Category: Tropical papers

Eye precancerous lesions mimic benign pyogenic granuloma

Not all pyogenic granulomas are equally safe. Some of them may comprise an elements of ocular surface squamous neoplasia, OSSN (conjunctival intraepithelial neoplasia, CIN). The paper Herwig-Carl MC, Grossniklaus HE, Müller PL, et al. Br J Ophthalmol Epub. doi:10.1136/ bjophthalmol-2018-312960 highlighted 9 such cases.

OSSN is extremely common in the areas with widespread HIV-prevalence. Human papilloma virus is responsible for this, as a typical opportunistic infection. Knowledge of the potential of OSSN to mimic pterygia and pyogenic granulomas is crucial, especially for the mid level ophthalmic personnel, as they are the primary surgeons for these conditions in many areas.

Pyogenic Granuloma Associated With Conjunctival Epithelial Neoplasia: Report of Nine Cases

Aims: To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as-and also masquerading-pyogenic granuloma.

Methods: Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.

Results: All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.

Conclusion: Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.

Keywords: conjunctival intraepithelial neoplasia; histology; pyogenic granuloma; squamous cell carcinoma; tumour.

How many ophthalmologists are there in the world?

A new data from 2015 (ICO and co.). Actually, there are 232,866 ophthodocs, which makes it 31,7 ophthalmologists per 1,000,000 of world population. Not bad, until we dig into the details.

Take Zambia or Zimbabwe: ~ 30 ophthalmologists per 16,000,000 of population of each country. ~1,9 ophthalmologist per million!

Russia: 13,700 ophthalmologists (95,5 ophthalmologists per 1,000,000).

Germany: 7,300 ophthalmologists (90,5 per million).

USA: 17,600 (54,7 per million).

UK: 3000 (46,4 per million).

Australia: 961 (40,1 per million).

Belarus: 600 (63,2)

Ukraine: 2973 (66,3).

A great job done by the ICO and S. Resnikoff:

Br J Ophthalmol. 2020 Apr; 104(4): 588–592.
Published online 2019 Jul 2. doi: 10.1136/bjophthalmol-2019-314336
PMCID: PMC7147181
PMID: 31266774
Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?

Background/aims
To estimate 2015 global ophthalmologist data and analyse their relationship to income groups, prevalence rates of blindness and visual impairment and gross domestic product (GDP) per capita.

Methods
Online surveys were emailed to presidents/chairpersons of national societies of ophthalmology and Ministry of Health representatives from all 194 countries to capture the number and density (per million population) of ophthalmologists, the number/density performing cataract surgery and refraction, and annual ophthalmologist population growth trends. Correlations between these data and income group, GDP per capita and prevalence rates of blindness and visual impairment were analysed.

Results
In 2015, there were an estimated 232 866 ophthalmologists in 194 countries. Income was positively associated with ophthalmologist density (a mean 3.7 per million population in low-income countries vs a mean 76.2 in high-income countries). Most countries reported positive growth (94/156; 60.3%). There was a weak, inverse correlation between the prevalence of blindness and the ophthalmologist density. There were weak, positive correlations between the density of ophthalmologists performing cataract surgery and GDP per capita and the prevalence of blindness, as well as between GDP per capita and the density of ophthalmologists doing refractions.

Conclusions
Although the estimated global ophthalmologist workforce appears to be growing, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.

Results of MSICS Cataract Surgical Camps – A Case of Tansania

Interesting paper on results of eye surgical camp in Tansania. The results of 42 surgeries show that only 14% of patients at the postoperative day 5-9 have gotten a visual acuity > 0,3. That is unusually low in comparison to our experience in Zambia and to the results published elsewhere in the literature. The case may be due to, as indeed stated in the paper, the highly complicated cases (i.e., also poor selection of cases), and occasionally the quality of the technique and instruments used.

Sumbawanga Augencamp follow-up Studie 2019

Results

A total of 42 postoperative patients from the eye camp could be examined within 5–9 days after cataract sugery. The following parameters were found: median postoperative visual acuity 0.26, spherical equivalent −2.82 dpt, astigmatism −2.2 dpt, axis 113°. Visual acuity >0.3 in 14.2% (WHO 80%), vision 0.1–0.3 in 62% (WHO 15%), vision <0.1 in 23.8% (WHO 5%). Prolonged healing time and intraocular irritation in 29% of the cases.

Conclusion

Although the vision improved, the results are sobering when taken in the context of the WHO guidelines. The postoperative refraction showed a myopic shift and an high level of astigmatism. The reasons are manifold: ocular comorbidities, limited diagnostic and therapeutic possibilities in a nonclinical setting. Other factors are the kind of training of the staff in the camp, the difficult circumstances and advanced findings. Consideration of the results of this study is imperative to be able to measure the quality of the work and to create the potential to make future improvements.

Corneal Ulcers: a Neglected Tropical Disease!

So far we have had only trachoma, onchocerciasis and leprosy that were named “neglected tropical diseases” and related to ophthalmology. However, in July 2019 the WHO had suggested also infectious corneal ulcers to be named “neglected”. Why is that important? Because of the measures, that could be universally introduced to fight the disease (see “SAFE” strategy for trachoma, ivermectin distribution for onchocerciasis etc.). Looking also at the cases presented here in the Gallery one may guess that corneal ulcers are frequent in Tropics. And that is definitely true.

Infectious corneal ulceration: a proposal for neglected tropical disease status

Bulletin of the World Health Organization 2019;97:854-856. doi: http://dx.doi.org/10.2471/BLT.19.232660

In ophthalmology, the designation of trachoma, onchocerciasis and leprosy as neglected tropical diseases (NTDs) has sustained efforts to combat these blinding conditions worldwide. Over the past 50 years, NTD designations have enabled the joining of political, social and economic forces to promote research and interventions for diseases that overwhelmingly affect the 3 billion people who subsist on less than 2 United States dollars (US$) a day. The global public health landscape is still dominated by focus on human immunodeficiency virus (HIV), tuberculosis and malaria. However, NTDs are now increasingly recognized as important causes of morbidity and mortality in low-income settings, perpetuating stigma and social isolation, with many NTDs leading to disfiguring complications. In international public health diplomacy, formal disease recognition is essential. The pursuit of this recognition drives proposals from World Health Organization’s (WHO’s) Member States to include additional diseases in the list of NTDs. The intention is to strengthen the development of partnerships, epidemiological frameworks and commitment of resources to achieve the aims set by the sustainable development goals.