Indications for Surgical Removal of the Eye in Rural Areas in Cameroon

Abstract

OBJECTIVE

To determine the main clinical indications for surgical removal of the eye in rural areas in Cameroon.

DESIGN

Retrospective non-comparative case series.

PARTICIPANTS

A total of 253 patients presenting to the Manna eye clinic Nkongsamba who underwent destructive eye surgery (DES) between January 2006 and December 2010 were reviewed.

MAIN OUTCOME MEASURE

Age, gender, occupation, prior medication, visual acuity, operation indications, and type of operation.

RESULTS

There were 58.10% (n = 147) men and 41.90% (n = 106) women. Median age was 29 years (interquartile range: 14–69 years); age ranged from 10 to 88 years. A total of 67.19% (n = 170) of participants were farmers and lived in rural zones. In all, 79.05% (n = 200) confessed to have trying a medication before the presentation. Surgical indications included infective causes (perforated corneal ulcer 33.20% (n = 84) and endophthalmitis 18.20% (n = 46)), trauma 17.40% (n = 44), painful blind eyes 11.50% (n = 29), malignancy 10.70% (n = 27), and others 9.10% (n = 23).

CONCLUSION

The most common causes of DES in this series could be avoided. Therefore, preventive measures including extensive health education of the public and traditional healers on the risks linked to the use of traditional medicines in ophthalmology and the late presentation of eye disease, quality control of the campaigns that offer free cataract operations in the country.

Introduction

Destructive surgery of the eyeball is a heavy, traumatic, and dramatic intervention that has a crippling effect on the psychology of the patient. Enucleation involves the surgical removal of the entire globe, including the sclera, and it is achieved by dividing the extraocular muscles and optic nerve. Evisceration refers to the removal of the intraocular contents, leaving the sclera and optic nerve intact.¹ Contrary to the objective of cataract surgery, which aims at improving vision, the main goal of destructive eye surgery (DES) is to improve the quality of life of the patient. Many eye diseases, either by their nature (malignancy) or by their gravity (infection, trauma), lead the ophthalmologists to make the ultimate decision to either totally or partially ablate the eyeball. This procedure may have a significant impact on the patient’s quality of life. In one hospital-based study conducted in Nigeria, Mpyet et al.² showed that eye trauma was the most frequent indication for DES in the urban milieu. In the United States, Yousuf et al.³ also reported ocular trauma as the first indication of the mutilation of the eyeball. The purpose of the present study was to determine the main clinical indications of DES in a rural zone in Cameroon, thereby proposing some useful preventive solutions.

Materials and Methods

In this retrospective, noncomparative, and consecutive case series, the medical records of all patients who underwent DES at the Manna Eye Clinic in Nkongsamba, Cameroon between January 2006 and December 2010 were reviewed. The local ethics committee approved the study (N. Ref: 1756/L/Udm/ISSS). Participants’ written informed consent was obtained after explaining the nature of the procedure to all patients (or their legal relatives) before surgery. Epidemiological data (age, sex, profession, residence, and previous treatment), as well as clinical data (visual acuity, slit lamp examination, and indication of surgery), were analyzed. Removal of the eyeball was performed under local anesthesia without orbital implant. Patients were assessed at one week and three weeks postoperatively; at the six-week follow-up visit, patients were evaluated for prosthesis and a prescription for protective glasses. Further follow-up visits were scheduled at two months and every four months thereafter. All patients less than 10 years old presenting with an indication for DES were sent to the general hospital, which houses a facility for general anesthesia; thus, these patients were excluded from the study. Data were analyzed using Epi Info™ 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Qualitative variables were presented in percentages (%). Quantitative variables were not normally distributed, and were thus presented as the median (interquartile range). The chi-squared test was used to compare the proportions. P-values < 0.05 were considered statistically significant.

Results

Between January 2006 and December 2010, 12,475 patients were operated on at the Manna Eye Clinic in Nkongsamba, Cameroon, among which 253 (2%) underwent eyeball destruction. There were 147 (58.10%) males and 106 (41.90%) females. The patients’ ages ranged from 10 to 88 years; their median age was 29 years (interquartile range: 14–69 years). A total of 170 patients (67.19%) were farmers.

All patients included in the study were blind in the affected eye at the time of presentation, with a visual acuity of no light perception. A total of 200 patients (79.05%) confirmed self-medicating their condition with various medicines before their medical consultation. Specifically, 146 (73%) patients reported using traditional eye medicines (TEM), whereas 54 (27%) patients used unknown medicines bought from the roadside. In 78 patients (30.83%), surgery was indicated after the failure of conservative treatment (tarsorrhaphy, retrobulbar injection of alcohol, conjunctiva flap). DES was indicated as a primary surgical intervention in 173 (69.17%) cases. Operations included evisceration (n = 181; 71.54%), enucleation (n = 69; 27.27%), and exenteration (n = 3; 1.18%). Eye prosthesis was fitted to 93 patients.

The main indications for DES are shown in Table 1. Infective causes (perforated cornea ulcer (33.2%) and endophthalmitis (18.2%)) were the most frequent indication of DES (P = 0.00). These infective causes were associated to many factors; the main factors are presented in Table 2.

Table 1.

Indications for DES.

INDICATIONS	FREQUENCY (n)	PERCENTAGE (%)
Infective
-Perforated corneal ulcer	84	33.2
-Endophthalmitis	46	18.2
Trauma	44	17.4
Painful blind eye	29	11.5
Malignancy	27	10.7
Staphyloma	23	9.1
Total	253	100

Table 2.

Factors associated with infective causes.

	PERFORATED CORNEA ULCER n (%)	ENDOPHTALMITIS n (%)
TEM	61 (72.61%)	20 (43.47%)
Unknown medicine	23 (27.38%)	10 (21.76%)
Postoperative		16 (34,78%)

Discussion

The Manna Eye Clinic in Nkongsamba is one of the largest eye centers in Cameroon, which is characterized by a highly rural patient population. The low cost and the high quality of the services offered explain its high volume of visits. In this study, DES represented 2% of all surgeries. In a retrospective study, Pandey⁴ reported an incidence of DES of 1.40%. The male preponderance reported in our study was similar to that described by other authors.^4,5 This could be related to the activities of the male gender. The young age reported in the current study is consistent with that observed in the previous literature.⁶ This age group is the most economically active and productive population. The use of TEM or drug abuse as auto-medication before their presentation at the clinic has also been reported by Nwosu⁷ in Nigeria. Sociocultural beliefs, poverty, and difficultly accessing eye care services could explain this behavior.

In our survey, as well as in some previous studies,^8,9 all patients (100%) were blind in the affected eye before surgery. The eyeball was then removed to save the other eye, save the patient’s life, or enhance the quality of life of the patient. A conservative approach must be attempted before the mutilation of the eyeball can be performed. However, in three-quarters of our patients, eye removal was indicated, as the patients presented with advanced ophthalmic disease with very poor visual prognosis.

Eye infective diseases are the predominant cause of DES in our milieu (51.20%). Several sources in Africa^10,11 have also reported infective diseases as the leading indication for eye removal. Perforated corneal ulcer (Figure 1), which is the most common infective cause, is favored by activities in the rural zones. The most common associated factors identified were sociocultural belief, mismanagement with TEM, drug abuse, and late presentation. Perforation of a corneal ulcer will inevitably lead to the loss of the visual organ in our milieu because there is no center that performs penetrating keratoplasty in Cameroon. DES appears to be a cleaning surgery aimed at enhancing the quality of life of the patient. Tahiri et al.¹² reported that perforated corneal ulcer was the fifth cause of DES in Morocco.

Figure 1.

Perforeted corneal ulcer after the use of traditional eye medicine (TME).

Endophthalmitis represents the second infective indication of eye mutilation in our study. It primarily occurred in two main contexts: either it resulted as neglected or poorly managed eye trauma by traditional practitioners or it appeared in the perioperative setting. The recrudescence of postoperative endophthalmitis in our milieu is linked to multiple campaigns for free cataract surgery organized in the country. These sporadic and massive campaigns in favor of cataract surgery present a flaw: the absence of acceptable postoperative follow-up. Patients are seen only on the first day following the surgery, as the campaign generally lasts for only a week, and all late and long-term postoperative complications are not taken into account with these nongovernmental organization campaigns. Other factors that may increase the postoperative endophthalmitis rate include eye drop administration and conservation.

Eye traumas represent the second indication for DES in our series. It is dominated by open globe injury with uveal prolapse, globe rupture, perforation, and intraocular foreign body because of farming or hunting accidents, land brawls, and diver’s aggressions. Erdurman et al.¹³ reported that 28% of patients with ocular injuries resulting from improvised explosive devices required DES as a primary surgical intervention. Several investigators^2,13 have reported eye trauma as one of the most common indication for DES in the urban milieu. The main goal of a destructive procedure is the prevention of sympathetic ophthalmia which, from a pathophysiological perspective, is believed to be an immunologic response to the exposure of previously sequestered intraocular tissue.¹⁴ Painful blind eye, despite the maximal use of an analgesic, represented the most frequently accepted causative diagnoses for DES in our series. Painful blind eye represents the second most common cause of mutilation of the eyeball in Nepal.⁹ The pain intensity pushed many patients to request mutilation of their eye, with the aim of achieving both pain control and an improvement in cosmesis. However, Agarwal and Dubey¹⁵ reported a significant regression of the iris, angle neovascularization, and pain control following intracameral Avastin^® (Genentech, Inc., San Francisco, CA, USA) in a dose of 0.25 mg/0.02 mL.

Tumors accounted for 10.70% (n = 27) of all the cases in our study, and they were mostly common in immune-compromised patients. Invasive squamous cell carcinoma and advanced periorbital malignancy were the most common tumors. Several authors who included children in their series found that retinoblastoma was the most frequent tumor leading to DES.⁵ Evisceration (Fig. 2) was performed most commonly (P = 0.033). Similar findings were also reported in other series.^3,16 Exenteration (Fig. 3) was performed in three patients presenting with invasive tumors. Removable acrylic prosthesis was fitted only to 36.75% of our patients (Fig. 4). In a rural milieu, patients are more likely to refuse eye prosthesis because of sociocultural behaviors.

Figure 2.

Eviscerated right eye six week after surgery.

Figure 3.

Partial exenteration for invasive squamous cell carcinoma by immuncompromised patient (at 6 months follow-up visit).

Figure 4.

Eviscerated right eye six week after surgery with eye prosthesis.

In summary, DES, an act of last resort, is frequently performed in our rural milieu. In fact, the members of the population see it as a failure for the ophthalmologist, who must ultimately save sight. This study demonstrated that the most common indication for removing the eye in the rural areas in Cameroon was because of infective causes, which could thus be avoided. Therefore, preventive measures must be carried out to mitigate eye morbidity. These include providing extensive health education to the public and traditional healers on the risks linked to the use of traditional medicines in ophthalmology, and to patients’ late presentation to the clinic; providing education to non-ophthalmologic health care workers at the primary care level about the management of eye problems before referring the patient to the clinic; educating practitioners regarding early presentation of eye disease; providing quality control of the surgery; and offering postoperative care as a part of the campaigns that offer free cataract operations in the country. A center for corneal graft should be created in our country.