RESUMO
BACKGROUND: Little was known about the population coverage and causes of sight impairment (SI) registration within the Caribbean, or the extent to which register studies offer insights into population eye health. METHODS: We compared causes of SI registration in the Trinidad and Tobago Blind Welfare Association (TTBWA) register with findings from the 2014 National Eye Survey of Trinidad and Tobago (NESTT), and estimated registration coverage. Cross-sectional validation studies of registered clients included interviews, visual function and cause ascertainment in July 2013, and interviews and visual function in July 2016. RESULTS: The TTBWA register included 863 people (all ages, 48.1%(n = 415) male) registered between 1951 and 2015. The NESTT identified 1.1%(75/7158) people aged ≥5years eligible for partial or severe SI registration, of whom 49.3%(n = 37) were male. Registration coverage was approximately 7% of the eligible population of Trinidad. Nevertheless, there was close agreement in the causes of SI comparing the register and population-representative survey. Glaucoma was the leading cause in both the register (26.1%,n = 225) and population-based survey (26.1%, 18/69 adults), followed by cataract and diabetic retinopathy. In the validation studies combined, 62.6%(93/151) clients had severe SI, 28.5%(43/151) had partial SI and 9.9%(15/151) did not meet SI eligibility criteria. SI was potentially avoidable in at least 58%(n = 36/62) adults and 50%(n = 7/14) children. CONCLUSION: We report very low register coverage of the SI population, but close agreement in causes of SI to a contemporaneous national population-based eye survey, half of which resulted from preventable or treatable eye disease.
Assuntos
Sistema de Registros , Humanos , Trinidad e Tobago/epidemiologia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Transversais , Adulto , Adolescente , Idoso , Criança , Cegueira/epidemiologia , Pré-Escolar , Inquéritos Epidemiológicos , Adulto Jovem , Pessoas com Deficiência Visual/estatística & dados numéricos , Idoso de 80 Anos ou mais , LactenteRESUMO
AIM: To estimate the prevalence, causes and risk factors for presenting distance and near vision impairment (VI) in Trinidad and Tobago. METHODS: This is a national, population-based survey using multistage, cluster random sampling in 120 clusters with probability-proportionate-to-size methods. Stage 1 included standardised, community-based measurement of visual acuity. Stage 2 invited all 4263 people aged ≥40 years for comprehensive clinic-based assessment. The Moorfields Eye Hospital Reading Centre graded fundus photographs and optical coherence tomography images independently. RESULTS: The response rates were 84.2% (n=3589) (stage 1) and 65.4% (n=2790) (stage 2), including 97.1% with VI. The mean age was 57.2 (SD 11.9) years, 54.5% were female, 42.6% were of African descent and 39.0% were of South Asian descent. 11.88% (95% CI 10.88 to 12.97, n=468) had distance VI (logarithm of the minimum angle of resolution [logMAR] >0.30), including blindness (logMAR >1.30) in 0.73% (95% CI 0.48 to 0.97, n=31), after adjustment for study design, non-response, age, sex and municipality. The leading causes of blindness included glaucoma (31.7%, 95% CI 18.7 to 44.8), cataract (28.8%, 95% CI 12.6 to 45.1) and diabetic retinopathy (19.1%, 95% CI 4.2 to 34.0). The leading cause of distance VI was uncorrected refractive error (47.4%, 95% CI 43.4 to 51.3). Potentially avoidable VI accounted for 86.1% (95% CI 82.88 to 88.81), an estimated 176 323 cases in the national population aged ≥40 years. 22.3% (95% CI 20.7 to 23.8, n=695) had uncorrected near VI (logMAR >0.30 at 40 cm with distance acuity <0.30). Significant independent associations with distance VI included increasing age, diagnosed diabetes and unemployment. Significant independent associations with near VI included male sex, no health insurance and unemployment. CONCLUSIONS: Trinidad and Tobago's burden of avoidable VI exceeds that of other high-income countries. Population and health system priorities are identified to help close the gap.
Assuntos
Baixa Visão/epidemiologia , Pessoas com Deficiência Visual/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Cegueira/epidemiologia , Cegueira/etiologia , Cegueira/fisiopatologia , Catarata/complicações , Catarata/epidemiologia , Estudos Transversais , Retinopatia Diabética/complicações , Retinopatia Diabética/epidemiologia , Glaucoma/complicações , Glaucoma/epidemiologia , Inquéritos Epidemiológicos , Humanos , Pessoa de Meia-Idade , Prevalência , Erros de Refração/complicações , Erros de Refração/epidemiologia , Fatores de Risco , Trinidad e Tobago/epidemiologia , Baixa Visão/etiologia , Baixa Visão/fisiopatologia , Acuidade VisualRESUMO
Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.
Assuntos
Oftalmologia/organização & administração , Análise de Sistemas , Adulto , Idoso , Idoso de 80 Anos ou mais , Cegueira/prevenção & controle , Oftalmopatias/epidemiologia , Oftalmopatias/cirurgia , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmologistas/estatística & dados numéricos , Oftalmologia/economia , Oftalmologia/instrumentação , Optometristas/estatística & dados numéricos , Pacientes Ambulatoriais , Inquéritos e Questionários , Trinidad e Tobago , Recursos HumanosRESUMO
PURPOSE: This paper describes the rationale, study design and procedures of the National Eye Survey of Trinidad and Tobago (NESTT). The main objective of this survey is to obtain prevalence estimates of vision impairment and blindness for planning and policy development. METHODS: A population-based, cross-sectional survey was undertaken using random multistage cluster sampling, with probability-proportionate-to-size methods. Eligible participants aged 5 years and older were sampled from the non-institutional population in each of 120 cluster segments. Presenting distance and near visual acuity were screened in their communities. People aged 40 years and older, and selected younger people, were invited for comprehensive clinic assessment. The interview included information on potential risk factors for vision loss, associated costs and quality of life. The examination included measurement of anthropometrics, blood glucose, refraction, ocular biometry, corneal hysteresis, and detailed assessment of the anterior and posterior segments, with photography and optical coherence tomography imaging. Adult participants were invited to donate saliva samples for DNA extraction and storage. RESULTS: The fieldwork was conducted over 13 months in 2013-2014. A representative sample of 10,651 individuals in 3410 households within 120 cluster segments identified 9913 people who were eligible for recruitment. CONCLUSION: The study methodology was robust and adequate to provide the first population-based estimates of the prevalence and causes of visual impairment and blindness in Trinidad and Tobago. Information was also gathered on risk factors, costs and quality of life associated with vision loss, and on normal ocular parameters for the population aged 40 years and older.
Assuntos
Cegueira/epidemiologia , Baixa Visão/epidemiologia , Pessoas com Deficiência Visual/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Cegueira/economia , Criança , Pré-Escolar , Análise por Conglomerados , Estudos Transversais , Feminino , Custos de Cuidados de Saúde , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Qualidade de Vida , Fatores de Risco , Distribuição por Sexo , Trinidad e Tobago/epidemiologia , Baixa Visão/economia , Adulto JovemRESUMO
Cataract extraction, being the most frequent ocular surgical procedure, demands our best effort at maintaining satisfactory outcomes. Phacoemulsification is not readily available to most Opthalmologists in the region. It is also not necessarily the best technique for many of our patients who present with dense cataracts. A customized surgical plan will ensure that we adopt the most appropriate approach in each case. The following should be considered: (a) Need for sedation-route, quantum and timing (b) Anaesthesia technique (c) Surgical approach depends on: -Is the cataract mature or not? -Adult or Paediatric, -Phaco-emulsification; manual extra-capsular cataract extraction; non-phaco small incision techniques. -Capsular opening and use of ICG or methylene blue, -Viscoelastic, -Astigmatism. Adoption of an individualized surgical plan will ensure preparedness in the operating room but adaptability may be dictated by inoperative changes. (AU)
Assuntos
Humanos , Extração de Catarata/métodos , Procedimentos Cirúrgicos OftalmológicosRESUMO
We have been using an Excimer Laser with flying spot technology to perform LASIK for the past 3 months. Both eyes are treated at the same sitting unless surgery is indicated in only one. Thirty-one patients have been treated, 30 had both eyes done while one had only one. The author has been privileged to follow the progress of 32 eyes of 16 patients. Target correction was achieved in 72 percent; correction acceptable to patient in 87.5 percent, enhancements were required in (4 eyes) 12.5 percent. Follow-up extended over 2 weeks to 3 months. Refractive errors corrected: hyperopia (two eyes), myopia (2 eyes) hyperopic astigmatism (10), myopic astigmatism (14), mixed astigmatism (4) Range of errors -8:50 DS to + 3:00 DS, and up to -4.25 DC. Age ranged from 26-68yrs; with 2 patients in their 60s and 3 in their 40s. Pre-operative best corrected visual acuity (BCVA) was 20/20 for distance and 20/20 for near, in all eyes. No loss of BCVA was recorded. COMPLICATIONS AND SIDE EFFECTS: One eye suffered a button-hole flap leading to minor off-axis scarring. Uncorrected vision of 20/20 for near was achieved as desired. One patient needs spectacles for glare at night. One patient is experiencing fluctuating vision at 2 weeks post op. (20/20 to 20/40). One eye with undesired astigmatism of -1.75 DC. Undercorrection in one eye: myopic ending -0.75; -1.50 being desired. These results have been very encouraging. The patients came from businesses and professional groups with one office clerk, an airline pilot and a sporting personality. With enhancements and the development of personal nomograms, a high success rate is anticipated. (AU)
Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Erros de Refração/cirurgia , Ceratectomia Fotorrefrativa/estatística & dados numéricos , Ceratectomia Fotorrefrativa/efeitos adversos , Hiperopia/terapia , Miopia/terapia , Astigmatismo/terapiaRESUMO
Buying into a practice does not assure one's success. A successful practice is built and the investment in your training demands your best effort at "Brand Name" development. THE PHYSICIAN: -introduce and present your self to sources of referral; -be responsive; -communicate; -what's your gimmick? THE AMBIENCE: -Location; -A plesant purpose-built office layout; -Facilitate patient flow; -Image is important; -Use technology (Computerized system) THE STAFF: -You get what you pay for; -Inferior staff never leave; THE SERVICES -Control appointment system; -Plan 6 to 12 months ahead; -Information brochures; MARKETING: -Brand Name development; - Use the subtle media; -Develop own strategies; -Niche markets; -Feed back to sources; -Use of the Internet. (AU)
Assuntos
Humanos , Prática Privada/normas , Prática Profissional/normas , Marketing de Serviços de Saúde , Serviços de Saúde/normasRESUMO
A well constructed wound and an adequate capsulorrhexis are necessary pre-requisities to phaco-emulsification. The freshman should avoid a cataract that is too soft since these do not crack readily. Nuclei are too hard are also unsuitable for beginners as they are difficult to emulsify and prone to complications. Good hydrodissection, hydrodelineation and moblisation of the nucleus are essential. Viscoelastic is used to deepen the anterior chamber (AC) and protect the corneal endothelium. The phaco tip enters the AC in the infusion mode to ensure that the AC depth is maintained. The four-quadrant "divide and conquer" technique is probably easiest to learn and safest to execute. A phaco-chopper and the phaco-needle are used for cracking the nucleus and separating the quadrants. The quadrants are engaged with the vacuum at 100 mm Hg and brought to the centre of the pupil, where the AC is deepest, for emulsification. The epinucleus is removed in the pulse mode and cortical remnants aspirated by a bimanual technique, the posterior capsule being polished with aspiration cannula at low vacuum. There should be preparations for converting immediately to extracapsular extraction, if necessary. A plan for learning the phaco should include wet laboratories; for example, at the congress of the American Association of Ophthalmologists or of the Ophthalmology society of the West Indies (OSWI), An experienced colleague may guide the novice through his or her first cases. In this regard, I thank my OSWI colleague, Dr. Alfred Anduze, for assisting me in my first cases.(AU)
Assuntos
Humanos , Capsulorrexe/instrumentação , Facoemulsificação/métodos , Extração de Catarata/instrumentação , Região do CaribeRESUMO
The increasing use of the computer in our practice led to the development of a customised database which will allow scheduling and recalls, storage of patient data, facilitate research and generation of practice letters, and other functions. Access programme has been used to create databases for our surgery patients. These keep track of billing and permit outcomes analyses. Accounting records are kept using Quicken which covers income, expenditure, bank reconciliations and production of reports adequate for our accountant. Research and keeping up-to-date are facilitated by the Internet using such sites as Medline and the Digital Journal of Ophthalmology. Registration for conferences and hotel bookings are also done via the Internet. E-mail is checked twice daily as an average of five communications arrive each day for the medical staff and the organisations we represent. It has also been useful in accessing consultations and obtaining patient appointments at institutions abroad. Every member of staff uses the computer, with the less skilled being sent on formal training courses. This has proven to be a great morale booster for staff who generate an increasing number of patient information booklets which include graphics. We have a reasonably advanced computer system which allows networking between remote offices. However, more economical units are available for solo practices. There are tremendous possibilities for efficiency in practice without the tedium paperwork, but one must be cautious of commercial programmes which are expensive and not tailored to one's needs (AU)
Assuntos
Oftalmologia/métodos , Tomada de Decisões Assistida por ComputadorRESUMO
A review of 42 patients who had penetrating keratoplasty between 1990 and 1997 in North Trinidad revealed that the two main indications for surgery were keratoconous and aphakic or pseudophakic corneal decompensation. There were 47 grafts with visual outcome showing improvement in 30 (63.8 percent), being unchanging in 8 (17.0 percent), and worse in 5 (10.6 percent). Records of 4 were inadequate. 34 (72.3 percent) had associated complications; i.e., raised intraocular pressure in 20 (42.6 percent), rejection in 12 (25.5 percent), and keratitis (one case); and retinal detachment (one case). Control of intraocular pressure was achieved in 17 cases. There were 8 graft failures, 6 of which were due to rejection. The 60 percent visual acuity of 6/18 (20/60) or better in this study compares well with results from Australia and Israel. The complications and graft failure rates are both acceptable at international levels. This study reflects measured success to corneal grafting locally. A major positive introduction would be the establishment of a corneal graft bank.(AU)
Assuntos
Humanos , Transplante de Córnea , Transplante de Córnea/efeitos adversos , Trinidad e TobagoRESUMO
This retrospective study reviewed data on all new patients in a general ophthalmological service between January and June 1997. Of 1,286 new patients 156 (12.6 percent) were diabetic. 75 percent of these presented for their first eye examination by an ophthalmologist, 25 percent had at least one previous examination and 10 percent were previously diagnosed with diabetic retinopathy. Over 75 percent were diabetic for more than 5 years. Only 23 percent sought consultation as a routine. 77 percent attended because of visual complaints. Most diabetics (58 percent) were East Indian, in keeping with previously reported studies. Blindness occurred in 19 to 21 percent of diabetics depending on the definition. Of 142 whose fundi could be examined, 74 or 52 percent had retinopathy. In spite of increasing knowledge from studies such as the Diabetic Retinopathy Study, the Early Treatment Diabetic Retinopathy Study and the Diabetes Control and Complication Trial, it seems that the message is not filtering through to the level of primary care and to patients. Our review demonstrates the most patient present for ophthalmological assessment only on experiencing visual symptoms. The majority are seen after they have been diabetic for over five years and most patients attend on self referral. Greater effort is required to promote the guidelines of the World Health Organization and the American Academy of the Ophthalmology for the ophthalmic management of diabetic patients in order to reduce the blindness rate due to this epidemic.(AU)