Ophthalmology in Luanda (Angola): a hospital based report

British Journal of Ophthalmology 1995; 79: 926-933

Ophthalmology in Luanda (Angola): a hospitalbased report

F J Carreras, F Rodriguez-Hurtado, H David

AbstractAims/Background-As part of a 4 yearSpanish development aid programme, anophthalmic hospital was set up in Luandain 1991 for the in situ training oflocal oph-thalmologists. Presented here are the dataobtained from 4201 patients treatedduring the first 2 years ofthe project.Methods-Patients were referred to theinstitute from the emergency ward at theLuanda General Hospital, selected mainlyaccording to the severity of their disease.The following data were collected from theclinical reports: age, sex, diagnosis (singleor multiple), type of treatment (medicalor surgical), acuity of the best eye at thetime of diagnosis, and main diseasegroup.

Results-The main causes of blindnesstreated were: cataracts; glaucoma; opticnerve diseases (neuritis and atrophy);trauma; xerophthalmia; uveitis; heredi-tary retinal diseases (degenerativemyopia, retinitis pigmentosa, albinism,and Stargardt's disease); retinal detach-ment; and diabetic retinopathy.Conclusions-Sanitary resources inAngola are generally inadequate, andophthalmic care is no exception to this.Owing to the high percentage of pre-ventable or treatable blinding diseases inthis environment, a campaign of socialeducation should always be held alongwith any medical programme, in order tooptimise the available resources.

(Br_J Ophthalmol 1995; 79: 926-933)

Department ofSurgery(Ophthalmology),Faculty ofMedicine,Granada, SpainF J Carreras

Service ofOphthalmology,Hospital Ruiz de Alda,Granada, SpainF Rodrigues-Hurtado

InstitutoOftalmologico,Luanda, AngolaH David

Correspondence to:Dr F J Carreras, Plaza deSan Pedro, 3, 4-1, 04001Almeria, Spain.Accepted for publication17 May 1995

The population of Angola is officially estimatedat six million, although the true figure may nowbe substantially less, as the country has seen 30years of active fighting, which started with thestruggles for independence and has continuedto date as open civil war. Luanda, the capital,was designed by the Portuguese colonists for apopulation of half a million; today, as a result ofthe influx of refugees, there are over two millioninhabitants.The typical distribution pattern of medical

facilities and human resources found in mostAfrican countries, with most hospitals anddoctors being concentrated in large cities, isespecially marked in Angola. When the projectdescribed in this paper began, there were onlythree Angolan ophthalmologists in Luanda,working alongside half a dozen aid workersfrom communist or former communistcountries such as Cuba, Vietnam, and Russia.Outside the capital there were no ophthalmicspecialists at all.

As part of a Spanish development aid pro-gramme, an ophthalmic hospital was set up inLuanda. The aim was for two Spanish ophthal-mologists and one Angolan specialist to trainnew ophthalmologists and optometry special-ists. The hospital was equipped with 20 bedsand two operating theatres, with auxiliaryelectrical and water supplies available in case ofemergency.

During the first phase of the project all typesof basic ophthalmic surgery were performed,except for intravitreal surgery and cornealgrafts. Cataract surgery included both extraand intracapsular procedures, but intraocularlens implants were only performed in the thirdyear of the project. Also in the third year, argonand YAG laser therapies were added to therange of services. On site pharmacy facilitiesensured the availability of the treatmentsprescribed.Owing to the persistent fighting and short-

age ofhuman resources it would not have beenpractical to undertake a study of the prevalenceof ophthalmic diseases in Angola. The aim ofthe project was not to provide direct care forthe population at large, but rather to trainophthalmologists who could later spreadthroughout the country in order to address thehealthcare needs of the people.

Ophthalmological diagnosis requires con-siderable expertise and the use of sophisticatedequipment. Both requirements were fulfilled atthe Ophthalmic Institute in Luanda, for thefirst time in 30 years.

In this paper the data obtained from morethan 4000 patients treated during the first 2years of the-project (starting in October 1991)are presented. Although the data cannot beextrapolated to the general population, theinformation they provide should be ofvalue forfuture planners of hospital resources in similarprojects in Angola and neighbouring countries.

Materials and methods

SELECTION OF PATIENTSPatients were selected twice weekly from theemergency ward at the Luanda GeneralHospital. The institute acted only as a centrefor referrals rather than as an emergency ward.This decision was taken in view of the limitedavailability of staff able to provide ophthalmicassistance at the beginning of the project. Theinstitute thus maintained its teaching characterand avoided the risk of being overwhelmed bythe needs of the general population. An aver-age of 70 patients per day were treated twice aweek in the emergency ward (that is, 100%capacity). A team of one ophthalmologist and

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Ophthalmology in Luanda (Angola): a hospital based report

four residents carried out preliminary diag-nosis and treatment and selected cases forreferral to the Ophthalmic Institute. The teamoperated on surgical emergencies the same

aftemoon and the following day. Owing to thelimited capacity of the institute, a number ofbanal pathologies - mainly conjunctivitis andblepharitis - were treated in the generalhospital and not recorded in the institute'sfiles. The criteria used for selecting patients tobe referred to the institute were mainly theseverity of the disease or its relevance to theteaching programme. The institute alsoreceived patients from the optometry section ofthe general hospital. Most patients were

civilians, since the institute did not usuallytreat military casualties.

During the first 2 years of the project, 4201patients were treated at the institute andincluded in the present study.

CLINICAL METHODSPatients were treated by appointment at theOphthalmic Institute by the team that had firstexamined them in the emergency ward at thegeneral hospital. An individual case file was

opened and the patient's clinical history andgeneral examination findings were recorded.The standard examination consisted of:inspection of the general complexion (face,brows, eyelids); corneal reflex position; ocularmovements and cover test; pupil size and lightreflex; manual keratometry and streakretinoscopy; determination of the best visualacuity; slit-lamp examination of the anteriorsegment; Goldmann applanation tonometry;and direct, and frequently indirect, ophthal-moscopy. Optional explorations, such as-

Goldmann perimetry or Hertel exophthal-mometry, were carried out only when requiredby the previous findings.

DATA COLLECTIONThe following data were collected from theclinical reports: age; sex; diagnoses (single or

multiple); type of treatment (medical or surgi-cal); acuity of the best eye at the time of diag-nosis; main disease group (cornea, retina,glaucoma, etc).

All diagnoses were classified with a threeletter code and grouped into one of the follow-ing categories: (1) lids; (2) orbit; (3) lacrimalsystem; (4) conjunctiva; (5) cornea-sclera;(6) uveitis-endophthalmitis; (7) glaucoma;(8) lens; (9) retinal and choroidal diseasesother than uveitis; (10) squint; (11) neuro-

ophthalmology; (12) syndromes-congenitalanomalies; (13) ametropies; (14) trauma.

Duplication of diagnoses was avoided suchthat myopia magna, for instance, appears onlyamong retinal diseases and not amongametropies. Nevertheless, multiple categorisa-tion of the same patient did occur on occasion,if the pathological process presented by the eyewas not covered with a single diagnosis. Forexample, secondary cataracts were primarilyincluded among cataracts, and secondarilyamong trauma or uveitis, if the cause of the

cataractogenic process could be inferred witha sufficient degree of certainty. Unfortunatelythis was not always the case, as many patientsin this environment commonly attribute alltheir diseases to old traumas. A typical casewould be that of iridocyclitis with high intra-ocular pressure, which we recorded under bothsecondary glaucoma and uveitis. If such a casewere to be found once the active disease hadpassed however - with a tranquil eye andunilateral optic atrophy with excavation, withor without elevated intraocular pressure - noattempt would be made to attribute the uni-lateral neuropathy to an unobserved uveitis.As the number of different diagnoses was

high, each category was divided into singlediagnoses or groups of closely related diseases,so as to present less than 15 groups percategory. Data management was carried outwith an Apple Macintosh Quadra 650 com-puter using SYSTAT 5.0 software (from SystatCo).

DEFINITIONSFollowing the definition of the World HealthOrganisation,l 2 we considered as blind thosepatients with a corrected visual acuity in thebetter eye of less than 3/60 (10/200), and asvisually impaired (significant visual loss) thosewith visual acuity in the better eye of less than6/18. Only bilateral blindness and visual losswere considered in this study.

ResultsResults are summarised in Table 1 and Figures1-10. Figure 1 shows the distribution ofpatients across the 14 categories considered.Each category has been broken down to showthe main diseases in each group. Distributionby age and sex is also shown for the main cate-gories.We studied 4201 patients, 2363 of whom

had an ophthalmic disease, the remainderbeing only ametropies. Of these, 49-2% werefemale and 50.8% male.

BLINDNESS AND SIGNIFICANT VISUAL LOSSA total of 265 of our patients were blindaccording to the definition of the World HealthOrganisation.12 Patients were considered asblind if their corrected visual acuity in thebetter eye was less than 3/60. In this group,111 were female (41*9%) and 154 male

Table 1 Main causes of blindness at the OphthalmicInstitute ofLuanda

Main diagnosis Frequency %

Cataract 64 24-2Glaucoma 55 20-9Optic atrophy 24 9-1Hereditary retinal disease 22 8-3Trauma 20 7-6Optic neuritis l1 4-1Xerophthalmia 1 1 4-1Uveitis 10 3-8Retinal detachment 8 3 0Diabetic retinopathy 3 11Other 37 13 9Total 265 100

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Carreras, Rodriguez-Hurtado, David

Trauma

Ametropies

Syndromes-congenital anomaliesNeuro-ophthalmology

SquintRetina-uvea

Lens

Glaucoma

Uveitis-endophthalmitisCornea-sclera

Conjunctiva

400 r

381

1 1838

] 25= 146

= 128

11 3751 420

179

11861 213

1 261Lacrimal system r17

OrbitLids

] 45

187

0 500 1000 1500

A

2000

o Females| Males

300 H

200 H

100 F

B

0 0 0 0 0 0 0 0D

T-, N1 C' le CD 0 r-~

Age (years)Figure 1 (A) Distribution of 4201 patients across the 14 categories considered. (B) Distribution of all pathologies by age and sex.

(58i1%); 127 (47d1%) were totally blind - thatis, with no light perception whatsoever. Whenametropies were discounted and only 2363patients with pathologies considered, the blindaccounted for 11 2% of all pathologies.

Patients were considered as visuallyimpaired if their visual acuity was less than6/18 in the better eye.1 2 In our series a total of159 patients presented with significant visualloss, 60 of whom were female (37 7%) and 99male (62-3%). Both groups totalled 424 withblindness or severely reduced visual acuity -that is, 17-9% of all the pathologies.

In the blind group, 80 patients (30-2%)received surgical treatment. The remaining185 (69-8%) were limited to medical treat-ment. In the visually impaired group, 23(14-5%) underwent surgery and 136 (85-5%)received medical treatment. The main causesof blindness among the patients were cataractglaucoma, optic atrophy, hereditary retinal

25 r

20 H

151-

10

5o Femalesm Males

diseases, trauma, optic neuritis, xero-phthalmia, uveitis, retinal detachment, anddiabetic retinopathy. Frequencies and per-centages are presented in Table 1.

ANATOMICAL SITE OF BLINDNESS

Anterior segmentCataracts and xerophthalmia totalled 28-3% ofthe blind group. When these diseases wereconsidered together with uveitis (3 0%),trauma affecting the anterior segment andultimately conducive to blindness (5 3%),and other cases (6-0%), anterior segmentpathology totalled 42-6%.

Posterior segmentSome 25-3% of the cases ofblindness were dueto posterior segment damage - that is, retinaldetachment, hereditary retinopathies, opticneuritis and atrophy, and diabetic retinopathy.Along with 1 1% of cases of posterior uveitisand 6-4% of other pathologies, posterior poledamage was observed in 32-8% of the blindgroup.

Whole eyeIn advanced glaucoma both anterior and pos-terior segments are affected. These cases,together with 2-3% of the traumas affecting thewhole eye and 1 5% of other pathologies,totalled 24-6% of the blind in which the ante-rior and posterior poles were compromised.

PREVENTABLE AND TREATABLE BLINDNESSCataracts and retinal detachment are treatable,

0 O O O O O O O and the two taken together accounted forO ' * ' FI 27-4% of the blinding diseases. Xerophthalmia

CN m 4 Ln @ is a fully preventable disease. Glaucoma andAge (years) trauma are partially preventable. Altogether,

Figure 2 Distribution of blindness by age and sex these accounted for 32-5% of the causes of(n=265). blindness.

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Lens luxation

Congenital cataract

A

2

313

Secondary cataract L: 14

Juvenile cataract D 18

60r

50K

40 [-

B

o Females| Males

30 F-Traumatic cataract W 22

Presenile cataract liz 23 20 H

Childhood cataract 32

Senile cataraal10i

0

t 0 284

0 100 200 300 0 0 0 0

- CNX-1 ID CD

Age (years)Figure 3 (A) Breakdown of lens diseases. Classification ofpimary cataracts depend on the age at which it was first noticed: congenital, less than 2 years;childhood, between 3 and 9 years; juvenile, between 10 and 30years; presenile, between 31 and 45; senile, older than 45. Among traumatic cataracts, onlysequelae ofold traumas are included. Recent traumas affecting the lens are not included here. (B) Distribution oflens diseases by age and sex.

Some of the cases of uveitis could be pre-ventable if dependent on endemic infectiousdiseases such as tuberculosis. Early treatmentand close follow up of uveitis and diabetesmellitus could partly reduce 4 9% of the blindincluded in both groups.

DiscussionThe Ophthalmic Institute was the only centrefor the treatment of ophthalmic diseases opento civilians in Luanda at the time of the study.As only banal pathologies were discountedfrom the records (although they were alwaystreated), the data presented here show some ofthe main diseases found in the population ofthe city, although no estimates of prevalencecan be inferred. All hospital based data aresubject to a number of biases; however, in theabsence of a population based study, our datamay, with some caution, be compared with thefrequencies reported in surveys of ophthalmicpathologies in other African countries. Themain purpose of the present study was toidentify the main blinding diseases to be dealtwith in ophthalmic healthcare projects in the

Angolan capital, which may also help in theplanning of development aid programmes inAngola and other comparable countries (forexample, Mozambique).

CAUSES OF BLINDNESSThe reported causes of blindness in Africa are,in order of importance: cataracts, trachoma,glaucoma, xerophthalmia, onchocerciasis, age-related macular degeneration, diabeticretinopathy and leprosy.3 Reports from geo-graphically similar countries such asZimbabwe and Kenya also identify cataracts,comeal opacity, and open angle glaucoma asthe main causes of blindness.4Among our patients the main causes of

blindness before treatment were: cataracts,glaucoma, optic nerve diseases (neuritis andatrophy), trauma, xerophthalmia, uveitis,hereditary retinal diseases (degenerativemyopia, retinitis pigmentosa, albinism, andStargardt's disease), retinal detachment, anddiabetic retinopathy (Table 1, Fig 2).

In African adults, cataract is the principalcause of blindness.1 As in other reports,

ALow tension 4

Traumatic p 12

Congenital p 14

Closed angle 19

Secondary

Primary open angle

26

1134

25 r

20

15 1-

10

5

0

0 60 100 160 O o Q o o o o ob

_- 4 XY qt VL co f-

Age (years) Age (years)Figure 4 (A) Breakdown ofglaucoma (n=209). (B) Distribution of all glaucomas by age and sex (n=209). (C) Distribution ofprimary open angleglaucoma by age and sex (n= 134).

25 r

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Carreras, Rodriguez-Hurtado, David

20 r

A

2

15

114

Papilloedema

Chiasmal compression L

Ocular nerve paralysis -

Cortical blindness -

Optic neuritis t

Optic atrophy

Other

0 10 20

B

o Femalesm Males

10K16

31

5161

30 40 50 60 70 o-1 o14 oII) ot Lo co r- a)8

XI

CN c'n w in co C-

Age (years)Figure 5 (A) Breakdown of neural diseases (n= 142). (B) Distribution of neural diseases by age and sex (n= 142).

cataracts were the main cause of bilateralblindness in our series. Training in cataractsurgery was one of the main objectives of ourprogramme. In children under 12, cataractremains the chief cause of blindness (Fig 3).Glaucoma is quoted as being a significant

cause of blindness in hospital based reports inwest Africa.5 In our records, glaucoma was thesecond most common cause of blindness.Congenital glaucoma in males was double thatfound in females. Figures 4A and B show thedistribution of all types ofglaucoma by age andsex. Figure 4C shows the distribution ofprimary open angle glaucoma (POAG) by ageand sex. Although middle aged females seemto be less affected by POAG, the number ofglaucoma cases was equal in both sexes for theover 60s.

Optic atrophy and optic neuritis were thethird major cause of bilateral blindness amongour patients (Fig 5). Although it is listed in sixth

place among the causes of bilateral blindness inblack American patients,6 optic nerve disease isnot reported as a major cause of blindness inother reports from African countries.4 7-9 Opticatrophy is listed in fourth place among aetiolo-gies of childhood blindness in Africa.'0 InGambia, optic atrophy was found to be respon-sible for 2% of cases of blindness." Althoughthese data and ours are not fully comparable,the high proportion of optic nerve disease in ourseries may point towards a high level of genetic,nutritional, or infectious susceptibility amongthe population of Luanda.Trachoma blindness is frequently found in

the arid regions of north Africa, the Sahel andthe dry plains of east and central Africa.3Trachoma is closely related to standard ofliving, and is currently a significant problem inunderserved rural areas or urban slums.'2 InLuanda we saw numerous cases of inclusionconjunctivitis but few cases of blinding

A

Parasitic conjunctivitis ] 1

50

40Trachoma m 6

Phlyctenular conjunctivitis 14

Tumour 116

Bacterial conjunctivitis 118

Viral conjunctivitis I 1 21

Allergic conjunctivitis

Inclusion conjunctivitic

Pterygiurr

Other

I

-1 28

] 5910179

r 115

0 10 20 30 40 50 60 70 80o

30

20

B

o Females| Males

o o 0 0)r- C- CY) I- U) CD C-- 0Y)

CN CY) X ) O rC

Age (years)Figure 6 (A) Breakdown of conjunctival diseases (n=258). Only a sample of the cases of inclusion conjunctivitis diagnosed were included in the records.Pterygium is included among conjunctival disorders. (B) Distribution of conjunctival diseases by age and sex (n=258).

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40AGlaucoma pI 10

Optic nerve Dl] 10

Retina | 1 23

Vitreous haemorrhage i 1 34

Cornea | 137

Orbit

Lens

Eyeball

1 41

] 140

60 100 160 o o o o o o o oaC%X X LD Or a)

8 VI r rto rI T

0

Age (years)Figure 7 (A) Breakdown of traumatic diseases according to the anatomical structure involved (n=380). (B)Distribution of injuries by age and sex.

trachoma. Inclusion conjunctivitis is endemicin Luanda, and present in children as well asadolescents and adults. Cases of this type ofconjunctivitis treated in the emergency wardwere so numerous that they were revised at thegeneral hospital in order to avoid overcrowdingat the institute. Only a few selected cases werereferred to the institute, where they underwenta thorough examination. Although the numberof cases reported here is only testimonial, allcases of true trachoma diagnosed in the emer-gency ward were treated at the institute. Truetrachoma seems to be rare in Luanda, account-ing for only 2% of our cases of conjunctivitis. Abreakdown of conjunctival cases is given inFigure 6. Pterygia is included among conjunc-tival disorders. Its frequency appears to behigher than that of inclusion conjunctivitissince the residents frequently referred cases ofpterygia to the institute for surgery.Trauma is the fourth most common cause of

bilateral blindness in our data. The importanceof trauma in unilateral blindness is evengreater. Not only does the country suffer theeffects of violent conflict, but personal attacks

on civilians are everyday occurrences, sincethe perpetrators are never prosecuted. Abreakdown of types of traumatism is given inFigure 7. 'Eyeball' indicates rupture of the eye-ball by blunt trauma and is the most frequentform of traumatism. Adolescents are the mostseriously affected group, and young femalesare almost as frequently involved as males. Apotentially fatal blow to the eye is a commonmethod of punishment used by abusive maleson their female partners. Trauma was found tobe the second most prevalent blinding condi-tion in the Kenya Rural Blindness PreventionProject. 13

Vitamin A deficiency and measles areresponsible for more than half the childhoodblindness in Africa.3 In our series, xeroph-thalmia was ranked in fifth place for all agegroups. Among children under 6, xero-phthalmia and cataracts share first place. Inour records, xerophthalmia was found inundernourished children affected by measlesor acute respiratory disease, usually accom-panied by diarrhoea. Corneal disease, whenpresent, was often severe in such cases.

50A

Other dystrophies p 3

Mooren's ulcer 6

Keratoconus 7

Interstitial keratitis

Bacterial keratitis

Trauma

Viral keratitis

Leucoma 135

Other

40

301Z10

723

12720

1ztI

10] 48

II0

B

o Females* Males

00D(DC 0 0 CT)

oIN mX) LO E D r-

Age (years)Figure 8 (A) Breakdown of corneal diseases (n=226). (B) Distribution of corneal diseases by age and sex.

0 10 20 30 40 50

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Carreras, Rodniguez-Hurtado, David

iOn

A

8

Intermediate LI 2

6Posterior [ 9

4Panuveitis 15

Anterioi 2r 165

0 10 20 30 40 50 60 70

Figure 9 (A) Breakdown of uveal diseases based on the location of the princilby age and sex (n= 91)

Comeal ulcers are associated with a rapiddecrease in vitamin A reserves in the debili-tated organism.14 Angola is a producer ofpalm oil, the richest natural source of vitaminA precursors, which would explain whychronic nutritional xerophthalmia is absentfrom our series. The main corneal pathologydiagnosed at the institute is shown in Figure 8.

Uveitis is the sixth most common cause ofblindness in our study. Only cases of activeuveitis at the time of diagnosis were includedin this category. Sequelae of probable uveitisorigin, but not diagnosed by us where active,are not included here, but rather under theaffected tissue (for example, secondarycataract). Maximal incidence of active uveitiswas found among young adults (75% wereunder 30). A large number of patients (58% ofgranulomatous uveitis) gave a positive tuber-culin skin test. The incidence of active tuber-culosis in the province of Luanda is high:official 1990 figures estimated it at 41 newcases per 100 000 inhabitants.'5 Oncho-cerciasis is a major cause of blindness in west

B

o Females| Males

0 0 0 0 0 0 0

NI''4m LO CD

Age (years)pal lesion. (B) Distribution of uveal diseases

and central Africa.'2 Although northernAngola falls within the limits of the endemicarea, Luanda lies in the semiarid coastalregion, and only one case with active filariasiswas diagnosed in our centre. Distribution ofuveitis according to its primary location isshown in Figure 9.A group of congenital retinal degenerations

share seventh place among the most commoncauses of blindness in our data (Fig 10).Degenerative myopia is by far the most import-ant of the group. Age-related macular degener-ation (ARMD) is in tenth place within thisgroup, and is less frequent than retinitis pig-mentosa and 'bull's eye maculopathy'. ARMDwas not quoted as an important cause of blind-ness among black Americans in the BaltimoreEye Survey6; nor was it explicitly mentioned instudies of prevalence of ophthalmic diseases inGambia and Kenya.2 11

The diagnosis of retinal diseases at theOphthalmic Institute was made in the absenceof electrophysiological tests. In a countrywhere family diseases are almost never known

RetinoblastomaToxoplasmosis

110 A

=11Traumatic macular atrophy LIII 11

Age-related macular degeneration

Diabetic retinopathyOther maculopathiesMacular dystrophiesRetinitis pigmentosa

Other congenital diseasesRetinal detachment

Hypertensive retinopathyOther vasculopathies

Other

0

17

1 19

12112224

11261130

132133

j 12315

50 100 150

B40 r

o Females* Males

30 K

20 H

10 -

00 0 0 0 0 0 a~N C") C? 1, 0)

- N C) * It) COID1

Age (years)Figure 10 (A) Breakdown of retinal diseases (n=394). (B) Distribution of retinal diseases by age and sex.

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Ophthalmology in Luanda (Angola): a hospita based report

to the patients and where the massive con-sumption of self prescribed antimalaria drugsis widespread, the discrimination betweenfamily and acquired diseases is precarious. Thediagnosis of bull's eye maculopathy remainedmerely descriptive.

SOCIAL ASPECTS OF BLINDNESSDistribution of blindness by age shows abimodal curve, with the modes at 15 and 60years (Fig 2). An increase in mortality has beenfound to be associated with blindness in ruralAfrica (central Tanzania), especially amongwomen.16 The lower number of cases of blind-ness among middle aged people treated at theinstitute may reflect the reduced chances ofsurvival for the young blind in the Angolanenvironment. Among the young blind, thehigher frequency of fatal cases of trauma inyoung males seems to be counterbalanced bythe higher frequency of blinding optic nervedisorders in young females. The nature ofopticneuritis and atrophy in this environment isuncertain. As the disease does not respond totreatment, and because of its importance as ablinding disease, especially among youngpeople, any programme which attempted toascertain the causes would be worth pursuingand preventive measures could be of consider-able help.

Retinal detachment surgery requires earlyidentification in order for the treatment to beeffective, which largely depends on patientsrecognising the early signs and promptly seek-ing help. Here, as in other painless blindingdiseases, such as silent uveitis, sanitary educa-tion of the population is of great importance.Glaucoma is preventable with early diagnosisbut, being symptom free, demands a popula-tion wide programme for its early detection.

Sanitary education is also the key to theprevention of xerophthalmia, as the necessaryresources are readily available in the country.The large number of cases of blindness causedby traumatism, normally the result ofcommon

assaults, highlights the importance of socialeducation.The importance of cataracts in all age

groups cannot be overestimated. There is anurgent need to train Angolan ophthalmologistsin extracapsular lens extraction techniques,although intraocular lens implants might notbe considered as appropriate treatment indeveloping countries.'Angola suffers a considerable deficit of sani-

tary services, including ophthalmological care.In order to optimise the available resources, asocial education campaign ought always tocomplement any medical programme.

1 Foster A. Cataract blindness in Africa. Int Ophthalmol 1987;18: 384-8.

2 Loewenthal R, Pe'er J. A prevalence survey of ophthalmicdiseases among the Turkana tribe in north-west Kenya.BrJ Ophthalmol 1990; 74: 84-8.

3 Foster A, Johnson GJ. Magnitude and causes of blindnessin the developing world. Int Ophthalmol 1990; 14: 135-40.

4 Schwab L. Ophthalmology in Zimbabwe. Arch Ophthalmol1989; 107: 284.

5 Wormald R, Foster A. Clinical and pathological features ofchronic glaucoma in North-East Ghana. Eye 1990; 4:107-14.

6 Sommer A, Tielsch JM, Royall RW, Witt KA, Ezrine S.Racial differences in the cause-specific prevalence ofblind-ness in East Baltimore. NEnglJMed 1991; 325: 1412-7.

7 Adamson I, Taylor HR. Major causes of world blindness:their treatment and prevention. Curr Opin Ophthalmol1990; 1: 635-42.

8 Thompson JR, Rosenthal AR. Epidemiology ofworld blind-ness. Curr Opin Ophthalmol 1990; 1: 649-53.

9 Searle AET, Fielder AR. Screening for ocular disease andvisual impairment. Curr Opin Ophthalmol 1990; 1: 654-9.

10 Kagame K, Schwab L. Childhood blindness: DatelineAfrica. Ophthalmic Surg 1989; 20: 128-31.

11 Faal H, Minassian D, Sowa S, Foster A. National surveyof blindness and low vision in the Gambia: results.BrJ Ophthalmol 1989; 73: 82-7.

12 Thylefors B, Negrel AD, Pararajasegaram R. Epidemiologicaspects of global blindness prevention. Curr OpinOphthalmol 1992; 3: 824-34.

13 Whitfield R, Schwab L, Ross-Degnan D, Steinkuller PSwartwood J. Blindness and eye disease in Kenya: ocularstatus survey results from the Kenya Rural BlindnessPrevention Project. Br J Ophthalmol 1990; 74: 333-40.

14 Sommer A, Muhilal H. Nutritional factors in cornealxerophthalmia and keratomalacia. Arch Ophthalmol 1982;100: 399-403.

15 Relat6rio anual de vigilancia epidemiologica de 1990.Delegaqao Provincial de Saude de Luanda. Direci;aoProvincial de Saude Publica e Control de Endemias.Repuiblica Popular de Angola: Ministerio da Sauide,1991.

16 Taylor HR, Katala S, Munoz B, Turner V. Increase inmortality associated with blindness in rural Africa. BullWHO 1991; 69: 335-8.

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hospital based report.Ophthalmology in Luanda (Angola): a

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Documents

Ophthalmology in Luanda (Angola): a hospital based report