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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 18

Demand of ophthalmic services in a rural district of Costa Rica


1 Department of Ophthalmology, Hospital Calderón Guardia, Caja Costarricense del Seguro Social, San José; Department of Ophthalmology, Clinica Acon, Cañas; Asociados de Macula, Vitreo y Retina de Costa Rica, San José, Costa Rica
2 Department of Ophthalmology, Sanatorio del Salvador, Córdoba, Argentina
3 Asociados de Macula, Vitreo y Retina de Costa Rica, San José, Costa Rica; Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA

Date of Submission22-Mar-2021
Date of Acceptance12-May-2021
Date of Web Publication18-Jun-2021

Correspondence Address:
Dr. Lihteh Wu
Asociados de Macula, Vitreo y Retina de Costa Rica, Primer Piso Torre Mercedes Paseo Colon, San José

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_85_21

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  Abstract 


Purpose: To report the demand of ophthalmic services and the prevalence of the main ophthalmic pathologies in a rural population of Costa Rica.
Study Design: A cross-sectional study of all individuals seen at the ophthalmology outpatient clinic during March 2016 to February 2017.
Methods: All cases presenting to the ophthalmology outpatient clinic during March 2016 to February 2017 were reviewed (n = 895 patients, 1790 eyes). Visual acuity was measured using the Snellen chart.
Results: The most common reasons for consultation were decreased visual acuity in 37.7% (326/865), foreign-body sensation 20.2% (175/865), glaucoma control 5.9% (51/865), screening or follow-up of diabetes mellitus (DM) 5.8% (50/865), and blunt trauma in 5% (43/865) of patients. A total of 252 (14.1%) eyes presented with a best-corrected visual acuity (BCVA) ≤20/200; 357 (19.9%) eyes had a BCVA <20/40 and >20/200; and 1181 (65.9%) had a BCVA ≥20/40. There were 40 (4.5%) patients that had a BCVA ≤20/200 bilaterally. The most common ophthalmic findings included cataract in 552 (30.8%) eyes, pterygium in 296 (16.5%) eyes, primary open angle glaucoma (POAG) in 187 (10.4%) eyes, age-related macular degeneration in 168 (9.4%) eyes, and 131 (7.3%) eyes with diabetic retinopathy (DR).
Conclusions: The most common cause of ophthalmic consultation was decreased vision, of which 14% had a BCVA ≤20/200. The common findings included cataract, pterygia, POAG, age-related macular degeneration, and DR. Seventy-five percent of bilateral visual loss is avoidable.

Keywords: Blindness Costa Rica, blindness Latin America, visual impairment Costa Rica, visual impairment Latin America


How to cite this article:
Acon D, Crim N, Wu L. Demand of ophthalmic services in a rural district of Costa Rica. Pan Am J Ophthalmol 2021;3:18

How to cite this URL:
Acon D, Crim N, Wu L. Demand of ophthalmic services in a rural district of Costa Rica. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Dec 5];3:18. Available from: https://www.thepajo.org/text.asp?2021/3/1/18/318797




  Introduction Top


Costa Rica is the second smallest country in Central America with an area of 51,000 km2. According to the last census of 2011, it had around 5 million inhabitants.[1] In Costa Rica, there is nearly universal health-care coverage reaching 98% of the population. It consists of a primary level of 893 basic units responsible for comprehensive care. These units comprise a general practitioner, a nurse and a health technician. The secondary level is made up of 178 clinics and 20 regional hospitals. The tertiary level is constituted by nine national hospitals. The handling of disease is carried out in sequential form in the three levels according to the complexity and complications encountered during the patient management.[2]

The Guapiles hospital is one of the 20 regional hospitals in the country. It serves the counties of Pococi, Guacimo, and Siquirres of the province of Limon and the county of Sarapiqui in the province of Heredia. According to the last census of 2011, a total of 264,000 people live in these counties.[1] The ophthalmology department consists of an ophthalmologist, an optometrist and a nurse that takes care of all the ophthalmic needs of this population.

There is a dearth of information on the prevalence or incidence of ophthalmic diseases in Costa Rica. The purpose of the current study is to report the demand of ophthalmic services and the prevalence of the main ophthalmic pathologies seen at the Guapiles Hospital.


  Methods Top


All cases presenting to the ophthalmology outpatient clinic during March 2016 to February 2017 were reviewed (n = 895 patients, 1790 eyes). Written informed consent was obtained from all the patients. The study and data accumulation were carried out in adherence to the tenets of the declaration of Helsinki. Local IRB approval was obtained (CCSS CEC-2016-88). Individual informed consent was not obtained as the study was retrospective and de-identified data were used.

Visual acuity was measured using the Snellen chart and logMAR equivalents were calculated to facilitate the statistical analysis. All patients underwent a complete ophthalmic examination by an ophthalmologist (DA). The complete ophthalmic examination included a pupillary examination, ductions and versions, slit-lamp examination, slit-lamp biomicroscopy, indirect ophthalmoscopy through a dilated pupil, and Goldmann applanation tonometry.

Statistical analysis was performed with Infostat 2019 (Universidad Nacional de Cordoba, Cordoba, Argentina).


  Results Top


We reviewed the clinical records of 895 patients (1790 eyes), of which 441 (49.3%) were female. The mean age was 56.4 ± 20.7 years old for female patients and 55.4 ± 21.3 years old for male patients.

The most common reasons for consultation were decreased visual acuity in 37.7% (326/865), foreign-body sensation 20.2% (175/865), glaucoma control 5.9% (51/865), screening or follow-up of diabetes mellitus (DM) 5.8% (50/865), and blunt trauma in 5% (43/865) of patients. Other causes of referral to the ophthalmologist included chemical trauma, ocular pain, and red eye among others.

The most common findings included cataract in 552 (30.8%) eyes, pterygia in 296 (16.5%) eyes, primary open angle glaucoma (POAG) in 187 (10.4%) eyes, age-related macular degeneration (AMD) in 168 (9.4%) eyes, 131 (7.3%) eyes with diabetic retinopathy (DR), and 69 (3.8%) with an uncorrected refractive error. Cataracts were diagnosed in 330 patients, pterygia in 184 patients, DR in 131 patients, POAG in 105 patients, and AMD in 91 patients. The distribution and average logMAR BCVA of these conditions are summarized in [Table 1].
Table 1: Visual acuity distribution according to ophthalmic diagnosis

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A total of 252 (14.1%) eyes presented with a BCVA ≤20/200; 357 (19.9%) eyes had a BCVA <20/40 and >20/200; and 1181 (65.9%) had a BCVA ≥20/40. There were 40 (4.5%) patients that had a BCVA ≤20/200 bilaterally. The breakdown of these patients included 45 eyes with cataracts, 6 eyes with pseudophakic bullous keratopathy, 6 eyes with AMD (4 eyes with exudative AMD), 6 eyes with proliferative DR (PDR), 4 eyes with POAG, 4 eyes with a macular scar presumably secondary to toxoplasmosis, 3 eyes of complications from cataract surgery, 2 eyes with retinitis pigmentosa, 2 eyes with pathologic myopia, and 2 eyes with anterior segment dysgenesis.

The most common systemic comorbidity was systemic hypertension. High blood pressure was present in 376 (42%) patients. The second most common disease was DM, which was present in 210 (23.5%) patients. Of these, 46.7% (98/210) were on insulin and 72.8% (153/210) were solely on oral hypoglycemic agents. The mean time of duration of DM was 12.2 ± 9.7 years (range 0.25–50 years). Seventy-nine (37.6%) patients did not have any evidence of DR. Of the 131 (62.4%) patients with DR, 38 (30%) had mild non-PDR (NPDR), 42 (32%) moderate NPDR, 29 (23%) severe NPDR, and 22 (17%) PDR. There were also 22 eyes with diabetic macular edema (DME). Eleven of the eyes with DME had moderate NPDR, 10 eyes severe NPDR, and 1 eye with PDR. In summary, the eyes at risk of visual loss (eyes with severe NPDR, PDR, or macular edema) were 10.2% (43/420) of eyes.


  Discussion Top


There is very little data on the epidemiology of ophthalmic diseases in Latin America particularly in Costa Rica. Leasher et al.[3] specifically named Costa Rica as one of the four countries in Latin America where epidemiological surveys were particularly needed. A recent study used the rapid assessment of avoidable blindness (RAAB) methodology to report that the main causes of avoidable blindness in decreasing order of magnitude were cataracts, glaucoma, and DR.[4] Our current study differs from the above in several aspects. The RAAB only looked at individuals older than 50 years, whereas in our current study, all patients were included regardless of age. In all our patients, we performed a complete ophthalmic examination including slit-lamp biomicroscopy to examine the macula by an experienced ophthalmologist, whereas in the other study, macular assessment was performed by indirect ophthalmoscopy with a 20 D lens by ophthalmology residents. Finally, our study was based in a rural district, whereas in the study by Acevedo Castellón et al.,[4] the setting of the study was not defined.

Similar to other countries in the region, cataracts were the most frequent cause of decreased vision in our cohort.[5] In the current study, cataracts accounted for more than half of the bilaterally blind (≤20/200) patients. It is reassuring that more than half of the eyes with cataract had a BCVA of ≥20/40.

Surprisingly uncorrected refractive error was not a major cause of visual loss. It only accounted for 3.8% (69/1790) of the causes of visual loss. Acevedo Castellón et al.[4] did not report any uncorrected refractive error, which is even more surprising. In contrast, in a similar study from Ecuador, uncorrected refractive error accounted for 37% of cases of bilateral blindness, its largest cause. The relatively young cohort of our study may explain this finding. Alternatively, it may have been that the expansion of several optical chains in the general area of the hospital may have alleviated the need for patients to seek attention at the local hospital, particularly since the wait list for a new appointment in the ophthalmology department was 18 months.

The prevalence of DM in Costa Rica has been reported to be between 8% and 10.8%.[6],[7],[8] The prevalence of DR is highly variable and depends on the population studied among many other factors.[9],[10] In a prior study based on the use of nonmydriatic cameras, the prevalence of any DR in an urban district of San José, Costa Rica was 15% and 5.8% were at risk of visual loss (eyes with severe NPDR, PDR or macular oedema).[11] In contrast, in our current study based in a rural district, the prevalence of any DR was much higher at 62.4% and the eyes at risk of visual loss was also much higher at 10.2% (43/420) of eyes. In Acevedo Castellón et al.'s[4] study, the prevalence of any DR was 23.5% and sight threatening retinopathy 6.2%. One of the major flaws of their study was that the diagnosis of DR and DME was made by indirect ophthalmoscopy by 3rd year residents. In the current study, DME was confirmed by macular spectral-domain optical coherence tomography.

Several ophthalmic conditions such as DME, PDR, exudative AMD, and POAG among others need to be treated on a timely basis. Delay in treatment will lead to worse outcomes. Of the 40 patients with bilateral BCVA ≤20/200, there were 59 eyes (73.8%) that suffered from one of these conditions. Thus, almost 75% of the bilateral loss of vision was avoidable. This result is in line with the 70% of avoidable blindness reported by Acevedo Castellón et al.[4] As Cass et al.[12] correctly point out affordability and availability are the key challenges that need to be overcome. With a wait time of 18 months, many patients will suffer irreversible visual loss that could have been prevented by a timely intervention.

One of the main limitations of the current study is the fact that the study was hospital based. Ideally, a population-based study should be conducted, but at the current time, the resources are simply not available. The other limitation is its small sample size. The major strength of the study was that all the patients that were seen in the course of the year were included in the study and all of them had a complete ophthalmic examination. Despite these limitations, we believe that the results are important as it sheds some light on the nature of the demand of ophthalmic services in a rural Costa Rican district.


  Conclusions Top


The most common cause of ophthalmic consultation was decreased vision of which 14% had a BCVA ≤ 20/200. Common findings included cataract, pterygia, primary open angle glaucoma, age-related macular degeneration and diabetic retinopathy. 75% of bilateral visual loss is avoidable

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: http://www.inec.go.cr/censos/censos-2011. [Last Accessed on 2021 May 11].  Back to cited text no. 1
    
2.
Sáenz Mdel R, Acosta M, Muiser J, Bermúdez JL. The health system of Costa Rica. Salud Publica Mex 2011;53 Suppl 2:s156-67.  Back to cited text no. 2
    
3.
Leasher JL, Lansingh V, Flaxman SR, Jonas JB, Keeffe J, Naidoo K, et al. Prevalence and causes of vision loss in Latin America and the Caribbean: 1990-2010. Br J Ophthalmol 2014;98:619-28.  Back to cited text no. 3
    
4.
Acevedo Castellón RI, Carranza Vargas E, Cortés Chavarría RE, Rodríguez Vargas GA. Rapid assessment of avoidable blindness and diabetic retinopathy in individuals aged 50 years or older in Costa Rica. PLoS One 2019;14:e0212660.  Back to cited text no. 4
    
5.
Silva JC, Mújica OJ, Vega E, Barcelo A, Lansingh VC, McLeod J, et al. A comparative assessment of avoidable blindness and visual impairment in seven Latin American countries: prevalence, coverage, and inequality. Rev Panam Salud Publica 2015;37:13-20.  Back to cited text no. 5
    
6.
Cerdas M. Epidemiology and control of hypertension and diabetes in Costa Rica. Ren Fail 2006;28:693-6.  Back to cited text no. 6
    
7.
Wong-McClure R, Gregg EW, Barcelo A, Sanabria-Lopez L, Lee K, Abarca-Gomez L, et al. Prevalence of diabetes and impaired fasting glucose in Costa Rica: Costa Rican National Cardiovascular Risk Factors Survey, 2010. J Diabetes 2016;8:686-92.  Back to cited text no. 7
    
8.
Barcelo A, Gregg EW, Gerzoff RB, Wong R, Perez Flores E, Ramirez-Zea M, et al. Prevalence of diabetes and intermediate hyperglycemia among adults from the first multinational study of noncommunicable diseases in six Central American countries: the Central America Diabetes Initiative (CAMDI). Diabetes Care 2012;35:738-40.  Back to cited text no. 8
    
9.
Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984;102:520-6.  Back to cited text no. 9
    
10.
Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol 1984;102:527-32.  Back to cited text no. 10
    
11.
Martinez J, Hernandez-Bogantes E, Wu L. Diabetic retinopathy screening using single-field digital fundus photography at a district level in Costa Rica: A pilot study. Int Ophthalmol 2011;31:83-8.  Back to cited text no. 11
    
12.
Cass H, Landers J, Benitez P. Causes of blindness among hospital outpatients in Ecuador. Clin Exp Ophthalmol 2006;34:146-51.  Back to cited text no. 12
    



 
 
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