Nepalese Journal of Ophthalmology最新文献

Introduction: Ethambutol is an antibiotic used as a first line drug in the treatment of tuberculosis and a vision threatening side effect of EMB is ethambutol-induced optic neuropathy (EON). The aim of the study is to create awareness about the potentiality of ethambutol to cause ethambutol-induced optic neuropathy, careful monitoring of dose and patient education.

Materials and methods: A retrospective observational study of 14 patients whose complete Anti- tubercular treatment records could be retrieved were included. Epidemiological data including age, sex, systemic illness were recorded. Duration between optic nerve toxicity , usage of ethambutol and the drug dosage were noted. Best corrected visual acuity, anterior segment examination including pupils, extraocular movements, colour vision, central fields and fundus examination were evaluated. The patients were followed up at one and three month intervals.

Results: Associated systemic illness was found to be a confounding factor for the development of ethambutol-induced optic neuropathy. 57% of patients had diabetes mellitus followed by hypertension (14.2%), renal disease (7.1%). The average daily dose of Ethambutol ingested was 1078.5 mg (21 mg/kg) and this high dose could have been the primary cause for development of ethambutol-induced optic neuropathy. Vision ranged from total blindness to mild visual impairment and poor recovery of vision was noted even after discontinuing ethambutol.

Conclusion: Only a minority of patients showed improvement in visual function following discontinuation of ethambutol and the toxicity was found to be dose-dependent. Patients with comorbidities like renal impairment and diabetes mellitus appeared to be at greater risk. Ophthalmological examination before commencing treatment and periodic evaluation thereafter is mandatory.

Introduction: This study aimed to analyse the clinical retinal examination findings and undilated Optomap ultrawide field retinal imaging for the detection of proliferative diabetic retinopathy (DR) as compared to the fluorescein angiography (FA).

Materials and methods: In this retrospective cross-sectional study, five hundred and twenty-three patients diagnosed with diabetic retinopathy on dilated retinal examination underwent fluorescein angiography and undilated Optomap imaging. Fluorescein angiography and undilated Optomap images were graded by masked graders and the diagnosis was labelled either as proliferative diabetic retinopathy or non-proliferative diabetic retinopathy. Sensitivity and specificity was calculated comparing the diagnosis obtained from the dilated retinal examination and the undilated Optomap images against the fluorescein angiography image findings.

Results: Gradable quality fluorescein angiography and undilated Optomap images with a clinical diagnosis mentioned in the medical record for that particular visit were available in 980 (right eye - 656; 67%; left eye - 324; 33%) eyes of 496 patients. There were 332 (67%) males and 164 (33%) females with a mean age of 60.3 ± 9.51 years (range: 32 - 81 years). Sensitivity of clinical examination and undilated Optomap images in accurately identifying proliferative diabetic retinopathy was 63.5% and 43.5% respectively. Specificity of clinical examination and undilated Optomap images in accurately identifying proliferative diabetic retinopathy was 88.5% and 76.2% respectively. On comparison of the undilated Optomap imaging findings against the clinical examination findings, the sensitivity and specificity were 47.7% and 75.1% respectively.

Conclusion: Both clinical fundus evaluation and undilated Optomap imaging were relatively inferior to fluorescein angiography in the detection of proliferative diabetic retinopathy, which hence remains the choice of imaging modality giving scope for wider application.

Introduction: Glaucoma is one of the common causes of blindness worldwide, and the leading cause of irreversible blindness .The overall prevalence of glaucoma in Nepal is 1.9%. Though poorly understood, primary open angle glaucoma (POAG) is believed to have a genetic or familial component that may occur through polygenic or multifactorial transmission. First-degree relatives of POAG patients have 4-16% risk of developing POAG. Given the circumstances and the prevalence of POAG in first degree relatives of POAG patients, screening the first degree relative/s accompanying the patient to the hospital can be a cost effective and viable tool for glaucoma screening that will not add any extra cost of travel and accommodation.

Materials and methods: The authors performed a hospital-based cross-sectional study at a tertiary eye hospital in Nepal. All first-degree family members of POAG patients who accompanied them to the glaucoma clinic underwent a full ophthalmic examination.The optic disc was evaluated and intraocular pressure (IOP) was measured. POAG and glaucoma suspect were defined as per ISGEO classification.

Results: Sixty one first degree relatives of 54 glaucoma patients were examined. The mean age was 30.67 years (±12.71). Fifty five(90.2%) of 61 of accompanying first degree relatives were off springs, 6 (9.8%) were siblings. Five out of 61 (8.2%) were diagnosed as glaucoma and started on anti-glaucoma medication. Fourteen participants (23%) were glaucoma suspects. Forty two (68.9%) of the participants had no sign of glaucoma.

Conclusion: Ocular examination of the first-degree relatives accompanying POAG patients helped to identify a remarkable number of individuals with glaucoma and thus might be used as an effective and viable tool for screening glaucoma in a hospital setting. Awareness regarding glaucoma is very low even among the first degree relatives of glaucoma patients.

Introduction: Endoscopic Endonasal Dacryocystorhinostomy (EENDCR) is effective, safe and less time consuming procedure and scar free to manage patients with epiphora. Traditionally, EENDCR is performed under general anesthesia. Limited general anesthesia facility in our country has made EENDCR surgery limited to the hospitals with GA facilities. EENDCR surgery under local or assisted local anesthesia could be an alternative solution. The aim of the study was to study the pain tolerability of the patient undergoing EENDCR under local anesthesia (LA) or assisted local anesthesia (ALA). To the best of our knowledge, there is a lack of similar studies in Nepal.

Materials and methods: This was a prospective, nonrandomized, interventional study done at a tertiary eye care center. After sample collection the study was aimed to evaluate the pain tolerability of patients undergoing EENDCR under LA or ALA. The case collection and the surgery were done by a single surgeon from 2018 Jan- 2019 April and followed for 6 to 24 months. All consecutive cases were enrolled in the study. Informed consent was obtained from all the patients. Inclusion criteria included chronic dacryocystitis with NLDO (Nasolacrimal duct obstruction), lacrimal sac mucocele and lacrimal sac pyocele. Previously failed DCR surgery was not included in the study. Total of 100 patients of EENDCR with a tube who completed a minimum 6 months follow up postoperatively were included in the study. Verbal rating scale (VRS) was used to report response to pain during different steps of surgery.

Results: There were 100 patients within the age range of 13-41 years of age. One hundred and six EENDCR were performed on 100 patients. Eighty-seven patients were adult (19-41) years and 13 patients were of pediatrics age group (13-18) years. There were 74 female and 26 male patients. Thirty-seven were RE (right eye), 57 were LE (Left eye) and 6 were BL (bilateral). Duration of illness was less than 6 months in 9 patients and more than 6 months in 91 patients. Ninety-two eyes were operated under LA and fourteen eyes of 11 patients asked for sedation in addition to local anesthesia (ALA). Patients reported pain during the creation of the bony ostium with Keryson's rounger (24 eyes, VRS 3-4) and while using the drill (19 eyes, VRS 5-6). On pain scoring, there was no pain (0-2) in patients who underwent EENDCR under ALA. Pain scoring in patients who underwent EENDCR under LA showed no pain (0-2) in 51.08%, mild pain (3-4) in 26.08%, and moderate pain (5-6) in 20.65%. Duration of surgery ranged from 15 to 45 minutes. Duration of follow up was 6- 24 months. There was a 96.2% success rate in this study.

Conclusion: EENDCR can be done under LA or ALA depending on the indication and demand of the patient.

Introduction: The study aimed to assess the outcome of the modified wheeler technique with lower eyelid retractor plication for the correction of Involutional (senile) entropion among the study patients Materials and methods: A retrospective case series study was conducted in two tertiary eye hospitals of Bangladesh from 1 July to 31 December, 2020. This study included all patients undergoing modified wheeler technique with inferior lid retractor plication and followed up to at least one year and six months between 01 January 2015 to 31 December, 2019. All patients were suffering from senile entropion of the lower eyelid. All surgeries were performed by a single surgeon and the study sample size was selected purposively. Patients were operated by the modification of modified wheeler technique for the correction of lower eyelid entropion in this study. The outcome of the surgical techniques was assessed at regular intervals on each follow up.

Results: Thirty eyes of thirty patients were evaluated. Success rate was 100% in the 18 months follow up time with no recurrence in any. Ecchymosis, skin scarring and/or minimal pain were observed as post-operative complications.

Conclusion: The modified wheeler technique with inferior eyelid retractor plication is the definitive and permanent procedure for the correction of involutional entropion with minimal or no recurrence.

Introduction: Major cause of irreversible blindness is glaucoma which is increasing as a significant global health problem. Knowledge of glaucoma burden and its clinical characteristics in this region is essential.

Materials and methods: This was a cross-sectional hospital -based study conducted at Glaucoma unit in CHEERS Hospital, Bhaktapur from August 2015 to July 2019. Patients' demographic profile, along with comprehensive eye examination findings were reviewed from the records. Data analysis was done with IBM SPSS version 24 and was presented in mean (±SD), frequency and proportions and a chi- square test was applied. P value < 0.05 was considered statistically significant.

Results: Total of 310 glaucoma cases were included in this study. The mean age presentation was 61.89±14.4 years, and the majority of patients (52.9%) were in the age group 60-79 years. Most patients had primary open angle glaucoma (171, 55.2%) followed by primary angle closure glaucoma (92, 29.7%).

Conclusion: Primary open angle glaucoma is the most common form of glaucoma. The proportion of glaucoma increased with increasing age (> 40 years). Provision of screening programs targeting persons with risk factors and opportunistic eye examinations would be beneficial in detection of glaucoma.

Introduction: Mycotic scleral abscess after pars plana vitrectomy (PPV) is a rare entity and a scleral abscess caused by Aspergillus flavus following PPV has not been reported in the literature. We describe the clinical presentation, complication and management outcome in a patient, who developed a mycotic scleral abscess at the infusion port site after 20 gauge pars plana vitrectomy.

Case: Two weeks after pars plana vitrectomy, a patient presented with a scleral abscess at the site of infusion port. He was a known diabetic, had a history of pulmonary tuberculosis and was using steroid eye drop at the time of presentation. Surgical debridement of the abscess was performed and he was treated with topical and systemic antifungal drugs. After three days of incubation, Sabouraud dextrose agar identified growth of Aspergillus flavus. After showing initial resolution, at 4 weeks follow up, the scleral abscess was noted to have progressed to involve the adjacent cornea. Corneoscleral patch graft was performed and treatment with topical and systemic antifungal was continued, which led to complete resolution of the corneoscleral abscess with corneal opacity and scar formation, over a period of eight weeks.

Conclusion: Scleral abscess is a rare complication after pars plana vitrectomy and requires early and appropriate treatment to decrease the ocular morbidity. Dissemination of the infection to involve the cornea can be managed with corneo scleral patch graft and appropriate antifungal medications to salvage the eye.

Introduction: Hypotrichosis with juvenile macular dystrophy (HJMD) is an autosomal recessive disease with progressive macular degeneration leading to blindness in the first three decades of life along with hypotrichosis.

Case: We herein report a case of a five year old boy with hypotrichosis with juvenile macular dystrophy diagnosed with multi-modal imaging which was later confirmed by genetic testing by whole genome sequencing.

Observations: Fundus examination of both eyes revealed symmetrical hypopigmentation in peripapillary retinal pigment epithelium (RPE) involving posterior pole and surrounded by a mottled hyperpigmented border. Fundus autofluorescence showed central hypo autofluorescence with surrounding hyper autofluorescence corresponding to RPE atrophy and a faint hypo autofluorescence at the junction of normal retina. SD-OCT showed segmental outer retinal and choriocapillaris atrophy temporal to fovea with interdigitation zone and ellipsoid zone loss and RPE irregularities with hyperreflective subretinal deposits at the fovea. Electroretinogram showed normal waves but a slight reduction of b wave amplitude in both eyes. He had sparse scalp-hair.

Conclusion: Children with reduced vision not falling into a typical macular degeneration should be examined systemically and may just have sparse scalp hair and still have a genetic disease. A regular follow-up should be emphasized in view of progressive nature of the disease.

Introduction: The eye hospitals of low-income countries including Nepal are not equipped with imaging modalities including CT scan, UBM and Pentacam but most of them have ophthalmic ultrasound. We evaluate the utility of routine ultrasound for proper localization and confirmation of the intra-lenticular foreign body along with detection of the status of the posterior capsule using immersion technique.

Case: Four consecutive cases with intra-lenticular foreign bodies presenting to the vitreo-retina department of Lumbini Eye Institute were included in the study. Ultrasound immersion technique was used to detect the ILFB along with x-ray. Planned ILFB removal with phacoemulsification or lens aspiration and foldable IOL implantation as a single-stage procedure was done in all the patients. They were followed up to 3 months after the surgery.

Observations: Intra-lenticular location of IOFB was confirmed by ultrasound immersion technique in all 4 eyes. Intactness of the posterior capsule was also detected preoperatively in all 4 eyes. ILFBs were removed with Utrata's capsulorrhexis forcep in all cases following capsulorrhexis. Phacoemulsification was performed to remove cataract in 2 cases whereas lens aspiration with Simcoe canula was performed in other two cases. Single piece acrylic foldable intraocular lens was implanted in all cases. Posterior capsule was intact in all 4 cases intra-operatively. Features of siderosis were observed in one case. Mild postoperative uveitis was seen in all cases and was controlled with topical steroids. Best corrected visual acuity at the last examination was 6/9 or better in all cases.

Conclusions: Ultrasound immersion technique is very useful tool in management of intra-lenticular foreign body at least in low resource setting. Phacoemulsification /lens aspiration with ILFB removal and IOL implantation provides good visual outcome in these eyes.

Introduction: Virtual Reality technology helps in creating virtual environments for evaluation of visual performance of low vision individuals with holistic experience. The purpose of this study was to develop a virtual reality (VR) platform for the objective assessment of functional vision in patients with low vision in two categories, central and peripheral vision loss .

Materials and methods: Focus group discussions (FGD) were organized to understand the difficulties faced on a day to day basis by patients with low vision. Based on the results of the focus group discussions, a virtual bank scenario incorporating specific visual tasks was developed. A pilot study was conducted which involved people with normal vision; low vision Patients secondary to central field loss (CFL) and peripheral field loss (PFL). Each subject completed all the tasks in the objective assessment; the data obtained from the assessment were further analyzed to understand the pattern.

Results: Comparing the three groups, there was a significant difference in distance (central field loss was lowest) and near visual angle, and three visual search tasks (peripheral field loss was lowest). In assessing the time taken, peripheral field loss group was again found to take the most time to complete tasks.

Conclusion: Based on a newly developed virtual reality platform, assessment of functional vision of specially abled persons could be tested and was inferior to that of normal sighted persons. in a close to realistic environment. Multiple visual tasks were performed in the virtual environment and the visual performance was compared among all three groups of participants. Participants were matched for age and gender. Irrespective of the nature of tasks, visual performance of the normal group seemed significantly better than people with CFL and PFL.