Browsing by Author "Arunga, Simon"
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Item Bilateral Candida keratitis in an HIV patient with asymptomatic genitourinary candidiasis in Uganda(Medical mycology case reports, 2018) Arunga, Simon; Kwaga, Teddy; Leck, Astrid; Hub, Victor H.; Burton, Matthew J.A 35-year-old male presented with Candida keratitis in the left eye. He was HIV positive with a CD4 of 352 cells/ μL. The eye quickly deteriorated, despite intensive antifungal treatment and was eviscerated. Five months later, he re-presented with Candida keratitis in his right eye. A focal source of Candida infection was suspected and a urine culture identified Candida spp, despite being asymptomatic for genitourinary candidiasis. He was subsequently treated with good outcome (max. 75 words)Item Changing ophthalmic practice during the COVID-19 pandemic in Uganda(Community Eye Health, 2020) Rizwan Kanji, Raheel; Arunga, SimonMbarara University and Referral Hospital Eye Centre (MURHEC) is a governmentowned tertiary referral eye unit that provides eye care to the South Western part of Uganda, providing over 10,000 consultations per year. It also offers residency training in ophthalmology and currently has 20 residents.Item Chlorhexidine gluconate 0.2% as a treatment for recalcitrant fungal keratitis in Uganda: a pilot study(BMJ open ophthalmology, 2021) Arunga, Simon; Mbarak, Tumu; Ebong, Abel; Mwesigye, James; Kuguminkiriza, Dan; Mohamed-Ahmed, Abeer H. A.; John Hoffman, Jeremy; Leck, Astrid; Hu, Victor; Burton, MatthewFungal keratitis is a major ophthalmic public health problem, particularly in low-income and middle-income countries. The options for treating fungal keratitis are limited. Our study aimed to describe the outcomes of using chlorhexidine 0.2% eye-drops as additional treatment in the management of patients with recalcitrant fungal keratitis. Methods This study was nested within a large cohort study of people presenting with microbial keratitis in Uganda. We enrolled patients with recalcitrant fungal keratitis not improving with topical natamycin 5% and commenced chlorhexidine 0.2%. Follow-up was scheduled for 3 months and 1 year. The main outcome measures were healing, visual acuity and scar size at final follow-up. Results Thirteen patients were followed in this substudy. The patients were aged 27–73 years (median 43 years). Filamentous fungi were identified by microscopy of corneal scrape samples in all cases. Isolated organisms included Aspergillus spp, Fusarium spp, Candida spp, Bipolaris spp and Acremoninum spp. At the final follow-up, nine patients (75%) had healed; three had vision of better than 6/18. Three patients lost their eyes due to infection. In the remaining nine cases, corneal scarring was variable ranging from 4.6 to 9.4 mm (median 6.6 mm, IQR 5.9–8.0 mm); of these five had dense scars, three had moderate scars and one had a mild scar. None of the patients demonstrated signs of chlorhexidine toxicity during the follow-up. Conclusion Chlorhexidine 0.2% was found to be a useful sequential adjunctive topical antifungal in cases of fungal keratitis not responding to natamycin 5%, which warrants further evaluation.Item Corneal endothelial cell density and associated factors among adults at a regional referral hospital in Uganda: a cross-sectional study(BioMed Central Ltd, 2024-04-15) Namwase, Shamiim; Ruvuma, Sam; Onyango, John; Kwaga, Teddy; Ebong, Abel; Atwine, Daniel; Mukunya, David; Arunga, SimonBackground To assess the prevalence of low corneal endothelial cell density and correlates of corneal endothelial cell density among adults attending Mbarara University and Referral Hospital Eye Centre in Uganda. Methods In this hospital-based cross-sectional study, participants 18 years and older, were enrolled. We obtained informed consent, and basic demographic data. We also conducted visual acuity, a detailed slit lamp examination, intra-ocular pressure, corneal diameter, tear-film break-up time, keratometry, A-scan, and pachymetry on all participants. A confocal microscope Heidelberg HRT3 was used to examine the central cornea and to obtain the mean cell density (cells/mm.sup.2). To calculate the proportion of low endothelial cell density, descriptive statistics were used, whereas correlates of endothelial cell density were assessed, using linear regression analyses. Results We evaluated a total of 798 eyes of 404 participants aged between 18 and 90 years (males = 187, females = 217). The average endothelial cell density was 2763.6 cells/mm.sup.2, and there was a decrease in endothelial cell density with increasing age, irrespective of gender. There was no significant difference in endothelial cell density between males and females. Increasing age (adjusted coefficient - 10.1, p < 0.001), history of smoking (adjusted coefficient - 439.6, p = 0.004), history of ocular surgery (adjusted coefficient - 168.0, p = 0.023), having dry eye (adjusted coefficient - 136.0, p = 0.051), and having arcus senilis (adjusted coefficient - 132.0, p = 0.08), were correlated with lower endothelial cell density. However, increasing corneal diameter (adjusted coefficient 134.0, p = 0.006), increasing central corneal thickness (adjusted coefficient 1.2, p = 0.058), and increasing axial length (adjusted coefficient 65.8, p = 0.026), were correlated with higher endothelial cell density. We found five eyes (0.63%) from different participants with a low endothelial cell density (< 1000cells/mm.sup.2). Conclusion Our study established baseline normal ranges of ECD in a predominantly black African population, and found that low ECD is rare in our population. The elderly, smokers, and those with past ocular surgery are the most vulnerable. The low prevalence could be due to a lack of reference values for the black African population. Keywords: Cornea, Endothelial cell density, UgandaItem Delay in accessing definitive care for patients with microbial keratitis in Nepal(Frontiers in Medicine, 2022) Hoffman, Jeremy J.; Yadav, Reena; Das Sanyam, Sandip; Chaudhary, Pankaj; Roshan, Abhishek; Singh, Sanjay K.; Mishra, Sailesh K.; Arunga, Simon; Hu, Victor H.; Macleod, David; Leck, Astrid; Burton, Matthew J.The aim of this study was to describe the health-seeking journey for patients withmicrobial keratitis (MK) in Nepal and identify factors associated with delay. Methods: Prospective cohort study where MK patients attending a large, tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. We collected demographic details, clinical history, and examination findings. Care-seeking journey details were captured including places attended, number of journeys, time fromsymptomonset, and costs.We compared “direct” with “indirect” presenters, analyzing for predictors of delay. Results: We enrolled 643 patients with MK. The majority (96%) self-referred. “Direct” attenders accounted for only 23.6% (152/643) of patients, the majority of “indirect” patients initially presented to a pharmacy (255/491). Over half (328/643) of all cases presented after at least 7 days. The total cost of care increased with increasing numbers of facilities visited (p < 0.001). Those living furthest away were least likely to present directly (p < 0.001). Factors independently associated with delayed presentation included distance >50 km from the eye hospital [aOR 5.760 (95% CI 1.829–18.14, p = 0.003)], previous antifungal use [aOR 4.706 (95% CI 3.139–5.360)], and two or more previous journeys [aOR 1.442 (95% CI 1.111–3.255)]. Conclusions: Most patients visited at least one facility prior to our institution, with time to presentation and costs increasing with the number of prior journeys. Distance to the eye hospital is a significant barrier to prompt, direct presentation. Based on these findings, improving access to eye care services, strengthening referral networks and encouraging early appropriate treatment are recommended to reduce delay, ultimately improving clinical outcomes.Item Diagnosis of Fungal Keratitis in Low-Income Countries: Evaluation of Smear Microscopy, Culture, and In Vivo Confocal Microscopy in Nepal(Journal of Fungi, 2022) Hoffman, Jeremy J.; Yadav, Reena; Das Sanyam, Sandip; Chaudhary, Pankaj; Roshan, Abhishek; Kumar Singh, Sanjay; Arunga, Simon; Hu, Victor H.; Macleod, David; Leck, Astrid; Burton, Matthew J.Clinically diagnosing fungal keratitis (FK) is challenging; diagnosis can be assisted by investigations including in vivo confocal microscopy (IVCM), smear microscopy, and culture. The aim of this study was to estimate the sensitivity in detecting fungal keratitis (FK) using IVCM, smear microscopy, and culture in a setting with a high prevalence of FK. In this cross-sectional study nested within a prospective cohort study, consecutive microbial keratitis (MK) patients attending a tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. IVCM and corneal scrapes for smear microscopy and culture were performed using a standardised protocol. Smear microscopy was performed using potassium hydroxide (KOH), Gram stain, and calcofluor white. The primary outcomes were sensitivities with 95% confidence intervals [95% CI] for IVCM, smear microscopy and culture, and for each different microscopy stain independently, to detect FK compared to a composite referent. We enrolled 642 patients with MK; 468/642 (72.9%) were filamentous FK, 32/642 (5.0%) were bacterial keratitis and 64/642 (10.0%) were mixed bacterial-filamentous FK, with one yeast infection (0.16%). No organism was identified in 77/642 (12.0%). Smear microscopy had the highest sensitivity (90.7% [87.9–93.1%]), followed by IVCM (89.8% [86.9–92.3%]) and culture (75.7% [71.8–79.3%]). Of the three smear microscopy stains, KOH had the highest sensitivity (85.3% [81.9–88.4%]), followed by Gram stain (83.2% [79.7–86.4%]) and calcofluor white (79.1% [75.4–82.5%]). Smear microscopy and IVCM were the most sensitive tools for identifying FK in our cohort. In low-resource settings we recommend clinicians perform corneal scrapes for microscopy using KOH and Gram staining. Culture remains an important tool to diagnose bacterial infection, identify causative fungi and enable antimicrobial susceptibility testing.Item Emergency management: microbial keratitis(Community eye health, 2018) Arunga, Simon; Burton, MatthewMicrobial keratitis is an infection of the cornea that can be caused by bacteria, fungi or protozoa such as Acanthamoeba spp. In low- and middle-income countries, management is often more challenging because of late presentation, the use of traditional eye medicines, insufficient diagnostic support, a lack of effective drugs and insufficient keratoplasty services. Our experience in East Africa is that most patients will visit a primary health centre within a day or two of onset of symptoms, but may take another two weeks to reach the eye unit; by which time it can be too late to save the eye. All health care workers, including front-line primary health workers, must therefore know how to identify microbial keratitis early, provide immediate treatment, refer patients for specialist treatment and make sure they are able to take up the referral.Item Epidemiology of Microbial Keratitis in Uganda: A Cohort Study(Ophthalmic Epidemiology, 2020) Arunga, Simon; Kintoki, Guyguy M.; Mwesigye, James; Ayebazibwe, Bosco; Onyango, John; Bazira, Joel; Newton, Rob; Gichuhi, Stephen; Leck, Astrid; Macleod, David; Hu, Victor H.; Burton, Matthew J.To describe the epidemiology of Microbial Keratitis (MK) in Uganda. Methods: We prospectively recruited patients presenting with MK at two main eye units in Southern Uganda between December 2016 and March 2018. We collected information on clinical history and presentation, microbiology and 3-month outcomes. Poor vision was defined as vision < 6/60). Results: 313 individuals were enrolled. Median age was 47 years (range 18–96) and 174 (56%) were male. Median presentation time was 17 days from onset (IQR 8–32). Trauma was reported by 29% and use of Traditional Eye Medicine by 60%. Majority presented with severe infections (median infiltrate size 5.2 mm); 47% were blind in the affected eye (vision < 3/60). Microbiology was available from 270 cases: 62% were fungal, 7% mixed (bacterial and fungal), 7% bacterial and 24% no organism detected. At 3 months, 30% of the participants were blind in the affected eye, while 9% had lost their eye from the infection. Delayed presentation (overall p = .007) and prior use of Traditional Eye Medicine (aOR 1.58 [95% CI 1.04–2.42], p = .033) were responsible for poor presentation. Predictors of poor vision at 3 months were: baseline vision (aOR 2.98 [95%CI 2.12–4.19], p < .0001), infiltrate size (aOR 1.19 [95%CI 1.03–1.36], p < .020) and perforation at presentation (aOR 9.93 [95% CI 3.70–26.6], p < .0001). Conclusion: The most important outcome predictor was the state of the eye at presentation, facilitated by prior use of Traditional Eye Medicine and delayed presentation. In order to improve outcomes, we need effective early interventions.Item Experiences and Perceptions of Ophthalmic Simulation-Based Surgical Education in Sub-Saharan Africa(Journal of surgical education, 2021) Annoh, Roxanne; Morgon Banks, Lena; Gichuhi, Stephen; Buchan, John; Makupa, William; Otiti, Juliet; Mukome, Agrippa; Arunga, Simon; Burton, Matthew J.; Dean, William H.Simulation-based surgical education (SBSE) can positively impact trainee surgical competence. However, a detailed qualitative study of the role of simulation in ophthalmic surgical education has not previously been conducted. OBJECTIVE: To explore the experiences of trainee ophthalmologists and ophthalmic surgeon educators’ use of simulation, and the perceived challenges in surgical training. METHODS: A multi-center, multi-country qualitative study was conducted between October 2017 and August 2020. Trainee ophthalmologists from six training centers in sub-Saharan Africa (SSA) (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) participated in semi-structured interviews, before and after an intense simulation training course in intraocular surgery. Semi-structured interviews were also conducted with experienced ophthalmic surgeon educators. Interviews were anonymized, recorded, transcribed and coded. An inductive, bottom-up, constant comparative method was used for thematic analysis. RESULTS: Twenty-seven trainee ophthalmologists and 12 ophthalmic surgeon educators were included in the study and interviewed. The benefits and challenges of conventional surgical teaching, attributes of surgical educators, value of simulation in training and barriers to implementing ophthalmic surgical simulation were identified as major themes. Almost all trainees and trainers reported patient safety, a calm environment, the possibility of repetitive practice, and facilitation of reflective learning as beneficial aspects of ophthalmic SBSE. Perceived barriers in surgical training included a lack of surgical cases, poor supervision and limited simulation facilities. CONCLUSIONS: Simulation is perceived as an important and valuable model for education amongst trainees and ophthalmic surgeon educators in SSA. Advocating for the expansion and integration of educationally robust simulation surgical skills centers may improve the delivery of ophthalmic surgical education throughout SSA.Item Eye care where there are no ophthalmologists: the Uganda experience(Community Eye Health, 2020) Magyezi, Joseph; Arunga, SimonA shortage in human resources for eye health is a huge problem in many parts of sub-Saharan Africa, with most countries failing to achieve the ratio of 4 ophthalmologists per million population recommended by the World Health Organization in 2006.1,2 Uganda’s population of 40 million is served by just 40 ophthalmologists (1 per million population), and half of them work in the capital city, Kampala. This means that the majority of eye care services in the country are provided by non-ophthalmologists.Item HIV and the eye(HIV, 2020) Gichuhi, Stephen; Arunga, SimonThe main ocular effects of HIV are related to immune suppression and impaired immune surveillance of tumours. HIV compromises cell-mediated immunity, thereby increasing the risk of infection with: • bacteria (e.g., those causing tuberculosis and syphilis) • fungi (e.g., Candida spp. and Cryptococcus spp.) • parasites (e.g., Toxoplasma gondii) • viruses (e.g., herpes zoster virus, human papillomavirus, Kaposi sarcoma-associated herpes virus, cytomegalovirus and Epstein-Barr virus). Patients with lower CD4 counts are more likely to have ocular manifestations1; however, use of antiretroviral therapy (ART) has modified the epidemiology of ocular manifestations and variations in the predominant subtype of HIV may also lead to geographical differences in eye disease.Item The impact of microbial keratitis on quality of life in Uganda(BMJ Open Ophthalmology, 2019) Arunga, Simon; Wiafe, Geoffrey; Habtamu, Esmael; Onyango, John; Gichuhi, Stephen; Leck, Astrid; Macleod, David; Hu, Victor; Burton, MatthewMicrobial keratitis (MK) is a frequent cause of sight loss in sub-Saharan Africa. However, no studies have formally measured its impact on quality of life (QoL) in this context. Methods As part of a nested case–control design for risk factors of MK, we recruited patients presenting with MK at two eye units in Southern Uganda between December 2016 and March 2018 and unaffected individuals, individually matched for sex, age and location. QoL was measured using WHO Health-Related and Vision-Related QoL tools (at presentation and 3 months after start of treatment in cases). Mean QoL scores for both groups were compared. Factors associated with QoL among the cases were analysed in a linear regression model. Results 215 case-controls pairs were enrolled. The presentation QoL scores for the cases ranged from 20 to 65 points. The lowest QoL was visual symptom domain; mean 20.7 (95% CI 18.8 to 22.7) and the highest was psychosocial domain; mean 65.6 (95% CI 62.5 to 68.8). At 3 months, QoL scores for the patients ranged from 80 to 90 points while scores for the controls ranged from 90 to 100. The mean QoL scores of the cases were lower than controls across all domains. Determinants of QoL among the cases at 3 months included visual acuity at 3 months and history of eye loss. Conclusion MK severely reduces QoL in the acute phase. With treatment and healing, QoL subsequently improves. Despite this improvement, QoL of someone affected by MK (even with normal vision) remains lower than unaffected controls.Item Intense Simulation-Based Surgical Education for Manual Small-Incision Cataract Surgery The Ophthalmic Learning and Improvement Initiative in Cataract Surgery Randomized Clinical Trial in Kenya, Tanzania, Uganda, and Zimbabwe(JAMA ophthalmology, 2021) Dean, William H.; Gichuhi, Stephen; Buchan, John C.; Makupa, William; Mukome, Agrippa; Otiti-Sengeri, Juliet; Arunga, Simon; Mukherjee, Subhashis; Kim, Min J.; Harrison-Williams, Lloyd; MacLeod, David; Cook, Colin; Burton, Matthew J.Cataracts account for 40% of cases of blindness globally, with surgery the only treatment. OBJECTIVE To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees. DESIGN, SETTING, AND PARTICIPANTS A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis. INTERVENTIONS The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period. MAIN OUTCOMES AND MEASURES The primary outcome measurewas overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period. RESULTS Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95%CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95%CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8%(42 of 537) for the intervention group and 26.6%(54 of 203) for the control group (difference, 18.8%; 95%CI, 12.3%-25.3%; P < .001). CONCLUSIONS AND RELEVANCE This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety.Item Local Ugandan Production of Stable 0.2% Chlorhexidine Eye Drops(Translational Vision Science and Technology, 2023) Picken, Christina A. R.; Brocchini, Steve; Burton, Matthew J.; Blundell-Hunter, George; Kuguminkiriza, Dan; Kaur, Harparkash; Hoffman, Jeremy J.; Arunga, Simon; Mohamed-Ahmed, Abeer H. A.The purpose of this study was to develop a protocol to prepare buffered chlorhexidine (CHX) eye drops (0.2% w/v) in the United Kingdom that can be reproduced at a production facility in Uganda. Buffered CHX eye drops can prevent CHX degradation and improve ocular tolerability during the treatment of fungal keratitis. Methods: Buffered CHX eye drops in amber glass containers were prepared using sodium acetate buffer at pH 5.90 to 6.75. Two commercial CHX solutions and CHX in water were used as controls. Eye drops were stored at 40°C (70% humidity, 21 months) in the United Kingdom and at ambient temperature in Uganda (30 months). Highperformance liquid chromatographywas used to determine CHX stability over time, and pH was monitored. Sterility was achieved using an autoclave (121°C, 15 minutes) and water bath (100°C, 30 minutes). Results: The pH of acetate-buffered CHX eye drops did not change over 21 months at 40°C or at ambient temperature (30 months), whereas the pHof the unbuffered aqueous CHX displayed significant fluctuations, with an increase in acidity. The CHX concentration remained the same in both buffered and unbuffered eye-drop solutions. Eye drops sterilization was successful using an autoclave and a water bath. Conclusions: Stable, sterile, buffered CHX eye drops (pH 6.75) were successfully prepared first in the United Kingdom and then reproducibly in Uganda. This eye drops can be prepared in a hospital or pharmacy setting with limited resources, thus providing a cost-effective treatment for fungal keratitis.Item Management of Filamentous Fungal Keratitis: A Pragmatic Approach(Journal of Fungi, 2022) Hoffman, Jeremy J.; Arunga, Simon; Mohamed Ahmed, Abeer H. A.; Hu, Victor H.; Burton, Matthew J.Filamentous fungal infections of the cornea known as filamentous fungal keratitis (FK) are challenging to treat. Topical natamycin 5% is usually first-line treatment following the results of several landmark clinical trials. However, even when treated intensively, infections may progress to corneal perforation. Current topical antifungals are not always effective and are often unavailable. Alternatives topical therapies to natamycin include voriconazole, chlorhexidine, amphotericin B and econazole. Surgical therapy, typically in the form of therapeutic penetrating keratoplasty, may be required for severe cases or following corneal perforation. Alternative treatment strategies such as intrastromal or intracameral injections of antifungals may be used. However, there is often no clear treatment strategy and the evidence to guide therapy is often lacking. This review describes the different treatment options and their evidence and provides a pragmatic approach to the management of fungal keratitis, particularly for clinicians working in tropical, low-resource settings where fungal keratitis is most prevalent.Item The management of microbial keratitis within Uganda’s primary health system: a situational analysis [version 1; peer review: 3 approved](Wellcome Open Research, 2019) Arunga, Simon; Kyomugasho, Naome; Kwaga, Teddy; Onyango, John; Leck, Astrid; Macleod, David; Hu, Victor; Burton, MatthewMicrobial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.Item The management of microbial keratitis within Uganda’s primary health system: a situational analysis [version 1; peer review: 3 approved](Wellcome Open Research, 2019) Arunga, Simon; Kyomugasho, Naome; Kwaga, Teddy; Onyango, John; Leck, Astrid; Macleod, David; Hu, Victor; Burton, MatthewMicrobial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.Item Microbial Keratitis in Nepal: Predicting the Microbial Aetiology from Clinical Features(Journal of Fungi, 2022) Hoffman, Jeremy J.; Yadav, Reena; Sanyam, Sandip Das; Chaudhary, Pankaj; Roshan, Abhishek; Kumar Singh, Sanjay; Arunga, Simon; Hu, Victor H.; Macleod, David; Leck, Astrid; Burton, Matthew J.Fungal corneal infection (keratitis) is a common clinical problem in South Asia. However, it is often challenging to distinguish this from other aetiologies, such as bacteria or acanthamoeba. In this prospective study, we investigated clinical and epidemiological features that can predict the microbial aetiology of microbial keratitis in Nepal. We recruited patients presenting with keratitis to a tertiary eye hospital in lowland eastern Nepal between June 2019 and November 2020. A structured assessment, including demographics, history, and clinical signs, was carried out. The aetiology was investigated with in vivo confocal microscopy and corneal scrape for microscopy and culture. A predictor score was developed using odds ratios calculated to predict aetiology from features. A fungal cause was identified in 482/642 (75.1%) of cases, which increased to 532/642 (82.9%) when including mixed infections. Unusually, dematiaceous fungi accounted for half of the culture-positive cases (50.6%). Serrated infiltrate margins, patent nasolacrimal duct, raised corneal slough, and organic trauma were independently associated with fungal keratitis (p < 0.01). These four features were combined in a predictor score. The probability of fungal keratitis was 30.1% if one feature was present, increasing to 96.3% if all four were present. Whilst microbiological diagnosis is the “gold standard” to determine the aetiology of an infection, certain clinical signs can help direct the clinician to find a presumptive infectious cause, allowing appropriate treatment to be started without delay. Additionally, this study identified dematiaceous fungi, specifically Curvularia spp., as the main causative agent for fungal keratitis in this region. This novel finding warrants further research to understand potential implications and any trends over time.Item Outcome of intravitreal Avastin® injections in patients with macular oedema in Uganda: a cohort study(Eye, 2022) Kabunga, Rachel R.; Onyango, John; Ruvuma, Sam; Arunga, SimonTo determine the outcome of Intravitreal Avastin (IVA) injections in patients with Macular Oedema (MO) in Uganda. METHODS: We prospectively recruited patients presenting with MO at the Department of Ophthalmology of Mbarara University of Science and Technology in Southern Uganda from November 2018 to April 2019. We treated them with intravitreal injection of Bevacizumab (Avastin®) and followed them up for three consecutive months after the initial injection. We collected information on baseline clinical presentation and 3 month outcomes. We performed a Student’s t-test to compare central macular thickness (CMT) and best corrected visual acuity (BCVA) at baseline and at 3 months after IVA injections. We performed linear regression to test for predictors of change in CMT and BCVA at 3 months. RESULTS: We enroled 32 patients (35 eyes) of which 29 patients (32 eyes) completed the follow up. The mean age was 62.8 ± 11.8 years, and 53% were male. At 3 months after IVA, the mean CMT improved significantly from 426.90 ± 135.9 μm at baseline to 311.20 ± 134.80 μm (p = 0.0008). The mean BCVA improved from 0.70 ± 0.38 at baseline to 0.38 ± 0.36 logMAR units (p = 0.003). The improvement in CMT and BCVA were more marked in patients who had Diabetic ME compared to other causes. A high baseline CMT was a strong predictor of improvement in CMT at 3 months after IVA therapy. A worse baseline visual acuity was a predictor of improvement in vision at 3 months after IVA. CONCLUSIONS: IVA therapy results in anatomical and visual improvement at 3 months especially in patients with Diabetic MO. Having a high baseline CMT was a predictor of good CMT outcome at 3 months while a worse vision at baseline was a predictor of better visual outcome at 3 months.Item Responding to COVID-19 in eye health(Community Eye Health Journal, 2020) Hu, Victor; Kyari, Fatima; Prajna, N. Venkatesh; Leck, Astrid; Arunga, Simon; Habtamu, Esmael; Wolvaardt, Elmien; Philippin, HeikoMillions of people have been infected with the SARS-CoV-2 virus and many have become seriously ill, threatening to overwhelm the ability of health systems to cope. Many lives have been lost – including those of health care workers.