|Year : 2019 | Volume
| Issue : 1 | Page : 29-32
Incidence and Pattern of Ophthalmic Emergencies in Onitsha Nigeria
Sebastian N N Nwosu, Chinasa A Nnubia, Cyriacus U Akudinobi, Nonso E Okpala, Akunne I Apakama
Guinness Eye Center, Onitsha, Nigeria
|Date of Web Publication||4-Jul-2019|
Prof. Sebastian N N Nwosu
Guinness Eye Center, PMB 1534, Onitsha
Source of Support: None, Conflict of Interest: None
Objectives: This study aims to determine the incidence and pattern of ophthalmic emergencies at the Guinness Eye Center, Onitsha, Nigeria. Materials and Methods: Cases seen as emergency at the Guinness Eye Center Onitsha over a 6-month period were reviewed. Information obtained included age, sex, disease duration, presenting features, and posttreatment visual acuity. Results: Of 4118 new patients, 144 (3.5%) presented as emergency. There were 103 (71.5%) males and 41 (28.5%) females. The age range was 6 months to 85 years, and median was 26 years. The causes were trauma, 93 (64.6%), infections, 32 (22.2%), nontraumatic uveitis, 14 (9.7%), and anatomical peculiarities, 5 (3.5%). The major clinical diagnoses were uveitis, 45 (31.3%), open globe injury, 19 (13.2%), corneal ulcer, 18 (12.5%), ocular and adnexal burns, 11 (7.6%), traumatic hyphema, 9 (6.3%), and lid laceration, 8 (5.6%). Disease duration prior to presentation ranged from 1 h to 6 weeks with a median of 10 days. Eighty nine (61.8%) required immediate surgical intervention. At presentation, 90 (62.5%) were blind in the affected eye(s), and this reduced to 40 (27.8%) posttreatment. Conclusions: Ocular injuries and infections are the commonest ophthalmic emergencies in our hospital. Ophthalmic emergencies are associated with great ocular morbidity even after treatment. Preventive measures and early presentation are advocated, too.
Keywords: Emergency, eye diseases, incidence, pattern, visual impairment
|How to cite this article:|
Nwosu SN, Nnubia CA, Akudinobi CU, Okpala NE, Apakama AI. Incidence and Pattern of Ophthalmic Emergencies in Onitsha Nigeria. Niger J Ophthalmol 2019;27:29-32
| Introduction|| |
Emergencies in medical practice are afflictions in which a delay will lead to irreversible organ damage or death of the patient. Disorders in different organs and systems in the body, including the eye, can present as emergency requiring immediate attention in order to salvage life. Early attention to ophthalmic emergencies is critical. For instance, a 30-min delay in attending to true ophthalmic emergencies such as chemical burns or central retinal artery occlusion (CRAO) will lead permanent visual loss or deformity.
Ocular emergencies have different causes, including infections, traumatic, and nontraumatic afflictions. There are few specific studies on ocular emergencies in Nigeria. Nonetheless, there are many studies on causes of ocular morbidity in Nigeria; in the ensuing discourse, the contributions of ocular emergencies are highlighted.,,,,,, In one of the specific studies of ophthalmic emergencies, Dawodu et al. in Benin City documented that ocular trauma was the most common emergency, accounting for over half of the cases.
The Guinness Eye Center Onitsha is the ophthalmic wing of the Nnamdi Azikiwe University Teaching Hospital, Nnewi. It is the only publicly owned eye hospital in Anambra State. Although private eye clinics exist as well as some government hospitals have eye units or departments, the Guinness Eye Center has the highest concentration of facilities and manpower and receives referral from these small eye-care facilities. It attends to patients from all over Nigeria and beyond, although most of the patients come from Anambra State and its environs. The aim of the present study is to determine the incidence and pattern of ophthalmic emergencies at the Guinness Eye Center Onitsha over a 6-month period.
| Materials and Methods|| |
Records of all emergency cases seen at the Guinness Eye Center Onitsha between 1 February and 31 July 2016 were examined. For this study, ophthalmic emergency was defined as clinical conditions in which a delay in management may lead to irreversible damage. It includes all patients presenting with the red eye, blunt or penetrating eye injury, chemical eye injury, acute primary angle closure, retinal artery occlusion, intraocular inflammation, infections such as corneal ulcer, endophthalmitis, panophthalmitis, infective conjunctivitis, etc. Information obtained included sociodemographic variables, disease duration, clinical diagnosis, as well as pretreatment and posttreatment visual acuity. The protocol for this study was approved by the Guinness Eye Center Onitsha and, adhering to its ethical directive, the confidentiality of the information obtained from the patients’ case notes was strictly maintained.
| Results|| |
A total of 144 out of 4118 (3.5%) new patients seen in the hospital during the study period were emergencies. There were 103 male and 41 female patients (M:F = 2.5:1). The age range was 6 months to 85 years, and median was 26 years. The modal age was 22 years. The age and sex distribution of the patients are shown in [Table 1]. The disease duration before presentation ranged from 1 day to 6 weeks; median was 10 days and mode was 8 days. Patients with chemical burns tended to present earlier; median was 2 days and range was 1–7 days. The patient with CRAO presented 10 days after a sudden visual loss, redness, and headache. This was the first time CRAO presented as emergency in our hospital. Patients with acute angle closure presented 12 days to 6 weeks after onset of symptoms.
The patients’ clinical diagnosis is shown in [Table 2]. Trauma (including blunt, penetrating, and chemical ocular and adnexal injuries) was the most common reason for presenting in the emergency room, accounting for 93 (64.6%) cases. Of the 45 cases of uveitis, 31 (68.9%) were due to trauma. Open globe injuries accounted for 19 (13.2%) of the cases; this was closely followed by infective corneal ulcers in 18 (12.5%) patients. Of the cases of acute angle closure, one was secondary to lens subluxation and the other was secondary to rubeosis; none had permanent angle synechiae. Etiologically, the ophthalmic emergencies in this study were due to eye injuries, 93 (64.6%), eye and adnexal infections, 32 (22.2%), nontraumatic (endogenous) uveitis, 14 (9.7%), and peculiar anatomical configuration (causing primary angle closure), 5 (3.5%). Although 10 (6.9%) patients had presenting acuity ≥6/18, the number rose to 18 (12.5%) posttreatment; similarly at presentation, 44 (30.6%) had acuity <6/18–3/60, which rose to 86 (59.7%) posttreatment. Finally 90 (62.5%) patients were blind at presentation which reduced to 40 (27.8%) posttreatment.
Immediate surgical intervention was required in two-third of the patients. These included paracentesis, repair of lacerations, intravitreal antibiotics injections, and foreign body removal.
| Discussion|| |
The intention was to collect information on ocular emergencies in our hospital over a longer period. However, this was not possible because of the frequent industrial action by health workers that truncate the continuity of clinical services. This study therefore reviewed emergency ophthalmic cases seen in our hospital over a 6-month period of continuous, uninterrupted clinical services.
The preponderance of males and young people (median age 26 years) may be due to the fact that over nearly two-third of the emergencies were due to trauma. Previous studies have shown that males more than females engaged in risky jobs, sports, and other ventures that put them at risk for injuries.,
Ophthalmology emergencies are traditionally classified into true emergencies, urgent situations, and semi-urgent situations. All the cases herein reviewed fall into true emergencies and urgent situations. At an incidence of 3.5%, ophthalmic emergencies apparently constitute a small part of new patients at the Guinness Eye Center Onitsha. However, the associated ocular morbidity is much: 93.1% do not have useful vision (with 62.5% blind) at presentation.
The visual outcome, though better after intervention, could still be improved upon. With the median presentation time to our hospital of 10 days, it is clear that most patients actually present to the hospital late. Late presentation does not help matters when nearly half of the patients came with open globe injuries, deep infections, vascular accidents, and acute angle closure. In Benin City, Dawodu et al. noted that late presentation greatly accounted for poor visual outcome.
Eye injury accounted for 64.6% of cases in the present study. This is comparable to 55.5% reported in Benin City. It is also a common reason for surgical removal of the eye. Eye injury could be due to accidents or violence. However, the retrospective nature of this study could not allow for the determination of the agents of injury and activities leading to injuries. But a previous study in our hospital found accidental self-inflicted injuries and domestic violence as major causes.
Ocular and adnexal infections constituted the second most common cases presenting as emergency with corneal ulcers accounting for more than half of the infections [[Table 2]]. The ulcers were secondary to injuries in the farm, use of traditional eye medicines, and abuse of steroids. The problems of managing agriculture-related eye injuries as well as making definite etiological diagnosis due to weak laboratory support in our environment had been highlighted in the previous studies. Although some of the infections such as corneal ulcer threaten sight, others such as orbital cellulitis threaten both sight and life. However, late presentation to hospital and self-medication worsen the prognosis of such superficial eye infections as infective conjunctivitis. Poorly managed ocular infections had been documented as a common reason for surgical removal of the eyeball in our hospital.
True emergencies (chemical burns, central artery occlusion, and acute angle closure) constituted 11% of the cases. CRAO is presumed to be rare, even nonexistent, in our environment. A previous case of cilioretinal artery occlusion in our hospital was seen in a Caucasian. However, the recording of this case, albeit with late presentation, suggests that there may be more cases within the community. With increasing incidence of cardiovascular and metabolic diseases in our people, retinal arterial vascular accidents will expectedly increase. A high index of suspicion is thus required.Primary angle closure and angle closure glaucoma were thought to be very rare in Nigeria., This is perhaps because most glaucoma patients do not present with the dramatic symptoms and signs of primary angle closure. However, some studies in Nigeria incorporating gonioscopy show the contrary., The present study recorded cases of both primary and secondary angle closure. Primary angle closure could be aborted and vision preserved before it leads to primary angle closure glaucoma. But this is only feasible if the patient is seen before irreversible damage had taken place.
In conclusion, the limitations of this study should be acknowledged. Being a retrospective study, certain information such as agents of eye injury, activity leading to injury, factors predisposing to ocular infections, and health-seeking behavior, which were not documented in the case files, were not fully captured in this review. A prospective study will address these issues. Nevertheless, the study shows that eye injuries and eye infections constitute 86.8% of ophthalmic emergencies in the present study [[Table 2]]. Some traumatic cases involved laceration or rupture of the eyeball. The nontraumatic causes included deep ocular and adnexal infections that endanger both sight and life. Vision can be restored in the patients with early intervention. But most of our patients presented late. It is conceivable that more improved visual outcome would have been recorded if patients presented early and more modern microsurgical facilities (e.g., vitrectomy) were available. Therefore, preventive measures, early presentation to hospital, and provision of modern microsurgical equipment are advocated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]