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Ophthalmic Mortality In A Tertiary Eye Care Centre In South-Eastern Nigeria
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• • • • • Acute Toxicity and Blood Profile of Adult Clarias gariepinus Exposed to Lead Nitrate Cigarette smoking and age at natural menopause of women in Poland Human Immunodeficiency Virus (Hiv) Infection Among Medical Outpatients Of Federal Medical Centre, Gombe North Eastern Nigeria Osteogenesis imperfecta: A Report Of Two Cases An Audit Of Otorhinolaryngological Practice In A Nigerian
Eze. The Internet Journal of Ophthalmology and Visual Science. FMCOphth. J.Teaching Hospital Boniface Ikenna Eze MBBS. Shiweobi : Ophthalmic Mortality In A Tertiary Eye Care Centre In South-Eastern Nigeria. FWACS. Uche & J. FICS Lecturer/Consultant Ophthalmologist Department of Ophthalmology University of Nigerian Teaching Hospital (UNTH) Address: Enugu Nigeria Judith Nkechi Uche MBBS Senior Registrar Department of Ophthalmology University of Nigerian Teaching Hospital (UNTH) Address: Enugu Nigeria Jude Obinna Shiweobi MBBS Registrar Department of Ophthalmology University of Nigerian Teaching Hospital (UNTH) Address: Enugu Nigeria Citation: B. 2010 Volume 8 Number 1 Keywords: mortality | ophthalmic inpatients | tertiary centre | Nigeria Table of Contents • • • • • • • • Introduction Methods Background Data analysis Results Cases 1 and 2 Case 3 Case 4 .
Data was analysed to yield percentages.3% and females -41. during the study period. there were 9(0. 8 and 9 Discussion Conclusions Acknowledgement Correspondence to Abstract Objectives: To determine the prevalence. choroidal melanoma-1. and proportions. and congenital glaucoma-1. their recalled clinical charts provided data on demography. Peri-operative anaesthetic complications-5. rhino-orbital mucormycosis-1. congenital cataract-2. frequencies. Conclusions: The inpatient ophthalmic mortality rate at UNTH is low. Methods: The eye ward admission/discharge records from January 1997. and provision of adequate resources for management of life threatening eye conditions would reverse the trend. control. In the resource deficient third world setting.58. at UNTH. were also obtained. The mortality cases were managed for retinoblastoma-3. Often. inadequate care. Nigeria. Enugu. and disseminated carcinomatosis-2 were the causes of death. and causes of death among ophthalmic inpatients at the University of Nigeria Teaching Hospital (UNTH). Majority of the deaths were avoidable. Worldwide. Compared with other medical specialties. ophthalmic mortality rates are higher and often attributable to avoidable and potentially treatable causes like peri-operative .3%) deaths comprising of 4 males and 5 females. metastatic orbital malignancy2. The number of admissions and deaths. clinical diagnosis. Introduction A mortality outcome in the management of any disease condition sign posts failure of therapeutic interventions aimed at cure. mortalities arising from pathologies of the eye and its adnexae are relatively uncommon1. or inherently fatal natural course of the disease process. Results: Of the 2.574 ophthalmic admissions consisting of males. or palliation.• • • • • • • Case 5 Case 6 Cases 7. this is attributable to late presentation. timely presentation of cases. clinical and post-mortem causes of death.December 2008 were examined to determine the number of admissions and deaths.7% . Adequate pre-operative screening. septicemia-2. there exists an inter-regional variation in the rate and causation of ophthalmic mortality.
or systemic complications3. is a tertiary health care facility located in Enugu state. are associated with poor visual.11. one of the five component states of the south-east geopolitical zone of Nigeria. the ophthalmology department delivers promotive. in developed economies. ocular. Methods Background The University of Nigeria Teaching Hospital (UNTH). Primary orbito-ocular malignant neoplasms. the prognosis is further jeopardized by the advanced stage of tumour at presentation1. Majority of such deaths are avoidable and often result from surgical.1-5. appropriate pre-operative cross-consultation with other medical specialties. haemtogenous spread or peri-neural spread around the optic nerve. preventive.12. intra-cranial. and orbito-ocular malignancies. and eye care providers in planning and execution of eye care programmes. Infection-related ophthalmic mortality often results from overwhelming bacterial or fungal orbito-ocular infections which are often associated with orbital. Peri-operative mortality following ophthalmic surgical intervention in an apparently systemically normal individual is unfortunate considering the minimal systemic haemodynamic changes induced by ophthalmic surgical procedures8. severe infections. inadequate facilities for adjunctive non-surgical therapies. underlying systemic immune deficiency states like HIV-Aids14 and uncontrolled diabetes mellitus15. At UNTH. involving the cranial cavity or para-nasal sinuses either by direct tissue invasion.complications. and rehabilitative eye .17. and patient’s deficient financial resource4. it is a multi-disciplinary centre. the rates are lower and mainly due to unavoidable causes6. preferably in a pre-operative anaesthetic clinic. and scarcity of facilities for accurate timely diagnosis and surgical treatment of complications16 have been variously implicated in mortality outcomes of infective orbito-ocular conditions. A survey of causes and pattern of ophthalmic mortality is fundamental in generating baseline data to assist makers and implementers of eye care policy. undergraduate and postgraduate medical and paramedical training. Established in 1971. and survival prognosis 6. curative. engaged in provision of tertiary health care services.7.5. In developing countries. Meticulous pre-operative evaluation. where facilities are available and access barriers to optimal eye care have been largely overcome. anaesthetic. Contrarily. this would guide in optimizing the available resources within the existing eye care delivery system or suggest system modifications necessary to satisfy the identified eye care needs of the population hitherto unmet by the existing eye care programmes. or administrative lapses in the peri-operative management of the patient9.10. and provision of resources for adequate anaesthetic care are established effective measures in reducing the incidence of perioperative deaths7. Ituku-Ozalla. Specifically. non-availability of potent new generation anti-microbial agents16. Enugu. Late presentation13. and research.
data on definitive clinical diagnosis. time to presentation. Enugu. version 3.7 ±12. January 1997 to December 2008. . we recalled their inpatient charts and extracted information on their age.4SD) were admitted and managed in the ophthalmic ward of UNTH. and autopsy diagnosis of cause of death were obtained. with a 27 bed capacity. to determine the total number of admissions. using the Statistical Package for Social Sciences Software (SPSS). we determined the total number of admissions and deaths at UNTH. sex. male to female ratio of 1. Results Between January 1997 and December 2008. We examined the admission and discharge records of the ophthalmic ward over a 12 year period. which is more frequently utilised.4:1. ethical approval was obtained for the UNTH’s Institutional review board.7%) females . and percentages.074(41. houses medical and surgical eye patients requiring inpatient care. cross-consultation with other medical specialties. primary cause of death.care services through outpatient and inpatient care. type of anaesthesia. and referral interval. 2. proportions. Enugu.500(58. Data analysis Data was subjected to simple descriptive statistical analysis. and identify patients who died while on hospital admission. to generate frequencies.74 years (mean= 44. and nurses. Also. During the same period. type of treatment offered – medical and or surgical. The eye care workforce on the ground consists of ophthalmologists-consultants and trainees. optometrists. Prior to commencement of the study. The ophthalmic ward. The anaesthetic staffs are rostered from their parent department of anaesthesia to handle both elective and emergency surgical cases requiring general anesthesia.3%) males and 1.4. The age and sex distribution of ophthalmic inpatients is shown in table 1. is administered by the ophthalmologists who are mandatorily trained on that during their residency programme. The data was crossvalidated by interfacing it with the records obtained from the UNTH’s central Medical Records Department For the mortality cases. aged 2 months. Local anaesthesia.574 eye patients consisting of 1.
They were co-managed with the paediatric oncology team. Clinical evaluation and ancillary investigations. cytotoxic chemotherapy. from septicemia and carcinomatosis. Histology of tumour biopsy specimen confirmed a diagnosis of maxillary sinus carcinoma with orbital invasion. established diagnosis of choroidal melanoma with hepato-biliary metastasis.Table 1: Age and sex distribution of ophthalmic inpatients.3 and aged 4months-60 years died while on admission. and tumour debulking surgery performed under general anaesthesia. Abdominal and bone secondaries were later detected by radiologic . There were more paediatric-5(0.4%) ophthalmic inpatient deaths. Case 3 A referral case of biopsy-proven nasopharyngeal carcinoma with left orbital metastasis in a 46 year old male artisan worker who presented at the ophthalmic out patient on account of the orbital involvement. Patient eventually died from disseminated carcinomatosis and hepatic failure. and were attributed to anaesthesia. Management was in conjunction with the medical oncology unit and otolaryngology team and consisted of supportive measures and tumour chemotherapy. including histology.3%) patients made up of 4(44. Case 4 A 49 year old male petty trader who presented with rapidly progressive left orbital mass. aged 3 and 4 years respectively. Case 5 A 35 year old male civil servant with right hemi-facial swelling and progressive ipsi-lateral proptosis. Both deaths occurred in the eye ward. He had overwhelming super-infection and his condition deteriorated until he died 4 weeks after admission. While Case 1 never recovered fully from the surgical anaesthesia and died 2 hours after surgery. and weight loss. The summaries of the mortality cases are as follows: Cases 1 and 2 both males.4%) males and 5 (55. not in the operating theater. Permission for postmortem examination was not granted by the relatives of both patients. At presentation. Tumour debulking. and managed for late presentation unilateral retinoblastoma involving the right eye.6%) females with sex ratio of 1:1. Case 2 achieved full recovery but later developed fatal haemo-dynamic instability. treatment consisted of general supportive measures. Tumour mass was reduced surgically in a joint session with the maxillofacial unit and chemotherapy was commenced afterwards.6%) than adult -4 (0. Of these. in addition to medical oncology-supervised chemotherapy were the mainstay of treatment. both had fungating orbital tumour with complete destruction of the ipsilateral globe. abdominal swelling. 9 (0.
all under general anaesthesia. This seems to suggest that the quality of paediatric eye care services. While the observed age distribution could be attributed to dominance. revealed extensive pulmonary haemorrhage as the autopsy diagnosis of cause of death. but sharply contrasts with the 37.6%). Rahman et al reported on orbital tumour related mortality and Uy et al was specific for mortalities in patients with orbital cellulitis. and marked pallor. Discussion The 0. She had associated fever. The analysis of the demographic profile of the mortality cases showed a slight predominance of paediatric (55. The observed age and sex distribution differed from the results of similar studies elsewhere1.9%) patients. ophthalmic admissions and mortalities accounted for 3. wasting. permitted only on case 9. Cases 7. Patient condition continued on a downhill course until death 2 weeks after admission apparently from septicemia.4% independently reported by Fafowora & Ubah1.2. and Omoti & Ogbedo2 from two tertiary eye care centres in Nigeria. Surgical debridement of lesion was also performed. and 3% documented by Uy & Co-workers18. and female (55. Enugu during the study period.investigations.2.5% reported by Rahman et al6. in the present report. at UNTH. The overall low ophthalmic mortality rate documented in the present survey and previously reported elsewhere from Nigeria is consistent with the established lower mortality rate among ophthalmic inpatients compared with other medical specialties8. Cases 7 &9 had lens washout without anterior vitrectomy while case 8 had trabeculectomy.8% respectively. 4 months. Case 6 A 60 year old female with necrotic naso-orbital lesion covered with black devitalised tissue. of paediatric diseases. is probably sub- . Based on positive fungal elements from the examination of the biopsy material. Cases seven and 9 had bilateral cataracts while 8 had congenital glaucoma. Cases 7 & 8 failed to recover from anaesthesia while 9 died shortly after surgery from haemo-dynamic complications of anaesthesia. 8 and 9 all females aged 18 months. systemic anti-fungal treatment was started in addition to antibiotic therapy and general supportive measures. Of the total admissions and mortalities at UNTH.3% inpatient ophthalmic mortality rate observed in this study is comparable to the rate of 0.4% and 0. Patient eventually died from disseminated carcinomatosis and severe anaemia. Paediatric evaluation did not reveal any associated systemic anomalies in all the cases. the explanation for the sex distribution is not immediately clear. While the present study shares similarity in study setting and study population with previous Nigerian studies1.19-22. and 5years respectively. Autopsy examination.
Orbito-ocular malignancies (55. especially in the paediatric age group. in addition to the enormous treatment challenges imposed by late presentation. Currently. Perioperative deaths attributable to anaesthesia in not uncommon in developing countries and they are frequently due to avoidable factors9. Furthermore.25. potentially avoidable anaesthetic complication was the primary cause of death in 55. this probably explains the high frequency of anaesthetic deaths. This differed from the results from Ibadan1 and Benin2.8%) and Infection (42.6%) and congenital anomalies (33. post-mortem examination was permitted only in one patient (11. This differed slightly from the reports from Ibadan1 and Benin2. The spectrum of diseases which pre-staged mortality in this study is consistent with the reported trend in a typical third world setting where. it is hoped. human and material resources for effective therapeutic interventions for these conditions are grossly deficient23.24.1%). While the former had malignancy followed by infection as the main clinical diagnosis.26. Unfortunately.2% each of the total deaths. Similar to the socio-cultural settings at Ibadan and Benin. at Enugu. would ensure early diagnosis and timely referral of potentially curable but otherwise fatal eye diseases. especially curative tertiary eye care services. there is no fellowship trained paediatric anaesthesiologist.6% of the recorded mortalities followed by septicemia and disseminated carcinomatosis /organ failure which accounted for22. There is an urgent need to bridge this crucial health information gap. implies an urgent need for commencement of fellowship training in paediatric anaesthesia for consultant anaesthesiologists. The regrettably high prevalence of anaesthetic death despite appropriate preoperative cross-consultation. In the present report. between health . This. This. would equip them with requisite knowledge and skills for the peri-operative management of paediatric patients and impact positively on the survival outcome of paediatric eye patients undergoing ophthalmic surgery under general anaesthesia.8%) were the main primary causes of death respectively. the reverse was the case with the later. and Omoti & Ogbedo2. where consent for post-mortem examination was withheld across board by relations of all the deceased patients.3%) were the leading clinical diagnoses among the mortality cases examined in this study. this has implications for prioritization of needs and resource allocation during future planning and implementation of curative eye care programmes. the findings suggest the need for modification of eye health seeking behavior of the population through intensive promotive and preventive eye care activities. hopefully. Literature search for similar studies elsewhere outside Africa yielded no results for inter-regional comparison. at UNTH Enugu. In the peculiar resource deficient setting in developing countries. where malignancy (53.optimal. This is in partial agreement with the findings of Fafowora & Ubah1. was the main obstacle to acceptance of post-mortem examination by the relations of the deceased. both in Nigeria. rigid cultural taboos premised on unfounded beliefs in re-incarnation.
com References 1. Lakhey M. Sah SP. Mckebbin N. needs-based provision of material resources for eye care delivery. Rahman I. Omoti AE. Mortality on an ophthalmic ward. Enugu. Acknowledgement The authors acknowledge the assistance of the staff of the ophthalmic outpatient and medical records departments of University of Nigeria Teaching Hospital (UNTH). 44(7): 262-72 (s) 9. 31(5):415-7 (s) 6. Holck DE. 14(1):54-6 (s) 3. and retention of appropriate and adequate ophthalmic and relevant anaesthetic manpower. Thakur SK. Fafowora OF. Conclusions The ophthalmic mortality rate at UNTH is low. Mortality following exenteration for malignant tumours of the orbit. Postoperative mortality in a general Hospital. Rev Esp Anestesiol Reanim 1997 Aug-Sep. Cook AE. Primary malignant tumours of eye and adnexa in Eastern Nepal. 114(2):345-54 (s) 4. Chaudry IA. South-eastern Nigeria. Sinclair JR. 10(Pt 1): 138-40 (s) 8. heredity and reincarnation. Eye 1996. Uche NJ. Peri-operative mortality in . recruitment. Perez-Torres C. Outcome of treated orbital cellulitis in a tertiary eye care centre in the Middle East. 18(3):211-3 (s) 2. we recommend training. Majority of the deaths are potentially avoidable. Ubah JN. Chuka-Okosa CM. Ophthalmology 2007 Feb. Orbito-ocular neoplasms in Enugu. Badhu BP. To reverse the trend. Ogbedo E. Correspondence to Boniface Ikenna Eze E-mail: xy3165767@yahoo. Wilson IH. Heywood AJ. West Afr J Med 2008 Jul.care providers and the public. 89:1445-1448 (s) 7. Shamsi FA. Suan C. Leatherbarrow AE. 27(3): 144-7 (s) 5. Al-Rashed W. Mano A. The preoperative assessment and investigation of ophthalmic patients. West Afr J Med 1999 Sept. Ophthalmic mortality in a tertiary centre in Nigeria. Kizor-Akaraiwe NN. Al-Anezi F. Niger Postgrad Med J 2007Mar. Elzaridi E. Clin Experiment Ophthalmol 2003 Oct. and intensification of community based promotive and preventive aye care activities to ensure timely presentation for uptake curative eye care. Br J Ophthalmol 2003. Arat YO. Al-Amri A. concerning death. Herrera A.
Maradona JA. McLeish WM. Diabetes Res Clin Pract 2002 Aug. 18(10): 510-6. Saravanappa N. Eur J Emerg Med 2005 Feb. Topalka A. Kano. A three year review of mortality patterns in the medical wards of Aminu Kano Teaching Hospital. Herman BW. Simultaneous intra-cranial and orbital complications of acute rhino. Yilmaz S. Clin Otolaryngol Allied Sci 2004 Dec. Arribas JM. 71(6): 354-8 (s) 10. Courtney-Harris R. J Fr Ophthalmol 2000 Apr. Yudiz E. Ramos Rincon JM. Lewis DM. Borodo MM. Tuano PM. Manzatti J. Elaedi N. Aliaga Matas F. 2(1): 6-9 (s) 14. Vucero J. Kyprianou I. Alonso F. Malignant tumours of the eye and adnexae in Congo-Kinshasa. Niger Postgrad Med J 2007 Dec. Uy HS. 26(1) 33-7 (s) 19. Mohammed AZ. Transfer from ophthalmology to another service is a marker of high risk medical events. Adekunle O. Orbital infections in patients with human immunodeficiency virus infection. Herrero Halerta F. Hospital mortality in an internal medicine service. Ophthalmology 1996 Sep. Lozano Cutillas MC. Poso MY. Urrutia L. Schvartzman E. 21(7): 317-21 (s) 22.D’ Souza A. 10(9): 1483-9 (s) 15. Gilberq SM. Panella D. Referral patterns in paediatric orbital cellulitis. Fandino A. Preseptal and orbital cellulitis in a developing Country. Scott KR.sinusitis in children. Kayenibe DL. Johnson TE. Canbany E. Olatunde IO. Orbit 2007 Mar. Llanos Llanos R. 23(4):327-32 (s) 18.Zambia. Barcons M. Ann R Coll Surg Engl 1989 Nov. Causes and pattern of death in a tertiary health institution in South-western Nigeria. (s) 23. 14(4):250-4 (s) 12. Carrera R. Enterm Infecc Microbiol Clin 1996 Apr. Arch Dis Child 1999 Feb. An Med Intern 2004 Jul. Mwanza JC. Kronish JW. 80(2):171-4 (s) . Sanclemento C. Howe L. Garcia Ruiperez D. Bapp A. (s) 21. Diabetic keto-acidosis and rhino-orbital mucormycosis. An Med Intern 2001Oct. 22(1):7-11 (s) 11. Schachat AP. 57(2) : 139-42. Int J Paediatr Otolaryngol 2004 May. 14(4): 347-51. Dokmetas HS. Nigeria. Ophthalmic Surg 1991 Jan. Niger Postgrad Med J 2008 Dec.AbdulLateef RM. Forsen JW Jnr. 29(6): 725-8 (s) 17. 15(4) :247-50. Anglada A. Moliero MA. Chatanda G. Late diagnosis of retinoblastoma in a developing country. Guidelines for the management of peri-orbital cellulitis/abscess. Sani MU. Carton JA. 68(5) : 619-625 (s) 13. Specific mortality rates by DRG and main diagnosis according to CIE-9-MC at a level II hospital. Wu WC. Oztoprak I. Severe orbital cellulitis: therapeutic results in 9 patients and review of literature. Aseni V. (s) 20. (s) 16. Toribio R. Corrent GF. Jones NS.
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