PROF. KARIMURIO JEFITHA

The East African Journal of Ophthalmology (EAJO) is the offi cial Journal of the Ophthalmological Society of East
Africa (OSEA). It was established in 1976 and aims to improve all aspects of ophthalmology and community eye
health. To achieve these objectives, the journal publishes original scientifi c articles, reviews, clinical case reports
and letters dealing with any factor impacting eye health. From 2007, the EAJO will be published quarterly on
line.

Introduction A survey to determine the prevalence of trachomatous trichiasis (Tl] requires a large sample size and the recommended participant age is 2': 15 years. This study sought to establish the appropriate age range of individuals to be included in Tl surveys. Methods Data from six previous surveys of adults 2': 15 years old were reanalysed. Results Reanalysis indicated that 69.6-93.3% (average 87.0%) of untreated n occurred in those aged 40+ years and 52.2-86.7% (average 73.1%) in those aged 50 + years (age 2':50 years is used in rapid assessment of avoidable blindness). Age 2':40 years was adopted in a Tl survey conducted in Turkana district because it allowed a smaller sample size than age 2':15 years. Conclusions The estimated backlog of untreated Tl in people aged 2':40 years old in Turkana was 5932 and the overall n backlog was likely to be 6358-8523. These findings cannot be generalised because all surveys were carried out in the same country.

Prevalence surveys are mandatory before new trachoma control projects are funded and existing ones continued. When a large administrative district with >200,000 people is surveyed as one trachoma intervention unit, the survey clusters are widely spaced and it is difficult to establish the distribution of the disease at the sub-district level with certainty. As a result, some trachoma-endemic areas in Kenya have been missed out and non-endemic areas included in mass antibiotic treatment. The other challenge is the large sample size required in standard trachomatous trichiasis (TT) surveys that include participants aged >15 years. The main objective of this study was to develop an effective and efficient survey method to justify administration of mass antibiotic treatment for active trachoma. The other objective was to establish the optimum lower age limit of TT survey participants, to ensure that the time required to complete a TT survey was the same as the time required to complete a TF survey, while ensuring that the sample was adequately representative of the TT backlog. The costs of surveys and administration of mass antibiotic treatment were determined for comparison of the standard and new survey methods. Data sets for previous surveys were re-analysed to calculate the optimum lower age limit of TT survey participants and correction factors to extrapolate the total backlog of TT.

A “Trachoma Survey by Segment” (TSS) method was developed to justify and reduce the cost of mass antibiotic treatment. It was tested in Turkana, a large hyper-endemic district with 543,199 people and Narok, a meso-endemic district with 576,388 people. Each district was divided into five geographical areas (segments). A segment had a population of 100,000–200,000 people. Areas with similar risk of trachoma were aggregated in the same segment. The segments with <10% prevalence of TF in children 1-9 years were excluded (knocked-out) from mass treatment, 10%-30% treated for 3 years and >30% treated for 5 years.

An efficient TT40 survey method was also developed where the backlog of TT was estimated in people >40 years old and correction factors used to extrapolate the total backlog. A TT40 survey required a smaller survey sample than a standard TT survey. The backlog correction factor for the lower age limit of 40 years was 1.1.

In Turkana district 3,962 children aged 1-9 years were examined and the prevalence of TF in the whole district was 38.0% (95%CI: 32.2%-43.9%). If the survey was conducted using the standard survey by administrative district method the whole population would have been treated for 5 years. However, the TSS method revealed that two segments needed treatment for 3 years and three segments for 5 years. After mass treatment the areas will be re-surveyed to justify further treatment.

In Narok district 3,998 children aged 1-9 years were examined and the prevalence of TF was 11.0% (95%CI: 8.0%-14.0%). The entire district had received three rounds of mass antibiotic treatment prior to this study. If this study was conducted by administrative district method, the whole population could have been treated for another three years. The TSS method identified three non-endemic segments which were excluded (knocked-out) from further treatment.

In Turkana district 2,962 people >40 years were examined and 7.8% (95%CI: 6.8%-8.8%) had TT while in Narok 2,996 people >40 years were examined and 2.9% (95%CI: 2.2%-3.6%) had TT. All the segments in both districts needed TT surgical services.

The cost of a survey by the administrative district method was $15,726 to $28,905, while by the TSS method it was $31,917 to $40,610 ($6,383 to $8,122 per segment). In 2009, the unit cost of administration of mass treatment was $0.20 to $0.42 per person treated. In Turkana district (hyper-endemic setting), the total cost of a survey and administration of mass treatment by the TSS method was $11,705 (1.7%) more expensive that by the administrative district method. In Narok district (meso-endemic setting with clustered trachoma) the survey by TSS method and administration of mass treatment was cheaper by $168,275 (53.2%).

It was concluded that the TSS is an effective trachoma survey method to identify the areas that need mass antibiotic treatment. For short term (<3 years) mass treatment in a hyper-endemic district like Turkana, the TSS method has no advantage over the administrative district method. For long term treatment, the TSS method is recommended because some segments may not require treatment for >3 years. The TT40 is an efficient trachoma survey method to determine the backlog of people with TT.

Purpose: To determine and compare the cost of MDA using two survey methods.
Methods: An impact survey was conducted to justify continuation of MDA in Narok district (543,199 people). The district was segmented into 5 segments (trachoma districts) of approximately equal population and surveyed. Cost of MDA was estimated using the prevalence estimate for the entire district (the standard survey method) and for individual segments (proposed survey by trachoma district method). The starting threshold for MDA is 10% prevalence of active trachoma in children aged 1-9 years.
Results: Prevalence in the entire district was 11.0% and MDA was justified while in the segments it was 0.4%, 2.3%, 4.1%, 21.6% and 26.8% and MDA was justified two segments only. The cost of MDA in the entire district was 28,246 dollars. The cost of conducting survey by the standard and the “trachoma district” methods was 27,160 and 32,592 dollars respectively.
Conclusions: The cost of MDA was higher than the cost of survey since MDA is administered annually. Exclusion of three segments from MDA justified the added cost of conducting the survey by “trachoma districts”.

Introduction: A survey to determine the prevalence of trachomatous trichiasis (TT) requires a large sample size and the recommended participant age is >15 years. This study sought to establish the appropriate age range of individuals to be included in TT surveys.
Methods: Data from six previous surveys of adults >15 years old were reanalysed.
Results: Reanalysis indicated that 69.6-93.3% (average
87.0%) of untreated TT occurred in those aged 40+ years and 52.2e86.7% (average 73.1%) in those aged 50+ years (age >50 years is used in rapid assessment of avoidable blindness). Age >40 years was adopted in a TT survey conducted in Turkana district because it allowed a smaller sample size than age >15 years.
Conclusions: The estimated backlog of untreated TT in people aged >40 years old in Turkana was 5932 and the overall TT backlog was likely to be 6358-8523. These findings cannot be generalised because all surveys were carried out in the same country.

Purpose: To determine possible differences in visual acuity, socio-demographic factors and visionrelated Quality of Life (QoL) between people accepting and people refusing sponsored cataract surgery.
Methods: Three hundred and fifty seven local residents with visually impairing cataract, presenting at screening sites in Kwale District, Kenya were clinically assessed and interviewed. The World Health Organization (WHO) QoL-questionnaire WHO/Prevention of Blindness and Deafness Visual Functioning Questionnaire 20 (PBD-VFQ20) was used to determine the vision-related QoL. A standardized questionnaire asked for socio-demographic data and prior cataract surgery in one eye. After interview, patients were offered free surgery. Primary outcome was the mean QoL-score between acceptors and non-acceptors. Secondary outcomes were visual acuity and socio-demographic factors and their contribution to QoL-scores and the decision on acceptance or refusal.
Results: Fifty nine people (16.5%) refused and 298 accepted cataract surgery. Vision-related QoL was poorer in people accepting than in those refusing (mean score 51.54 and 43.12 respectively). People with poor visual acuity were only slightly more likely to accept surgery than people with better vision; the strongest predictors of acceptance were the QoL-score and gender. Men were twice as likely to accept compared to women. Of people who accepted surgery, 73.8% had best eye vision of 20/200 or better.
Conclusion: In this population, visual acuity was of limited use to predict a person’s decision to accept or refuse cataract surgery. QoL-scores provide further insight into which individuals will agree to surgery and it might be useful to adapt the QoL-questions for field use. Gender inequities remain a matter of concern with men being more likely to get sight-restoring surgery.

Objective: To determine the barriers to uptake of eye care services and to establish the pattern of utilization of eye care services in the Nairobi Comprehensive Eye Care Services (NCES) Project; the catchment area of the Mbagathi District Eye Unit of Nairobi.
Design: Community based survey conducted from 15th to 31st October 2007
Setting: Kibera and Dagoreti divisions of Nairobi City
Subjects: Of the 4,200 people of all ages who were randomly selected; 4,056 were examined giving a response rate of 96.6%. Of those not examined, 126 (3.0%) were not available and 15 (0.4%) refused to be examined. Mean age of the study population was 22 years.
Results: A total of 294 subjects (7.2%) despite having some ocular disorder, had not visited any health facility to seek treatment. The majority, 144 (49%) gave the reason as no perceived need to seek treatment as the problem did not bother them; especially those with refractive error. A third, 97 (33%), gave the reason as lack of money, 22 (7.5%) said that they did not know where to seek eye care and 20 (6.8%) said they had no time to seek eye care. Only 3 said that the health facility where to go for eye care was too far. The population in the survey area has vast number of nearby secondary and tertiary eye care facilities to choose from. The majority of subjects indicated Mbagathi District Hospital (20.9%), Kikuyu Eye Unit (18.5%), Kenyatta National Hospital (12.1%) and private clinics (10.9%) as their health facilities of choice for eye care. The rest preferred Lions Sight First Eye Hospital, St Mary’s Hospital, City Council Health Centers and optical shops. 7.7% of the subjects would visit a health centre or dispensary if they had an eye problem. A signifi cant proportion of respondents (7.5%) had no idea where they could seek treatment for eye disorders; most of them knew Mbagathi District Hospital and Kenyatta National Hospital but were not aware that eye care services were available at these facilities.
Conclusion: Despite the large number of eye care facilities surrounding the NCES, community members are not able to access their services mainly because of lack of felt need (ignorance) and lack of money (poverty).
Recommendations: There is need for eye health education and review of cost of services to the very poor communities within the NCES. It is important to strengthen the community eye care structures and referral network now that the project area has excess secondary and tertiary health facilities offering eye care services.

Objectives: To establish the prevalence of active trachoma (TF) in childrenaged 1-9 years; potentially blinding trachoma (TT) in adults >15 years and to document the magnitude of selected known trachoma risk factors.
Design: Baseline community based survey conducted in March 2008 using the standardized WHO protocol.
Setting: Evangelical Lutheran Church of Kenya (ELCK)-Arsim Integrated Development Project area, Samburu District, Lift Valley Province, Kenya.
Subjects: A total of 47 villages and 71 households were visited. 862 children aged 1-9 years and 1,044 adults aged ≥15 yrs were examined. 427 (49.5%) of the children were boys and 435 (50.5%) were girls. 330 (31.6%) of the adults were males and 714 (68.4%) were females. 97.6% of adults and 90.0% of children over 5 years had never gone to school.
Results: The prevalence of active trachoma (TF) in children was 31.3% (95% CI: 28.2 – 34.4). Boys and girls were equally affected. Children 1-5 years of age were most affected. The prevalence of potentially blinding trachoma (TT) in adults >15 years was 2.2% (95% CI: 1.5–2.9). Of those with TT, 5 (22%) were males and 18 (78%) females. The prevalence of TT increased with age. Eight (34.8%) of those with TT had coexisting corneal opacity meaning that they were either blind or going blind. Of he 1044 adults examined during the survey, 371 (35.5%) had TS giving a TT to TS ratio of 1:16. This implies that it will take time before potentially blinding trachoma (TT) is eliminated. Known trachoma risk factors were documented. During the dry season, most households take about 3 hours to fetch water. During the wet season, they take about 1 hour. A total of 460 (53.4%) children examined had dirty faces. No household had a leaky tin. No household has a leaky tin. Ten of the 47 villages visited did not have any communal water point. In most households (97.4%) animals were kept no more than 20 meters of the house. Most (57.4%) households had animals kept inside the house at times. Only 7 (11%) of the 155 households had latrines (built as part of a demonstration project). 58 households (37.4%) had uncovered human faeces in/around the compound. In 125 (80.6%) of the households, garbage was scattered all over the compound.
Conclusions: It was concluded that both, active and potentially blinding trachoma are a public health problem in the ELCK-Arisim integrated development project area.
Recommendations: The whole population (23,607 people) living in the project area need mass antibiotic treatment. About 312 adults living in the project area have potentially blinding TT and need of immediate surgery.

Objective: To determine the prevalence and pattern of eye diseases and visual impairment in the Nairobi Comprehensive Eye Care Services (NCES) Project; the catchment area of the Mbagathi District Eye Unit of Nairobi.
Design: Community based survey conducted from October 15th to 31st 2007 Setting: Kibera and Dagoreti divisions of Nairobi City
Subjects: 4200 people of all ages were randomly selected; 4056 were examined (96.6% response rate). 122 (2.9%) were not available and 15 (0.4%) declined to be examined.
Results: Females: 54.2%, Males: 45.8%. Mean age; 22.4 years, SD; 16.5. Only 241(5.9%) aged >50years old. The leading eye disorders in Kibera and Dagoretti divisions are conjunctival disorders including allergic conjunctivitis and conjunctival growths. This was found to affect 7.6% of the subjects. This was followed by refractive errors found in 5.3% of the subjects. Cataract was found in 30 subjects (0.7%). Disorders of the retina and the optic nerve were found in 1.1% of the subjects and corneal disorders in 0.5%. The prevalence of visual impairment was 0.6%, severe visual impairment was 0.05% and blindness was 0.1%. This indicates that most of the ocular disorders encountered were not visually threatening. The main cause of visual impairment is refractive errors and the causes of severe visual impairment and blindness are cataract, corneal opacity and glaucoma.
Conclusion: The population of the NCES is relatively young and the prevalence of blindness and visual impairment is low. The main cause of visual impairment was refractive errors and the causes of severe visual impairment and blindness were cataract, corneal opacity and glaucoma.
Recommendations: The level of blindness in NCES is low and the project should focus more on rendering eye care and not treatment of blindness. There is need to address the issue of refractive errors as this was one of the main ocular problems encountered. In this survey, it was not possible to perform detailed refraction and hence it was recommend that a refractive error survey be conducted; especially in school going children.

Objectives: To determine whether height can be used as an alternative to weight in mass treatment of children aged 1-15 years with active trachoma using azithromycin and propose a height-based dose stick for Kenyan children.
Design: community based operational research Subjects: A total of 2,020 children were included: 987(48.9%) male and 1033 (51.1%) female. 369 (18.3%) were from Kajiado, 772 (38.2%) from West Pokot and 879 (43.5%) from Baringo.
Settings: The study was carried out in three trachoma endemic districts: West Pokot, Baringo and Kajiado. A baseline trachoma survey had been conducted in the three districts in preparation for the implementation of SAFE.
Results: Children from West Pokot were heavier and taller than those from Kajiado and Baringo (P < 0.001). The body mass index (BMI) of the children in the three study areas was comparable. There was a close relationship between weight and height and the distribution was near linear. Height explained 92.8% of the variance of weight. A height based dose stick that recommends the use of 40mg/ml suspension and 125mg (half tablet) incremental dosage predicted doses within tolerance limits (15-30mg/kg) to 98.8% of children and 100%
with extended dose range (13 -35 mg/kg). If 40mg/ml suspension and 1 tablet (250mg) incremental dosage were to be used, the height stick would predict doses within tolerance limits to 97.5% of the children and 99.9% with extended dose range (13 -35 mg/kg).
Conclusions: The theoretical model based on the use of 40mg/ml suspension and
125mg (half tablet) incremental offers better dosing ranges to all the children of West Pokot, Baringo and Kajiado districts when the extended dosage range (13-35mgs/kg) is applied.
Recommendations: Similar studies should be conducted in other trachoma endemic communities in Kenya to determine whether a single height-based dose stick can be used in the entire country. The manufacturer should look into the possibility of producing 125mg tablet for mass treatment.

Objective: To assess the cataract surgical coverage, outcome of cataract surgery
and barriers to uptake of cataract surgical services.
Setting: Kericho, Bureti and Bomet districts CES Project.
Design: Cross-sectional population based survey using rapid assessment of
avoidable blindness (RAAB) method.
Participants: Fifty one clusters of 50 people aged 50 years or older were selected by probability proportionate to size sampling of clusters. Compact segment sampling was used to select households within the clusters. Two thousand five hundred and forty six people were eligible for the survey of which 2419 (95%) were examined.
Methods: Participants underwent a comprehensive ocular examination in their homes by an ophthalmologist. The visual acuity was measured using a tumbling E chart. The cause of visual impairment was established. Those who had undergone cataract surgery were questioned about the details of the operation and their satisfaction with the surgery. Those who were visually impaired from cataract were asked why they had not gone for surgery.
Results: Cataract was found to be the main cause of blindness (42.9%) and visual impairment (42.7%) in those aged 50 years and older. The cataract surgical coverage was high, with 87.2% of those with bilateral cataract who needed surgery having had surgery at V/A<3/60. The quality of surgery was of concern with 20.7% of the 222 eyes that had undergone cataract surgery having a best corrected vision of <6/60. The main barriers to cataract surgery were cost and lack of awareness.
Conclusions: The cataract surgical coverage in Kericho, Bureti and Bomet districts is high. The outcome of surgery is below the WHO standard and needs improvement.

Aim: To evaluate the efficacy of topical prednisolone phosphate 1% eye drops in reducing recurrences after bare sclera pterygium surgery.
Design: Randomized controlled clinical trial.
Setting: Kenyatta, Nakuru, Embu, Murang’a, and Machakos eye clinics of Kenya.
Subjects: 51 eyes of 46 patients (17 males and 29 females) operated between May and November 1997 at the above eye units. The youngest was 22 years and the oldest 76 years.
Results: 24 out of 31 pterygia in the prednisolone group and 15 of 20 controls were evaluated. 16.7% of the eyes in the prednisolone group developed recurrences as compared to 53.3% in the control group (p=0.0017). All except one of the recurrences developed within 8 weeks. Recurrences were more common in younger patients. There was no statistically significant difference in the recurrence rate between males and females.
Conclusions: Topical prednisolone phosphate 1% eye drops; a cheap and easily available eye medication is an effective adjunctive treatment after bare sclera pterygium surgery.
Recommendations: Other adjunctive treatments and surgical techniques should also be explored preferably in a multi-centre setup.

Objective: To determine the prevalence and magnitude of eye disease in a group at high risk for HIV: the Majengo commercial sex worker (CSW) cohort and see how it differs from the general population.
Design: Cross sectional study
Setting: Commercial sex workers (CSW) clinic, Majengo slums, Nairobi in November and December 2003.
Subjects: An open cohort of CSWs on follow-up by the department of Microbiology, University of Nairobi.
Results: There are over 600 CSWs on regular follow-up at the Majengo clinic. 151 aged between 21 years and 56 years were examined. 107 were Kenyan, 40 Tanzanian, 3 Ugandan and 1 Rwandese. 72 were HIV +ve and 79 were HIV –ve. 13.9 % of the HIV+ve CSWs examined were on HAART. The prevalence of general eye disease in the HIV+ve and HIV negative subsets was 86.1% and 69.6% respectively. The prevalence of HIV related eye illnesses in the HIV+ve CSWs was 18.1% with choroidal lesions being the most common. Profound immunodefi ciency characterized by a CD4 count less than 50 was observed in 4 CSWs. While 3 of these CSWs were assymptomatic, one had a retinal hemorrhage and tortuous blood vessels suggestive of HIV retinopathy.
Conclusion: In this C.S.W cohort HIV specifi c cytotoxic T-lymphocytes and genital mucosal antibodies may have caused the lower prevalence of ocular manifestations than that reported in studies in non-high risk groups (30-80%). Some members of this cohort have special immunity to HIV.

Objective: To establish the prevailing eye practices among traditional healers in Kitui district and establish whether these healers are able to identify ocular emergencies and refer in good time.
Design: Community based qualitative survey
Setting: Kitui district, Eastern Kenya
Subjects: A total of 87 healers from 3 divisions of Kitui district were interviewed.
Results: Seventy six (87.4%) said that they treat at least one of the eye conditions presented to them. Instillation of plant extracts into the conjuctival sac was the most preferred treatment modality and was practiced by 46(52.9%) healers for cataracts, 48(55.2%) for ocular injuries and 21(24.1%) for allergic conjunctivitis. The most commonly performed surgical procedures included rubbing the underside of the upper lid with a specifi c leaf for allergic conjunctivitis with papillary reaction performed by 43 (49.4%) healers; piercing chalazia with a thorn or needle by 11(12.6%) healers and making small incisions and applying herbs for ocular swelling by 4(4.6%) healers. The most preferred treatment for chemical injury was breast milk from any breast feeding mother practiced by 29 (33.3%) healers. Small extra ocular foreign bodies are removed by introducing seed from a specifi c plant in to the conjunctival sac by 51(58.6%) healers. Some healers mix traditional medicine with exorcism and rituals especially for squint as practiced by 14(16%) healers and ocular tumors by 9(10.3%) healers. The conditions the healers said they would refer included ocular tumors reported by 48(55.5%) healers, cataracts by 34(52.9%) healers, ocular injury by 30(34.5%) healers and squint by 21(24.1%) healers.
Conclusion: Majority of the healers interviewed treat patients who present to them with eye diseases. Most did not refer emergencies like ocular injuries.

Objectives: To estimate with reasonable precision the prevalence of active trachoma (TF) in children aged 1-9 years and potentially blinding trachoma (TT) in adults 15 years and older in Laikipia District.
Design: Baseline community based survey conducted from 22nd to 30th July 2007 using the standardized WHO protocol.
Setting: Laikipia District of the Lift Valley Province of Kenya.
Subjects: A total of 348 households were visited. 1,017 children aged 1-9 years and 1,225 adults aged >15 years were examined.
Results: Ninety seven out of the 1,017 children had TF hence the prevalence of TF in Laikipia is 9.5% (95% CI: 6.3-13.9). 14 out of the 1,225 adults had TT. Prevalence of TT in Laikipia is 1.1% (95% CI: 0.5-2.4).
Conclusions: Active trachoma is not a district wide public health problem in Laikipia. Potentially blinding trachoma (TT) is a district wide public health.
Recommendations: District-wide mass antibiotic treatment is not justifi able but all the suspected endemic sub-locations should be surveyed and treated where necessary. There is need for TT surgical services in the entire district.

Objectives: To conduct a rapid assessment of cataract surgical services in Embu District.
Design: Community based survey
Setting: Embu district of the Eastern Province of Kenya
Subjects: 85 clusters selected by systematic method. Each cluster had 40 people aged >50
years.
Results: The prevalence of blindness in people aged >50 years in Embu district is 2.0% (95%CI: 1.5%-2.5%). Cataract is the commonest cause of blindness (39.7%; 95%CI: 38.9%-40.5%). The Cataract surgical coverage for cataract blind persons is 65.7 %. The outcome of cataract surgery with IOL is good in 39.5% of all the operated eyes and improved to 53.5% with best correction/VA with pinhole. Most of the cataract operations are done in voluntary/charity hospitals (47.4%) and in government hospitals (44.9%). The main barriers to utilization of cataract surgical services in the district are lack of awareness and cost of surgery.
Conclusions: Most of the cataract blind patients (65.7%) have assess to surgical services. The proportion of cataract surgeries resulting in good surgical outcomes is low.
Recommendations: There is need to improve the outcome of cataract surgery in Embu through continuing skills update courses for existing staff, supply of biometry equipment and vitrectomy machine plus establishing a cataract audit system. Collaboration between the Government and charitable eye care institutions should be strengthened because they are equal partners in delivery of cataract surgical services in the district. There is need to initiate community eye health promotion activities and cost-containment strategies in order to break the barriers to utilization of surgical services.

Objectives: To determine the prevalence and pattern of refractive errors among African type II diabetes mellitus patients and establish the relationship between baseline refractive status and degree of glycaemic control.
Design: A hospital based cross sectional study.
Setting: Diabetic medical and eye clinics at Kenyatta National Hospital (KNH).
Subjects: 96 type II diabetes mellitus patients.
Results: Ninety-six patients aged 28 to 76 years were examined. The male to female ratio was 1:1.5 and about half of the patients (52.1%) had good glycaemic control. The prevalence of myopia was 39.5% and that of hypermetropia was 19.0%. 22.6% of the study patients had mild diabetic retinopathy (DR). Of the eyes with DR, 20.0% (15/75) were myopic, 19.4% (7/36) were hypermetropic and 26.6% (21/79) were emmetropic. There was no statistically significant correlation between baseline refractive status with DR (p=0.358), or HBA1C (glycosylated haemoglobin) (rho=0.130, p-value=0.249 among myopes) or FBS (fasting blood sugar) (rho=-0.089, p-value=0.438 among myopes and rho=0.158, p-value=0.350 among hyperopes). However, there was a statistically significant correlation between baseline hypermetropic refractive status and HBA1C (rho=0.401, p-value=0.014).
Conclusions: Refractive errors were seen in 58.5% of the patients with myopia being the commonest type (39.5%) followed by hypermetropia 19.0%. There was no statistically significant relationship between baseline refractive status and indicators of glycaemic control except for hypermetropic refractive status and HBA1C.
Recommendations: According to the results of this study, it is not mandatory to ask for HBA1C or FBS results before issuing spectacle prescription to adult patients with type II diabetes mellitus who are already on treatment. However, there is need to emphasize the need for good glycaemic control to minimize the other ocular complications. A similar study should be done on young people with type I diabetes mellitus.

To report on and share the experiences, accomplishments and lessons learnt by African Medical and Research Foundation (AMREF), Sight Savers International (SSI), University of Nairobi (UON) and the Ministry of Health (MOH) during implementation of a three year Shompole trachoma control pilot study using azithromycin. The target of the project was to reduce the prevalence of active and potentially blinding trachoma by 50% by the year 2005. Design: Community based survey. Setting: Shompole location, Magadi division, Kajiado district of the Rift Valley Province of Kenya. Subjects: Five hundred and twenty six randomly selected households from 166 manyattas (bomas/ homesteads) proportionately distributed in all the 13 villages of the four sub-locations of Shompole location were visited. Nine hundred and ninety eight children (1-9 years) and 898 adults (≥15 years) were examined for active trachoma (TF) and potentially blinding trachoma (TT) respectively. Results: The prevalence of active trachoma (TF) in children has dropped from 46.4% in 2002 to 16.0% in 2006 and that of potentially blinding trachoma (TT) from 4.5% to 1.7% in the same period. Women have more TT than men. Out of the 15 cases of TT reported in the survey, only two were recurrences. The prevalence of active trachoma (TF) is higher in boys than girls, p=0.044. The proportion of children with clean faces has not changed but the proportion of children with many (>5) flies has drastically reduced from 48.0% in 2002 to 6.0% in 2006. The community holds strong negative believes about pit latrines. The project is sustainable. Conclusions: This project has positively influenced eye care policy locally and globally. The targets for “SA” components of SAFE were achieved while “FE” components were partially achieved. Recommendations: The ongoing scale up of the project to cover the whole of Kajiado district is justified. Formative study and review of the project’s health promotion strategy is necessary. Collaboration and joint planning with neighbouring endemic districts of Kenya and Tanzania should be encouraged because of the nomadic nature of the Maasai who are the project beneficiaries.

Objectives: To determine the prevalence and pattern of ocular manifestations in adults
with intracranial neoplasms.
Design: Cross sectional hospital based study
Settings: Neurosurgical Clinic and Ward of Kenyatta National Hospital (KNH) from November 2005 to January 2006.
Subjects: 60 adult with intracranial neoplasm (32 females and 28 males)
Results: 31(52%) of the studied patients had not had any previous eye examination. Ocular symptoms were reported in 44 (73%) patients. 38 (63%) had colour vision defects, 20 (33%) papilloedema, 16 (27%) bilateral optic disc atrophy, 16 (27%) defective extra-ocular motility, 11(18%) bilaterally blind, 10 (17%) nystagmus, 6 (10%) proptosis and 4 (7%) diplopia. Only 11 (18%) of the patients had normal visual field. 40 (67%) were booked for routine follow-up at the Kenyatta Eye Clinic while 9 (15%) were referred for Low Vision Assessment. All the 11 (18%) blind patients were referred for rehabilitation.
Conclusion: Majority (73%) of patients attending the KNH Neurosurgical Clinic and those admitted in Neurosurgical ward have ocular involvement and visual loss. Colour vision defects were the commonest manifestations while total blindness was the most serious complication.
Recommendation: Neurosurgeons and ophthalmologists should work together as a team to ensure timely and comprehensive assessment and management of all patients with intracranial tumours both pre-operative and post-operatively. Stable patients with irreversibly visual impairment and blindness should be referred for Low vision therapy and rehabilitation.

Objectives: This study was conducted to estimate the prevalence and pattern of CSCC in patients with HIV infection.
Design: A hospital based cross sectional study conducted from the 3rd of November, 2003 to 30th May, 2004
Setting: Kenyatta National Hospital (KNH) and Kikuyu Eye Unit (KEU)
Subjects: Four hundred and nine HIV positive patients (409)
Results Four hundred and nine HIV positive patients (409) aged 25 to 53 years were screened. Male to Female ratio was 1:1. One hundred and three (103) had conjunctival growths. Thirty two (32) had histologically proven conjunctiva squamous cell carcinoma (CSCC). Estimated prevalence of CSCC among HIV positive patients was 7.8%. The average duration of growth of the conjunctival masses was 21.8 months. The average size of the lesions at the time of presentation was 6.6mm. 22 (68.8%) patients had primary CSCC, while 10 (31.2%) had recurrent lesions. The pattern of the histopathology results was: 15 (46.9%) patients had poorly differentiated squamous cell carcinoma; 9 (28%) had moderately differentiated squamous cell carcinoma; 5 patients (15.6%) had CIN; 2 patients (6.3%) had dysplasia and 1 patient (3.1%) had a well differentiated squamous cell carcinoma.
Conclusions: Prevalence of CSCC in HIV / AIDS patients is 7.8%. Patients present late with advanced lesions. Recurrence rates from previous surgery are high. The often uncharacteristic complaints and findings on presentation complicate the clinical diagnosis.
Recommendations: Active search for early manifestations of CSCC in HIV / AIDS patients, complete surgical excision and close follow up is necessary. Alternative treatment methods and techniques like the topical use of antimetabolites should be explored further.

VISION 2020: “The Right to Sight” Global Initiative is the WHO adopted 20 -Year global plan
for the elimination of avoidable blindness by the year 2020. It brings together all the partners involved in prevention of blindness. The three essential components (pillars) of VISION 2020 are:
>Cost-effective disease control interventions,
>Human resource development
>Infrastructure development

Objectives: To estimate the prevalence of active trachoma (TF) in children aged one to nine years and potentially blinding trachoma (TT) in adults aged 15 years and older in six known trachomaendemic districts in Kenya.
Design: Community based survey.
Setting: Six known trachoma endemic districts in Kenya (Samburu, Narok, West Pokot, Kajiado Baringo and Meru North).
Subjects: A total of 6,982 children aged one to nine years and 8,045 adults aged 15 years and older were randomly selected in a two stage random cluster sampling method: Twenty sub-locations (clusters) per district and three villages per sub-location were randomly selected. Eligible children and adults were enumerated and examined for signs of trachoma.
Results: Blinding trachoma was found to be a public health problem in all the surveyed districts. Active trachoma was a district wide public health problem in four districts (Samburu, Narok,
West Pokot and Kajiado) and only in some of the sub-locations of the other two (Baringo and
Meru North).
Conclusions: There is need for district trachoma control programmes preferably using the WHO recommended SAFE strategy in all the surveyed districts. Extrapolation of these survey results to the entire country could not be justified. There is need to survey the remaining 12 suspected endemic districts in Kenya.

Objective: To determine the prevalence and causes of visual impairment and blindness among Kibera slum dwellers.
Design: Population based Survey.
Setting: Kibera Slums, Kibera Division, Nairobi, Kenya.
Subjects: One thousand four hundred and thirty eight randomly selected slum dwellers.
Results: The prevalence of blindness and visual impairment was 0.6% (95% CI: 0.21 to 1.0), and 6.2% (95% CI: 4.95 to 7.15) respectively. 37.5% of those found blind were due to cataract followed by refractive errors 25.0%. 58.1% of those with visual impairment had refractive errors while 35.5% had cataracts. Females had a higher prevalence of visual impairment compared to males but the difference was not statistically significant (P = 0.104).
Conclusions: Prevalence of blindness in Kibera slums is slightly lower than the estimated national average (0.7%) while that of visual impairment is almost three times higher. The leading causes of blindness are cataract followed by refractive errors. For visual impairment, refractive error was the leading cause followed by cataract.
Recommendation: Kibera slum dwellers are in need of comprehensive eye care services offering cataract surgery and low cost spectacles.

Objectives: To determine the prevalence and pattern of significant refractive errors in standard 8 pupils attending public school.
Design: Cross sectional community based study
Setting: Langata Location of Kibera Division, Nairobi Province
Subjects: All (1,253) year 2003 standard 8 pupils in school during the study
Results: The prevalence of significant refractive errors 10.2%, myopia 9.4%, hypermetropia 0.3% and astigmatism 0.5%. Of these, only 11.7 % (15/128) students had spectacles with the correct power.
Conclusions: About 10.2% of class 8 pupils attending public primary schools in Langata need spectacles but only a few have them.
Recommendation: There is need for a school screening programme offering low cost spectacles so that children who may be having learning difficulties due to lack of spectacles can be identified and assisted promptly.

Objectives: To assess the vision of PSV drivers operating in Nairobi city and to establish whether poor sight is associated with the occurrence of motor vehicle accidents.
Design: Cross-sectional study
Setting: Nairobi city bus and matatu (small vans and minibuses) terminuses.
Subjects: 539 randomly selected PSV drivers.
Results: Sixty eight percent of the drivers did not have their sight checked during driving test. Drivers with inadequate vision were more frequently involved in accidents than those with adequate vision but difference was not statistically significant (p=0.76). Drivers with cataracts were 3 times more likely to be involved in accidents than those without (p=0.007).
Conclusions: Majority of PSV drivers do not undergo visual acuity testing before acquiring driving licenses.
Recommendation: Visual acuity testing should be made mandatory when applying for and renewing driving licenses.

Objectives: To identify the main barriers to utilisation of eye care services among the slum population of Kibera in Nairobi, Kenya.
Design: Community based survey
Setting: Kibera Slums, Nairobi City, Kenya
Subjects: Randomly selected 1,438 Kibera slum dwellers aged over 2 years.
Results: Majority of subjects 83.3% do not utilise the nearby well-established eye clinics. Twenty one percent of those with poor vision do not seek treatment at all. The main barriers to seeking eye care services were lack of money, ignorance, and the problem not causing much discomfort to warrant medical attention. There was significant, association between the level of education and health seeking behaviour (P = 0.008).
Conclusions: Majority of Kibera slum dwellers have no access to eye care.
Recommendation: There is need to establish a comprehensive Primary Eye Care project to provide low cost but quality services affordable to Kibera slum dwellers.

The Kenya Ophthalmic Programme (KOP) is a Ministry of Health (MOH) programme receiving administrative support from the Kenya Society for the Blind (KSB). It started as a small project in 1956 but has grown into a major National Programme rendering comprehensive eye care (CEC) through a network of about 70
Government and NGO static and outreach service delivery points scattered all over the country. About half a million patients are treated annually.

Introduction

Cataract which is defined as opacity of the crystalline lens of the eye is the leading cause of visual impairment and blindness inKenyaand in the whole world in general. Majority of cataracts are age related. Resources allocated for the treatment of cataract inKenyalike in other developing nations, are not only scarce but have also been shrinking with time. Surgical removal of the opaque lens and correction with an intraocular lens implant are the only treatment options available inKenya. Prioritisation during planning and resource allocation should be done for the benefit of the majority. This can only be possible if we are aware of the costs incurred in cataract surgery and the ways by which costs can be contained. When the cost of cataract surgery is known, it is easy to estimate how much service user charges (cost recovery and cost sharing) to charge the patients. Overcharging lowers utilisation while undercharging threatens sustainability of the heath services. It is also possible to identify the costs of each cataract surgical item (or procedure) and plan how to contain the costs without compromising the quality. The exact cost per unit service (in this case cataract surgery) should thus be reviewed regularly.

Aim

To describe the costs and productivity of cataract surgery in the different Eye Care delivery settings inKenya.

Objectives :

To estimate and compare the costs of consumables used in cataract surgery in different eye care settings.

To estimate and compare the productivity of cataract surgery in different eye care settings.

Methods

Three Eye Units representing three unique Eye Care delivery settings inKenyawere selected for the study. Kikuyu Eye Unit represented the typical Kenyan NGDO setting, Lions Eye Unit a service club setting and Nakuru Eye Unit the Government Eye Care delivery setting. The productivity of cataract surgery was calculated from the information extracted from the Eye Units monthly returns and annual reports. The information was further counterchecked with the theatre registers and the data from the National Eye Health Information Office. The cost of each of the consumable items used for cataract surgery was calculated separately using the information gathered from hospital store records and from the surgeons and other theatre staff using the data collection form. The costs of all the items were finally summed up to get the unit cost of consumables used in a single cataract operation. The data were finally entered into summary tables. The productivity and costs of consumables for the three Eye Units were compared and conclusions made.

Results

Kikuyu performed 53%, Lions 9% and Nakuru 4% of all the 9495 cataract operations reported in the 1998 annual report of the Kenya Ophthalmic Programme.

Kikuyu Eye Unit theatre did 100, Lions 17 and Nakuru 7 cataract operations per week.

In one theatre day, Kikuyu operated on 20, Lions 9 and Nakuru 4 cataracts.

Cataract operations per surgeon per week was 13 at Kikuyu, 9 at Lions and 2 at Nakuru. None of the three Eye Units in the study had a waiting list for cataract surgery.

The unit cost of consumable items used in a single cataract operation was US$ 11.2 at Lions US$ 14.6 at Kikuyu Eye Units and US$ 23.5 at Nakuru.

The IOL and the corneal suture were the most expensive items. The two accounted for 40 %, 61 % and 63 % of the total cost of consumable items used in a single cataract operation at Lions, Kikuyu and Nakuru respectively.

Conclusions

None of the three Units had realised its full potential in productivity of cataract surgery. The IOL was the single most expensive consumable item used for cataract surgery at Kikuyu and Lions Eye Units. At Nakuru, it was the corneal suture.

Kikuyu Eye Unit which represented the typical Kenyan NGDO Eye Care delivery setting had the highest productivity of cataract surgery at the cost of US$ 14.6 per one unit of consumable.

Lions Eye Unit which represented an NGO Eye Care setting whereby the sponsoring NGDO also managed the day to day running of the unit it was sponsoring performed cataract operation at the lowest cost per unit of consumables (US$ 11.2). The unit had low productivity of cataract surgery when compared to Kikuyu.

Nakuru Eye Unit represented the Government of Eye Care delivery setting. The unit had the lowest productivity of cataract surgery and the highest cost of a unit cost of consumables (US$ 23.5).

Recommendations

- Improve cataract surgical services through Social Marketing.

- Monitor productivity and cost of cataract surgery regularly.

Hard copy available at the Department of Ophthalmology of the University of Nairobi.