Changing trends in the prevalence of visual impairment, uncorrected refractive errors and use of spectacles in Mahbubnagar district in South India.

Background/Aim: The Andhra Pradesh Eye disease Study (APEDS) was a conventional cross‑sectional study conducted in four locations during 1996‑2000. Ten years later, a Rapid Assessment of Refractive Errors (RARE) survey was conducted in one of the geographical regions. The prevalence of visual impairment (VI), uncorrected refractive error (URE), spectacles use obtained from both the surveys was compared. Settings and Design: Rural settings; cross‑sectional studies. Materials and Methods: In both the surveys, distance visual acuity (VA) was assessed using a logMAR chart. Pinhole VA was assessed if presenting VA was <20/20 in APEDS and <20/40 in RARE. VI was defined as presenting VA <20/40 in the better eye. URE was defined as presenting VA <20/40 and improving to ≥20/40 with a pinhole. Statistical Analysis Used: Performed using Statistical Package for Social Sciences (SPSS). Chi square tests and t‑test were used. Results and Conclusions: The results from a RARE survey with 3,095 subjects were compared with an APEDS dataset that had 1,232 subjects in the same age group of 15-49 years. The prevalence of VI has decreased from 9.5% (95% CI, 7.7-11.1) in APEDS to 2.7% (95% CI, 2.1-3.3) in RARE. Similarly, the prevalence of URE in the better eye decreased from 5.8% (95% CI, 4.5-7.1) to 2.3% (95% CI, 1.8- 2.8). The usage of spectacles increased from 6.6% (95% CI, 5.2-8.0) to 9.7% (95% CI, 8.7-10.7). There is a decreasing trend in the prevalence of VI and URE in Mahbubnagar district in Andhra Pradesh over a decade.

Changing trends in the prevalence of blindness and visual impairment in a rural district of India: Systematic observations over a decade.

Context: Globally, limited data are available on changing trends of blindness from a single region. Aims: To report the changing trends in the prevalence of blindness, visual impairment (VI), and visual outcomes of cataract surgery in a rural district of Andhra Pradesh, India, over period of one decade. Settings and Design: Rural setting; cross-sectional study. Materials and Methods: Using a validated Rapid Assessment of Cataract Surgical Services (RACSS) method, population-based, cross-sectional survey was done in a rural district in the state of Andhra Pradesh, India. Two-stage sampling procedure was used to select participants ≥50 years of age. Further, a comparative analysis was done with participants ≥50 years from the previously concluded Andhra Pradesh Eye Disease Study (APEDS) study, who belonged to the same district. Statistical Analysis: Done using 11th version of Stata. Results: Using RACSS, 2160/2300 (93.9%) participants were examined as compared with the APEDS dataset (n=521). Age and sex adjusted prevalence of blindness in RACSS and APEDS was 8% (95% CI, 6.9–9.1%) and 11% (95% CI, 8.3–13.7%), while that of VI was 13.6% (95% CI, 12.2–15.1%) and 40.3% (95% CI, 36.1–44.5%), respectively. Cataract was the major cause of blindness in both the studies. There was a significant reduction in blindness following cataract surgery as observed through RACSS (17.3%; 95% CI, 13.5–21.8%) compared with APEDS (34%; 95% CI, 20.9–49.3%). Conclusion: There was a significant reduction in prevalence of blindness and VI in this rural district of India over a decade.

Key factors determining success of primary eye care through vision centres in rural India: Patients’ perspectives.

Aim: This paper intends to discuss the patients’ perspective on the determinants of primary eye care services from vision centers (VC) in rural India. Materials and Methods: A retrospective study design and interview method was used on 127 randomly selected patients who accessed the 4 VCs in 2007. Factor analyses and linear regression models were used to predict the associations with patient satisfaction. Results: The three factors derived from factor analyses were: (1)-vision technician (VT), (2)-location of VC, and (3)-access to VC; explaining 60% of the variance in total patients’ satisfaction with VC. The first model (R2: 0.61; F1,124=144.36, P<0.001), indicated that respondents who had ‘difficulty to travel to the place of VC’ and those who can afford to pay had less satisfaction with VT services. The second model (R2=0.18; F1,124=29.5, P<0.001) explained that respondents’ difficulty to identify the building of VC had decreased patients’ satisfaction and the third model (R2=0.36; F1,124=45.6, P<0.001) indicated that those who had to travel<5 km to the VC and had 0.38 units of increased satisfaction level with the services of VC. Conclusion: A good VT can enhance patient satisfaction. However, patient expectations are not only confined to the provider but also other factors such as ability to pay and convenient transportation that helps patients reach the location of the VC with ease.

Rapid assessment methods in eye care: An overview.

Reliable information is required for the planning and management of eye care services. While classical research methods provide reliable estimates, they are prohibitively expensive and resource intensive. Rapid assessment (RA) methods are indispensable tools in situations where data are needed quickly and where time- or cost-related factors prohibit the use of classical epidemiological surveys. These methods have been developed and field tested, and can be applied across almost the entire gamut of health care. The 1990s witnessed the emergence of RA methods in eye care for cataract, onchocerciasis, and trachoma and, more recently, the main causes of avoidable blindness and visual impairment. The important features of RA methods include the use of local resources, simplified sampling methodology, and a simple examination protocol/data collection method that can be performed by locally available personnel. The analysis is quick and easy to interpret. The entire process is inexpensive, so the survey may be repeated once every 5–10 years to assess the changing trends in disease burden. RA survey methods are typically linked with an intervention. This article provides an overview of the RA methods commonly used in eye care, and emphasizes the selection of appropriate methods based on the local need and context.

Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience.

Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.

Comparison of patient satisfaction with services of Vision Centers in rural areas of Andhra Pradesh, India.

Aim: To compare the satisfaction of patients with the services of Vision Center services (primary eye care) in large village (s) and small village (s) in rural settings in Andhra Pradesh state, India. Materials and Methods: We have administered standard questionnaires to randomly selected patients to assess patient satisfaction when assessing Vision Center Services. We used the Chi-square (P <0.05) to explore differences in satisfaction of patients with Vision Center services located in the large village (s) and small village (s) rural settings. Results: Vision Center patients at the large village (s) expressed higher levels of satisfaction (median 78%) than patients treated at the Vision Center at small village (s) (median 69%). The difference was statistically significant (Chi square P value ranging from <0.001 to 0.03) for all the items except two – ‘easy to identify vision center location’ and ‘spectacles dispensing time’ as compared to other (privately run optometry) facilities (Chi square P value=0.498 and 0.993 respectively). The location of the Vision Center, convenience of journey, ophthalmic technician’s behavior with patients, are some of the most important factors that determined the patient perception about Vision Center services. Conclusion: The overall satisfaction levels of the Vision Center experience at 78% and 69% were good. However, continual improvement is to be made in service time, staff performance, cost and quality of vision care, especially at more remote primary eye Care Centers.

Review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis: Experience of over a decade.

Purpose: To review the epidemiological characteristics, microbiological profile, and treatment outcome of patients with suspected microbial keratitis. Materials and Methods: Retrospective analysis of a non-comparative series from the database was done. All the patients presenting with corneal stromal infiltrate underwent standard microbiologic evaluation of their corneal scrapings, and smear and culture-guided antimicrobial therapy. Results: Out of 5897 suspected cases of microbial keratitis 3563 (60.4%) were culture-proven (bacterial – 1849, 51.9%; fungal – 1360, 38.2%; Acanthamoeba – 86, 2.4%; mixed – 268, 7.5%). Patients with agriculture-based activities were at 1.33 times (CI 1.16–1.51) greater risk of developing microbial keratitis and patients with ocular trauma were 5.33 times (CI 6.41–6.44) more likely to develop microbial keratitis. Potassium hydroxide with calcofluor white was most sensitive for detecting fungi (90.6%) and Acanthamoeba (84.0%) in corneal scrapings, however, Gram stain had a low sensitivity of 56.6% in detection of bacteria. Majority of the bacterial infections were caused by Staphylococcus epidermidis (42.3%) and Fusarium species (36.6%) was the leading cause of fungal infections. A significantly larger number of patients (691/1360, 50.8%) with fungal keratitis required surgical intervention compared to bacterial (799/1849, 43.2%) and Acanthamoeba (15/86, 17.4%) keratitis. Corneal healed scar was achieved in 75.5%, 64.8%, and 90.0% of patients with bacterial, fungal, and Acanthamoeba keratitis respectively. Conclusions: While diagnostic and treatment modalities are well in place the final outcome is suboptimal in fungal keratitis. With more effective treatment available for bacterial and Acanthamoeba keratitis, the treatment of fungal keratitis is truly a challenge.

Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India.

PURPOSE: To understand the reasons why people in rural south India with visual impairment arising from various ocular diseases do not seek eye care. MATERIALS AND METHODS: A total of 5,573 persons above the age of 15 were interviewed and examined in the South Indian state of Andhra Pradesh covering the districts of Adilabad, West Godavari and Mahaboobnagar. A pre-tested structured questionnaire on barriers to eye care was administered by trained field investigators. RESULTS: Of the eligible subjects, 1234 (22.1%, N=5573)) presented with distant visual acuity < 20/60 or equivalent visual field loss in the better eye. Of these, 898 (72.7%, N=1234) subjects had not sought treatment despite noticing a decrease in vision citing personal, economic and social reasons. The analysis also showed that the odds of seeking treatment was significantly higher for literates [odds ratio (OR) 1.91, 95% confidence interval (CI) 1.38 to 2.65], for those who would be defined as blind by visual acuity category (OR 1.35, 95% CI 0.96 to 1.90) and for those with cataract and other causes of visual impairment (OR 1.50, 95% CI 1.11 to 2.03). Barriers to seeking treatment among those who had not sought treatment despite noticing a decrease in vision over the past five years were personal in 52% of the respondents, economic in 37% and social in 21%. CONCLUSION: Routine planning for eye care services in rural areas of India must address the barriers to eye care perceived by communities to increase the utilization of services.

Clinical outcome of autologous cultivated limbal epithelium transplantation.

PURPOSE: To report the clinical outcome of autologous cultivated limbal epithelial transplantation. METHODS: Eighty-six patients' records and their clinical photographs were reviewed for demographics, primary etiology, type of limbal transplantation, ocular surface stability, visual acuity, final outcome and possible factors affecting outcome and complications. RESULTS: Eighty-eight eyes of 86 patients with limbal stem cell deficiency (LSCD) underwent autologous cultivated limbal epithelium transplantation between March 2001 and May 2003, with a mean follow-up of 18.3 months. The etiology of LSCD was alkali burns in 64% patients. Sixty-one eyes had total LSCD. Thirty-two of the 88 eyes had undergone amniotic membrane transplantation and 10 eyes had previously undergone limbal transplantation with unfavorable outcome. Nineteen eyes underwent penetrating keratoplasty, of which 11 grafts survived at the final follow-up. Finally, 57 eyes (73.1%, 95% CI: 63.3-82.9) had a successful outcome with a stable ocular surface without conjunctivalization, 21 eyes (26.9%, 95%CI: 17.1-36.7) were considered failures and 10 patients were lost to follow-up. CONCLUSION: LSCD can be successfully treated by autologous cultivated limbal epithelium transplantation in majority of the cases.

Awareness of glaucoma in the rural population of Southern India.

PURPOSE: To explore the awareness of glaucoma amongst the rural population of Andhra Pradesh, India. MATERIALS AND METHODS: A total of 7775 subjects of all ages, representative of the rural population of Andhra Pradesh, participated in the Andhra Pradesh Eye Disease Study. The responses of subjects older than 15 years (n=5573) who completed a structured questionnaire regarding awareness (heard of glaucoma) and knowledge (understanding of disease) of glaucoma formed the basis of this study. RESULTS: Awareness of glaucoma (n=18; 0.32%) was very poor in this rural population, and females were significantly less aware (p=0.007). Awareness of glaucoma was also significantly less among illiterate persons (p<0.0001), and socially backward population (p<0.0001). Majority of the respondents who were aware of glaucoma (n=10; 55.6%) did not know if visual loss due to glaucoma was permanent or reversible. The major source of awareness of glaucoma in this population was TV/magazines and other media followed by information from a relative or acquaintance suffering from the disease. CONCLUSION: Awareness of glaucoma is very poor in the rural areas of southern India. The data suggest the need for community-based health education programmes to increase the level of awareness and knowledge about glaucoma.

Early results of penetrating keratoplasty following limbal stem cell transplantation.

PURPOSE: To describe the early results of penetrating keratoplasty (PKP) in patients who had earlier received limbal transplantation (LT). METHODS: Prospective, non-comparative interventional case series comprising of four patients with limbal stem cell deficiency (LSCD) due to chemical injury (Cases 1, 2, 4) and xeroderma pigmentosum (Case 3). Cadaveric kerato-limbal allografts or living-related conjunctival-limbal allografts were done in four eyes followed by PKP for visual rehabilitation 3-4.5 months later. The following details were noted: demographics, primary aetiology, type of limbal transplant (cadaveric or living-related), immunosuppression, vision and ocular surface stability before and after LT and PKP, surgical complications and outcome of PKP. RESULTS: Three eyes received living-related conjunctival-limbal allotransplantation and one received cadaveric kerato-limbal allograft. Duration of follow up after PKP ranged from 4 to 11 months. Visual acuity improved in the early postoperative period in all patients but reduced in 2 due to endothelial rejection and after trans-scleral cyclophotocoagulation for medically uncontrolled glaucoma. The ocular surface remained stable in all patients. All patients were started on immunosuppression on the first postoperative day. This was continued till the last follow-up visit. Post-PKP complications were punctate epithelial keratopathy, corneal allograft rejection and secondary glaucoma (one patient each). CONCLUSION: Satisfactory visual rehabilitation is possible after PKP following LT without compromising ocular surface stability. However, a prolonged and close follow-up is warranted to avert complications.

Amniotic membrane transplantation for reconstruction of corneal epithelial surface in cases of partial limbal stem cell deficiency.

PURPOSE: To assess the efficacy of amniotic membrane for treatment of partial limbal stem cell deficiency (LSCD). METHODS: Medical records of four patients with partial LSCD who underwent pannus resection and amniotic membrane transplantation (AMT) were reviewed for ocular surface stability and improvement in visual acuity. Clinico-histopathological correlation was done with the resected pannus tissue. RESULTS: All the eyes exhibited stable corneal epithelial surface by an average of 7 weeks postoperatively with improvement in subjective symptoms. Best corrected visual acuity improved from preoperative (range: 6/9p-6/120) to postoperative (range: 6/6p-6/15) by an average of 4.5 lines on Snellen visual acuity charts. Histopathological examination of excised tissue showed features of conjunctivalisation. CONCLUSION: Amniotic membrane transplantation appears to be an effective means of reconstructing the corneal epithelial surface and for visual rehabilitation of patients with partial limbal stem cell deficiency. It may be considered as an alternative primary procedure to limbal transplantation in these cases.

Clinical resistance of Staphylococcus keratitis to ciprofloxacin monotherapy.

PURPOSE: To review the in vitro susceptibility and the clinical response to 0.3% ciprofloxacin in Staphylococcus aureus keratitis. METHODS: This is a non-comparative case series derived from a prospectively collected database and analysed retrospectively. One hundred and twenty one patients presenting in the cornea service of LV Prasad Eye Institute, Hyderabad, India, between January 1993 and December 2000, and identified to have S. aureus keratitis were included in the study. All patients had received slitlamp evaluation of the cornea and diagnostic microbiologic workup. They were treated with topical antimicrobial therapy based on smear and culture results. All S. aureus isolates were tested for antibiotic susceptibility by disk diffusion and those resistant to ciprofloxacin were confirmed by testing for minimum inhibitory concentration. The patients' clinical response to the antimicrobial therapy was noted. RESULTS: Twenty-five (20.6%) of 121 isolates resistant to ciprofloxacin on in vitro susceptibility testing were further analysed in this study. Fifteen of these 25 (60%) patients were initially treated with topical ciprofloxacin. Twelve of 15 (80%) patients showed no clinical improvement (3-8 days). Based on antibiotic susceptibility results, the antibiotic therapy was modified to fortified cefazolin and gentamicin in seven (58.3%), to vancomycin in one and to chloramphenicol in four cases. The corneal infiltrate resolved in 11 (73.3%) of 15 cases. Two patients required penetrating keratoplasty (PK), one required evisceration, and one patient was lost to follow up. Nine of 25 patients were initially started on fortified cefazolin and gentamicin therapy based on smear positive for gram-positive cocci; this resulted in resolution of infiltrate in 44.4% (4/9) while three required change of antibiotics (vancomycin-2, chloramphenicol-1), one required PK and one patient was lost to follow up. One of 25 patients started and continued on chloramphenicol, showed no response and required PK. CONCLUSIONS: This study shows a significant resistance of S. aureus to many antibiotics including ciprofloxacin and highlights the need for an alternative to ciprofloxacin monotherapy for the treatment of staphylococcal keratitis.

Awareness of eye donation in the rural population of India.

PURPOSE: To determine the "awareness of eye donation" and "willingness to pledge eyes for donation" in the rural population of Andhra Pradesh, southern India. METHODS: A total of 7,775 subjects of all ages, representative of the rural population of Andhra Pradesh, participated in the Andhra Pradesh Eye Disease Study (APEDS). Subjects older than 15 years were interviewed regarding awareness of eye donation and willingness to pledge eyes for donation. RESULTS: Age-gender adjusted prevalence of awareness of eye donation in this population was 30.7% (95% CI: 29.5-31.9) but only 0.1% (age-gender adjusted prevalence) (95% CI: 0.05-0.25) had pledged eyes. On multivariate analysis the awareness of eye donation was significantly less in those subjects > or = 70 years old (OR 0.7; 95% CI: 0.6-0.8), illiterates (OR 0.2; 95% CI: 0.1-0.2), females (OR 0.8; 95% CI: 0.7-0.9), lower socioeconomic status group (OR 0.4; 95% CI: 0.4-0.5) and Christians (OR 0.2; 95% CI: 0.1-0.6). Media comprised the major source of information about eye donation. Of those aware of eye donation, 32.9% were willing to pledge eyes, and 50.6% needed more information to decide whether or not to pledge their eyes. CONCLUSIONS: There needs to be more transfer of knowledge if more eyes are to be pledged. One-third of those aware of eye donation have not pledged their eyes, and an additional 50.6% needed more information to decide. This means only about one-fifth of those aware of eye donations have pledged their eyes.

Ophthalmic complications and management of Stevens-Johnson syndrome at a tertiary eye care centre in south India.

PURPOSE: To review the possible aetiological factors, ocular complications and their management in patients of Stevens-Johnson syndrome with ocular involvement, seen at a tertiary eye care centre. METHODS: We retrospectively reviewed the medical records of patients with Stevens-Johnson syndrome seen between 1987-1998 at L V Prasad Eye Institute. The demographic and possible aetiological factors data causing Stevens-Johnson syndrome were collected. The details of the ocular examination and treatment were collected and examined to determine the pattern of presentation, complications, treatment response and outcome. RESULTS: A total of 95 patients, 40 males (42.10%) and 55 females (57.89%), were identified during the 11-year period. A majority of the patients (n = 53; 55.78%) were between 20 and 40 years of age. All patients had bilateral involvement and most (n = 93; 97.89%) had bilateral symmetrical presentation. The duration from the onset of symptoms to the time of presentation at the institute varied from 6 days to 18 years with most patients presenting after one year (n = 39; 41.05%). The most commonly identified possible causative factor was drugs (n = 55; 51.89%). No definitive cause was identified in 37 (38.94%) patients, and 3 (3.15%) patients had a history of viral fever preceding the onset of Stevens-Johnson syndrome. The best corrected visual acuity at initial presentation was 6/12 or better in 32 (33.68%) patients. Lid abnormalities were observed in 87 (91.51%) patients, conjunctival abnormalities in 92 (96.84%) and corneal complications in 93 (97.89%). All patients were managed medically and 26 (27.36%) patients underwent surgery. CONCLUSION: Stevens-Johnson syndrome remains an important cause of severe visual loss and ocular morbidity, both of which significantly affect the quality of life. Not many medical or surgical options are available even in tertiary eye-care centres. Future advances in immune modulation techniques may prevent many of the sequelae that continue to occur despite the best possible medical care.