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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 11  |  Page : 1606-1610

Trends in glaucoma procedures and surgeries at the eye foundation hospital group, Nigeria


1 Department of Community Ophthalmology, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria
2 Department of Retina, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria
3 Department of Glaucoma, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria
4 Department of Medical Retina, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria
5 Department of Paediatric Ophthalmology, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria
6 Department of Cornea/Keratorefractive, Eye Foundation Hospital Group, GRA Ikeja, Lagos, Nigeria

Date of Submission14-Oct-2018
Date of Acceptance27-Jun-2019
Date of Web Publication13-Nov-2019

Correspondence Address:
Dr. T Bogunjoko
Eye Foundation Hospital Group, 27, Isaac John Street, GRA Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_519_18

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   Abstract 


Aims: To review the trends in glaucoma procedural treatments from January 2009 to December 2017. Methodology: A retrospective search was carried out from the operating theater and laser room records of the Eye Foundation Hospitals in Lagos, Abuja, and Ijebu-Imushin. Consecutive glaucoma procedures for each year from January 2009 to December 2017 were recorded in the data sheet prepared for the study. Data were analyzed using SPSS version 25. Results: From 2009 to 2017, trabeculectomy had been decreasing in frequency from 117 to 65 (44%), except for 2015. The frequency of use of glaucoma drainage device (GDD) has been steadily increasing from 1 in 2013 to 26 in 2017, but this is not statistically significant. The frequency of cataract extraction with trabeculectomy reduced drastically from 20 in 2009 to 3 (566%) in 2014. Bleb review (BR) increased from 2 in 2009 to 18 (800%) in 2015, however, it dropped to 6 in 2017 (66%). Among the laser procedures, transscleral cyclophotocoagulation (g-probe) is commonly done. It increased from 40 procedures in 2009 to 98 in 2014 (145%). There has been an increase in laser trabeculoplasty from 15 in 2009 to 44 in 2013 (193%). Laser iridotomy increased from 12 in 2009 to 26 in 2015 (116%). From 2009 to 2015, there was an increase in glaucoma procedures and surgeries – 206 to 325 (58%) but this declined by 27% from 2015 to 2017. Conclusion: Trabeculectomy is the most performed procedure at our centers. This is followed by g-probe and laser trabeculoplasty. The rate of trabeculectomy is on the decrease, while the rate of GDD is increasing. The laser procedures are also on the increase.

Keywords: Eye Foundation Hospital Group, glaucoma surgeries, trends, types


How to cite this article:
Bogunjoko T, Hassan A, Ogunro A, Akanbi T, Ulaikere M, Ashaye A. Trends in glaucoma procedures and surgeries at the eye foundation hospital group, Nigeria. Niger J Clin Pract 2019;22:1606-10

How to cite this URL:
Bogunjoko T, Hassan A, Ogunro A, Akanbi T, Ulaikere M, Ashaye A. Trends in glaucoma procedures and surgeries at the eye foundation hospital group, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2022 Jan 25];22:1606-10. Available from: https://www.njcponline.com/text.asp?2019/22/11/1606/270865




   Introduction Top


Glaucoma is still the most common cause of blindness after unoperated cataract and uncorrected refractive error.[1],[2] It is the most important cause of irreversible blindness worldwide and in Africa. It is responsible for 8% of global blindness; this represents about 3.1 million people.[1],[2] Prevalence of glaucoma-related blindness was found to be 0.7% in Nigeria, and it the second most common cause of blindness (16.7%) after cataract, in individuals 40 years and older.[2],[3],[4]

Trabeculectomy (Trabec) with 5FU was the most frequently performed glaucoma procedure in 2009, responsible for 81.0% of total glaucoma surgeries in Lagos, Nigeria.[2]

Trends in glaucoma management are driven by demographic changes (population and providers), improvements in technology, and availability of new treatments and clinical trials demonstrating the benefit of new therapies.[5],[6]

Management of glaucoma, which could be medical, surgical, or laser, is challenging. With the advent of new generation of antiglaucoma medications, new lasers, and aqueous shunting devices, the practice of Trabec has decreased significantly in the developed world.[7] However, it remains the most common drainage procedure for glaucoma and the gold standard drainage surgical procedure for the treatment of glaucoma. In Africa and other developing economies, medical and laser treatments are fraught with challenges of affordability, availability, accessibility, and sustainability of treatment and follow-up care.[7],[8],[9] The aim of this study is to review the trends in glaucoma procedural treatments from January 2009 to December 2017 at the Eye Foundation Hospital Group (EFHG) in Nigeria.


   Methodology Top


A retrospective search was carried out from the operating theater and laser room records at the Eye Foundation Hospitals in Lagos, Abuja, and Ijebu-Imushin. Consecutive glaucoma procedures for each year from January 2009 to December 2017 were recorded in the data sheet prepared for the study.

Design

This is a descriptive retrospective study.

Participants

Consecutive glaucoma patients 18 years and older seen at the EFHG, Nigeria, constituted the study population.

Only procedures performed were included in the study including Trabec combined with cataract surgery. Repeat surgeries were excluded. Eyes were counted instead of patients. The number of times the different procedures were performed was tabulated for descriptive statistics to be calculated. Different codes were used for various surgeries and procedures. For example, trabeculectomy – Trabec, laser iridotomy – LIT, laser iridoplasty – LIP, and laser trabeculoplasty – LTP. The main outcome measures were as follows: the number of glaucoma-related procedures performed – Trabec, LTP, laser transscleral cyclophotocoagulation (g-probe), aqueous shunt procedures [glaucoma drainage device (GDD)], LIT, and Trabec with cataract extraction. Data were collated in a spread sheet format (Microsoft Excel) to produce both tabulated and graphical representation. Analysis of variance was used to assess trends over the years. P value of less than 0.05 is considered as statistically significant.

Ethical consideration

Ethical approval was obtained from Olabisi Onabanjo University Teaching Hospital Health Research Ethics Committee. Local approval was obtained to collect data from the authorities of EFHG.


   Results Top


The total number of glaucoma surgeries and laser procedures done in the EFHG from 2009 to 2017 was 2186. In all, 1150 (52.6%) were surgical procedures and 1036 (47.4%) laser procedures.

Surgical procedures

Trabec is the most performed procedure. It totaled 848 from 2009 to 2017. About 117 was done in 2009, but reduced to 67 the following year (2010). From 2010, there was significant increase, peaking at 136 in 2015 (P = 0.03). This dropped to 65 in 2017 (P = 0.02).

From 2009 to 2017, Trabec had been decreasing in frequency, 117 to 65 (44%), except for 2015. The frequency of GDD has been steadily increasing from 1 in 2013 to 26 in 2017, an increase of about 25-folds but this is not statistically significant (P = 0.95) [Table 1] and [Figure 1]. Cataract extraction with Trabec was done in the first 4 years of this review at an average of 32 per year until it reduced drastically in 2014 from 20 to 3 (566%), it peaked to 23 in 2016, and then 7 in 2017 (185%). Bleb review (BR) increased from 2 in 2009 to 18 (800%) in 2015. It has dropped to 6 in 2017 from 18 in 2015 (66%) [Figure 2].
Table 1: Number of glaucoma surgeries and laser procedures done in the Eye Foundation Hospital Group from 2009 to 2017

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Figure 1: Trends of Trabec, G-probe and GDD from 2009 to 2017. GDD started in 2013

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Figure 2: Trends of cataract extraction and trabeculectomy and bleb review from 2019 to 2017

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Laser procedures

Among the laser procedures, g-probe is commonly done. It increased from 40 procedures in 2009 to 98 in 2014 (145%). This was followed by LTP which had increased from 15 in 2009 to 44 in 2013 (193%) and slightly reduced to 32 in 2017 (27%). The third commonly done was LIT which increased from 12 to 26 in 2015 (116%) [Figure 3].
Figure 3: Trends of laser, laser trabeculoplasty and G-probe from 2009 to 2017

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From 2009 to 2015, there was increase in glaucoma procedures and surgeries: 206 to 325 (58%) as shown in [Table 1] and [Figure 1]. But from 2015 to 2017, there is a decrease by 27% [Table 1]. During this period (2009–2017), Trabec was the most performed procedure, followed by g-probe and then LTP [Figure 1]. Among surgical procedures, Trabec is on the decrease and recently introduced GDD on increase. The laser procedures are generally on the increase [Table 1] and [Figure 1].


   Discussion Top


This is the first study of its type that the authors are aware of about trends in glaucoma procedural treatments (lasers and incisional surgeries) in Nigeria and sub-Saharan Africa. In about a decade, our result has demonstrated that Trabec is the most performed procedure. This is the only procedure that showed statistical significance with increasing frequency (P = 0.03) and decreasing frequency (P = 0.02). GDD that started 5 years ago is on dramatic increase, but the numbers of procedures done are still very small. The laser procedures are generally on the increase.

Surgical (incisional) procedures

Primary Trabec is the most performed surgical procedure, but the frequency is decreasing: 44% decrease from 2009 to 2017, except a spike in 2015. This decrease in the number of Trabec has been observed in developed countries like Australia [5] and the United States [6] except in Canada where Szigiato et al.[10] found that there has been no change in the rate. Trabec is done by glaucoma specialists and some other ophthalmic specialists in the EFHG and it is affordable by a majority of the patients. It is equally the most performed glaucoma surgical procedure among Nigerian ophthalmologists.[2],[7],[11] But with the advent of very effective drugs, shunt procedures, and laser treatment, there are more alternative treatments.

GDD was introduced half a decade ago. One was done in 2013 and the number has risen to 26 in 2017, an increase of about 25-folds. Many of the elites and those who can pay for the surgery have opted for this procedure instead of the conventional Trabec. This is the same trend in the industrialized world as reported by Kerr et al. in Australia,[5] Arora et al. in the United States,[6] and Szigiato et al. in Canada [10] where there has been 2-6 fold increase. Although 26 that was done in 2017 is still less than half the number of trabeculectomies done. Many of the glaucoma specialists all over the world have shifted to doing GDD because of the result of Trabec versus tube clinical trial study, which reported decreased rates of complications with GDDs compared with Trabec.[12],[13] Furthermore, in the EFHG, the increase in the number of GDD could be ascribed to more secondary glaucomas from cataract surgeries, vitrectomies done from vitreous hemorrhage, and failed trabeculectomies in which GDD is done for many of these.

Cataract extraction with Trabec has reduced drastically by about 6-folds from 2009 to 2014. This is because most of the surgeons now prefer to do one at a time (either trabec or cataract extraction first) which has been observed to have fewer complications. In Ontario, Canada, it has reduced by 2-folds over a decade, but this has been attributed to cataract extraction being done with GDD as reported by Szigiato et al.[10] It is also speculated that because of the increase in the number of cataract extraction being done in the EFHG especially with the Hilton Cataract Initiative (now ACCESS)[14] that was introduced in 2013 till date, this might have led to reduction in the number of combined surgery done and also Trabec. It is a known fact that intraocular pressure tends to lower with cataract extraction.[5],[15]

BR which is needling for drainage of encysted bleb following Trabec is done by the glaucoma specialists and the frequency increased from 2009 to 2015 by 800% until its dramatic decline by 66% in 2017. This could be because of new knowledge from published works that Trabec could be revitalized with this technique.[5] We are of the opinion that there are more functioning blebs and decrease in the frequency of doing Trabec.

Laser procedures

G-probe is the most common laser procedure done in the group. It has been on the increase since 2009 till 2015 until it plateaued from 2015 to 2017. This may be attributable to late presentation of the disease since it is mainly done for refractory glaucoma and more recently used in cases where Trabec is indicated in eyes with good visual acuity.[16] The rate is also on the increase from studies in Australia by Kerr et al.[5] and the Unites States by Arora et al.[6]

The next common laser procedure is LTP; its rate of use has been on the increase till 2013 and it has remained constant up till now. This is likely to be because of more awareness about glaucoma leading to early presentation especially among the educated and this causes the specialist to introduce this procedure early. In the developed world, the use of LTP has been unstable: it increased at a period and the use reduced after some time.[5],[6],[10] This has been attributed to the fact that potent medications (eye drops) were introduced at those period which were found to be very useful.

Laser iridotomy

The use of LIT has been on the increase till 2015 (116%). It has remained almost the same till now. The most plausible explanation is that more angle closure glaucomas are being diagnosed and manual peripheral iridectomy is being replaced with this procedure. This has been the experience in published articles from Australia, the United States, and Canada.[5],[6],[10]

Limitations of this study

  1. Retrospective study with attendant selection bias: data may not be adequately captured
  2. Study did not involve other hospitals, apart from those in the EFHG. The result of this study may not be generalized
  3. Period of time may not be long enough, for example, GDD started 5 years ago
  4. Prevalence and population not taken into consideration
  5. Sociodemographic data of each patient not taken into consideration
  6. Some conclusions like increase in GDD that are due to presentation of complicated glaucomas may not really be due to changing trend which also can create bias.


However, this is a multicenter study in different parts of Nigeria among adults. It is a good account of trends in glaucoma procedural treatments in Nigeria.


   Conclusion Top


Trabec is the most performed procedure, followed by g-probe and LTP. The rate of Trabec is on decrease and the rate of GDD is on significant increase. The laser procedures are generally on the increase. This information is important for allocation of health resources and planning of workforce.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bourne RRA, Flaxman SR, Braithwaite T, Cicinelli MV, Das A, Jonas JB, et al. Vision Loss Expert Group. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: A systematic review and meta-analysis. Lancet Glob Health 2017;5:e888-97.  Back to cited text no. 1
    
2.
Adekoya BJ, Situational Analysis of Glaucoma Services in Lagos State, Nigeria. London school of hygiene and tropical medicine. MSc Community Eye Health project report 2010.  Back to cited text no. 2
    
3.
Abdull MM, Sivasubramaniam S, Murthy GVS, Gilbert C, Abubakar T, Ezelum C, et al. Causes of blindness and visual impairment in Nigeria: The Nigeria National Blindness and Visual Impairment Survey. Invest Ophthalmol Vis Sci 2009;50:4114-20.  Back to cited text no. 3
    
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Kyari F, Gudlavalleti MVS, Sivsubramaniam S, Gilbert CE, Abdull MM, Entekume G, et al. Prevalence of blindness and visual impairment in Nigeria: The National Blindness and Visual Impairment Survey. Invest Ophthalmol Vis Sci 2009;50:2033-9.  Back to cited text no. 4
    
5.
Kerr NM, Kumar HK, Crowston JG, Wlland MJ. Glaucoma laser and surgical procedure rates in Australia. Br J Ophthalmol 2016;100:1686-91.  Back to cited text no. 5
    
6.
Arora KS, Robin AL, Corcoran KJ, Corcoran SL, Ramulu PY. Use of various glaucoma surgeries and procedures in medicare beneficiaries from 1994 to 2012. Ophthalmology 2015;122:1615-24.  Back to cited text no. 6
    
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Kizor-Akaraiwe NN, Ogbonnaya CE. Practice of trabeculectomy by ophthalmologists in Nigeria. Niger J Clin Pract 2017;20:507-11.  Back to cited text no. 7
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Lewallen S, Courtright P. Blindness in Africa: Present situation and future needs. Br J Ophthalmol 2001;85:879-903.  Back to cited text no. 8
    
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Strutton D, Walt J. Trends in glaucoma surgery before and after introduction of new topical glaucoma pharmacotherapies. J Glaucoma 2004;13:221-6.  Back to cited text no. 9
    
10.
Szigiato AA, Trope GE, Jin Y, Buys YM. Trends in glaucoma surgical procedures in Ontario: 1992-2012. Can J Ophthalmol 2015;50:338-44.  Back to cited text no. 10
    
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Kyari F, Nolan W, Gilbert C. Ophthalmologists' practice patterns and challenges in achieving optimal management for glaucoma in Nigeria: Results from a nationwide survey. BMJ Open 2016;6:e012230.  Back to cited text no. 11
    
12.
Murphy C, Ogston S, Cobb C, MacEwen C. Recent trends in glaucoma surgery in Scotland, England and Wales. Br J Ophthalmol 2015;99:308-12.  Back to cited text no. 12
    
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Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC. Postoperative complications in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol 2012;153:804-14.e1.  Back to cited text no. 13
    
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Bogunjoko TJ, Hassan AO, Ajayi BGK, Oderinlo O, Okonkwo O, Ashaye A, etal. Impact of cataract surgical services in Ogun State, Nigeria. J Eye Cataract Surg DOI: 10.21767/2471-8300.100016.  Back to cited text no. 14
    
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Fraser SG, Wormald RPL. Hospital episode statistics and changing trends in glaucoma surgery. Eye (Lond) 2008;22:3-7.  Back to cited text no. 15
    
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Abdull MM, Kyari F, Muazu F, Evans J, Broadway D, Gilbert C. Safety and effectiveness of primary transscleral diode laser cyclophotoablation for glaucoma in Nigeria. Clin Exp Ophthalmol 2018;46:1041-7  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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