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ORIGINAL ARTICLE
Year : 2022 | Volume
: 21
| Issue : 4 | Page : 421-425
Pattern of eye diseases in adults at the general outpatient clinic of a Tertiary Hospital in Nigeria
Adaora Amaoge Onyiaorah1, Nkiru N Kizor-Akaraiwe2, Sebastian N N. Nwosu3
1 Department of Ophthalmology, Nnamdi Azikiwe University, Awka, Anambra State; Department of Ophthalmology, Enugu State University of Science and Technology Teaching Hospital, Parklane, Enugu, Enugu State, Nigeria
2 Department of Ophthalmology, Enugu State University of Science and Technology Teaching Hospital, Parklane, Enugu, Enugu State, Nigeria
3 Department of Ophthalmology, Nnamdi Azikiwe University, Awka, Anambra State, India
Correspondence Address:
Adaora Amaoge Onyiaorah
Department of Ophthalmology, Nnamdi Azikiwe University, Awka, Anambra State
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_152_21
Abstract
Objective: To determine the pattern of eye diseases at the general outpatient department (GOPD) of a Nigerian tertiary hospital. Materials and Methods: Patients selected by systematic random sampling at the GOPD of a Nigerian tertiary hospital were studied. Information on sociodemographics and ocular complaints were obtained using interviewer-administered questionnaire. Ocular examination included visual acuity measurement and anterior and posterior segments examinations. Data analysis was with Statistical Package for the Social Sciences. Results: Three hundred and eighty-two patients, comprising 124 (32.5%) males and 258 (67.5%) females, aged between 18 and 86 years, mean 44.8 ± 15.4 years, were studied; 112 (29.3%) had eye diseases but only 88 (78.6%) patients complained of ocular disorder(s). Common complaints were poor vision 53 (60.4%), red eye and grittiness 15 (17.0%) each. Common eye diseases were lens 52 (13.6%) and conjunctiva 46 (12.0%) disorders. Attaining higher education was protective against eye diseases (P < 0.05). Conclusion: Nearly a third of patients at the GOPD have eye diseases. Therefore, primary eye care should be integrated into the GOPD service with provision of relevant manpower and facilities for care of the ophthalmic patients.
Abstract in French Résumé
Objectif: Pour déterminer le schéma des maladies oculaires au service général de consultation externe d'un hôpital tertiaire nigérian. Matériels et Méthodes: Des malades sélectionnés par échantillonnages aléatoires systématiques au service ambulatoire général, d'un hôpital tertiaire au nigérian on été étudies. Les informations sur les données sociodémographiques et les plaintes oculaires ont été obtenues à l'aide d'un questionnaire lors d un interview. L'examen oculaire comprenait la mesure de l'acuité visuelle et de l'examen des segments antérieur et postérieur. L'analyse données a été effectuée par le progiciel des sciences sociales. Résultats: Trois cent quatre-vingt-deux malades, comprenant 124(32,5%) hommes et 258 (67,5%) femmes, âges entre 18 et 86 ans, moyenne 44,8 ± 15,4 ans, ont été étudiés ; 112 (29,3%) avaient des maladies oculaires mais seulement 88 (78,6%) malades se plaignaient de trouble(s) oculaire(s). Les plaintes les plus courantes étaient une mauvaise vision 53 (60,4%), les yeux rouges et la sécheresse oculaire 15(17,0%) chacun. les maladies oculaires courants étaient les troubles du cristallin 52(13,6%) et la conjonctive 46 (12,0%). le fait d'avoir fait des études supérieures ont protégé contre les maladies oculaires courant (P<0.05). Conclusion: Près d'un tiers des malades de la service ambulatoire général, Nigérian ont des maladies oculaires. Par conséquent, les soins oculaires primaires doivent être intégrés dans le service ambulatoire généra avec la fourniture de la main-d'œuvre et des installations nécessaires pour les soins a les malades d'ophtalmiques.
Mots-clés: Maladies oculaires, troubles oculaire, service ambulatoire général, Nigérian
Keywords: Eye diseases, eye disorders, general outpatient department, Nigeria
Introduction 
The general outpatient department (GOPD) of a hospital is essentially the primary health-care section of a teaching hospital. Curative as well as preventive health-care services are offered for a wide range of diseases, including the eye disorders. The GOPD is the first point of contact for most patients presenting to a tertiary hospital. It is from the GOPD that patients are referred to other specialist clinics including the eye clinic.
Ophthalmic disorders have been reported among patients in general practice in Nigeria[1],[2] and in the United Kingdom.[3],[4] Different studies in general practice settings reported that conjunctivitis accounted for 32.9%,[1] 53.7%,[4] 59%,[3] and 73%.[5] Other common ocular conditions reported were cataract (1.8%,[5] 4.8%,[4] and 14.7%[1]), refractive errors (0.8%,[4] 9.9%,[1] and 17.3%[5]), and glaucoma (1.9%,[5] 2.3%,[4] and 5.3%[1]). The common complaints reported in a Nigerian[2] study were poor vision (39.2%), itching (26.6%), and red eye (8.0%). Some of these studies were done in primary health-care facility settings within communities. At present, the magnitude and pattern of eye diseases in the GOPD of many tertiary hospitals in Nigeria have not been reported.
This study was, therefore, conducted to obtain data on the incidence and pattern of eye diseases among patients presenting at the GOPD of a Nigerian teaching hospital. Information obtained would expectedly be useful in the formulation of necessary management guidelines for eye conditions in general medical practice.
Materials and Methods This study was approved by the Ethical Committee of the Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria. Informed consent was also obtained from all the participants.
New adult patients who presented to the GOPD between June and August 2017, selected by systematic random sampling, were the subjects of this study. Available records from the GOPD showed that an average of 60 new patients were seen daily. Data collection for this study endured for 3 months. There are 60 working days in a 3-month period. This gives an estimated population size of 3600 patients.
Using the Leslie–Kish formula,[6] for population <10,000, the calculated minimum sample size at 95% confidence interval was 382. Given this minimum sample size and an estimated patients population of 3600, the interval for selection of patients by systematic random sampling technique was 9.
The first participant was, thus, randomly selected between numbers 1 and 9. Subsequent participants were selected in multiples of the number 9 until the desired sample size was achieved. Given the time it takes to interview and examine each participant, a maximum of 7 participants were examined each day.
All new patients presenting at the GOPD of ESUT Teaching Hospital, Parklane, Enugu, during the study period who gave consent were included in the study; excluded were very ill patients, old (follow up) patients and those who withheld consent.
Using a pre-tested, structured, questionnaire two trained interviewers obtained information on socio-demographics, ocular complaint, and previous eye disease from each participant. An inter-rater agreement between the interviewers was Kappa score of 0.8 was. Ocular examination was performed by an ophthalmologist using the ophthalmic equipment used in general practice setting. These were visual acuity assessment with the Snellen or illiterate E chart and pinhole occlude as applicable, anterior segment examination with a pen torch and a head-mounted magnifying loupe and direct ophthalmoscopy using the Welch Allyn ophthalmoscope for posterior segment examination.
Data obtained was analyzed using the Statistical Package for the Social Sciences (SPSS) version 23 (SPSS Inc., Chicago, Illinois, USA). Analysis of variables included descriptive statistics such as means with standard deviation, frequencies, and percentages. The relationship between variables was tested using inferential statistics such as the χ2 or Fisher's exact test as applicable with alpha level at 0.05.
For the purpose of this study, the following definitions of important parameters were used:
Glaucoma was defined as a vertical cup-disc ratio of ≥0.75 or an asymmetry of ≥0.2 between the two eyes.[7] This definition was used in this study based on direct ophthalmoscopic findings, the instrument expected to be used by the general practitioner for ocular examinationRefractive error was defined as visual acuity of <6/12 which improved to 6/12 or better with the pinhole.[8] Again the definition is not comprehensive but since the general practitioner is not expected to perform refraction, pinhole acuity is a good screening tool for ametropia[9]Cataract was defined as any visible opacity of the crystalline lens[10]Age-related macular degeneration was be defined as presence of drusen or pigment disturbances with atrophy or hemorrhage at the macula in the absence of other known causes in those aged 50 years and above[10]Subconjunctival hemorrhage was defined as patch of blood under the conjunctivaAllergic conjunctivitis was defined when there was red eye, no pain, watery or serous discharge with moderate to severe itching[11]Infective conjunctivitis was defined as red with mild or no pain, more copious serous or mucopurulent discharge but mild or no itching[11]Pterygium was defined as a triangular, fleshy growth on the conjunctiva extending onto the corneaCorneal foreign body was defined as any foreign material embedded in the corneaCorneal ulcer was defined as a defect in the corneal epithelium with involvement of the underlying stroma. Staining was done with fluoresceinPseudophakia and aphakia were defined as absence of the crystalline lens from its anatomical location with and without intraocular lens respectively Results Three hundred and eighty-two patients, made up of 124 (32.5%) male and 258 (67.5%) females participated in the study. The age range was 18–86 years. The mean age was 44.8 ± 15.4 years. The commonest age group was 51–60. The sociodemographic characteristics of participants are shown in [Table 1]. Three hundred and forty-two out of 382 (89.5%) had formal education with 142 (37.2%) attaining post-secondary education. Civil servants, 124 (32.4%) had the highest representation of all the occupations. Up to 234 (61.3%) of the patients were married. Two hundred and ninety-one (76.2%) patients were urban dwellers.
Up to 112 (29.3%) patients had at least one eye disease, among which 55 (49.1%) had multiple eye diseases. Of these 112 patients, 88 (78.6%) actually complained of an eye problem. The common ocular complaints were poor vision 53 (60.2%), red eye 15 (17.0%), grittiness 15 (17.0%), itching 14 (15.9%), tearing 14 (15.9%), and pain 9 (10.2%).
The distribution of eye diseases is shown in [Table 2]. The eye diseases (according to anatomy) were lens disorders 52 (13.6%), conjunctival disorders 46 (12.0%), retina diseases 27 (7.1%), and ametropia 27 (7.1%). In terms of specific diagnosis, the most frequent eye diseases were cataract 50 (13.0%), pterygium 29 (7.5%), refractive errors 27 (7.1%), age-related macular degeneration 22 (5.8%), and glaucoma 12 (3.1%). These account for 46.6%, 25.9%, 24.1%, 19.6%, and 10.7%, respectively, of the 112 patients that had eye diseases. The presenting visual acuity in the better eye of participants is shown in [Table 3]; 344 (90.1%) patients had mild or no visual impairment while 7 (1.8%) patients were blind.
The relationship between sociodemographic characteristics and eye diseases is shown in [Table 4]. Increasing age and poor educational (less than or equal to primary school) status appears to be risk factors for having eye disease (P < 0.05). Of 112 participants in which eye diseases were detected, 64 (57.1%) were aged 50 years and above. Forty-nine out of 102 (48.0%) patients with primary education and below had eye disease compared with 63 out of 280 (22.5%) of those with secondary education and above.
Discussion The results of our study suggest that 2 out of 3 patients seen at the GOPD were females. This, however, differed from other Nigerian studies by Scott and Ajaiyeoba[1] in Ibadan and Oladigbolu et al.[5] in Zaria where there were more males. A female preponderance was also observed in the two studies by Sheldrick et al. in Nottingham, United Kingdom.[4],[12] The female preponderance in the present study may be because of the hospital policy mandating all patients attending the gynecology and family planning clinics, (which are females' only clinics) to first pass through the GOPD. A comparison of age of patients in this study with those in similar studies within and outside Nigeria may be difficult as the age ranges of the studies were different since these studies[1],[4] involved both adults and children while we studied adults only. Persons aged >50 years constituted 40.6% of the participants with the 51–60 year age bracket alone accounting for nearly a quarter of the participants [Table 1]. It is thus not surprising that age-related and degenerative eye diseases accounting for 30.2% of the eye diseases [Table 2].
Majority of the patients had either secondary or postsecondary education. More than half of the patients were civil servants or traders and most patients (76.2%) were urban dwellers. These findings are not unexpected as the hospital is centrally located in Enugu metropolis, the capital of Enugu State with many institutions of higher learning, government offices, and large markets. This probably implies that many of the participants are sufficiently literate and enlightened to understand health information and may exhibit better health-seeking behavior. Furthermore, many of the participants would probably be better economically empowered and thus would be able to pay for health-care services. Services in the hospital are not free even for children.
The proportion of eye diseases found in the present study is higher than was obtained in studies on general practice patients in the United Kingdom,[3],[4] Egypt[14] and in Ibadan Nigeria.[1] This may be because in the United Kingdom and Egypt studies, ocular diagnosis was not made by an ophthalmologist but from clinical records of the general practitioners. In the Ibadan study,[1] though ocular diagnosis was made by an ophthalmologist, the study was conducted over two decades ago and the difference may be due to increased health awareness, through persistent health promotion activities and consequent improved health-seeking behavior with increase in attendance to hospital over the years.
The 29.3% incidence of eye diseases in the GOPD as found in the present study should be of interest to health service planners and administrators. Health workers must thus be prepared to adequately handle these patients, including treatment, and/or referral as appropriate. The finding of a significant proportion of patients with eye diseases in our study highlights a need for continued collaboration between the ophthalmologist and the general practitioner as well as support for the general practitioner in carrying out his role in eye care including the initial history, examination, diagnosis, treatment, and/or referral ophthalmic patients which is vital to the final outcome of the ocular problem.[15] This is especially necessary as 1 in 5 of these patients with eye disease did not complain about eye problem and it is known that consultation with a general practitioner creates an opportunity for screening of ocular diseases.[16],[17]
Unlike in the present study, other studies[1],[3],[4] reported that conjunctivitis was the commonest eye disease. This difference may be from patient selection because our study did not include children, in whom some diseases like allergic conjunctivitis occur more.[18] Glaucoma made up a higher proportion (10.7%) among eye diseases found in the present study compared to similar studies done within (5.3% and 1.9%)[1],[5] and outside (2.3%)[4] Nigeria. Although gonioscopy was not part of the tools of ocular assessment of the participants thus making it difficult to delineate participants into open or closed angle types, participants diagnosed with glaucoma were symptomless. This asymptomatic presentation is typical of primary open angle glaucoma (POAG). The Nigerian National Blindness and Visual Impairment Survey[7] documented the highest prevalence of POAG in South-East Nigeria; the present study was conducted in Enugu, South-East Nigeria. Therefore, all health workers especially in South-East Nigeria should be aware of this and refer appropriately to mitigate irreversible blindness.
The present study did not include children, and eye diseases, including glaucoma, are known to occur more with increasing age.[19] This difference in patient selection may also account for the higher proportion of age-related macular degeneration found in the present study, compared to another study.[4] Furthermore, another reflection of differences in patient selection is the finding that refractive error was lower in this study than was reported in other studies in Nigeria[1],[5] and higher than was reported in the United Kingdom[4] in which children were included unlike in our study. Proportions of the corneal and eye lid disorders found in the present study were similar to that reported in the United Kingdom.[4] This shows that these diseases are not very common in the populations studied.
The finding of lower eye disease rate among those with higher educational attainment may probably be because educated persons expectedly would be more health conscious, may afford care more, have better health-seeking behavior and may not wait till deterioration of their condition. Senyonjo et al.[2] similarly reported that the odds of having an eye disease increased with lower educational attainment. Our findings differed from a study in India[20] where female sex had significantly higher prevalence of ocular morbidities.
Conclusion Eye diseases are common among patients presenting to the GOPD, with cataract, pterygium, refractive errors, age-related macula degeneration, and glaucoma being the most common. General practitioners attending to these patients need to be aware of these and be equipped to treat the much they can and refer complex cases. A smooth practicable referral chain is desirable.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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