Eye Surgery in Africa

Abba Hydara 

Sheikh Zayed Regional Eye Care Centre, Kanifing - The Gambia.              

Correspondence to: Dr. Abba Hydara; email: ahydara@gmail.com

Received: 22 May 2021; Revised: 31 May 2021; Accepted: 31 May 2021; Available online: 14 Jun 2021

Keywords: Case Series; Corneal Transplant, Indications; Small Incision Cataract, Phacoemulsification; Prostate Cancer, Screening, Focus Group

Ann Afr Surg. 2021 ; 18(3): 126-129 
DOI: http://dx.doi.org/10.4314/aas.v18i3.1
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

In this edition of the Annals of African Surgery, we have several exciting original articles that drew our attention to the challenges of quality health-care service delivery, especially in our part of the world: low- and middle-income countries (LMICs). We shall look at three articles and discuss their implications for the practice of surgery in Africa. The first article discussed corneal transplants in Ghana. The second article also came from Ghana and compared the two most common modern surgical procedures for cataracts: manual small incision and phacoemulsification. Finally, the third article focused on the uptake of prostate cancer screening in rural Kenya.
The first two articles were hospital-based, medical records review, also called retrospective case series. They both carry classic lessons defined by case selection. The third was an explorative qualitative study that utilized focus group discussions with in-depth interviews. This latter study was robust and has immediate implication for policy as well as for reshaping key behavioral change communication messages for overcoming sensitive service uptake challenges.
From the Kwame Nkrumah University of Science and Technology in Ghana, Seth Lartey et al. undertook a retrospective case series review that looked at corneal transplants performed at the Komfo Anokye (pronounced as comefornokey) Teaching Hospital in Kumasi between 2014 and 2018. Seventy-five eyes were finally analyzed with a very wide age range (10 to 99 years). The most common indication for corneal transplant in this series was pseudophakic bullous keratopathy, a complication of complicated cataract surgery that damages the corneal endothelium, leading to a persistently opaque, cloudy, and edematous cornea. This edematous cornea develops blisters (bullae) that cause significant discomfort, photophobia, pain, and severely reduced vision. The corneal endothelium is a monolayer of terminally differentiated hexagonal cells that actively keep the cornea in a state of relative dehydration (deturgescence) and thus clear (1). Endothelial cells get damaged during intraocular surgery such as cataract extraction. The remaining cells do not regenerate to replace damaged ones: they stretch in an attempt to fill up the gaps that result, a process called polymegathism (1). Bullous keratopathy from damaged endothelium shall remain for the foreseeable future as long as cataract remains the leading cause of surgically treatable blindness globally.
A brief understanding of the surgical anatomy of the cornea is critical in order to appreciate the importance of corneal transplants in our environment. The cornea is a clear, glass-like avascular structure that forms the anterior part of the eyeball. It is made up of five distinct layers and is responsible for most of the refractive power of the eye. Being avascular confers some level of protection from immune surveillance. This makes the cornea the most favorable transplant organ. The first successful human allograft corneal transplant was performed by Dr. Eduard Konrad Zirm (1863–1944), an Austrian ophthalmologist from Vienna on December 7, 1905, in the Czech Republic, on a laborer who was blind due to lime eye injuries. The donor cornea came from a boy who lost his eye from a penetrating scleral injury that necessitated an enucleation (2).
The Brightbill (3) classification of corneal graft prognosis graded five levels of the prognosticating diseases. This list is important if we wish to achieve predictably successful transplants. Even though Seth Lartey et al. did not give us a grading of their cases according to the Brightbill classification, we know that bullous keratopathy has good prognosis. In these modern times, the best surgical technique for treating bullous keratopathy is direct replacement of the damaged endothelium. It introduced a shift from traditional whole cornea transplantation to utilizing strictly what was needed. This has implications in the maximal and efficient utilization of scarce resources such as donated organs. The shift is about favoring lamellar keratoplasty over penetrating (full-thickness) keratoplasty, whereby the posterior corneal layers are utilized for bullous keratoplasty from whatever cause, while the anterior corneal layers are utilized for mainly corneal dystrophies and scars affecting the superficial anterior layers.
The authors pointed to the paucity of subspecialty-trained cornea surgeons in Ghana. This is not unique to Ghana alone, but is a common human resource for health challenge all over sub-Saharan Africa. However, of note is the high success rate reported in this series, with only 14% failure after 1 year for a mainly Brightbill grade II-prognosticated indication. We (4) found keratoconus to be the leading indication (49%) for penetrating keratoplasty in Kenya, with 90% of grafts remaining clear after 24 months, with 72% of eyes having uncorrected visual acuity of 6/60 or better (4). It is curious to note that the majority of persons who underwent corneal transplant were in the 20–39 age bracket, and keratoconus was not their identified problem.
The common causes of bilateral corneal blindness in sub-Saharan Africa are mainly due to severe vernal keratoconjunctivitis coupled with other infectious causes. Severe vernal keratoconjunctivitis is typified by intensely itchy eyes with eye rubbing. The repeated eye rubbing, especially by young people, leads to corneal ectasia and worsening poor vision as the keratoconus develops. Trachoma, as the leading infectious cause of blindness, remains important in some parts of Africa, but in 2018, Ghana was the first African country to successfully reduce trachoma to a level where it ceased to be of public health significance, thus warranting a World Health Organization (WHO) certification as having reached a trachoma elimination status (5). Therefore, it was not surprising that this Ghanaian series made no mention of corneal opacification specifically attributable to trachoma. Implementation of the WHO SAFE Strategy, with reference to surgery for the cicatricial distortion of the upper eyelids that cause entropion with trichiasis and the consequential corneal opacification that results. Trachoma corneal opacification causes corneal vascularization, which is a poor prognostic indicator for corneal transplant (a Brightbill grade III indication has a poor outcome).
Lastly, organ donation is a major challenge in Africa. Procuring corneas from the USA, Sri Lanka, or Europe is fraught with many hurdles. Transp