtration surgery: Trabeculectomy or tube shunt? Am J Ophthalmol. 2012;153(5):787-788. doi: 10.1016/j. ajo.2011.11.036.
18. Lim R. The surgical management of glaucoma: A review. Clin Exp Ophthalmol. 2022;50(2):213231. doi:10.1111/ceo.14028.
19. Casson R, Rahman R, Salmon JF. Long term results and complications of trabeculectomy augmented with low dose mitomycin C in patients at risk for filtration failure. Br J Ophthalmol. 2001;85(6):686-688. doi:10.1136/ bjo.85.6.686.
23. Musch DC, Gillespie BW, Niziol LM, Cashwell LF, Lichter PR. Factors Associated with Intraocular Pressure before and during 9 Years of Treatment in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2008;115(6):927-933. doi: 10.1016/j. ophtha.2007.08.010.
24. Sugimoto Y, Mochizuki H, Ohkubo S, Higashide T, Sugiyama K, Kiuchi Y. Intraocular pressure outcomes and risk factors for failure in the collaborative bleb-related infection incidence and treatment study. American Academy of Ophthalmology. 2015;122(11):2223-2233. doi: 10.1016/j.ophtha.2015.06.038.
25. Fernández-Vigo JI, Shi H, Burgos-Blasco B, et al. Impact of age, sex and refractive error on Tenon’s capsule thickness dimensions. Int Ophthalmol. 2021;41(11):3687-3698. doi:10.1007/10792-021-01928-5.
26. Sturmer J, Broadway D, Hitchings R. Young Patient Trabeculectomy: Assessment of Risk Factors for Failure. Ophthalmology. 1993;100(6):928-939. doi:10.1016/ S0161-6420(93)31552-6.
27. Broadway D, Chang L. Basic Sciences in Clinical Glaucoma Trabeculectomy, Risk Factors for Failure and the Preoperative State of the Conjunctiva. J Glaucoma. 2001;10(3):237-249.
28. Rodriguez-Una I, Rotchford AP, King AJ. Outcome of repeat trabeculectomies: Long-term follow-up. Br. J. Ophthalmol 2017;101(9):1269-1274. doi:10.1136/ bjophthalmol-2016-309318.
A retrospective chart review of orbital cellulitis cases that presented to Inkosi Albert Luthuli Central Hospital (IALCH) over a period of 5 years
A Narayan MBChB, DipOphth, FCOphth, Department of Ophthalmology, University of KwaZulu-Natal, Durban, South Africa.
ORCID: https://orcid.org/0009-0007-9639-8082
C-H Kruse MBChB, FCOphth, MMed (Ophth), Department of Ophthalmology, University of KwaZulu-Natal, Durban, South Africa.
ORCID: https://orcid.org/0000-0002-8805-8383
M Du Bruyn MBChB, DipOphth, FCOphth, MMed (Ophth), Department of Ophthalmology, University of KwaZulu-Natal, Durban, South Africa.
ORCID: https://orcid.org/0000-0002-0120-3438
Corresponding author: A Narayan, email: ajmeel@gmail.com This article submission forms part of an MMed dissertation by publication.
Abstract
Background: Orbital cellulitis is a condition that can be fatal and impair vision, yet there is a dearth of information regarding cases in South Africa. The purpose of this study was to determine the demographics, causes, and management of patients with orbital cellulitis in KwaZulu-Natal (KZN), while also assessing radiological risk factors.
Methods: This was a retrospective, descriptive study that included all paediatric and adult patients admitted with postseptal orbital cellulitis to the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, KZN, between May 2017 to March 2022. In cases of sinogenic orbital cellulitis, the clinical severity of sinusitis, determined by an ENT specialist, using the LundMackay CT score, was compared to the Chandler classification.
Results: A total of 83 patients were included in this study, with 75% of patients less than 20 years old and a 65% male predominance. The most common cause of orbital cellulitis overall was underlying sinusitis (70%). Patients less than 20 years old are three times more likely to have underlying sinusitis (p = 0.04; 95% C.I), with sinusitis accounting for 75% of orbital cellulitis cases in this age group. Subperiosteal abscess (Chandler grade 3) was the most common orbital presentation, with ethmoid sinusitis noted in 98% of patients with sinogenic orbital cellulitis. Patients were managed both medically and surgically with 19% requiring only medical management, 38 patients requiring orbital drainage, and 54 patients requiring sinus surgery. There was no correlation found between the
Introduction
Orbital cellulitis is an inflammatory process, typically infectious in origin, which involves the tissues posterior to the orbital septum. The infection may
Lund-Mackay score and the Chandler classification (p = 0.71), in patients with sinogenic orbital cellulitis.
Conclusion: Orbital cellulitis occurs more frequently in the paediatric and adolescent population of KZN, with sinusitis being the most common cause, especially in this age group. There was no correlation found between the radiological extent of sinus disease and the clinical severity of orbital cellulitis. This suggests that the evaluation of sinus opacification on CT scan has no value in predicting the severity of sinogenic orbital cellulitis.
Subperiosteal abscess is the most common presentation of orbital cellulitis in KZN, with associated ethmoid sinusitis noted in almost all patients with sinogenic orbital cellulitis. Broad spectrum antibiotics still form the mainstay of treatment; however, a high percentage of patients require both orbital drainage and sinus surgery.
There was poor documentation of important ophthalmological findings and thus, a multidisciplinary approach is advised in the management of patients with orbital cellulitis.
Funding and conflict of interest: The authors have no funding or conflicts of interest to declare.
Keywords: Orbital cellulitis, sinusitis, Chandler classification, Lund-Mackay score, KwaZulu-Natal
Acknowledgements: I would like to thank Dr Tanusha Nandkishore for assisting with the review and grading of the CT scans.
result in abscess formation in the orbital compartment and present with fever, headache, proptosis, ophthalmoplegia, eyelid oedema and conjunctival chemosis. It may result in sight and life-threatening
complications including optic neuropathy, cavernous sinus thrombosis, intracranial abscess and systemic sepsis which may lead to death.1,2
The most common cause of orbital
cellulitis is due to underlying sinusitis,1-4 with reported rates as high as 100%.1 Other causes include upper respiratory tract infection, trauma or surgery to the orbit or surrounding anatomy, orbital foreign body, panophthalmitis, haematogenic spread in the setting of bacteraemia 2,3,5 and odontogenic infection. Orbital cellulitis presents as an emergency and affects all age groups but is more common in the paediatric population and young adults, 2,3,7,8 with little seasonal prevalence, 2 however, little data is available in a South African setting.
The main risk factor is young age (pre-pubertal patients). Other risk factors may include Diabetes Mellitus (DM), Human Immunodeficiency Virus (HIV) infection, chronic sinusitis, and immunosuppression.9
The orbital septum together with the periorbita forms a barrier to infection in the orbital space. Breach of this barrier determines the distinction between preseptal and postseptal cellulitis. In preseptal cellulitis the infection lies anterior to the orbital septum, whereas in orbital (postseptal) cellulitis there is involvement of the orbital soft tissue.
The paranasal sinuses are intimately linked with the orbit. The medial orbital wall that separates the orbit from the ethmoid sinus is formed by a paperthin bone (lamina papyracea) with perforations.10,11 Ethmoid sinusitis is thus the leading cause of orbital cellulitis due to sinusitis, especially in children.12,13
Orbital cellulitis can be classified using the Chandler classification.14 See Table I
Table I: Chandler classification of orbital cellulitis.
infections, 8,9,16 but there is a paucity of information in a South African setting.
Methods
This was a retrospective, descriptive study that focused on the aetiology, management and outcomes of orbital cellulitis cases. We also sought to determine whether, in cases of sinogenic orbital cellulitis, the degree of sinus opacification correlated with the severity of orbital cellulitis. The study included all paediatric and adult patients admitted with orbital cellulitis to the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, KwaZulu Natal (KZN) between 1 May 2017 to 31 March 2022. IALCH is a quaternary referral hospital with ophthalmology, otorhinolaryngology (ENT) and neurosurgery services.
Inclusion criteria
All patients that have postseptal orbital cellulitis
Exclusion criteria
The Lund-Mackay (LM) score is a numerical rating system that uses computerised tomography (CT) scans to assess the degree of opacification of the sinus cavities and the nasal passages.15 The score ranges from 0 to 24, with higher scores indicating more severe sinusitis. Points are assigned (0-2) according to involvement of the sinuses on both sides. See Table II.
The advent of antibiotics has decreased the frequency of sinogenic orbital
Patients with preseptal orbital cellulitis only
Data collection method and tools
Information relating to patients’ age, sex, race, underlying cause of cellulitis, clinical features, CT findings, management, and outcome were collected. This was obtained from the patients’ charts which were recorded as computer data on the hospital information system at IALCH. The CT reports and images were accessed via the hospital’s picture
archiving and communication system (PACS). The scan images were analysed in conjunction with an ENT specialist; each scan was graded using the Chandler classification and the LM scoring system, to correlate severity of sinusitis as a causative factor.
Statistical methods
Descriptive statistics were used to summarise the data. The association between demographic and clinical characteristics of patients and Chandler and Lund classifications (measured on an ordinal scale) were examined using Kruskal-Wallis or two sample MannWhitney tests and Chi-square tests used for the presence of complications. The Lund MacKay classification was also summarised using a median (IQR) and Kruskal-Wallis tests used to compare Chandler scores stratified by age group and complications. Stata V17 was used for statistical analysis.
Ethical considerations
This study was approved by the Biomedical Research and Ethics Council (BREC). There were no conflicts of interest to note.
Results Demographics
A total of 83 patients were included in the study: 54 males (65%) and 29 females (35%) with a male to female ratio of 1.86:1. The ages of the patients ranged from two months to 71 years old with a mean age of 17 years. There were 62 patients (75%) below 20 years old, with age group 0-10
Table II: Lund-Mackay score of sinusitis.
years most affected (41%) followed by age group 11-19 years (34%), indicating that orbital cellulitis presents more frequently in younger patients. Most patients (n = 79; 95.18%) were African. See Figure 1.
Aetiology
Sinusitis was the most common underlying cause of orbital cellulitis (n = 58; 70%). There were 19 patients (23%) that presented with other causes, which included: trauma, facial abscess, dacryoadenitis, dacryocystitis, odontogenic abscess and preseptal cellulitis, with six patients (7%) having inadequate documentation. See Figure 2.
As mentioned above, orbital cellulitis occurs more commonly in younger patients. In this data set, 75% of patients less than 20 years old presented with sinusitis as the underlying cause, whereas in patients 20 years and older, sinusitis accounted for 56.5% of orbital cellulitis diagnoses. See Figure 3
Patients 19 years or younger are therefore three times more likely to have underlying sinusitis when compared to
those 20 years or older (p = 0.04; 95% C.I).
In terms of underlying medical factors there were: Two diabetic patients, one patient with acute myeloid leukaemia (AML), and seven patients with documented HIV infection (14 were documented as unknown).
Clinical presentation
Clinically 78 patients presented with unilateral orbital cellulitis (38 right sided and 40 left sided) with five patients having bilateral disease. The majority of patients (77%) presented with an extraconal orbital abscess collection, and the remainder (23%) had intraconal orbital cellulitis (with or without an abscess collection).
The distribution of signs and symptoms are depicted in Figure 4. Complications such as decreased visual acuity (VA) and relative afferent pupillary defect (RAPD) were poorly documented. Decreased VA was noted in 33 patients, with 34 undocumented results, RAPD was noted in nine patients with 20 undocumented results. All patients (n = 7) that presented with altered mental state (AMS) had associated intracranial pathology (intracranial abscess/cerebritis/ meningitis/cavernous sinus thrombosis), this was statistically significant (p < 0.001). There were two deaths noted, but both were unrelated to the orbital cellulitis (one patient had advanced AML, and there was one iatrogenic complication).
Patients were distributed according to the Chandler classification, with subperiosteal abscess (Chandler grade 3) being the most common presentation overall (n = 55; 66.27%), as well as in each
Figure 1: Graph illustrating the race of patients that presented with orbital cellulitis to Inkosi Albert Luthuli Central Hospital.
Figure 4: Distribution of signs and symptoms of patients with orbital cellulitis.
Figure 2: Pie Chart illustrating the
cellulitis.
age group separately. See Table III and Figure 5.
Table III: Chandler classification of all patients that presented to Inkosi Albert Luthuli Central Hospital with orbital cellulitis.
The degree of sinus involvement was scored using the LM system, with at least partial opacification (LM score of 1) indicating sinus involvement. Ethmoid
sinusitis was present in 98% of patients with sinogenic orbital cellulitis. See Figure 6.
Management
All patients were managed with broad spectrum intravenous antibiotics as per hospital protocol, 16 patients (19%) were managed with antibiotic therapy alone, with one patient having inadequate documentation. A total of 38 patients (46%) required orbital drainage for an abscess collection, with 25 (43%) sinogenic orbital cellulitis cases requiring orbital drainage. Only four patients (7%) with sinogenic orbital cellulitis were managed with antibiotic therapy alone. There
were 19 patients with non-sinogenic orbital cellulitis (other causes), and these patients were managed with an equal distribution of antibiotic therapy only (n = 9) and orbital drainage (n = 10). The six patients without a documented diagnosis were also managed with an equal distribution of antibiotic therapy (n = 3) and orbital drainage (n = 3). Patients with an extraconal orbital collection presented with a higher mean LM score (M = 9; SD = 6.64) compared to patients with an intraconal collection (M = 4.26; SD = 5.11), this was statistically significant (p = 0.002). See Figure 7.
Figure 7: Line graph demonstrating mean and median LM scores for patients with either extraconal or intraconal orbital collection.
A total of 54 patients (93% of sinogenic orbital cellulitis/65% of total orbital cellulitis cases) required sinus drainage surgery via functional endoscopic sinus surgery (FESS) and/or combined external sinus drainage. Some patients required a combination of both FESS and external sinus surgery. The degree of sinus opacification was assessed for those patients that required sinus surgery, with a higher LM score correlating with patients requiring surgical sinus drainage (FESS p = 0.005) (external sinus surgery p < 0.001). See Table IV.
Figure 5: Bar graph indicating the Chandler classification by age grouping.
Table IV: Breakdown of Lund-Mackay scores for patients that
sinus
Figure 6: Sinus involvement in patients with sinogenic orbital cellulitis.
Complex
In patients with sinogenic orbital cellulitis, one of our objectives was to assess the relationship between the degree of sinus involvement and the severity of orbital cellulitis, to do this we compared the LM score to the Chandler grade. We found that a higher LM score did not correlate with a more severe Chandler grading (p = 0.71) in our patient population. See Table V.
Discussion
From our review of the literature, this study of 83 cases of orbital cellulitis from a referral hospital in KZN over a five-year period represents the first of its kind in South Africa. The findings from this study support earlier findings from studies in Europe, the Middle East and Africa, that underlying sinusitis is the most common cause of orbital cellulitis. 3,4,17-19 There was a male predominance amongst this cohort of patients, which was also in keeping with international norms.1-4 The cause of male predominance in orbital cellulitis is unknown but may be attributable to higher immunological competency in females.17
Worldwide there is consistent evidence that paediatric and adolescent patients are more likely to present with orbital cellulitis, with underlying sinusitis being the most prevalent cause amongst these individuals. 2,3,7,8,12,20 A similar pattern was seen in our study with the vast majority of patients being less than 20 years old (n = 62; 75%), and sinusitis accounting for 75% of orbital cellulitis diagnoses in this age group. There was an equal distribution in terms of the laterality of orbital cellulitis, with very few patients presenting with bilateral disease. A study in Nigeria noted a left-sided predominance, 21 although the cause is unknown.
The ethmoids are the most commonly affected sinuses in patients with sinogenic orbital cellulitis. 2,12,13,17,20-22 In this study we also noted this trend; the ethmoid sinuses were opacified in all but one patient (98%), with maxillary sinusitis (86%) noted in most patients.
Very few patients presented with underlying immunologic compromise in the form of HIV or DM, although other studies have demonstrated these conditions as risk factors,9,13 we were unable to corroborate these findings in our population.
Clinically most patients presented with proptosis, chemosis and ophthalmoplegia, this was in keeping with other studies in Africa and internationally. 2,3,4,16 Fewer patients presented with fever, decreased VA, RAPD and AMS; however, there was poor documentation of initial VA and the presence of a RAPD. In KZN, suspected orbital cellulitis cases are referred to the ENT department and might not be evaluated by an ophthalmologist at initial presentation; this could account for the inadequate documentation of visual data. We have identified this as an issue that requires improvement. Only two patients in this study were noted to have decreased vision in their notes upon discharge. Other studies have shown that the initial presence of decreased VA and RAPD indicate a worse prognosis for visual outcome after management of orbital cellulitis. 3,8,23
Radiological imaging (especially CT scan) of the orbit and sinuses in patients with orbital cellulitis should be performed if available, as this provides vital information regarding the location of the orbital collection as well as establishing an underlying cause.18,24,25 It is important to also image the brain to assess for complications e.g. intracranial abscess or cavernous sinus thrombosis.11,24 AMS was a reliable indicator of intracranial complication in this study, all patients that presented with this sign had associated intracranial pathology; however, the number of patients that presented with AMS was low (n = 7). Orbital cellulitis can be managed both medically and surgically. 5,7-9,16,20,26,27
All our patients received intravenous antibiotic therapy, with less than 20% receiving antibiotics alone. Almost half the number of patients in this study (46%)
needed an orbital drainage procedure. This was higher than a study in Nigeria, by Adedeji et al. which found that 21% of patients required orbital drainage, but comparable to the percentage of patients (46%) that required surgical drainage for an orbital abscess in a study by Chaudhry et al. in Saudi Arabia. There was an equal distribution between medical and surgical management in patients with non-sinogenic orbital cellulitis, as well as those with undocumented causes in our cohort.
In patients with sinogenic orbital cellulitis, we found that 25 (43%) required orbital drainage, and almost all (93%) required sinus surgery. Additionally, a statistically significant association was shown between a patient’s higher LM score and the likelihood that they would require sinus surgery. Only four patients (7%) with sinogenic orbital cellulitis were managed with antibiotic therapy alone, indicating that most patients with this condition require surgical management in our setting. Interestingly a study in New Zealand by Botting et al noted that 23% of postseptal orbital cellulitis cases required sinus surgery whereas 77% of patients responded to intravenous antibiotic treatment. This may indicate that, in comparison to a first world setting, patients in KZN present later and with more advanced disease.
Upon reviewing our data, addressing the sinus collection alone does not always resolve the orbital cellulitis. It is thus important to note the location of the orbital collection in relation to the sinus disease and manage patients in a multidisciplinary setting.
While both the LM score and the Chandler classification are useful in diagnosing and treating orbital cellulitis, they provide different information. The LM score is primarily used to assess the severity of sinusitis based on objective imaging findings, while the Chandler classification is more focused on the location of orbital cellulitis and its progression over time.
Table V: The Lund-Mackay score compared to Chandler grading in patients with sinogenic orbital cellulitis.
Although sinusitis is the most common cause of orbital cellulitis, there was no correlation found between a higher LM score and a higher Chandler grade in this study (p = 0.71), which suggests that the evaluation of the degree of sinus opacification on CT scan has no value in predicting the severity of orbital cellulitis. However, patients with an extraconal orbital collection presented with a higher mean LM score, indicating that sinusitis (especially ethmoidal sinusitis) 12,13 is more likely to result in an extraconal collection or subperiosteal abscess. The LM score and the Chandler classification are therefore complementary tools, they provide different forms of information and are based on different criteria. Clinical correlation of radiological findings is always necessary in the management of these patients.
Conclusion
Orbital cellulitis is more common in the paediatric and adolescent population of KZN, with underlying sinusitis being the most common cause, especially in younger patients. The extent of sinogenic orbital cellulitis (Chandler classification) did not correlate with the CT findings of sinus disease (LM score).
Subperiosteal abscess (Chandler grade 3) is the most common presentation of orbital cellulitis in KZN, with ethmoid sinusitis noted in almost all patients with sinogenic orbital cellulitis. Broad spectrum antibiotics still form the mainstay of treatment; however, a high percentage of our patients require both orbital drainage and sinus surgery.
There was poor documentation of important ophthalmological findings (VA and RAPD) in this study group. All patients with possible orbital cellulitis should, at the very least, have a formal VA documented at the time of initial presentation. Current referral patterns should be amended to ensure prompt ophthalmology consultation even in patients with suspected sinogenic orbital cellulitis. A multidisciplinary approach is advised in the management of these patients.
Limitations of this study are the typical challenges associated with retrospective studies based on patient file data.
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17. Adedeji T, Olaosun A, Tobih J, Adejumo O, Adejumo O. Sinogenic orbital infections in a Nigerian Teaching Hospital. Adv Trop Med Pub Health Int . 2013;3(4):101-9.
18. Aldemir Kocabaş B, Karbuz A, Özdemir H, Çiftçi E, İnce E. Periorbital and Orbital Cellulitis: From Presentation to Outcome. J. Pediatr. Infect. Dis. 2014;8(4):148-52.
20. Mukund B, Chaudhary S, Bhat V, Vineet V, Adhikari KM. Orbital cellulitis –Incidence, management and outcome from coastal hospitals. J. Pediatr. Crit. CARE 2019;6(3):25-30.
21. O. G. B. Nwaorgu FJA, P. A. Onakoya and A. A. Awobem. Orbital cellulitis complicating sinusitis: a 15-year review. Niger. J. Surg. Research 2004; Vol. 6:14-6.
22. Yadalla D, Jayagayathri R, Padmanaban K, Ramasamy R, Rammohan R, Nisar SP, et al. Bacterial orbital cellulitis – A review. Indian J Ophthalmol. 2023;71(7):2687-93.
23. Chang YS, Chen PL, Hung JH, Chen HY, Lai CC, Ou CY, et al . Orbital complications of paranasal sinusitis in Taiwan, 1988 through 2015: Acute ophthalmological manifestations, diagnosis, and management. PLoS One. 2017;12(10): e0184477.
24. Le TD, Liu ES, Adatia FA, Buncic JR, Blaser S. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS 2014;18(3):271-7.
25. LeBedis CA, Sakai O. Nontraumatic orbital conditions: diagnosis with CT and MR imaging in the emergent setting. Radiographics . 2008;28(6):1741-53.
26. Wan Y, Shi G, Wang H. Treatment of Orbital Complications Following Acute Rhinosinusitis in Children. Balkan Med J. 2016;33(4):401-6.
27. Anosike BI, Ganapathy V, Nakamura MM. Epidemiology and Management of Orbital Cellulitis in Children. J Pediatric Infect Dis Soc . 2022;11(5):214-20.
16. Ferguson MP, Fraco AAM. Current treatment and outcome in orbital cellulitis. Australian and New Zealand Journal of Ophthalmology 1999;27(6):375-9.
Spectrum of glaucomatous disease at Charlotte Maxeke Johannesburg Academic Hospital:
A retrospective clinical audit
I Walters MBChB, FCOphth (SA), BOptom (UJ); Division of Ophthalmology, Department of Neurosciences, Faculty of Health Sciences, University of the Witwatersrand, South Africa
ORCID: https://orcid.org/0000-0001-9159-8930
S Williams MBChB, MMED (Ophth), FCOphth (SA), FRCSEd, PGD-HSE, PhD; Division of Ophthalmology, Department of Neurosciences, Faculty of Health Sciences, University of the Witwatersrand, South Africa
ORCID: https://orcid.org/0000-0002-4479-8638
Corresponding author: Dr Ingrid Walters, email: Ingrid.walters@yahoo.co.uk
Abstract
Background: Glaucoma is the second most common cause of blindness worldwide. A disproportionately high number of these patients live in low- and middle-income countries, placing a huge burden on the health care system. The purpose of this study was to describe how glaucoma patients presented to a dedicated glaucoma clinic at a large referral centre/tertiary hospital in central Johannesburg, South Africa. The objectives were to describe the spectrum of glaucomatous disease in these patients as well as the demographics, risk factors and severity of disease in this patient population. The secondary objective was to describe how glaucoma was being managed in the glaucoma clinic patient population.
Methods: This retrospective descriptive study which was a clinical audit of the Charlotte Maxeke Johannesburg Academic Hospital’s (CMJAH) glaucoma REDCap database. 787 patient records were included in the study which were patients seen and managed in a 5-year period, from 1 January 2016 to 31 December 2020.
Results: Of the 787 patients assessed the mean age at presentation was 59 years (n = 739, SD = 16), 50.3% were female and 49.7% male. The majority (74.9%) were black African, and the most common diagnosis was Primary Open Angle Glaucoma (POAG) (59%). Black African patients with POAG were significantly younger than other racial groups, p<0.001, with 7% being younger than 35 years. 23.3% of patients had a family history of glaucoma. The median intraocular pressure (IOP)
Introduction
Glaucoma is a group of ocular conditions that encompasses an irreversible optic neuropathy associated with a characteristic structural damage to the optic nerve and associated functional visual field loss.1-8
was 15 mmHg (n = 690) and median vertical cup to disc ratio (VCDR) was 0.9 (n = 605). Using World Health Organisation (WHO) definitions, 32.2% patients had visual acuity (VA) ≤6/120 in the better seeing eye fulfilling criteria for blindness (n = 686) and 64.6% of patients had VA≤6/18 in the better eye fulfilling criteria for visual impairment. 68% (n = 722) patients were on medical therapy and most patients received on average three agents. There were 426 laser procedures performed, selective laser trabeculoplasty (SLT) accounting for the bulk (65.3%), and 210 glaucoma surgeries were performed.
Conclusion: This study supports and reinforces the notion that black South African glaucoma patients managed at a tertiary institution are most likely to have POAG, present at a younger age and have more advanced disease with higher rates of visual impairment and blindness. The management of these patients was largely medical with more than one medication. Glaucoma surgery is an important management tool in advanced glaucoma and is being underutilised.
Conflict of interest: The authors have no conflict of interest to declare with respect to this study.
Acknowledgements: Dr Erica-Mari Nel who assisted with the data formatting and statistical analysis.
Glaucoma is the second most common cause of blindness worldwide, estimated to affect approximately 80 million people in 2020.1-4,9,10 Over 11.1 million people are bilaterally blind because of glaucoma, a disproportionately high number of these patients live in low-to -middle
income countries, especially sub-Saharan Africa.1,2,4,9,10 Glaucoma places a huge burden on the healthcare system, and it is expected to increase exponentially.1,9
The global prevalence of all types of glaucoma for patients above 40 years old is 3.5%.1,3,11 The prevalence statistics
for glaucoma in sub-Saharan Africa are higher. In South Africa, Rotchford et al.12 found an overall prevalence of 4.5% in a Zulu population in KwaZulu-Natal and a prevalence of glaucoma of 5.3% in black residents of Temba.13
Glaucoma can be classified according to the ISGEO (International Society for Geographical and Epidemiological Ophthalmology) 2,8 criteria as open or closed angle based on the appearance on gonioscopy. Three-quarters of patients with glaucoma have open angle glaucoma (OAG).1-5 Both open and closed angle glaucoma can be divided into primary and secondary subtypes. 8
Primary open-angle glaucoma (POAG) is diagnosed if there is structural optic nerve damage in the form an enlarged vertical cup-disc ratio (VCDR) or on optical coherence tomography (OCT). 2,8. A VCDR of ≥0.7 (97.5th percentile), or VCDR asymmetry ≥0.2 with functional visual field defect is a category 1 diagnosis of glaucoma. Category 2 and 3 diagnosis requires a VCDR of ≥0.8 or asymmetry of ≥0.3 (99.5th percentile) in instances where visual field testing cannot be performed. If the optic nerve cannot be visualised an elevated IOP ≥99.5th percentile can be diagnostic. 2,8 Gonioscopy examination of the drainage angle should reveal open angles with no identifiable secondary cause of the glaucoma. 8,14,20 POAG disproportionately affects people of black African descent and15-19 the prevalence of irreversible blindness as a result of glaucoma is also four times higher in Africans.1-11,21 Blindness is defined by the World Health Organisation (WHO) as a visual acuity of ≤6/120 in the better eye and visual impairment is defined as VA ≤6/18 in the better seeing eye.11,22,23.
Primary angle closure glaucoma (PACG) follows when the anterior chamber angle, seen on gonioscopy, is narrowed, or closed. 8 This form of glaucoma is more common in Asian ethnic groups due to anatomical predisposition. 3,4,6,8,9,14 Secondary glaucoma is caused by an underlying ocular or systemic condition. These commonly include exfoliation glaucoma (XFG), pigment dispersion glaucoma, angle recession glaucoma (ARG), uveitic glaucoma, neovascular glaucoma (NVG), and crystalline lens related glaucomas. 8
Glaucoma can also uncommonly present in childhood. Determining glaucoma prevalence in childhood is difficult as few population studies exist due to its rarity. 20 Primary childhood glaucoma includes
congenital glaucoma (PCG) and juvenile open-angle glaucoma (JOAG). 20
Risk factors for glaucoma development include increasing age,1-9 African ethnicity, family history, increased intraocular pressure, myopia for open-angle glaucomas and hyperopia for closed-angle glaucomas.1,12,13,17,19,20-23
The available management options for glaucoma are medical, laser therapy and surgery all targeted at reducing IOP. Initial treatment is usually medical. Selective laser trabeculoplasty (SLT) has shown promising IOP lowering effects in patients with POAG and other open angle glaucomas in African patients.11,24 It is a safe, less invasive, and costeffective option.11,24 Surgical procedures of which filtration surgery remains the gold standard may be required to obtain optimal IOP, especially in patients with advanced glaucoma. 25
The aim of this study was to describe the spectrum of glaucomatous disease in patients who presented to a dedicated tertiary referral hospital in South Africa as well as their demographics, risk factors and severity of disease. The secondary objective was to describe how glaucoma was being managed in the adult glaucoma clinic patients.
Methods
The study was a retrospective clinical audit of the Charlotte Maxeke Johannesburg Academic Hospital’s (CMJAH) glaucoma REDCap electronic database. 26,27 The database includes all patients seen in the glaucoma clinic from the time of presentation and includes all subsequent
clinical visits and treatments. 787 patients were included in the study which included all the patients’ clinical records over a five-year period, from 1 January 2016 till 31 December 2020. Missing or incomplete records were correlated with hard copy records that are kept in the glaucoma clinic.
Patients’ data was extracted then anonymised using a unique reference number to protect anonymity and data was exported to an excel spread sheet for statistical analysis. The demographic data collected included patients’ ethnicity (this was self-reported using the South African Census categories 28), age, sex, medical history (hypertension, diabetes, HIV, asthma, migraine) and family history of glaucoma or blindness.
The type of glaucoma diagnosis as well as the gonioscopic appearance of the angles were collected. Disease severity parameters including best corrected Snellen visual acuity (BCVA), intraocular pressure (IOP) using Goldman applanation tonometry and vertical cup-to-disc ratio (VCDR) where recorded. Where available, visual field mean deviation (MD) and optical coherence tomography (OCT) retinal nerve fibre layer (RNFL) thickness and macular ganglion cell complex (GCC) thickness was collected. Central corneal thickness (CCT) was not routinely measured in the glaucoma clinic and not included in the study.
Management data were collected including which topical medications patients received (Beta blocker, prostaglandin analogue, alpha agonist, topical carbonic anhydrase inhibitor (CAI)
Figure 1: Race profile of CMJAH glaucoma clinic as well as 2011 census data of Gauteng and South Africa (Stats SA). 28
or pilocarpine) as well as oral acetazolamide (Diamox). All procedures including laser and surgical procedures performed over the five-year study period were collected.
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of the Witwatersrand Human Research Ethics Committee (No.M221019). Signed informed consent was obtained from patients prior to entering their data onto the REDCap database and Ethical clearance for the database (M190671) was obtained.
Statistical analysis
Data were exported from REDCap with allocated patient reference numbers. Statistics were performed using Microsoft Excel and STATA (version 17). Skewness and kurtosis were calculated to assess for normality of distribution of continuous data. Mean and standard deviation were calculated for age. Median and interquartile ranges were calculated for the other continuous parameters. Frequencies were calculated for categorical variables. A Chi squared test or Fisher’s exact test, where appropriate, was performed to analyse categorical data. An ANOVA was used to compare ages between diagnostic groups. A p-value less than 0.05 was regarded as statistically significant.
Results
A total of 787 patients were analysed over the five-year study period. The mean age at presentation was 59 years ± 16 years old (n = 739). There were 50.3% females and 49.7% males (n = 760), with a male: female ratio of 1:1. Most of the patients
presenting self-identified as black (74.9%), with the minority identifying as white (11.7%), Asian/Indian (6.8%), coloured (4.1%) and mixed race (2.5%) (n = 753). See Figure 1 comparing the race profile of CMJAH glaucoma clinic with that of Gauteng and South Africa as per the 2011 census (Stats SA). 28
The most common glaucoma diagnosis was POAG, comprising 59% of patients (n = 438) (Figure 2). In 26 patients the diagnosis was not captured or not known. Within the POAG group, patients with normal tension glaucoma (NTG) comprised 15%. The second most common glaucoma was secondary glaucoma compromising a total of 26.8%. Exfoliative glaucoma (XFG), the most common type of secondary glaucoma accounted for 10.6% of all glaucomas (40% of the secondary glaucomas). Other secondary glaucomas (16.2%) with causes that included, secondary open angle glaucoma (OAG) (4.3%), angle recession glaucoma (ARG) (4.1%) and others. Angle closure glaucomas, which include primary angle closure glaucoma and secondary angle closure glaucomas such as Neovascular glaucoma (NVG) accounted for 6.7% of glaucoma.
The mean age of the patients at enrolment into the database was
significantly different between the diagnostic groups (p < 0.001). Patients with secondary glaucoma were much younger (49 years ± 18 years) and patients with XFG were much older (68 years ± 10 years) (Table I).
Black African patients with POAG were significantly younger and white patients significantly older than other racial groups with POAG (p < 0.001) (Table II). Only in the Black African patient group had patients who presented with POAG before 36 years of age (7%, n = 31).
Table II: Age of POAG patients per racial group.
The glaucoma diagnoses were significantly different between different race groups (p<0.001). Asian/Indian and mixed-race patients were less likely to have POAG and more likely to have secondary glaucoma. Black African patients were more likely to have XFG. Angle closure glaucoma was seen more in white patients. (Figure 3).
In 23.3% of patients there was a family history of glaucoma (n = 524) and in 21.3% there was a family history of blindness (n = 506). In 13.2% of the patients there was both a family history of blindness and glaucoma (n = 506).
The commonest comorbidities were hypertension (28.2%) and type II diabetes (7.1%), while 28.1% had no known comorbidities (n = 720). HIV, migraine,
Figure 3: Proportional diagnoses of patients at the glaucoma clinic per racial group.
Figure 2: Glaucoma subtypes of patients at the CMJAH glaucoma clinic (n = 761).
Table I: Age of patients per diagnostic group.
and asthma were so rarely reported they were excluded from statistical analysis. Patients with POAG were more likely to have hypertension and/or diabetes, while patients with secondary glaucoma were more likely to have no co-morbidities (p < 0.001, n = 715).
The median intraocular pressure (IOP) for both eyes at the time of presentation was 15 mmHg (IQR 12 – 20 mmHg) (n = 690). Most patients were already on intraocular pressure lowering therapy at the time of enrolment into the study.
The mean vertical cup to disc ratio (VCDR) for the right eye was 0.9 (IQR 0.7 –1.0) (n = 599) and for the left eye was 0.9 (IQR 0.6 – 1.0) (n = 605). The mean visual field mean deviation (VF MD) performed on 24-2 Humphrey Visual Field of the right eye was -9.7dB (IQR -3.08dB to -13.20dB) (n = 165) and for the left eye was -9.8dB (IQR -4.0dB to -14.0dB) (n = 153). A normal mean deviation is between 0 and -2dB. 28
The median optical coherence tomography (OCT) on the Cirrus HD-OCT (Carl Zeiss) macula ganglion cell (GCC) thickness for the right eye was 58.5 µm (IQR 29 - 79) (n = 179) and for the left eye was 61µm (33 – 79.8) (n = 179). Average normal GCC is 97 +/-6.9 µm. 29 The median OCT (retinal nerve fibre layer) RNFL thickness for the right eye was 52µm (IQR 42 – 72) (n = 181) and for the left eye was 52µm (IQR 41 - 75) (n = 180). Normal overall nerve fibre layer thickness on average is 99.2+/-9.9 µm according to the Advanced Imaging for Glaucoma Study. 30
32.2% of patients had a VA of worse than 6/120 in the better eye fulfilling WHO criteria for blindness (n = 686). 64.6% of patients had VA’s worse than 6/18 in the better eye fulfilling the WHO criteria for visual impairment.
In this study 68% (n = 772) of patients were receiving medical IOP lowering therapy at enrolment into the database as the glaucoma clinic at CMJAH is a tertiary referral centre. Most patients were receiving three topical agents. The most common combinations of agents used were beta-blockers + prostaglandin + alpha agonist (30.4 %) and beta-blockers + prostaglandin + alpha analogue + topical carbonic anhydrase inhibitor (CAI) (15.6 %). There were 426 laser procedures performed. Selective laser trabeculoplasty (SLT) was the commonest laser procedure (65.3%), followed by Nd:YAG goniopuncture (20.7%) and YAG PI (5.9%). (Figure 4)
During the study period there were 210 glaucoma surgeries performed. The most
common surgery performed in 59.5% of patients was deep sclerectomy. Secondary procedures (these included bleb needling, bleb revision and iris sweeps) were
the second most common group of procedures (16.2%) and trabeculectomies were performed in 11.9% of patients.
(Figure 5)
Figure 4: Laser procedures performed for various types of glaucoma. The accompanying table shows absolute counts.
Figure 5: Glaucoma surgeries per diagnosis. The accompanying table shows absolute counts.
CMJAH clinic Gauteng South Africa
There were 200 cataract surgeries performed, 79.5% (n = 159) received phacoemulsification and intraocular lens implantation.
Discussion
This study described the demographic, clinical characteristics and management received of glaucoma patients referred to a tertiary glaucoma clinic. The race profile of patients seen at the clinic is similar to the race distribution of Gauteng and South Africa, as per the 2011 census 28 and therefore is fairly representative of South Africa’s patient population.
Our study found the most prevalent glaucoma diagnosis was POAG (59%), which is consistent with multiple other previously performed population studies. POAG was present in 56% and 54% of patients in Rotchford et al.’s Themba and KwaZulu-Natal studies respectively.12,13 Studies from the Caribbean demonstrate the highest proportion of POAG amongst their black population.19 Our study demonstrated that black patients with POAG were significantly younger than the other racial groups which has also been found in other studies across Africa. 6 Studies have demonstrated that individuals of African descent are 4-5 times more likely to develop open angle glaucoma, compared with people of European descent. 3,5,6,15,21 This increased susceptibility is likely due to a combination of genetic and environmental factors. 7,17,21,22 POAG in persons of African descent progresses more rapidly and effects on average, younger patients. 7,16,22 Anatomical predispositions in Africans, according to the African Descent and Glaucoma Evaluation Study (ADAGES), include higher refractive error, thinner corneal thickness, larger cup-to-disc ratios and larger disc areas. 7 The South African Eye Study (SAES) found black South Africans had thinner corneas and higher IOPs when compared to other ethnicities.19
Asian/Indian and mixed-race patients in our study were more likely to have secondary glaucoma while angle closure glaucoma (ACG) was seen more in white patients. Salmon et al. studied a mixedrace population in the Western Cape and found a majority of primary angle closure glaucoma (PACG), likely reflecting this population’s Asian heritage.14 Although only accounting for approximately 26% of worldwide glaucoma ACG accounts for 50% of the global burden of blindness due to glaucoma.4,9
Secondary glaucomas occurred in 36% of patients in Rotchford’s South African Temba study.13 The vast majority (45% of secondary cases) were due to exfoliation glaucoma followed by 20% of cases being secondary to trauma.13 Our study found 26.8% of patients had secondary glaucoma where 40% of these had exfoliation glaucoma. Excluding the XFG cases, the remainder of the secondary glaucomas were predominately angle recession glaucoma (ARG). These patients were considerably younger which can be explained by trauma often affecting younger individuals. The rates of secondary glaucomas elsewhere in the world are much lower, only 0.49% in Tanzania 3 and 0.7% in Barbados. 3,19
Our study found 23.3% of patients had a family history of glaucoma which is in keeping with other studies which found a positive family history in 16.1%-35% of POAG cases, with family history, conferring a three-fold increased risk of developing open-angle glaucoma.16-18 Hypertension/ hypotension, migraine and diabetes have been postulated as possible risk factors for primary open angle glaucoma and have been studied extensively but there is no good evidence supporting any systemic co-morbidies as risk factors for POAG development.1,6-8,16-18,21-23 Our study demonstrated that hypertension and diabetes were more prevalent in the POAG patients as opposed to secondary glaucoma patients, but this is most likely due to the difference in ages between these groups.
Intra-ocular pressure (IOP) remains the most important and only modifiable risk factor in glaucoma.1-16 African patients have higher presenting IOPs than other population groups. 21 A subset of POAG, with normal IOP, known as normal tension glaucoma (NTG) has varying prevalences, for example a prevalence of 33% in the Barbados Eye Studies but a prevalence of as much as 85% in Asian populations.1-11,16,18,21 We found a prevalence of only 15% of NTG in our POAG cohort. The median IOP of 15 mmHg found in our study is not representative of the presenting IOP in these patients as the CMJAH glaucoma clinic is a tertiary referral clinic. The patients on presentation to our clinic and enrolment into the database would already have been started on topical IOP lowering agents prior to referral. Some would even have had a prior intervention such as cataract surgery, glaucoma surgery or laser. This is a limitation of the study.
Our study found a mean vertical cup-to disc ratio (VCDR) of 0.9 which highlights the severity of glaucoma in our population sample. In patients who underwent automated perimetry a mean deviation of -9.7dB and -9.8dB for the right and left eye respectively was found. Based on the Canadian Ophthalmological Society Guidelines, the majority of our patients who had visual field testing are therefore graded as moderate glaucoma. 6,31 Only approximately one in seven patients in our database underwent visual field testing which is also a limitation of the study but a known challenge in the South African context. 32 As visual fields are generally only performed on patients with fair visual acuities this biases the visual field data towards the less severe glaucoma patients who can fixate and perform the tests. The median macular ganglion cell thickness and retinal nerve fibre layer thickness on OCT, although not performed on all patients was incredibly thin which was in keeping with the severity of glaucoma seen in our clinic. The proportion of patients blind from glaucoma is stated to be 22% in South Africa. 2,10,12 Half of African patients are already blind in one eye at diagnosis, and 14% are binocularly blind at diagnosis. 6,16-18,21-23 Postulated reasons for this include higher prevalence, inadequate control, poor awareness and screening, socioeconomic factors, lack of access to health services and late presentation. 3,11,22 Our study found 32.2% of patients fulfilling WHO criteria for blindness at presentation (VA≤6/120 in better seeing eye) and 64.6% fulfilling the criteria for visual impairment (VA≤6/18 in better seeing eye). The visual acuities in the study are pinhole VA’s, ocular co-morbidies such as cataracts and refractive errors may have also contributed to the levels of visual impairment and blindness in our patients.
Our study found patients in our glaucoma clinic were predominately being managed medically (68%) and most patients were on multiple agents. The Primary Open Angle African American Glaucoma Genetics study (POAAGG) performed on African Americans with POAG found 67.1% were on topical medication, 36.2% had been treated with glaucoma surgery or laser and 33% of this group were also on topical glaucoma medication.17 Specific challenges in medical treatment in African patients include the advanced
stage of the glaucoma at presentation, local availably and affordability of certain treatment options, side-effects and their acceptability by patients all of which impact adherence and long-term success. 6,15 Major glaucoma landmark trials that guide medical treatment options were performed on largely non-African subjects.11,15,21
Glaucoma surgery was performed in 210 patients in this study which only represents 27% of the patient cohort. There are significant barriers to increasing glaucoma surgery numbers such as resource constraints and patient related factors.
The main limitation of this study is its retrospective nature. Despite correlating missing and incomplete records with hard copies there was still some missing data. Entries into the Redcap database were performed by different doctors as well as non-medical personal, which increases the risk of data capturing errors.
Conclusion
This study supports and reinforces the notion that black South African patients are most likely to have POAG, present at a younger age and have more advanced disease with very high rates of visual impairment and blindness. Screening affected individuals’ family members for glaucoma should be offered. The management of these patients is largely medical with more than one medication. Glaucoma surgery is an important management tool in advanced glaucoma and is probably being underutilised in this clinic. Further studies are warranted.
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Engineered to adhere to the ocular surface, for post-operative inflammation 6-8
Uniform dose delivery, in every drop 7, 9
References: 1. Pavesio CE, et al. Treatment of ocular inflammatory conditions with loteprednol etabonate. Br J Ophthalmol 2008;92:455– 459. 2. Dell SJ, et al. A randomized, double-masked, placebo-controlled parallel study of 0.2% loteprednol etabonate in patients with seasonal allergic conjunctivitis. J Allergy Clin Immunol 1998;102:251-5. 3. Gong L, et al. Loteprednol Etabonate Suspension 0.2% Administered QID Compared With Olopatadine Solution 0.1% Administered BID in the Treatment of Seasonal Allergic Conjunctivitis: A Multicenter, Randomized, Investigator Masked, Parallel Group Study in Chinese Patients. Clin Ther. 2012;34:1259–1272. 4. Comstock TL, et al. Advances in Corticosteroid Therapy for Ocular Inflammation:Loteprednol Etabonate. Int J Inflam 2012; 789623:1-11. 5. Ilyas H, et al. Long-term safety of loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic conjunctivitis. Eye Contact Lens 2004;30(1):10-13. 6. Lotemax® Ophthalmic Gel package insert, August 2022. 7. Fong R., et al. Loteprednol etabonate gel 0.5% for postoperative pain and inflammation after cataract surgery: results of a multicentre trial. Clin Ophthalmol. 2012;6:1113-1124. 8. Shaikh R et al. Mucoadhesive drug delivery systems. J Pharm Bioallied Sci. 2011;3:89-100. 9. Co ey MJ and Davio SR. Presented at: ARVO 2012; May 2012; Ft. Lauderdale, FL. Poster D1143. S4 Proprietary name and dosage form: Lotemax ophthalmic suspension, eye drops. Composition: Each 1 ml contains: Loteprednol Etabonate 5,00 mg (0,5 % m/v) and Benzalkonium chloride (preservative) 0,01 % m/v Pharmacological classification: A 15.2 Ophthalmic preparations with corticosteroids. Registration number: 37/15.2/0588. S4 Proprietary name and dosage form: Alrex Ophthalmic Suspension. Composition: Each 1 ml contains: Loteprednol etabonate 2,00 mg (0,2 % m/v) and Benzalkonium chloride (preservative) 0,01 % m/v Pharmacological classification: A 15.2 Ophthalmic preparations with corticosteroids. Registration number: 38/15.2/0203. S4 Proprietary name and dosage form: Lotemax Ophthalmic Gel. Composition: Loteprednol etabonate 5,00 mg (0,5 % m/v) and Benzalkonium chloride (preservative) 0,003 %
Early postoperative intraocular pressure elevation following trainee cataract surgery at a tertiary training hospital in Johannesburg
E Jansen MBChB, Registrar, Department of Neurosciences, Division of Ophthalmology, University of Witwatersrand, Johannesburg, South Africa.
ORCID: https://orcid.org/0009-0006-5455-5863
R Hӧllhumer MBChB, FC Ophth, MMed (Ophth), MBA, Department of Neurosciences, Division of Ophthalmology, University of the Witwatersrand, Johannesburg, South Africa and The Cornea Foundation, Johannesburg, South Africa.
ORCID: https://orcid.org/0000-0002-4375-2224
Corresponding author: E Jansen, email: steljansen@gmail.com
Abstract
Background: A common complication following cataract surgery is early intraocular pressure (IOP) spikes. Although it is usually transient, it can result in significant patient discomfort and rarely permanent vision loss. Registrar-performed surgeries are a known risk factor for early IOP spikes.
Method: The population of this prospective study consisted of all patients who underwent registrar-performed cataract surgery between February 2023 and October 2023 at St John’s Eye Hospital, Soweto, Gauteng. The IOP in the operated eye was measured 3-7 hours after surgery, with an iCare tonometer and the data was reported in a data collection sheet.
Results: Eighty patients were recruited. The mean age was 68 years old, with the median time between surgery completion and IOP measurement was 3h30. The overall mean IOP was
Introduction
Cataracts are a leading cause of poor vision and blindness in South Africa,1 hence cataract surgery is one of the most commonly performed surgeries. Cataract surgery is a safe procedure, with complications occurring in less than 5% of patients. 2 Post-operative complications range from corneal oedema, wound leak, iris prolapse, intraocular lens dislocation, inflammatory and infective complications, as well as intraocular pressure (IOP) elevation.
Early IOP spikes have been found to occur in up to 8% of cases. 3 Authors are not in agreement about the definition of an “IOP spike”. Values of 21 mmHg up to 30 mmHg have been used in various articles, 3-7 while some authors prefer to use an increase of 10 mmHg from baseline and others opt to use a relative value, for example, a 50% increase in IOP.7 Although it is usually transient, it can result in significant patient discomfort, severe eye and brow pain,
23 mmHg. There was no significant association between any of the study variables and the year of study of the surgeon. Conclusion: Early IOP elevation following phacoemulsification is a known and frequent complication. This study found that more than half of the patients who underwent phacoemulsification at a tertiary ophthalmology hospital had an IOP > 20 mmHg in the first 3-7 hours following surgery. Trainee surgeons can consider prophylactic IOP lowering treatment, especially in high-risk groups.
No financial interest to declare MMed dissertation by publication.
Acknowledgments:
Dr Petra Gaylard for assistance with data analysis.
nausea, vomiting, compromised visual function, and rarely, permanent vision loss.
Transient IOP elevation after cataract surgery can cause visual field constrictions, anterior ischaemic optic neuropathy, and central retinal vein occlusions in glaucomatous eyes. 3,8 In non-glaucomatous eyes, iris ischaemia, delayed wound healing, and cystoid macula oedema have been reported.4
Numerous authors agree that the peak post-operative pressure occurs within the first 3-7 hours following surgery.7,9,10 The pathogenesis for early IOP elevation is multifactorial. Inflammation and prostaglandin release following surgical trauma remains the biggest culprit. Mechanical deformation of the anterior chamber structures, haemorrhage, pigment dispersion, retained lenticular material, and residual ophthalmic viscoelastic device (OVD) have been implicated.10 Furthermore, the type of OVD also plays a role in the postoperative IOP. The molecular structure
of dispersive OVD is more difficult to remove as it tends to adhere to intraocular structures, resulting in higher IOP.7,11
Risk factors for early postoperative IOP spikes include the type of cataract surgery, elevated pre-operative intraocular pressure, longer axial length, Tamsulosin use, postoperative topical corticosteroid use, and registrar-performed surgery.6 Intra-operative complications are also closely related to postoperative IOP spikes. Complications associated with IOP spikes include vitreous loss, anterior capsular tear, posterior capsular tear, as well as zonulysis.12
As mentioned earlier, registrar-performed surgeries are a known risk factor for early IOP spikes. Elfersy et al. have shown that postoperative IOP can be two to five times higher when surgery is performed by junior surgeons, compared to that of experienced surgeons.13 This could be due to a longer surgery time, more surgical trauma, and incomplete OVD washout.13
Holm states that good IOP-lowering
effects can be gained by a single postoperative treatment dose.14 Implementing a single-dose prophylactic treatment strategy would be cost-effective and unlikely to cause significant systemic side effects. Current literature suggests the use of topical medication that contains Timolol, although a single dose of oral Acetazolamide has also been used with success.14
One study showed that patients who had immediate same-day intervention maintained an IOP lower than 21 mmHg. The IOP lowering effect was maintained at the day one follow up and by day four, most patients had an IOP below preoperative levels.4
No drug has been found to completely prevent early postoperative IOP spikes.7,15 Furthermore, opinions regarding the optimal treatment protocol are diverse. There is no standard pharmacological regimen to guide the decision-making process about these IOP spikes. However, a recent systematic review and meta-analysis recommends that “all eyes undergoing routine phacoemulsification should receive prophylactic treatment where possible”, due to the high incidence of IOP spikes.16 Prophylactic treatment with the greatest IOP-lowering effects according to this study, was intracameral cholinergics or topical fixed-combination carbonic anhydrase inhibitor-beta-blocker-formulations.
In summary, elevated intraocular pressure is a common complication and occurs in the first 3-7 hours following cataract surgery. It is a treatable and mostly preventable complication that can result in unnecessary patient discomfort and potential long-term complications. This study aims to establish the prevalence of early elevated IOP following uncomplicated cataract surgery performed by registrars.
Methods
This study had a prospective cohort design. Ethical clearance was obtained from the Human Research Ethics Committee, University of Witwatersrand (M221047). Permission was granted by Chris Hani Baragwanath Academic Hospital to conduct the study.
The study population consisted of all patients who underwent registrarperformed cataract surgery between February 2023 and October 2023 at St John’s Eye Hospital, Soweto, Gauteng. Only patients who accepted to participate and completed the informed consent form were considered. Participation was confirmed if the cataract surgery was uneventful.
Inclusion criteria:
1. Age-related cataracts.
2. Uncomplicated cataract surgeries performed by registrars in years two to four of training.
3. Cataract surgery type: phacoemulsification.
Exclusion criteria:
1. Patients with glaucoma (primary or secondary).
2. Conditions associated with glaucoma: previous uveitis and pseudoexfoliation syndrome.
3. Patients who have eyes with optic nerves suggestive of glaucomatous changes.
4. Patients with ocular hypertension.
5. Complicated cataract surgery, including posterior capsule rent, vitreous loss, iridodialysis, and haemorrhage.
6. Patients with previous eye trauma or ocular surgery.
7. Axial length < 22.0mm and > 25.0mm.
8. Tamsulosin use before surgery. Each patient eligible and willing to participate in this study had a data collection sheet, which included the age and gender of the patient, the side of the eye being operated, the time that surgery was finished, the time that the IOP measurement was taken, the time elapsed between these two occasions, the IOP in mmHg and the year of training of the surgeon. (Appendix 1) Patients underwent routine
phacoemulsification under a peribulbar block. After 3-7 hours the intraocular pressure was measured with an iCare tonometer. The pressure was considered elevated if it was over 20 mmHg. Patients with raised IOP were further grouped according to the IOP, <20, 20-30, >30 mmHg. If the intraocular pressure was found to be above 20 mmHg, treatment was immediately given in the form of 500mg Diamox orally.
The sample size for prevalence was determined using the formula n = (Z 2P(1-P))/d2 , where n is the sample size, Z is the Z-statistic for the chosen level of confidence, P is the expected prevalence and d is the precision. A 95% confidence interval was used, with 6% precision, and from the literature we know that the estimated prevalence is 8%. This brought the sample size to 80 patients.
All baseline study variables were compared between surgeon groups (year of study - YOS) to determine differences in case mix between the groups. Categorical variables (gender, eye operated) were assessed by the Χ2 test. Fisher’s exact test was used where the requirements for the Χ2 test could not be met. Continuous variables (age, time to measurement) were assessed by one-way Analysis of Variance (ANOVA). Where the data did not meet the assumptions of this test, a non-parametric alternative, the Kruskal-Wallis test was used. The relationship between each study variable and the post-operative IOP
8.
APPENDIX 1
Table II: IOP(mmHg) measurements.
Time elapsed: time between surgery completion and IOP measurement IQR: interquartile range IOP: intra-ocular pressure
Table III: Odds ratios for different patient characteristic.
(hours):
Time
category was assessed using multinomial logistic regression, with the <20 mmHg IOP category as the reference category.
Data analysis was carried out in Stata. A 5% significance level was used.
Results
The demographics of the study population are summarised in Table I. Eighty patients were recruited during the study period. The mean age was 68 years old, with a range of 47-87 years old. Fifty-seven (71%) patients were female and 23 (29%) were male. The right eye was operated in 41 (51%) patients, while 39 (49%) received surgery to the left eye.
The median time between surgery completion and IOP measurement was 3h30 (ranging from 3h00 to 6h20). The overall mean IOP was 23 mmHg with a range between 2 mmHg - 59 mmHg (Table II). The average IOP in the YOS 2 group was 23 mmHg (7 mmHg - 59 mmHg), while the YOS 3 group average was 24 mmHg (2 mmHg - 43 mmHg) and the YOS 4 group average was 23 mmHg (2 mmHg - 41 mmHg). Of the 80 patients, 50 (62.5%) had an IOP of >20 mmHg, and 19 (23.7%) had an IOP of >30 mmHg. There was a total of 32 patients in the YOS 2 group, 20 patients in the YOS 3 group, and 28 patients in the YOS 4 group. Surgery was performed by 16 trainees in total.
There was no significant association between any of the study variables and the YOS of the surgeon. We also note that there was no significant association between the IOP category and YOS of the surgeon (p = 0.21), as illustrated below in Figure 1
Age, gender, eye, the time between surgery and IOP measurement, and YOS of the surgeon, were not significantly associated with increased IOP.
Discussion
This study aimed to establish the prevalence of early elevated IOP following uncomplicated cataract surgery performed by trainees. Fifty of the 80 patients (62.5%) had an early post-operative IOP of 20 mmHg or more. The first postoperative follow-up visit, which includes IOP measurement, is routinely done 24 hours after surgery, which means that many patients with elevated IOP are going undetected.
The main cause of these pressure spikes is postulated to be due to retained OVD, which mechanically obstructs the trabecular meshwork.17 Therefore, it is essential to thoroughly wash out all the OVD. Removal of OVD behind the
Table I: Patient demographics.
Figure
IOL is critical to prevent IOP spikes, IOL decentration, and capsular block syndromes. 7 Surgical techniques of IOL implantation without the assistance of OVD, such as hydroimplantation, have been suggested to mitigate this risk. 7 During hydroimplantation, intraocular lens implantation is performed with balanced saline solution irrigation. Özcura et al. reports that this is a safe and effective technique, associated with reduced time of surgery, as well as reduced cost.
Subconjunctival corticosteroids at the end of surgery are commonly used at our facility. This can also be associated with higher IOPs. However, corticosteroid use will likely result in a prolonged IOP rise, rather than a transient elevation7
In our study, the degree of IOP elevation was not related to the registrar’s years of study. This result was not in keeping with our hypothesis, as beginner surgeons often have longer operative times and more tissue manipulations resulting in a greater inflammatory response and more iris pigment release.9
On the other hand, we have also noted that some patients had very low postoperative IOPs. This can be explained by suboptimal anterior chamber inflation at the end of surgery or wound leaks. 3 Ciliary body shutdown can also occur after peribulbar anaesthesia. It can be a direct effect of the anaesthetic agent on aqueous production, but also because of reduced choroidal blood flow with secondary ciliary body hypoperfusion. 3 In our study, we specifically excluded patients with glaucoma, as these eyes are in a higher risk category to develop post-operative IOP elevation. Ahmed et al. found that the pressure spikes occur more often and with greater magnitude when compared to nonglaucomatous eyes.4 Numerous authors agree that a diagnosis of glaucoma and ocular hypertension is a significant risk factor for raised IOP following surgery. 3
Limitations to this study include a small sample size. Furthermore, a single investigator collected the data for this study, which may have resulted in unintended bias. A rebound tonometer, the iCare, was used to measure all the IOPs. Goldmann applanation tonometry (GAT) remains the reference standard when measuring intraocular pressure but rebound tonometry (RT) is a safe alternative in patients with IOP in the low to moderate range. The accuracy of RT becomes less in higher IOP ranges when compared to GAT.19 We were more interested in the IOP trend, rather than
the exact IOP value. Furthermore, the iCare was considered a safer option due to the absence of disposable tonometry tips for the GAT. Lastly, we acknowledge that the year of study of the surgeon is not equivalent to surgical experience. Future studies could investigate the effect of different OVDs on early postoperative IOP elevation. The central corneal thickness in the postoperative eye can be investigated, as well as the effect of cataract surgery on IOP in glaucomatous eyes.
Conclusion
Early IOP elevation following phacoemulsification is a known and frequent complication.6 This study found that more than half of the patients who underwent phacoemulsification by registrars at a tertiary ophthalmology hospital had an IOP > 20 mmHg in the first 3-7 hours following surgery. Trainee surgeons can consider prophylactic IOP lowering treatment, especially in high-risk groups.
References
1. Lecuona K, Cook C. South Africa’s cataract surgery rates: why are we not meeting our targets? South Afr Med J Suid-Afr Tydskr Vir Geneeskd. 2011 Jul 25;101(8):510–2.
2. Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg. 2012 Aug;38(8):1360–9.
3. Browning AC, Alwitry A, Hamilton R, Rotchford A, Bhan A, Amoaku WM. Role of intraocular pressure measurement on the day of phacoemulsification cataract surgery. J Cataract Refract Surg. 2002 Sep;28(9):1601–6.
4. Ahmed IIK, Kranemann C, Chipman M, Malam F. Revisiting early postoperative follow-up after phacoemulsification. J Cataract Refract Surg. 2002 Jan;28(1):100–8.
5. Coban-Karatas M, Sizmaz S, Altan-Yaycioglu R, Canan H, Akova YA. Risk factors for intraocular pressure rise following phacoemulsification. Indian J Ophthalmol. 2013 Mar;61(3):115–8.
6. O’Brien P, Ho S, Fitzpatrick P, Power W. Risk factors for a postoperative intraocular pressure spike after phacoemulsification. Can J Ophthalmol [Internet]. 2007 Feb [cited 2022 Jun 11];42(1). Available from: https://pubmed.ncbi. nlm.nih.gov/17361241/
7. Grzybowski A, Kanclerz P. Early postoperative intraocular pressure elevation following cataract surgery. Curr Opin Ophthalmol. 2019 Jan;30(1):56–62.
8. Shingleton B, Rosenberg R, Teixeira R, O’Donoghue M. Evaluation of intraocular pressure in the immediate postoperative
period after phacoemulsification. J Cataract Refract Surg [Internet]. 2007 Nov [cited 2022 Jun 11];33(11). Available from: https://pubmed. ncbi.nlm.nih.gov/17964404/
9. Todorović M, Šarenac Vulović T, Petrović N, Todorović D, Srećković S. Intraocular pressure changes after uneventful phacoemulsification in early postoperative period in healthy eyes. Acta Clin Croat. 2019 Sep;58(3):467–72.
10. Kim J, Jo M, Brauner S, Ferrufino-Ponce Z, Ali R, Cremers S, et al. Increased intraocular pressure on the first postoperative day following resident-performed cataract surgery. Eye Lond Engl [Internet]. 2011 Jul [cited 2022 Jun 11];25(7). Available from: https://pubmed.ncbi. nlm.nih.gov/21527959/
11. Monaco G, Gari M, Pelizzari S, Lanfranchi A, Ruggi G, Tinto I, et al. New ophthalmic dualviscoelastic device in cataract surgery: a comparative study. BMJ Open Ophthalmol. 2019 Aug 15;4(1): e000280.
12. Annam K, Chen AJ, Lee IM, Paul AA, Rivera JJ, Greenberg PB. Risk Factors for Early Intraocular Pressure Elevation After Cataract Surgery in a Cohort of United States Veterans. Mil Med. 2018 Sep 1;183(9–10): e427–33.
13. Elfersy A, Prinzi R, Peracha Z, Kim D, Crandall D, Darnley-Fisch D, et al. IOP Elevation After Cataract Surgery: Results for Residents and Senior Staff at Henry Ford Health System. J Glaucoma [Internet]. 2016 Oct [cited 2022 Jun 11];25(10). Available from: https://pubmed.ncbi. nlm.nih.gov/27027228/
14. Holm JL, Bach-Holm D, Holm LM, Vestergaard AH. Prophylactic treatment of intraocular pressure elevation after uncomplicated cataract surgery in nonglaucomatous eyes - a systematic review. Acta Ophthalmol (Copenh). 2019 Sep;97(6):545–57.
15. Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? Graefes Arch Clin Exp Ophthalmol. 2019 May;257(5):855–61.
16. Kanjee R, Popovic M, Salimi A, Hutnik C, Ahmed I, Saheb H. Prophylaxis against intraocular pressure spikes following uncomplicated phacoemulsification: a systematic-review and meta-analysis. Eye. 2024 Feb 7;38.
17. Borazan M, Karalezli A, Akman A, Akova YA. Effect of antiglaucoma agents on postoperative intraocular pressure after cataract surgery with Viscoat. J Cataract Refract Surg. 2007 Nov;33(11):1941–5.
18. Özcura F, Çevik S. Hydroimplantation versus viscoimplantation: comparison of intraocular lens implantation with and without ophthalmic viscoelastic device in phacoemulsification. Romanian J Ophthalmol. 2018;62(4):282–7.
19. Gao F, Liu X, Zhao Q, Pan Y. Comparison of the iCare rebound tonometer and the Goldmann applanation tonometer. Exp Ther Med. 2017 May;13(5):1912–6.
For the prevention and treatment of pain and inflammation associated with cataract surgery1 For reduction in risk of postoperative macular oedema associated with cataract surgery in diabetic patients1
References: 1. ILEVRO® 0.3 % eye drops, suspension Professional Information; Novartis South Africa (Pty) Ltd. 21 January 2021. 2. Kjaerbo H. Nepafenac in the Treatment of Ocular Inflammation Following Cataract Surgery (Pseudophakic Macular Oedema) – an Update. European Ophthalmic Review. 2018;12(1):32–38. For full prescribing information, refer to the Professional Information approved by the South African Health Products Regulatory Authority. S3 ILEVRO® 3 mg/ml eye drops, suspension. Reg. No.: 52/15.4/0575. Each 1 ml of suspension contains 3 mg nepafenac.
Novartis South Africa (Pty) Ltd. Magwa Crescent West, Waterfall City, Jukskei View 2090. Tel. +27 11 347 6600. Co. Reg. No. 1946/020671/07. Novartis Adverse Drug Reaction Reporting: Email: patientsafety.sacg@novartis.com. Web: www.novartis.com/report. Tel: 0861 929-929. Marketed and Distributed by Adcock Ingram Limited. Co. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. Customer Care: 0860 ADCOCK / 232625. www.adcock.com FA-11227774 Exp.: 15/7/2026
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A case of trilateral retinoblastoma initially presenting unilaterally in an infant evolving to a diagnosis of germline retinoblastoma: diagnostic dilemmas and therapeutic challenges in the presence of pineal gland cysts
N Narainswami, MBBCH(Wits), Dip(Ophth)SA, Dip(HIV Man)SA, FCOphth(SA), (MMed) SA, Consultant ophthalmologist Grey’s Hospital Pietermaritzburg, Fellow in Paediatric Ophthalmology and Strabismus, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
ORCID: https://orcid.org/0000-0002-5495-7153
N Freeman, MB ChB (Stell), FCOphth (SA), MMed (Ophth) (Stell); Head of Clinical Unit, Paediatric Ophthalmology, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.
ORCID: https://orcid.org/0000-0002-1110-9795
T Seobi, MBBCH (Wits), MMed(Wits), FCOphth(SA); Consultant, Paediatric Ophthalmology, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.
ORCID: https://orcid.org/0000-0001-7125-4217
H Mustak, MBChB (UCT), Dip(Ophth) SA, FCOphth(SA); Professor Division of Ophthalmology, Oculoplastics and Oncology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
ORCID: https://orcid.org/0000-0002-8538-7296
Corresponding author: N Narainswami, neerannarainswami@gmail.com
Abstract
This case report seeks to describe the clinical signs and symptoms and management of this rare clinical entity of trilateral retinoblastoma (TRB) seemingly presenting in a child diagnosed initially with unilateral retinoblastoma at Red Cross War Memorial Children’s Hospital (RCWMCH). Despite the lack of family history, the subsequent development of tumours in the fellow eye seemed to support germline, heritable rather than sporadic retinoblastoma (RB).
Background: Trilateral retinoblastoma is usually seen in the setting of bilateral heritable retinoblastoma (RB) with a midline CNS primitive neuroectodermal tumour (PNET). Approximately 10-15% of children with unilateral retinoblastoma however can have germline mutations. The term “trilateral retinoblastoma” may therefore be a misnomer creating a false sense of security in unilaterally affected germline patients.
Trilateral retinoblastoma has an incidence of approximately 3% among hereditary retinoblastoma cases. There have been even fewer isolated reports of trilateral retinoblastoma presenting unilaterally. Further compounding the clinical picture is the concurrent diagnosis of benign pineal cystic lesions in the setting of retinoblastoma.
This case report highlights the challenges in making a
Case
A fifteen- month- old toddler was referred to the eye clinic at Red Cross Children’s hospital with the diagnosis of suspected left retinoblastoma. Her parents
definitive diagnosis and subsequent therapeutic challenges in these rare instances.
Methods: Observational case report.
Case study: Baby JD was referred to Red Cross War Memorial Children’s Hospital with a diagnosis of suspected left retinoblastoma for further assessment and management. MRI neuro-imaging revealed the presence of a left retinoblastoma, an irregularly walled pineal gland cyst suspicious for pinealoblastoma and suspected drop metastases in the spine. The right eye had no mass lesions on clinical exam and imaging. Pinealoblastoma and trilateral retinoblastoma are rare but associated with a poorer prognosis in hereditary retinoblastoma.
Conclusion: Trilateral retinoblastoma in the setting of unilateral eye involvement is rare but documented in the literature. PNET may present before RB, concurrently or after (95% within five years). Pineal gland cysts in the setting of RB further confounds diagnosis and present challenging therapeutic dilemmas.
had noticed a white pupillary reflex approximately three months prior. There was no family history of retinoblastoma. She was an otherwise well child with systematic review being non-contributory.
Urgent MRI of the brain and orbits revealed a large lobulated inferior hyperintense retinal mass without any optic nerve, scleral nor extraocular extension. Of note a small solid-cystic
Figure 1: Pre and post completion chemotherapy fundal views of the left eye showing marked calcific and atrophic regression of all tumours.
mass of the pineal gland measuring 7.5mm x 10mm x 6mm with eccentrically thickened walls suggestive of a synchronous pinealoblastoma was also evident. Following a recommendation from oncology; a full body MRI as part of a metastatic work-up was done which revealed the presence of hyperintensities along the lumbo-sacral spinal cord suspicious for drop metastases. Formal examination under anaesthesia revealed a normal right eye with no retinal lesions. Anterior segment examination of the left eye was normal, however a large inferior endophytic retinal mass with multiple smaller masses involving the posterior pole was noted on fundus examination with extensive vitreous and subretinal seeding. Clinically the diagnosis was unilateral multifocal Group D retinoblastoma of the left eye with pinealoblastoma (TRB) and spinal metastases.
Lumbar puncture for CSF analysis and cytospin was negative but bone marrow and trephine biopsy of the left iliac crest was positive for small hyperchromic atypical cells reminiscent of retinoblasts. The multidisciplinary team decision was made to commence high dose systemic intravenous chemotherapy with four agents, vincristine, cyclophosphamide, cisplatin and etoposide (OPEC) with monthly EUAs to determine response to therapy and assess for need for focal consolidation therapy. The parents were counselled extensively as to treatment options including primary enucleation. Monthly EUAs with documented fundus imaging (RetcamR ) showed progressive regression of all lesions. After 16 weeks of OPEC (6 cycles) examination revealed marked calcific and atrophic regression of all lesions including subretinal and vitreous seeds. Follow up MRI of the brain and spinal cord showed marked reduction of the left retinal mass, minimal flattening of the pineal mass and resolution of the spinal hyperintensities.
Five months post completion of chemotherapy examination under anaesthesia revealed two new small peripheral retinal lesions in the right eye which subsequently underwent transpupillary thermotherapy (TTT). Multiple small new lesions were evident in the left eye which also received focal consolidation TTT as well as active areas on older lesions. After two sessions of consolidative TTT the lesions on the right eye showed regression but the left eye showed minimal response with several new lesions involving the macula and inferotemporal retina. A follow up MRI scan showed nil change in size nor morphology of the pineal mass but increase in size of the left retinal mass and a new mass in the supero-nasal quadrant. At this point the original diagnosis of trilateral retinoblastoma was revised to bilateral retinoblastoma with a probable pineal gland cyst. The decision was made to enucleate the left eye. Histology revealed intraocular retinoblastoma without scleral or choroidal invasion. The multidisciplinary team decision for our patient was to continue monthly EUAs post any consolidation treatments and extend to two to three monthly EUAs only with lesion regression. A further follow up MRI is scheduled for surveillance one year post last cycle of chemotherapy.
Discussion
Retinoblastoma is the commonest
Figure 2: Right eye and left eye post consolidation TTT x 2 with regression of lesions OU and subsequent increase in lesion size and new lesions OS.
primary intraocular malignancy in childhood accounting for 11% of all malignancies diagnosed in the first year of life.1 In South Africa the incidence rate is approximately 1 in 21 000 births.1,2 Sporadic cases account for approximately 60% of cases while heritable retinoblastoma accounts for 40% 2 . While the majority of unilateral retinoblastoma represent sporadic
3: Baseline sagittal MRI scan showing tumour arising from the retina with a synchronous pineal gland mass.
“somatic” retinoblastoma and bilateral retinoblastoma is almost always heritable, 10%-15% of unilateral cases can carry a germline mutation. 2,3 Laterality is thus an imperfect predictor of germline status.
Trilateral retinoblastoma (TRB) is the term given to an intracranial midline primitive neuroectodermal tumour occurring typically in the setting of germline retinoblastoma (bilateral or unilateral). The risk of developing TRB in familial or bilateral sporadic RB is reported to be around 3%-15% while unilateral sporadic disease is less than 0.5%.4,5 Most commonly the pineal gland is involved though other nonpineal suprasellar or parasellar tumours have been described. 5 Histologically the tissue resembles retinal tumour though it is important to remember that this does not represent metastatic retinoblastoma but rather an increased propensity for nonocular tumours in germline RB. 3-5 Both pineal gland and retina being embryonal neuroectoderm derivatives are prone to develop multifocal tumours in hereditary RB. There appears to be a higher risk for TRB in familial RB1 mutations than in denovo germline mutations. 6
A recent metanalysis on asynchronous pinealoblastoma in early retinoblastoma showed that MRI of the brain misses most pinealoblastomas before one year of age while most heritable RB presents before one year of age. 7 While optimally timed additional MRI scans of the brain (up to four a year or every three months) can increase the detection rate of asymptomatic pinealoblastoma this is not always feasible in resource-constrained settings. 7,10,11 The prognosis for TRB is dismal with most cases being fatal. The median survival time from diagnosis is approximately 10 months with five year survival rates of 15%. 8,9,13
Prior to 1995 external beam radiation therapy (EBRT) was associated with a seemingly higher rate of TRB while chemotherapy has been associated with a seemingly lower rate in the past two decades.10-12 The increased use of neoadjuvant chemotherapy (chemoreduction) was postulated by Shields et al to be responsible for the prevention of development of TRB and thus fewer cases being registered.9
Neoadjuvant chemotherapy (NAC) for the prevention of TRB is often an area of debate as most studies are small and retrospective due to the rarity of TRB. Larger multicentre prospective studies are thus needed to determine optimal agents and number of cycles (two versus six) to prevent the development of TRB. Current studies by the Retinoblastoma Study Group show that three agent VEC (vincristine, etoposide, carboplatin) protocols followed by local consolidative therapies (thermotherapy, cryotherapy, radiotherapy) can be used for final tumour control.9 Our patient underwent enucleation following six cycles of high dose chemotherapy and the absence of choroidal, scleral and optic nerve invasion on histology at that point could not definitely exclude extraocular spread. NAC typically downgrades the staging of RB and this needs to be borne in mind when interpreting histology in these patients.9
The presence of a pineal lesion on MRI in the setting of retinoblastoma can present a diagnostic dilemma as pineal gland lesions may or may not point to a PNET. Incidental pineal gland cysts may present in up to 8% of retinoblastoma patients with conventional MRI scans.10 -12 Even with diffusion weight imaging (DWI) and gadolinium administration the differentiation from PNET may be challenging. Pinealoblastomas characteristically spread via the subarachnoid space to the spinal canal to form intradural extramedullary metastases, also known as drop metastases. Other MRI features favouring a pinealoblastoma over a benign cyst include heterogenous solid, cystic spaces in the tumour, thick-walled lesions >2mm, regression post chemotherapy and growth documented in consecutive scans.10-15 The propensity for PNET to infiltrate adjacent structures such as the third ventricle can cause obstructivehydrocephalus and secondary intracranial hypertension though this represents advanced symptomatic and usually fatal disease.13,14 Recent literature suggests
that synchronous pinealoblastoma is frequently smaller, more often cystic and asymptomatic compared to metachronous (presenting at least six months after primary RB diagnosis) pinealoblastoma.11
The lack of significant reduction or increase in size of the pineal lesion in our patient after two follow up MRI scans three and six months from baseline together with the asymptomatic clinical picture favoured a benign pineal cyst rather than a pinealoblastoma and thus a revision in initial diagnosis. A systematic review of 211 TRB cases in the past decade found that high dose chemotherapy with autologous stem cell rescue resulted in significantly longer (five year survival rate of 50%) survival rates in six out of twelve cases.16 The lower five year survival rate of 11% in those receiving conventional chemotherapy suggests that high dose chemotherapy should be considered a potential treatment option in TRB as was employed in our patient. The critical aspect though is meticulous follow- up preferably with fundus imaging to document any new lesions or growth in previously regressed lesions and utilising focal consolidative therapies for tumour control.
While systemic chemotherapy has been traditionally viewed as controversial in the treatment of TRB, newer regimens including high dose and four agent chemotherapy with or without autologous stem cell rescue seem to mitigate these concerns.17,18 Our patient initially responded well with all retinal lesions
Figure
Figure 4: Spinal MRI showing hyperintensities of the lower cord suggestive of drop metastases.
Figure 5: Baseline right normal fundus and one of two new peripheral lesions postchemotherapy, lesion post consolidation TTT x2.
regressing and resolution of apparent spinal drop metastases. Unilateral RB with a pineal tumour may also represent temporal variation in involvement of TRB with tumours having not manifested yet in the other eye.
Conclusion
Unilateral retinoblastoma is usually sporadic and unifocal. Up to 10-15% of unilateral RB may be hereditary and may simply represent temporal variation of truly bilateral germline RB. A full metastatic work up including baseline MRI brain and orbits is critical to exclude PNET. Pineal gland cysts remain a diagnostic and therapeutic dilemma in the setting of retinoblastoma. Long term and close follow up of the fellow eye and systemically for tumour recurrence is critical.
References
1. Kelsey V. Stuart, Daniel J. Shepherd, Mariana Kruger & Elvira Singh (2022) The Incidence of Retinoblastoma in South Africa: Findings from the South African National Cancer Registry (2004-2018), Ophthalmic Epidemiology, 29:6, 681-687, DOI:
10.1080/09286586.2021.2013900
2. Fabian ID, Sagoo MS. Understanding retinoblastoma: epidemiology and genetics. Community Eye Health. 2018;31(101):7. PMID: 29915458; PMCID: PMC5998389.
3. Kooi, I., Mol, B., Massink, M. et al. Somatic genomic alterations in retinoblastoma beyond RB1 are rare and limited to copy number changes. Sci Rep 6, 25264 (2016). https://doi.org/10.1038/srep25264
4. Global Retinoblastoma Treatment OutcomesAssociation with National Income Level Ankit Singh Tomar, MD Paul T. Finger, MD Brenda Gallie, MD Genoveva Correa-Llano, MD Elisa Carreras, MD for the American Joint Committee on Cancer Ophthalmic Oncology Task Force Open Access Published: September 29, 2020DOI:https://doi.org/10.1016/j. ophtha.2020.09.032 Marcus C. de Jong, Wijnanda A. Kors, Pim de Graaf, Jonas A. Castelijns, Annette C. Moll, Tero Kivelä.
5. The Incidence of Trilateral Retinoblastoma: A Systematic Review and Meta-Analysis, Am. J. Ophthalmol, Volume 160, Issue 6, 2015, Pages 1116-1126.e5,ISSN 0002-9394,https:// doi.org/10.1016/j.ajo.2015.09.009.
6. Dennis M. Marcus, Steven E. Brooks, Gayle Leff, Robert Mccormick, Todd Thompson, Scott Anfinson, Jacques Lasudry, Daniel M. Albert, Trilateral Retinoblastoma: Insights Into Histogenesis and Management, Survey of Ophthalmology, Volume 43, Issue 1, 1998, Pages 59-70, ISSN 0039-6257, https://doi. org/10.1016/S0039-6257(98)00019-8.
7. Silvera VM, Guerin JB, Brinjikji W, Dalvin LA. Retinoblastoma: What the Neuroradiologist Needs to Know. AJNR Am J Neuroradiol. 2 021 Apr;42(4):618-626. doi: 10.3174/ajnr.A6949. Epub 2021 Jan 28. PMID: 33509920; PMCID: PMC8041013.
8. Wright KD, Qaddoumi I, Patay Z, Gajjar A, Wilson MW, Rodriguez-Galindo C. Successful treatment of early detected trilateral retinoblastoma using standard infant brain tumor therapy. Pediatr Blood Cancer. 2010 Sep;55(3):570-2. doi: 10.1002/pbc.22545. PMID: 20658634; PMCID: PMC3115715.
9. Shields CL, Bas Z, Laiton A et al. Retinoblastoma: emerging concepts in genetics, global disease burden, chemotherapy outcomes, and psychological impact. Eye 37, 815-822 (2023). https://doi. org/10.1038/s41433-022-01980-0
10. De Ioris MA, Valente P, Randisi F, Buzzonetti L, Carai A, Cozza R, Del Bufalo F, Romanzo A, Angioni A, Cacchione A, Bernardi B, Mastronuzzi A. Baseline central nervous system magnetic resonance imaging in early detection of trilateral retinoblastoma: pitfalls in the diagnosis of pineal gland lesions. Anticancer Res. 2014
Dec;34(12):7449-54. PMID: 25503186.
11. Rodjan F, de Graaf P, Brisse HJ, Göricke S, Maeder P, Galluzzi P, Aerts I, Alapetite C, Desjardins L, Wieland R, Popovic MB, Diezi M, Munier FL, Hadjistilianou T, Knol DL, Moll AC, Castelijns JA. Trilateral retinoblastoma: neuroimaging characteristics and value of routine brain screening on admission. J Neurooncol. 2012 Sep;109(3):535-44. doi: 10.1007/s11060-012-0922-4. Epub 2012 Jul 18. PMID: 22802019; PMCID: PMC3434888.
12. Sana Qureshi, Jasmine H. Francis, Sofia S. Haque, Ira J. Dunkel, Mark M. Souweidane, Danielle N. Friedman, David H. Abramson,Magnetic Resonance Imaging Screening for Trilateral Retinoblastoma: The Memorial Sloan Kettering Cancer Center Experience 2006-2016, Ophthalmology Retina, Volume 4, Issue 3, 2020, Pages 327335,ISSN 2468-6530,https://doi.org/10.1016/j. oret.2019.10.010.
13. Blach LE, McCormick B, Abramson DH, Ellsworth RM. Trilateral retinoblastomaincidence and outcome: a decade of experience. Int J Radiat Oncol Biol Phys. 1994 Jul 1;29(4):729-33. doi: 10.1016/03603016(94)90560-6. PMID: 8040018.
14. de Jong MC, Kors WA, Moll AC, de Graaf P, Castelijns JA, Jansen RW, Gallie B, Soliman SE, Shaikh F, Dimaras H, Kivelä TT. Screening for Pineal Trilateral Retinoblastoma Revisited: A Meta-analysis. Ophthalmology. 2020 May;127(5):601-607. doi: 10.1016/j. ophtha.2019.10.040. Epub 2019 Nov 9. PMID: 32061409.
15. de Jong MC, Shaikh F, Gallie B, Kors WA, Jansen RW, Dommering C, de Graaf P, Moll AC, Dimaras H, Shroff M, Kivelä TT, Soliman SE. Asynchronous pineoblastoma is more likely after early diagnosis of retinoblastoma: a meta-analysis. Acta Ophthalmol. 2022 Feb;100(1):e47-e52. doi: 10.1111/aos.14855. Epub 2021 May 3. PMID: 33939299; PMCID: PMC9292554.
16. Yamanaka, R., Hayano, A. & Takashima, Y. Trilateral retinoblastoma: A systematic review of 211 cases. Neurosurg Rev 42, 39-48 (2019). https://doi.org/10.1007/ s10143-017-0890-4
17. Ramasubramanian A, Kytasty C, Meadows AT, Shields JA, Leahey A, Shields CL. Incidence of pineal gland cyst and pineoblastoma in children with retinoblastoma during the chemoreduction era. Am J Ophthalmol. 2013 Oct;156(4):825-9. doi: 10.1016/j.ajo.2013.05.023. Epub 2013 Jul 20. PMID: 23876864.
18. Dimaras H, Héon E, Doyle J, et al Multifaceted Chemotherapy for Trilateral Retinoblastoma. Arch Ophthalmol. 2011;129(3):360-371. doi:10.1001/ archophthalmol.2011.17
2024 OLYMPICS:
A model for striving toward excellence in Ophthalmology
It is with great excitement that we enter four-year cycle of the Olympic Games. Our society, like the upcoming Olympic Games, is a testament to the spirit of excellence, collaboration, and the pursuit of improvement.
The Olympic Games, which bring together the world’s best athletes to compete at the highest level, serve as a fitting analogy for our mission. Just as athletes prepare for years to achieve peak performance, we too must continually strive for excellence in our field. Our executive committee, comprised of 12 distinguished members, mirrors the teamwork and diverse skills seen in Olympic teams. Each member brings unique strengths and perspectives, contributing to our collective goal of advancing eye care in South Africa.
In recent years, the field of ophthalmology has seen remarkable advancements. Innovations in surgical techniques, diagnostics, and treatments have transformed our ability to address ocular diseases and improve patient outcomes. As we embrace these advancements, it is essential that we remain committed to ongoing education and professional development. Our annual conference in Gqeberha in February this year was a resounding success, with a series of conferences, workshops, and lectures featuring renowned local and international experts. These workshops and lectures allow us to stay updated with the latest
developments, much like athletes refining their techniques.
Research is another cornerstone of our society, analogous to the relentless quest for new records and breakthroughs in sports. OSSA continues to support and encourage research initiatives that push the boundaries of our understanding of eye health. By collaborating with academic institutions and research centres we can drive innovation and contribute to the global body of ophthalmic knowledge. Together we can achieve new milestones and set new standards in our field.
Equitable access to eye care remains a significant challenge, much like ensuring fair play and inclusivity in the Olympics. Many communities in South Africa, particularly in rural and underserved areas, still lack access to quality eye care services. As a society, we have a responsibility to advocate for policies that prioritise eye health and ensure the availability of essential resources for all South Africans. OSSA regularly engages with government bodies, non-governmental organisations, and other stakeholders to develop and implement strategies that bridge the gap in eye care access. By championing these efforts, we can make a meaningful impact on the lives of those in need.
Public awareness and education about eye health are also vital components of our mission. Early detection and treatment of eye conditions can prevent serious complications, just as early training and
proper coaching can lead to athletic success. We raise awareness about the importance of regular eye examinations, proper eye care practices, and the early signs of common ocular diseases. Through targeted campaigns such as the Glaucoma awareness week, Myopia awareness week and others, we aim to empower individuals to take charge of their eye health.
Together, we have the power to shape the future of ophthalmology in our country, improve patient care, and make a lasting impact on eye health in our community. Let us embrace this opportunity with dedication, passion, and a commitment to excellence, much like athletes striving for Olympic glory.
Dr Steven Lapere MMed (Ophth) Cape Town, FC Ophth (SA) (MB ChB Free State President Ophthalmology Society, South Africa steven.lapere@gmail.com
Global foundation launches programme to ignite RURAL optometry businesses
Optometry students from the University joined the OneSight EssilorLuxottica Foundation team to celebrate the 6 entrepreneurs opening rural Optical shops across Limpopo.
Good vision has the potential to unleash an individual’s full potential. It is a basic human right that can help one to learn better, be safer and promote more inclusive societies. Yet, uncorrected poor vision still affects approximately 2.7 billion people around the
world despite existing solutions having the potential to solve 80% of all vision problems.
The OneSight EssilorLuxottica Foundation envisions a world where everyone can see more and be more. Reflecting EssilorLuxottica’s commitment to eliminating
O er Neuroprotection1
uncorrected poor vision within a generation, the Foundation adopts an innovative approach to philanthropy, partnerships, and awareness-raising to ensure sustainable access to vision care.
The Foundation collaborates with
governments, NGOs, and like-minded private organisations to create sustainable access to vision care. It provides free eye exams and glasses to those most in need, funds local vision care programmes, and raises awareness about poor vision among policymakers and communities. Adding to their track record of impact since launching in South Africa in 2018, the Foundation has implemented a graduate development programme in partnership with four universities as part of its mission to make vision care more accessible.
“The project called Vula Amehlo meaning ‘open your eyes’ is not just a healthcare solution, but a rural economic development programme, because it empowers Optometry graduates to open their own eye care business in a rural location that has no current access to such services,” says Lameez Eksteen: Country Manager for the OneSight EssilorLuxottica Foundation in South Africa.
Graduates that have not found permanent employment were nominated by their universities for the Vula Amehlo programme. They were enrolled in an Entrepreneurship course, followed by a competency test. Successful students were then tasked to find a location meeting specific criteria to open their own optical shop.
Anurag Hans, President of the OneSight EssilorLuxottica Foundation and Optometry Entrepreneur Ngwato Kgoogo in front of his newly opened shop in Ga-Ramongwana.
The project will launch in a phased approach, starting today, with seven sites in Limpopo followed by teo sites in KZN and one in Gauteng.
OneSight EssilorLuxottica Foundation will cover the costs for shopfitting the prefabricated units from which the business will operate. The Foundation will further cover the transport from the manufacturer to the approved location, rent for two years, equipment, a three-month
supply of spectacles and ongoing training and mentorship.
Each practice is valued at a start-up cost of R2 million. The entrepreneur will own and run it as an independent business going forward, with guidance from a business mentor. Various vision care services will be available to the public and glasses will be dispensed at a cost of R500 per pair.
“We are excited about furthering the reach of vision care services more widely across South Africa, but also to actively contribute to job creation for graduates who have invested in their education towards an aspect of healthcare where great need still exists,” added Eksteen.
The optical shops will be clearly identifiable by the OneSight EssilorLuxottica branding and are strategically being opened near public transport and natural high foot traffic areas to ensure ease of access for communities.
Since 2013, the Foundation along with its partners has created permanent access to vision care for over 872 million people globally, equipping more than 77 million people in underserved regions with eyeglasses and creating rural livelihoods in vision care through more than 29 300 rural optical points.
An anti-infective and corticosteroid combination to treat a wide range of ocular infl ammation with infection or a risk of infection 1
0,5 % Loteprednol Etabonate with site-specific, high anti-inflammatory e cacy 2-4 0,3 % Tobramycin with broad spectrum activity 5 Reduced propensity for elevation in intraocular pressure 6 When inflammation and infection hits, strike back with our
By
Everything you ever wanted to know about the NHI but were afraid to ask
The National Health Insurance Bill signed by President Cyril Ramaphosa on Wednesday is a notoriously complex piece of legislation which few people have actually read. We break it down.
What is the NHI?
The most important thing to note is that it is not a health system (as per Britain’s National Health Service), but a fund – which the government will use to buy healthcare services for people from both the public and private sectors.
Who will run the NHI fund?
A board which will report to the minister of health. It will consist of
no more than 11 people, the bill specifies, appointed by the minister. Board members may not be government employees and cannot serve for longer than five years. A CEO will be appointed by the board, subject to the approval of the minister.
When the NHI kicks in, how much will I pay for healthcare?
Nothing. This is the idea, anyway. You will be able to walk into the nearest hospital, clinic or GP’s office that has a contract with the NHI fund and get treated for free. The first time you do so, you will have to register using your ID book or passport and have your fingerprints taken.
What about foreigners?
This has been one of the points of contention for civil society. All South African citizens, permanent residents and refugees will be covered, as will all children. But asylum seekers and illegal foreigners will only be covered for certain conditions and emergency care.
Where will the money for the NHI come from?
“Our taxes”, says a fact sheet from the Government Communication and Information System (GCIS). Many have pointed out that the South African tax base is very small
The country has 7.1 million registered taxpayers, but just three million pay 90% of personal income tax. Personal income tax is the “primary revenue source in South Africa’s fiscal system”, according to economist Andrew Donaldson.
The NHI means taxes will rise: GCIS says there will be a ‘surcharge’ on income tax and a ‘payroll tax payable by employers and employees’.
What kind of health services will I be able to access?
‘Comprehensive, including palliative care and mental health services.
So, is this the end of private healthcare in South Africa?
No, insists GCIS: “Contrary to some public narrative[s], the NHI is not going to abolish or do away with private health providers.” In fact, government maintains that the NHI will actually benefit private healthcare providers – because entering into contracts with the NHI Fund will give them a much larger pool of patients, and “they will be able to provide services to patients throughout the year, not worried about depletion of funds of patients at any stage”. That’s because the NHI Fund will settle the bill.
One thing that will be different, however, is that private healthcare providers will no longer be able to set their own fees in terms of the NHI contract. The NHI Fund will decide the fees – a prospect which doubtless strikes fear into the heart of many practice owners.
Published in SAOJ with permission from the author.
Rebecca Davis, Daily Maverick
What about medical aid schemes?
They would seem to be in a world of trouble, which is why so many have immediately threatened court action . This is because medical aids will no longer be able to cover you for any service covered by the NHI Fund – which, government keeps maintaining, will cover almost everything. (This aspect of the legislation, Discovery has said, is globally unprecedented.)
You will still be able to be a member of a medical aid scheme, but the prospect does not seem very appealing. Medical aid schemes will be decimated financially since the fees they would be able to charge would presumably only be a fraction of the king’s ransom they can command now.
GCIS acknowledges that “some will be too small to survive, so they will consolidate with others to maintain a viable risk pool for the benefits that they may still cover.”
Can I opt out of the NHI, or opt out of making contributions to the NHI? Nope.
How long will this all take to implement?
Eylea Advert.pdf 1 2024/07/15 13:22
The smart money is on ‘literally decades’ – if
indeed it ever comes to fruition. Ferial Haffajee quotes one expert here as estimating 30 years.
In theory, there are supposed to be two phases, with the first unrolling between 2023 and 2026 and the second ending in 2028.
The Department of Health’s NHI head Nicholas Crisp told Bhekisisa in 2023: “You won’t feel anything in the first year, nothing. [The system] won’t change in a short time; it will take a couple of years before we see the first steps.”
Health Minister Joe Phaahla said that come 2028, anyone will be able to walk into any private health facility and be treated free of charge. This will almost certainly not be the case by then.
How do doctors feel about the NHI?
A number of industry bodies representing healthcare workers have indicated that they will litigate the matter. Some private-sector doctors interviewed by News24 said that they refused to work for the state and would emigrate if forced to do so.
Is anyone very positively disposed towards the NHI?
The ANC, obviously, and its allies in the
trade union movement. The GOOD party released a statement supporting the signing of the bill but urging government to ‘iron out identified wrinkles’.
Pretty much all other political parties have condemned it, with even the EFF terming it ‘misguided, disingenuous and opportunistic’.
Then again, it is peak election season –and the signing of this bill is a gift to the opposition as well as to the ANC.
Does nationalised healthcare ever work?
Yes. Please see Tim Cohen’s excellent (very NHI-sceptical) piece which includes a table laying out the comparative costs and outcomes for various national health systems across the world.
But can it work in South Africa? There is abundant reason to be doubtful – and not just because of the potential for corruption and mismanagement or the parlous existing state of the public health service.
Public buy-in to the idea also requires a kind of social compact, in terms of the wealthier cross-subsidising the poorer, to which the deeply polarised atmosphere of the moment in South Africa seems distinctly unsuited.
Advances in EYE TREATMENT
Smart contact lens revolutionises eye pressure monitoring Researchers unveil an innovative ‘smart’ contact lens revolutionising glaucoma detection. The lens accurately measures eye pressure despite temperature fluctuations, a common challenge.
Traditional methods like ‘air puff tests’ often miss subtle pressure elevations indicative of glaucoma. Dengbao Xiao’s team breakthrough introduces a temperature-resistant lens capable of continuous monitoring and wireless data transmission. Unlike previous versions, this lens maintains accuracy across diverse climates. With glaucoma affecting millions worldwide, early detection is crucial. This advancement offers hope for improved diagnostics and proactive vision care.
Reference
Xu Li et al., Temperature Self-Compensating Intelligent Wireless Measuring Contact Lens for Quantitative Intraocular Pressure Monitoring, ACS Applied Materials & Interfaces (2024). DOI: 10.1021/acsami.4c02289
3d retinal electrodes offer hope for vision restoration in blind individuals
Professor Sohee Kim’s team at Daegu Gyeongbuk Institute of Science & Technology introduces innovative three-dimensional retinal electrodes, resembling convex Braille, for treating blindness. Published in Advanced Materials Technologies, the research targets blindness caused by damaged photoreceptor cells in conditions like diabetic retinopathy and macular degeneration. Unlike traditional
implants, their design closely adheres to retinal curvature, enhancing efficiency and cell preservation. Successful experiments on mice and primates demonstrate induced visual responses, promising future commercialisation in Korea. Led by Namju Kim et al., the study marks a significant stride in medical engineering.
Reference
Namju Kim et al., Double-Sided, Thin-Film Microelectrode Array with Hemispheric Electrodes for Subretinal Stimulation, Advanced Materials Technologies (2024). DOI:10.1002/admt.202302155
Gene therapy enhances vision in children afflicted by leber Congenital amaurosis
In a groundbreaking trial, CRISPR-Cas9 gene editing shows promise in treating inherited blindness, particularly Leber Congenital Amaurosis (LCA) caused by CEP290 gene mutations. The BRILLIANCE trial, conducted by the Perelman School of Medicine and Children’s Hospital of Philadelphia (CHOP), involves 14 participants, including two children. Published in the New England Journal of Medicine, the results indicate significant vision improvements in nearly half of the participants, including paediatric cases. The therapy, utilising EDIT-101 by Editas Medicine Inc., demonstrates safety without side effects. Supported by prestigious institutions and grants, this study paves the way for gene editing in treating genetic diseases, setting a precedent for future treatments.
Reference
Gene Editing for CEP290- Associated Retinal Degeneration, New England Journal of Medicine (2024). DOI: 10.1056/NEJMoa2309915
mg/ml MOXIFLOXACIN EYE DROPS, SOLUTION)
Rapid, broad spectrum, bactericidal activity1,4
Minimal risk of antibacterial resistance3
Convenient dosing
1 Drop, 3x daily for 7 days4
Safe and e ective in paediatric patients, including neonates 4
References: 1. Keating GM. Moxifloxacin 0.5% Ophthalmic Solution In Bacterial Conjunctivitis. Drugs 2011; 71(1):89-99. 2. Alfonso E, Crider J. Ophthalmic Infections and Their Antiinfective Challenges. Surv Ophthalmol 2005; 50:S1–S6. 3. Benitez-del-Castillo J, Verboven Y, Stroman D, Kodjikian L. The Role of Topical Moxifloxacin, a New Antibacterial in Europe, in the Treatment of Bacterial Conjunctivitis. Clin Drug Investig 2011; 31(8):543-557. 4. VIGAMOX Eye drops, solution approved professional information 25 May 2022.
For full prescribing information, refer to the Professional Information approved by the South African Health Products Regulatory Authority. S4 VIGAMOX Eye drops, solution. Reg. No. 40/15.1/0164. 1 ml of solution contains 5.45 mg moxifloxacin hydrochloride equivalent to 5 mg moxifloxacin base.
Holder of Certificate of Registration: Novartis South Africa (Pty) Ltd. Magwa Crescent West, Waterfall City, Jukskei View, 2090. Tel. +27 11 347 6600. Co. Reg. No. 1946/020671/07. Novartis Adverse Drug Reaction Reporting: Email: patientsafety.sacg@novartis.com. Web: https://novartis.com/report. Tel: 0861 929-929.
Marketed and Distributed by Adcock Ingram Limited. Co. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Customer Care: 0860 ADCOCK/232625. www.adcock.com. ZA2307282014 Exp date: 07/2025
South African & Africa congresses and meetings 2024
OPTICAL tr.
2024
Your partner in vision since 1989
We are proud to announce the new multipurpose which combines the complete REVO 80 functionality with a Fundus Camera. A single versatile device featuring high resolution OCT and true color fundus imaging for time and space efficiency.
The built-in 12.3 Mpix camera guarantees excellent image reproduction. REVO FC meets all requirements for modern optical tomographs.
The combination of an All in One OCT technology with a Full Color Fundus Camera in one compact system gives you high quality OCT images and a detailed color image for a multipurpose diagnosis.
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International conference on Ophthalmology and Retinal Disease treatments
Designed for complete versatility and ultimate performance, LIGHTLas TruScan Pro V2.0 is the only laser in its class with a choice of four customizable wavelength options.
LIGHTLas TruScan Pro V2.0 is the only modular laser on the market that allows a physician to obtain the system in single-wavelength form and add up to 3 additional wavelengths in the future. Available wavelengths include green 532nm, yellow 561nm or 577nm, red 670nm and infrared 810nm.
LIGHTLas TruScan Pro V2.0 increases treatment speed, safety, and convenience with a large selection of scanning patterns. Enhance conventional treatment outcomes and your patients’ comfort levels with the fastest scanning system on the market.
Available with a choice of up to 4 customizable wavelengths, the LIGHTLas TruScan Pro V2.0 is designed for traditional use or highly specialized needs in all types of clinical settings. Its modular, compact and portable console helps meet and exceed treatment goals.
Tel 012 370 4175 or contact Ahmed 082 414 1472 or Faisal 079 242 2817
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4 BOOK REVIEWS FOR 2024
Title: History of Ophthalmic Medicine –Treatments and Diagnoses
Described by a Surgeon and Professor of Ophthalmology in the 19th Century
Ophthalmologist Nathaniel L MacBride discusses the various maladies of the eye –first published in 1897, this book offers insight into the history of ophthalmology and eye medicine.
Author: Nathaniel L MacBride Paperback / Softback Price: R349
Title: Oxford Handbook of Ophthalmology
Fully revised and updated throughout, the fourth edition of the Oxford Handbook of Ophthalmology now includes free access to the ophthalmic online media bank.
Authors: Alastair K O
Denniston and Philip I Murray
Publisher: OUP Oxford
Paperback
Price: R898
Title: Inside the Eye Disease Just the Facts: A Resource Manual for the Vision Rehabilitation Professionals
The majority of Vision Rehabilitation Professionals who
teach clients how to use their remaining field of view are constantly asked to recommend the right book to explain eye diseases. Although there are several great textbooks on the visual field available, none seems to meet the need and standard of vision rehabilitation professionals to satisfy their clients’ needs. This book is the prescription that encompasses the major topics of eye disease in relation to low vision, orientation and mobility specialists and vision therapy. This book answers all the questions about the anatomy, physiology, pathophysiology, pathology, treatment, prevention, and vision rehabilitation therapy of any abnormally of the eye. This book can serve as a companion text for not only vision rehabilitation professional but also all medical or blindness students along with family.
Author: Prince MD Mba-Healthcare Mgt
Ms-Cvrt CLV
Price: R879
Title: AgeRelated Changes of the Human Eye
Aging research on the human eyes crosses all areas of ophthalmology and relies on biological, morphological, physiological, and biochemical tools for its study.
In addition to descriptions of age-related changes in almost all the structures of the human eyes, the authors also include interesting accounts of personal experiments and data.
Aging research on the human eyes crosses all areas of ophthalmology and also relies upon biological, morphological, physiological, and biochemical tools for its study. This book reviews all aspects of human eye aging. In addition to descriptions of agerelated changes in almost all the structures of the human eyes, the authors also include interesting accounts of personal experiments and data. It provides an extensive panorama of what happens during aging in the eye.
Publisher: Humana
Authors: Carlo Cavallotti and Luciano Cerulli Price: R8295.00
All books available on Amazon, South Africa. Prices correct at the time of going to print.
Target multiple pro-inflammatory mediators to help treat oedema in DME and RVO with OZURDEX®1-7
OZURDEX® contains dexamethasone.1 Dexamethasone has been shown to help treat oedema by targeting and suppressing VEGF,* MCP-1, IL-6, IL-8 and ICAM-1 pro-inflammatory mediators involved in, and significant to, the pathophysiology of DME and RVO.1-7
OZURDEX® is indicated for the treatment of adult patients with visual impairment due to diabetic macular oedema (DME) who are pseudophakic or who are considered insufficiently responsive to, or unsuitable for non-corticosteroid therapy and for adult patients with macular oedema following either branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO).1
*Corticosteroids have been shown to have some inhibitive effect on the expression of VEGF , to a lesser extent than anti-VEGFs. Supporting evidence contains data from animal models and in vitro studies which cannot necessarily be extrapolated to clinical situations. BRVO: Branch retinal vein occlusion; CRVO: Central retinal vein occlusion; DME: Diabetic macular oedema; ICAM: Intercellular adhesion molecule; IL: Interleukin; MCP:Monocyte chemoattractant protein; RVO: Retinal vein occlusion; VEGF: Vascular endothelial growth factor. OZURDEX intravitreal implant. Contains dexamethasone 700 μg in a polymer matrix. Registration numbers: South Africa: 44/15.2/0045; Mauritius: PB12805/11/2016. AbbVie (Pty) Ltd, Reg. 2012/068113/07. Address: Building 7, Waterfall Corporate Campus, 74 Waterfall Drive, Midrand, 1685, South Africa. Tel: 011 031 1600. Date of Publication of this material: March 2024. Promo. No. ZA-OZU-240004. For full prescribing information refer to the professional information approved by the medicines regulatory authority, accessible by e-mailing medicalinfo.za@abbvie.com. For adverse events, report to MEAPV@abbvie.com.
REFERENCES: 1. Ozurdex® professional information, April 2023. 2. Garcia-Layana A et al. Ophthalmologica 2018; doi: 10.1159/000486800 (accessed February 2024). 3. Wang K et al. Biol Pharm Bull 2008; 31(8): 1541-6. 4. RezarDreindl S et al. Acta Ophthalmol 2017; 95(2): e119-27. http://dx.doi.org/10.1155/2013/438412 (accessed February 2024). 5. Edelman JL et al. Exp Eye Res 2005; 80: 249-58. 6. Tamura H et al. Invest Ophthalmol Vis Sci 2005; 46(4): 1440-4. 7. Nehme A and Edelman J. Invest Ophthalmol Vis Sci 2008; 49(5): 2030-8.
