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Original Article

Indications and Pattern of Ophthalmic Surgical


Intervention among Children in a Tertiary Center in
North-central Nigeria: A 14 Year Review

Odugbo OP.1, Wade PD.1, Ewuga RO.2, Mpyet CD.1


1
Department of Ophthalmology, Faculty of Clinical Sciences, College of Health Sciences, University of Jos, P.M.B. 2084, Jos, Nigeria
2
Department of Ophthalmology, Dalhatu Araf Specialist Hospital, Lafia-Nigeria

* Correspondence: Department of Ophthalmology, Faculty of Clinical Sciences, College of Health Sciences, University
of Jos, P.M.B. 2084, Jos-Nigeria.. Email: odugp@yahoo.com

ABSTRACT For reprints contact: chsjournals@gmail.com

The study assessed the pattern of ophthalmic surgical intervention among children. The ophthalmic surgical database was
retrospectively reviewed to obtain information on children who had surgical intervention from 1st January 2004-31st December
2017. These included demographic data; preoperative diagnosis, surgical procedure, type of anaesthesia administered and rank
of the surgeon. The data was entered into Epi Info version 3.4 and analyzed after validation by double entry. Seven hundred and
forty seven children (aged <18years) underwent a procedure during this period;withmore males 487(65.2%) than females
260(34.8%), Male:Female ratio was 1.9:1.The mean age was 6.9±4.6years.General anaesthesia was administered on 697
(93.3%) participants, 457 (61.2%) had their surgeries performed by consultant ophthalmic surgeons. Eight hundred and twenty
nine eyes were operated. The main indications for surgical intervention included trauma to 372(44.9%) eyes, cataract
242(29.2%), glaucoma 93(11.2%) and orbito-ocular tumours/cysts in 47(5.7%) eyes. The main surgical procedures were
cataract surgeries (inclusive of traumatic cataract) in 347(41.9%) eyes, intervention due to injuries (exclusive of traumatic
cataract) in 251(30.3%) eyes, trabeculectomy in 93(11.2%) and destructive eye surgeries in 81(9.8%).We observed that a male
child is twice more likely to have an ophthalmic surgical intervention. A statistically significant difference in the indications for
surgical intervention was observed among the genders. A higher proportion of males had trauma 51.4% (χ2=9.96, p=0.004), as
indication for surgery while a higher proportion of females had conjunctival mass 3.1% (Fischer’s exact test = 5.39, p=0.03),
ectropion 1.9% (Fischer’s exact test = 6.24, p=0.013) and strabismus 1.9% (Fischer’s exact test = 6.25, p=0.012) as indications
for surgery.

Keywords: Children, Cataract, Indications, Ophthalmic, Surgical, Trauma.

INTRODUCTION

a major (75%) cause in developing countries.1,2 Cataracts are


C hildren experience a variety of eye problems, many
quite distinct from adult eye diseases. Surgical
morbidities include congenital/developmental cataract, ocular
opacities of the crystalline lens. Because they frequently
interfere with normal visual development, they represent an
trauma, congenital glaucoma, congenital malformations important problem in paediatric ophthalmology.1 Blindness
155 involving the orbit, eyes and ocular adnexae, benign nodules from cataract occurs in about 10-40 per 100,000 children in
and cyst, strabismus and neoplasms among others. Childhood the developing world and 1 to 4 per 100,000 children in the
blindness is the second most important cause of blind person developed world.1,3 The wide variety of lenticular
years globally and congenital/developmental cataract remain involvement, from tiny spots to complete opacification, is

Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019


Odugbo et al: Indications and Pattern of Ophthalmic Surgical Intervention among Children

well known. Infants may be visually impaired from birth and Neoplasms that involve the orbito-ocular region could be
develop nystagmus and amblyopia. The opacities are usually benign or malignant. The age distribution of ocular and
bilateral and progressive. Lens opacities can be associated adnexal malignant tumours is known to be bimodal with one
with chromosomal aberrations, developmental conditions, peak during early childhood and another peak during
intrauterine infections, acquired infections, uveitis, trauma adulthood.14 Strabismus, which is a misalignment of the eyes
and metabolic errors. It could also be drug induced, affects 2-4% of the population and may require surgical
radiation-induced or idiopathic. A congenital cataract, though correction in childhood. Amblyopia (lazy eye) occurs when
present at birth, is not necessarily associated with a the vision of one eye is significantly better than the other eye,
significant visual defect from birth (such as with a small and the brain begins to rely on the better eye and ignore the
anterior polar cataract) or at least not at all stages of its weaker one. Amblyopia affects 4% of the population and
development; it is the onset of the visual defect that is the strabismus is an important cause.15
important factor and the most difficult to determine.4 Lens Ectropion refers to an outward rotation of the eyelid margin
removal may be required in early infancy or childhood. which may require surgical correction. The cause could be
Ocular trauma is another important cause of surgical congenital or acquired following trauma in most instances.16
morbidity among children. Several factors can place a child The period of development in which experience plays an
at risk for a serious eye injury. Children aged ≤5 years are influential role has been termed as the ‘critical period’.17A
probably at a greater risk with boys more frequently affected critical period exists for normal visual development, this is
particularly in the age group >6years.5,6 A lack of parental gradually replaced with a more mature visual system. Its
supervision is a risk factor. Younger children are more often fragility however remains, and any new insult has the
injured by a fall or being struck with a sharp projectile while potential for impairing good vision.18The cause of insult
in older children sporting events (e.g. football, tennis ball, (which may be congenital or acquired) is not as important as
baseball etc) is a common cause.5,6 other critical factors which include the age of onset, severity
Congenital glaucoma develops due to ocular hypertension of the insult, the age of initiation of treatment, compliance
and is evident either at birth or within the first few years of with treatment and the health of the fellow eye. In general,
life. Malformations in the anterior chamber angle obstructs the younger the age of onset, the more severely damaging is
aqueous outflow.7,8Congenital malformations affecting the the insulting factor. 17,18
naso-lacrimal drainage system constitute a common group of Abnormal visual development begets abnormal child
morbidity in childhood.9 In congenital ankyloblepharon, the development. Vision is the most important sense for general
eyelid margins are partially or completely fused together. development and education.19 Babies learn by imitating, by
The horizontal palpebral aperture is reduced.10Dermoid cysts becoming aware of their own hands and feet through vision,
of the orbit and periorbital region are common in childhood, and by eye contact with parents which provide clues about
accounting for 3-9% of orbital masses in most series. They their performance. The blind or partially sighted baby is
are developmental choristomas which are thought to arise deprived to varying degrees of these ingredients of normal
from aberrant ectodermal tissue trapped at suture lines or development. Therefore, we assessed the indications and
within mesenchyme during orbital development.11 pattern of ophthalmic surgical interventions among children
Benign nodules and cysts among children could necessitate in our center with a view to plan for an enhanced
surgical intervention. A chalazion is a lipogranuloma of the performance in the delivery of paediatric eye care services in
meibomian gland that results from obstruction of the gland our center.
duct and is usually located in the mid portion of the tarsus,
away from the lid margin. If conservative management fails, MATERIALS AND METHODS
surgical intervention by incision and curettage is indicated. A
secondary infection of a chalazion is known as internal The ophthalmic surgical database was retrospectively
hordeolum.12 Conjunctival tissue may be sequestered as a reviewed to obtain information on children aged <18years 156
primary embryological malformation or as a result of trauma who had surgical intervention from 1st January 2004-31st
or surgery. This may be seen as a blister-like conjunctival December 2017 (14years). These included demographic data;
swelling, filled with clear fluid.13 preoperative diagnosis, type of surgical procedure, type of

Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019


anaesthesia administered and the rank of the surgeon. The Table 2: Indications for surgical intervention (eyes)

data was entered into Epi Info statistical software, version S/no Diagnosis No %
3.4 and analyzed after validation by double entry. 1. Trauma related
Foreign body on the eyelid 1
Descriptive statistics was used to yield frequencies, Lid laceration ±canalicular injury 25
percentages and proportions. Analytical statistics was applied Limbal rupture 11
Corneal/scleral/corneo-scleral laceration 193
and a p value <0.05 was considered statistically significant. Traumatic hyphaema 5
Ethical approval was obtained from the Institutional Medical Traumatic cataract 105
Intraocular and orbital foreign body 17
Research Ethics Committee. Ruptured globe 15
Total 372 44.9
2. Cataract
RESULTS Congenital/developmental cataract 232
Secondary cataract/diabetic cataract 7
Dislocated/subluxated cataract 3
747 children (aged <18years) underwent a procedure during Total 242 29.2
this period with an annual average of 53/year; there were
more males 487(65.2%) than females 260(34.8%) with a 3. Glaucomas
Congenital glaucoma 92
male:female ratio of 1.9:1. The mean age was 6.9±4.6years, Secondary glaucoma 1
with a range of 2.3-11.5years (mean±SD). Table 1 revealed Total 93 11.2
the highest proportion of participants 263(35.2%) were aged
1-5years, 335(44.8%) were aged ≤5years and 566(75.7%) 4. Infections/inflammations
Lid abscess/orbital abscess 5
were aged ≤10years. Molluscumcontagiosum 2
Internal hordeolum 1
Table 1: Age-sex distribution of study participants Chronic dacryocystitis 1
Recurrent wart 1
Age group Male Female Total Conjunctival granuloma 6
(years) No % No % No % Painful blind eye 2
<1 39 8.0 33 12.7 72 9.6 Intractable intraocular infections 21
1-5 170 34.9 93 35.7 263 35.2 Total 39 4.3
6-10 151 31.0 80 30.8 231 30.9
11-15 102 21.0 36 13.9 138 18.5 5 Orbito-ocular tumours/cysts
16-17 25 5.1 18 6.9 43 5.8 Orbito-ocular malignancies 35
Total 487 100 260 100 747 100 Dermoid cysts 9
Orbital mass 2
Chi square 8.2, p=0.09 Capillary haemangioma 1
Total 47 5.7
697 (93.3%) children had generalanaesthesiaadministered, 6 Bening growths and cysts
457 (61.2%) had their surgeries performed by consultant Lid growths 8
ophthalmic surgeons. Up to 82 children had surgery in both Chalazion 7
Conjunctival growths and cysts 10
eyes. A total of 829 eyes were operated. Pterygium 2
Total 27 3.3
Table 2 revealed the main indications for surgery which
7 Nasolacrimal duct obstruction 14 1.7
included trauma to 372(44.9%) eyes, cataract 242(29.2%), 8 Anterior staphyloma 8 1.0
glaucoma 93(11.2%) and orbito-ocular tumours/cysts in 9 Ectropion (congenital &cicatricial) 7 0.8
47(5.7%) eyes. Table 3 showed the main surgical procedures 10 Strabismus 7 0.8
were cataract surgeries (inclusive of traumatic cataract) in 11 Symblepharon 4 0.5
12 Congenital ankyloblepharon 2 0.2
347(41.9%) eyes, intervention due to injuries (exclusive of 13 Others 8 1.0
traumatic cataract) in 251(30.3%) eyes, trabeculectomy in
* Based on 829 eyes **some eyes had more >1 diagnosis. ***one eye had an intraorbital
93(11.2%) and destructive eye surgeries in 81(9.8%). foreign body

157

Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019


Table 3: Distribution of types of surgical procedures performed

S/no Procedure (eyes) No %

1. Trauma related (without traumatic cataract)


Removal of foreign body on the eyelid 1
Lid laceration ±canalicular repair 25
Limbal repair 11
Corneal/scleral/corneo-scleral repair 193
Anterior chamber paracentesis 5
Intraocular foreign body removal 16
Total 251 30.3

2. Cataract (inclusive of traumatic cataract)


ECCE+PCIOL 257
Lens washout 47
ECCE+ primary capsulotomy 18
ECCE 17
ECCE+ACIOL 4
ICCE+ACIOL 4
Total 347 41.9

3. Trabeculectomy 93 11.2

4. Destructive eye surgeries


Evisceration 46
Enucleation 24
Modified exenteration 11
Total 81 9.8

5. Biopsies
Excisional biopsy 36
Incisional biopsy 2
Total 38 4.6

Adnexal surgeries
Probing and dilatation of the NLD system 11
Dacryocystorhinostomy 3
Release of contracture/ FTSG 7
Incision and curettage 7
Incision and drainage 6
Release of ankyloblepharon 2
Lid bracing 1
Shave excision 2
Tarsorrhaphy 1
Adhesiolysis with either amniotic membrane or conjunctival graft
4
Pterygium excision 2
Conjunctival resection 1
Conjunctival flap 1
Total 48 5.8

Optical iridectomy 3 0.4


Squint surgery 7 0.8
Orbital exploration 2 0.2
Socket reconstruction 1 0.1

* Based on 829 eyes **Two eyes had >1 procedure


Key: PCIOL: Posterior chamber intraocular lens, ECCE: Extracapsular cataract extraction, ICCE: Intracapsular cataract extraction, ACIOL: Anterior chamber
intraocular lens, NLD: Nasolacrimal drainage, FTSG: Full thickness skin graft

A higher proportion of males had trauma 51.4% (χ2=9.96, p=0.004), glaucoma 8.5%(χ2=2.12, p=0.17) and
infection/inflammation 5.5% (χ2=0.31, p=0.61) as indications for surgery while a higher proportion of females had cataract
27.3% (χ2=1.84, p=0.15), lid mass 2.7% (χ2=2.14, p=0.19), conjunctival mass 3.1% (Fischer’s exact test = 5.39, p=0.03),
ectropion 1.9% (Fischer’s exact test = 6.24, p<0.013)and strabismus 1.9% (Fischer’s exact test = 6.25, p=0.012) as indications
for surgery (Table 4). 158

Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019


Table 4: Distribution of indications for surgery by gender (persons)

S/no Diagnosis Male Female Total *Test statistic/p


value
No % No % No %
1 Trauma related 250 51.4 102 39.2 352 47.1 9.96, p=0.004
2 Cataract 112 23.0 71 27.3 183 24.5 1.84, p=0.15
3 Glaucoma 41 8.5 15 5.8 56 7.5 2.12, p=0.17
4 Infections/Inflammations 27 5.5 12 4.6 39 5.2 0.31, p=0.61
5 Orbito-ocular tumour& cysts 29 6.0 18 7.0 47 6.3 0.38, p=0.63
6 Bening lid mass 6 1.2 7 2.7 13 1.7 2.14, p=0.19
7 Pterygium, conjuntival growths and cysts 4 0.8 8 3.1 12 1.6 5.39, p=0.03
8 Nasolacrimal duct obstruction 7 1.4 4 1.5 11 1.5 0.11, p=0.87
9 Anterior staphyloma 4 0.8 4 1.5 8 1.1 0.80, p=0.74
10 Ectropion 2 0.4 5 1.9 7 0.9 6.24, p=0.013
11 Strabismus 1 0.2 5 1.9 6 0.8 6.25, p=0.012
12 Symblepharon 1 0.2 3 1.2 4 0.5 2.07, p=0.21
13 Congenital ankylobleharon 0 0.0 1 0.4 1 0.1 1.21, p=0.31
14 Others 3 0.6 5 1.9 8 1.1 2.74, p=0.11
Total 487 100 260 100 747 100

*= Chi square test or Fisher’s exact test.


prevention.Care givers (parents, teachers, nannies, older
DISCUSSION siblings etc) should be encouraged to supervise play and
sports, players who participate in games involving small
Majority of the children that underwent a surgical procedure
balls should wear suitable protective goggles. 5,6,21,24-28
were in the 1-5 year age group with a mean age (6.9 years)
Cataract surgery for congenital/developmental cataract was
comparable with 6.88 years reported by Umar et al on review
the second most common procedure. The age of participants
of pediatric cataract surgeries in Kaduna, Nigeria and
with cataract varied. Cataracts that develop during the critical
8.7years reported by Adioet al while reviewing corneal
period are of utmost importance. From a practical standpoint,
injuries among children in Port Harcourt, Nigeria.20,21About
the clinician is rarely completely assured of what a child’s
two-thirds of participants were males which is also in tandem
past visual experience has been. The benefit of the doubt was
with observations by Umar et al,20Adioet al,21 and Duke et
given and treatment rendered as promptly as possible. In a
al22. This could be attributed to the fact that most surgeries
neonate, infant or toddler, a dense axial opacity 3mm or
were done as a result of injuries and boys tend to sustain
larger will most certainly lead to deprivation amblyopia if
ocular trauma that require surgical intervention more often
left untreated. If medically feasible, surgical removal within
than their female counterparts. Furthermore,in a typical
2 to 4 weeks of detection is indicated.29 When children
African setting, male children are often valued more than
beyond infancy present with dense, central opacities of
females and thus do have their health needs attended to more
uncertain duration and Snellen visual acuity cannot be
than female children.5,6,23A significantly high proportion
accurately measured, surgery is indicated within a few weeks
(44.8%) of participants were aged ≤5years and over three-
of detection.30Partial cataracts are sometimes managed
quarters were aged ≤10years. The ophthalmic surgical
initially with non-surgical methods. In a young child, a
morbidities among children observed are in consonance with
cataract does not merely blur the image received by the
reports in literature.1-16
retina, it also disrupts the development of the visual
Ocular trauma was the most common indication for surgical
pathways in the central nervous system.29Childhood cataracts
intervention with the male child being twice more likely to
are seldom removed too early but are frequently removed too
have an ophthalmic surgical intervention due to trauma
late.
compared to a female child. This also is in consonance with
An aphakic eye could be rehabilitated with spectacles,
findings documented in literature.5,6,21,24-28 In our setting boys
contact lenses or intraocular lenses. Intraocular lenses are
are generally allowed more liberty to play than girls, they
being used increasingly to optically correct aphakia in
159 spend more outdoor time with their peers and are encouraged children with good visual results.20,22,30-35Of the 347 eyes that
to exhibit more aggressive behavior as part of their normal
had cataract surgery, 257(74.1%) had small incision cataract
development. These place boys at a higher risk of trauma.23-
26 surgery (SICS) with posterior chamber intraocular lens
. The best form of management for ocular trauma is
implantation. This is comparable to an intraocular lens lens

Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019


Odugbo et al: Indications and Pattern of Ophthalmic Surgical Intervention among Children

(IOL) implantation rate of 83.4% and 65.2% reported by months of age is associated with a decreased success rate of
Umar et al and Duke et al respectively.20,22 In recent times, initial probing.9 Congenital ankyloblepharon was an
the rehabilitation of aphakic eyes with posterior chamber indication for surgery in both eyes of 1 participant who
intraocular lens (PCIOL) in children age >2years has become however had no associated ectodermal defects.Ectropion was
a standard care among paediatric ophthalmologists. Currently an indication for surgery in 7(0.8%) eyes. The indications for
an ‘in-the-bag’single piece polymethylmethacrylate lens is surgery included exposure keratopathy and cosmetic
the most popular method.However, IOL implantation in blemish. Strabismus is an extremely common referral
infancy continues to be hotly debated. It is currently diagnosis in children. It was an indication for surgical
contraindicated during infancy because of the difficulty of intervention in 7(0.8%) eyes. One must constantly keep in
accurately predicting the most appropriate lens power to mind the interplay between strabismus and amblyopia.15 We
insert (due to marked axial length and refractive changes) observed that surgeries that improved aesthetic appearance
and the increased incidence of complications due to were significantly more common among females. This was
increased tissue sensitivity in these eyes.31,36 not surprising as cosmetic blemish was probably one of the
The surgical outcome of these procedures will be the subject reasons why participant/parents sought for surgical
of another manuscript. intervention.
Congenital glaucoma was an indication for surgery in 11.2% In conclusion, the uptake of ophthalmic surgeries among
of eyes. The object of trabeculectomy is to create a full- children in our center was high and indicative of a very busy
thickness hole in the peripheral cornea and cover it with a paediatric ophthalmology unit. A male child is twice more
lamellar corneoscleral flap. likely to have ophthalmic surgical intervention compared to a
Orbito-ocular tumours/cysts were indications for surgical female. Trauma, cataract and congenital glaucoma were the
intervention in 5.7% of eyes with orbito-ocular malignancies main indications for surgeries. There is a need for more
being the most common indication. Studies of orbito-ocular equipment to further enhance pediatric eye care services in
lesions in Nigeria and other African countries suggest that our center.
retinoblastoma remains the most common ocular malignancy
among the paediatric age group.14,38-41 Dermoid cysts Conflict of Interest
accounted for 19.1% of orbito-ocular masses observed in this None declared
study. This is comparable to figures noted in literature 11 as it
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Journal of Research in Basic & Clinical Sciences | Volume 1 |Issue 2| 2019

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