AN AUDIT OF MINOR OPHTHALMIC SURGICAL INTERVENTIONS IN A TERTIARY EYE CARE FACILITY IN NORTHERN NIGERIA

Abstract

Background

An estimated 285 million persons are visually impaired globally, and 39 million of them are blind. Majority of the blind population reside in developing countries. Over 60% of blindness is attributable to surgical causes of blindness. A surgical audit reveals areas of performance that require improvement.

Aim:

To assess the output and pattern of minor ophthalmic surgeries over a seven year period.

Method

The minor ophthalmic surgical records of Jos University Teaching Hospital, Jos, Nigeria were retrospectively reviewed to obtain information on the patients’demographics, diagnosis, indication, type of surgery, type of anaesthesia administered, outcome of management, histology report and the rank of surgeon. The data obtained were analyzed using Epi Info Statistical version 3.4, Atlanta, Georgia USA.

Results

A total of 536 patients had minor ophthalmic operations at the Jos University Teaching Hospital between January 2008 and December 2014. There were 281(52.4%) males and 255(47.6%) females (χ²=9.4, p>0.1) with a mean age of 37.2 years (SD:24). Furthermore, 41(7.6%) patients had surgery in both eyes. The main anatomical sites of ocular morbidity were eyelid/lashes, conjunctiva and anterior segment observed in 237 (41.1%), 166(28.8%) and 94(16.3%) eyes respectively. Posterior segment lesions as indication for minor surgery was observed in 11(1.9%) eyes in the year 2013 and increased to 38(6.6%) eyes in 2014. Most (75%) minor surgical procedures were performed by resident doctors under supervision (χ²=13.7, p<0.05). A total of 584 procedures were performed comprising over 33 different types of minor surgeries. The main surgical procedures included pterygium excision in 104(17.8%) cases, eyelid repair in 74(12.7%) cases and incision and curettage for chalazion in 65(11.1%) cases (χ2=23.9, p<0.001). A recurrence rate of 31.6% and 6.1% was observed in eyes that had pterygium excision and incision and curretage for chalazion respectively; 83.8% of eyelids repaired had no postoperative sequelae while notching of the eyelid margin was observed in 9.4% of eyelids repaired.

Conclusion

Minor ophthalmic surgeries constitute an important aspect of comprehensive eye care delivery with significant impact on control of blindness programmes. Most minor ophthalmic surgeries are performed on the ocular adnexa, hence the need for strengthening of the orbito-oculoplastic sub-specialty in the hospital.

Introduction

In the year 2010, estimates of the World Health Organisation (WHO) indicate there are 285 million visually impaired persons (visual acuity of <6/18 in the better eye) worldwide out of which 39 million are blind with visual acuity of <3/60 in the better eye1. Majority (72.5%) of the blind population reside in developing countries particularly Asia and Africa1. Up to 75% of blindness and visual impairment are due to avoidable causes of blindness (i.e. causes of blindness that are either preventable or treatable)2. Treatment modalities in ophthalmic practice include medical, surgical, optical and LASER therapy which could either be used alone or in combination3. Surgical condition includes all morbidities for which an invasive procedure may provide cure, treatment or palliation. Some surgical conditions may not require an incision4. Over 60% of blindness worldwide is attributable to surgical causes (e.g cataract, glaucoma, trachoma among others) therefore the importance of surgical interventions in eye care services cannot be overemphasized1.

A minor ophthalmic surgical procedure in this study is defined as a procedure which is superficial, with limited operative site (most of which can be carried out under local anaesthesia) and a minimal access intervention (which is either a therapeutic or diagnostic procedure that is not considered major in terms of the size of the operative site) 5.

The reasons for the utilization of ophthalmic surgical services are multi-factorial. These could be patient- related and to a large extent also dependent on the availability of highly skilled manpower, appropriate infrastructural development and an adequately funded eye care system 4.

Ophthalmic surgical audit is also essential in monitoring service delivery in line with the global initiative “VISION 2020: The Right to Sight”2. Consequently, this research assessed the output, outcome and pattern of minor ophthalmic surgical interventions over a period of seven years from January 2008 to December 2014 as well as its implication for service delivery, ophthalmic manpower and infrastructural development.

Patients & Methods

The minor ophthalmic surgical database was retrospectively reviewed to obtain information on the patients’ demographics, clinical features, indications for surgery, type and date of surgery, type of anaesthesia administered, the rank of surgeon (resident doctor or consultant ophthalmologist) and the outcome of management. The data obtained was entered into Epi Info statistical software, version 3.4 (Epi InfoTM, Atlanta, Georgia,USA) and analysed after the data entry was validated by double entry. Descriptive statistics was used to yield frequencies, percentages and proportions. Analytical statistics was by chi-square test and a p value <0.05 was considered statistically significant. The demographics of patients, the output, and types of minor ophthalmic surgeries were assessed. The output of minor surgeries among resident doctors and its implication for residency training was also assessed. Ethical approval was obtained from the Institutional Medical Research Ethics Committee.

Results

A total of 536 patients had minor ophthalmic surgical intervention within the study period. There were 281(52.4%) males and 255(47.6%) females with a male: female ratio of 1.1:1. There was no statistically significant difference in the utilization of minor ophthalmic surgical services between the genders (χ2=9.4, p>0.1). The mean age was 38.1(±24) years with a range of 0-86.1 years (mean ±2SD). Over two-thirds (70.3%) of the study population were aged 21-60 years, while 66 (12.3%) patients were aged >60years as shown in figure 1. In this study an average of 77 patients had minor ophthalmic surgeries per year, 41 (7.6%) patients had surgeries in both eyes and a total 577 eyes were operated upon. Table 1 shows the main anatomical site of ophthalmic morbidity in 577 eyes. Up to 70.6% of all morbidities were on the ocular adnexa comprising the eyelid/lashes, conjunctiva and nasolacrimal drainage system. The ocular adnexa remained the main anatomical sites of morbidity over the period under review figure 2 comprising 75.7% of all minor ophthalmic surgeries in the year 2008 and 43.2% in 2014 (χ2=53.7, p<0.001).

Figure 1. Age Distribution of Study Population .

Table 1 . Anatomical Classification of Ophthalmic Morbidity.

Anatomical site	No	%
Lid/Lashes	237	41.1
Conjunctiva	166	28.8
Nasolacrimal drainage system	4	0.7
Anterior segment	94	16.3
Posterior segment	49	8.5
Whole globe	15	2.6
Orbit	12	2.1
Total	577	100

Figure 2. Pattern of ocular adnexal morbidities .

Sixty five (12.1%) persons had eyelid lacerations and 9(13.8%) of these had bilateral involvement. There were 52(80%) males and 13(20%) females, with a male: female ratio of 4:1 (χ2=8.9, p<0.05). The main causes of eyelid laceration included road traffic accidents (RTA), assaults and fall from height being responsible for 34%, 30% and 27% of cases respectively. Others causes included sharp objects; stick injury and high velocity metal accounting for eyelid laceration in 3% of cases each.

Posterior segment morbidity (mainly due to vitreo-retinal manifestation of systemic diseases like diabetes mellitus and hypertension) as an indication for minor surgical intervention became apparent in the year 2013, observed in 11(1.9%) eyes. This increased to 38(6.6%) eyes in 2014 figure 3.

Figure 3. Pattern of ophthalmic morbidities .

Majority (90%) of minor ophthalmic surgeries were performed under local anaesthesia. Most (75%) minor surgical procedures were performed by resident doctors under supervision (χ²=13.7, p<0.05)

A total of 584 minor ophthalmic surgeries (7 eyes had more than 1 surgical procedure) comprising over 33 different types of surgeries were performed Table 2, with an annual average of 83 surgeries. The main procedures included pterygium excision 104(17.8%), eyelid repair 74(12.7%) and incision and curettage (I&C) for chalazion 65(11.1%). Excision biopsy of eyelid swellings and conjunctival growth was performed on 54(9.2%) and 57(9.8%) eyes respectively. The above procedures constituted 60.6% of all minor surgeries performed. (χ²=23.9, p<0.001).

Table 2 . Distribution of minor ophthalmic surgical procedures.

Serial NO
		No	%
	A. Lid and Lashes
1	Eyelid repair	74	12.7
2	Incision and curettage for chalazion	65	11.1
3	Excision biopsy	54	9.2
4	Bilamellar tarsal rotation	8	1.4
5	Tarsorrhaphy	8	1.4
6	Adhesiolysis	7	1.2
7	Wedge resection for ectropion	6	1.0
8	Scar release and full thickness skin grafting	6	1.0
9	Incision and drainage	4	0.7
10	Others	12	2.1
	Sub-total:	244	41.8
	B. Conjunctiva
11	Pterygium excision	104	17.8
12	Excision biopsy	57	9.8
13	Conjunctival flap	15	2.5
14	Conjunctivectomy: Mooren’s ulcer	5	0.9
15	Pingueculum excision	2	0.3
16	Others	4	0.7
	Sub-total:	187	32.0
	C. Nasolacrimal drainage system
17	Probing	1	0.2
18	Canalicular repair	1	0.2
	Sub-total:	2	0.4
	D. Anterior Segment
19	Iris repositioning/abscission	30	5.1
20	Suture removal	19	3.3
21	Soft lens matter: wash out	5	0.9
22	Anterior chamber paracentesis	5	0.9
23	Corneal ulcer: scrapping	4	0.7
24	Inflammatory membrane: excision	4	0.7
25	Corneal foreign body removal	4	0.7
26	Gaping limbal wound repair	2	0.3
27	Others	7	1.2
	Sub-total	80	13.7
	E. Posterior segment
28	Intravitreal Avastin injection	51	8.7
29	Vitreous tap	4	0.7
	Sub-total	55	9.4
	F. Orbit
30	Retrobulbar alcohol injection	10	1.7
31	Orbital fat prolapsed: excision	2	0.3
32	Others	3	0.5
	Sub-total	15	2.5
	G. Others
33	Socket reconstruction	1	0.2
	Sub-total	1	0.2
	GRAND TOTAL	584	100

A recurrence rate of 31.6% was observed among eyes that had pterygium excision within the study period while 83.8% of eyelids repaired had no post-operative sequelae, however 12(16.2%) eyes developed post-operative complications which included notching of the eyelid margin in 7(9.4%) eyes, gaping wound in 2(2.7%), ptosis, cicatricial ectropion and preseptal cellulitis in 1(1.4%) eye each. The outcome of I & C for chalazion was satisfactory in 90.8% of eyes, however recurrence was observed in 4(6.1%) eyes while postoperative conjunctival granuloma was observed in 2(3.1%).

Tarsorrhaphy was performed on 8(1.4%) eyes. Adhesiolysis was performed on 7(1.2%) eyes, which included 2 eyes with congenital ankyloblepharon (partial fusion of the eyelid margins) and 5 eyes with symblepharon (adhesion between the bulbar conjunctiva and the palpebral conjunctiva). In order to prevent recurrence, adhesiolysis was combined with a conjunctival graft in two eyes and with an amniotic membrane graft in one eye with good outcome as none of these eyes developed recurrence during the period under review. However 2 eyes that had no grafting performed developed recurrence with Steven Johnson’s syndrome as the underlying systemic disease in 1 patient. A wedge resection to correct involutional ectropion was performed on 6 (1.0%) eyes. Six eyelids (1.0%) with cicatricial ectropion were corrected with a dual procedure of release of contracture and full thickness skin grafting with good outcome in 5 eyes and post-operative cicatricial ectropion in 1 eye.

Iris abscission/reposition with wound repair after cataract extraction was the main procedure performed on the anterior segment of the eye in 30(5.1%) eyes while intravitreal Avastin injection was the main posterior segment procedure performed on 51(8.7%) eyes. Of these 51 eyes, indications for intravitreal Avastin injection included diabetic retinopathy in 30(58.8%) eyes, retinal vein occlusion in 18(35.3%) eyes while other indications accounted for 5.9%.

Thirty two patients who had either an eyelid mass or cystic swelling were further reviewed in this study. All the excision biopsies of these patients were unilateral. Most (92.3%) eyelid tumours were benign. Verrucae/squamous cell papilloma and epidermal cysts were the main types of eyelid tumours observed in 33% and 25% of eyes respectively figure 4. The outcome of excision biopsy in these patients were satisfactory as only one case of recurrence of dermatofibroma and one case of postoperative conjunctival granuloma was observed within the study period.

Figure 4. Distribution of types of eyelid tumours in the study population .

Fourteen patients who had biopsy of conjunctival mass were further reviewed. Of these 12 patients had their histopathology reports ready which revealed squamous cell carcinoma in 7(58.3%) eyes, squamous cell papilloma in 3(25%) eyes, junctional naevus and dermoid cysts in 1(8.3%) eye each. No case of recurrence was observed among these eyes within the study period.

Discussion

It was observed that over two-thirds of all minor ophthalmic surgeries were performed on the ocular adnexa There is easy surgical access to the ocular adnexa and most surgical procedures on the ocular adnexa can be performed with local anaesthesia as was observed in this study5, this is similar to what was observed in southern Nigeria6^-7. Of interest is the emergence of vitreo-retinal diseases (posterior segment lesions) as an indication for minor surgical intervention in the year 2013, attaining prominence in the year 2014 figure 3. Most of these being due to a high demand for intravitreal Avastin injection among patients with diabetic retinopathy, retinal vein occlusion and other retinal vascular diseases. There is an increase in the prevalence of vitreo-retinal diseases globally due to an exponential population growth, increased longevity and an ageing population. Furthermore, increased urbanization, increase in the prevalence of obesity as a result of dietary changes and sedentary life style has led to an increase in the prevalence of non-communicable diseases such as diabetes mellitus and systemic hypertension. Ocular manifestation of these systemic diseases involves the retina and vitreous among others8^-10.The vitreo-retinal subspeciality unit of our facility became very active in the year 2013 with an urgent need for both human resource and infrastructural development to cope with the high demand on the unit being currently experienced.

A total of 584 minor procedures comprising over 33 different types of surgeries were performed. Pterygium excision, eyelid repair and incision and curettage for chalazion were the main procedures. Pterygium excision was also the most common minor ophthalmic surgery observed in southern Nigeria 6,7,11. Pterygium is a common lesion, if it encroaches on the visual axis it could lead to visual impairment. In Nigeria, 1% of moderate visual impairment and 0.5% of blindness are attributable to pterygium in persons aged ≥40 years12. Pterygium is common in persons who live in tropical climate and may represent response to chronic dryness and ultraviolet exposure. Surgical excision is the modality of treatment13. Recurrence is a fairly common post-operative complication. The 31.6% rate of pterygium recurrence observed in this study is comparable to 40% reported by Ashaye in Ibadan14. The most widely used technique to minimize recurrence which is also being used in our center involves excising the pterygium and primarily covering the sclera with a conjunctival autograft or an amniotic membrane graft. Adjunctive treatment with mitomycin C is also effective in preventing recurrence but may be complicated by post-operative scleromalacia13.

The high preponderance of lid trauma among the male gender and the causes observed is similar to what was observed in a hospital-based study where 86.4% of the male genders were observed to have sustained lid lacerations with the main causes being road traffic accidents (RTA) and assaults observed in 27.3% and 21.2% of cases respectively15. Eye injuries from road traffic accidents are a growing public health issue. Efforts need to be intensified to reduce RTA in Nigeria. Useful measures include improved road designs and maintenance, more stringent vehicular certification and an insistence on full ophthalmological assessment as a pre-requisite for issuance and renewal of drivers licence.

Most of the eyelid tumours were benign and higher in proportion than what was observed in Nepal where only 41.1% of patients requiring eyelid reconstructive surgery had benign tumours16. The main types of eyelid tumours were verrucae/squamous cell papilloma and epidermal cysts. Epidermal cysts occur due to implantation of surface epidermis from trauma or surgery. A few cases are developmental and occur along embryonic lines of closure. Papillomas affecting the eye primarily appear on the skin of the eyelid. They are sometimes referred to as viral papillomas/verrucas17.

Close to two-thirds of conjunctival tumours excised were squamous cell carcinoma of the conjunctiva. Studies in Benin City, Nigeria18, Uganda and Malawi 19revealed that 70-75% of patients with squamous cell carcinoma of the conjunctiva were seropositive for HIV. Squamous cell carcinoma of the conjunctiva is a well documented marker for HIV seropositivity.

Only 8 (1.3%) cases of bilamellar tarsal rotation (eyelid surgery for correction of cicatrical entropion commonly secondary to trachoma) were performed in the hospital in the last 7 years. This could be attributed to the global decline in the prevalence of active trachoma as was also observed in the Nigerian National blindness and visual impairment survey1,12. Tarsorrhaphy (both temporary and permanent) were performed on 1.3% of eyes; it is a surgical procedure that involves suturing of the lateral margins of the eyelids together with the aim of shortening the interpalpebral fissure20. Indications for tarsorrhaphy as observed in this study included lagophthalmos and orbitopathies (which include orbital tumours and retrobulbar haemorrhage). One participant had bilateral congenital ankyloblepharon (a congenital blepharocanthal abnormality). In ankyloblepharon, the eyelid margins are partially or completely fused together. The horizontal palpebral fissure is reduced. This rare abnormality may be inherited as an autosomal dominant trait and may occur in association with ectodermal defects such as cleft lip and palate21.

Four cases of corneal ulcer scrapping and 2 cases of corneal foreign body removal were performed in theatre in the period under review. This is quite low compared to findings from southern Nigeria6,7,11. This is because in our facility, most of these procedures are carried out in the eye clinic.

Iris abscission and repositioning with surgical wound repair was the main anterior segment procedure performed. The most common indication was iris prolapsed following cataract extraction. Early recognition and management is crucial. Retained soft lens mater after cataract extraction; if significant, may precipitate a severe post-operative uvetis and has to be washed out.

The outcome of the main surgical procedures observed in this study is satisfactory and comparable to findings from other tertiary eye care centers in Nigeria as well as what is obtainable in literature 6,7,11,13,17 .

Postoperative complications were appropriately managed. Gaping wounds following eyelid repair were revisited and repaired, one case of preseptal cellulitis was treated with broad spectrum antibiotics and anti-inflammatory agents. All eyes with recurrent eyelid growth after I&C for chalazion had excision biopsy done. Two eyes with postoperative conjunctival granuloma had it excised while 1 eye was treated with topical anti-inflammatory drugs.

This study population is relatively young as over two thirds are in the productive age group almost evenly distributed between male and female patients. This is inconsistent with what was observed in south-eastern Nigeria and with global findings that women accessed surgery at two-thirds the rate of men6,7,22. Other workers had indicated that the elderly and females have limited exposure to health care information and have less disposable income; their health care needs could thus be accorded a lower priority23. This is not consistent with the finding of this study probably due to the relative affordability of minor ophthalmic surgical services.

A minimal difference was observed between the number of persons who had surgeries and the number of eyes that were operated. This indicates that not too many minor surgical procedures were performed on both eyes of the same person during the study period.

Most minor ophthalmic surgeries in the hospital were performed by resident doctors under supervision. The development of expertise in surgical technique must parallel the acquisition of knowledge and correct professional attitudes during residency training24. The format of surgical skill assessment has undergone changes in recent years, with a shifting trend from the apprenticeship model to standardized objective methods of assessment. Various tools have been devised to objectively assess resident’s surgical skills and intra-operative events. They include Eye Surgical Skills Assessment Test (ESSAT) among others25. They can also be used to assess a resident’s surgical care of patients as well as resident’s surgical knowledge, preparedness and interpersonal skill. The relatively low output of minor surgeries observed is not surprising as many minor surgeries are carried out in secondary eye care facilities in the state and thus not too many of these cases present to the tertiary health care facility. However the need for widespread health education on common ocular morbidities and services available should be carried out. Cost saving measures should also be in place in service centres to enhance uptake of services23,26,27.

The tertiary hospital-based nature of this study is a limitation as most patients with minor ophthalmic surgical conditions (pterygia, chalazia, bening adnexal tumours etc) may never even reach a health facility that offers ophthalmic surgical services. A population-based survey is more appropriate in assessing unmet needs and help to ensure that ocular morbidities endured by millions of people in developing countries will not continue to remain invisible to the rest of the world4. In the meantime, hospital and community-based eye health education will help raise awareness of common minor ophthalmic surgical conditions among the populace.

Our findings, though hospital-based, are relevant for eye care programme planners and implementers.

The surgical log book is an important and potentially useful source of information which could be transformed into a computerized data base with the development of appropriate coding systems. Ophthalmologists in Nigeria should develop a national surgical data base and the quality of this data base should be such that recording and coding ambiguity are eliminated. This will form an important baseline national statistical database for the National health insurance scheme (NHIS) in Nigeria. Such database has been used to monitor output of surgeries, observe year to year trends in pattern of ophthalmic surgery and assess the provision of ophthalmic surgical care in some developed countries28.

In conclusion, minor ophthalmic surgeries constitute an important aspect of comprehensive eye care delivery with significant impact on control of blindness programmes. Most minor ophthalmic surgeries were performed on the ocular adnexa, hence the need for strengthening of the orbito-oculoplastic sub-specialty in the hospital.