|
 
 |
| 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
Nkiru Kizor-Akaraiwe MBBS, FWACS, FICS 1, Nkechi Uche2, Jude Shiweobi3, Edak Ezeanosike4, Chinyelu Ezisi5
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 Submission | 12-Aug-2020 |
| Date of Decision | 03-Dec-2020 |
| Date of Acceptance | 03-Feb-2021 |
| Date of Web Publication | 16-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
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njo.njo_30_20
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 |
| Introduction | |  |
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 | | |
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 | | |
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
Click here to view |
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 3 Sociodemographic comparison of patients who failed and who kept their follow-up appointments during COVID-19 lockdown
Click here to view |
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].
| Discussion | | |
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
Click here to view |
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 | | |
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.
| References | | |
| 1. | Li LQ, Huang T, Wang YQ et al. COVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol 2020;92:577-83.  |
| 2. | Singhal T. A review of coronavirus disease-2019 (COVID-19). Indian J Pediatr 2020;87:281-6. |
| 3. | |
| 4. | Tham 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;121:2081-90. |
| 5. | Kyari F, Abdull MM, Bastawrous A, Gilbert CE, Faal H. Epidemiology of glaucoma in sub-Saharan Africa: prevalence, incidence and risk factors. Middle East Afr J Ophthalmol 2013;20:111-25. [ PUBMED] [Full text] |
| 6. | Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90:262-7. |
| 7. | McMonnies CW. Glaucoma history and risk factors. J Optom 2017;10:71-8. |
| 8. | Goldberg I. Asia Pacific Glaucoma Guidelines. 2nd ed. Catonsville, USA: Scientific Communications International; 2005. |
| 9. | Verrey JD, Foster A, Wormald R, Akuamoa C. Chronic glaucoma in Northern Ghana: a retrospective study of 397 patients. Eye 1990;4:115-20. |
| 10. | Adekoya BJ, Shah SP, Onakoya AO, Ayanniyi AA. Glaucoma in southwest Nigeria: clinical presentation, family history and perceptions. Int Ophthalmol 2014;34:1027-36. |
| 11. | Racette L, Wilson R, Zangwill L, Weinreb R, Sample P. Primary open-angle glaucoma in blacks: a review. Surv Ophthalmol 2003;48:295-313. |
| 12. | Kyari F, Gudlavalleti MVS, Sivsubramaniam S et al. Prevalence of blindness and visual impairment in Nigeria: the National Blindness and Visual Impairment survey. Invest Ophthalmol Vis Sci 2009;50:2033-9. |
| 13. | Kyari F, Entekume G, Rabiu M et al. A population-based survey of the prevalence and types of glaucoma in Nigeria: results from the Nigeria National Blindness and Visual Impairment survey. BMC Ophthalmol 2015;15:176. |
| 14. | Dufrane R, Ehongo A. Treatment of glaucoma. Rev Med Brux 2014;35:291-7. |
| 15. | Lichter PR, Musch DC, Gillespie BW et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology 2001;108:1943-53. |
| 16. | European Glaucoma Society. Terminolology and Guidelines for Glaucoma. 4th ed. Italy: PubliComm; 2014. |
| 17. | Gupta D, Chen PP. Glaucoma. Am Fam Physician 2016;93:668-74. |
| 18. | |
| 19. | Kaur D, Gupta A, Singh G. Perspectives on quality of life in glaucoma. J Curr Glaucoma Pract 2012;6:9-12. |
| 20. | National Institute for Health and Care Excellence [NICE]. Glaucoma: diagnosis and management. NICE Guidance. 2017. 1-41. Available from: https://www.nice.org.uk/guidance/ng81. [Accessed on 17 July 2020]. |
| 21. | |
| 22. | |
| 23. | |
| 24. | |
| 25. | Kizor-Akaraiwe NN. Follow-up and adherence to glaucoma care by newly diagnosed glaucoma patients in Enugu, Nigeria. Ophthalmic Epidemiol 2019;26:1-7. |
| 26. | Lee BW. Predictors of and barriers associated with poor follow-up in patients with glaucoma in South India. Arch Ophthalmol 2008;126:1448. |
| 27. | Ung C, Murakami Y, Zhang E, Alfaro T, Zhang M, Seider MI et al. The association between compliance with recommended follow-up and glaucomatous disease severity in a county hospital population. Am J Ophthalmol 2013;156:362-9. |
| 28. | Hark LA, Johnson DM, Berardi G et al. A randomized, controlled trial to test the effectiveness of a glaucoma patient navigator to improve appointment adherence. Patient Prefer Adherence 2016;10:1739-48. |
| 29. | Abdull MM, Gilbert CC, Evans J. Primary open angle glaucoma in northern Nigeria: stage at presentation and acceptance of treatment. BMC Ophthalmol 2015;15:111. |
| 30. | Kyari F, Abdull MM, Wormald R et al. Risk factors for open-angle glaucoma in Nigeria: results from the Nigeria National Blindness and Visual Impairment survey. BMC Ophthalmol 2016;16:78. |
| 31. | Landers J, Goldberg I, Graham SL. Analysis of risk factors that may be associated with progression from ocular hypertension to primary open angle glaucoma. Clin Exp Ophthalmol 2002;30:242-7. |
| 32. | Fudemberg SJ, Lee B, Waisbourd M et al. Factors contributing to nonadherence to follow-up appointments in a resident glaucoma clinic versus primary eye care clinic. Patient Prefer Adherence 2016;10:19-25. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for