The impact of ocular trauma during the Nepal earthquake in 2015.

BACKGROUND: Nepal was struck by a massive earthquake on the 25th April 2015 and major aftershock on the 12th of May 2015, resulting in widespread devastation with a death toll in the thousands. The burden of ocular trauma resulting from the recent earthquakes in Nepal has not been described thus far. The aim of this study was to determine the types of ocular injuries sustained in the earthquake in Nepal and its management in Tilganga Institute of Ophthalmology (TIO) in Gaushala, Kathmandu. METHODS: This is a hospital-based retrospective study of patients presenting to TIO following repeated earthquake. Variables that were recorded included patients' presenting symptoms and time to presentation, visual acuities at presentation and at follow-up, diagnosis of ocular injury and surgery performed. RESULTS: There were 59 cases of earthquake victims visiting TIO, Gaushala, Kathmandu from April 2015 to July 2015, with 64 affected eyes due to 5 cases of bilateral involvement. The majority of patients were from the district Sindhupalchowk (14 cases, 23.7%), which was the epicenter of the main earthquake. The average duration between the earthquake and presentation was 13 · 9 days (range 1-120 days). Closed globe injury was most frequent (23 cases), followed by open globe injuries (8 cases). While 24 patients (38%) initially presented with a visual acuity <3/60 in their affected eye, 15 patients (23%) had a visual acuity of <3/60 on follow-up. A variety of surgical treatments were required including anterior and posterior segment repair. CONCLUSIONS: Immediate management of ocular trauma is critical in order to prevent blindness. Characterizing the burden of earthquake-related ocular trauma will facilitate planning for service provision in the event of a future earthquake in Nepal, or in countries, which are similarly at risk of having natural disasters.

Retinoblastoma: geographic distribution and presentation at a tertiary eye care centre in Kathmandu, Nepal.

INTRODUCTION: Several aspects of retinoblastoma in Nepal remain enigmatic. OBJECTIVE: To assess the demographic and geographic distribution, clinical presentation, and treatment methods of retinoblastoma at a tertiary level ophthalmic institution in Kathmandu, Nepal. MATERIALS AND METHODS: A retrospective analysis of all the patients diagnosed with retinoblastoma at Tilganga Institute of Ophthalmology from July 2004 to June 2008 was performed. The main outcome measures included region of residence, treatment options and histopathological findings. The histopathological analysis was performed on enucleated and exenterated specimens. STATISTICS: The statistical analysis was performed with SPSS Version 11.5. Descriptive statistics are represented as mean ± standard deviation. All tests were two-sided and the P-values of less than 0.05 were considered statistically significant. RESULTS: Thirty patients presented with retinoblastoma during the study period. The mean age at presentation was 2.5 ± 1.6 years (range five months to seven years). Ten of the 12 patients who presented with bilateral retinoblastoma (83 %) were from the Terai region of Nepal. The ratio of unilateral to bilateral cases in the Terai region was 1:2. This differed significantly with the ratio in the hilly region (Fisher's Exact Test, p = 0.0012). The mean duration of symptoms before presentation was 2.5 3.2 months (range three days to 12 months). Twenty-four patients (80 %) presented with leukocoria. Eleven patients (36.6 %) presented with leukocoria as their only symptom. Ninety-seven percent of the patients underwent either enucleation (90 %) or exenteration (6.7 %) of at least one eye. CONCLUSION: Bilateral retinoblastoma is more prevalent in the Terai region of Nepal. The majority of the patients present with leucokoria and are treated with enucleation.

Indications for keratoplasty in Nepal: 2005 - 2010.

INTRODUCTION: Corneal disease, especially infective keratitis, is one of the major causes of visual impairment and blindness in developing countries. OBJECTIVE: To find out the current indications for keratoplasty, how these indications have changed over time as well as how they are different from those in other parts of the world. MATERIALS AND METHODS: A retrospective study of a case series of 645 keratoplasty surgeries (589 patients) was conducted at the Tilganga Institute of Ophthalmology from January 2005 to December 2010. OUTCOME MEASURES: The cases were evaluated in terms of demographic parameters, preoperative diagnosis and the type of surgery performed. RESULTS: The most common indication for surgery was active infectious keratitis (264 eyes, 40.9 %), followed by corneal opacity (173 eyes, 26.8 %), regraft (73 eyes, 11.2 %), bullous keratopathy (58 eyes, 9.0 %), keratoconus (45 eyes, 7.0 %) and corneal dystrophy (11 eyes, 1.7 %). The mean recipient age was 41.7 ± 19.9 years with over a half of the patients between 15 to 49 years of age. More men (64.1 %) underwent keratoplasty than women (35.8 %). 59.8 % of the eyes with infectious keratitis had a perforated corneal ulcer. 49.7 % of corneal opacities were due to previous infectious keratitis. 72 % of regrafts were for endothelial failure of various causes. In older patients (> 50 years), bullous keratopathy was an important indication, after infectious keratitis. Keratoconus and corneal scar were major causes of keratoplasty in children of 14 years or less. Four percent of the patients had keratoplasty in both the eyes. 17.1 % of the patients who had one eye operated on had a blind fellow eye with a vision of less than 3/60. CONCLUSION: Currently, keratitis, either active or healed, is the major indication for keratoplasty, suggesting that improved primary eye health care is necessary to decrease the prevalence of corneal blindness.

Glaucoma at a tertiary referral eye hospital in Nepal.

BACKGROUND: Glaucoma is an important cause of blindness. OBJECTIVE: To report the distribution of various types of glaucoma among patients presenting to a tertiary eye hospital in Nepal. MATERIALS AND METHODS: All new patients visiting the hospital between March 2007 and February 2008 underwent a comprehensive eye examination. Whenever glaucoma was suspected, patients were referred to fellowship-trained glaucoma specialists. Patients received a comprehensive glaucoma workup including applanation tonometry, stereoscopic examination of the optic nerve head performed by the glaucoma specialists, and a Humphrey visual field analysis (SITA 24 - 2). RESULTS: 447 patients were newly diagnosed with glaucoma. 171 (38.2 %) patients had primary open-angle glaucoma (POAG), while 143 (32 %) had primary angle-closure glaucoma (PACG). The average age of presentation of patients with POAG was 65.78 ± 9.1 years, while the average age for PACG patients was 54.6 ±12.8 years. 30 (21 %) patients with PACG had acute angle-closure on presentation, while 113 (79 %) had chronic angle closure glaucoma. 107 (75 %) of these patients with PACG had visual acuity of less than 3/60 (20/400) in the worse eye at presentation. The most common form of secondary glaucoma was lens-induced (5.3 %), followed by neovascular (3.2 %) and uveitic glaucoma (3.2 %). CONCLUSION: The most common glaucoma seen in a tertiary referral eye hospital of Nepal is primary open-angle glaucoma. Among the angle-closure glaucoma, chronic angle-closure is the most common. Lens-induced glaucoma is still the commonest cause of secondary glaucoma.

Age-related macular degeneration in Nepal.

BACKGROUND: The Age related Macular Degeneration (AMD) is a common cause of visual impairment and blindness worldwide in elderly. OBJECTIVE: This study aimed to explore the demographic characteristics, pattern and risk factors for AMD at a tertiary referral eye centre in Nepal. METHODS: This is a hospital-based prospective study, conducted at Tilganga Institute of Ophthalmology, Nepal from September 2008 to May 2009. All the consecutive cases of AMD diagnosed at the institute were included. RESULTS: A total of 141 patients (266 eyes) with AMD recruited for the study. The mean age was 69.5 years (9.1SD) with three fifth males (58.9%). Housewives and occupations like agriculture comprised of 38.3% and 42.5% respectively. Three fourth (75.6%) of the patients were illiterate. The proportion of dry and wet AMD were found in 62.4% and 37.6% respectively. Bilateral involvement was seen in 88.7% of the subjects. Three fourth (71.4%) of the AMD eyes had presenting visual acuity less than 6/18. History of smoking was found in 69.9% of patients. Hypertension was the predominant systemic problem (45.4%) followed by diabetes mellitus (12.8%). CONCLUSION: AMD is correlated with ageing in our study as well. Dry AMD is more in age groups 45-64 years and wet AMD at 65 years and older. Bilateral involvement with one eye dry and fellow eye wet AMD is more predominant (44%). Smoking and occupations like agriculture and housewife are significant risk factors for AMD. Likewise male sex, illiteracy and hypertension are other risk factors for AMD in hospital settings.

Ocular morbidity among orphanages.

INTRODUCTION: The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley. METHODS: A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression. RESULTS: A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbidity was 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall). CONCLUSIONS: Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal.

Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation.

BACKGROUND/AIMS: The aim of the study was to compare surgical outcomes of external dacryocystorhinostomy (DCR) with and without silastic intubation for treatment of primary uncomplicated nasolacrimal duct obstruction (NLDO). DESIGN: The study was a prospective randomised trial conducted at the Tilganga Eye Centre (Kathmandu, Nepal). METHODS: One-hundred consecutive patients with uncomplicated primary NLDO were randomly assigned into two groups (44 underwent DCR with silastic intubation and 56 underwent DCR without intubation). Patients were re-assessed at 1 week, 6 weeks and 6 months after surgery. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The success rate at 6 months was 90% for DCR with silastic intubation and 87% for DCR without silastic intubation. There was no statistically significant difference between the two groups (p = 0.77). No complications were encountered in either group. Silicone tubes increased surgical cost by 20% at the Tilganga Eye Centre. CONCLUSION: DCR without silastic intubation is less expensive than DCR with silastic intubation in primary uncomplicated NLDO, and has a similar success rate. DCR with silastic intubation may create increased burden for patients in the form of more post-surgical follow-up visits. In cases of uncomplicated primary NLDO, the use of silastic intubation in DCR may be unnecessary.

Ocular telemedicine between Nepal and the USA: prevalence of vitreoretinal disease in rural Nepal.

This study is aimed at reporting experiences with telemedicine between Nepal and the USA and at reporting the prevalence of age-related macular degeneration (AMD) and diabetic retinopathy (DR) in rural Nepal. AMD and DR are becoming more significant factors for non-reversible vision loss in rural Nepal due to increasing life expectancy and urbanisation. The prevalence of DM is low compared with the developed world, but the percentage of diabetics with DR is high, presumably due to limited access to healthcare. The higher prevalence of DM in Hetauda is explained as being due to a more urban lifestyle, dietary habits (more deep-fried food) and more advanced age.

A retrospective study on the causes for evisceration at Tilganga Eye Centre.

BACKGROUND: Evisceration is one of destructive surgery of eye after which a patient loses his hope of restoration of sight forever. AIM AND OBJECTIVES: To identify the major causes of evisceration at a tertiary eye centre of Nepal. MATERIALS AND METHODS: This is hospital based retrospective study of patients presented at Tilganga eye centre, Kathmandu, Nepal over a period of two years (10 Nov 2004 to 10 Nov 2006). Out of 2,31,976 total OPD patients, 71 patients who had evisceration with or without implant were selected and finally, only 67 patients record were enrolled for study as data were insufficient in the remaining records to fi ll up the study format. Data processing and analysis done using computer SPSS 11.5. RESULTS: A total of 67 cases, with age ranging from 1.5 years to 85 years, out of which 33 male and 34 were female. Evisceration was performed most commonly due to trauma and it's subsequent sequele in 37 cases (55.2% of total cases), who were within the age group of 30 - 59 years (p = 0.033) and predominantly male 25 cases(p = 0.001). Most of the patients presented from outside Kathmandu valley, with visual acuity of no perception of light. CONCLUSION: Evisceration without implant was most common surgical procedure, with trauma being the leading cause for it and most of the trauma was seen in active, potential and young male patients. So prevention of ocular injuries together with early treatment protocol is best way to decrease the rate of evisceration due to ocular trauma. To prevent ocular injuries news paper, television and health education may play an important role.

Prevalence of diabetic retinopathy following a community screening for diabetes.

Diabetic retinopathy is a public health challenge in developing countries including Nepal and is not like other preventable or treatable causes of blindness. The aim of study was to estimate the prevalence of diabetic retinopathy following a community screening for diabetes. A community-based, cross sectional study was designed to screen for diabetes in people age > or =40 years in a semi-urban community of Kathmandu, Nepal. In those individuals with detected diabetes, a comprehensive eye examination was performed by an ophthalmologist and diabetic retinopathy was graded using a standard protocol. 1475 persons were screened for diabetes with a mean age of 54.7 +/- 12 years with sex ratio of 0.69 male per female. Thirty-four subjects were found to have impaired fasting glucose and sixty subjects had diabetes. The prevalence of diabetes mellitus was 4.1% (60) but 6.4% (94) had an abnormal blood sugar level. Fifty-seven diabetic patients visited at-Tilganga Eye Centre for ocular examination. Among examined patients, the prevalence of diabetic retinopathy was 19.3% (11). Only one person had clinically significant macular edema requiring laser therapy. The prevalence of hypertension and cataracts were the same among patients with and without diabetic retinopathy. The prevalence of diabetic retinopathy was low but one of sixteen newly diagnosed diabetics did have evidence of diabetic retinopathy. Eighty-four percent of known diabetics had never had their eyes examined for ocular complications. Community awareness and physician coordination should be emphasized to increase the eye examination rate.

Seasonal hyper acute pan uveitis--recent scenario in Nepal.

Seasonal hyperacute panuveitis (SHAPU), characterized by an unusual form of unilateral severe hyper acute diffused intraocular inflammation, is one of the mysterious eye diseases of which the definite cause and treatment remains yet to be tound out. In this study, a total of six cases were included. Aqueous and vitreous samples were subjected to direct microscopy and culture (bacterial or fungal). Of the six cases included, two yielded Streptococcus pneumoniae and one Acinetobactor sp. on culture. All three culture positive samples showed pus cells in direct microscopic examination (gram stain). All cases were subjected to vitrectomy and intravitreal antibiotic and steroid injection, along with oral antibiotics and steroid. Five cases were also treated with antiviral agent. After treatment four cases showed reversal of hypotony and three cases recovered some vision.

Outcome of pneumatic retinopexy at a tertiary eye care centre in Nepal.

BACKGROUND: Rhegmatogenous retinal detachment is one of the commonly encountered retinal problems where timely treatment could prevent irreversible vision loss. Pneumatic retinopexy (PR) is a simple and minimally invasive procedure for retinal reattachment. AIM: This study aimed to assess the outcome of pneumatic retinopexy in primary rhegmatogenous retinal detachment at our facility. STUDY DESIGN: This was a retrospective- prospective, interventional case series. MATERIALS AND METHODS: All subjects with rhegmatogenous retinal detachment who underwent pneumatic retinopexy at Tilganga Eye Centre of Nepal from January 2002 to June 2007 were included in this study. RESULTS: A total of 32 cases were included in the study. The mean age of patients was 55.2 year (SD=11.0). The majority of cases (62.5%) presented within two weeks of symptoms with blurring of vision in 90% of cases. Pre-operatively, 56.3% (18) patients had a best corrected distance visual acuity of <6/60. Retinal detachment involving less than two quadrants consisted of 37.5% (12). A single retinal break was present in 78.1% (25) of cases and 87.5% (28) of the retinal breaks were located in the superotemporal quadrant. The macula was attached in 37.5% (12) of the cases. Sulfurhexafluoride and Perfluoropropane were used in 68.8% (22) and 31.3% (10) respectively. The average follow up period was 1.02 years (range one month to four years). The retina was completely attached in 81.3% (26) of cases at the last follow up. The best corrected distance visual acuity of 6/18-6/60 was found in 40.6% (13) of subjects in the last follow up. There was a transient rise in intraocular pressure in 6.3% (2) of subjects after the procedure. CONCLUSION: The anatomical success rate following pneumatic retinopexy is quite high (81.3%) with good visual recovery and less morbidity translating to higher productivity for the patient. This procedure, being quicker than the alternatives, will also save surgeon's time making PR a good choice for managing primary rhegmatogenous retinal detachment in countries like Nepal where resources are scarce.

Prevalence of and factors associated with diabetic retinopathy among diabetics in Nepal: a hospital based study.

Diabetic retinopathy is the one of the leading cause of visual impairment in world including Nepal. The objective of the study is to estimate the prevalence of and factors associated with Diabetic Retinopathy among diabetics in a Tertiary Eye Care Centre, Nepal. A hospital-based, cross sectional study, was conducted at Tilganga Eye Centre, Nepal. 371 consecutive subjects were recruited during a period of study. Ophthalmologist performed comprehensive eye examinations, which were reconfirmed by senior ophthalmologist. Diabetic Retinopathy was graded using the Early Treatment Diabetic Retinopathy Study. Total 371 consecutive diabetics were examined, mean of 57.4 years (SD 12.0) having the sex ratio of 0.72 male per female. The prevalence of Diabetic Retinopathy was 44.7% (166) with non-proliferative Diabetic Retinopathy presented 85.5% (142) and 14.5% (24) were proliferative Diabetic Retinopathy. Clinically significant macular edema was found in 19.2% (32). The age at onset of diabetes, duration of diabetes and hypertension were significantly associated with Diabetic Retinopathy (p = < 0.05) whereas ethnicity, sex and cataract surgery were not associated with it (p = > 0.05). The prevalence of Diabetic Retinopathy was within the range of previous studies with a high rate of proliferative diabetic retinopathy. Factors associated with diabetic retinopathy were similar to other developed countries. To prevent this condition of Diabetic Retinopathy, the coordination between physician and ophthalmologist needs to be strengthened.

Optimal single intraocular lens power for the Nepali population.

AIM: To evaluate optimal standard intraocular lens power for Nepalese eye camp cataract patients. METHOD: A retrospective case series of 5109 preoperative cataract patients. RESULTS: Average axial length of 23.08 (SD 1.26). Average dioptre intraocular lens power 21.37 (3.04). CONCLUSION: An increase in the intraocular lens power used at Nepalese eye camps from +21.0 to 22.5 dioptres would improve overall visual outcome.

Willingness to pay for cataract surgery in Kathmandu valley.

AIM: A cross sectional study was carried out on 78 screened cataract patients of two screening camps in Kathmandu valley, Nepal, to assess the willingness to pay for cataract surgery. METHODS: A non-probability sampling technique with open ended and close ended questionnaires was used. RESULTS: The average age of patients was 68.8 years. The ratio of men and women was 0.9:1. 42.3% (33) of patients were willing to pay for cataract surgery. Among them 48.5% (16) of people were willing to pay less than dollars 13 and 51.5% (17) were willing to pay more than dollars 13. The mean was dollars 2.3 (SD dollars 15.5) per case. Patients with bilateral cataract were more willing to pay than unilateral cases. Poverty (44.4%, 20) was the main barrier for unwillingness to pay for cataract surgery. Other reasons were the lack of family support (28.9%, 13), lack of knowledge of surgery and belief that it was an unnecessary procedure (15.6%, seven), and waiting for a free surgical service (11.1%, five). CONCLUSION: This study clearly indicates that although there was awareness of the availability of treatment and services provided within the reach, people are not willing to pay for the surgery and use the facility primarily because of poverty. Hence, to change patients' attitudes, a more holistic approach is needed, keeping in view the cultural, social, and economic background of the society.

Ketamine anaesthesia for paediatric ophthalmology surgery.

AIMS: Children with treatable, vision impairing conditions may not have access to surgical care when they live in regions where anaesthesia is unavailable. The use of ketamine anaesthesia in a developing region was studied to determine its safety and effectiveness. METHODS: This is a consecutive series of 679 children who had a variety of paediatric eye disorders necessitating a short general anaesthesia. Ketamine was administered intravenously by a paediatrician with training in paediatric resuscitation procedures. Both intraocular and extraocular procedures were performed. The location of treatment was the Tilganga Eye Hospital in Kathmandu, Nepal, a developing region of the world. The study took place over a 5 year period. RESULTS: All procedures were performed without any anaesthetic complications. No child required unanticipated resuscitation or laryngeal intubation. Postoperative dysphoria occurred occasionally and was difficult to measure quantitatively. This side effect of ketamine resolved by the first postoperative day. CONCLUSION: Ketamine is an effective agent for both intraocular and extraocular surgery in the paediatric age group. None of the children in this series needed resuscitation or intubations, and the ophthalmic surgery was carried out safely. Ketamine can be used safely in any ophthalmic procedure of short duration by a person having some training in anaesthetic resuscitation procedures. Because of its simplicity and safety, ketamine may be useful in a simple ophthalmic setup in the developing word.

An innovation in developing world cataract surgery: sutureless extracapsular cataract extraction with intraocular lens implantation.

PURPOSE: The benefits of sutureless cataract surgery have not been available to the majority of developing world patients. This report describes a surgical technique developed to gain the benefits of self-sealing sutureless techniques, without the need for costly, complex instrumentation, expensive consumables, or difficult nucleus fragmentation manoeuvres in the anterior chamber. METHOD: A detailed description of a sutureless technique that uses only standard manual extracapsular cataract extraction instrumentation is presented. The clinical records of 362 consecutive completed sutureless surgeries were reviewed, and preliminary indicative data of visual outcome for those having follow up between postoperative weeks 3 and 8 are also presented. RESULTS: Hospital and eye camp experience confirms this operation offers speed, routinely 5 min or less with mature cataracts, reduced cost because no suture, viscoelastic or anterior chamber maintainer is needed, wound security and stability, and rapid effective visual rehabilitation. Uncorrected distance visual acuity during the third to eighth postoperative week was available for 266 of the 362 patients (73%): 10, 145, 101, and 10 had acuities of better than 6/9, 6/9-6/18, 6/24-6/60, and worse than 6/60, respectively. Ninety-seven, 165, 12, and two of the 276 (76%) patients with recorded corrected distance acuity were in the same groups. Comparing postoperative with preoperative corneal astigmatism for each patient with postoperative information available (208), without regard to axis, the amplitude of astigmatism worsened by a mean of 0.94 dioptres (+/- 0.17, 95% confidence; +/- 1.23 standard deviation; 7.5D maximum worsening; 2.5D maximum improvement). No attempt has been made to analyse complication type or frequency in this preliminary report. CONCLUSION: The authors believe this sutureless cataract extraction technique to be an innovation with widespread application in the developing world. Further and more exhaustive critical appraisal is warranted.