Précis: In the largest clinic-based study to date, our review of 588 patients presenting with glaucoma in Northern Ghana revealed 36% of these had primary angle closure glaucoma (PACG). Objective: Glaucoma is the second leading cause of blindness worldwide. In Africa, glaucoma is an established public health problem, and PACG is not commonly discussed. Recognizing it is important because of its negative impact on visual morbidity, and also because its treatment is different from primary open angle glaucoma. In response to the observation of many PACG cases at the Northern Community Eye Hospital in Tamale, Ghana, we investigated the proportion of those attending with a first diagnosis of glaucoma who had PACG. Patients and Methods: Using the electronic records, we identified 976 patients who attended with a first diagnosis of glaucoma between January 2021 and October 2022. Of these, 588 met the inclusion criterion of a clear glaucoma subtype diagnosis. Results: Of these 316 (53.7%) had primary open angle glaucoma, 210 (35.7%) PACG, and 62 (10.5%) secondary glaucoma. Thus, over a third of presenting glaucomas had PACG. Conclusion: This study highlights that PACG is present in about a third of patients presenting to our clinic in North Ghana. Our study demonstrates the importance of a clear diagnostic pathway including gonioscopy in the assessment of glaucoma patients and the consideration of wider training on angle closure glaucoma diagnosis and management.

Purpose: To describe the process of development of the West African College of Surgeons (WACS) Basic Ophthalmology Educational Resource and to report the feedback from the first five cohorts to utilise the resource at the commencement of their training in ophthalmology. Methods: After initial meetings topics considered essential foundations for training in ophthalmology were identified. Faculty members subsequently searched the internet to identify suitable online open source learning materials relevant to each topic, which were then collated and cataloged. Where suitable quality learning materials could not be identified, materials were created or re-used from existing WACS courses. Following the creation of the resource, questions were developed for a summative assessment, taken by learners upon completion of the resource. Results: The resource went 'live' on 10th July 2019. As of March 2024, a total of 203 learners in 5 cohorts had completed the course. The feedback responses of 150 (74%) learners from the first 5 cohorts are described in this report. Regarding their overall assessment of the course, 64 (43%) learners rated the resource as very good', 63 (42%) as 'good', and 23 (15%) as 'satisfactory’. Most (>98%) respondents reported that the course met their expectations and that the content was relevant to their learning needs. Conclusion: The WACS Basic Ophthalmology Resource appears to be a valuable opportunity for acquiring foundational knowledge.

Abstract Background/Objectives: Glaucoma is the second leading cause of blindness worldwide. In Africa, glaucoma is an established public health problem, and primary angle-closure glaucoma (PACG) is not commonly discussed. Recognizing it is important because of its negative impact on visual morbidity, and also because its treatment is different from primary open angle glaucoma (POAG). In response to the observation of many PACG cases at the Northern Community Eye Hospital in Tamale, Ghana, we investigated the proportion of those attending with a first diagnosis of glaucoma who had PACG. Subjects/Methods: Using the electronic records, we identified 976 patients who attended with a first diagnosis of glaucoma between January 2021 and October 2022. Of these, 588 met the inclusion criterion of a clear glaucoma subtype diagnosis. Results: Of these 316 (53.7%) had POAG, 210 (35.7%) PACG, and 62 (10.5%) secondary glaucoma. Thus, over a third of presenting glaucomas had PACG. Conclusion: This highlights that PACG is present in a large proportion of our African population. Our study demonstrates the importance of a clear diagnostic pathway including gonioscopy in the assessment of glaucoma patients and the consideration of wider training on angle closure glaucoma diagnosis and management.

Précis: β-radiation is a neglected antiscarring therapy with past concerns for safety. This report found it safe and efficacious when used as an adjuvant to trabeculectomy surgery in 101 people (135 eyes) over 20 years Purpose: β-radiation has been used as an adjunct to prevent scarring in trabeculectomy surgery for many decades. Safety concerns were raised with the use of high doses on the bare sclera. Moorfields Eye Hospital has a large cohort of patients who have received β-radiation therapy. We report a review of the long-term safety and efficacy. Methods: Cases undertaken between August 1992 and August 1996 were reviewed. Those with records available for postoperative review of more than 5 years were included. Failure (reintervention/>21 mm Hg on 2 successive occasions) and any complication previously reported in association with β-radiation were the primary outcomes. Results: In total, 292 operations using β-radiation were recorded and 101 people (135 eyes) with trabeculectomy surgery and postoperative follow-up for over 4.5 years were included. The median follow-up period was 22.5 years. At the final follow-up, 48 (48%) single eyes per person had failed and 20/51 (51%) eyes with primary open angle glaucoma had cataract surgery. Other complications were rare and associated with copathology. Conclusion: In glaucoma patients at risk of scarring and failure after trabeculectomy, as an antiscarring adjuvant, a 750 cGY dose of β-radiation was found to be safe and efficacious in the long term.

BACKGROUND: Bleeding is one of the commonest complications affecting children undergoing cardiac surgery on cardiopulmonary bypass. Antifibrinolytic drugs are part of a multifaceted approach aimed at reducing bleeding, though sufficiently sized pediatric studies are sparse, and dosing algorithms are heterogeneous. Our objective was to evaluate the efficacy and safety of antifibrinolytic agents as well as the effectiveness of different dosing regimens in pediatric cardiac surgery using cardiopulmonary bypass. METHODS: We performed a systematic review and meta-analysis evaluating randomized controlled trials published between 1980 and 2019, identified by searching the databases MEDLINE, EMBASE, PubMed, and CENTRAL. All studies investigating patients <18 years of age without underlying hematological disorders were included. The primary outcome was postoperative bleeding; secondary end points included blood product transfusion, mortality, and safety (thromboses, anaphylaxis, renal or neurological dysfunction, and seizures). Different dosing regimens were compared. Studies were dual appraised, outcomes were reported descriptively and, if appropriate, quantitatively using the Review Manager 5 (REVMAN 5) software (The Cochrane Collaboration). RESULTS: Thirty of 209 articles were included, evaluating the following drugs versus control: aprotinin n = 14, tranexamic acid (TXA) n = 12, and epsilon-aminocaproic acid (EACA) n = 4. The number of participants per intervention group ranged from 11 to 100 (median, 25; interquartile range [IQR], 20.5) with a wide age span (mean, 13 days to 5.8 years) and weight range (mean, 3.1–26.3 kg). Methodological quality was low to moderate. All agents reduced mean 24-hour blood loss compared to control: aprotinin by 6.0 mL/kg (95% confidence interval [CI], −9.1 to −3.0; P = .0001), TXA by 9.0 mL/kg (95% CI, −11.3 to −6.8; P < .00001), and EACA by 10.5 mL/kg (95% CI, −21.1 to 0.0; P = .05). Heterogeneity was low for TXA (I2 = 29%; P = .19), moderate for aprotinin (I2 = 41%; P = .11), and high for EACA (I2 = 95%; P < .00001). All agents also reduced 24-hour blood product transfusion. There was no clear dose-response effect for TXA nor aprotinin. Studies were underpowered to detect significant differences in mortality, thromboses, anaphylaxis, and renal or neurological dysfunction. CONCLUSIONS: The available data demonstrate efficacy for all 3 antifibrinolytic drugs. Therefore, the agent with the most favorable safety profile should be used. As sufficient data are lacking, large comparative trials are warranted to assess the relative safety and appropriate dosing regimens in pediatrics.

BACKGROUND/AIMS:Diurnal variation in intraocular pressure (IOP) is a routine assessment in glaucoma management. Providing patients the opportunity to perform self-tonometry might empower them and free hospital resource. We previously demonstrated that 74% of patients can use the Icare® HOME tonometer. This study further explores Icare® HOME patient self-monitoring.METHODS:Patients were trained by standard protocol to use the Icare® HOME rebound tonometer. Patient self-tonometry was compared to Goldmann applanation tonometry (GAT) over one clinical day. Following this, each patient was instructed to undertake further data collection that evening and over the subsequent two days.RESULTS:Eighteen patients (35 eyes) participated. Good agreement was demonstrated between GAT and Icare® HOME for IOPs up to 15 mm Hg. Above this IOP the Icare® tended to over-read, largely explained by 2 patients with corneal thickness >600 um. The mean peak IOP during 'clinic hours' phasing was 16.7 mm Hg and 18.5 mm Hg (p = 0.24) over three days. An average range of 5.0, 7.0 and 9.8 mm Hg was shown during single day clinic, single day home and three day home phasing respectively (p =<0.001). The range of IOP was lower in eyes with prior trabeculectomy (6.1 mm Hg vs 12.2 mm Hg). All patients undertook one reading in the early morning at home with an average of 4.8 readings during, and 3.1 readings after office hours.CONCLUSIONS:This small study shows that self-tonometry is feasible. The findings from home phasing demonstrated higher peak and trough IOPs, providing additional clinical information. Home phasing is a viable alternative. The cost-effectiveness of this approach has yet to be addressed.

We would like to thank Ian Murdoch and David Crabb for their important letter pointing out the tendency to underestimate the global burden of glaucoma when focusing solely on central vision loss. Glaucoma is the leading cause of irreversible vision loss globally, whose share of overall blindness prevalence has been growing steadily as investments have begun to pay off in the fight against diseases such as cataract and trachoma.1Burton MJ Ramke J Marques AP et al.The Lancet Global Health Commission on Global Eye Health: vision beyond 2020.Lancet Glob Health. 2021; 9: e489-e551Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 2Bourne R Steinmetz JD Flaxman S et al.Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study.Lancet Glob Health. 2021; 9: e130-e143Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar We fully agree that reliance only on central vision as an index of disease severity is particularly poorly suited to accurately estimating the glaucoma burden.3Tham YC Li X Wong TY Quigley HA Aung T Cheng CY Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Summary Full Text Full Text PDF PubMed Scopus (2499) Google Scholar Glaucoma has already done substantial harm to the eye and to visual function by the time central vision is affected. Activities such as safe driving might become impossible because of loss of peripheral vision from glaucoma, long before central vision is affected.4Blane A Through the looking glass: a review of the literature investigating the impact of glaucoma on crash risk, driving performance, and driver self-regulation in older drivers.J Glaucoma. 2016; 25: 113-121Crossref PubMed Scopus (16) Google Scholar Other substantial underestimates also result from this approach. As pointed out in the Lancet Global Health Commission, many individuals with early glaucoma need timely treatment to avoid later vision loss and certain high-risk groups, such as adults aged 40 years and older and people of African descent, require screening care for the same reason.1Burton MJ Ramke J Marques AP et al.The Lancet Global Health Commission on Global Eye Health: vision beyond 2020.Lancet Glob Health. 2021; 9: e489-e551Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar All of these demands on the health-care system are missed when we account for the magnitude of glaucoma solely using central vision loss as a measure. Besides more inclusive and sensitive measures of glaucoma prevalence and the disease's health-care implications, we would also like to highlight again the following pressing needs in the global response to glaucoma, as outlined in the Commission: (1) low-cost screening outreach models for low-income and middle-income countries—eg, leveraging existing cataract outreach efforts and eye-screening programmes for patients with diabetes; (2) trials of cost-effective, scalable, and locally acceptable glaucoma treatments that are appropriate for low-resource settings, such as low-cost laser trabeculoplasty; (3) rigorous studies of inexpensive interventions to improve knowledge about and demand for glaucoma care in underserved areas; (4) capacity strengthening among eye-care professionals, particularly in sub-Saharan Africa and east Asia, where the magnitude of glaucoma blindness is especially high, to improve skills in glaucoma detection and management with appropriate resourcing of ongoing chronic care that is stratified by risk of vision loss; and (5) evidence-based advocacy to governments to include glaucoma in national eye health planning. We fully agree with Murdoch and Crabb that global efforts to reduce the glaucoma burden depend heavily on an accurate and inclusive accounting of its precise extent. We cannot fight what we do not know. NC reports professional fees from Belkin Laser. All other authors declare no competing interests. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness. Full-Text PDF Open AccessVisual function rather than visual acuityWe would like to express our gratitude to Matthew Burton and colleagues for the Commission on Global Eye Health (April, 2021),1 which highlights the magnitude of the challenge. As a plea we would like to mention the glaucomas. We feel this preventable cause of blindness has been insufficiently represented and the burden of this disease group understated because of the use of visual acuity alone to measure disability. Full-Text PDF Open Access

Aims To determine the cost and quality of life impact imposed by glaucoma in Tanzania, East Africa. Methods An expert panel of eye health professionals was convened to agree current glaucoma practice in Tanzania. In addition a structured patient survey was developed and administered. Supplemental cost and quality of life information was collected using cost questionnaires and validated quality of life measures, including the EQ5D and VFQ-25. Results Key findings include following. Non-adherence is a major issue, especially in rural settings where over 50% of the patients may fail to return for review. Whilst medical therapy is overwhelmingly the first line treatment, the cost of maintaining this represents up to 25% of a patient’s income. There is an impact of glaucoma on patients general well-being as determined by the EQ-5D and more tellingly on visual function with particular impact on role limitations as determined by the VF25. Despite our sample being taken in a private clinic and thus containing a much larger proportion of professionals than the general population, one third of the population earned Tanzanian Shillings (TZS) 170,000 per month which is below the minimum wage. Conclusion These findings are of great importance for health care planners seeking to determine cost-effective, acceptable methods of both identifying and treating this major cause of preventable blindness.

Background/Objectives Adherence is a major challenge in topical glaucoma therapy, particularly in an African context. We report a pilot study assessing adherence independently for the first time in an African context. Subjects/Methods Participants with newly diagnosed open-angle glaucoma received a weighed bottle of Lumigan 0.01% with counselling on therapy. The bottles were returned monthly for renewal and weighed on return to estimate drops taken during the period. Data collection was for one year with a short compliance questionnaire. Results 11 patients participated. 5 (45%) failed to complete one full year of topical therapy. The overall mean number of drops per eye per day was 1.74 (SD 0.69) for the 6 with one year of monthly returned bottles and controlled IOPs at each visit. Self-perception of compliance in these patients was good. Conclusion The signs of poor adherence based on both self-report (previous literature), and in this small-scale study of an objective measure suggest medication may not be the first-line treatment of choice in this environment. Our report does, however, raise the possibility that those patients who return for repeat prescriptions and review are indeed adhering to their treatment regimens.

Purpose To determine whether a purpose-built glare tester, in combination with new glare-specific questions, can better assess glaucoma patients’ experience of glare and visual disability than visual acuity (VA) or visual fields alone. Patients and methods Consecutive patients attending for visual fields in a single glaucoma clinic from 03/06/2019–01/11/2019 underwent VA assessment using a Brightness Acuity Tester as a glare source, examination for media opacities, and completed the VFQ-25 with four additional glare-related questions. One hundred and sixteen eyes (64 patients) were included for analysis. The amount of disability glare (VA reduction due to glare) was compared according to presence/absence of media opacity and glaucoma severity. Subjective glare symptoms were compared with objective disability glare measurement using a Bland–Altman plot. Results Patients with advanced–severe glaucoma had significantly worse disability glare than those with mild–moderate glaucoma. VA reduction due to glare from mild–moderate to acute–severe glaucoma (mean −3.4 letters, P = 0.01, CI −0.8, −6.0) was of almost identical magnitude to that due to presence of any media opacity (mean −3.3 letters, P = 0.03, CI −0.4, −6.2). There was a trend towards greater disability glare in more symptomatic patients, with good agreement between subjective and objective glare measurements for those with few glare signs or symptoms, but progressively more variation either side of agreement as either measurement worsened. Conclusions Glaucoma is associated with objective and subjective acuity reduction in the presence of glare. We demonstrated an increase in disability glare in patients with more severe glaucoma. The worse the glare symptoms or signs, the more variable the agreement between objective and subjective assessments.

Introduction: The glaucomas often co-exist with cataract. We previously reported a large trial of anti-scarring treatment in combined phacotrabeculectomy surgery. Long-term outcomes in an African population are extremely rarely reported. We present here the outcomes in IOP, acuity, bleb morphology and patient perceptions at 3–5-years post surgery. Methods: Tanzanian patients with glaucoma and visually significant cataract underwent combined phacotrabeculectomy surgery. In November 2015 an attempt was made to contact all participants in the study inviting them for a repeat examination. All who attended were given a detailed examination. A semi-structured interview in Swahili was administrated to determine patient experience and satisfaction with the surgery. Results: Sixty-eight (23%) attended for repeat review in 2015. The mean time from original surgery was 4.5-years (range 2.3–6.6-years). Overall 53 (78%) had IOP < 21 mm Hg and 29 (43%) an IOP < 16 mm Hg at final follow-up. A flat bleb at 26 and 100 days was associated with failure by IOP criteria at 4.5-years post-operatively. A vascular bleb at those time points was not any more associated with late failure than a non-vascular bleb. A majority of patients were pleased with the surgery. The cost of surgery is high but it is a price patients were willing to pay. Nearly all patients (95%) would recommend the service to family and friends. Discussion: Owing to the small proportion reviewed, our conclusions are severely limited. Phacotrabeculectomy worked well in a majority of the reviewed population long-term and is accepted by a majority of these patients as worthwhile.

To evaluate ophthalmology trainees’ perception of their gonioscopy learning experience in the Ophthalmology Specialty Training programme. A cross-sectional electronic survey was conducted amongst ophthalmology trainees across London Deaneries. The ten questions survey collected parameters, including training grade, previous level of gonioscopy training, confidence in performing the procedure, level of satisfaction with the training formats received, potential barriers and improvements to the training programme. The respondents were also invited to express any additional comments. Fifty-seven complete responses were analysed. The respondents included 25 junior trainees (ST1–3) and 32 senior trainees (ST4–7 and fellows). One-fifth of the respondents (11/57) were unconfident in performing gonioscopy, the majority being junior trainees (9/11). Over a quarter of the respondents were dissatisfied with the quantity of the gonioscopy training received. Teaching formats, such as consultant teaching (mean 8.0 ± 0.50), self-directed learning (mean 8.0 ± 0.38) and small-group tutorials (mean 7.6 ± 1.6) were all well received. Overall, lack of clinical time was considered as the major barrier to gonioscopy training; however, lack of training was considered as the major barrier in the low-confidence group. This study highlighted ophthalmology trainees’ dissatisfaction in the current gonioscopy training curriculum and a lack of confidence in performing the procedure. Appropriate modifications to the Ophthalmology Specialty Training programme could enhance trainees’ gonioscopy learning experience.

In this work, a small core, Fibre Bragg Grating (FBG)-based smart contact lens for intraocular pressure (IOP) measurement has been demonstrated. Further, an integral temperature compensation mechanism has been developed and included in the sensor design, allowing it to offer good long-term measurement capability while allowing for any local temperature fluctuations. The sensitivity of the device has been shown to be 12.9 p.m./mmHg, yielding good repeatability in tests carried out. Such a small core fibre, FBG-based smart contact lens shows significant potential for improving the management and therapy of glaucoma, the second most common cause of preventable blindness in the world.

Following the publication of the above article the authors noted an error in the author list, 2 authors were mistakenly omitted. Zena Rodrigues and Faisal Ahmed have now been added to the author list and the PDF and HTML versions of the paper have been corrected.

Objective: We aimed to systematically describe, via a scoping review, the literature reporting strategies for prevention and management of mediastinal bleeding post pediatric cardiopulmonary bypass surgery. Data Sources: MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL Register. Study Selection: Two authors independently screened publications from 1980 to 2016 reporting the effect of therapeutic interventions on bleeding-related postoperative outcomes, including mediastinal drain loss, transfusion, chest re-exploration rate, and coagulation variables. Inclusions: less than 18 years, cardiac surgery on cardiopulmonary bypass. Data Extraction: Data from eligible studies were extracted using a standard data collection sheet. Data Synthesis: Overall, 299 of 7,434 screened articles were included, with observational studies being almost twice as common (n = 187, 63%) than controlled trials (n = 112, 38%). The most frequently evaluated interventions were antifibrinolytic drugs (75 studies, 25%), blood products (59 studies, 20%), point-of-care testing (47 studies, 16%), and cardiopulmonary bypass circuit modifications (46 studies, 15%). The publication rate for controlled trials remained constant over time (4-6/yr); however, trials were small (median participants, 51; interquartile range, 57) and overwhelmingly single center (98%). Controlled trials originated from 22 countries, with the United States, India, and Germany accounting for 50%. The commonest outcomes were mediastinal blood loss and transfusion requirements; however, these were defined inconsistently (blood loss being reported over nine different time periods). The majority of trials were aimed at bleeding prevention (98%) rather than treatment (10%), nine studies assessed both. Conclusions: Overall, this review demonstrates small trial sizes, low level of evidence, and marked heterogeneity of reported endpoints in the included studies. The need for more, higher quality studies reporting clinically relevant, comparable outcomes is highlighted. Emerging fields such as the use of coagulation factor concentrates, goal-directed guidelines, and anti-inflammatory therapies appear to be of particular interest. This scoping review can potentially guide future trial design and form the basis for therapy-specific systematic reviews.

Aim: There is no universal grading system for age-related cataracts. ‘Lens Opacities Classification System III’ (LOCS III), the current gold standard, requires lengthy training, is not time or costeffective and can have poor patient cooperation. These challenges are compounded in resource poor settings. In this study, we explore the OQUAL™ grid as a potential lens grading system compared to the gold standard to overcome these constraints. Method: Pensioners aged over 49 years in Mekelle, Ethiopia were offered a free eye examination and involved in the study if a cataractous lens was present. The degree of crystalline lens opacity was graded using LOCS III and the OQUAL™ grid. Bland-Altman plots were constructed to investigate agreement between both methods of cataract assessment. Results: Bland-Altman plots demonstrated good agreement between both both methods for pure nuclear sclerotic (NS) cataracts. There was weak agreement between both methods for other lens opacity with no systematic bias. A significant association with visual acuity was demonstrated with both OQUAL™ (Chi2=79.0 p=0.019) and a composite LOCS score (Chi2=73.7 p=0.004). Conclusion: This study confirms the OQUAL™ method bears comparison with LOCS III in predicting visual acuity and good agreement exists between the methods when assessing pure NS cataracts which are regarded as difficult to diagnose and grade. The OQUAL™ system detects severe cataracts with worse visual acuities, it is portable, simple, objective, cheap and requires a shorter training period than LOCS III. This allows for large-scale screening, case-finding or research to be conducted in a time and cost effective manner as OQUAL™ can be utilized by a technician on a largescale.

Aims To compare success proportions at 5 years in three surgical groups: group 1, trabeculectomy alone; group 2, trabeculectomy followed by cataract surgery within 2 years; and group 3, trabeculectomy performed on a pseudophakic eye. Methods A retrospective cohort study. 194 eyes of 194 patients were identified with at least 5 years’ follow-up post trabeculectomy (N=85, 60 and 49 in groups 1, 2 and 3, respectively). Main outcome measures 1. Primary outcome measure: intraocular pressure (IOP) at 5 years post-trabeculectomy surgery, 2.Secondary outcome measure: change in visual acuity at 5 years. Results At 5 years, the mean IOP (SD) was 12.9 (3.5), 12.5 (4.8) and 12.7 (4.8) mm Hg in groups 1, 2 and 3, respectively. Overall success was almost identical, 58%, 57% and 59% in groups 1, 2 and 3, respectively. There was no significant difference between the groups in terms of percentage IOP reduction, number of medications, proportion restarting medication and reoperation rates at 5 years. Logistic regression for an outcome of failure showed men to be at increased risk of failure OR 1.97 (95% CI 1.10 to 3.52, p=0.02). Nearly 80% of patients retained or improved their vision following their initial trabeculectomy. Conclusions The sequence in which surgery is carried out does not appear to affect trabeculectomy function at 5 years, success being similar to trabeculectomy alone. In our study, men may be at increased risk of failure.