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Eye Diseases Seen in Sub-Saharan Africa
Tropical Eye Diseases Atlas (last update: 6th June 2019; more coming)
Lens & Cataract
Optics & Refraction
Cicatricial ectropion upper lid 2 months after skin-grafting
Traumatic anterior lens dislocation
Upper eyelid avulsion
Squamous cell carcinoma of the conjunctiva
Lens dislocation into vitreous
Normal pupillary reactions in monocular blindness
Canthotomy and cantholysis after iatrogenic retrobulbar hemorrhage
Recurrent dermolipoma: upper - primary, lower pic - secondary.
Intraocular lens optic partial pupil capture in pediatric case
Stevens-Johnson Syndrome of the Eye
Non-traumatic enophthalmos left eye
Scrofuloderma, tuberculous cold abscess, tuberculous periostitis, tuberculous osteomyelitis
Complicated eyelid reconstruction: Tenzel flap
Lens dislocation under Tenon's capsule
Pterygium excision caused corneal perforation. Recurrence one month later.
Fish-hook eye perforation
African ophthalmology cases mix
Invasive SCC of conjunctiva
Subtotal persisting pupillary membrane
Combination of super-big and super-small eye
Pterygium-Werewolf: benign or malignant?
Retinoblastoma - Group E
Corneal perforation after cobra spit
Vitreous wick syndrome after cataract extraction
Congenital bilateral corneal opacity differentials
Dacryops, simple lacrimal gland cyst and corneal scars post cicatricial trachoma
Traumatic posterior lens dislocation
Traumatic anterior staphyloma
Arlt's line in trachoma
Macular tear and retinal detachment in juvenile maculoschisis
Probable choroidal melanoma in single seeing eye
Fresh thermal burn, cicatricial upper eyelid ectropion, lagophthalmos
Probable Intraocular Tuberculosis
Methanol optic neuropathy
Stereo-image of cupping in moderate stage juvenile glaucoma
Bilateral large colloid drusen
Familial dominant drusen
Trabeculectomies for juvenile open angle glaucoma
Recurrent pterygium causing ptosis
Advanced bilateral conjunctival SCC
Eye prosthesis for bilaterally blind patient
Total conjunctivotenon's flap for melting old corneal laceration
Compressive optic neuropathy in thyroid eye disease
Differential: Coats Vs retinoblastoma
Spontaneous iridodialysis (retroillumination)
Cicatricial upper lid ectropion after thermal burn
Glaucoma led to eye explosion
Orbital fat prolapse
Traumatic lens subluxation
A new case immediately upon my return to the duty from a long absence in Africa. Male, 20 yo with eye ruptured supposedly due to a blunt trauma with a tree branch. The patient presented himself one week after trauma (a long distance travel). Huge uveal prolapse, scleral and cornea rupture from 10 o'clock to 4 o'clock, full-thickness upper and lower lid margin laceration, no vision. Treated with evisceration+orbital implant+repair of the eyelids (pentagonal wedge style reconstruction). Huge intraocular plastic foreign body retrieved during wound revision. Most probably - improper history and an assault, and not the tree, is a reason of this sad outcome.
Presumably OSSN (very unsusual appearance though, intrinsic vascularity typical for SCC). Tumor in the right eye of 35yo gentleman. He has a history of OSSN excised from the other eye 2 years ago. Now treated with chemoreduction first (upper photo - at presentation, lower - after two weeks of treatment). Noticeable tumor shrinkage occured. Treatment continued. No-touch excision+5-FU application planned with possible cryotherapy for conjunctival margins.
Tunnel failure 2 weeks after SICS (small incision cataract surgery). Tunnel was designed by the trainee-cataract surgeon under my direct supervision, and the rest of surgery done by myself. No signs of danger were seen immediately after the surgery or on first postop day. Two weeks later: tunnel superficial lip retraction, a lot of fibrin in the AC, turned out to be endophthalmitis on the following day, when tunnel repair was performed together with intravitreal ceftriaxone and AC wash-out (no vancomycin here!..). Patient had this only seeing eye. Luckily enough, the only VR-surgeon in the country (private hospital) agreed to do the case at no cost (very expensive otherwise). The vision was preserved in this eye. Lesson for the future: no trainees on single eyes. No supervision is a guarantee.
Conjunctival melanoma in 5yo african girl.
Severe bilateral trachomatous cicatricial upper eyelid entropion with massive trichiasis rubbing both corneas. Unfortunately there were contraindications for general anesthesia (and she was not a suitable candidate for local). Household cyanoacrylate ("superglue") was used for glue-tarsorrhaphy (in order to give corneas temporary relief). Upper photo shows extremely severe blepharospasm (6 year long habbit!). Tarsorrhaphy had been effective for one week, when the surgery became possible (Ballen's procedure, see next photo).
Severe bilateral trachomatous cicatricial upper eyelid entropion with massive trichiasis rubbing both corneas. Managed with Ballen's procedure to correct entropion (bilamellar tarsal plate rotation). She felt much better, started opening her eyes, and was able to walk alone now. Swelling will subside, the sutures were absorbable, and the patient went back to the village until follow-up after 6 months.
Severe bilateral trachomatous cicatricial upper eyelid entropion with massive trichiasis rubbing both corneas. Girl 9yo with the disease started 6 years ago! Very strong Bell's phenomenon and blepharospasm. Functionally blind. Managed with glue tarsorrhaphy initially (see the next picture) and then with bilateral upper lid Ballen's procedure (so colled "bilamellar tarsal plate rotation" recommended by the WHO for trachomatous trichiasis). Dramatic relief achieved.
Presumably SCC as a recurrence after primary excision, performed 8 years ago. Some kind of extended enucleation is planned in hope to preserve as much conjunctiva as possible for future prostesis. Histopathology to be performed after amputation. Consultation from oculoplastic specialists requested.
OSSN conrverted in SCC. 39yo newly HIV-reactive lady. Corneal intraepithelial spread visible. No fornices involved, but invasion of sclera is very likely. Vision is 6/9 and prognosis is not so good (high possibility of recurrence after excision). Chemoreduction initiated with 1% 5-FU eyedrops for possible future excision/5-FU/cryo procedure.
Two cases of internal hordeolum (or indeed infected chalazion!). Internal hordeolum (infection of meibomian gland) usually should be more diffuse. Infected chalazion can be localized, like these cases. Managed with incision and curettage.
Anterior staphyloma: case of corneal abscess turned into bulging. Evisceration seemed the only option here (no tectonic grafts were available as an alternative in the country). The patient never showed up for the procedure.
Distichiasis: additional lashes growing from the abnormal place (meibomian orifices). Can be managed with cryotherapy to prevent multiple recurrences (as seen in simple epilation).
Conjunctival congenital nevus in 10yo girl, growing since 2yo. Cystic spaces visible. Managed with observation.
Disastrous case of retained intraocular metal foreign body (?piece of umbrella parts). 5 yo boy. Surgical removal was complicated with foreign body retracted further into the vitreous body. The scleral wound was closed and the patient referral planned. The mother took the child to the village and they never came back. I would expect sympathetic ophthalmia here... Disastrous case.
Symblepharon and eyelids deformation and full-thickness tissue loss in an unfortunate RTA case with poor primary surgical management (the patient had come from the neighbour country). Several attempts of upper eyelid repair were made, but there was no oculoplastic expert available locally, so some amount of lid defect persisted after treatment. Photograph shows presentation.
Pseudophakic bullous keratopathy, persisting despite attempt of acetazolamide, topical steroids, beta-blockers and hyperosmotic glucose treatment. Rare unfortunate case, when SICS gives permanent corneal haze. Long-term follow-up is unknown though.
Descemetocele - bulging of Descemet membrane after resolution of corneal ulcer. Managed with frequent antibiotics and bandage contact lens in hope of soonest scarring promotion. Next option will be paracentral tarsorrhaphy with the same purposes +/- conjunctival pedunculated flap or scleral autograft.
Dacryops - simple lacrimal gland ductal cyst. Classic clinical picture: bluish cystic lesion in the area of lacrimal gland with bright transillumination; painless and soft on palpation. Case in a 40yo male without any history of trachoma (which would be very typical for dacryops). Managed with marsupialization. Photographs arranged in stereo-fasion.
Traumatic corneal full-thickness self-sealed fresh laceration with intracameral metal foreign body (~4x2x1,5 mm, where 1,5 is a thickness). Managed with extraction of FB through the sclerocorneal tunnel at 12 o'clock and suturing of self-sealed laceration (10-0 nylon). Vision is remaining good (6/18 at presentation). This is a rare case, where the trauma happened at the same day of presentation (patient resides in the same area). Hover image shows Postop day1 status after anterior chamber metal foreign body extraction and self-sealed shelved full-thickness corneal laceration repair with a single 10-0 nylon. Marked corneal stroma edema and striate keratopathy noted, causing distortion of the wound. I still think the distortion will resolve once corneal edema will subside. Vision is slightly decresed due to cornea condition, and no traumatic cataract was noticed yet. Patient is on antibacterial and anti-inflammatory systemic and topical treatment.
Hyperacute gonococcal keratoconjunctivitis with fulminant corneal melt in a young lady, despite appropriate systemic and local treatment
Tylosis (also called pachyblepharon - thickened eyelid margins) and madarosis of each of four eyelids. Status post chronic severe ulcerative blepharitis. Corneas also suffered.
Atypical ocular surface squamous neoplasia pattern. Before and after excision, with pyogenic granuloma formation (managed with excision later).
Retinoblastoma and secondary buphthalmos seen in a 4yo girl with marked yellowish leukocoria. Managed with referral that time.
These growths (separate cases) were confirmed as pterygium by excisional histopathology. Despite the appearance highly suggestive of OSSN. Very common behaviour of pterygia in Africa. Difficult to guess.
Different appearance of ocular surface squamous neoplasia (OSSN, seen frequently in HIV patients and associated with human papilloma virus). Managed with excisional biopsy +/- cryotherapy or antimetabolites application/chemoreduction.
Upper pictures show the appearance of conjunctival autografts for pterygium excision after sutureless glueless (autoblood) fixation (inappropriate depth and size of grafts caused retraction and contraction). Lower photo shows autograft fixated with wet-field cautery.
Extensive inclusion cyst of lower lid tarsal conjunctiva in 2yo baby. Observation!
Pleomorphic adenoma (confirmed by excisional biopsy) in elderly lady
Iris prolapse in perforated cornea after acute bacterial keratoconjunctivitis (probably gonococcal infection) in young lady. Managed with conjunctival flap and epithelialized iris excision.
Conjunctival nevus (congenital and growing in a young child). Containing microcysts. Observation,
Conjunctival autograft for pterygium excision (cautery-fixated)
Climatic droplet keratopathy, condition seen occasionally in tropics. A case in a young boy, Managed with superficial keratectomy, with a chance for recurrence though.
Endophthalmitis after Small Incision Cataract Surgery (SICS, performed by someone else). Managed with evisceration (late presentation).
Very difficult case of bilateral Mooren's ulcer type II in 18 yo boy. Painful progressing ulcer, initially started and stabilized on right eye, and than followed in left eye (the latter managed with conjunctivectomy). Right eye perforated later.
Social trauma (bitten by husband). Inferior rectus avulsion. Managed with repair.
Typical appearance of ocular surface squamous neoplasia (OSSN). Usually managed with excisional biopsy (no-touch technique), followed by 5-FU application. 5-FU primary chemoreduction with 1% eyedrops is an option in some cases (and some of them can be exclusively treated by 5-FU drops). Associated with HIV and human papilloma virus.
Papillomatous type of ocular surface squamous neoplasia. Managed with no-touch excision surgery.
Bilateral retrobulbar mass in a child. Referred for imaging and further management. Leukemia? Lymphoma? Never came for follow-up.
Typical appearance of ocular surface squamous neoplasia (OSSN). Usually managed with excisional biopsy (no-touch technique), followed by 5-FU application. 5-FU primary chemoreduction with 1% eyedrops is an option in some cases (and some of them can be exclusively treated by 5-FU drops).
Anteryor staphyloma as a result of long-standyng uveitis with corneal involvement. The lady was against any eye removal. Eye managed with conjunctival pedunculated flap. There was a relative stabilization of staphyloma. I would recommend long-term follow-up and be on a look-out for sympathetic ophthalmia. I would still recommend evisceration, orbital implant and custom artificial eye for better esthetics.