Contribution of the Fundus Examination in the Management of General Pathologies in Hospital in Lomé-Togo

Many general conditions have an impact on the fundus. The purpose of our work was to study the epidemiological profile of patients referred to our service for a review of the fundus and analyze the results. It was a retrospective study description of the examinations of the fundus during the period from January 2016 to December 2017. In the ophthalmology department of the Lomé University Hospital Center, during the study period, 1019 consultations were recorded, of which 727 were for fundus 6.84%. There were 336 men and 391 women, a sex ratio of 0.85. The age group 40 - 69 years accounted for 61.9%. The frequency of the main reasons for the request was hypertension 54.2% (N = 394); hypertension complicated or associated with other conditions (CKI, CKD, pregnancy and diabetes) accounted for 21.6% (N = 157), headache associated with a decrease in visual acuity 8.25% (N = 60), diabetes 6.46% (N = 47) and sickle cell disease 0.69% (N = 5). Hospitalized patients 52.41% (N = 381). The fundus was abnormal in 546 patients or 75.11%. Hypertensive retinopathy was found 80.21% cases in hypertensive patients, diabetic retinopathy 43.42 in diabetic patients. Diabetics Fundus examination in hospital practice found a retinal lesion in three-quarters of cases. It so important to ask the examination of the fundus most often in the current pactise.


Introduction
Ophthalmological involvement is common in many general conditions with resounding on the fundus. The main pathologies are related to an attack inflammatory or vascular system including arterial hypertension, diabetes and other conditions systemic inflammatory. Their care goes through a diagnosis and the assessment of ocular repercussions because of the risk of blindness that they can represent [1]. Screening with a fundus of diabetic retinopathy found its prevalence in Africa is 47.8% in Maseru in Lesotho, 45.1% in Ilorin Nigeria, and 34% in Lusaka Zambia [2]. This retinopathy is 39.2% associated with nephropathy according to Lokrou et al. [3]. Different teams (Beaver Dam Study, Atheroscle- It has been shown that fundus involvement can be used as an indicator of target organ damage such as kidney, central nervous system and eye [5]. A study also showed that the risk for a patient to have a stroke at 3 years was 4% in the presence of white matter lesions on MRI (RR: 2.6) and 18% (RR: 18.1) when specific retinal abnormalities were associated with hemorrhages deep rounds [4]. Clinical examination and specialized imaging techniques are often necessary in the detection of retinal lesions. However the most simple is the use of the direct ophthalmoscope. This is an atraumatic examination, although supported by the patient, achievable both in the ophthalmology department and at the bedside hospitalized patient. Performing a complete retinal examination requires a pupil completely dilated. Pupillary dilation can be obtained by various agents including Tropicamide 1%, Phenylephrine 2.5%, and Cyclopentolate 1%. Generally, it is not necessary to use pharmacological agents of action prolonged [6].
The purpose of our work is to study the epidemiological profile of patients referred in our service for a review of the fundus and analyze the results

Patients and Methods
This was a retrospective and descriptive study conducted in the ophthalmology  with a threshold of significance set at 0.05. The limit of the study was essentially the fact that it did not take into account the others hospital centers.

Epidemiological Data
Of the 1019 patients consulted during study period 727 were referred for review fundus is a frequency of 6.84%. Inpatients accounted for 381 cases, or 52.41%.
Whose majority were hospitalized in cardiology 178 cases or 24.48%. Patients referred from the consultation 346 cases or 47.59% (Table 1).

Age and Sex
The mean age was 48 years (SD = 16.42) with extremes ranging from 1 year to 90 years. The age group 40 -69 years was the most represented with 450 cases or 61.9%. There were 336 men and 391 women is a sex ratio of 0.85.

Reasons for Requesting the Examination
First reason: pure hypertension (HTA) 394 cases or 54.20%, complicated hypertension or associated with other general conditions (stroke, insufficiency) chronic renal disease (CKD), pregnancy and diabetes) accounted for 157 cases, or 21.6% ( Table 2). The headache associated with a decrease in visual acuity 60 cases, is 8.25% (Table 3); diabetes 47 cases 6.46%.

Results of the Fundus Examination
Of the 727 patients included, the fundus was normal in 174 cases or 23  Keith and Wagener was the most common with 146 cases or 26.50% (Figure 1).
In diabetic patients the fundus was abnormal in 55 cases, is 72.36%. A diabetic retinopathy was present in 33 cases 43.42%. Diabetic retinopathy not Proliferation was predominant with 23 cases, is 30.26% (Figure 2). Stage II hypertensive retinopathy was predominant in 38.10% of patients with patients with stroke according to the Keith and Wagner classification (Table 4).

Epidemiological Aspects
In our study the fundus examination accounted for 6.84%, which is lower than the Diallo et al. In Burkina in 2015 which was 7.37% [7]. This could be explained by the fact that our study was conducted in a hospital setting. The average age of our patients was 48 years with an age range of 40 -69 years which is superior to the results of the same author who found an average age of 42 years with an age range of 40 -59 years. Women was the most represented in our study 53.78% however the same study noted a male predominance. This could be explained by the recruitment of patients from the gynecology. The main indications of the request for a fundus examination were the balance sheets of resonance of high blood pressure, headaches associated with lowering of acuity visual, diabetes.

 Hypertension
High blood pressure (hypertension) is one of the major risk factors for mortality and cardiovascular morbidity in the world [8] [9] [10]. It is a cardiovascular risk factor major cause of stroke, kidney failure and stroke [5]. Mortality during pregnancy is the leading cause of death in the world [11] [12]. In Togo, a prevalence of 36.7% is reported in Lomé [13]. In our HTA study accounted for 54.20% of fundus requests, this frequency was significantly higher to that found by Diallo et al. in 2015 which 43.15% [7]. Hypertensive retinopathy was found in 80.21% of our study of which 20.63% of hypertensive retinopathies were stage III; this same observation was made in the thesis of Yaméogo et al. in a hospital Bobo Dioulasso who found a higher frequency of 65.3% of cases of retinopathy stage III hypertensive in the same classification [14]. We can see that hospitalized patients had more advanced retinopathies may be related to the decompensation of the disease. Achievement of the fundus can be used as an indicator of organ involvement target such as kidney, central nervous system and eye [5].
Wong et al reported that hypertensive retinopathy is an indicator of risk of morbidity and mortality systemic [15]. Hypertensive patients complicated with stroke accounted for 2.89% in our study. Stage II accounted for 38.10%, Ame-Open Journal of Internal Medicine dome et al. 2016 also found a lower frequency in 32.4% at the same stage [16].
In our study the preeclampsia-eclampsia prevalence was 14.03%; 75.49% of pre-eclamptic and 24.51% of eclamptics. Ngwanou et al. in Cameroon in 2015 hadfound a pre-eclamptic and eclamptic prevalence of 7.08% with 62.8% pre-eclamptic and 37.2% eclamptic [17]. The fundus summer pathological in women pregnant in 79.41% in our study against the same author found a frequency less than 48.8%.
Hypertension associated with diabetes was found in 4% of cases in our study.  [24]. In Africa, several studies have been conducted to evaluate the frequency and to analyze the characteristics of diabetic retinopathy [25] [26]. In Togo Balo et al. in 1995 reported a prevalence of 52% [27]. In Burkina Faso studies in hospitals in Ouagadougou Sawadogo reports a frequency lower than our RD of 37.5% and Medica 43.1% [28] [29]. The latter was similar to 43.42%. This could be explained that hospitalized patients would have unbalanced diabetes and poorly monitored diabetes. Diallo et al. Burkina Faso found a lower rate of 25.92% [7]. Non-proliferative retinopathy was 30.26% in our study; however, the same author had found 24.53% of non-proliferative diabetic retinopathy. The diagnosis of diabetic retinopathy is based on a biomicroscopy examination of the fundus after pupillary dilatation. This examination Complications of RD are causes of blindness and low vision. They can be avoided by early management of RD, annual fundus monitoring in diabetic patients [30] [31].

Conclusion
The hospital demand for a fundus examination represents a considerable activity on the total of ophthalmic consultations which is 6.84%. Its realization helps to assert some diagnoses to other cerebrovascular complications. Retinal lesions are more severe in hospitalized patients. In our work setting, hypertension blood pressure, headaches associated with decreased visual acuity, and diabetes were the main reasons for application. All hospital practitioners must request an examination of the fundus of the at-risk population in order to improve the quality of the patient load.