Transactions of the Ophthalmological Society of Nigeria
The Transactions of the Ophthalmological Society of Nigeria an Official journal of the Ophthalmological Society of Nigeria publishes proceedings from the annual congress of the Society. They comprise of referenced abstracts of presentations during the congress. The scope of articles include clinical, laboratory and community medicine, basic medical sciences, medical technology, as well as the economics and management of health care delivery, especially in the African environment as they relate to the eyes. Articles are considered on the basis of subspecialty of Ophthalmology affected, including but not restricted to cornea and anterior segment, glaucoma, low vision, orbit and oculoplasty, vitreoretinal, neuro-ophthalmology, Paediatric ophthalmoloy, and public health ophthalmology.
Challenges of managing rare ophthalmic cases in a resource-poor setting
BACKGROUND Managing ophthalmic cases not seen routinely is fraught with numerous challenges, including non-adherence to investigations, treatment and follow-up. Such challenges are often related to economic constraints and poor information. OBJECTIVE To highlight problems of managing special ophthalmic cases in a resource-poor setting. CASE REPORTS Three cases are described. Informed consent for publication was obtained from each patient/ caregiver. Case I: One-day-old male, born with bilateral upper eyelid eversion and swelling; left eyelid had reverted before presentation. Examination showed a healthy new-born with eversion of the right upper eyelid, chemosis, mild discharge, and mild left lid ecchymosis. A diagnosis of congenital ectropion was made. Tobramycin eye drops and ointment were administered, and the eye was padded with hypertonic saline-impregnated gauze. Mother declined admission due to poor family support and defaulted from follow-up. Case II: Fourteen-year-old boy with an 11-month history of double vision on lifting and lowering his chin, absent on covering either eye. He reported that images appeared one on top of the other, with mild pain on upgaze; there was a history of previous left blunt ocular trauma. Left ocular examination showed enophthalmos, limitation of elevation and positive forced duction test. The intraocular pressure difference between the primary position and upgaze was 2 mmHg and 6 mmHg on the right and left, respectively. A diagnosis of restrictive ocular motility disorder, possibly Inferior rectus muscle entrapment/fibrosis, was made. Father declined orbital computed tomography scan due to cost and defaulted. Case III: A two-year-old with a 1-month history of white reflex in the left eye. There was left hazy cornea and leukocoria with normal findings in the right eye. A diagnosis of retinoblastoma was made. Mother was counselled about management, including enucleation, but she defaulted and returned a year later with a protruding fungating left eye mass, right leukocoria and masses on the head. Exenteration was done, he received a course of chemotherapy, defaulted from follow-up and subsequently died at home. DISCUSSION These cases highlight challenges of managing relatively uncommon cases in a resource-poor setting, including late presentation, which could be related to ignorance and misinformation in society and limited access to accurate information.1,2 It is important to scale up activities that promote awareness of eye care among the public in order to improve eye care-seeking behaviour. Another factor is delay in diagnosis, which may be due to poor knowledge among health workers, multiple second opinions and inadequate diagnostic facilities. Nwosu, Okoye and Ulasi3 bemoaned the adverse consequences of delayed diagnosis of retinoblastoma by health workers. The establishment of a robust primary eye care system and good referral pathways are likely to promote timely diagnosis. Ignorance, poor information, and misconceptions could affect patients’ responses to their disease management.4 Eyecare professionals must dedicate time and resources to counselling and support of patients with these conditions. Economic factors are barriers to utilising eye care services by patients.5–9 Rare cases often require specialised, expensive care, with patients paying out of pocket. Expanding coverage of the National Health Insurance Scheme is likely to be beneficial. Active social welfare services and telephone calls could improve patients’ adherence, as was reported by Kizor-Akaraiwe10 for glaucoma patients during the COVID-19 lockdown. CONCLUSION Financial constraints, ignorance and loss to follow-up hamper management of patients. Education on early presentation and adherence to management plans is vital.
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Community Utilization of Ophthalmic Services: Assessment of Agbowa Rural Community, Lagos State, Nigeria
BACKGROUND Eye health is a public health concern. Community-based ophthalmic services aim to bring eye care to the people's doorsteps, particularly rural dwellers who are often deprived of essential health care.1,2 The World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) promote Integrated Primary Eye Care (IPEC) within existing primary health systems to facilitate eye services delivery.3,4 Studies have, however, revealed that even where available, community utilization sometimes remains poor.5,6 Most studies have focused on interviewing people in rural communities to assess their use of eye care services and the barriers they face.7,8 However, very limited studies within the study environment have assessed ophthalmic services utilization at the base primary eye care centers. This study aims to assess ophthalmic service utilization at a rural community, determine the prevalence of ocular diseases and identify gaps in service delivery with the goal of suggesting measures for improved and sustainable service. METHODS A retrospective cross-sectional study was conducted. The study duration was February 2021 (from the inception of the IPEC) to December 2023. All eye clinic attendees in this agro-based (farming and fishing) community were included. Data on demographics, ocular diseases, medical, optical and surgical interventions were obtained from the eye clinic, refraction clinics, and operating theatre records. Data analysis was done using IBM SPSS version 29. Ethical approval was obtained from Ikosi–Ejirin Local Council Development Area and Institutional Health Research and Ethics Committee. RESULTS There were 1,102 patient visits, with 737 (67%) as new cases. Age ranged from 4 months to 88 years (mean 47.29 ± 22.78 years). Females constituted 54.3%. Utilization of ophthalmic services was most prevalent among females (54.3%); patients in the presbyopic age range, 40-49 years (17.6%); older adults aged 60-69 years (15.7%); and middle-aged 50-59 years (15.1%) (Table 1). Follow-up visits were more frequent among patients aged 40 years and above (Table 1). Prevalent ocular diseases (Figure 1) were uncorrected refractive errors (18.8%), cataracts (18.5%), glaucoma (11.3%), vernal conjunctivitis (8.0%), and pterygium (5.4%). A total of 401 (36.4%) individuals benefited from refractive error services, predominantly middle-aged patients in the 4th (28.4%) and 5th decades (18.0%), as well as adolescents aged 11-20 years (17.0%), while 99 (8.9%) had surgery. Figure 2 shows a fall in yearly attendance from 458 to 267 cases - a 17.4% decline in service utilization. Declines in surgical uptake (51.6%) and refraction services (27.4%) were also recorded. DISCUSSION In this study, an initial satisfactory ophthalmic service utilization was reported. Females, middle-aged, elderly and adolescents utilized the services more, similar to previous studies8,9, probably because they are more domiciled in the community. All age groups reported appreciable initial service uptake, followed later by poor uptake similar to an earlier study.10 The community needs for presbyopic correction, age-related cataract, refractive errors, glaucoma, pterygium, and allergic conjunctivitis are comparable to earlier studies.11-13 Major identifiable gaps were a decline in ophthalmic, surgical and refractive services uptake. Barriers to clinic utilization may be accessibility, affordability, lack of eye health education, personnel and infrastructure deficiencies. 7,14-16 CONCLUSION Ophthalmic services, though well utilized at inception, suffered a significant decline over the following years. Efforts to improve service utilization and sustainability, such as reinforced community awareness outreach and school eye health programs, are recommended.
Pattern of Eye Diseases at a Tertiary Hospital in Southern Nigeria
BACKGROUND The pattern of eye diseases varies from place to place and time to time. Therefore, it is important to review the pattern periodically to monitor trends. Globally, the commonest causes of visual impairment and blindness are uncorrected refractive error, cataract, age-related macular degeneration, glaucoma and diabetic retinopathy.1 Studies from developing countries indicate that conjunctivitis, refractive error and cataract were the commonest eye diseases encountered.2-7 The Nigerian National Blindness and Visual Impairment Survey8 reported that the causes of blindness were avoidable (preventable and treatable) in 84% of the cases, and glaucoma was more prevalent in the Southern and Eastern regions of the country.9 OBJECTIVE To determine the pattern of eye diseases among patients attending a tertiary hospital in Southern Nigeria. METHODS A retrospective hospital-based cross-sectional study was conducted. Data was obtained from the medical records of all consecutive patients who were managed between August 2022 and July 2024 at the Ophthalmology Department of the University of Uyo Teaching Hospital, Uyo. Data extracted included age, gender, presenting visual acuity, slit lamp anterior segment examination, fundal examination and refraction. Any p-value < 0.05% was significant. Ethical approval was obtained from the ethical committee of the Hospital. RESULTS A total of 6,382 patients were analyzed. There were more female (56.6%) than male (43.4%) patients with a Male/Female ratio of 1:1.3. This difference between the proportions of male and female patients was statistically significant (p=0.047). The mean age of patients was 43.5 ± 22.8 years. The largest proportion (43.7%) of the patients were aged between 41 and 65 years (Table 1). Unilateral and bilateral blindness (Visual acuity < 3/60) were reported in 16.8% and 1.8% of patients, respectively. The commonest causes of eye diseases were glaucoma (23%), cataract (12.9%), refractive errors (12.8%) and conjunctivitis (10.7%) (Table 2). DISCUSSION Glaucoma was the commonest disorder in this study, in other hospital-based studies2,10, and in a community-based study11 in Southern Nigeria. The hype in glaucoma awareness campaigns may have contributed to this observation. Cataract, uncorrected refractive error and conjunctivitis were the second, third and fourth commonest eye diseases observed. These three eye disorders contributed significantly to avoidable visual loss. Conjunctivitis is commoner in the younger populations 7 while presbyopia is commoner in persons above 40 years.11 Contrary to the index study, cataract was the leading eye disorder in some other studies.12-13 Improving the cataract surgical services with good outcomes will reduce the contribution of cataract to the burden of visual impairment and blindness. CONCLUSION Glaucoma was the major cause of eye disease in the hospital, emphasizing the need for screening and early treatment of the condition.
Relationship between platelet indices and diabetic retinopathy in patients with type 2 diabetes mellitus: a hospital-based prospective study
BACKGROUND Diabetic retinopathy (DR) is the most common microvascular complication of Type 2 diabetes mellitus (T2DM) patients.1,2 Increased platelet activity is an important pathogenic factor. Platelet count (PLT), mean platelet volume (MPV) and platelet distribution width (PDW) are important indices that reflect platelet activity.3-6 These indices may serve as measures associated with the development and progression of DR. This study was aimed at determining the relationship between platelet indices and diabetic retinopathy in patients with type 2 diabetes mellitus. METHODS A cross-sectional study was conducted on 181 T2DM participants under the Tenets of the Declaration of Helsinki.7 Ethical clearance for this study was obtained from the University of Calabar Teaching Hospital Health Research Ethics Committee, and written informed consent was obtained from each of the eligible participants. After fundoscopic examination, participants were divided into two groups: T2DM with DR and T2DM without DR. Their PLT, MPV and PDW were assayed. Statistical analyses, including Chi-square test, Student T-test, and binary logistic regression, were performed using Statistical Package for the Social Sciences Version 25.0 (Chicago, IL). RESULTS The T2DM patients were aged 35 to 80 years, with a mean age of 56.4±10.9 years. There were more females than males, with a ratio of 3:1. The PLT, MPV and PDW were significantly higher among type 2 diabetes mellitus with DR as compared with type 2 diabetes mellitus without DR (Table 1). On regression analysis, elevated PDW was found as an independent determinant for the likelihood of diabetic retinopathy (Odds ratio: 1.259; 95% confidence interval: 1.081-1.466; p = 0.003). CONCLUSION The study demonstrated that elevated levels of PLT, MPV and PDW were significantly associated with the development of DR. However, PDW appears to be a more likely predictor of DR in T2DM. We hold the view that the utility of these platelet indices as hemorheological markers of DR makes potential sense for early diagnosis and monitoring of DR.
A case of central retinal vein occlusion associated with retrobulbar optic neuritis
BACKGROUND Central retinal vein occlusion (CRVO) secondary to retrobulbar optic neuritis is a rare manifestation, and we did not find a reported case from Nigeria in the literature. There are very few reported cases of both pathologies co-existing in the same patient.1-3 CLINICAL PRESENTATION A 58-year-old gentleman, a known glaucoma patient, presented in our clinic with a one-hour history of painless, sudden loss of vision in the left eye. One month prior to the loss of vision, his eye felt heavy, but there was no redness, no pain on ocular movement or reduction in vision. On presentation to the clinic, we examined a middle-aged, healthy-looking man; he had a blood pressure of 130/70 mmHg, and all other aspects of his systemic examination, including the neurological examination, were normal, apart from the ocular examination. Visual acuity was 6/6 in the right eye and counting fingers at 3m (3MCF) in the left eye; intraocular pressures were 20 and 22 mmHg, respectively. His right ocular examination findings were normal. On the left, there was a relative afferent pupillary defect (RAPD), and posterior segment examination revealed a pale disc and cup disc ratio of 0.75, with distinct margins but dilated tortuous venules in all quadrants with mild retinal haemorrhages (Figure 1). Color desaturation was 100:30 and light appreciation was 100:20 in the right and left eyes, respectively. Fundus fluorescein angiography showed a delay in venule filling in all quadrants, worse inferotemporally. There was no area of capillary dropout and no feature suggestive of macula oedema (Figure 2); however, the late images showed hyperfluorescence (Figure 3) in the disc, suggesting an inflammatory process, i.e. retrobulbar neuritis, in the left eye. The optical coherence tomography showed no significant macula oedema (Figure 4). Brain magnetic resonance imaging (MRI) showed nonspecific white matter changes; the MRI spine did not show any significant white matter changes. A diagnosis of left mild central retinal vein occlusion associated with retrobulbar neuritis secondary to multiple sclerosis (Clinical Isolated Syndrome) was made. He was placed on intravenous methylprednisolone 1g daily for 3 days and continued on 60 mg prednisolone daily, which was subsequently tapered off. His vision on the first day after commencing steroids improved to 6/12, and at 2 weeks, his vision had improved to 6/6, although he still had significant visual field changes (Figures 5 and 6). Over the last 4 months of follow-up, the left visual acuity remained 6/6, but he still had significant visual field changes (Figure 7). The patient consented to this case report, and ethical approval was obtained from the research ethics committee of Asokoro District Hospital, Abuja. DISCUSSION Although he had features suggestive of a central retinal vein occlusion (CRVO), these could not explain the visual acuity of 3MCF and relative afferent pupillary defect, as the features of CRVO were mild. Retrobulbar neuritis was the main cause of reduced vision because of the visual acuity, RAPD, markedly reduced light appreciation and color desaturation, leakages around the optic nerve head seen in the late stages of FFA and the great improvement on commencing intravenous methylprednisolone. CONCLUSION A high index of suspicion is required to rule out retrobulbar neuritis when it co-exists with a retinal vein occlusion that cannot account for the clinical features seen.
Hemiretinal cone-rod dystrophy in two male siblings: an unusual presentation
INTRODUCTION Cone-rod dystrophies are inherited retinal disorders occurring in the first three decades of life and rarely, the fifth decade.1,2 The prevalence is 1 in 40,000. The ABCA4 gene is the most prominent causal gene known.3 Symptoms and signs include decreased vision, central scotomas, colour vision loss, photophobia, bone-spicule pigmentation, macular and retinal atrophy.2-5 Typical findings include bone-spicule pigmentation, macular and retinal atrophy.5 On multimodal imaging, characteristic electroretinography and visual field abnormalities are seen. 2,3 Hemiretinal variants of rod-cone dystrophies are relatively rare.6 METHODS Case reports of two male siblings with hemiretinal cone-rod dystrophy by multimodal imaging. Informed consent was obtained from the patients for this report. CASE PRESENTATION The first patient is an 18-year-old male who presented with diminished vision since childhood. He had used spectacles for two years with little improvement. Best corrected visual acuity for distance and near was 6/36 and N12 in both eyes. Pendular nystagmus was present. The intraocular pressure was 10 mmHg bilaterally. He had disc pallor and atrophic macula with bull's eye maculopathy bilaterally. Hyperpigmented bone-spicule changes and attenuated vessels were restricted to the inferior and nasal retina bilaterally. (Figure 1a). Fundus autofluorescence showed hypoautofluorescent patches in the inferior and nasal hemiretina and alternating hyper- and hypo-fluorescent pattern at the macula, in a bull’s eye pattern (Figure 1b). Optical coherence tomography (OCT) scan revealed retinal thinning with disruption of the ellipsoid layer, typifying photoreceptor loss (Figure 1c). Central visual field showed early ring scotoma pattern, and electroretinography showed reduced amplitudes in the photopic phase, reduced extinguished response in the scotopic phase across the whole retina. The second patient is a 16-year-old male presenting with defective vision since childhood. Best corrected visual acuity was 6/36 in both eyes. Pendular nystagmus was present. The intraocular pressure was 12 mmHg bilaterally. Pale discs, attenuated vessels, symmetrical retinal pigment epithelium atrophic changes and pigmentation in the inferior and nasal retina were present. Atrophic elliptical macula lesions were seen (Figure 2a). Hypoautofluorescence was seen in the inferior & and nasal retina (Figure 2b). OCT revealed distorted architecture of the retinal layers, altered foveal contour, atrophy and corrugations (Figure 2c). Central visual field showed peripherally constricted fields. Electroretinography showed extinguished waves with diminished amplitudes in the photopic phase involving the whole retina. Findings were in keeping with atypical hemiretinal cone-rod dystrophy in both patients. DISCUSSION Hemiretinal cone-rod dystrophy is a rare variant of cone-rod dystrophy with few cases reported in literature. It has been reported in a seven-year-old female with a mutation at C1490Y of the ABCA4 gene.6 Amelogenesis imperfecta with hemiretinal and bone spicule pigmentation is described in 3 families due to a mutation in CNNM 4.7,8 The autosomal recessive form of amelanogenesis imperfecta is linked with hemiretinal cone dystrophy.9 Our patients had characteristic cone-rod dystrophy symptoms such as decreased vision and colour vision loss and bull’s-eye maculopathy.3,4 Electroretinography findings of cone-rod dystrophy involving the whole retina, despite signs only in the inferior and temporal retina, may be an indication of evolving or early-stage typical cone-rod dystrophy.
To integrate eye health in wider health care systems as part of universal health coverage
2030 IN SIGHT is a sector strategy which aims to ensure that by 2030, no one experiences preventable sight loss, and everyone can achieve their full potential.1 To ensure that eye care and rehabilitation services are accessible, inclusive, and affordable to everyone, everywhere, whenever they are needed (Figure 1), and people understand the importance of caring for their own eye health and demand access to services, free from the weight of any social stigma. Integration helps the eye health sector to advance the direct and indirect sustainable development goals (SDGs) to which it is related, creating a fair, prosperous and sustainable world.2 Apart from (Universal Health Coverage (UHC), no poverty, zero hunger, gender equality, decent work and economic growth, climate action, partnerships for the goals, The (National Eye Health Programme (NEHP) brings together the WHO World Report on Vision, the WHA resolutions, the Lancet Global Health Commission on Global Eye Health and the Landmark UN resolution, Vision for Everyone and The Nigerian constitution, national regulations, policies, plans and data to achieve this specific sector strategy for all Nigerians.
2030 In Sight: “To ACTIVATE consumer demand and market change by raising public demand to ensure markets are responsive, remove barriers to care and make services available and affordable”
The International Agency for the Prevention of Blindness (IAPB)’s 10-year mission, 2030 In Sight, recognizes the hurdles that need to be overcome and presents the eye health sector with a new approach to ELEVATE, INTEGRATE and ACTIVATE. The Activate Strategy is the key to translating the overarching goals of this initiative into actionable outcomes at national and global levels. To activate this strategy successfully, adopting a multifaceted approach that includes eye health campaign reforms, financial mobilization, equity-focused actions, and active community participation is essential. Increased funding and collaboration across stakeholders, as well as robust monitoring and evaluation frameworks, will be key to ensuring that the global burden of preventable sight loss is reduced. Community engagement and public awareness are vital to seeking care early and adhering to treatment regimens. Public eye health campaigns also play a critical role in breaking down stigma and empowering individuals to take charge of their eye health. Ensuring equitable access to eye care is crucial for success, and financial models that reduce costs for underserved communities will improve outcomes and increase demand for services. This review explores the key components of the 2030 In Sight Activate Strategy, the critical actions required to implement it, what has been done so far, the challenges that need to be addressed for successful activation, and proffers suggestions about what we can do locally to drive consumer demand for eye care services. In conclusion, with concerted effort, 2030 In Sight can achieve its goal of significantly improving eye health outcomes worldwide, particularly for the most vulnerable populations.
Raising the next generation of surgeons: mentor-mentee relationships
This is the title given to me (IM) for the 2024 Ophthalmological Society of Nigeria conference. The concept of mentor-mentee relationships in medicine is as old as the profession itself. The original derivation of the word “mentor” relates to a person. Mentor was a friend of Odysseus in Greek mythology. When Odysseus went to fight the Trojan War, he left Mentor with two jobs. The first was to oversee his palace, and the second was to look after and teach his son Telemachus. Thus, the first mentor we know about was Mentor himself, and Mentor advised and trained Odysseus’s son; a deeper commitment than simply being a teacher.
Bilateral Morning Glory syndrome: a case report
INTRODUCTION The term Morning Glory Syndrome (MGS) was first described in 1970 by Peter Kindler and derived its name from its resemblance to a morning glory flower.1 MGS is a rare congenital malformation of the optic nerve which is frequently associated with midline abnormalities of the brain and skull.2 It is characterized by an enlarged, funnel-shaped excavation in the optic disc with peripapillary, chorio-retinal pigmentary changes, radial vessels and overlying central white glial tuft.3,4 The prevalence of MGS has been reported to be 2.6 per 100,000 with rare bilateral cases.5 It affects both sexes but females more commonly, and is rare in Africans.6 AIM To report a rare case of bilateral Morning Glory Syndrome in a 6-year-old girl. CASE REPORT A 6-year-old girl presented with poor distance vision and poor speech, observed one year before presentation. There was a positive history of use of herbal medications by the mother during pregnancy, on account of 9 years of infertility. Mother, who was 38 years old at the time of pregnancy, had a first-trimester febrile illness. The neonatal period was eventful with episodes of fever and jaundice. General examination showed a plump child, well-oriented, with left head tilt. Ocular examination showed visual acuity of 3/60 bilaterally, 30 degrees of alternating exotropia, and round pupils with pupillary reaction. Enlarged pale optic discs, predominantly radial vessels, and a surrounding hypopigmented cuff within an excavated area were seen on dilated fundoscopy. Visual acuity improved to 6/36 with -1.50 DS in both eyes after cycloplegic refraction. Oto-rhinolaryngology review showed pre-auricular sinus, bilateral impacted earwax, no septal deviation or cleft palate. Bilateral ear syringing and referral for speech therapy were done. Ultrasonography, Optical coherence tomography (OCT) and brain magnetic resonance imaging (MRI) were requested, but her father declined due to personal reasons. Consent for this report was obtained from her parents. DISCUSSION MGS is a rare congenital optic disc anomaly associated with ocular and non-ocular abnormalities.7 It presents in early childhood with decreased vision, strabismus, cleft lip/palate or basal encephalocele.8 Visual acuity is usually poor. Occlusion therapy or refraction may help improve the vision of the affected eye(s).9 Other ocular associations include: Nystagmus, Amblyopia, Retinal detachment, Persistent hyperplastic primary vitreous (PHPV), Congenital Cataract, microphthalmia, leucoma, optic nerve glioma, drusen, eyelid hemangioma.10 Our patient presented with some of the ocular and non-ocular features of MGS, including speech defect, alternating exotropia, myopia and poor vision in both eyes. Fundus photography revealed fundoscopic features seen in MGS. Ultrasonography, OCT, Fundus fluorescein angiography (FFA), CT scan, and MRI are the investigative approaches for the diagnosis of MGS and detection of the associations.10,11 Management requires an interdisciplinary approach. Prevention of amblyopia, improvement of vision and management of other non-ocular disorders are the treatment goals. Counselling of parents is essential to help them understand the condition and prognosis. A close differential diagnosis for the index case is optic disc coloboma. Others include optic nerve pit, optic atrophy, optic nerve hypoplasia, and peripapillary staphyloma.12
Presenting visual status of patients with corneal pathology
BACKGROUND The cornea serves as a meniscus lens, accounting for up to three-fourths of the total optical power of the human eye.1 Expectedly, any distortion of the cornea, even at an early stage, will profoundly impact on vision. Corneal disorders, whether infectious or non-infectious in origin, alter the corneal configuration and transparency with resultant visual deterioration and blindness in extreme cases.2, 3 Therefore, this study seeks to determine the visual status at presentation of patients with corneal diseases. METHODS It was a retrospective hospital-based cross-sectional study in the Eye Clinic, University of Calabar Teaching Hospital (UCTH), Cross River State, Nigeria. The records of patients (≥ 18 years) with clinical diagnosis of any corneal pathology between January 2018 and December 2022 were retrieved. Information retrieved included demographic characteristics, presenting visual acuity and clinical diagnosis. Data obtained were analysed with STATA/IC version 15.0. The study adhered to the tenets of the Declaration of Helsinki, and ethical approval was obtained from the Institutional Review Board of UCTH. RESULTS A total of 462 patients with clinical diagnosis of various corneal diseases involving 498 eyes were identified. The patients’ mean age was 41.9±15.1 years, and the male-to-female ratio was 1.6:1. Patients aged 21 to 40 years accounted for 238 (51.3%) of the study population. Only one-fifth 99 (20.0%) of eyes presented with normal vision. The remaining four-fifths presented with vision impairment (VI); slightly over half, 256 eyes (51.4%) presented blind, while 43 (8.6%) eyes had mild VI (Figure 1). Infectious keratitis was the predominant primary disease, accounting for 258 (51.8%) eyes. Most (68.0%) of cases of infectious keratitis were preceded by trauma from vegetative matter. CONCLUSION Corneal diseases grievously distort vision, with most (51.4%) presenting blind. Unfortunately, the young adult male segment of the population, which accounts for the most productive workforce of any economy, is predominantly afflicted. Infectious keratitis, a largely avoidable cause of blindness, is the most implicated. The foregoing is quite worrisome as corneal diseases may constitute a snag towards achieving critical Sustainable Development Goals (SDG 1-3, 5, 8, 10, 11). The resultant vision impairment can lead to decreased access to decent work, hinder inclusion and pose a threat to long-term health and wellbeing. Correspondingly, a recent report by the International Labour Organization (ILO) and the International Agency for the Prevention of Blindness (IAPB) highlighted that eye health significantly affects labour: people with vision impairment are 30% less likely to be employed and productive compared to those without.4 This underscores the need for coordinated global, national and regional eye health initiatives towards eliminating corneal blinding conditions.
Comparison of Arclight Loupe vs Traditional Direct Ophthalmoscope in evaluation of Corneal Epithelial Defects by General Practitioners: a proposal synopsis
BACKGROUND Corneal blindness is the 5th, 4th and 3rd leading cause of blindness globally, in Sub-Saharan Africa and Nigeria, respectively.1-3 Globally, corneal epithelial defects (CEDs), particularly corneal ulcers, constitute the major cause of corneal blindness.4 Regrettably, under-resourced areas and low- and middle-income countries (LMICs) with the least capacity to manage corneal lesions bear the greatest burden.4 Therefore, in order to encourage timely diagnosis of CEDs, the use of the +10 dioptre lens of the traditional direct ophthalmoscope (TDO) along with fluorescein dye has been advocated for use by non-ophthalmologists in the evaluation of suspected corneal lesions.5 Unfortunately, TDO use by non-ophthalmologists, including the general practitioners (GPs), the first-line physicians, is grossly limited. TDO skills deficiency, its bulk, relatively high cost, and sophistication are largely implicated.6 Arclight Loupe (AL), a portable, relatively low-cost and less sophisticated multipurpose diagnostic tool consisting of an anterior segment loupe, ophthalmoscope and otoscope, offers a reliable alternative to TDO.7 However, its utility in CEDs by GPs has not been assessed. OBJECTIVE To compare the utility of AL vs TDO in the clinical examination of corneal epithelial defects by GPs. METHODS A comparative cross-sectional study shall be undertaken. The study shall adhere to the tenets of the Declaration of Helsinki, and ethical approval shall be obtained from the Institutional Review Board of the University of Calabar Teaching Hospital, Calabar. Ten (10) TDO-exposed GPs will be recruited, trained and subsequently randomly assigned into two groups of 5 GPs each (group 1 & group 2). A cross-over design will be utilised in which group 1 uses the Arclight (Figures 1 and 2) first and subsequently the TDO, while group 2 will use the instruments in the reverse order. Study subjects (CED+ve vs CED-ve) shall be consecutively recruited and independently examined by the GPs. Three experienced Ophthalmologists (SL1-3) shall work together examining each consecutive subject with the Slit Lamp to establish the CED parameters (presence/location/shape/size/depth) as the “reference standard”. This study will compare the Arclight loupe to the Welch Allyn 11720-VC ophthalmoscope in terms of four measures: (1) accuracy of CED parameters (compared against the “reference standard”), (2) ease of examination (EOE) for the examiners (GPs) using a score of 1–8, (3) ease of use (EOU) for the examiners (GPs) using a score of 1–5, (4) ocular comfort level (OCL) as determine by the level of glare experienced by the subject using a score of 1–4, and (5) length of examination (LOE) as determined by the subject’s perceived duration of the assessment using a score of 1–4. RESULTS Data obtained shall be entered and appropriately analysed with STATA/IC version 15.0. CONCLUSION The prospective utility in the diagnosis of corneal epithelial defects using AL compared to TDO among GPs in our environment shall be objectively ascertained.
Early steroid responders post pterygium surgery: case series of adult patients in a tertiary hospital in Nigeria
INTRODUCTION Intraocular pressure (IOP) elevation can occur with the use of ocular and systemic steroids, particularly among steroid responders. Topical steroids are used to reduce post-operative inflammation following pterygium surgery. About 30-40% of adults are steroid responders1, and such a response may occur as early as three weeks postoperatively. The mechanism of IOP elevation results from increased aqueous outflow resistance due to morphological changes in the trabecular meshwork.2 An elevated IOP of a high magnitude and duration may damage the optic nerve and result in visual field loss. Our report aims to increase awareness among ophthalmologists regarding the occurrence of early intraocular pressure elevation in patients on topical steroid therapy following pterygium surgery. MATERIALS AND METHODS This was a single-centre study that evaluated three patients who underwent unilateral pterygium excision and conjunctival autograft at the University of Calabar Teaching Hospital, Calabar, during a one-month period (April-May 2024). Data collected from patient charts included age, gender, date of surgery, number of follow-up visits, IOP measurements in both eyes and past ocular history. Postoperatively, all patients received topical antibiotics (ciprofloxacin eyedrops 3 times a day) and steroid drops (dexamethasone eye drops 4 times a day). Postoperative follow-up visits were at day 1, one week, three months, and six months after surgery. Ocular examination and IOP measurements (using the Goldmann applanation tonometer) were performed at each visit. RESULTS A total of 6 eyes of 3 patients were studied. Their ages were 51 years, 44 years and 60 years respectively; two of them were females. The patients’ demographic and clinical data are presented in Table 1. Table 2 shows the IOP measurements before and after pterygium surgery. All six eyes had normal IOP (10- 11 mmHg) preoperatively. The 3 operated eyes all had elevated IOP during the post-operative period, with the peak IOP ranging from 20 -30 mmHg. DISCUSSION Steroid responders are individuals who experience an IOP rise in the setting of glucocorticoid use. The timeline over which the IOP rise may occur depends on the potency of the steroid, dose and route of administration.3 In our study, the IOP measurements were similar between both eyes in three patients pre-operatively. However, an increase in the IOP of greater than 6 mmHg was noticed on the first postoperative day in all three patients, necessitating the addition of a topical IOP-lowering medication to their medication regimen. This finding corroborates the study done by Toseafa et al 4 in Ghana, who reported steroid-induced hypertension as a common complication of pterygium excision. Similarly, Wu et al 5 reported the probability of experiencing elevated IOP after pterygium excision among Africans to be 10.91% at 1 week, 16.6% at 1 month, and 34.8% at three months, respectively. CONCLUSION We advocate close IOP monitoring after pterygium excision to enable early detection of steroid responders and timely intervention with IOP-lowering medications.
Occurrence of indapamide-induced acute angle closure in a predisposed patient calls for increased physician ophthalmologist collaboration: a case report
BACKGROUND Drug-induced Acute Angle Closure (AAC) is a sight-threatening ophthalmic emergency that occurs more commonly in predisposed patients. Acute angle-closure glaucoma occurs when the circulation of aqueous humor from the posterior to the anterior chamber is blocked, causing the pressure inside the eye to rise rapidly.1 This is an ocular emergency because if it is not treated quickly, it can lead to permanent loss of vision.2 Risk factors include anatomical factors such as shallow anterior chamber (AC) depth, short axial length, and plateau iris configuration. Demographic factors include female sex, Asian ethnicity, family history, and advanced age. In addition, some medications known as trigger drugs include adrenergic agonists, anticholinergics, cholinergics, sulfonamides, supplements, and serotonergic medications.3 OBJECTIVES The purpose of this case report is to draw the attention of ophthalmologists, physicians and general practitioners to the seriousness of drug-induced Acute Angle closure; to highlight the need to know the inciting classes of drugs and the need for physicians to collaborate with ophthalmologists to rule out predisposing eye conditions in patients before commencement of such medications. CASE PRESENTATION A 56-year-old male civil servant, a known hypertensive and diabetic, was recently placed on oral indapamide by his physician. He developed sudden, very severe ocular pain in his left eye (LE), soon after taking the first dose of oral indapamide 2.5mg. By the second dose, ocular pain became severe with profound diminution of vision, and seeing haloes around light. Ocular examination revealed visual acuity (VA) of counting fingers, conjunctival congestion, corneal haziness, shallow anterior chamber and mid-dilated, unreactive pupil. The left eyeball was notably hard, and intraocular pressure (IOP) was greater than 70 mmHg. He had recently been diagnosed with Primary Angle closure suspect based on shallow AC and occludable angles on gonioscopy in the same eye. He procrastinated the recommended urgent Laser peripheral iridectomy (LPI). He had previously undergone trabeculectomy in the right eye on account of primary angle-closure glaucoma. He was immediately advised to stop taking the indapamide and was treated with intravenous 20% Mannitol 250mls over 20 mins, Eye drops Pilocarpine 4% thrice daily, Dorzolamide/timolol fixed drug combination twice daily and oral Acetazolamide 250mg thrice daily. He was scheduled for immediate LPI, but this was delayed due to persistent hazy cornea with IOP above 45 mmHg. The cornea eventually cleared after discontinuation of Acetazolamide. The LPI was subsequently performed with good outcome as VA improved to 6/9 while IOP reduced to 10 mmHg. DISCUSSION This case report flags indapamide as a trigger for drug-induced AAC in a predisposed patient. Indapamide is a derivative of benzolsulphonamide, hence a sulphonamide.4 It is also noteworthy that whereas Diamox (acetazolamide) was indicated as an IOP-lowering agent to help this patient, it appeared to worsen his symptoms, also being a sulphonamide. Sulphonamide-induced angle closure glaucoma was first described in 1962.5 Indapamide is a very useful drug, growing in popularity as an effective antihypertensive treatment, especially among diabetic patients, probably because it is a thiazide-like diuretic without glucose or lipid disturbances.6 It is indicated for the treatment of hypertension and edema due to Congestive cardiac failure.4 However, like some other sulphonamides, it has been implicated as a trigger for drug-induced acute angle closure. The proposed mechanisms for sulphonamide-induced angle closure glaucoma include: Osmotic Disturbance within the crystalline lens leading to hydration of the lens and subsequent thickening with anterior displacement of the lens-Iris diaphragm5 Induction of ciliary body edema with subsequent supraciliary effusion resulting in forward rotation of the ciliary body and mechanical angle closure5 Accommodative spasm of the ciliary muscles7 A case report of a multimodal imaging study of indapamide-induced choroidal effusion showed evidence supporting the second of the three mechanisms described above.7
Social media as a frontier for creating glaucoma awareness: strategies, prospects and challenges
BACKGROUND Social media, across various platforms, has introduced innovative methods for disseminating information through the use of compelling videos and graphics, thereby enhancing the capacity for information absorption and comprehension.1 Through the years, traditional ways of creating glaucoma awareness, including radio, television broadcasts and community outreach programs, which are limited by geographical boundaries, have been employed. Despite this, awareness and knowledge about glaucoma remain low, particularly in developing countries.2 Social media platforms present an opportunity to reach a global audience with crucial glaucoma health information and allow feedback and engagement. We hereby present the results of a social media awareness campaign carried out during the 2024 World Glaucoma Week (WGW). METHODS We conducted a retrospective analysis of social media content and engagements created using the social media handles of the Ophthalmology department of the University of Ilorin teaching hospital, Ilorin, on four social media platforms during the 2024 World Glaucoma Week. The platforms used were Facebook, Instagram, YouTube and Twitter. Core patient information messages were put together by selected members of the eye care team of the Hospital. Graphic designs of patient information flyers were made. Patient information videos were created to give enough content for the awareness campaign, and these were uploaded daily throughout the WGW. Student and staff volunteers were named as glaucoma awareness ambassadors who worked to share and repost the social media posts and create engagement. Attempts were also made to contact the celebrities on social media pages in Nigeria, but no tangible responses were received from them. RESULTS A total of 24 posts, including 11 videos, 5 infographics and pictures, were made and shared across all 4 platforms. The 11 Instagram videos got a total of 1,753 views and 194 likes, the 11 Facebook videos got a total of 2,351 views, the 11 YouTube videos got 795 views, and the 11 Twitter videos got 380 views, 5440 impressions and 203 likes. The same videos were shared across all platforms. A total of 45 glaucoma awareness ambassadors worked throughout the glaucoma week to share the social media content. The absence of a dedicated social media manager posed significant challenges, requiring team members to spend additional time outside their regular professional schedule to manage content and engagement. Also, limited technical skills in digital media management hindered the optimal utilization of the social platforms. The specific limitations included the need for continuous posting of content, tracking insights made by the social media platforms, ensuring impressions on viewers’ comments, technical skills of continued creation of infographics/ carousels, monitoring of growth metrics on the social media pages, and a lack of familiarity with paid social media tools. The prohibitive cost of engaging social media influencers was also a limitation, as well as sustainability, as social media requires dedicated and consistent effort over time to yield results. CONCLUSION Social media is a frontier for creating glaucoma awareness and education to encourage early detection, which should be explored more by the eye care community.
Pattern of refractive error among staff of a tertiary health facility in Northwest Nigeria
Background: Globally, uncorrected refractive error is a major cause of blindness, visual impairment and low vision. Healthcare providers require optimal vision to function effectively; therefore, it is essential to determine their refractive state and provide appropriate intervention when necessary. Aim: To determine the refractive status and pattern of refractive error among staff of a tertiary health facility. Methods: A descriptive cross-sectional study conducted among staff of the Federal Teaching Hospital Birnin Kebbi between May and June 2018. Clinical and sociodemographic data, including level of education, tribe, department/unit, refractive state, and usage of corrective spectacles, were collected using a questionnaire designed for the study. Visual acuity was assessed using a Snellen chart; those with visual acuity less than 6/6 were further assessed using a pinhole. Streak retinoscopy at a working distance of two-thirds of a meter was performed in the eye clinic for those with features of refractive error. The data was analyzed using IBM SPSS version 21. Results: A total of 507 staff were examined; 113 (22.3%) had refractive error, 105(20.7%) had presbyopia, and 289 (57.0%) did not have any refractive error. There were 347(68.5%) males and 160(31.5%) females. Seventy-one subjects (14.0%) had myopia, 24(4.7%) had hypermetropia, while 18 (3.6%) had astigmatism. The commonest presbyopic correction was +1.00D. Conclusion: Refractive error is fairly common among the staff of this health facility. Health care workers are advised to regularly check their eyes and obtain refractive correction, if necessary, for optimal vision and effective function.
Is iCare rebound tonometry as accurate as Goldmann applanation tonometry in the measurement of intraocular pressure?
Background: Intraocular pressure (IOP) measurement is an important examination in ophthalmic practice, especially in the diagnosis of optic nerve disease. Aim: To compare intraocular pressure measurements obtained using the Goldmann applanation (GAT) tonometer with the iCare rebound tonometer (RBT) and evaluate the suitability of the iCare tonometer for routine clinical use. Methods: A total of 410 eyes of 205 patients were studied. Using GAT measurements, patients were classified into three groups: Group A (7–15 mmHg), Group B (16–22 mmHg) and Group C (≥23 mmHg). The RBT measurements were compared with the GAT measurements using Student's paired t-test and Pearson's correlation. Statistical significance was set at p<0.05, while a difference of ±3 mmHg between the two instruments was considered clinically significant. Results: There were 140 (34.2%) eyes in Group A, 206 (50.2%) eyes in Group B and 64 (15.6%) eyes in Group C. Overall, the mean difference in IOP values between GAT and RBT was 2.505±0.99 mmHg (p=0.096), while for Group C only, there was a statistically significant difference in the mean values of IOP obtained by GAT versus RBT (2.20±3.5 mmHg, p<0.01). There was a statistically significant correlation (r=0.84) between GAT and RBT measurements. Conclusion: iCare significantly underestimated IOP at high IOP levels compared with GAT. Nevertheless, differences in the overall mean IOP values obtained by GAT and RBT were statistically insignificant. This suggests that the two instruments may be used interchangeably, but with caution in glaucoma patients when elevated IOP values are anticipated.
Penetrating Ocular Trauma with A Retained Fishing Hook: A Case Report
Ocular trauma, a major cause of vision loss, may occur from diverse circumstances and agents. The outcome of ocular trauma is dependent on the cause, severity, and the immediate care given. This case report of a 10-year-old boy with sudden loss of vision following a fishing hook entry into his left eye aims to present a safe surgical technique for fishing hook removal and also highlight the need for early intervention following ocular injuries from a fishing hook.
Digital ocular massage to the rescue of failing blebs after filtering surgery
Modalities for the prevention and treatment of early bleb failure include augmentation with antimetabolites like mitomycin C, an intensive regimen of topical steroids, and various forms of bleb manipulation such as massage. Digital ocular massage involves application of gentle, controlled pressure with a finger on the eye through the upper eyelid to encourage aqueous flow through the bleb and prevent scarring. This article reports the outcomes of massage and other interventions in 3 patients after trabeculectomy. All patients had mitomycin C (MMC) augmented trabeculectomy (0.4mg/ml MMC applied for 3 minutes); cases #1 and #2 underwent fixed sutures technique, while case #3 had releasable sutures technique. Patients were instructed to massage by applying gentle pressure to the globe using the thumb through the upper eyelid. Case # 1 was a 6-year-old female noticed to have intraocular pressure (IOP) elevated to 22 mmHg 4 weeks post-operatively; and IOP reduced to 5 mmHg by the 9th post-operative week. Case #2 was a 10-year-old male noticed to have an IOP of 40 mmHg 6 weeks after surgery; he received 5-fluorouracil (5 FU) injections in addition to the massage, and IOP reduced to 13 mmHg by the 8th week after surgery. Case #3 was a 24-year-old male whose IOP increased to 23 mmHg 3 weeks after surgery. The patient had 5FU injections, needling and with ocular massage IOP reduced to 6 mmHg. Bleb fibrosis can be managed in the early post-operative period with ocular massage along with other interventions to improve bleb function.
I feel honoured to give this presidential lecture, and both myself and our family have very affectionate memories of five eventful years lived here in the 1960s and 70s. A quotation from the Danish 19th-century philosopher Soren Kierkegaard is a good starting point to reflect on my life since that formative time in Nigeria. “You must live life looking forward, but you can only understand life looking backward”. I have spent the last 60 years both teaching and practising ophthalmology in the UK, Nigeria and several other developing countries. As I reflect on these years, I hope I can offer some suggestions to a much younger audience with their work and career in front of them.
Minimal orbicularis oculi myectomy for treatment of severe benign essential blepharospasm: a case report
BACKGROUND Benign essential blepharospasm (BEB) is a type of dystonia that causes excessive involuntary spasms of the orbicularis oculi muscle.1 The spasms can have a significant impact on the daily activities of patients by causing visual disturbance or functional blindness, anxiety and depression.2 The most effective and commonly employed treatment option for BEB is the use of botulinum neurotoxin A.2 Botulinum toxin, which is expensive and only provides temporary relief of symptoms, was unaffordable to our patient. The successful management of a case of severe BEB by minimal orbicularis oculi myectomy (MOOM) with lasting symptom relief is hereby reported. CASE PRESENTATION A 60-year-old woman presented to our center with the complaint of inability to open her eyes for 6 weeks due to spasm of her eyelids. This was preceded by a 7-month history of excessive blinking and increasing difficulty keeping her eyes open voluntarily and unusual sensitivity to light. The spasms were worse during the day and forced her to keep her eyelids closed for almost the entire day, with minimal relief at night. There was no associated twitching or spasm of any other part of her body. She was a known diabetic and hypertensive and on oral medication for their control. On examination, the eyelids were tightly closed and the protractor muscles (orbicularis oculi, procerus and corrugator muscles) were spastic (Figure 1A). Attempts at manual opening of the eyelids were unsuccessful due to spasm of the eyelids. She was unable to keep her eyes open for visual acuity assessment, slit lamp examination and fundoscopy. Systemic evaluation and assessment by a neurologist revealed no other abnormality, and a diagnosis of severe benign essential blepharospasm was made. Botulinum toxin A (BTA) injection was recommended to her. However, she was unable to afford the cost. Besides, it was not readily available in our locality. We decided to try bilateral MOOM surgery on her under local anesthesia. At surgery, after routine cleaning and draping, the eyelids were infiltrated with local anesthesia (2% lignocaine with 1:1000 adrenaline). The orbicularis muscle of the upper eyelid was exposed through a lid crease incision. A muscle strip, 8 mm wide, was excised starting from above the tarsus about 2 centimeters from the lateral canthal angle up to the superior orbital rim in a diagonal direction upward and laterally (Figure 2). The strip included the orbital, septal and distal part of the pretarsal orbicularis muscle. Care was taken to leave the proximal half of the pretarsal muscle intact. The lower eyelid orbicularis muscle was exposed through a sub-ciliary skin incision and an 8 mm wide strip of orbicularis muscle was excised in a similar fashion to the upper eyelid. The same procedure was done on the contralateral eyelids. Incisions were closed with 5/0 Vicryl suture in an interrupted fashion. Pressure dressings were applied for 24 hours. She was prescribed prophylactic antibiotics and anti-inflammatory/analgesic medications. On the first post-operative day, her blepharospasm had decreased. There was eyelid oedema and ecchymosis. She was prescribed topical methylcellulose eye drops 4 times daily. At 3 weeks follow-up, the blepharospasm had significantly diminished and as well as the eyelid oedema, and she was able to open and close her eyes voluntarily (Figure 1B). Her visual acuity was 6/12 in both eyes and 6/6 with a pinhole. She had sustained significant relief from symptoms at 14 months of follow-up. The patient’s consent was obtained to publish this case report. CONCLUSION Minimal orbicularis oculi myectomy was effective in providing long-term significant relief of spasms. This may be a viable option for the treatment of BEB in low-income countries like Nigeria.
Clinical Activity Scores and Quality of Life in Thyroid Eye Disease: a study among Nigerian patients
BACKGROUND Thyroid eye disease (TED) is a rare, debilitating autoimmune disorder associated with orbital inflammation, pain, proptosis, diplopia, facial disfigurement and in severe cases, visual loss. Consequently, limitations in visual and psychosocial functioning could significantly impact the quality of life (QOL) of affected individuals. The clinical activity score (CAS)1 and the European Group on Graves’ Orbitopathy (EUGOGO) questionnaire 2,3 are widely used standardized assessment tools for disease severity and impact on QOL, respectively. Efforts to improve the standard of care in TED prompted the adoption of CAS & EUGOGO QOL. This study aims to utilize these tools to assess the impact of TED among Nigerian patients attending a tertiary health institution, with the goal of improving the standard of care. METHODS A prospective cross-sectional study of all TED patients attending the Oculoplastics unit of the study tertiary centre from January 2017 to June 2024 was conducted. Data collection was done using the Clinical Activity Score (CAS) of the Graves’ Orbitopathy Clinic proforma for new patients and the self-administered GO-QOL EUGOGO questionnaire (English Version). The visual functioning subscale of the GO-QOL questionnaire was used to assess the impact on activities of daily living such as driving, reading, watching TV, and mobility. The psychosocial subscale was used to assess the impact of TED in the domains of appearance changes, emotional well-being, and social functioning. Patients were categorized according to disease activity, severity, and limitations in visual and psychosocial functioning. IBM-SPSS Version 29 was used for data analysis. Ethical approval was obtained from the Institutional Review Board, and informed consent was obtained from patients. RESULTS Eighty-four patients (aged 17 – 76 years) were studied. There were 71 (84.5%) females. Female-to-Male ratio was 5.5:1. Diagnosis of Graves’ disease (hyperthyroidism) was made in 63 (75%), euthyroid in 20 (23.8%) and hypothyroidism in 1 (1.2%). Clinical activity score revealed that 31 (36.9%) had active disease (CAS ≥ 3/7) and 53 (63.1%) had inactive disease. The associated soft tissue inflammatory changes are as shown in Figure 1. Seventy-one (84.5%) had mild TED, while 2 (2.4%) had severe TED. Fifty-nine (70.2%)had mild impairment in QOL. There were limitations in visual and psychosocial functioning in 35 (41.7%) and 39 (46.4%) of the study population, respectively. The various domains of limitations are as shown in Tables 1 and 2, with reading, watching TV and hobby being the leading visual limitations, while feeling of change in appearance, being stared at in the street and avoiding photographs were the leading psycho-social limitations. Figure 2 shows a negative correlation between CAS and QOL, represented by the visual functioning and psychosocial functioning subscales' scores. DISCUSSION We observed a high prevalence of inactive disease (63.1%), though a considerable proportion (36.9%) had active disease with mild severity (84.5%). However, our findings highlight negative correlations between disease activity, as measured by CAS, and patient-reported QOL outcomes. As CAS increases, QOL deteriorates, particularly as related to the visual and psychosocial functioning of affected patients. This is comparable to the findings of earlier authors.4,5,6 Important activities of daily living, such as reading, watching TV and being hindered from something they wanted to do, were the leading limitations in terms of visual functioning of the affected patients. Changes in appearance, feeling of being stared at in the streets, need to mask their appearance, reduced self-confidence and appearing less in photos were the leading psychosocial limitations that were very much affected, similar to the findings of Smith et al7 and Beata et al.8 CONCLUSION The study revealed that a significant proportion of TED patients exhibit disease activity, though a large number had mild disease. TED also exerted a considerable negative impact on QOL, as indicated by the high prevalence of visual and psychosocial dysfunction among the patients. It is recommended that physicians heighten awareness of these limitations and consider using CAS in conjunction with GO-QOL questionnaires to comprehensively evaluate and therefore improve the standard of care of TED patients.