A partnership model for capacity-building of primary care physicians in evidence-based management of diabetic retinopathy in India

In India, more than 72 million people have diabetes. Diabetic retinopathy (DR), a vision-threatening complication of people with diabetes, is an important cause of avoidable blindness. The delay in the detection of DR is due to lack of awareness and shortage of ophthalmologists trained in the management of DR. With this background, in 2015, we initiated a capacity-building program “Certificate Course in Evidence Based Management of Diabetic Retinopathy (CCDR)” with an objective to build the skills and core competencies of the physicians across India in the management of diabetes and DR. The program has completed four cycles and 578 physicians have been trained. The course elicited an excellent response, which reflects the much-felt need for skill improvement in DR diagnosis and management for physicians in India. This model demonstrates an innovative modality to address DR-related avoidable blindness in a resource-restraint country like India.

Prospective study of factors influencing timely versus delayed presentation of preterm babies for retinopathy of prematurity screening at a tertiary eye hospital in India - The Indian Twin Cities ROP Screening (ITCROPS) data base report number 6

Purpose: To evaluate the factors influencing timely versus delayed presentation of preterm babies for ROP evaluation. Methods: Preterm babies (?35 weeks gestational age, ?2000 g birth weight) were prospectively included in the study. Timely presentation was defined as babies who presented for the first ROP screening within 30 days of birth and Delayed as more than 30 days of birth. An event survey to assess factors influencing timely vs delayed presentation was administered to parents/guardian of babies after obtaining informed consent. Results: Data of 278 preterm babies (n = 139 timely vs n = 139 delayed presentation) collected in the event surveys were analyzed. The delayed presenters came at a median duration of 6.3 weeks (1st and 3rd quartiles: 5.3 and 9.1) after birth. The odds of any stage of ROP was 2.6 times and the odds of sight threatening ROP was 6.8 times in those presenting delayed compared to those presenting timely. Major Reasons for delayed presentation were not asked to do so/no referral from pediatrician in 64 (46%) participants and unaware of the importance by 46 (33%) participants. Conclusion: Deviation from screening protocol is an important modifiable risk factor in ROP screening. The study findings suggest the need for creating awareness about timely screening and referral guidelines among the pediatricians involved in “care” of preterm infants at risk of developing ROP.

Changing patterns of early childhood blinding conditions presenting to a tertiary eye center: The epidemic of retinopathy of prematurity in India

Purpose: Retinopathy of prematurity (ROP) is now emerging as one of the major causes of preventable childhood blindness. The proportion of preterm babies has increased dramatically over the past decade. Our study aims to emphasize the need for ROP screening and management services in these preterm infants. Methods: ICD-coded medical records of children less than 10 years of age presenting to a subspecialty eye hospital from 2000 to 2017 were reviewed. ROP, congenital cataract, congenital glaucoma, and vitamin A deficiency were the most common diagnoses. We evaluated the trend of these diseases from 2000 to 2017. Results: Our data suggested a 20-fold increase in the attendance of children with a diagnosis of ROP who now make over 2% of outpatient children. Vitamin A deficiency has declined over time whereas cataract and glaucoma have remained stable. Conclusion: Our data indicate a need to scale up ROP screening integrated with neonatal care, as well as to build capacity for the treatment of acute and late-stage ROP in India.

Community care for diabetic retinopathy and glaucoma in India: A panel discussion

Diabetic retinopathy (DR) and glaucoma are emerging causes of blindness and visual impairment in India and the world. Both diseases do not have any early warning symptoms, and once the symptoms appear, the diseases are reasonably advanced. Because of the long-standing nature of the diseases, one cannot adopt the cataract detection and treatment model so successfully developed in India. It requires an altogether different approach for screening and related infrastructure including human capital development. The solutions developed to reduce the burden of DR/glaucoma should be customized to urban, semi-urban, and rural areas. Greater advocacy, improving the health-seeking behavior, development of infrastructure and skilled personnel appropriate for the points of care, and an emphasis in comprehensive eye care are some of the solutions.

Management of Candida glabrata infectious crystalline keratopathy with endophthalmitis following penetrating keratoplasty

A 33-year-old male underwent an optical keratoplasty elsewhere in the right eye following which he developed endophthalmitis and subsequently underwent a pars plana vitrectomy and lensectomy. At presentation, he had a deep stromal crystalline infiltration along the graft–host junction. A large therapeutic keratoplasty was performed, and the excised corneal button was evaluated. Histopathology revealed gram-positive round-to-oval budding structures and microbiology identified the organism as Candida glabrata. He was treated with antifungals in the postoperative period. At 4 months after therapeutic keratoplasty, the patient developed recurrent endophthalmitis, following stoppage of antifungals. The treatment was reinstituted for another year, and the patient did well with a clear graft at 18-month-follow-up period after the recurrence episode. Management of infectious crystalline keratopathy with endophthalmitis is a challenging situation and requires long-term treatment.

Analysis of yield of retinal imaging in a rural diabetes eye care model

Purpose: The aim of this study is to analyze the yield of retinal images obtained in a rural diabetes eye care model. Methods: An analysis of a sample of nonmydriatic fundus photography (NMFP) of posterior segment ophthalmic images, obtained by an indigenous equipment (3 nethra-Forus Royal), was done in a district-wide rural diabetic retinopathy (DR) screening program; a trained optometrist did the initial image grading. DR and diabetic macular edema (DME) were classified based on international DR and DME severity scale. The agreement between the optometrist and retina specialist was very good (? = 0.932; standard error = 0.030; 95% confidence interval = 0.874�991). Results: Posterior segment images of 2000 eyes of 1000 people with diabetes mellitus (DM) were graded. The mean age of the participants was 55.7 � 11.5 standard deviation years. Nearly 42% of the screened participants (n = 420/1000) needed referral. The most common referable posterior segment abnormality was DR (8.2%). The proportion of people with any form of DR was seen in 110/1225 eyes, and sight-threatening DR was seen in 35/1225 eyes. About 62% of posterior segment images were gradable. The reasons for ungradable posterior segment images (34%) were small pupil, unfocused/partially available field of images, and cataract. Conclusion: A NMFP model was able to detect referable posterior segment abnormalities in a rural diabetes eye care program. Reasons found for ungradability of images in the present study can be addressed while designing future DR screening programs in the rural areas.