Challenges of managing rare ophthalmic cases in a resource-poor setting

Abstract

BACKGROUND

Managing ophthalmic cases not seen routinely is fraught with numerous challenges, including non-adherence to investigations, treatment and follow-up. Such challenges are often related to economic constraints and poor information.

OBJECTIVE

To highlight problems of managing special ophthalmic cases in a resource-poor setting.

CASE REPORTS

Three cases are described. Informed consent for publication was obtained from each patient/ caregiver.

Case I: One-day-old male, born with bilateral upper eyelid eversion and swelling; left eyelid had reverted before presentation. Examination showed a healthy new-born with eversion of the right upper eyelid, chemosis, mild discharge, and mild left lid ecchymosis. A diagnosis of congenital ectropion was made. Tobramycin eye drops and ointment were administered, and the eye was padded with hypertonic saline-impregnated gauze. Mother declined admission due to poor family support and defaulted from follow-up.

Case II: Fourteen-year-old boy with an 11-month history of double vision on lifting and lowering his chin, absent on covering either eye.  He reported that images appeared one on top of the other, with mild pain on upgaze; there was a history of previous left blunt ocular trauma. Left ocular examination showed enophthalmos, limitation of elevation and positive forced duction test. The intraocular pressure difference between the primary position and upgaze was 2 mmHg and 6 mmHg on the right and left, respectively. A diagnosis of restrictive ocular motility disorder, possibly Inferior rectus muscle entrapment/fibrosis, was made. Father declined orbital computed tomography scan due to cost and defaulted.

Case III: A two-year-old with a 1-month history of white reflex in the left eye. There was left hazy cornea and leukocoria with normal findings in the right eye. A diagnosis of retinoblastoma was made. Mother was counselled about management, including enucleation, but she defaulted and returned a year later with a protruding fungating left eye mass, right leukocoria and masses on the head. Exenteration was done, he received a course of chemotherapy, defaulted from follow-up and subsequently died at home.

DISCUSSION

These cases highlight challenges of managing relatively uncommon cases in a resource-poor setting, including late presentation, which could be related to ignorance and misinformation in society and limited access to accurate information.^1,2 It is important to scale up activities that promote awareness of eye care among the public in order to improve eye care-seeking behaviour.

Another factor is delay in diagnosis, which may be due to poor knowledge among health workers, multiple second opinions and inadequate diagnostic facilities. Nwosu, Okoye and Ulasi³ bemoaned the adverse consequences of delayed diagnosis of retinoblastoma by health workers. The establishment of a robust primary eye care system and good referral pathways are likely to promote timely diagnosis. Ignorance,  poor information, and misconceptions could affect patients’ responses to their disease management.⁴ Eyecare professionals must dedicate time and resources to counselling and support of patients with these conditions.

Economic factors are barriers to utilising eye care services by patients.^5–9 Rare cases often require specialised, expensive care, with patients paying out of pocket. Expanding coverage of the National Health Insurance Scheme is likely to be beneficial. Active social welfare services and telephone calls could improve patients’ adherence, as was reported by Kizor-Akaraiwe¹⁰ for glaucoma patients during the COVID-19 lockdown.

CONCLUSION

Financial constraints, ignorance and loss to follow-up hamper management of patients. Education on early presentation and adherence to management plans is vital.