Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 22-27

Glaucoma follow-up care in the face of COVID-19 pandemic in Enugu, Nigeria


1 Department of Ophthalmology, College of Medicine, Enugu State University of Science and Technology, Enugu; Department of Ophthalmology, Enugu State University Teaching Hospital Parklane, Enugu, Nigeria
2 Department of Ophthalmology, College of Medicine, University of Nigeria, Enugu; Department of Ophthalmology, University of Teaching Hospital, Enugu, Nigeria
3 Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State, Nigeria
4 Department of Ophthalmology, Federal Teaching Hospital, PMB 2, Abakaliki, Ebonyi State, Nigeria
5 Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State; College of Medicine, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria

Date of Submission12-Aug-2020
Date of Decision03-Dec-2020
Date of Acceptance03-Feb-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Nkiru Kizor-Akaraiwe
Department of Ophthalmology, College of Medicine, Enugu State University of Science and Technology, Enugu, Nigeria; Department of Ophthalmology, Enugu State University Teaching Hospital Parklane, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_30_20

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  Abstract 


Purpose: This study sought to find out the effect of the COVID-19 partial lockdown on adherence to glaucoma follow-up appointments and associated factors in a multispecialist eye care facility in Enugu, Nigeria. Methods: A retrospective cross-sectional survey of glaucoma patients who were booked for follow-up appointment and those who attended follow-up clinic at The Eye Specialists Hospital (TESH), Enugu, Nigeria before and during the COVID-19 lockdown. The hospital records of glaucoma appointments and visits in April 2019 and April 2020, corresponding to “before” and “during” COVID-19 lockdown, respectively, were used to collect information on visits to glaucoma clinic (with/without appointments). The primary outcome measure of this study was difference in adherence to follow-up appointments while the secondary outcome measure was the total glaucoma visits before and during the pandemic lockdown. Data entry and analysis was done using SPSS version 22. Results: Follow-up rate was not significantly different before (34.6%) and during (35.7%) the COVID-19 lockdown (P = 0.85). A total of 156 and 121 glaucoma visits were recorded before and during COVID-19 lockdown, respectively (P = 0.049). Patients within age group 60 to 80 years, males and persons with advanced glaucoma visited clinic more before and during the COVID-19 lockdown. Severity of glaucoma was significantly associated with more visits during the COVID-19 lockdown (P = 0.023). Conclusion: In TESH, Enugu, Nigeria, the COVID-19 partial lockdown affected total number of glaucoma visits but not adherence to follow-up appointments. Understanding the need for glaucoma follow-up checks and fear of blindness likely helps adherence to appointments.

Keywords: Adherence, appointments, COVID-19, follow-up care, glaucoma


How to cite this article:
Kizor-Akaraiwe N, Uche N, Shiweobi J, Ezeanosike E, Ezisi C. Glaucoma follow-up care in the face of COVID-19 pandemic in Enugu, Nigeria. Niger J Ophthalmol 2021;29:22-7

How to cite this URL:
Kizor-Akaraiwe N, Uche N, Shiweobi J, Ezeanosike E, Ezisi C. Glaucoma follow-up care in the face of COVID-19 pandemic in Enugu, Nigeria. Niger J Ophthalmol [serial online] 2021 [cited 2021 Nov 30];29:22-7. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2021/29/1/22/321643




  Introduction Top


The COVID-19 pandemic has caused ravaging impact around the world.[1],[2] In Nigeria, it gained relevance in public health from February 2020 when the country recorded her first case.[3] The World Health Organization in January 2020, listed Nigeria and other 13 African countries as high-risk countries for the spread of coronavirus which is responsible for the COVID-19 pandemic. Due to its rapid spread especially in the most populous city “Lagos” and the capital city Abuja, the government declared a complete lockdown of routine activities in such cities, while other less affected cities like Enugu, had partial lockdown with effect from April 1, 2020. There was also interstate restriction of movements. However, all these excluded essential services such as healthcare, electricity, food, etc. Eye hospitals, being a part of health care system were open to provide services especially emergencies, while observing safety practice guidelines such as temperature monitoring, social distancing, use of facemasks, and frequent hand washing to prevent further spread. Among the reasons, health care services were made available in places with partial lockdown, was to enable persons with lifelong medical conditions, such as glaucoma, diabetes mellitus, etc., have access to their periodic medical check.

Glaucoma, a group of optic neuropathies, is the leading cause of irreversible blindness worldwide.[4],[5],[6] With no clearly defined cause and cure, it has been found to be associated with several risk factors including being black, older age, raised intraocular pressure (IOP), positive family history among others.[7],[8] Glaucoma is asymptomatic in its early stages, causing more than 50% of patients to present in the advanced stage.[9],[10],[11] The last Nigerian National Blindness and Low Vision survey found glaucoma as the second leading cause of blindness with prevalence of 16.7%. The South-East geopolitical zone was found to have the highest prevalence in the country and Igbo ethnicity being a risk factor.[12],[13] Management of glaucoma is done with medications, laser, surgery, or a combination,[14],[15] and is aimed at reducing and maintaining the IOP at a set target IOP. This is expected to halt the disease progression.[8],[16],[17]

Glaucoma management is lifelong hence follow-up is an integral part of patient care.[8] Adherence to follow-up appointment is therefore very important to ensure that IOPs are within safe limits. During such visits examinations, tests, and procedures aimed at identifying or preventing further glaucomatous damage are carried out, medications are also replenished.[18],[19] Usually patients are given 1 to 4 months intervals for follow-up appointments depending on IOP control and stability of visual fields.[20],[21] Quite often glaucoma patients not on appointment come to the clinic when they observe adverse reactions to their medications or have missed an earlier appointment.

There is currently no cure to coronavirus pandemic and infection rate is very high causing a lot of fear of transmission. Furthermore, though it affects all age groups, the older age group who are said to be at greater risk of the COVID-19 infection, are also more affected by glaucoma.[22],[23] On the other hand, keeping glaucoma follow-up appointment is crucial to prevent blindness. Glaucoma patients on appointment during the COVID-19 lockdown faced the challenge of choosing between staying safe at home to avoid infection and deferring their glaucoma follow-up appointments which may be a threat to sight. With the usual and additional challenges of distance, cost, movement restrictions, and other issues which accompanied the COVID-19 pandemic, glaucoma follow-up care was expected to be affected negatively. This study, however, sought to find out the effect of the COVID-19 lockdown on adherence to glaucoma follow-up appointments in a multispecialist eye care facility in Enugu, Nigeria.


  Methods Top


Study design

This was a retrospective cross-sectional study.

Study area

Enugu is the capital of Enugu State in Nigeria. It is a city located in southeastern Nigeria with a population of 722,664 according to the 2006 Nigerian census.[24] The state is predominantly inhabited by persons of the Igbo ethnic group. The Eye Specialists Hospital (TESH) is a multispecialty eye care facility that provides eye care services to over 4 million residents in Enugu State, its environs and the surrounding states. The hospital provides diverse eye care services with about 10,000 visits yearly. In TESH, there are three glaucoma specialists apart from eight other ophthalmologists who also manage glaucoma patients. The hospital also provides glaucoma counseling services to all glaucoma patients routinely.

Sample size and sampling technique

The sample size consisted of all previously diagnosed glaucoma patients who were booked for follow-up appointment and those who attended follow-up clinic in April 2020 at TESH, Enugu, Nigeria. The peak of the COVID-19 lockdown in Nigeria was in April 2020. The findings were compared with the figures of April 2019, a similar month before the COVID-19 pandemic, though TESH was partly shut down for a week in April 2020.

Study instrument

The hospital records of glaucoma appointments and visits in April 2019 and April 2020 were used to collect information on patients who were given appointments and those who kept to their appointments. Patients’ hospital folders were retrieved to enter information on Excel sheet on demographics and glaucoma severity.

Study terms

Follow-up visit was defined as keeping an appointment as requested by the doctor while checkup visit was defined as visits to glaucoma clinic not on appointment. Total glaucoma visits were regarded as all visits of glaucoma patients to see their doctor whether on appointment or not. Month in view before COVID-19 was April 2019 while the month in view during COVID-19 was April 2020. The primary outcome measure of this study was difference in glaucoma follow-up visits before and during the pandemic lockdown.

The study abided by the guidelines of the Declaration of Helsinki for a study.

Data were entered into the SPSS version 22 (IBM SPSS Statiatics version 22 - Property of IBM Corp Copyright IBM Corporation and others 2013) and analyzed. Results were presented in tables showing frequencies and percentages. The association between sociodemographic characteristics and other variables were assessed using chi-square test, likewise association between severity of disease and keeping appointments. P-value ≤ 0.05 was considered significant.


  Results Top


A total of 156 and 121 glaucoma visits were recorded before and during COVID-19 lockdown, respectively. Sociodemographics of patients are shown in [Table 1]. Patients within age group 60 to 80 years and male patients visited glaucoma clinic more before and during the COVID-19 lockdown. There was no significant difference in the sociodemographics of patients who attended glaucoma clinic during the periods except for clinical features. There was a significant association between severity of the disease and total glaucoma visits during the COVID-19 lockdown, as patients with advanced glaucoma visited the clinic more during the pandemic [Table 1].
Table 1 Sociodemographic and clinical characteristics of total glaucoma patients’ visits

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A total of 156 and 157 glaucoma patients were given appointment before and during COVID-19, respectively. Among these, 54 (34.6%) kept their appointments before COVID-19 while 56 (35.7%) kept their appointments during the COVID-19 lockdown.

There was no significant difference in keeping appointments before and during the COVID-19 pandemic (P = 0.845) [Table 2] and also no significant difference in sociodemographics of patients who kept their appointments and those who defaulted [Table 3].
Table 2 Appointments before and during COVID-19 lockdown

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Table 3 Sociodemographic comparison of patients who failed and who kept their follow-up appointments during COVID-19 lockdown

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Despite similarity in follow-up rates before and during COVID-19, the total glaucoma visits decreased significantly during COVID-19 lockdown (P = 0.049). In April 2019, 102 (65.4%) glaucoma patients of 156 total glaucoma visits were on checkup visit while in April 2020, 65 (53.7%) of 121 total glaucoma visits were on checkup visit [Table 4].
Table 4 Total glaucoma visits before and during COVID-19 lockdown

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  Discussion Top


This retrospective cross-sectional study of glaucoma follow-up visit among previously diagnosed patients revealed no significant difference in rate of adherence to glaucoma follow-up appointments in the eye care facility before (34.6%) and during (35.7%) the COVID-19 lockdown. In the study center, glaucoma patient education and counseling had increased in regularity over the preceding 2 years; therefore, adherence to follow-up was expected to be higher. However, the low rate of adherence observed might be due to highly restricted interstate movements, increased consultation fees, and increased transportation prices that were prevalent at the time. On the other hand, the education and counseling system may not have affected follow-up adherence since total glaucoma visits decreased significantly. There is the need to continue encouraging better adherence among glaucoma patients as well as devise new methods, approaches, and technologies to bridge this gap. Nonavailability of funds, accessibility to eye care facilities, lack of awareness of diagnosis, and suboptimal knowledge of glaucoma’s natural history have been found as influencing factors on follow-up adherence.[25],[26] In Enugu, the lockdown was partial which could have played a role in the unchanged follow-up rate among glaucoma patients. Partial lockdown affords people in the city some level of freedom to access essential care. If lockdown was total, follow-up rate may have been affected significantly since inter- and intrastate movements will be highly restricted [Figure 1].
Figure 1 Glaucoma appointments and visits before and during the COVID-19 lockdown

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There was a significant decrease in total glaucoma visits during the COVID-19 lockdown (P = 0.049). The difference in total glaucoma visits was among checkup visits (glaucoma visits not on appointment). This may be so due to the fact that those not on appointments may have needed serious reasons to defy the fear of infection by COVID-19. Usually patients in this category are those who had missed their appointments, those who were uncomfortable with their medications, or those with other ocular complaints. The overall decrease in total glaucoma visits may be more of those who stay in other states, especially as interstate movements were highly restricted apart from other reasons affecting adherence.

Before the COVID-19 lockdown, more persons who visited glaucoma clinic were persons with mild to moderate field damage while during the COVID-19 pandemic, the proportion of persons with advanced disease increased significantly (P = 0.023) [Table 1]. Adherence to glaucoma follow-up appointment has been found to be associated with glaucoma severity by some authors.[27],[28] About 50% of persons who present with advanced disease have severe visual impairments or are already blind in one eye.[11],[29] A greater percentage of those who had advanced disease in this study kept their appointments [Table 3]. It is likely that fear of losing vision in the better eye or going blind completely might account for the increased adherence to follow-up appointments. On the other hand, patients with mild to moderate disease would likely fear exposure to COVID-19 infection more than fear of blindness, since blindness is not an immediate threat for their stage of disease. A study among Indian glaucoma patients showed that patients believe that follow-up is less important if one uses glaucoma medications and has no noticeable visual changes.[26] Ophthalmologists are also more likely to give shorter appointments to persons with advanced glaucoma as well as ensuring they understand the need for follow-up appointments. However, Ung et al. found reduced adherence rate among patients with severe disease.[27] Poor vision or lack of improvement in vision in persons with severe disease may be demotivators for keeping their appointments.

In Nigeria, known risk factors for glaucoma among others are older age, male gender, and Igbo ethnicity.[30],[31] In this study, males and those within the age group 60 to <80 years generally attended glaucoma clinics most, both before and during the COVID-19 lockdown [Table 1] and [Table 3]. Similarly, in the Wills’ glaucoma clinic, Philadelphia, patients between 50 and 80 years of age were more adherent to follow-up appointments.[32] This is unexpected as this age group is more at risk of the COVID-19 infection and was expected to have a decrease in clinic attendance.

From the findings of this study, the COVID-19 pandemic did not reduce adherence to follow-up appointments but revealed the continued low rate of adherence in the system. There is the need to step up counseling/education on glaucoma follow-up among patients. Even though glaucoma follow-up cost is high, cost of blindness is higher. Patients should be made aware that despite usage of medications, follow-up care is to ensure IOPs are controlled and visual field damage does not progress. Home-based devices may help patients check their progress and get reminders on their routine checks.

Limitation

The reasons for defaulting in follow-up were not evaluated to ascertain the reasons for default.


  Conclusions Top


In TESH, Enugu, Nigeria, there was no significant difference in adherence to follow-up appointments before and during the COVID-19 lockdown though total glaucoma visits were reduced. Older patients with advanced disease were more likely to adhere to their appointments.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors report no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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