Objective To determine the common indications for, and outcomes of pars plana vitrectomy surgery among black Africans in a low-resource setting.
Methods and Analysis A retrospective, non-comparative case review was undertaken. Data from 1000 consecutive eyes of 1000 patients in a single centre who underwent pars plana vitrectomy surgery between May 2005 and July 2013 were used for the study. Demographic data, primary indication for surgery, ocular status and outcomes were assessed.
Results Rhegmatogenous retinal detachment was the most common primary indication occurring in 61.8% of eyes. Diabetic vitrectomy, trauma and proliferative sickle cell retinopathy were also common indications occurring in 10.1%, 6.1% and 4.5% of eyes, respectively. At presentation, 33% of patients with retinal detachment had some form of proliferative vitreoretinopathy, and half of those had the more advanced grades C and D. Patients presented on an average of 13.5 months after onset of symptoms. As a result, visual outcomes were less than other reported studies.
Conclusion Retinal detachment was the most common indication for vitrectomy, but even these cases presented late with an advanced presentation. This study highlights the need for affordable and accessible vitreoretinal services in Sub-Saharan Africa and increased awareness of general eye health, along with strategies to reduce trauma and identify early those at risk of chronic eye diseases, such as diabetic retinopathy and sickle cell retinopathy.
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What is already known about this subject?
There is limited information and publication on vitreoretinal surgical services in black Sub-Saharan Africa.
Few vitreoretinal units exist in the region and several countries have no vitreoretinal service present.
While blindness prevalence studies in the region focus on the more treatable causes of vision impairment such as cataract, the need for vitreoretinal surgeons and role of vitreoretinal services is under-recognised.
What are the new findings?
This study establishes that rhegmatogenous retinal detachment and proliferative diabetic retinopathy are a significant problem requiring vitreoretinal intervention.
Proliferative vitreoretinopathy rates reported in this study are more than is reported in wealthier nations and reflect delayed presentation, contributing to poorer outcomes after vitrectomy.
Also, diabetic vitrectomy features as an important indication in the region, while macular hole (which is a priority in the more advanced nations) is a less common indication.
How might these results change the focus of research or clinical practice?
The focus following this study should be on changing the behaviour of patients and physicians in the region through education, and also promoting earlier presentation and management of retinal detachment cases.
We make a case for a more aggressive approach in preventing retinal detachment, by promoting retinal prophylaxis, for example, use of laser photocoagulation or cryotherapy to treat predisposing retinal lesions and retinal tears.
Healthcare systems in the region should focus on establishing and promoting viable diabetic retinopathy screening programmes and timely retinal laser intervention, which may ultimately reduce the need for diabetic vitrectomy.
Vitrectomy as a surgical procedure was first performed in a human eye in 1970, but since then has become very useful in combination with other procedures to treat many vitreoretinal (VR) conditions, restoring sight and preventing blinding complications in many eyes.1 Refinements in technique and instrumentation have also led to confidence in earlier intervention and increasing numbers being performed worldwide.2–4 However, the cost of viewing systems, instruments, consumables and maintenance required for vitrectomy is much higher than for other ophthalmic interventions. As a result, in Africa, there are very few ophthalmology centres providing comprehensive VR service, limiting access for patients who need the service and local training opportunities in this subspecialty. Subsequently data on indications, presentation and outcomes of vitrectomy in this population are few and far between. A key paper, in 2002, reviewing retinal detachment outcomes in East Africa by Yorston et al,5 highlighted the late presentation of patients in Africa and advocated the need for more VR services. However there have been few papers since that time. One of such studies is the paper from Ethiopia, which describes the clinical presentation of retinal detachment.6
This study aims to capture the experience of a single-centre VR team who together have performed over 1000 vitrectomies between 2005 and 2013 as a starting point for identifying further priorities for research, training and developments in this subspecialty.
A retrospective, non-comparative consecutive case series was performed involving a thousand consecutive eyes that underwent a vitrectomy surgery from May 2005 to July 2013 at the Eye Foundation Retina Institute, Lagos, Nigeria. The Eye Foundation Retina Institute is a department of the Eye Foundation Hospital, which is an indigenous private training institution that comprises multispecialty eye clinics and surgeries. The Eye Foundation Retina Institute receives VR referrals from other eye centres within the state of Lagos and the country. There are a total of five VR centres in Lagos, serving an approximate population of 20 million. The majority of the patients pay privately for their eye care, while others may be sponsored, use health insurance or request for low-cost services.
The case records of the study patients were identified from the operating room log, and information from the case records was extracted. When a case record was not available or was missing, the next in the series was selected. All non-blacks were excluded. The primary information extracted was indication for surgery, outcomes and complications. In a situation where more than one indication for vitrectomy surgery was noted, the most significant indication was chosen as the primary indication.
Other information extracted included the patient’s gender, laterality, visual acuity of the index eye and the fellow eye, symptom duration before presentation, duration of follow-up and number of revitrectomies. When retinal detachment was the primary indication, additional information including the presence of any proliferative vitreoretinopathy (PVR) and also of advanced PVR that is grade C or D and giant retinal tear (GRT) was noted. PVR grade C in this study was defined as the presence of fixed retinal folds, and grade D the presence of a funnel-shaped total retinal detachment. Also, intraoperative combination with cataract extraction, scleral buckle and use of endotamponade was also noted. Retina laser photocoagulation was the method of retinopexy in all cases. Cryotherapy was not used.
All surgeries were performed using the Accurus vitrectomy system (Alcon), and mostly 20G surgery was performed by the same VR team consisting of one senior consultant and two junior consultants. Over the study period, there were significant upgrades in technique and instrumentation (such as the change to transconjunctival surgery, the use of smaller gauge cutters and more recent wider angle viewing systems). Silicone oil was most commonly used as it was more available than expansile gases during the study period.
Of the 1000 eyes that had vitrectomy, 18 case records were missing, but were replaced with the next in line in the series. The overall age of patients seen ranged from 1 to 85 years (the average age was 47 years, with 709 males and 291 females (ratio 2.4:1)).
Of the one thousand vitrectomy surgeries performed within the study period, the top three indications for surgery were rhegmatogenous retinal detachment (62%), followed by diabetic retinopathy (DR) (10%) and trauma (6%), and this is illustrated in table 1. Vitreous haemorrhage (VH) secondary to sickle cell proliferative retinopathy and branch vein occlusions were the next most common indication for vitrectomy (5% and 3%, respectively). Endophthalmitis, vitritis, haemorrhagic posterior vitreous detachment, macular hole, dislocated lens, trauma and cataract-related vitrectomy were less common indications, each accounting for about 1% of patients. Rare indications, occurring in less than 1% of cases, included macular degeneration, polypoidal choroidal vasculopathy, asteroid hyalosis, dropped nucleus, vitreous opacities and VR fibrosis. Details of indications and number of eyes are shown in table 1.