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Rules of Thumb in Ophthalmology
Background
Ophthalmology in sub-Saharan Africa faces several challenges, including high rates of preventable blindness, cataracts, glaucoma, refractive errors, and infections like trachoma. The scarcity of ophthalmologists, limited access to eye care services, and inadequate infrastructure in rural areas exacerbate the region’s burden of eye diseases. However, following rules of thumb and guidelines tailored to the region’s resource constraints can help in delivering effective eye care.
Rules of thumb
1. Cataract Management
Cataracts are the leading cause of blindness in sub-Saharan Africa. Early identification and surgical intervention can restore vision in most affected individuals.
Rules of Thumb
Prioritize Early Detection:
Encourage regular eye screenings, particularly in elderly populations, to identify cataracts early. Cataracts are often left untreated until they cause significant visual impairment due to delayed access to care.
Low-Cost Surgical Solutions:
Utilize low-cost cataract surgery methods, such as manual small incision cataract surgery (MSICS), the use of outreaches whereby Ophthalmologists move to communities to screen and operate cataract patients using MSICS instead of waiting for the patients to present in eye clinics which is effective and more affordable than phacoemulsification in resource-limited settings.
Use of Intraocular Lenses (IOLs): In cataract surgery, ensure the use of intraocular lenses (IOLs) to improve visual outcomes. Where availability or cost is an issue, prioritize their use in those with bilateral cataract blindness.
Guidelines
WHO Guidelines for Cataract Surgery: Recommend early intervention and surgery when cataracts impact daily activities. WHO guidelines also encourage increasing the number of cataract surgery centers in rural areas and using cost-effective surgical techniques such as MSICS.
2. Glaucoma Management
Glaucoma is a leading cause of irreversible blindness in sub-Saharan Africa, often diagnosed too late due to the silent progression of the disease.
Rules of Thumb
Routine Screening for At-Risk Populations:
Regularly screen individuals over the age of 40 and those with a family history of glaucoma, as early detection is key to preserving vision.
Medical Management for Early Cases:
In the early stages of glaucoma, use medications such as prostaglandin analogs to lower intraocular pressure (IOP). Ensure compliance by educating patients about the importance of lifelong treatment.
Surgical Intervention for Advanced Cases:
In advanced glaucoma cases, especially where medical management is ineffective or unavailable, surgery (such as trabeculectomy) may be necessary. Laser treatments can also be an option, but access may be limited in rural areas.
Guidelines
WHO Guidelines on Glaucoma: Recommend integrating glaucoma screening into routine primary care services, especially for high-risk individuals. Surgical treatment is encouraged in cases where medical management fails, and efforts should be made to make both medication and surgery more accessible.
3. Trachoma Control
Trachoma, a preventable and treatable infectious disease, is still endemic in parts of sub-Saharan Africa and is a significant cause of blindness.
Rules of Thumb
Implementation of the SAFE Strategy:
The SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvement) strategy remains the most effective way to combat trachoma. Surgical correction of trichiasis, antibiotics to control infection, improved hygiene, and sanitation are all critical.
Mass Drug Administration (MDA):
In endemic areas, conduct mass drug administration (MDA) with azithromycin to reduce the prevalence of active trachoma infections.
Focus on Facial Cleanliness:
Educate communities about facial cleanliness in children, as it helps reduce the spread of the disease by breaking the transmission cycle.
Guidelines
WHO Trachoma Elimination Guidelines: Recommend full implementation of the SAFE strategy in endemic regions. These guidelines emphasize that MDA should continue annually in areas where the prevalence of active trachoma is greater than 5%.
4. Refractive Error and Low Vision
Refractive errors such as myopia, hyperopia, and astigmatism are common but often untreated in sub-Saharan Africa due to a lack of access to eye exams and corrective lenses.
Rules of Thumb
School Screening Programs:
Implement school-based vision screening programs to identify refractive errors in children, as early detection can significantly improve educational outcomes and quality of life.
Affordable Eyeglasses:
Promote the availability of low-cost eyeglasses and visual aids, especially for children and elderly populations. Subsidized programs or partnerships with NGOs can help improve access to corrective lenses.
Task Shifting:
In settings with a shortage of ophthalmologists, train non-specialists (e.g., nurses, optometrists, and community health workers) to conduct basic vision screening and prescribe eyeglasses.
Guidelines
WHO Guidelines on Refractive Error: Advocate for the integration of refractive error screening into primary care and educational systems. The guidelines also stress the importance of providing affordable eyeglasses and low vision aids to underserved populations.
It is important for incorporation of school eye Health for early screening and intervention for refractive errors and paediatric ophthalmology cases.
5. Retinopathy of Prematurity (ROP)
Retinopathy of Prematurity is a growing concern with the increase in neonatal survival rates due to improvements in maternal and child healthcare.
Rules of Thumb
Screening in Premature Infants:
Screen all infants born before 32 weeks gestation or weighing less than 1,500 grams for ROP. Early screening is critical to prevent irreversible blindness.
Timely Laser Treatment:
For severe cases of ROP, timely laser therapy is essential to prevent retinal detachment and vision loss. In resource-limited settings, prioritize this treatment for those at highest risk.
Preventative Care in Neonatal Units:
Focus on improving neonatal care, particularly oxygen management, as improper oxygen administration is a leading cause of ROP in premature infants.
Guidelines
WHO Guidelines on ROP Screening and Treatment: Recommend routine ROP screening in high-risk infants and timely treatment in cases of severe disease. These guidelines stress the importance of neonatal care practices that prevent ROP, such as proper oxygen monitoring.
6. Onchocerciasis (River Blindness)
Onchocerciasis, caused by the parasitic worm Onchocerca volvulus, is endemic in certain parts of sub-Saharan Africa and is a significant cause of preventable blindness.
Rules of Thumb
Mass Treatment with Ivermectin:
Conduct annual or bi-annual mass treatment with Ivermectin in endemic areas to control the disease and prevent blindness. Early treatment is essential to halt disease progression.
Monitor for Complications:
In patients with advanced disease, monitor for complications such as optic nerve atrophy or irreversible blindness. Patients with severe complications should be referred for supportive care.
Community Engagement:
Engage local communities in the treatment and prevention of onchocerciasis by raising awareness about the importance of mass drug administration (MDA) and vector control.
Guidelines
WHO Onchocerciasis Elimination Guidelines: Recommend ivermectin MDA to reduce transmission and prevent the disease. Guidelines also emphasize the need for comprehensive eye care services to manage complications in those already affected.
7. Paediatric Ophthalmology
Childhood blindness, largely due to cataracts, trauma, and corneal scarring from vitamin A deficiency, remains a major challenge in sub-Saharan Africa.
Rules of Thumb
Vitamin A Supplementation:
Ensure children receive adequate vitamin A supplementation as part of routine child health programs. This can prevent corneal blindness caused by vitamin A deficiency.
Early Intervention for Paediatric Cataracts:
Early detection and surgical intervention for paediatric cataracts can restore vision. Delay in surgery can lead to amblyopia (lazy eye) and permanent vision loss.
Prevent Eye Trauma:
Educate communities on preventing eye trauma in children, particularly injuries related to falls, sharp objects, and chemical burns. Prompt treatment of eye injuries is essential to preserving vision.
Guidelines
WHO Guidelines on Childhood Blindness: Recommend vitamin A supplementation in all children under five years of age, especially in regions with high rates of malnutrition. Surgical correction of cataracts and other preventable causes of childhood blindness is emphasized.
8. Postoperative Care in Ophthalmology
Effective postoperative care is essential to ensure successful outcomes and prevent complications like infections or secondary glaucoma.
Rules of Thumb
Monitor for Postoperative Infections:
After eye surgery, closely monitor for signs of infection, such as redness, swelling, or discharge. Early treatment with antibiotics can prevent serious complications.
Educate Patients on Postoperative Care:
Instruct patients on proper postoperative care, including using prescribed eye drops, protecting the eye from trauma, and attending follow-up appointments.
Prioritize Follow-up:
Ensure regular follow-up visits, particularly after glaucoma and cataract surgeries, to monitor for complications like increased intraocular pressure or graft rejection in corneal surgeries.
Guidelines
WHO Postoperative Care Guidelines: Stress the importance of patient education, infection prevention, and regular follow-up after surgery to detect and manage complications early. Postoperative antibiotic use is recommended to prevent infections.
Conclusion
Ophthalmology in sub-Saharan Africa requires a concerted effort to address the high burden of preventable blindness and other eye diseases. By adhering to basic rules of thumb—such as early detection, cost-effective treatment, and community engagement ophthalmic care can be significantly improved in resource-constrained settings. WHO guidelines, which emphasize the SAFE strategy for trachoma, mass drug administration for onchocerciasis, and early cataract surgery, provide a framework for effective eye care.
Capacity building through training healthcare workers, improving access to affordable treatments, and implementing prevention programs are essential steps toward addressing the eye health challenges in sub-Saharan Africa. With a strong focus on early detection, community-based interventions, and affordable, scalable solutions, many of the region’s most common causes of blindness and visual impairment can be reduced or eliminated. Collaboration between local health systems, governments, and international partners is critical to ensuring that ophthalmic care reaches underserved populations, particularly in rural areas. Adopting WHO guidelines and adhering to best practices will help in creating sustainable eye care programs that improve visual outcomes and reduce the burden of blindness across sub-Saharan Africa.
Further readings
- Zhang JH, Ramke J, Lee CN, Gordon I, Safi S, Lingham G, Evans JR, Keel S. A Systematic Review of Clinical Practice Guidelines for Cataract: Evidence to Support the Development of the WHO Package of Eye Care Interventions. Vision (Basel). 2022 Jun 20;6(2):36. doi: 10.3390/vision6020036. PMID: 35737423; PMCID: PMC9227019.
- World Health Organization. WHO launches new guide on integrating eye care in health systems. 24th May 2022. WHO launches new guide on integrating eye care in health systems Accessed 13th September 2024
- Glaucoma: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2022 Jan 26. (NICE Guideline, No. 81.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK579558/
- World Health Organization. Eye care, vision impairment and blindness: Refractive errors 21 August 2024 Eye care, vision impairment and blindness: Refractive errors (who.int) Accessed 13th September 2024
- Evans JR, Lawrenson JG, Ramke J, Virgili G, Gordon I, Lingham G, Yasmin S, Keel S. Identification and critical appraisal of evidence for interventions for refractive error to support the development of the WHO package of eye care interventions: a systematic review of clinical practice guidelines. Ophthalmic Physiol Opt. 2022 May;42(3):526-533. doi: 10.1111/opo.12963. Epub 2022 Feb 21. PMID: 35191063; PMCID: PMC9306966.
- Vinekar A, Azad R, Dogra MR, Jalali S, Bhende P, Chandra P, Venkatapathy N, Kulkarni S. Preferred practice guidelines for retinopathy of prematurity screening during the COVID-19 pandemic. World J Clin Pediatr. 2022 May 9;11(3):215-220. doi: 10.5409/wjcp.v11.i3.215. PMID: 35663008; PMCID: PMC9134152.
- Cupp E, Sauerbrey M, Cama V, Eberhard M, Lammie PJ, Unnasch TR. Elimination of onchocerciasis in Africa by 2025: the need for a broad perspective. Infectious Diseases of Poverty. 2019 Dec;8:1-5.
- Lakwo T, Oguttu D, Ukety T, Post R, Bakajika D. Onchocerciasis elimination: progress and challenges. Research and Reports in Tropical Medicine. 2020 Oct 7:81-95.
- World Health Organization. Blindness and vision impairment. 10th August 2023. Blindness and vision impairment (who.int) Accessed 13th September 2024
- World Health Organization. Postoperative Care. INTENSIVE CARE UNIT (who.int) Accessed 13th September 2024
