Prevalence of Diabetes and Diabetic Retinopathy in Far-western Province of Nepal.

BACKGROUND: Although diabetes is emerging as growing public health problem, there is limited population based data about the prevalence of the disease in Nepal. METHODS: This cross-sectional population-based survey, conducted in the Far-western province of Nepal from April 2020 to April 2021, used standardized RAAB + DR methodology. Diabetes was diagnosed on the basis of treatment history and random blood sugar test results of greater than 200 mg/dl. Diabetic retinopathy screening was done by ophthalmologists. All relevant data were imported into the RAAB software package (RAAB V.6) for analysis. RESULTS: Among 4615 study population, 2.8 % (n=129) had diabetes, and 35.7% (n=46) of the diabetics were newly identified cases. Of the known diabetics, 61.4% (n=51) never had an eye examination, and only 27.7% (n=23) of cases had their eye checked for DR in the last year. Fundus examination showed 13.2 % (n=17) of the diabetic patients to have some form of diabetic retinopathy and 6.2% (n=8) had diabetic maculopathy. Only 0.8% (n=1) of the cases were categorized as sight-threatening DR but a greater number of diabetes patients had severe visual impairment or blindness (3.9%) as compared to non-diabetic patients (1.8%). CONCLUSIONS: Prevalence of diabetes and DR were relatively lower in Far-western Nepal. However poor coverage of screening examinations have left many of these cases undetected in the communities. Effective community-based diabetes and DR screening and referral programs can help to detect and treat diabetes and DR early on to prevent vision loss and other diabetic complications.

High Velocity Sharp Metal Piece Penetrating the Larynx and Impacted in Oesophagus: A Rare Case Report.

High speed metal foreign body (FB) caused penetrating injury, with midline fracture of the thyroid cartilage, to the larynx and got impacted in the oesophagus, later passed down to stomach. The larynx was repaired and FB was retrieved with gastrotomy under general anaesthesia. The patient was kept on total parental nutrition for 7 days and discharged on post-operative day 14.

A Prospective Observational Study to Determine the Added Clinical Value of Videokymography to Videostroboscopy in Patients with Change in Voice.

Videolaryngostroboscopy (VLS) is considered gold standard method for assessing voice disorders. But patients with irregular waveform of vocal folds cannot benefit from the VLS. Videokymography [VKG] is a single line real time, high speed imaging technique. It detects voice disorders based on vocal fold vibration characteristics whether the vibrations are regular or irregular. There is no standard clinical protocol or evidence on the clinical relevance of VKG for functional assessment of voice disorders. Since mechanism of voice production depends on vibration characteristics, VKG imaging leads to new possibilities for diagnosis, objective documentation and monitoring of vocal fold behavior in clinical practice in case of voice disorders. This study aims to evaluate clinical value of VKG in addition to VLS as a complementary tool for the assessment of voice disorder.

Paranasal Sinus Malignant Peripheral Nerve Sheath Tumour: A Rare Case Report.

Malignant Peripheral Nerve Sheath Tumour (MPNST) is a neoplastic lesion rarely reported in literature. In approximately 5% of cases it is associated with Neurofibromatosis type 1 syndrome. Pathognomic features of MPNST include slow growth rate, aggressive nature, nearly circumscribed, unencapsulated arising from non myelinated Schwann cells. In this case report we elaborate probable molecular pathogenesis, clinical features, histopathology (HPE) and radiological findings in a unique case of MPNST. A 52 year old female patient presented with Right cheek swelling, Loss of sensations over right maxillary region, U/L nasal obstruction and watery nasal discharge, palatal buldge and intermittent pain over right maxillary region and generalised headache. Following Magnetic resonance imaging studies (MRI scan) of paranasal sinuses, Biopsy was taken from maxillary mass and palatal swelling. HPE report was suggestive of Spindle cell proliferation against myxoid stroma. Positron Emmision Tomography (PET-Scan) was done and Biopsy specimen was subjected for Immunohistochemistry staining (IHC). After confirmation of MPNST on IHC, patient was referred to skull base surgeon for complete excision of the tumour and reconstruction.

Pre- and Postoperative High-Speed Videolaryngoscopy Findings in Adductor Spasmodic Dysphonia Following Transoral CO2 LASER-Guided Thyroarytenoid Myoneurectomy.

INTRODUCTION: Vocal cord vibration after transoral CO2 LASER-guided thyroarytenoid (TA) myoneurectomy in adductor spasmodic dysphonia (AdSD) patients is unclear to date. The precise vibratory patterns in AdSD patients are difficult to evaluate with routine videolaryngostroboscopy. High-speed videolaryngoscopy (HSV) is an ideal choice to evaluate such patients. This study was performed to compare pre- and postoperative, after 6 months, vocal fold vibratory onset delay (VFVOD) and closed phase glottal cycle (CPGC) in AdSD patients following transoral CO2 LASER-guided TA myoneurectomy using the HSV. MATERIALS AND METHODS: Retrospective study, conducted from January, 2016 to January, 2019, of the AdSD patients who underwent transoral CO2 LASER-guided TA myoneurectomy using the HSV. Patient data were acquired from the hospital database to evaluate VFVOD and CPGC from HSV recordings of the patients. VFVOD was calculated as sum of prephonatory delay (PPD) and steady-state delay (SSD). The PPD and SSD were evaluated and compared separately for each patient. The MedCal Version 19.2.6 was used for data analysis. Paired sample t test was performed to compute the significance of the difference between the mean of the dataset. A P value less than 0.05 was considered significant. RESULTS: A total of nine patients were included in the study, out of which three were females and six were males. The average age was 45.5 ± 6.9 years. The mean of postoperative PPD (166.8 ± 22.1), SSD (76.5 ± 8.6), and CPGC (62.6 ± 4.8) were significantly less than mean of preoperative PPD (222.6 ± 22.1), SSD (97.7 ± 9.5), and CPGC (71.6 ± 5 %), with P values of 0.0007, 0.0001, and 0.0001, respectively. CONCLUSIONS: There was a significant decrease in VFVOD and CPGC posttransoral CO2 LASER-guided TA myoneurectomy in AdSD patients after 6 months follow-up. This study also establishes efficiency of the HSV to measure the vocal cord vibration in the patients with AdSD. The primary limitations of the study were the small sample size and its retrospective nature. Future prospective studies with increased sample size can further substantiate the findings of the work performed here.

Low Grade Laryngeal Chondrosarcoma: Clinical Presentation, Management and Short Term Outcome.

Low grade laryngeal chondrosarcomas are rare, slow growing tumors. Surgical removal of the tumor along with preservation of laryngeal function is the preferred modality of treatment. We report a case of a large low grade chondrosarcoma removed by transoral CO2 LASER surgery which had avoided an open surgery.

Long term Follow Up of Severe Laryngomalacia Patients Following CO2 LASER Supraglottoplasty.

Laryngomalacia is the most common cause of stridor. It is believed to be due to delayed development of the supraglottic structures. On the basis of presentation, it has been divided into 3 grades. Management is dependent upon the grades: Mild and moderate laryngomalacia are managed conservatively, while CO2 LASER supraglottoplasty is the surgical management of choice for severe disease. In this study we evaluated the outcomes of supraglottopasty in long term follow up. It was a retrospective study which included patients with severe laryngomalacia who have undergone supraglottoplasty for the dates from July 2013 to July 2018. Weight and height of the patients were taken during the follow up visit after one year and have been compared with that of the normal children of comparable age using the pediatrics growth charts. Follow up was done by telephonic conversation to evaluate the status of other symptoms associated with laryngomalacia. Total of 44 patients were included in the study, 47.7% and 52.3% females and males respectively. Weight for age, weight for height and height for age were normal in 80.9%, 80.9% and 76.1% of patients respectively after supraglottoplasty. Of the patients studied, stridor was resolved in 80.9%, early tiredness during play was resolved in 43.2%, swallowing was normal in 85.7% and there was no aspiration in 90.5%. It can be concluded that patients with severe laryngomalacia improved with respect to airway symptoms, as well as, weight and height on long term follow up after CO2 LASER supraglottoplasty. It is important to evaluate the general status of the patients as a whole to truly assess the success of the surgery in addition to the airway symptoms.

Acute pancreatitis in pregnancy following COVID-19 vaccine: a case report.

BACKGROUND: Since the approval of the Pfizer-BioNTech (BNT162b2) mRNA vaccine for COVID-19 infection, a few adverse effects have been reported. Acute pancreatitis has been reported in a few patients. However, there is currently no research showing a direct relationship between the vaccine and acute pancreatitis. Here, we report a case of acute pancreatitis following Pfizer vaccination in a young healthy pregnant woman without any known risk factors. To our knowledge, this is the first case report of possible vaccine-induced pancreatitis in a pregnant woman. CASE PRESENTATION: The patient, a 24-year-old South-Asian female, at 31 weeks of gestation, presented with severe epigastric pain radiating to the back and worsening on lying supine, associated with nausea and vomiting. She was diagnosed with acute pancreatitis with a serum lipase level of 4376 U/L and an ultrasound showing features of pancreatitis. The patient received her first dose of the Pfizer vaccine 1 week prior to these symptoms. Detailed evaluation did not show any etiological cause of pancreatitis. The patient had a spontaneous vaginal delivery and the baby was shifted to the neonatal intensive care unit in a stable condition. A computed tomography scan postpartum (day 2) demonstrated acute interstitial edematous pancreatitis. The patient was managed conservatively in the intensive care unit and discharged home in a stable condition. CONCLUSION: This report highlights the importance of a detailed history and evaluation, and the close monitoring of any patient presenting with abdominal pain after vaccination. Acute pancreatitis can be fatal if not picked up early.

Evaluation of Resident Satisfaction Towards Cataract Surgery Training in Nepalese Ophthalmology Residency Programs.

INTRODUCTION: Although cataract surgery training is considered an integral part of all ophthalmology residency programs in Nepal, there is no literature about the training patterns and its effectiveness. The objective was to study the perspectives of young ophthalmologists towards the patterns and quality of cataract surgery training in their residency programs. MATERIALS AND METHODS: An anonymous web-based survey was conducted among MD Ophthalmology graduates completing their residency between January 2018 and December 2020 in Nepal. RESULTS: A total of 74 respondents included graduates from all 13 medical colleges under four universities/ academic bodies. All the respondents were primarily trained in Manual Small Incision Cataract Surgery technique (MSICS) with 28.4% (n=21) also having limited exposure to phacoemulsification. Overall, 62.1 % (n=46) of respondents had some exposure to wet lab training. Around 42% (n=31) had performed less than 25 cataract surgeries as a primary surgeon during residency and only 36.5 % (n=27) felt confident enough to perform cataract surgery independently after completion. More than 47 % (n=35) graded their cataract surgery training experience to be poor or below average. CONCLUSIONS: Ophthalmology residency programs may need to reassess their surgical training methods as the majority of recently graduated ophthalmologists from Nepal feel inadequately trained in cataract surgeries.

Smell and Taste Disturbance in COVID-19 Patients: A Prospective Multicenteric Review.

To study the incidence of the smell and taste disturbance in the COVID-19 patients and a follow up at 4 months to observe for the duration of resolution of these symptoms. This is a multicentric prospective study carried out in 3 different countries, from April, 2020 to January, 2021. The COVID-19 positive patients, aged between 15 and 60 years, were inquired about the presence of any smell or taste related symptoms. The same patients were followed up with the telephonic interview after 2 months and then after 4 months, respectively. The duration of resolution of the smell and taste disturbance symptoms was noted. Total of 188 COVID-19 positive patients, average age 33.1 ± 1.7 years, 54.2% males and 45.8% female were included in the study. The smell disturbance was present in 60.6% (hyposmia 36.1%, anosmia 20.2%, and parosmia 4.2%) and taste disturbance in 28.7% of patients (hypogeusia 20.2%, ageusia 6.9%, and parageusia 1.6%). There was improvement of anosmia by 97.4, hyposmia by 95.6%, parosmia by 100%, ageusia by 100%, hypogeusia 94.8%, and parageusia by 66.7%, at 4 months follow up. The present study concludes that the smell and taste disturbances are one of the main early presenting features of the COVID-19 infection. The temporary effect of the COVID-19 infection on the olfactory and gustatory pathway was also highlighted with more than 95% patients improving at 4 months of follow up.

Safety Protocols for Videolaryngoscopy During the COVID-19 Pandemic: A Prospective Review of 196 Cases.

To prepare safety protocols for performing videolaryngoscopy (VLS) during COVID-19 pandemic, that would be feasible for patients, hospital and the health care providers. This was a prospective study performed from March 01, 2020 to June 30, 2020. It analyzed the precautions adapted for VLS initially and subsequently describes modifications with the time. The safety protocols are developed considering the safety aspect, the feasibility aspect (due to increase in number of the VLS), and the financial aspect. The VLS was performed with the personal protective equipment (PPE), including the face shield mask and head cover. The PPE was re-used after sterilization with ethylene oxide. For local anesthesia, the oropharynx was sprayed with 15% xylocaine and nose packed with 4% xylocaine soaked pledget. Following the VLS, the scope was wiped three times with 80% alcohol and then immersed in 5.25% sodium hypochlorite and 0.55% ortho-phthalaldehyde for 10 min each. Each VLS was spaced by at least 15 min gap. The endoscopy suite maintained with laminar air flow. It can be concluded that during the COVID-19 pandemic, the VLS must be performed using PPE with proper sterilization of the scope and the endoscopy suite after the procedure. The use of face shield mask and 15% xylocaine spray into the oropharynx were also highlighted. The financial burden should be minimized by reusing the materials whenever possible.

Outcomes of Cataract Surgeries Performed in Makeshift Operating Rooms in Rural Camps, Compared to Hospital-based Surgeries in Nepal.

PURPOSE: This study was undertaken to evaluate the complication rates and visual outcomes of outreach cataract surgeries done in makeshift operating rooms. METHOD: In this retrospective study, surgical outcomes of consecutive Manual Small Incision Cataract Surgeries (MSICS) done in 11 rural camps in Nepal were compared with the results of consecutive hospital surgeries (MSICS and phacoemulsification) done by the same surgeon. Surgeries were done from September 2018 to March 2020. RESULTS: Out of 1034 study population in each group, a significantly higher number (p < .001) of camp patients (27%, n = 279) were either blind or had severe visual impairment when compared to hospital patients (18.6%, n = 192). Around 88.9% (n = 919) of cases operated in camps and 85.7% (n = 886) in the hospital achieved uncorrected visual acuity (VA) of 6/18 or better on the first postoperative day. Poor outcome (VA<6/60) was seen in 3.7% (n = 38) of cases in camps and 3.9% (n = 40) in the hospital. The difference in visual outcomes was not significant (p = .162) when the results were controlled for other associated variables. There was no significant difference (p = .126) between complication rates in camps (1.9%, n = 20) and hospital surgeries (3.5%, n = 36) when preoperative conditions were statistically controlled. No cases of endophthalmitis were reported. CONCLUSIONS: Makeshift operating rooms can be used for cataract surgeries in rural areas where no standard operating rooms are available. If appropriate patient selection criteria and standard surgical protocols are followed, good surgical outcomes can be achieved in camps by an experienced surgical team.

Study of Hearing Status in COVID-19 Patients: A Multicentered Review.

To evaluate the hearing status of COVID-19 patients and compare with control group. Prospective study carried out in 9 institutes. The pure tone audiogram and impedance audiometry of COVID-19 patients performed initially and at 3 months follow up. The control group consisted COVID-19 negative individuals with no history of ear related diseases. The average of air and bone conduction threshold (AC and BC) were compared between the COVID-19 patients and control group using independent t-test with a p value of less than 0.05 considered significant. Total of 331 patients, age 32 ± 4.3 years, 66.7% males and 33.3% females were included in the study. There were 80 individuals in the control group. Aural symptoms were, tinnitus in 1.8%, aural fullness in 1.4%, hearing loss in 3. 9%, and ear ache in 1.8% were present initially, resolved at 3 months follow up. The impedance audiometry demonstrated type B and type C curve in 5.1% and 1.15% ears, and out of these 64.7% and 40% improved at 3 months follow up respectively. No significant difference observed between the average AC and BC of the COVID-19 patients and control group. The COVID-19 infection may present with aural symptoms; however, it was concluded that there was no significant difference in the hearing status of the COVID-19 positive patients in comparison to the control group. The presence of some changes in the normal functioning of the eustachian tube and middle ear in the COVID-19 infection was also highlighted.

Foreign Body Denture in the Esophagus for 2 months: A Case Report.

Foreign body (FB) denture with 3 teeth impacted in the esophagus for 2 months without any obvious symptoms and signs is being reported. The FB, 4*3 cm was removed 26 cm from the upper incisor with rigid esophagoscope. The post-operative period was uneventful, and follow up endoscopy demonstrated normal findings.

Angiomatous Nasal Polyp: The Great Emulator-A Case Report.

Angiomatous nasal polyps are rare, benign and non-neoplastic lesions rarely reported in literature. Clinically and radiologically it mimics sinonasal neoplasm. In 5% of inflammatory or allergic sinonasal polyps, extensive vascularisation and ectasia with pseudoamyloid deposition is noted. Pathognomic features of ANP are angiogenesis, accumulation of amorphous eosinophilic substance and atypical stromal cells. In this case report we elaborate probable etiology, clinical features, histopathology (HPE) and radiological findings in a unique case of ANP which mimicked sinonasal mass. Patient presented with U/L nasal obstruction and recurrent episodes of epistaxis. He was operated for similar complaints 8 years ago, details of which were not available with the patient. Patient was recently diagnosed with Hypertension (HTN) and Diabetes Mellitus (DM). On Diagnostic Nasal endoscopy and Radiological imaging, the nasal mass appeared to be a sinonasal vascular lesion. Revision Functional endoscopic sinus surgery was done and on HPE, ANP was reported. Thus, we conclude that ANPs are rare pathological entity and can cause a significant diagnostic dilemma. Thorough knowledge about the clinical presentation and histopathological features is important in establishing an early definitive diagnosis. Also we have made an attempt to establish the possible role of DM and HTN in pathophysiology of ANP.

Postoperative endophthalmitis with and without intracameral moxifloxacin prophylaxis in a high volume surgery setting.

OBJECTIVE: This study was conducted to understand the effects of intracameral moxifloxacin in decreasing the incidence of postoperative endophthalmitis after cataract surgery in an eye hospital with a high volume surgical load. METHODS AND ANALYSIS: In this single-centre, retrospective, clinical registry-based study, we compared the rates of postoperative endophthalmitis in 31 340 cataract surgery patients operated during 22 months after June 2018 who received intracameral moxifloxacin to 80 643 patients operated during 41 months before June 2018 who did not receive intracameral moxifloxacin. All patients received subconjunctival gentamycin and dexamethasone. Combined surgical procedures were excluded from the study. RESULTS: There was a significant reduction (p<0.001) of postoperative endophthalmitis rates in cataract surgeries from 0.144% (116/80 643) to 0.025% (8/31 340) after initiation of intracameral moxifloxacin. Endophthalmitis rates decreased from 0.120% (12/9942) to 0.009% (1/10 787) in phacoemulsification group and from 0.147% (104/70 701) to 0.034% (7/20 553) in manual small-incision cataract surgeries. Gram-positive organisms including Coagulase-negative staphylococci (37.9%, n=11) and Staphylococcus aureus (S. aureus 34.5%, n=10) were the most common organisms isolated out of 29 culture-positive cases. 24.1% (28/116) endophthalmitis cases in group without moxifloxacin were culture positive compared with 14.3% (1/7) of cases in moxifloxacin group. 72% (n=8) of the Coagulase-negative staphylococci and 80% of S. aureus isolates (n=8) showed in vitro sensitivity to moxifloxacin. CONCLUSION: Prophylactic use of intracameral moxifloxacin injection in addition to subconjunctival gentamycin in cataract surgery is associated with a significant decrease in rates of postoperative endophthalmitis when compared with the use of subconjunctival gentamycin alone in high volume settings.

Pre- and post-operative high-speed videolaryngoscopy in unilateral vocal cord paralysis following autologous fat augmentation.

PURPOSE: To compare high-speed videolaryngoscopy (HSV) parameters such as open quotient (OQ), amplitude symmetry index (ASI), phase symmetry index (PSI), and frequency symmetry index (FSI), of the unilateral vocal cord paralysis (UVCP) patients pre and post (after 6 months) autologous fat augmentation. MATERIALS AND METHODS: This retrospective study evaluated all age and gender patients with UVCP that underwent autologous fat augmentation from July 2016 to July 2019. The OQ, ASI, PSI, and FSI were calculated from the HSV recordings by using the montage and fast Fourier transform point analysis. The pre-and post-operative means were compared using a paired student t-test, with a p-value less than 0.05 considered significant. RESULT: A total of 37 patients, age 41.2 ± 11.3 years (21 to 67 years), 59.4% females and 40.6% males, were included in the study. The average duration of symptom onset was 2.3 ± 0.87 months. The post-operative mean values of OQ, ASI, PSI, and FSI following the fat augmentation were significantly improved compared to the pre-operative mean values with p-values <0.0001, 0.0018, 0.0011, and 0.0006, respectively. CONCLUSION: There was a significant improvement in the OQ, ASI, PSI, and FSI in UVCP patients after 6 months of autologous fat augmentation, signifying an enhanced vibratory function. The ability of HSV to measure the minute details of vocal cord vibration by providing quantitative measurements has also been highlighted. The need for future prospective research with an increased sample size and longer duration of follow up is recommended.

Bilateral Cryptophthalmus: First Case Report from Nepal.

INTRODUCTION: Cryptophthalmus is characterized by a partial or complete casing of the eyeball by the skin. Cryptophthalmus alongside other systemic abnormalities is well-known as Fraser syndrome. It is an unusual genetic disorder with limited literature. The complexities of disease and limited experience pose challenges in its management. CASE: A two-day-male neonate was brought by his parents with a complaint of swelling in the right orbital region and deformed left eye since birth. Examination revealed bilobed globular swelling in the right orbital region covered by a continuous sheet of skin from forehead to cheek with no visible ocular tissue. On the left side, there was absence of upper lid margin and eyelashes and superior symblepharon. He also had bilateral ear abnormalities and right renal agenesis. Surgical intervention was done. On the right side, removal of the globe and cyst was done. On the left side, upper eyelid reconstruction with symblepharon release was done with amniotic membrane transplantation. CONCLUSIONS: The management of cryptophthalmus is challenging. Reconstructive surgeries allow cosmesis but useful vision is rarely gained. This is the first case report from Nepal to date to the best of our knowledge.

High-speed videolaryngoscopy in early glottic carcinoma patients following transoral CO2 LASER cordectomy.

PURPOSE: To compare high-speed videolaryngoscopy (HSV) findings, like open quotient (OQ), vocal fold vibratory onset delay (VFVOD), amplitude symmetry index (ASI) and phase symmetry index (PSI), after 6 months of cordectomy with that after 1 year, and to compare later with the control group. METHODS: Retrospective analysis of HSV recordings of 33 patients of early glottic carcinoma after cordectomy was performed after 6 months and 1 year of cordectomy with the help of videokymogram and digital kymogram. The control group of ten individuals was selected from patients who came to hospital with complaints other than larynx. The comparison was done for different types of cordectomy separately. RESULTS: The mean of OQ, VFVOD, ASI and PSI was found to be significantly higher after 6-month follow-up than after 1-year follow-up, the later was in turn found to be significantly higher than that of the control group, for type II and III cordectomy. The mean of OQ, VFVOD, ASI and PSI for other types of cordectomy also showed similar results, but the significance was not calculated due to less sample size. CONCLUSION: There was significant improvement in OQ, VFVOD, PSI and ASI following CO2 LASER cordectomy after 1 year of follow-up, making it a good management option for early glottic carcinoma. The ability of the HSV to measure variations in the vocal cord vibration, following cordectomy, was well established by this study.