Red Eye The Role of Primary Care

Community Eye Health
JOURNA L
Volume 18 | Issue No.53 | March 2005
EDITORIAL
Red eye: the role of primary care

Allen Foster
Sue Stevens
Professor, International Centre
for Eye Health, London School
of Hygiene and Tropical Medicine,
Keppel Street, London WC1E 7HT, UK.
One of the most common eye problems

to present to health workers is acute
red eye(s). Approximately 40% of
all outpatients seen in Bawku,
Ghana, and in ten district hospitals
in Pakistan, present with red eyes
(Figure 1).
While the more serious causes of
red eye need prompt recognition and
management by an eye specialist, in
many cases red eye can be managed
at the first point of health care
(primary level). If primary health care
workers are able to differentiate the
various causes of red eye and provide
primary level treatment, there are two
important advantages:
Primary health
• Patients are managed quicker and care workers
closer to where they live examine a baby.
• Secondary centres will be relieved of CAMBODIA
treating simple conditions, allowing
more time and resources for eye
conditions that need the attention of specialists. Fig. 1. ‘Red eye is one of the most
This issue of the Community Eye Health Journal gives an common eye problems.
overview of what the primary level health care worker can Red Eye In 2004, approximately
do for patients presenting with red eye. We have limited
this to non-traumatic causes, as eye injuries will be
discussed in a separate issue of the journal later this year.
40% 40% of all outpatients
Isaac Baba’s article deals with first aid at the primary seen in Bawku Hospital,
level, and Tissa Senaratne and Clare Gilbert provide an Ghana, and in ten
overview of conjunctivitis, while Anthony Hall and Others
district hospitals in
Bernadetha Shilio give more information about the
difficult management of allergic eye disease including
practical guidelines on how to recognise and manage
60% Pakistan, presented
vernal keratoconjunctivitis. We also include useful summary with red eyes’
diagnostic and management tables and a quiz that can be used Source: Bawku Hospital figures: Isaac Baba
for training primary level eye care workers. Pakistan district hospitals figures: Babar Qureshi
IN THIS ISSUE...
EDITORIAL 73 Conjunctivitis 80 EXCHANGE
69 Red eye: the role of primary care Tissa Senaratne and Clare Gilbert Including 2004 PICO Community Eye Heath
Allen Foster MSc dissertation summaries
76 Vernal keratoconjunctivitis
ARTICLES Anthony Hall and Bernadetha Shilio 83 INDEX
70 The red eye – first aid at the primary level Covering issues 25 - 50
Isaac Baba 72 Red eye picture quiz answers
83 NEWS AND NOTICES
72 Red eye picture quiz 79 HOW TO... Including useful resources, upcoming
David Yorston and Marcia Zondervan Ophthalmic practice by Sue Stevens conferences and courses
COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 69

Community Eye Health PRIMARY EYE CARE
JOUR NA L
Supporting VISION 2020: The Right to Sight The red eye – first aid
The journal is produced in
collaboration with the
World Health Organization
at the primary level
Volume 18 | Issue No. 53 | March 2005 Isaac Baba The danger is use of harmful traditional
Cataract Surgeon, Bawku Hospital, medicines, which may make the eye worse.
Editor
Victoria Francis
PO Box 45, Bawku, Ghana. Allergic conjunctivitis (sometimes called
vernal conjunctivitis or vernal keratoconjunc-
Editorial Committee
Professor Allen Foster The red eye forms a big proportion of the eye tivitis) usually has a long history of intense
Dr Clare Gilbert problems seen in most eye clinics in devel- itching of both eyes. Chronic vernal conjunc-
Dr Murray McGavin oping countries. For example, in the Bawku tivitis gives the child’s eyes a dark brown
Dr Ian Murdoch appearance. In very severe cases these
Hospital eye unit, Ghana, in 2004 a total of
Dr Daksha Patel
Dr Richard Wormald 21,391 patients were seen as outpatients, children will need topical steroids prescribed
Dr David Yorston out of which 8,931 were red eyes of one by a specialist. Steroid eye preparations can
type or another, representing over 40% of be dangerous and should only be prescribed
Regional Consultants
Dr Grace Fobi (Cameroon) the total number of patients screened. by an eye specialist.
Professor Gordon Johnson (UK) The majority of red eyes are seen at
Dr Susan Lewallen (Tanzania) community clinics and health centres, where Conjunctivitis of the newborn
Dr Wanjiku Mathenge (Kenya)
diagnosis and management are done by Any eye infection in the first 28 days of life
Dr Babar Qureshi (Pakistan)
Dr Yuliya Semenova (Kazakhstan) community health nurses, primary eye care is known as neonatal conjunctivitis or
Dr B R Shamanna (India) workers and ophthalmic nurses. It is for this ophthalmia neonatorum. If this is due to
Professor Hugh Taylor (Australia) reason that adequate attention should be Gonococcus, it is serious. The eyelids are
Dr Andrea Zin (Brazil)
given to the prevention, early diagnosis and very swollen and pussy, the conjunctiva is
Advisors first aid management of these conditions. red and may be blood stained, the cornea
Dr Liz Barnett (Teaching and Learning) The common causes of acute red eye are is usually clear (but a white spot on it could
Catherine Cross (Infrastructure and Technology)
Sue Stevens (Ophthalmic Nursing and Teaching conjunctivitis and trachoma, corneal ulcer, be an ulcer which is serious and needs
Resources) acute iritis, acute glaucoma and injury (or urgent referral).
trauma). Red eye may also be due to the use
Administration
of harmful traditional medicines for other eye Management
Ann Naughton (Administrative Director)
Anita Shah (Editorial Assistant) conditions. This article deals mainly with first Clean the eyes gently with clean water or
aid (primary level) management of red eye, normal saline and apply tetracycline
Editorial Office
which is not due to an injury. ointment hourly. If the cornea is involved,
Community Eye Health Journal
International Centre for Eye Health refer to an eye centre where the baby will
be treated with intensive antibiotic eye drops
London School of Hygiene and Tropical Medicine,
Conjunctivitis and, sometimes, systemic antibiotics.
Tel: +44 207 612 7964/72 Conjunctivitis affecting all ages
Fax: +44 207 958 8317 This is the most common cause of red eye.
Email: [email protected] Prevention
It is usually painless and characterised by All babies should have their eyes cleaned
Information Service pussy or watery discharge. There are immediately after birth, and tetracycline
Sue Stevens different types of conjunctivitis: bacterial
Email: [email protected] ointment applied. During antenatal care, all
Tel: +44 207 958 8168 conjunctivitis caused by a bacterium e.g. mothers with vaginal infections should be
Staphylococcus or Streptococcus; viral treated. Educate traditional birth attendants,
On-line Edition (www.jceh.co.uk)
conjunctivitis caused by a virus e.g. herpes community health workers, and both parents
Sally Parsley
Email: [email protected] simplex; and allergic conjunctivitis caused by as this is often a sexually transmitted disease.
allergy e.g. smoke, cosmetics, medicines,
Community Eye Health Journal is published four
etc. The signs vary depending on the cause
times a year and sent free to developing
country applicants. Please send details of your but include swollen eyelids, red conjunctiva Corneal ulcer
name, occupation and postal address to Community and a watery or pussy discharge. The cornea Corneal ulcers have many causes. They can
Eye Health Journal, at the address above. and pupil are usually normal. be caused by infection – bacteria, fungus,
Subscription rates for applicants elsewhere: one
virus or acanthamoeba, or malnutrition, as in
year UK£28/US$45; two years UK£50/US$80.
Send credit card details or an international cheque/ Management measles/vitamin A deficiency, which occurs
banker’s order made payable to London School of Conjunctivitis normally does not affect vision mainly in infants between the ages of six
Hygiene and Tropical Medicine to the address above. and is simple to treat. To treat bacterial months and two years. Some causes are
Website conjunctivitis, clean the eyes and apply any mainly unilateral whereas others like vitamin
Back issues are available at topical antibiotic. In the absence of any A deficiency are often bilateral. The result
www.jceh.co.uk antibiotics, merely cleaning the eyes of of a corneal ulcer can be a corneal scar or
Content can be downloaded in both HTML and PDF formats. discharge regularly will allow the eyes to phthisis bulbi.
© International Centre for Eye Health, London
settle in a few days. A break in the corneal surface is known
Articles may be photocopied, reproduced or translated provided these are Usually no treatment is required for viral as a corneal abrasion/erosion/ulcer. For
not used for commercial or personal profit. Acknowledgements should be
made to the author(s) and to Community Eye Health Journal. All graphics conjunctivitis but an antibiotic ointment can simplicity we will refer to all lesions as ulcers.
by Victoria Francis unless stated otherwise.
reassure the patient. Viral conjunctivitis may There are superficial and deep ulcers. The
ISSN 0953-6833
occur in epidemics, affecting many people at patient will complain of a red painful eye.
The journal is produced in collaboration with the World Health
Organization. Signed articles are the responsibility of the named authors the same time. For example, a single school The eyelids may be swollen, the conjunctiva
alone and do not necessarily reflect the policies of the World Health
Organization. The World Health Organization does not warrant that the child with this condition could infect half the is red around the cornea, the pupil is normal,
information contained in this publication is complete and correct and shall
not be liable for any damages incurred as a result of its use. The mention
school in just one day. In cases like this it is and the visual acuity is often reduced. There
of specific companies or of certain manufacturers’ products does not imply better to close down the school for a couple is often a grey spot or mark on the cornea.
that they are endorsed or recommended by the World Health Organization
in preference to others of a similar nature that are not mentioned. of days to avoid its spread. This condition is The other eye is usually normal. There is a
popularly known in West Africa as ‘Apollo’. Continues on page 72 ➤
70 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Differential diagnosis of red eye with no injury
CONJUNCTIVITIS CORNEAL ULCER ACUTE IRITIS ACUTE GLAUCOMA
Eye Usually both eyes Usually one eye Usually one eye Usually one eye
Vision Normal Usually decreased Often decreased Marked decrease
Eye pain Normal or gritty Usually painful Moderate pain, light Severe pain
sensitive (headache and nausea)
Discharge Sticky or watery May be sticky Watering Watering
Conjunctiva Generalised (variable) Redness most marked Redness most marked Generalised marked
redness around the cornea around the cornea redness
Cornea Normal Grey, white spot Usually clear, (keratitic Hazy

(fluorescein staining) precipitates may be visible (due to fluid in the cornea)
with magnification)
Anterior Normal Usually normal Cells will be visible with Shallow or flat
chamber (AC) (occasionally hypopyon) magnification
Pupil size Normal and round Normal and round Small and irregular Dilated
Pupil response Active Active Minimal reaction as Minimal or no reaction

to light already small
Intraocular Normal (but do not Normal (but do not Normal Raised

pressure (IOP) attempt to measure IOP) attempt to measure IOP)
Useful diagnostic Pussy discharge in both Fluorescein staining of Irregular pupil as it dilates Raised IOP
sign / test eyes the cornea with drops
First aid management of a red eye with no injury
Conjunctivitis Corneal ulcer Acute iritis Acute glaucoma

Discharge in both eyes White spot or mark on Small pupil which Very painful eye with
with clear cornea and the cornea which stains becomes irregular as it poor vision and dilated
normal pupil with fluorescein dilates pupil
Treat Refer Refer Refer

Both charts: ICEH
Antibiotic ointment Hourly antibiotic drops Dilate the pupil if Oral diamox 500 mg
x 3/day for 5 days. or ointment possible and pilocarpine drops
Advise on hygiene if possible

PRIMARY EYE CARE
Red Eye
Picture Quiz
special test to identify corneal ulcers: a classified as harmful or harmless. Harmless
fluorescein strip is placed just inside the lower eye treatments include incantations by
eyelid and this will stain and outline any break traditional healers and use of salt solution,
in the epithelium a green colour. See page 79 to name a few. Examples of harmful eye What is wrong with these eyes?
for how to do this. medicines include alcohol, ground cowries,
What is the management?
donkey and cow dung, herbal preparations,
Management human sputum, bird and lizard faeces,
Quiz by David Yorston and Marcia Zondervan

Corneal ulcer is a serious eye problem. urine, etc. Eye care workers around the
Frequent (hourly) antibiotic eye drops should world would probably be able to add to this
be instilled, an eye pad applied, and the patient list from their own experience, and these
referred for help urgently. If the patient is aged concoctions differ from one culture to
one to ten years, Vitamin A 200,000 IU should another. The preparations put into the eye
also be given orally. All corneal ulcers should be
managed by an eye specialist as they can
can cause corneal ulcers or worsen existing
ones and end up as scars or eye perforations
1
A 14-year-old boy. Complains of
easily lead to corneal scarring and blindness. leading to blindness. itching eyes for three years with
The specialist will diagnose the cause and The primary eye worker has an important sticky clear discharge. VA 6/6.
manage appropriately. Bacterial ulcers are role to play in preventing blindness from the
treated with topical and sub-conjunctival use of traditional eye treatments. They are
antibiotics. Fungal ulcers are treated with often the first point of contact when
antifungals e.g. natamycin, but are difficult to something goes wrong with the treatment,
treat. Viral ulcers are treated with anti-virals and they are also close enough to the
e.g. acyclovir. Nutritional ulcers are usually community to discourage their use. The first
due to Vitamin A deficiency following measles step to preventing blindness from traditional
or malnutrition. Treatment involves giving
Vitamin A capsules according to age.
eye medicines is to establish trust and
respect between health care providers and
2
45-year-old female. Complains of
patients and communities. painful eye and discomfort in bright
Acute iritis It is important to understand the reasons light with watery discharge. VA 6/12.
Acute iritis is often of unknown cause. The why people use traditional eye treatments,
patient will complain of a red painful eye. and not to judge them. There is widespread
There is no discharge but the visual acuity is ignorance about the dangers of self-treatment
reduced. The conjunctiva is red but the for eye conditions. Many poor patients are put
cornea is clear. The pupil is usually small and off seeking help from health clinics because
may be irregular in shape – this is more of the negative attitudes of some health
3
obvious as the pupil dilates with treatment. workers. Socio-cultural beliefs in evil spirits
and witchcraft may lead people to think that
Management the best course of action is with spiritual Five-year-old girl. Severe pain and loss
This is a serious problem. If you can dilate the rather than medical healers; for many of vision for three days. Used traditional
patients, prescribed eye medicines are eye medicines one week ago. VA CF.
pupil with a short-acting mydriatic, such as
tropicamide, this should be done and refer considered very expensive. Furthermore, the
the patient quickly for help. distance to health facilities result in patients
taking help from the nearest source.
Acute glaucoma Management
This disease is uncommon in people of Most patients tend to come to hospital when
African origin but more common in people
from Asia. In acute glaucoma, the pressure in
the eye goes up very quickly. This causes a
the eye is already damaged. Treatment is with
water irrigation, if the traditional medicine 4
was recently applied, and then topical hourly Six-year-old male. Painful eye for ten days.
red very painful eye, with poor visual acuity. antibiotic eye drops. Had malaria one month ago. Corneal
The cornea is hazy due to oedema and the Every opportunity should be used to sensation reduced when tested. VA 6/60.
pupil is large and does not become small educate people and discourage the use of
when a bright light is shone into the eye. traditional eye medicine, for example, health
education in communities, schools, women’s
Management groups and clinics. Refer all patients with eye
This is a very serious and painful disease. The complications.
patient must be referred for help immediately.
5
If you have diamox tablets (250 mg each),
give two tablets by mouth and one tablet four Injury (or trauma)
times a day and refer the patient. Pilocarpine Traumatic injuries form about 10% of all red 25-year-old woman. No pain or
eye drops can be given (if available) to make eyes. These injuries may cause irreversible discharge. Complained of red eye
the pupil small. damage to the eye leading to blindness. Many since this morning. VA 6/6.
of these would need immediate referral to a
secondary or tertiary eye care facility. First aid
Traditional eye medicine management of red eye with injury at the
Traditional medicine is as old as man himself. primary level will be covered in a future issue
Traditional healers are highly respected of the journal, and so is not included here.
members of each community. Many patients
who present at an eye clinic in Africa would
6
Sources
have had some form of herbs or concoctions Sutter E, Foster A, and Francis V. Hanyane: A village struggles
applied in his/her eyes before coming to us. for eye health, Part 2: Common eye diseases for village
health workers. Part 3: Lecture notes on common eye 19-year-old male. Complains of gritty foreign
This is especially dangerous in children. diseases for ophthalmic assistants. London: International body sensation, painful eye for three days
Traditional eye treatments can be Centre for Eye Health. 1989. with sticky yellowish discharge. VA 6/9.
Answers on page 78
PRIMARY EYE CARE CONJUNCTIVITIS Tissa Senaratne
Consultant Ophthalmologist, Teaching
Hospital, Kandy, Sri Lanka.
Conjunctivitis Clare Gilbert

Senior Lecturer, International Centre for Eye Health,
London School of Hygiene and Tropical Medicine,
The conjunctiva is a thin, transparent mucous Table 1. Causes of conjunctivitis, and who is primarily affected
membrane, which lines the inner surface of the
eyelids and covers the sclera (the white part of the Cause of Newborn babies Children Adults
conjunctivitis
eye). The conjunctiva contains glands which produce
secretions that help to keep the eyes moist, and Viral infection Uncommon Usually affects Usually affects
antibodies, which reduce infection. both eyes both eyes
Conjunctivitis means ‘inflammation of the
conjunctiva’, and the commonest cause is infection
by viruses or bacteria. Conjunctivitis can also be due Bacterial May be severe and May affect one or May affect one or
to chemical irritants, traditional eye remedies or infection sight threatening both eyes. May be both eyes. May be
allergy. It is usual for both eyes to be affected in severe and sight severe and sight
infectious cases. The patient notices that the eyes threatening threatening
are red and uncomfortable, and there is discharge Chlamydia Can cause Causes trachoma, Usually affects both
which may make the eyelids stick together in the conjunctivitis of which usually eyes
morning. The vision is usually not affected. On the newborn affects both eyes
examination the eyelids may be slightly swollen,
the eyes are red, and there may be some visible Allergy Uncommon Usually affects Uncommon
discharge. The cornea should be bright, and the both eyes
pupils should be round, regular and react to light.
Conjunctivitis due to infection occurs at all ages, but
some of the less common causes affect particular Chemical Uncommon Can affect one or Can affect one or
age groups (Table 1). There is one form of conjuncti- irritants/ both eyes both eyes
vitis which can be sight threatening – that due to traditional eye
gonococcal infection. remedies
Viral conjunctivitis prevent secondary infection from bacteria,

and tetracycline eye ointment can be
soothing. Topical steroid eye drops should
Molluscum contagiosum
conjunctivitis
Several different viruses can cause
conjunctivitis. Some, such as entero- and never be given for conjunctivitis due to The virus that causes the skin infection
adenoviruses, can spread rapidly through infection. known as molluscum contagiosum can also
communities leading to epidemics of Health education: The patient should be infect the eye, if the molluscum is on the
conjunctivitis (e.g. Apollo red eye), while told that the condition is very infectious, eyelid. The patient (usually a child) presents
others primarily cause skin infections that they should not share face towels, and with a single or multiple eyelid lesions,
(molluscum contagiosum, herpes infection), should wash their hands regularly. In parts which are small, round, waxy, whitish,
and the eye can be infected if the eyelids of the world where traditional eye remedies umbilicated nodules on the eyelid. The
are involved. are commonly used, the patient should affected eye will be red, with some
be advised not to use traditional remedies discharge. Patients with HIV/AIDS can
and needs to be told that the infection will have multiple lesions (Figure 1).
Entero- or adenoviral get better. Continues over page ➤
conjunctivitis
This is an epidemic form of conjunctivitis
which almost always affects both eyes. The
patient may complain of a foreign body
sensation, with watering, discharge,
redness, and swelling of the lids. They may
also complain of the eyes being sensitive to
light, with blurred vision. The eyes appear
red, with discharge, but the cornea and
pupil are usually normal. In severe cases
there may be small haemorrhages in the
conjunctiva. The patient may also complain
of upper respiratory tract symptoms and
other generalized symptoms (sore throat,
fever and headache). The eye infection lasts
7-14 days, and usually gets better on its
own. The condition is very contagious:
health workers should wash their hands
after examining a patient and disinfect the
instruments they have used.
Ben Naafs
Treatment: There is no specific treatment

for viral conjunctivitis, and the condition
gets better on its own. Antibiotic eye drops Fig 1. Patients with HIV/AIDS can have multiple lesions caused by molluscum contagiosum

PRIMARY EYE CARE CONJUNCTIVITIS Continued
Treatment: This condition does not get Treatment of babies: Clean the eyelids, Trachoma
better on its own, and the treatment and show the mother how to do this. Gently
Trachoma infection principally affects
consists of removing the lid lesion, with a open the eyes, and instill tetracycline eye
children. The child may not complain of
curette or other blunt instrument. ointment, or other antibiotic eye ointment,
symptoms or may have some discomfort
Health education: Mothers and adult showing the mother how to do this. Make
and discharge. On examination, the upper
patients can be shown how to remove the sure she can instill the ointment, give her a
eyelids may be slightly swollen and drooping,
skin lesions. tube of tetracycline (or other antibiotic), and
and the eyes will be slightly red, with some
tell her to put it in both eyes every hour. Tell
discharge. The diagnosis is confirmed by
Herpes simplex blepharo- the mother that this is a very serious
everting the upper eyelid and examining the
infection, and that she and her baby should
conjunctivitis go urgently to an eye department as she
conjunctiva over the tarsal plate. Evert the
lid by i) ask the child to look down; ii) get
Again, this condition is more common in and her baby need an injection of antibiotic.
hold of the lashes of the upper eyelid; iii)
children. The child presents with fluid filled Treatment of adults: Prescribe antibiotic
place a narrow object, such as a matchstick
vesicles on the skin around one eye, and a eye drops or ointment, and tell the patient
2-3 mm above the lid margin, holding it
red, sore eye which may be sensitive to to use the treatment hourly. They should be
parallel to the lid margin; iv) fold the eyelid
light. The treatment is topical antiviral eye told that the infection is serious, and that
upwards, against the matchstick. The eyelid
drops or ointment (e.g. idoxuridine, acyclovir). they should go to an eye department.
will then evert.
Health education: Steroid eye drops Health education: If a newborn baby has
Active infection causes two eye signs:
should never be used as they make the conjunctivitis and Gonococcus is suspected,
trachoma with follicles ‘TF’ (Figure 3), and
infection much worse. the mother should take her baby to an eye
trachoma with intense inflammation ‘TI’
clinic immediately for treatment. She
(Figure 4).
Bacterial
should also should be treated as well as her
husband/partner. Communities should be
ICEH
warned of the potential dangers of traditional
conjunctivitis eye remedies, particularly urine, which may
have come from someone with gonorrhea.
Acute conjunctivitis
Conjunctivitis due to bacteria differs from Chronic bacterial
infection due to viruses, as it is more likely conjunctivitis
to affect only one eye, and the amount of
Bacterial infection of the eyelid margins
discharge and lid swelling is usually greater.
can lead to chronic conjunctivitis. The patient
The patient complains of irritation, a foreign
complains of sore eyelids and sore eyes with
body sensation, and the eyelids are stuck
little discharge. On examination, the eyelid
together in the mornings. Fig 3. Trachoma TF. There are at least five
margins are thickened, slightly inflamed and
Treatment: Broad-spectrum topical follicles (small, whitish spots) on the
crusty. The eyes themselves may look normal
antibiotic such as tetracycline eye ointment. everted eye lid, which are at least 1 mm
or slightly red.
across
Treatment: As the source of the
Conjunctivitis due to conjunctivitis is infection of the eyelids,
ICEH
Gonococcus treatment is aimed at the eyelids and
Certain groups of individuals are at risk of a consists of tetracycline eye ointment applied
very severe form of bacterial conjunctivitis to the lid margins three times a day, after
due to the Gonococcus organism (which cleaning the lid margins to remove the crusts.
causes gonorrhea): i) newborn babies, who
acquire the infection during delivery; ii) Chlamydial conjunctivitis
adults, who acquire the infection during Chlamydia are organisms which have
sexual activity; and iii) individuals of any age some characteristics of viruses and some
who have used urine infected with of bacteria. They can cause conjunctivitis
Gonococcus as a traditional remedy. Taking in three groups of individuals: i) newborn
a history is, therefore, very important. babies, who acquire the infection Fig 4. Trachoma TI. Very active infection
Infection with Gonococcus should be during delivery; ii) children, who develop when at least half of the blood vessels of
suspected in any age group (including trachoma; and iii) young adults, who the conjunctiva on the upper eyelid
babies) if the eyelids are very swollen, if the acquire the infection during sexual activity. cannot be seen because the conjunctiva
discharge is thick and profuse, and if the is so thickened and inflamed
cornea is ulcerated or perforated (Figure 2).
Neonatal chlamydial Treatment: The child should be treated
either with topical tetracycline eye ointment,
Pak Sang Lee
conjunctivitis three times a day for six weeks, or they

The infection starts a few days after birth, should be given a dose of azithromycin
and the mother notices that the eyelids are 20 mg per kg body weight.
swollen and there is discharge. The baby Health education: Trachoma is a
may also have chlamydial infection of the community disease which affects disadvan-
lungs, ears and nose. taged households. Seeing a child with
Treatment: Clean the eyelids, and instill trachoma almost certainly means that
tetracycline eye ointment. Show the there are other children from the same
mother how to do this and tell her to instill community who are infected, and there are
the ointment four times a day. The baby likely to be adults requiring lid surgery.
should also have a course of oral erythro- Health education should focus on the SAFE
Fig. 2. Baby suffering from conjuntivitis mycin to clear the infection from other parts strategy (see Community Eye Health Journal
due to Gonococcus of the body. Issue 52, 2004).

Allergic ‘Conjunctivitis is
Tissa Senaratne
common, but is only
conjunctivitis rarely sight threatening’
There are two forms: an acute form and
a chronic form.
Acute allergic ointment can be soothing and will prevent

conjunctivitis secondary bacterial infection.
Health education: People should not instill
The adult or child develops sudden and Fig 5. Eversion of the upper tarsus shows anything in their eyes that has not been
severe itching of the eyes and eyelids as a marked conjunctival papillae in vernal prescribed for them, and they should throw
result of coming into contact with something keratoconjunctivitis away eye drops after the bottle has been
the person is allergic to (e.g. pollen, cats).
open for one month or more.
The eyelids and conjunctiva become sensitivity, blurred vision and discoloration
markedly swollen and there is profuse of the eyes. The diagnosis is made by
watering of the eyes, which usually do not everting the eyelids when large, flat Equipment needed at the
become red. The condition gets better on its
own very quickly.
‘papillae’ become visible (Figure 5).
Treatment: Treatment is not easy at the
primary level to diagnose
Health education: The person needs to try primary level, and if the symptoms are and manage conjunctivitis
and find out what led to the reaction (e.g. severe, or the cornea looks hazy, the
eating certain food; sitting under a particular management is referral to an eye • Visual acuity chart
tree) and try to avoid this in the future. department (see pages 76-78). • Torch
They should be told not to rub their eyes, • Clean swabs for cleaning eyes
Chemical
as this makes the condition worse. • Tetracycline eye ointment
• Povidone iodine eye drops
Chronic allergic
conjunctivitis
conjunctivitis (vernal
Many different substances put in the Summary
keratoconjunctivitis) eyes can cause chemical reactions (e.g. Conjunctivitis is common but is only rarely
The cause of vernal keratoconjunctivitis is traditional remedies, reaction to the sight threatening. However, accurate
not known, but it is often associated with preservatives in eye drops). The findings diagnosis and prompt treatment at the
asthma or eczema and is probably due to a are similar to that seen in viral conjunctivitis, primary level is very important as it instills
longstanding allergic reaction. The condition and so the history is important. confidence in the community, and reduces
usually starts between the ages of three and Treatment: The person should be told to the risk that people may first try traditional
25 years, and the patient complains of chronic stop instilling the substance that has remedies, which can, and do, lead
itching, a thick, clear, stringy discharge, light caused the reaction. Tetracycline eye to blindness.
Table 2. Clinical features of conjunctivitis, by cause
Cause of Unilateral (U) Discharge Redness Other symptoms or Treatment

conjunctivitis or bilateral (B) signs
Viral, epidemic form B Watery +++, Fever, sore throat Tetracycline eye ointment;
+/- conj. haemorrhage povidone iodine eye drops
Viral – herpes U Watery +/- Vesicles on the eyelid Topical antiviral
Viral – molluscum U Watery +/- Molluscum on lid Remove molluscum
Bacterial – U or B Purulent +++ None Tetracycline eye ointment

non-gonococcal ++ or other antibiotic
Bacterial – B Purulent ++++ Marked lid swelling. Frequent antibiotic
gonococcal +++++ May have corneal ulcer REFER
Chlamydia – babies B Purulent ++ Lid swelling Tetracycline eye
++ ointment
Chlamydia – B Purulent + Signs on everted Tetracycline eye
trachoma + upper lid ointment, or azithromyin
Chlamydia – adults U or B Purulent + None Tetracycline eye
+ ointment
Allergy – acute B Watery ++++ Minimal Marked swelling of None – reassure
lids and conjunctiva
Allergy – chronic B Thick and stringy + Signs on everted upper Tetracycline eye ointment
lid. Discoloration of eye to eye lids – REFER
Chemical U or B Watery / purulent Varies May be lid reactions Tetracycline eye
ointment

ALLERGIC EYE DISEASE VERNAL KERATOCONJUNCTIVITIS
Anthony Hall Bernadetha Shilio
Vernal Head of
Department
Consultant
Ophthalmologist
keratoconjunctivitis Department of Ophthalmology, Kilimanjaro Christian

Medical Centre, PO Box 3010, Moshi, Tanzania.
Why is allergic eye disease a
Anthony Hall
problem for eye workers?
Why is allergic eye disease, and vernal keratoconjunctivitis (VKC) in
particular, a problem for eye workers and patients in hot climates?
A large number of children are affected
Over a quarter of 2,250 children seen at a tertiary referral paediatric
eye clinic in East Africa had vernal keratoconjunctivitis. Even more
came flocking to screening clinics complaining of itchy eyes.
This is time consuming and frustrating
Typically a child seen with VKC is given one bottle of a mast cell stabiliser
and is seen again a few months later apparently no better. Alternatively
steroids are used, without a mast cell stabiliser and no counselling
about the disease. Quite often children move from one clinic to another
picking up another bottle of steroids when the symptoms become
unbearable. Both patient and clinicians are frustrated. Over 50% of
patients may still have symptoms after five years.1
Patients may be blinded by the disease (Figure 4)
Up to 10% of patients develop corneal ulcers, which may lead to visual
loss due to corneal changes. The figure may be higher in hotter
climates. Other patients will have visual impairment due to glaucoma
and cataract2 or extensive cornea pannus (Figure 2 and Figure 6).
How can this frustrating

situation be improved?
1 By recognising the features of the disease, particularly potentially
blinding complications.
2 Ensuring that these patients get adequate continuous treatment
through good patient education and regular, long-term follow-up.
Fig.1. Adult with long standing severe vernal keratoconjunctivitis
(VKC)
Recognising the disease: clinical features
Anthony Hall
Anthony Hall
VKC is a bilateral chronic inflammation of the conjunctiva. It is more
common in young boys. The disease affects children between three to
16 years of age though it may appear earlier than that and continue
into adulthood (Figure 1). In the majority of cases, symptoms resolve at
puberty. Although the name vernal suggests a seasonal spring time
occurrence, frequently the disease persists throughout the year.
Symptoms
Symptoms include intense itching, irritation, photophobia (sensitivity to Fig.2. Right eye of patient Fig.3. Right eye of patient in
light) and burning. The itching is worse with exposure to wind, dust, bright in figure 1 figure 1
light and hot weather. Some patients complain of a sticky, stringy mucous Note the dilated, injected One week after supratarsal
discharge. Corneal involvement leads to complaints of reduced vision. conjunctival vessels, Trantas’ triamcinalone injection: the eye
dots, and corneal scarring is quiet and comfortable with
and vascularisation. The resolution of all signs of
Signs white tissue in the nasal inflammation.
In order to elicit the signs, patients should be examined using a slit portion of the pupil is
lamp or magnifying loupes. The use of fluorescein will help to identify
Anthony Hall
posterior capsule
sight threatening corneal involvement. The disease is characterised by opacification, following
giant papillae. In the palpebral form, giant, flat-topped papillae of the cataract surgery.
upper tarsal conjunctiva lead to a clinical picture of ‘cobblestones’.
Corneal involvement has been reported in as many as 50% of the
patients with the palpebral type of the disease. Corneal involvement
may range from superficial punctate keratopathy to shield-like ulcers.2
These may heal leaving a vascularised scar.
The limbal form is more common in dark-skinned races and Fig.4. Left eye of patient in
females. It is characterised by conjunctival hyperaemia and papillae at figure 1
the corneal-scleral (limbal) border and Trantas’ dots. The latter are Blinding VKC corneal scarring
aggregates of epithelial cells and eosinophils. A gelatinous pannus may and vascularisation.

‘Individual counselling backed up by patient information
leaflets is critical in breaking the cycle of inadequate
treatment of vernal keratoconjunctivitis’
invade the cornea (Figure 6). Neovascularisation symptoms occur because their effect is not
Anthony Hall
of the cornea may follow (Figure 4). Conjunctival immediate. If well used, they can limit or stop the
changes include hyperpigmentation (Figure 2), use of steroid drops. They do not have any of the
subconjunctival fibrosis, keratinisation and side effects of steroids and can therefore be used
symblepharon. for a prolonged period.
Visual impairment is more pronounced in
cases with shield ulcers and corneal plaques. Those presenting with corneal involvement and
The clinician also needs to be constantly on the more severe disease should be managed at
lookout for the other major complications of secondary and tertiary level where they may be
cataract and glaucoma especially with prolonged given topical steroid drops (e.g. prednisolone,
Fig.5. Technique of supratarsal
steroid use. dexamethasone), the most effective available
injection
topical medication for severe vernal keratocon-
Note the needle is parallel to the
Providing adequate junctivitis. A mast cell stabiliser should be started superior tarsal border – entering
when the steroids are started. Steroids should be from the temporal side.
continuous treatment used frequently initially and then tapered to a
Counselling stop once the acute stage of the disease is stabi-
Anthony Hall
Once the severity of the disease has been lised (usually a few weeks). Their use requires
characterised, a treatment plan is devised. monitoring because of the possible effect on
We examine and counsel the many children intraocular pressure.
coming to the free district eye clinics in groups.
Those with no signs of allergic eye disease are Those not responding to conventional treatment
given advice on frequent face washing and cold may be given supratarsal injection of steroids4
compresses. They should not be given a bottle of by an eye specialist (Figure 5). Both long-acting
steroid or chromoglycate drops, tempting as this steroids such as triamcinalone and shorter-acting
might be. Unnecessary drops can make the steroids (dexamethasone) have been found to
situation worse (Figure 7). be effective in bringing about resolution of the Fig.6. Child with severe limbal
Children with signs of allergic eye disease and eye signs. Some studies suggest that the recur- VKC
those presenting to the tertiary referral centre rence rate of the disease is lower following the Note the marked conjunctival
hyperaemia, Trantas’ dots and
who tend to have more severe disease are use of longer-acting steroids like triamcinolone.
invasion of cornea by thickened
examined in more detail and counselled individ- Theoretically there is an increased risk of gelatinous pannus.
ually. Individual counselling, backed up by patient persistent elevation of intraocular pressure with
information leaflets, is critical in breaking the the longer acting steroids. In children, these
Anthony Hall
cycle of inadequate treatment and resulting injections often need to be administered under
frustration. general anaesthesia. However, with good use of
Counselling stresses the chronic nature of the local anaesthesia and careful counselling,
disease, that sodium chromoglycate drops take children as young as 12 may be safely injected
time to work and need to be continued once the without recourse to general anaesthesia
child feels better. Children getting steroid drops (Figures 8 - 10).
are told to use these frequently initially. The need Cyclosporine A drops (0.5-2%) in olive oil or
to use these for only a short period of time in castor oil four times a day are an effective alter-
order to avoid complications is explained. The native to steroids in severe VKC, if available.5
majority of children and parents respond well to Cryotherapy of the palpebral conjunctiva may Fig. 7. Drug induced allergic
this counselling. As a result, many patients return produce additional inflammation with little benefit.2 conjunctivitis
for review before drops have run out and the Debridement of early mucus plaques may This man was seen at a health
symptoms and signs worsened. The use of a speed repair of the persistent epithelial defects. centre complaining of itchy dry
dedicated counsellor will save the busy clinician Bandage contact lenses are helpful in the eyes. He was given gentamicin and
prednisolone drops which he used
valuable time. treatment of these defects.
continuously for three weeks. He
Supportive therapy like artificial tears, cold came to us complaining that the
Drug treatment compresses and sunglasses often help and are eyes were now red and sore and
Treatment is symptomatic and tailored to the commonly overlooked. felt worse when the drops were put
severity of the disease. in. Note the conjunctival
Those with milder symptoms and no corneal Drug allergies hyperaeminia in the lower half of
involvement may be given mast cell stabilisers Allergic reaction in the conjunctiva can be the eye. The upper half is white
such as sodium chromoglycate or newer agents provoked by a drug or its preservative. Common and quiet.
such as alomide and nedocromil. (If you have drugs include neomycin and gentamicin. These
access to a low-cost drop manufacturer you can are common in postoperative drops. When
ask for 4% sodium chromoglycate for more examined, the conjunctiva and the lower eyelids
severe cases). Topical antihistamines are will be swollen. The skin may be excoriated. The
effective as well. first measure in the management is to stop using
The mast cell stabilisers must be used the allergen. Topical steroids may also be used to
regularly three to four times daily, even when relieve the symptoms. Far too often the offending
there are no symptoms in order to stabilise the drug has been given for a minor symptom
mast cells and prevent the release of histamine. because the patient expects drops. This often
They are of no value when used only when does more harm than good (Figure 7). Continues over page ➤

ALLERGIC EYE DISEASE VERNAL KERATOCONJUNCTIVITIS Continued
Red Eye Picture Quiz From page 72
Before After ANSWERS
Anthony Hall
Anthony Hall
A 14-year-old boy.
Complains of itching eyes
for three years with sticky
1 clear discharge. VA 6/6.
Vernal keratoconjunctivitis (Vernal catarrh)

The lumpy appearance of the conjunctiva is caused by swelling of
the conjunctiva due to the chronic inflammation. In most cases
allergic conjunctivitis will improve in adulthood and does not
require intensive treatment. Topical steroids should only be used
during acute attacks if there is evidence of corneal damage.
45-year-old female.
Complains of painful eye and
discomfort in bright light with
2 watery discharge. VA 6/12.
Acute anterior uveitis

Photophobia is typical in these patients as the pupil’s constriction
Fig. 8. Fig. 9. in the response to light causes pain. The redness is maximum near
the limbus (ciliary injection) and the pupil is irregular where it is
Anthony Hall
Anthony Hall
stuck to the front of the lens. Acute anterior uveitis should be
managed with atropine to keep the pupil dilated. Topical steroids
may be useful in severe cases.
Five-year-old girl. Severe pain

and loss of vision for three days.
Used traditional eye medicines
3 one week ago. VA CF.
Suppurative keratitis
Fig. 10. Fig. 11. The eye is very red and the iris cannot be seen clearly which
suggests the cornea is cloudy. This eye requires hourly topical
antibiotics. If facilities are available then a cornea scraping and
Fig. 8. gram stain should be performed before starting topical treatment.
13 year old girl with predominantly unilateral severe limbal vernal In some regions fungi are a common case of corneal ulcer and
keratoconjunctivitis. Note the lid swelling, increased skin pigmentation anti-fungal treatment will be required. The white line inferiorly is a
around the lid and the injected conjunctiva. The eye is watering and she looks hypopyon caused by pus formation in the anterior chamber. It
uncomfortable. The other eye appears by to be relatively normal by comparison. indicates severe inflammation. Traditional eye medicines are not
Fig. 9. sterile and may cause severe infections.
This is the same girl as in Figure 8 one month after supratarsal subconjunctival Six-year-old male. Painful eye
triamcinalone under local anaesthetic drops. She is happy and relaxed. The for ten days. Had malaria one
lid swelling has gone. She can now open her eye which is white and quiet. month ago. Corneal sensation
4
Her left eye which appeared to be relatively normal before, evidently has reduced when tested. VA 6/60.
moderate vernal keratoconjuctivitis too. The lids are a little swollen and the
limbal conjunctiva is injected and thickened. She is so pleased with the Herpes simplex keratitis
response in her right eye she is requesting an injection for her left eye. Not all cases of herpetic simplex keratitis present with a typical
dendritic/geographic ulcer. A useful sign of herpes is reduced
Fig. 10.
sensitivity of the cornea. This is thought to be due to damage to
Child with severe limbal VKC. This is a close up of the right eye of the girl in
the sensory nerves. Herpes keratitis is sometimes associated with
Figure 8. Note the marked conjunctival hyperaemia, Trantas’ dots and
febrile illness. Herpes keratitis is managed with a topical antiviral
invasion of cornea by thickened gelatinous pannus.
such as acyclovir or trifluorothymidine.
Fig. 11.
25-year-old woman. No pain
Right eye of child in Figures 8 and 9 one month after supratarsal
or discharge complained of
subconjunctival triamcinalone under local anaesthetic drops. Note that the
red eye since this morning.
conjunctiva hyperaemia has gone. The thickened vascularised gelatinous
pannus has resolved leaving a mildly pigmented flat scar. The vascular
pannus accompanying the pannus has resolved apart from the one larger
5 VA 6/6.
Sub-conjunctival haemorrhage
nasal feeder vessel. Visual acuity had improved from 6/18 to 6/6.
The lack of pain and discharge imply that there is no inflammation.
The very sharply defined edge is typical of a sub-conjunctival
References haemorrhage. No treatment is required and redness will clear over
1. Bonini S, Bonini S, Schiavone M, Centofanti M, et al. Vernal keratoconjunctivitis revisited: a course of 2 weeks.
a case series of 195 patients with long-term follow-up.
Ophthalmology. 2000;Jun;107(6):1157-63. 19-year-old male. Complains of
2. Bonini S, Coassin M, Aronni S, Lambiase A. Vernal keratoconjunctivitis. Eye 2004;18:345-51.
3. Cameron JA. Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis. gritty foreign body sensation,
Ophthalmology. 1995;102:985-93. painful eye for three days with
4. Saini JS, Gupta A, Pandey SK, Gupta V, Gupta P. Efficacy of supratarsal dexamethasone
versus triamcinalone injection in recalcitrant vernal keratoconjunctivitis. Acta Ophthalmol
Scand. 1999;77:515-8.
6 sticky yellowish discharge, VA 6/9.
5. Pucci N, Novembre E, Cianferoni A, et al. Efficacy and safety of cyclosporine eye drops in Bacterial conjunctivitis
vernal keratoconjunctivitis. Annal Allergy Asthma Immunol. 2002;89:298-303. The entire conjunctiva is red and eye is discharging pus on the lower
Acknowledgments
lid and on the eyelashes. This should be treated with intensive topical
The authors are grateful to Dr Amos Kibata for helpful comments on a draft of this manuscript.
antibiotics for one week. In very severe cases, particularly in young
Dr Debbie Carmichael set up the protocols for effective management of VKC at KCMC and men, you should consider doing a gram stain to look for Gonococcus,
prepared a patient information leaflet. and you should ask specifically about symptoms of urethritis.

HOW TO...
Ophthalmic practice
Sue Stevens
International Centre for Eye Health, London
School of Hygiene and Tropical Medicine,
Keppel Street , London WC1E 7HT, UK.
Eye health workers carry out many basic routine procedures. Sometimes bad practice develops and this, in
turn, may lead to new members of staff learning unsafe methods. Community Eye Health Journal plans to run
a series on practical procedures, when applicable, relating to the theme.
How to instil eye drops How to apply eye How to stain the cornea
Indications ointment Indications
• To aid examination – e.g., dilating the • To assess corneal epithelial damage,
Indications
pupil following trauma or in patients with ‘dry
• To treat a superficial corneal injury with
• To aid diagnosis – e.g., staining the eye’ problems, using diagnostic drops,
antibiotic
cornea e.g., Fluorescein 2% or Rose Bengal 1%.
• To deliver longer acting topical
• To treat eye conditions – e.g., antibiotic You will need
medication e.g.
drops. • Fluorescein 2% or Rose Bengal 1% –
– in the case of a child
You will need diagnostic drops or impregnated paper
– overnight, following medication
• Clean swab or paper tissue strips
by drop instillation during daytime
• Prescribed eye drops – these are • Normal saline drops
– when an eye needs to be padded
available in several types of container. • Local anaesthetic drops
for long periods.
Preparation • Clean cotton wool or gauze swabs
You will need
• Check that the drops are not date– • Torch or slit lamp (depending on availa-
• Clean swab or paper tissue
expired bility/skill level) for illumination.
• Prescribed eye ointment – produced in
• Check the patient’s name and eye Preparation
varying sizes and colours of tube.
drops label against the prescription. • Explain to the patient that he/she will
Preparation
Method experience a cold stinging sensation
• Check that the ointment is not date–
• Remove the cap from the bottle (or the when the drops are instilled.
expired
pipette from the bottle) Method
This is not always easy to read on the
If the fluid is discoloured, do not use! • Ask the
actual tube so be careful to take time
• Ask the patient to look up patient to
to do this. Some tubes also come in
• With the index finger of one hand take look up
a box where the expiry date is easier
a folded swab or paper tissue to gently • Instil the
to read.
hold down the lower eyelid diagnostic
• Check the patient’s name and eye Fluorescein
Do not make the eyelid turn out too
ointment against the prescription or Rose Bengal drops or use the paper
much as instilled drops may fall out
• Remove cap from nozzle strips.
on to the cheek.
• Ask the patient to look up. When using the strips, moisten with
• With the bottle or pipette held in the Method a small amount of normal saline or
other hand, between thumb and index • With the index finger of one hand take anaesthetic drop, taking care not to
finger, rest the side of the hand against a folded swab or tissue to gently hold touch the end of the strip (impreg-
the patient’s forehead above the down the lower eyelid nated with the dye) with the dropper.
affected eye • With the other hand take the tube of
• With the dropper about five centi- • Ask the patient to look up and gently
ointment and direct the nozzle towards
metres above the eye, squeeze the touch the inside of the lower eyelid with
the inner canthus
bottle or pipette rubber and allow one the moistened strip, taking care not to
• Squeeze tube slowly to allow about one
or two drops to fall inside the central touch the cornea
centimetre to emerge in a thin line
part of the lower eyelid • Ask the patient to close the eye, gently
along the inside of the lower eyelid.
Do not allow the drop to fall on to the wipe away any surplus fluid and wait
(Rather like putting toothpaste on a
cornea as this can be painful and about 30 seconds
toothbrush!)
may alarm the patient and cause • Using a torch or slit lamp with the
Do not touch the eye with the tube
loss of confidence. appropriate colour light (blue light, if
nozzle!
using Fluorescein, and white light, if
Do not allow the bottle or pipette to Do not touch the eyelid skin or using Rose Bengal), examine the
touch the eyelid skin or eye lashes as eyelashes with the tube nozzle – it corneal surface, note any staining and
it will cease to be sterile and need to will cease to be sterile and need to record in patient’s documentation.
be discarded. be discarded.
• Ask the patient to close the eye and • Wipe away any surplus ointment which Fluorescein stains green indicating
Murray McGavin (2)
wipe away any surplus fluid. may emerge when the patient closes corneal epithelial loss.
the eye.
Pak Sang Lee
Pak Sang Lee
Finally Finally Rose Bengal stains red indicating dead

• Secure the bottle top. • Secure the nozzle cap. tissue and mucus filaments.

EXCHANGE
Barriers to the uptake of cataract surgery for Enhancing the SAFE strategy through collaboration,
women in urban Cape Town participation, accountability and sustainability
Aditi Shah William Astle, Boateng Wiafe, April Ingram, Mike Mwanga,
University of Birmingham Medical School, UK. Colin Glassco
Alberta Children’s Hospital, Canada in collaboration with Lusaka Eye
Groote Schuur Hospital (GSH) is a mainly state-funded hospital in
Hospital, Zambia.
the southern suburbs of Cape Town, South Africa. The majority of
patients presenting to the Department of Ophthalmology cannot The purpose of our project was to determine the prevalence of
afford private medical care. trachoma, and to measure the impact of implementing the SAFE
According to the most recent WHO data on blindness, women strategy for controlling trachoma in the Gwembe District of southern
are 1.5 to 2.2 times more likely to be blind than men (WHO Bulletin Zambia. Implementation of the strategy was enhanced by ensuring
Nov 2004). In 2004, a qualitative study was conducted in the local input and cooperation at every stage of development. Direct
Department of Ophthalmology to identify and understand the barriers involvement at the village, community and government levels
that women face in accessing cataract surgery in and around Cape strengthened the commitment to the project, thereby promoting
Town. Eighteen female cataract patients (14 pre-operative and four accountability and responsibility for its success.
post-operative) were interviewed. Two focus groups were conducted, New, clean water wells were drilled under local supervision for each
one with doctors and the other with nurses. Interviews with identified village. All levels of government were aware of the project
healthcare professionals and paramedical staff were also performed. and approved each well and drilling location. All people living near
The study identified ten major barriers (Figure 1). Whilst the the wells were screened for trachoma, and then treated with antibiotic
barriers were applicable to both men and women, they were often if required. Education on personal and environmental hygiene was
exacerbated for women. provided by trained volunteers. Patients affected by significant
Transport was identified as a major problem by both health care trichiasis and corneal scarring received surgery, locally if possible.
professionals and women. Whilst the State paid for cataract surgery, Attempts were made to control fly populations by cleaning villages,
the socio-economic costs of surgery such as taking time off work penning livestock and digging latrines; this was done in consultation
and leaving daily responsibilities, acted as important barriers for with local villagers and government officials. Data was collected on
women as well as their carers. all variables normally associated with trachoma as well as variables
Stated barriers for women at the individual level included fear and relating to demographics, water quality, environment and hygiene.
lack of education. However healthcare professionals felt that barriers In total, 26 wells throughout the valley were drilled. While the
at the institutional and organisational level were more significant. total population of the valley area is approximately 60,000 people in
These included availability of funding and the cost of consumables, an area of 3,600 km2, the total sample population totalled 3,892
medical staff and equipment, hospital organisation and adminis- people, with 54% under 16 years of age. The overall prevalence of
tration (waiting times in the day hospitals, patient pathway at GSH,
trachoma in the area was 45% in 2001; however, prevalence was
waiting lists for surgery) and health system organisation (lack of
52% within the subset of children under 16 years. Two years of
resources to conduct cataract surgery at the secondary district level
intervention has reduced the overall prevalence of trachoma to
hospitals so the tertiary level was saturated with cataract patients).
6.5%, representing 9% in the child subset, and 3.8% among adults.
Strategies needed to overcome the barriers include: The drop in prevalence is likely to be due to the interventions but
• Community education there could also be other explanations.
• Increasing the capacity for cataract surgery Problems identified from baseline were: lack of water wells close
• Fast-tracking patients to reduce waiting lists to the communities; poor personal and environmental hygiene; and
• Decentralisation of ophthalmic care lack of awareness of the potential dangers of trachoma infection.
• Increased Government and NGO funding for staff and resources It is common in trachoma projects to encounter a high number of
• Intersectoral collaboration (government, NGOs and corporate patients who do not return for follow-up, yet we had only 4% lost to
organisations). follow-up in our study, due to the diligence of our staff. This loss
Before these strategies can be implemented, increased resources percentage is considered quite low in studies of this magnitude.
and funding for the hospital and health-system are needed to Continued monitoring will be required for long-term sustainability
increase the capacity for cataract surgery. of our trachoma control project in this area of Zambia. While it is
possible to control trachoma if the appropriate risk factors are
Fig. 1. Barriers preventing women from accessing cataract addressed, an approach including collaboration and active partici-
surgery in Urban Cape Town, South Africa pation at both local and federal levels will increase the long-term
Hospital factors Patient factors success of such a project.
Trachoma prevalence in southern Zambia

Socio-economic
consequencies for 100
Health system Transport
patients and
organisation issues
accompanying 90
persons Baseline trachoma % at each well
80
Hospital 70
organisation and Fear
administration
Barriers to 60
cataract surgery 50
for women Availability of
Funding and cost 40
education,
of consumables
information and
and medical staff 30
motivators
Follow-up trachoma % at each well
20
Availabilty
No perceived of people to Distance 10
need accompany and to travel
support 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Corneal ulcer in a Cambodian eye hospital Community Eye Health MSc
dissertation summaries from the
Tim Hall
Sheffield, UK.
Pakistan Institute of Community

Frans Lion
Medical Director, Takeo Eye Hospital, Caritas RBC, PB 123, Phnom Penh,
Ophthalmology Peshawar,
Cambodia. Email: fl[email protected]
Traumatic corneal ulcer is an important cause of bilateral and

monocular blindness in the developing world, with estimates of 5% Pakistan
of all blindness being trauma related. Cambodia is likely the poorest
country in South East Asia with no national survey of blindness Introduced by Muhammad Babar Qureshi
aetiology, although surveys were carried out in the provinces Kandal Director, Academics and Research, PICO, Peshawar, Pakistan.
(1996) and Battambang (1997). Most Cambodians are rice farmers
and agricultural work-related corneal trauma is a neglected area of The Community Eye Health Masters Programme at the
research. This retrospective case-series study in Takeo Eye Hospital Pakistan Institute of Community Ophthalmology (PICO) equips
in southern Cambodia looked at sex, age, history, surgery and doctors for a career in eye care management.
comparative visual acuity of affected eyes between presentation and Eight weeks in the academic year are dedicated to fieldwork
discharge of 130 patients with a corneal ulcer diagnosis between 21 leading to a dissertation, a requirement for the Masters degree from
May and 31 December 2001. Whilst the study cannot shed light on, the University of Peshawar. A topic is chosen in collaboration with
for example, corneal ulcer aetiology or the relative efficacy of the Institute from which the candidate comes, the provincial coordi-
different treatments, it can describe patterns in this particular patient nator for Prevention of Blindness in Pakistan (if the student is from
population that may prove useful and indicate areas for further research. Pakistan), and the supervisor at the Pakistan Institute of Community
Results: 55% patients were male, 45% female, aged 1-88 yrs. Ophthalmology.
Most were of working age. Of 121 cases, 51% recorded trauma. The candidate presents a synopsis to the research and ethical
There were 99 cases with a recorded acuity; 75 presented blind committee for approval prior to conducting the fieldwork, analyzing
(defined here <3/60); 15 had normal vision (defined here 6/6- the data and writing the dissertation. The dissertation is defended at
6/18). There were 14 fewer blind eyes and 9 more with normal the end-of-course examination.
vision at discharge. About a quarter improved in WHO category of The dissertations have provided the students, their institutions,
visual loss (including 6 from blind to normal), half stayed the same their provinces and their countries with some very valuable infor-
(12 maintained as normal and 58 remained blind); 4 eyes out of 99 mation which has been used for planning and implementing eye
deteriorated. 23 of the 24 eyes removed were blind on presentation. care projects within a defined unit of population in the students’
Conclusions: With a rough quarter of the sample showing an local setting. The students are encouraged to publish their original
improvement of one or more grades and deterioration in only 4%, piece of work in national and international journals. Below are three
patients are benefiting as a whole (some individuals dramatically) summaries of the MSc Community Eye Health 2004 batch.
from their treatment in Takeo Eye Hospital. However, most are
arriving with a blind eye and there is need for more research into Qualitative study of the barriers to the uptake of
how to prevent this. There is also a need to discover the extent of cataract surgery in Sharda Patwar Circle, Upper
under-reporting of corneal ulcer and of monocular blindness with a
prospective population-based study. The vast majority of patients
Neelum Valley District, Muzaffarabad, Azad Kashmir
were of working age (there were surprisingly few children given the Khawaja Muhammad Iqbal
economic environment). Do they present because they need to work Department of Ophthalmology, Combined Military Hospital,
but cannot see (most present blind) and not present because they Muzaffarabad Azad Jammu and Kashmir.
need to work and can still see? Their disability impacts the economy. Email: [email protected]
This study cannot reveal aetiology but it is worth noting that half the Objectives: To determine awareness about cataract blindness,
patients reported trauma. Trauma and corneal ulceration is largely a assess treatment-seeking behaviour of cataract blind and elicit the
cause of monocular blindness although it is an important cause of reasons for not opting for cataract surgery.
bilateral blindness as well. Added to a complex aetiology this makes Methods: We conducted twelve semi-structured interviews with
it a difficult area to tackle. It is sad but unsurprising that it is devel- cataract blind persons, followed by an informal discussion with
oping countries that suffer most from this silent epidemic. concerned families and interviews with key informants. The records
were summarised into case studies of the individual subjects,
Table 1. Comparison by visual acuity grading of affected eyes at
families and key-informants and analysed for recurrent themes.
presentation and at discharge
Results: Cost (both direct and indirect) emerged consistently as the
Visual Acuity At presentation At discharge main barrier to acceptance of cataract surgery. There was also fear
of poor visual outcome of surgery and post-operative discomfort.
6/6 - 6/18 15 24 Most subjects had sought treatment at some stage during the
< 6/18 - 6/60 7 12 blinding process but their concern was to obtain glasses or eye
< 6/60 - 3/60 2 2 drops. Eleven out of 12 subjects were well aware of their blinding
condition as they expressed in their local language as “Pholla or
< 3/60 75 61 Poh” (cataract). One subject made a rational decision in terms of
Total 99 99 the cost and perceived benefits of the cataract operation (cost of
the operation and visual outcome). Negative attitudes to cataract
surgical services included distrust of ways of treatment, need not
Table 2. Difference in grade between presentation and discharge
felt, lack of company, belief that blindness is a natural process or
as a percentage of sample.
the will of God, and loss of self esteem.
% Improved 23.2 Conclusions: Cost and fear are major barriers to the uptake of
cataract surgical services. The negative effect of poor visual
% Same 49.5 outcome due to unsuccessful surgeries outweighs the impact of the
% Deteriorated 4.0 successful ones. In the community studied, cataract surgery needs
to be made available, affordable and acceptable and visual results
% Removed 23.2
need to be closely monitored and evaluated.
Continues over page ➤
EXCHANGE
Perceptions amongst primary school teachers Prevalence of diabetic retinopathy at a diabetic

of visual problems affecting their pupils clinic, Mayo Hospital, Lahore
Mohammad Saeed Khan Zafar Shah
Layton Rahmatulla Benevolent Trust Eye Hospital, Quetta. Punjab Institute of Preventive Ophthalmology, Lahore, Pakistan.
Email: [email protected] Email: [email protected]
Objectives:
Aim: To estimate the prevalence of diabetic retinopathy among diabetics
• To determine the ability of primary school teachers to
of all ages presenting at the diabetic clinic, Mayo Hospital Lahore.
recognise visual problems in their pupils
• To determine the knowledge among primary school teachers
Introduction: Diabetes mellitus (DM) is a common condition and its
about the nature of visual problems (including refractive
frequency is increasing all over the world. Some 3.2 million people died
errors) among their pupils
in the year 2000 because of complications of DM. This compares with
• To estimate the need for training of primary school teachers
3 million deaths from AIDS. In the year 2000, 171 million people had
in detecting visual problems (refractive error and types of
diabetes globally and by the year 2030, this figure is expected to be more
visual problems).
than double and reach a total of 366 million. More than 75% of people
with diabetes will reside in developing countries. In Pakistan, there will be
Methods: The study was conducted during July to August
14.5 million diabetics in the year 2025. Six deaths can be attributed to
2004. Sixteen interviews and 16 questions for teachers
diabetes or related conditions somewhere in the world every minute.
(including school principals and headmistresses) were
With increasing incidence of diabetes, the incidence of diabetic retin-
conducted followed by four focus group discussions with other
opathy, one of the serious complications of diabetes, will increase. Some
teachers of primary section in two government and two private
studies suggest that prevalence of diabetic retinopathy in Pakistan ranges
schools.
from 21%-82% depending upon glycaemic control and duration of DM.
Qualitative research methods used were individual inter-
This problem remains largely unrecognised.
views, questionnaires and focus group discussions. The
information collected from the three sources was used to Methods: A screening programme/cross sectional/observational study
triangulate the data, thereby strengthening its trustworthiness. was undertaken from the first week of July till the end of August 2004.
All diabetic patients coming to the diabetic clinic during this period were
Results: The main findings of this study were that teachers included in the study. Those patients having known glaucoma, dense
perceive that: cataract or corneal opacity were excluded.
• The eye is a blessing of God After taking consent from the patient, demographic information was
• Eyesight is an important sense taken and entered in the proforma. Random blood sugar done routinely
• Discoloration of eyes is a sign of eye diseases amongst these patients was recorded. Blood pressure using mercury sphyg-
• Pupils’ behaviour can show visual problems momanometer and visual acuity using Snellen test chart were measured.
• Children with eye pain and decreased vision should be The anterior segment was examined using a torch and gross pathology
referred to a hospital was noted. Pupils were dilated with 1% tropicamide. After full pupillary
• Weak eyesight leads to headache and inability to recognise dilation, the posterior segment was examined with a direct ophthalmo-
words and objects scope. Finally all the posterior segment findings were verified by an
• Hot dusty weather and pollution is bad for the environment ophthalmologist using an indirect ophthalmoscope (Gold Standard).
and also eyes All those patients who needed surgery, follow-up or laser treatment
• Good knowledge and balanced diet are essential for health (where indicated) for diabetic retinopathy were referred and sent to the
• Poverty leads to blindness eye department for appropriate management. Data entry and analysis
• Iodine deficiency may lead to eye problems were done in EPI-INFO-6.
• Both eyes always have different vision
• Un-equal eyes create future problems Results: Total patients examined were 1,054. Their mean age was 47.2
• Every one needs bright light but some need dark light (the climax of working age). Out of 1,054, 343 (32.5%) were males,
• Addition of spectacles looks interesting while 711 (67.5%) were females. 536 (50.9%) out of the total had
• Teachers are always thirsty for knowledge diabetic retinopathy. Among males, 186 (54.2%), and among females
• Experiences, newspapers, magazines, journals and 350 (49.2%), had diabetic retinopathy.
clippings are the best source of eye knowledge for teachers Among patients with diabetic retinopathy, 82.1% had normal vision,
• Medical professors or eye doctors can select good training 17.5% had low vision and 0.4% were blind. Out of 536, 431 (80.4%) had
courses for primary school teachers. mild to moderate non-proliferative diabetic retinopathy, 81 (15.1%) had
severe non-proliferative diabetic retinopathy and 19 (3.5%) had prolifer-
Conclusion: The knowledge of teachers was based on ative diabetic retinopathy and 5 (0.9%) had advanced diabetic eye disease.
hearsay, personal experiences, layman talk, journals, and It was found that diabetic retinopathy increases with age and hence
magazine and newspaper clippings. with duration. Housewives and jobless patients had more prevalence of
They can detect the visual problems through the pupils’ diabetic retinopathy than employed (self employed or government
behaviour in class but have no idea how to refer them to employees). As far as risk factors are concerned, hypertension and
secondary/tertiary eye care health services. There is lack of smoking had an association but, amazingly, pregnancy (age group<45
any training about primary health care/primary eye care years) had not. Total number of diabetics having diabetic macular
teaching in the syllabus of primary teachers. The teachers oedema was 182 (17.2%). Among these, 45 (4.3%) had unilateral while
were enthusiastic to work for the betterment of school 137 (13.0%) had bilateral diabetic macular oedema.
children if they were given proper training and the chance to
serve. Poverty came out as a major problem and the Conclusions: The burden of diabetic retinopathy (50.9%) among
purchase of spectacles is out of the reach of many needy patients with diabetes mellitus is a public health problem. Awareness
children. The importance of the eyes was universally creation, a team work approach about diabetes and diabetic eye disease
accepted. Many of the teachers mentioned shyness as a and its screening, along with provision of good laser services, are needed
social problem, which causes pupils to abandon the use of to address these newly emerging challenges of blindness. The gravity of
glasses. The teachers were found to be quite able to identify the problem also demands that it be seriously considered for inclusion in
children with visual problems. the VISION 2020 priorities.

INDEX NOTICES
Community Eye Health Journal Courses and conferences

INDEX FOR ISSUES 25 – 50 Royal College of Nursing –
Ophthalmic Nursing Forum
Disease/Topic Volume Issue Disease/Topic Volume Issue Annual Conference and Exhibition, “Ophthalmic
Age-related macular degeneration 12 29 Refractive error 12 31 Nursing: Dimensions of care – to boldly go...”
Affordable eye care 14 37 13 33 June 24 - 26, 2005 Venue: Thistle Hotel, Bristol, UK
AIDS/HIV 16 47 15 43 For information, email: [email protected]
Azithromycin 12 32 Retina 16 46 VISION 2020
Blindness 13 36 Retinopathy of prematurity 14 40 One-week course
16 45 Teaching/learning – Series 13 33 4 - 8 July 2005 Venue: London School of Hygiene and
Case finding 11 28 13 34 Tropical Medicine, London Cost: £600
14 39 13 35 The course is for ophthalmologists and eye health
15 43 13 36 programme managers involved in the drive to eliminate
Cataract – age-related 15 43 14 37 avoidable blindness by the year 2020. For more
Cataract – outcome 13 35 14 38
information, email: [email protected]
15 44 14 40 World Ophthalmology Congress
Cataract – paediatric 17 50 15 41 (Previously called “International Congress of
Cataract – small incision 16 48 Technology – Series 15 42 Ophthalmology ICO”)
Cataract – surgery 15 42 15 43 February 19 - 24, 2006 Venue: Brazil
13 34 15 44 The World Ophthalmology Congress will be held in
Cataract – surgical coverage 11 25 16 45
conjunction with the XXVI Pan-American Congress of
Ophthalmology and the XVII Brazilian Congress on
Childhood blindness 11 27 16 46
Blindness Prevention.
12 31 16 47
Information on the congress and on the
14 40 16 48
committees, scientific programme and coordinators of
Community-based rehabilitation 11 28 17 49 different areas are available at the congress web site:
Community participation 12 31 17 50 www.ophthalmology2006.com.br
Elderly eye 12 29 Theatre management 15 44
15 43 Trachoma 12 32 New resources from ICEH
Epidemiology – Series 10 21 14 39
Santé Oculaire
10 22 Training 14 40
Communautaire –
10 23 15 42
French edition of Community
10 24 16 45 Eye Health Journal
11 26 Trichiasis 12 32 Copies of the first French-
11 27 15 42 language edition are now available
11 28 Vernal keratoconjunctivitis 14 40 free of charge. If you would like
12 29 Vitamin A 14 37 copies for your institution or
12 30 colleagues, please contact ICEH
12 31 Country Volume Issue at the address on page 70.
Evidence-based ophthalmology 16 48 Afghanistan 13 35
Chinese edition of the
17 49 Bangladesh 12 31
Journal
17 50 13 34
The Chinese edition of the
Gender 16 45 15 43
Community Eye Health Journal is
Glaucoma 14 39 17 50 now available from the Amity
Health promotion 12 31 Benin 12 29 Foundation, 71 Han Kou Road,
Human resource development 13 35 Brazil 13 36 Nanjing, 210008 China. Email:
Infection 12 30 Cambodia 13 36 [email protected]
16 47 Ethiopia 14 39
Injuries 12 29 16 47
14 39 Ghana 12 32
Monitoring cataract surgical
15 41 India 11 25 outcomes CD-ROM
IOLs 11 25 11 28 Contains different packages to
14 40 14 37 monitor the visual outcome of
Ivermectin 12 31 15 42 cataract surgery as well as instruction
14 38 15 43 guides and supporting documents:
Leprosy 11 28 Kenya 13 36
• Manual tally sheet system – instructions and formats
14 38 14 40
• Installation files for computer software to monitor
Low vision 14 40 Libya 12 29
visual outcome of cataract surgery
17 49 Madagascar 15 42 • Instruction manuals for the computer software
Onchocerciasis 11 26 Nepal 15 42 • Cataract surgery record forms in four different
14 38 Pakistan 15 43 measuring systems
Optometry 11 27 Papua New Guinea 13 34 • Training materials, with presentation and text
15 43 South Africa 14 39 • Further reading on monitoring cataract surgical
Patient’s perspective 12 31 Uganda 11 26 outcome.
15 41 11 28 Author: Hans Limburg. Copies of this CD-ROM are
Povidone iodine 16 46 14 40 available free of charge from the International Centre
Primary eye care 11 26 Zambia 15 41 for Eye Health. See contact details on page 70.

NOTICES
Obituary Useful Videos

Epidemic conjunctivitis (5-minute public
Sister Ishikande resources education video). Available in English and
Ndossi Telugu from ICARE (contact details above).
It is with great regret Books
Sutter E, Foster A, Francis V. Hanyane – Slide Sets
that we report the
A village struggles for eye health. Available Stevens S. Practical ophthalmic proce-
death of Sister
in English and French from ICEH (address on dures – Volumes 1, 2, 3, 4. Available from
Ishikande Ndossi.
page 70). Price: £5 plus £5 airmail post and ICEH (address on page 70). Price: £15 per
A former student at volume to developing countries (£20 elsewhere)
the International packing. Email: [email protected]
For Indian language editions, contact ICARE plus £5 post and packing.
Centre for Eye Email: [email protected]
Resource Centre, Post Bag No. 1 Kismatpur
Health, Sister
BO, Hyderabad 500 030, India. Posters in Chinese and Tibetan
Ndossi, completed
Email: [email protected] Prevent blindness through primary eye
the Diploma in
Community Eye Health in 1995, generously Francis V, Wiafe B. The healthy eyes care. Available in Chinese and Tibetan from
supported by the Department for activity book (for use in primary schools). Kunde Foundation, Health Bureau, Gesang
International Development (DFID) - then the Available in English from ICEH (address on Road 30, Zedang, Shannan Prefecture, Tibet
Overseas Development Administration page 70). 856000, China.
(ODA) - and also the British Council for the Price: £3 includes post and packing. Email: [email protected]
Prevention of Blindness (BCPB). Email: [email protected] Public awareness posters on general eye care
She first qualified as a registered general French version available from Task Force Sight are also available in Tibetan.
nurse and continued to work at Mvumi and Life, BP 2116, 4002, Basel, Switzerland. Materials available in Portuguese
Hospital, Dodoma, Tanzania specialising Email: [email protected] Folheto informativo – Conjunctivite
in ophthalmic nursing. In 1988 Sister Folheto infromativo – Proteja seus olhos
Ndossi began work with the Christoffel Participatory approaches for community Atenção primária ocular – Ações básicas-oms
Blindenmission(CBM) on the Prevention of health worker training in primary eye care. Manual de saúde ocular em nível de
Blindness Programme, based at Afgooye, Available from Project Orbis International, 520 atenção primária
Somalia where her main responsibility was 8th Avenue, 11th Floor, New York, NY 10018, Informações básicas sobre saúde ocular
coordinating in-patient care. She later USA. Email: [email protected] Available from Servico De Oftalmologica
worked as Field Assistant with the Rombo Sanitária, Avenida Dr. Arnaldo, 351 – 6 Andar,
An outline of basic ophthalmology.
Trachoma Research Project in Rombo Cerqueira Cesar, Sao Paolo, SP CEP 01246 –
Available in English and French from CBM,
District, Tanzania and most recently as 902, Brazil. Email: [email protected]
Nibelungenstrasse 124, 64625 Bensheim,
Patient Counsellor at the Kilimanjaro Centre Germany.
for Community Ophthalmology, Moshi. Email: [email protected]
Next issue
Sister Ndossi, a wonderful human being
who loved her family deeply, a dedicated Basic eye care (for community eye health
ophthalmic nurse, respected by her workers).
colleagues and patients alike, and a faithful Simple eye care (for those with minimal
friend to many people, passed way on formal eye care training). Available from Helen
November 15, 2004 following a long illness Keller International, 352 Park Avenue South,
which she bore so very bravely. Suite 1200, New York, NY 10010, USA.
We remember her with much affection Email: [email protected]
and convey our deepest sympathy to her Primary eye care. Available from Raja
parents, family and everyone whose lives Mumtaz Regional Learning Resource Centre,
she touched and who are saddened by her PICO, P O Box 125, Hayatabad Complex – The next issue of the Community Eye Health
untimely death. Phase 4, Hayaytabad, Peshawar, Pakistan. Journal will be on the theme VISION 2020
Sue Stevens Email: [email protected] at the district level.
Correction Community Eye Health

In the article titled Lessons from the
Moroccan National Trachoma Control
Programme (CEHJ 2005 Issue 52), there JOUR NA L Supported by
was an error in the map showing provinces
targetted for trachoma control. The correct
map is shown below. The journal apologises
for this error.
Christian Blind Mission International Sight Savers International Dark & Light Blind Care
Morocco
Tijssen Foundation
AFRICA
o
Mo rocc Figuig Conrad N. Hilton Foundation
Tijssen Foundation
Journal design by Lance Bellers
Ouarzazate Errachidia
Zagora
Thanks to Dr and Mrs Curran for
Tata their support to the journal
BCPB Orbis
Low risk Moderate risk High risk

Red Eye The Role of Primary Care

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Community Eye Health

Red eye: the role of primary care

One of the most common eye problems

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 69

70 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Vision Normal Usually decreased Often decreased Marked decrease

Discharge Sticky or watery May be sticky Watering Watering

Cornea Normal Grey, white spot Usually clear, (keratitic Hazy

Pupil response Active Active Minimal reaction as Minimal or no reaction

Intraocular Normal (but do not Normal (but do not Normal Raised

First aid management of a red eye with no injury

Conjunctivitis Corneal ulcer Acute iritis Acute glaucoma

Treat Refer Refer Refer

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 71

Quiz by David Yorston and Marcia Zondervan

Conjunctivitis Clare Gilbert

Viral conjunctivitis prevent secondary infection from bacteria,

Treatment: There is no speciﬁc treatment

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 73

conjunctivitis three times a day for six weeks, or they

74 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Acute allergic ointment can be soothing and will prevent

Table 2. Clinical features of conjunctivitis, by cause

Cause of Unilateral (U) Discharge Redness Other symptoms or Treatment

Viral – molluscum U Watery +/- Molluscum on lid Remove molluscum

Bacterial – U or B Purulent +++ None Tetracycline eye ointment

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 75

Anthony Hall Bernadetha Shilio

keratoconjunctivitis Department of Ophthalmology, Kilimanjaro Christian

Why is allergic eye disease a

How can this frustrating

76 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 77

1 clear discharge. VA 6/6.

Vernal keratoconjunctivitis (Vernal catarrh)

2 watery discharge. VA 6/12.

Acute anterior uveitis

Five-year-old girl. Severe pain

3 one week ago. VA CF.

78 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Pak Sang Lee

Finally Finally Rose Bengal stains red indicating dead

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 79

Trachoma prevalence in southern Zambia

80 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Pakistan Institute of Community

Traumatic corneal ulcer is an important cause of bilateral and

Perceptions amongst primary school teachers Prevalence of diabetic retinopathy at a diabetic

82 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

Community Eye Health Journal Courses and conferences

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005 83

Obituary Useful Videos

Correction Community Eye Health

84 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005

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