Contribution of the Fundus Examination in the Management of General Pathologies in Hospital in Lomé-Togo ()
1. 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, Atherosclerosis Risk in Communities (ARIC) and Blue Mountains study) studied the relationship between the fundus and the occurrence of pathology. Regardless of high blood pressure, there is an association between the presence of fundus abnormalities and the presence of white matter lesions at Magnetic resonance imaging (MRI) [relative risk (RR): 2.1 to 4] [4] .
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
2. Patients and Methods
This was a retrospective and descriptive study conducted in the ophthalmology department of the University Hospital Sylvanus Olympio (CHU-SO) of Lomé from January 2016 to December 2017. We included in the study all patients referred by practitioners hospitals for an examination of the fundus externally or hospitalized in the different services of the said center outside the ophthalmic service. Patients who were excluded came for other results than the examination of the fundus. The realization of the fundus in the hospitalized patients was practiced at bedside on their hospital beds after dilating both eyes with Tropicamide 1%. A drop was administered all 15 minutes for 30 minutes before the practice of the exam. Some who could move were examined in the service as all those who were addressed from the external consultation. Direct or indirect ophthalmoscopy was used for the realization of the exam. This is the portable direct ophthalmoscope for hospitalized patients and the Volk 90D lens for some who have moved into the service. The data are collected from patient records and the consultation register. The variables studied are: socio-demographic data, clinical history, patterns of fundus request, clinical results of fundus examination. Classifications used are Keith and Wagener for hypertensive retinopathy, ALFEDIAM for diabetic retinopathy. All of this collected data was captured and analyzed using the software EPI-Info version 7 and Microsoft Excel 2013. The difference between the variables was appreciated at using the Chi-square test, 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.
3. Results
3.1. 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).
3.2. 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.
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Table 1. Distribution of patients by recruitment method.
3.3. 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%.
3.4. Results of the Fundus Examination
Of the 727 patients included, the fundus was normal in 174 cases or 23.93%, abnormal in 546 cases or 75.11% and inaccessible because of intraocular disorders bilateral in 7 cases, is 0.96%.
In hypertensive patients, the fundus was abnormal in 450 cases or 81.67%, and the hypertensive retinopathy accounted for 442 cases or 80.21%. Stage III of
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Table 2. Patient distribution according to the fundus request pattern.
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Table 3. Distribution of patients by headache and BAV.
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).
Other affections see (Table 5).
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Figure 1. Distribution of hypertensive patients according to the Keith and Wagner classification.
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Figure 2. Distribution of diabetic patients according to the classification of ALFEDIAM.
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Table 4. Repartition of stroke patients according to the classification of Keith and Wagner.
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Table 5. Distribution of other lesions of the posterior pole.
4. Discussion
4.1. 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.
4.2. Clinical Aspects
Ø 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%, Amedome 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. F. Damorou et al. in 2008 in Togo found 7% the association between the two [18] . On the other hand Diallo et al. found a higher frequency of 10.27%. The fundus examination allows the diagnosis and monitoring of hypertensive patients and even to predict certain cerebrovascular complications, hence the interest of a demand systematically by cardiologists.
Ø Headaches and decreased visual acuity
Headache is one of the most common reasons for consultation in ophthalmology [19] [20] . The headaches associated with the AVB come in second position after HTA as a fundus request pattern representing 8.25% in our study. D. Kaimbo WA Kaimbo et al. in 2003 found a higher frequency of 15.6% [21] ; at Ramatoulaye Kane et al. in 2017, the decrease in visual acuity was the main reason for consultation Ophthalmology (55.9%) followed by headache (23.1%) [22] . This lower frequency could be explained by the fact that we only included those who come for examination from the fundus. The posterior pole lesions observed at the fundus were mainly suspicion of glaucomatous optic neuropathy in 58.33%, followed by retinopathy hypertensive in 6.67% and other lesions (age-related macular degeneration, retinitis pigmentary) in 16.67%. The same author had found a papillary pallor in 21%, followed vascular alterations related to hypertension in 16% and other lesions (degeneration macular, retinitis pigmentosa) in 13%.
Ø Diabetes
Diabetic retinopathy (DR) is a manifestation of microangiopathy occurring beyond 10 to 20 years of evolution of the diabetic disease. It is an important cause of low vision and the leading cause of blindness in people under 60 in countries industrialized countries [23] [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 makes it possible to identify the different signs of the Diabetic retinopathy. 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] .
5. 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.
Contributions of the authors
All authors state that they have read and approved the final version of the manuscript.