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Background Eye conditions in children can have negative consequences on visual functioning and quality of life. There is a lack of data on the magnitude of children with eye conditions who need services for effective planning of school eye health programmes. To address this, the School Eye Health Rapid Assessment (SEHRA) tool is being developed to collect data to support school eye health programme planning. Methods The module, ‘the magnitude and nature of local needs in school children’ is the first of six modules in the SEHRA tool. The module outlines a school-based cluster survey designed to determine the magnitude of eye health needs in children. This paper outlines the survey sampling strategy, and sample size calculations. Results The requirements for the SEHRA survey indicate that in regions where a larger sample size is required, or where fewer schools are recruited to the survey, confidence in the accuracy of the data will be lower. Conclusions The SEHRA survey module ‘the magnitude and nature of local needs in school children’ can be applied in any context. In certain circumstances, the confidence in the survey data will be reduced.

The Kilimanjaro Diabetic Programme has been running since 2010 and screens persons with diabetes for diabetic retinopathy (DR). It was noted that women were less likely to attend follow-up appointments compared to men. The aim of this study was to explore gender biases amongst persons registered with the screening programme.A prospective mixed-methods study was carried out using a questionnaire of closed-ended questions and a semi-structured interview guide.Of the 300 participants included in the quantitative component of the study, 193 (64.3%) were female and 107 (35.7%) were male. Females were significantly less educated (p 0.001) and self-reported as less likely to attend the tertiary hospital if referred (p = 0.022). Of the married participants, on multivariate analysis, men were significantly more likely to make both financial decisions in the household (p = 0.001) and to decide if, and when, family members should attend hospital compared to women (p = 0.0048), independent of age, education level and whether they were from an urban or rural area. Qualitative analysis of the 33 interviews revealed a good understanding of the threat to vision from DR, but limited appreciation of disease chronicity. A common theme was that men are regarded as the head of the household and therefore make the financial decisions; this was especially true in less educated families.As screening and treatment facilities for DR are developed in SSA, it is important that strategies are employed to reduce the burden of blindness and visual impairment from the under-utilisation of diabetic eye care services by women.

Background/AimGlaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma.MethodsWe designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months.ResultsTwenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, pConclusionThese results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery.Trial registration numberPACTR201803002159198.

BackgroundGlaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard.MethodsPost hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman’s rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma.Results382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma.ConclusionThis study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma.

Summary: Background: Glaucoma is a major cause of sight loss worldwide, with the highest regional prevalence and incidence reported in Africa. The most common low-cost treatment used to control glaucoma is long-term timolol eye drops. However, low adherence is a major challenge. We aimed to investigate whether selective laser trabeculoplasty (SLT) was superior to timolol eye drops for controlling intraocular pressure (IOP) in patients with open-angle glaucoma. Methods: We did a two-arm, parallel-group, single-masked randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Eligible participants (aged ≥18 years) had open-angle glaucoma and an IOP above 21 mm Hg, and did not have asthma or a history of glaucoma surgery or laser. Participants were randomly assigned (1:1) to receive 0·5% timolol eye drops to administer twice daily or to receive SLT. The primary outcome was the proportion of eyes from both groups with treatment success, defined as an IOP below or equal to target pressure according to glaucoma severity, at 12 months following randomisation. Re-explanation of eye drop application or a repeat SLT was permitted once. The primary analysis was by modified intention-to-treat, excluding participants lost to follow-up, using logistic regression; generalised estimating equations were used to adjust for the correlation between eyes. This trial was registered with the Pan African Clinical Trials Registry, number PACTR201508001235339. Findings: 840 patients were screened for eligibility, of whom 201 (24%) participants (382 eligible eyes) were enrolled between Aug 31, 2015, and May 12, 2017. 100 (50%) participants (191 eyes) were randomly assigned to the timolol group and 101 (50%; 191 eyes) to the SLT group. After 1 year, 339 (89%) of 382 eyes were analysed. Treatment was successful in 55 (31%) of 176 eyes in the timolol group (16 [29%] of 55 eyes required repeat administration counselling) and in 99 (61%) of 163 eyes in the SLT group (33 [33%] of 99 eyes required repeat SLT; odds ratio 3·37 [95% CI 1·96–5·80]; p

BACKGROUND Globally, the majority of visually impaired persons live in low- and middle-income countries. One of the reasons is a lack of ophthalmologists in the respective countries. Migration of qualified personnel would be an additional strain on ophthalmological patient care. OBJECTIVE This analysis aimed at evaluating the attitude of African residents in ophthalmology towards working in their home country or migrating abroad and comparing these findings with existing data also with respect to possible interventions. MATERIAL AND METHODS In 2016 and 2017, participants of ophthalmological training courses for residents in Dar es Salaam (Tanzania) and Addis Ababa (Ethiopia) as well as residents from Moshi (Tanzania) were interviewed on possible migration with the help of a questionnaire. RESULTS In total 60 questionnaires were analyzed. The main reasons for staying in the home country were: "want to support/serve community", "family" as well as "high demand of specialists". Prime motives for possible migration were: "better income", "better working structure/equipment" and "better education". CONCLUSION Links between German and African eye hospitals as they are supported, for example by the working group International Ophthalmology of the German Ophthalmological Society (DOG) and the German Committee for the Prevention of Blindness (DKVB), can contribute to improve some of the main reasons of migration, such as insufficient education, working structures and equipment and thus help to prevent a brain drain.

Introduction: Glaucoma in Sub Saharan Africa (SSA) poses a daunting challenge. Communities are often unaware of the serious implications of glaucoma and are faced with limited access to specialists, making early detection and management difficult. For those who have been diagnosed, socioeconomic barriers limit access to treatment.Since 2006, we have been involved in an innovative program we term ‘STOP Glaucoma in SSA’. The four main pillars of this program include building capacity, enhancing awareness, and improving glaucoma detection and management. The aim of this initiative is to train the first generation of highly qualified glaucoma subspecialist leaders and to develop centers of excellence for glaucoma care throughout SSA that are interconnected. Our ultimate aim is to reduce the burden of blindness from glaucoma in SSA.Areas covered: Our review addresses background context, provides learning from the first decade of this program, and offers solutions to help tackle the scourge of glaucoma ...

Purpose: To compare severity of visual field (VF) loss at first presentation in glaucoma clinics in England and Tanzania. Methods: Large archives of VF records from automated perimetry were used to retrospectively examine vision loss at first presentation in glaucoma clinics in Tanzania (N = 1,502) and England (N = 9,264). Mean deviation (MD) of the worse eye at the first hospital visit was used as an estimate of detectable VF loss severity. Results: In Tanzania, 44.7% {CI95%: 42.2, 47.2} of patients presented with severe VF loss (< −20 dB), versus 4.6% {4.1, 5.0} in England. If we consider late presentation to also include cases of advanced loss (-12.01 dB to -20 dB), then the proportion of patients presenting late was 58.1% {55.6, 60.6} and 14.0% {13.3, 14.7}, respectively. The proportion of late presentations was greater in Tanzania at all ages, but the difference was particularly pronounced among working-age adults, with 50.3% {46.9, 53.7} of 18–65-year-olds presenting with advanced or severe VF loss, versus 10.2% {9.3, 11.3} in England. In both countries, men were more likely to present late than women. Conclusions: Late presentation of glaucoma is a problem in England, and an even greater challenge in Tanzania. Possible solutions are discussed, including increased community eye-care, and a more proactive approach to case finding through the use of disruptive new technologies, such as low-cost, portable diagnostic aids.

By 2030, sub‐Saharan Africa is forecast to see the steepest rise in the number of people with hypertension of any world region. Hypertensive retinopathy is known to be a common complication of hypertension in developed countries and some studies suggest it is associated with the presence of other hypertension‐related end‐organ damage (EOD) such as stroke and cardiovascular disease. In Tanzania hypertension is relatively more common than in other parts of sub‐Saharan Africa, especially in the older population; however, the prevalence of hypertensive retinopathy and its association with EOD remain unknown. The authors conducted a cross‐sectional study of elderly, community‐dwelling, rural Tanzanians to determine the prevalence of hypertensive retinopathy and its association with hypertension and other forms of EOD. Hypertensive retinopathy was diagnosed based on retinal imaging. In a cohort of 61 patients with gradable images, the authors found the overall prevalence of hypertensive retinopathy to be 64% (n = 39), which was strongly associated with hypertension (X (2) [1] = 4.207, P = .004), with a significant trend towards more severe retinopathy with more severe hypertension (r = .377, P = .003). The authors did not find hypertensive retinopathy to be associated with other forms of EOD. Hypertensive retinopathy is highly prevalent in this population and is associated in most but not all cases with hypertension. These findings do not suggest that it could be used as a screening tool for EOD, but it is important to identify and educate patients with retinopathy about possible complications of the condition.

Objective To investigate the barriers to access to eye health services for patients with glaucoma in Tanzania with the aim of identifying key areas for improvement and further research. Design Qualitative investigation using face-to-face semi-structured interviews with patients recruited from the Kilimanjaro Christian Medical Centre (KCMC) outpatient eye clinic. This project is part of the international strategy of the Research into Glaucoma and Ethnicity (ReGAE) programme. Methods Interviews were conducted with the help of a translator; all data were transcribed in Swahili and then translated into English. Manual coding and qualitative analysis was used to identify major themes and relevant concepts. Data were collected during May and June 2013. Main outcome measures Qualitative data on glaucoma awareness and access to healthcare. Results 12 patients (7 men, 5 women) of mean age 67.5 years (range 53–86 years) were interviewed. All participants had a previous diagnosis of glaucoma and no other eye conditions. The understanding of glaucoma was limited and the capacity for healthcare providers to improve glaucoma knowledge seemed underused. Participants had particular difficulty in understanding the aetiology and chronicity of the disease. Socioeconomic factors also posed significant barriers to service usage. Conclusions Among many barriers to access to health services for patients with glaucoma, knowledge of the condition was identified as a key issue. Enhancing the understanding of glaucoma may improve access by triggering earlier presentation, informing those at risk and improving adherence to treatment. This is an area for further research with potential for improving service provision.

The purpose is to describe the outcome of trabeculectomy with transscleral cyclophotocoagulation (TSCPC) as an initial intervention for secondary childhood glaucoma in Northern Tanzania.A retrospective, consecutive case series was analyzed of all children with secondary childhood glaucoma who underwent initial trabeculectomy or TSCPC between 2000 and 2013 at a referral eye unit in Northern Tanzania. Retrospective data were collected on causes of glaucoma, intraocular pressure (IOP), visual acuity, complications, and subsequent interventions. Outcomes were evaluated using Kaplan-Meier survival analysis and compared with Cox regression analysis. The main outcome measure was failure (IOP21 mm Hg).Thirty-six eyes of 27 children (male, 21; median age, 9 y; range, 0.3 to 15 y) with secondary childhood glaucoma underwent trabeculectomy (19 eyes, 53%) or TSCPC (17 eyes, 47%). Causes included ocular trauma (13, 36%), previous cataract surgery (12, 33%), congenital aniridia (5, 14%), Sturge-Weber syndrome (2, 6%), steroid-induced glaucoma (2, 6%), uveitis (1, 3%), and unspecified leucoma (1, 3%). After 12 months, success was achieved in 48% after trabeculectomy and 18% after TSCPC, with visual acuity remaining unchanged in 11 of 14 (79%) and 4 of 5 eyes (80%), respectively. One third of the children did not return for follow-up after 1 year. Distance to the hospital (100 km) was a significant risk factor for trabeculectomy failure (P=0.031).A high proportion of secondary childhood glaucoma in Northern Tanzania was caused by trauma and previous cataract surgery. Trabeculectomy was associated with better IOP control but also a higher complication rate. The ability to maintain visual function was comparable after both interventions. Failure was associated with a journey to the eye hospital (100 km) possibly leading to late presentation with advanced disease and erratic follow-up.

Background Diabetes is an emerging public health problem in sub-Saharan Africa. Diabetic retinopathy is the commonest microvascular complication of diabetes and is a leading cause of blindness, mainly in adults of working age. Follow-up is crucial to the effective management of diabetic retinopathy, however, follow-up rates are often poor in sub-Saharan Africa. The aim of this study was to assess the proportion of patients not presenting for follow-up and the reasons for poor follow-up of diabetic patients after screening for retinopathy in Kilimanjaro Region of Tanzania. Methods All diabetic patients referred to a tertiary ophthalmology hospital after screening for retinopathy in 2012 were eligible for inclusion in the study. A randomly selected group of patients from the community-based diabetic retinopathy screening register were identified; among this group, follow-up was assessed. Interviews were conducted within this group to inform on the reasons for poor follow-up. Results Among the 203 patients interviewed in the study 50 patients (24.6 %) attended the recommended referral appointment and 153 (75.4 %) did not. Financial reasons were self-reported by 35.3 % of those who did not attend the follow-up appointment as the reason for non-attendance. Multiple logistic regression analysis showed that the patient report of the clarity of the referral process (p = 0.014) and the patient report of whether a healthcare worker told the patient that diabetic retinopathy could be treated (p = 0.005) were independently associated with attendance at a follow-up appointment. Income per month was not associated with attendance at a follow-up appointment on multivariate analysis. Conclusions Financial factors are commonly cited as the reason for non-compliance with follow-up recommendations. However, the reasons for poor compliance are likely to be more complicated. This study highlights the importance of health system factors. Improving the clarity of the referral process and frequent reminders to patients that diabetic retinopathy can be treated are practical strategies that should be incorporated into screening programmes to increase attendance at subsequent follow-up appointments. The results from this study are applicable to other screening programmes as well as those for diabetic retinopathy. Electronic supplementary material The online version of this article (doi:10.1186/s12886-016-0288-z) contains supplementary material, which is available to authorized users.

Objective The number of adults with diabetes in sub‐Saharan Africa (SSA) is expected to almost double by 2035. This study investigated the prevalence of diabetic retinopathy (DR) and its risk factors at entry into a community‐based screening programme. Methods All persons with diabetes screened for retinopathy at entry into a screening programme in Kilimanjaro Region, Tanzania between November 2010 and December 2014 were included. Fundus photographs were taken with a Topcon retinal camera following pupil dilation. Data were collected on BP, random blood sugar, duration of diabetes, BMI and visual acuity on entry. Results A total of 3187 persons were screened for DR. The prevalence of any DR was 27.9% (95%CI 26.4–29.5%) with background diabetic retinopathy (BDR), pre‐proliferative diabetic retinopathy (PPDR) and proliferative diabetic retinopathy (PDR) having a prevalence of 19.1% (95% CI 17.7–20.4%), 6.0% (95%CI 5.2–6.8%) and 2.9% (95%CI 2.3–3.5%), respectively. Maculopathy was present in 16.1% (95%CI 14.8–17.4%) of participants. Multivariable logistic regression analysis for the presence of any DR found independent associations with duration of diabetes (P < 0.0001), systolic BP (P < 0.0001), random blood sugar (P < 0.0001) and attending a government hospital diabetic clinic (P = 0.0339). Conclusions This study is the first to present data from a DR screening programme in SSA. The results will provide policymakers with data to aid planning of DR screening and treatment services in the African region. The study highlights the importance of managing comorbidities within DR screening programmes.

Aim To evaluate goniotomy, trabeculotomy, transscleral cyclophotocoagulation (TSCPC) and trabeculectomy as initial procedures in children with primary childhood glaucoma from Northern Tanzania. Methods A retrospective analysis of consecutive interventions for primary childhood glaucoma from 2000 to 2013 was conducted at the Kilimanjaro Christian Medical Centre. Success was defined as postoperative intraocular pressure (IOP) below 22 mmHg. Success rates, IOP, visual acuity (VA), subsequent interventions and potential risk factors for failure were reported for the respective interventions. Results The study included 116 eyes of 70 children (age 4.6±5.9 years) with primary childhood glaucoma; 46 (65.7%) children were male. The preoperative IOP was 33.1±10.2 mmHg, the preoperative cup/disc (CD) ratio 0.71±0.3 and the corneal diameter 13.3±1.4 mm. As a primary intervention, 61 (52.6%) eyes underwent goniotomy, 10 (8.6%) eyes trabeculotomy, 12 (10.3%) TSCPC and 33 (28.4%) trabeculectomy. Follow-up data after 12 months were available for 63 (54.3%) eyes. Success rates at 12 months were 38% (goniotomy), 30% (trabeculotomy), 17% (TSCPC) and 64% (trabeculectomy). All interventions achieved a statistically significant IOP reduction at 3, 6 and 12 months, except for trabeculotomy after 6 months and TSCPC at all time points. Postoperative endophthalmitis occurred in one child treated with trabeculectomy. VA in 82% of all eyes was maintained or had improved after 12 months. Conclusions Based on the success rates of this retrospective analysis, goniotomy or trabeculotomy for younger and trabeculectomy for older children can be recommended in our setting to reduce IOP. Late presentation in combination with advanced glaucomatous damage as well as erratic postoperative follow-up and treatment were likely factors that compromised overall success rates. More efforts are necessary to detect the blinding disease earlier and improve adherence to follow-up.

Background Trachoma, caused by Chlamydia trachomatis (Ct), is the leading infectious cause of blindness worldwide. Yearly azithromycin mass drug administration (MDA) plays a central role in efforts to eliminate blinding trachoma as a public health problem. Programmatic decision-making is currently based on the prevalence of the clinical sign “trachomatous inflammation-follicular” (TF) in children. We sought to test alternative tools for trachoma surveillance based on serology in the 12-year cohort of Kahe Mpya, Rombo District, Tanzania, where ocular chlamydial infection was eliminated with azithromycin MDA by 2005. Methodology and Principal Findings The present study was a community-based cross-sectional survey in Kahe Mpya. Of 989 residents, 571 people aged 6 months to 87 years were enrolled: 58% of the total population and 73% of 1–9 year olds, the key WHO indicator age group. Participants were examined for TF, had conjunctival swabs collected for nucleic acid amplification test (NAAT)-based detection of Ct, and blood collected for analysis of antibodies to the Ct antigens pgp3 and CT694 by multiplex bead-based immunoassay. Seroconversion rate was used to estimate changes in the force of infection in a reversible catalytic model. No conjunctival swabs tested positive for Ct infection by NAAT. Among 1–9 year olds, TF prevalence was 6.5%, whereas only 3.5% were seropositive. Force of infection modelling indicated a 10-fold decrease in seroconversion rate at a time corresponding to MDA commencement. Without baseline serological data, the inferences we can make about antibody status before MDA and the longevity of the antibody response are limited, though our use of catalytic modelling overcomes some of these limitations. Conclusions/Significance Serologic tests support NAAT findings of very low to zero prevalence of ocular Ct in this community and have potential to provide objective measures of transmission and useful surveillance tools for trachoma elimination programs., Author Summary Trachoma is the leading infectious cause of blindness. The infectious agent, Chlamydia trachomatis, can be treated with a single oral dose of azithromycin. Donated drug is a cornerstone of programs dedicated to the elimination of trachoma as a public health problem. Azithromycin is given to the entire district for 3–5 years when 10% or more of 1–9 year-olds in the district have signs of a defined follicular conjunctivitis in one or both eyes. However, follicles can be difficult to reliably diagnose and can be caused by other pathogens, especially in settings with low trachoma prevalence. More sensitive and specific ways to assess communities for trachoma transmission at program endpoints are needed. Herein we examined antibody responses in children living in a community in Tanzania born after stopping drug treatment 10 years previously. Low antibody levels (3.5% in 1–9 year-olds) reflected the lack of ocular chlamydial infection in these children. We also modelled the data to show that changes in age-specific antibody prevalence occurred when the mass drug treatment stopped. These data suggest that the age-specific prevalence of antibody responses may be of use to programs seeking to demonstrate the impact of interventions against trachoma.

Background. The Arclight ophthalmoscope is a low-cost alternative to standard direct ophthalmoscopes. This study compared the Arclight ophthalmoscope with the Heine K180 direct ophthalmoscope to evaluate its reliability in assessing the vertical cup disc ratio (VCDR) and its ease of use (EOU).Methods. Eight medical students used both the Arclight and the Heine ophthalmoscopes to examine the optic disc in 9 subjects. An EOU score was provided after every examination (a higher score indicating that the ophthalmoscope is easier to use). A consultant ophthalmologist provided the reference standard VCDR.Results. 288 examinations were performed. The number of examinations that yielded an estimation of the VCDR was significantly higher for the Arclight ophthalmoscope (125/144, 85%) compared to the Heine ophthalmoscope (88/144, 61%) (p<0.001). The mean difference from the reference standard VCDR was similar for both instruments, with a mean of −0.078 (95% CI: −0.10 to −0.056) for the Arclight and −0.072 (95% CI: −0.097 to −0.046) for Heine (p=0.69). The overall EOU score was significantly higher for the Arclight ophthalmoscope (p<0.001).Conclusion. The Arclight ophthalmoscope performs as well as, and is easier to use than, a standard direct ophthalmoscope, suggesting it is a reliable, low-cost alternative.