|Year : 2015 | Volume
| Issue : 4 | Page : 170-174
Profile of ocular disorders among patients attending clinic at federal neuro psychiatric hospital Kaduna, Nigeria
Emmanuel Raphael Abah1, Abiodun Fatima Mahmud-Ajeigbe1, Victor Obiajulu Olisah2, Taiwo Lateef Sheikh3, Istifanus A Joshua4
1 Department of Ophthalmology, Ahmadu Bello University, Zaria, Nigeria
2 Department of Psychiatry, Ahmadu Bello University, Zaria, Nigeria
3 Department of Clinical Services, Federal Neuro Psychiatric Hospital, Barnawa, Nigeria
4 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
|Date of Submission||06-Feb-2015|
|Date of Acceptance||30-Oct-2015|
|Date of Web Publication||22-Dec-2015|
Emmanuel Raphael Abah
Department of Ophthalmology, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: The practice of ophthalmology and psychiatry meet over several aspects of patient management such as diagnosis, treatment, and follow-up. In addition, many of the drugs used in psychiatry may have some ocular side effects. This study assessed the profile of ocular disorder among patients attending the clinic at Federal Neuro Psychiatric Hospital Kaduna. Nigeria. Materials and Methods: This was a descriptive cross-sectional study carried out between May and August 2013 using interviewer administered questionnaire and eye screening protocol. The data were analyzed using SPSS version 20.0. Results: The male: female ratio was 1:1.1, age range of 18-69 years with mean age of 34.7 ± 5.9 years. Normal vision was recorded in 197 (77.2%), moderate visual impairment in 52 (20.4%), and severe visual impairment in 5 (2.0%). One (0.4%) was blind. Ocular disorders were seen in 139 (54.6%) and are as follows: Refractive errors/presbyopia 76 (29.8%); cataract 22 (8.6%); glaucoma 15 (5.9%); allergic conjunctivitis 15 (5.9%); optic neuritis 3 (1.2%), squint, and eye movement disorders 2 (0.8%) each; neurofibromatosis, color deficiency, ptosis, and macular scar 1 (0.4%) each. Average duration of treatment with psychotropics was 3 years. Conclusion: Majority had good vision. The predominant ocular disorders were refractive errors/presbyopia, cataract, glaucoma, and allergic conjunctivitis. Psychotropic drugs could be responsible for some.
Keywords: Neuropsychiatry, ocular disorders, psychotropic drugs, visual assessment
|How to cite this article:|
Abah ER, Mahmud-Ajeigbe AF, Olisah VO, Sheikh TL, Joshua IA. Profile of ocular disorders among patients attending clinic at federal neuro psychiatric hospital Kaduna, Nigeria. Sub-Saharan Afr J Med 2015;2:170-4
|How to cite this URL:|
Abah ER, Mahmud-Ajeigbe AF, Olisah VO, Sheikh TL, Joshua IA. Profile of ocular disorders among patients attending clinic at federal neuro psychiatric hospital Kaduna, Nigeria. Sub-Saharan Afr J Med [serial online] 2015 [cited 2023 Mar 21];2:170-4. Available from: https://www.ssajm.org/text.asp?2015/2/4/170/172443
| Introduction|| |
The practice of ophthalmology and psychiatry meet over several aspects of patient diagnosis, management, and follow-up.  Patients under the care of psychiatrist can also suffer from any kind of eye diseases such as other individuals in the general population. In this environment like most part of the world, cataract is the most common cause of blindness (43.0%), glaucoma is second and is responsible for 16.7%, and corneal scarring from all causes is responsible for 7.9%. Uncorrected refractive errors are the most common cause of mild and moderate visual impairment (77.9% and 57.1%, respectively) but responsible for only 1.4% of blindness.  Some of these are comparable to global figures: Cataract, refractive errors, and glaucoma are responsible for
39%, 18%, and 10% of the world's blind population of 39 million, respectively. Others include age-related macular degeneration 7%, diabetic retinopathy (4%), corneal scar (4%), childhood blindness (3%), trachoma (3%), onchocerciasis (0.7%), and others (11%). ,,,,,,,,,
Although cataract remains the most common avoidable cause of blindness worldwide, and it is predominantly age-related, , it is important to consider other ocular diseases since many psychotropic medications have the potential to induce numerous and diverse unwanted ocular effects.
These effects can be divided into seven major categories: (1) Eyelid and ocular surface (cornea and conjunctival) disorders, mainly related to pigment deposits from phenothiazines and lithium; (2) uveal tract disorders, mainly associated with tricyclic antidepressants (TCAs), typical antipsychotics, topiramate, and selective serotonin reuptake inhibitors (SSRIs); (3) disorders related to accommodation/cycloplegia, TCAs, typical antipsychotic, and SSRIs can all cause mydriasis; (4) angle-closure glaucoma, TCAs, typical antipsychotic, and SSRIs may promote closure of angles in susceptible patients with narrow angles; (5) cataract from antipsychotics, mainly from high dosages of chlorpromazine or thioridazine, also predominantly due to pigment deposits; (6) retinopathy, related to high dosages and prolonged use of typical antipsychotics, mainly chlorpromazine and thioridazine; and (7) others; other visual problems of special concern are the ocular dystonias/oculogyric crisis (e.g., chlorpromazine, carbamazepine, topiramate, and SSRIs), other eye movement disorders (e.g., benzodiazepines and lithium), and decreased ability to perceive colors and to discriminate contrast (e.g., carbamazepine and lorazepam). Barbiturates and TCAs may cause optic neuritis.
This study was done to assess the profile of ocular disorder among patients attending clinic at
Federal Neuro Psychiatric Hospital Kaduna, Nigeria, to help psychiatrists, ophthalmologists, and patients to be aware of and prepared for medication-induced adverse effects, since early detection and intervention may ameliorate many of the serious and potentially irreversible ocular toxicities of these medications. ,
| Materials And Methods|| |
The Federal Neuro Psychiatric Hospital is a tertiary mental health institution under the Federal Ministry Health in Kaduna South, Nigeria.
It is one of the eight full-fledged psychiatric hospitals in Nigeria with a bed capacity of 154.
It renders a wide range of medical services including inpatients and outpatients care, social work services, occupational therapy, psychological services, drug rehabilitation, diagnostic laboratory services, and other specialized services such as electroencephalography, electroconvulsive therapy, and medical mental health research.
A descriptive cross-sectional study of 255 consecutive clinic attendees between the ages of 18 and 69 years, who met the inclusion criteria, was conducted between May and August 2013.
Study Population and Sample Size
The study population included consecutive patients seen at the clinic during the study period who met the inclusion criteria. The inclusion criteria were the use of psychotropic medications for at least 3 months and written informed consent for the study. Two hundred and twenty-five attendees were excluded. Those who did not consent (77), those with historical evidence of ocular disease preceding treatment with psychotropics (22), and those who were too ill to cooperate for the required ocular examination (126).
Data Collection Tools
The data were collected using semi-structured interviewer-administered questionnaire and an eye screening protocol designed by the authors. Visual acuity for distance (unaided and pinhole/correction) and near were done using the conventional Snellen chart and reduced Snellen chart, respectively. The presenting visual acuity for distance was categorized using the World Health Organization (WHO) criteria for visual impairment and blindness (normal [6/6-6/18], moderate visual impairment [<6/18-6/60], severe visual impairment [<6/60-3/60], and blindness [<3/60]).
Anterior and posterior segment ocular examinations were performed using pen torch, portable slit lamp bio-microscope (Keeler PSL Classic), direct and indirect ophthalmoscope, and 90 diopter lens. Fundus was dilated using phenylephrine hydrochloride 2.5% and tropicamide 1% for those with constricted pupils or media opacity such as cataract to aid fundus examination. Intraocular pressure and automated perimetry were conducted using Perkins applanation tonometer and Optos 1000 automated perimeter, respectively, for those with cup/disc ratio of ≥0.5. Color vision and Amsler grid testing were performed for all participants, but refraction was only conducted for those whose visual acuity improved with the use of pinhole. Refractive error was defined as an error of 0.5 diopters or more in either eye, while presbyopia was defined as difficulty reading N8 at 35 cm in those aged 35 years and above and correctable with convex lenses of 1.0 diopter or more. The eye examinations were conducted by two consultant ophthalmologists.
The data were analyzed by two statisticians using SPSS version 20.0 (IBM) statistical package and presented in tables. The statistical tests carried out were descriptive statistics, cross-tabulation, and Pearson's correlation.
Approval was obtained from the Ethical Research Board of the hospital, and the respondents also gave their written informed consent to participate in the study.
| Results|| |
The male:female ratio was 1:1.1 with age range of 18-69 years and the mean age of 34.7 ± 5.9 years. Normal visual acuity according to WHO classification was recorded in 197 (77.2%) but, 52 (20.4%) had moderate visual impairment, and 5 (2.0%) had severe visual impairment. Only 1 (0.4%) fell into the blind category [Table 1]. Ocular disorders were seen in 139 (54.6%). Of the 78 patients who had refractive error and presbyopia, 22 had refractive error only, 38 had presbyopia onlym, and18 had both.
|Table 1: Age, sex distribution, and visual acuity categorization of the respondents |
Click here to view
For those who had cataract two were bilateral mature cataract, and one was blind from bilateral postuveitic cataract. Sixteen had bilateral immature cataract predominantly posterior subcapsular. Ten had uniocular immature cataract. The color deficiency was in the yellow-green spectrum [Table 2].
Male:Female ratio - 1:1.2, age range of 18-69 years, mean age of 34.7 ± 5.9 years. The majority of the respondents were females. The major age bracket was 20-39 years and 197 (77.2%) had normal visual acuity of 6/6-6/18 [Table 1].
Refractive error and presbyopia constitute the major ocular disorders of the respondents with 76 (29.8%), and the least were neurofibromatosis, ocular deficiency, ptosis, and macular scar with 1 (0.4%) each [Table 2].
| Discussion|| |
The sex distribution in the studied population was skewed toward females (52.2%). This is in line with the findings of the Nigeria National Blindness and Visual Impairment Survey in our general population.  They were also relatively young with a mean age of 34.7 ± 5.9 years. Based on the WHO classification  of visual impairment and blindness, most of the clinic attendees had normal vision (77.2%), and this is similar to what is obtainable in the general population in Nigeria (76.9%).  This is quite good compared with the results of other scholars in London, Hong Kong, and Australia, who found significant visual impairment in 65%, 70%, and75%, respectively. ,,
The prevalence of blindness and eye disorders in our study were 0.4% and 54.6%, respectively. These were similar to what was found in Kenya, 0.4% and 41.3%, respectively.  These could have been higher considering the large number (126) that were excluded because they were too ill to be assessed but likely to harbor more of these ocular disorders.
The predominant eye disorders were refractive error (29.8%), cataract (8.6%), glaucoma (5.9%), and allergic conjunctivitis (5.9%). This pattern is similar to what is obtainable in the general population considering the age distribution (relatively young, so more uncorrected refractive error than cataract).  In Kenya, the common ocular disorders were refractive error (25.8%), cataract (5.6%), and glaucoma (4.8%).  The findings are close to what we found. Uncorrected refractive error was also top on the list in London.  In Chicago, the USA, refractive errors (54.3%) and cataracts (33%) were also top on the list. ,
There was a positive correlation between ocular disorders and duration of treatment [Table 3]. Those who had no ocular abnormalities had the shortest duration of exposure to psychotropics (1.6 years), while the majority of those with abnormalities were on the treatment for more than 2 years. In Kenya, it was observed that most of the side effects developed after 1 year. Hence, it is obvious that the relevance of pretreatment ophthalmic assessment and periodic eye examination while patients are on psychotropics cannot be overemphasized. It is the recommendation of the American Psychiatric Association guidelines (2004) on physical and laboratory assessments for patients with schizophrenia that ocular examination should be conducted every 2 years for patients under 40 years and every year for patients over 40 years. In our opinion, however, after the pretreatment evaluation, these patients should be examined at least annually irrespective of age to facilitate early detection of drug-related ocular abnormalities. ,,, This periodic examination will also provide opportunities for management of other eye diseases in these mentally ill patients who may not have insight and are often stigmatized. More so that they are not immune to other eye diseases found in the general population.
|Table 3: Ocular findings and average duration of treatment with psychotropics |
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The lack of self-inflicted ocular injuries in this study could be attributed to the high level of care and vigilance provided by health workers in the hospital. In addition, the violent patients are usually very ill, sedated, and admitted in the wards. Hence, they did not meet the inclusion criteria for the study.
It was difficult to attribute the ocular findings to a side effect of specific medications because of polypharmacy.
| Conclusion|| |
Most of the patients had good visual acuity. The predominant eye disorders were refractive error/presbyopia, cataract, glaucoma, and allergic conjunctivitis. Psychotropic drugs could be responsible for some of the ocular disorders. There is a need for periodic medical examinations; one before the commencement of psychotropic drugs and at least annually thereafter to aid early detection of ocular side effects of the medications.
It is a cross-sectional study, so it is difficult to attribute the ocular disorders to the side effects of the drugs since there were no baseline ophthalmic assessment and no control group. Second, very ill patients were excluded, and they are likely to harbor many drug-related ocular disorders.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Rajsekar K, Rajsekar YL, Chaturvedi SK. Psycho ophthalmology: The interface between psychiatry and ophthalmology. Indian J Psychiatry 1999;41:186-96.
Abdull MM, Sivasubramaniam S, Murthy GV, Gilbert C, Abubakar T, Ezelum C, et al.
Causes of blindness and visual impairment in Nigeria: The Nigeria national blindness and visual impairment survey. Invest Ophthalmol Vis Sci 2009;50:4114-20.
Foster A, Gilbert C, Johnson G. Changing patterns in global blindness: 1988-2008. Community Eye Health 2008;21:37-9.
Frick KD, Foster A, Bah M, Khan HA, Leibowitz HM, Ganley JP. The magnitude and cost of global blindness: An increasing problem that can be alleviated. Am J Ophthalmol 2003;135:471-6.
Resnikoff S, Gretchen A, Richard AW, Seth RF, Holly P, Jost B. Global data on visual impairment in the year 2002. Bull World Health Organ 2004;82:844-51.
Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ 2008;86:63-70.
International Agency for the Prevention of Blindness. State of the World's Sight. Vision 2020: The Right to Sight 1999-2005. London: IAPB; 2005.
Limburg H, Barria von-Bischhoffshausen F, Gomez P, Silva JC, Foster A. Review of recent surveys on blindness and visual impairment in Latin America. Br J Ophthalmol 2008;92:315-9.
Mariotti SP. New steps toward eliminating blinding trachoma. N Engl J Med 2004;351:2004-7.
Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90:262-7.
World Health Organization. Prevention of Blindness from Diabetes Mellitus. Geneva: WHO; 2006.
Andreoli CM, Miller JW. Anti-vascular endothelial growth factor therapy for ocular neovascular disease. Curr Opin Ophthalmol 2007;18:502-8.
Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents: A review. CNS Drugs 2010;24:501-26.
Hansen TE, Casey DE, Hoffman WF. Neuroleptic intolerance. Schizophr Bull 1997;23:567-82.
Punukollu B, Phelan M. Visual acuity and reported eye problems among psychiatric in-patients. Psychiatr Bull 2006;30:297-9.
Ungvari GS, Tang WK, Wong WK, Chiu HF. Distant visual acuity in chronic psychiatric patients. A pilot study. Soc Psychiatry Psychiatr Epidemiol 2002;37:488-91.
Smith D, Pantelis C, McGrath J, Tangas C, Copolov D. Ocular abnormalities in chronic schizophrenia: Clinical implications. Aust N Z J Psychiatry 1997;31:252-6.
Muinde T, Kimani K, Ilako D, Kathuku D. The prevalence and pattern of ocular disorders among mentally ill patients in Mathari Hospital, Nairobi, Kenya. East Afr J Ophthalmol 2008;14:55-9.
Maino DM, Rado ME, Pizzi WJ. Ocular anomalies of individuals with mental illness and dual diagnosis. J Am Optom Assoc 1996;67:740-8.
Bitrus JD. The prevalence of visual impairment among the mentally ill patients as a vulnerable group in the Gambia. J Community Eye Health 2005;18:130-1.
Oshika T. Ocular adverse effects of neuropsychiatric agents. Incidence and management. Drug Saf 1995;12:256-63.
Rasmussen K, Kirk L, Faurbye A. Deposits in the lens and cornea of the eye during long-term chlorpromazine medication. Acta Psychiatr Scand 1976;53:1-6.
McCarty CA, Wood CA, Fu CL, Livingston PM, Mackersey S, Stanislavsky Y, et al
. Schizophrenia psychotropic medication and cataract. Ophthalmology 1999;4:687.
Webber SK, Domniz Y, Sutton GL, Rogers CM, Lawless MA. Corneal deposition after high-dose chlorpromazine hydrochloride therapy. Cornea 2001;20:217-9.
[Table 1], [Table 2], [Table 3]