Clinicodemographic pattern and treatment outcome of Behcet's disease cases presenting in a tertiary eye center of Nepal.

PURPOSE: To know the clinical and demographic pattern, and the outcome of treatment of Behcet's disease (BD) cases in Nepal METHODS: Retrospective series of all the cases of BD who had come over the period of 12 years (Jan 2007-Dec 2015) Tilganga Institute of Ophthalmology. RESULT: Twenty-one cases were included, 17 (81%) male and four (19%) female. Mean age was 28.88 ± 9.18 years. Mean follow-up period was 3.6 ± 2.6 years. All had nongranulomatous panuveitis. Hypopyon was seen in 13 (61.9%) cases. Small retinal infiltrates in 13 (61.9%) cases and retinal vasculitis in ten (47.6%) cases were seen. Cataract (in 13, 61.9%) and optic atrophy (in 11, 52.4%) cases were present. Oral ulcer was present in 20 (95.2%), genital ulcer in 15 (72%), and skin lesions in 13 (62%) cases. CONCLUSION: BD affected mainly the most active age group and was predominant in male. Optic atrophy was the leading cause of irreversible vision loss. Despite being a less common condition, BD should be considered in the differential diagnosis of panuveitis cases in the Nepalese population.

High prevalence of anelloviruses in vitreous fluid of children with seasonal hyperacute panuveitis.

Seasonal hyperacute panuveitis (SHAPU) is a potentially blinding ocular disease occurring in Nepal that principally affects young children. Random amplification of partially purified vitreous fluid (VF)-derived nucleic acid revealed the presence of human anelloviruses in VF of SHAPU patients. In a comparative study of patients with different ocular pathologies, SHAPU patients were at highest risk of harboring anelloviruses in their eyes. The majority of SHAPU patients had multiple anelloviruses in their VF. The ocular anellovirus load in SHAPU and non-SHAPU patients did not differ and no SHAPU-specific anellovirus variant was detected. Analysis of paired serum and VF samples from SHAPU and non-SHAPU patients showed that the anellovirus detected in VF samples most likely originated from the systemic viral pool during viremia, potentially through breakdown of the blood-ocular barrier. The detection of anelloviruses in VF samples of uveitis patients, profoundly so in SHAPU patients, is imperative and warrants elucidation of its clinical significance.

Rhegmatogenous Retinal Detachment with Spontaneous Dialysis of the Ora Serrata in Neurofibromatosis Type 1: A Case Report.

Neurofibromatosis type 1 is a genetic disorder that follows an autosomal dominant pattern of inheritance. Ocular involvement is not uncommon, but spontaneous dialysis of the retina in the absence of a history of trauma is a rare clinical entity. Rare cases of retinal involvement such as retinal detachment or dialysis of ora serrata could be linked with the abnormal cell-matrix formation in neurofibromatosis type 1. Here, we present a case of a 36-year-old man having Neurofibromatosis Type 1 with spontaneous dialysis of ora serrata without prior history of ocular trauma. A routine fundoscopic examination should be done in addition to the examination of the anterior chamber in patients with neurofibromatosis type 1 despite the absence of ocular complaints. Keywords: case reports; neurfibromatosis type 1; ora serrata; retinal; retinal detachment.

Circumferential intimal tear with thrombosis of right superficial femoral artery due to penetrating injury by bull horn: A case report.

In agrarian countries where bulls are used for farming and stock breeding, bull horn injuries are common. Bull horn injuries range from blunt trauma to penetrating injuries, which can cause massive hemorrhage. Vascular injuries to the limbs by goring bull horn injury usually involve transection of vessels but rarely cause intimal tear with thrombus formation. Here, we report an unusual case of a 33-year-old male with circumferential intimal tear with thrombosis in the subintimal region of the right superficial femoral artery without transection of the vessel following penetrating injury to the right thigh caused by a bull's horn. There was a pulse deficit above the popliteal artery, and Doppler ultrasonography revealed decreased flow indicative of underlying femoral vessel injury for which the wound was surgically explored. It was followed by right superficial femoral arteriotomy at the site of the thrombus with the evacuation of a 6 cm long clot, revealing a 6 cm long endothelial injury in the same vessel. Next, an interposition reversed saphenous graft was placed in the same location. Following this, Doppler ultrasonography was done that revealed restoration of blood flow to the site of thrombosis. Thus, in a case of bull horn injury, thrombosis should be ruled out with prompt surgical wound exploration despite the presence of an intact vessel.

Effect of exposure to biomass smoke from cooking fuel types and eye disorders in women from hilly and plain regions of Nepal.

BACKGROUND/AIM: To study the association between exposure to biomass smoke from cooking fuels andi cataract, visual acuity and ocular symptoms in women. METHODS: We conducted a community-based cross-sectional study among women (≥20 years and without a previous diagnosis of cataract, ocular trauma or diabetes or those taking steroids) from hilly and plain regions of Nepal. Eligible participants received an interview and a comprehensive eye assessment (cataract development, visual acuity test and ocular symptoms). Participants' data on demographics, cooking fuel type and duration of use, and cooking habits were collected. We addressed potential confounders using the propensity score and other risk factors for ocular diseases through regression analysis. RESULTS: Of 784 participants, 30.6% used clean fuel (liquefied petroleum gas, methane, electricity) as their primary current fuel, and the remaining 69.4% used biomass fuels. Thirty-nine per cent of the total participants had cataracts-about twofold higher in those who currently used biomass fuel compared with those who used clean fuel (OR=2.27; 95% CI 1.09 to 4.77) and over threefold higher in those who always used biomass. Similarly, the nuclear cataract was twofold higher in the current biomass user group compared with the clean fuel user group (OR=2.53; 95% CI 1.18-5.42) and over threefold higher among those who always used biomass. A higher proportion of women using biomass had impaired vision, reported more ocular symptoms compared with those using clean fuel. Severe impaired vision and blindness were only present in biomass fuel users. However, the differences were only statistically significant for symptoms such as redness, burning sensation, a complaint of pain in the eye and tear in the eyes. CONCLUSIONS: Cataract was more prevalent in women using biomass for cooking compared with those using clean fuel.

Seasonal hyperacute panuveitis: an update.

PURPOSE OF REVIEW: Seasonal hyperacute panuveitis (SHAPU), a mysterious disease of Nepal, has increased the burden of childhood blindness ever since it was described in 1975. Although moths are suspected as the cause, this source is not yet proven. The management of this disease is still not well outlined. This article reviews recent developments in the understanding of SHAPU pathogenesis, clinical features, cause, and preventive measures as well as curative management. RECENT FINDINGS: Smaller summer outbreaks occur every even year together with larger autumn outbreaks every odd year. Vitreous fluid from some cases grew bacteria on culture. Viruses were isolated in one case. Tiny hair follicles have been identified in ocular structures. Several cases had decreased corneal sensation and few cases had iris atrophy. Early vitrectomy is beneficial. Intravitreal vancomycin, amikacin, and dexamethasone injection have given good results. Unlike previous reports, the use of repeated subconjunctival dexamethasone injection was also claimed to reverse the eye disease. However, treatment helped to save the vision in one eye or both only if cases presented early enough (within 7 days) for treatment. SUMMARY: Recent findings have shown a correlation between SHAPU and moths (probably Gazalina); therefore, more research on this moth is urged. Various new findings also hint towards the involvement of microbes; thus, further advanced studies are required to confirm this involvement.

Female Clients Satisfaction towards Primary and Secondary Eye Health Facilities and Cost of Eye Care in Nepal.

INTRODUCTION: In Nepal, females suffer from disproportionately higher burden of blindness and vision impairment with low access to eye care. The available knowledge is inadequate to address the issues related to gender and generate information to reduce the gender disparity. The aim of this study was to determine female clients' satisfaction with services at eye facilities in Nepal and to estimate the cost of cataract surgery. MATERIALS AND METHODS: Exit interviews were conducted in 2018 with 308 female clients from eight facilities in five districts. Face to face interviews were conducted using a pretested semi-structured questionnaire adopted from the midterm review of Vision 2020. RESULTS: The mean age of participants was 54±17 years. Ninety seven percent (97%) of the participants reported that they received service as per their expectation and were satisfied with the service of the facilities. Major factors for satisfaction were: thorough eye examination (54%), behavior of health staff (40%), and cleanliness of health facility (39%). Another eighty percent (80%) of the participants mentioned that they would recommend or return to the same facility. Fifteen percent of the participants perceived that they faced problems at the eye facility because of their gender. Around three quarters (73%) paid health expenses from their pocket. Most (83%) of the participants rated user fees as either reasonable or inexpensive. CONCLUSION: The majority of participants reported receiving service as expected and willingness to return to the same eye health facility for future consultation. However, most participants had to pay the health care expenses out-of-pocket.

The Risk Factors of Seasonal Hyperacute Panuveitis.

BACKGROUND: Seasonal Hyperacute Panuveitis (SHAPU) is an eye disease of unclear aetiology occurring cyclically during the autumn in odd years in Nepal causing blindness within a week. This study is the first of its type to investigate the risk factors of SHAPU. METHODS: A multicentric national level case-control study was performed during the 2017 SHAPU outbreak. Cases were matched to controls in a 1:3 ratio based on age, sex and geographic area.Questionnaire-based personal interview was used and risk factors were categorized as biological and behavioral. For univariate analysis, frequency, median and interquartile range was calculated. Chi-squared test with/without continuity correction and Fisher's exact test were used. Multivariate conditional logistic regressions were used for all the independent variables for p <0.1 in the univariate analyses. RESULTS: We identified 35 cases and 105 controls; 71.4% were children≤16 years (38-day infant to 50-year-old). All were immunocompetent individuals, males were 57.1% and females 42.9%. Potential risks such as visible moths/butterfly activity, contact with livestock, and attending mass gatherings of people were not reported more frequently in cases vs controls in univariate analyses. Differences in possibly protective factors such as self-reported mosquito net use, light off at night while sleeping, and habit of hands/face washing after physical contact/touch with any insects/butterflies/birds were not statistically significant between both groups. In multivariate model, SHAPU cases were significantly more likely than controls to report physical contact with butterflies/white moths (Adjusted OR:6.89; CI:2.79-17.01,p < .001). CONCLUSIONS: Direct physical contact with butterflies/moths was associated with significantly increased odds of SHAPU cases.

Diagnostic features of the presumed focal viral retinitis: A case series.

INTRODUCTION: Other than well-known herpetic retinopathies like acute retinal necrosis, progressive outer retinal necrosis and cytomegalovirus retinitis, there are few reports on atypical forms of viral retinitis caused by herpes virus from around the world. CASES: Presenting symptom was sudden onset of diminution of vision in all 6 cases. Mean duration of symptoms at presentation was 7.6 days. The mean age was 27.3 years (range 22-40 years). All were immunocompetent (4 females and 2 males), with unremarkable review of system. All had unilateral involvement. Presenting visual acuity ranged from CFCF to 6/60. Granulomatous anterior uveitis was present in 4 cases. All had focal retinitis with irregular margins, either juxtapapillary, macular or over one of the major vascular arcades. The diagnosis of focal viral retinitis was made solely based upon the clinical findings. All recovered after a course of oral acyclovir (one was given additional intravitreal acyclovir as well) and oral prednisolone, with final visual acuity of 6/6P to 6/9 in all except one. CONCLUSION: In case of focal retinitis with irregular margin, viral etiology should be borne in mind. Clinical features are typical enough to help in diagnosing without PCR test.

Microbiological patterns of endophthalmitis in a tertiary level hospital of Kathmandu, Nepal.

INTRODUCTION: Endophthalmitis is a serious ocular infection that can result in blindness and therefore is a major ophthalmic concern. The study was conducted to find out the microbial etiology in clinically diagnosed cases of endophthalmitis and to determine the antibacterial susceptibilities of bacterial isolates in vitro. MATERIALS AND METHODS: A retrospective analysis was carried out of all patients presenting between 15th January 2012 to 15th January 2013 with clinically diagnosed Endophthalmitis at Tilganga Institute of Ophthalmology (TIO). Intraocular specimens (aqueous or vitreous fluids) were collected from 102 patients. Along with intraocular aspirates, blood and urine specimens, chest X-ray from endogenous endophthalmitis and corneal scrapes from corneal ulcer leading to endophthalmitis were also collected. The intraocular specimens were then subjected to microbiological evaluation. Antibiotic susceptibility of isolates were determined for different ocular antibiotics using the Kirby-Bauer disk-diffusion test. RESULTS: Samples from 102 patients diagnosed with endophthalmitis underwent microbiological analysis, of which culture positive 34(33.33%). Out of 34, 29 (85.29%) had bacterial growth and the remaining 5 (14.70%) had fungal growth. Most of them (40.8%) were secondary to cataract surgery(postoperative). A total of 29 bacterial culture reports, 72.41% were gram-positive and 27.58% were gram-negative. Streptococcus pneumoniae (37.93%) was the most frequently isolated organism. The antimicrobial sensitivity for isolates was as follows: Ofloxacin - 86.2%, Chloramphenicol - 82.75%,Cefazolin- 82.7%, Gentamicin - 75.8%, Ceftazidime - 58.6%, Amikacin - 55.17% and Vancomycin - 51.7%. CONCLUSION: The data highlights low culture positivity and a predominance of gram positive bacteria as the major causes of infectious endophthalmitis, usually following cataract surgery. The most common isolate was Streptococcus pneumoniae. Ofloxacin and Chloramphenicol demonstrated greatest efficacy against these bacterial isolates.

Continuous Knowledge Translation in Action: Designing a Programmatic Research Trial for Equitable Eye Health for Rural Nepalese Women.

Reaching vulnerable populations through programmatic eye health interventions requires a focus on not only the intervention strategies, but the adaptability of the program design process itself. Knowing who is left behind and why solutions that will be effective on the ground at the time of implementation are not necessarily generated. There is a need for eye health programmatic design processes that can trial interventions and allow for continuous knowledge translation along the way. In rural Nepal, women are impacted by multiple and interconnected determinants of health, as well as unique barriers to accessing information and services, requiring targeted programming strategies. This article describes a programmatic design and knowledge translation process that aims to increase women's uptake of eye health services in rural Nepal. The article outlines key learnings of this knowledge translation process, and how this may contribute to addressing gender equity in eye health.

Outcome of cataract surgery in eyes with uveitis.

PURPOSE: To assess the outcome of cataract surgery in patients with uveitis without the use of prophylactic high dose (> 5-10 mg/day) systemic steroid. METHOD: A hospital based prospective study enrolling 64 eyes of 60 patients with uveitis and cataract from May 2013 to April 2014 having intraocular inflammation under control for at least 3 months preoperatively and underwent phacoemulsification with in bag placement of foldable acrylic intraocular lens (IOL). RESULTS: Twenty six male and 34 female were included with mean age of 47.23 ± 16.85SD (16-85) years. In 43.75 % of eyes the uveitis was idiopathic followed by sarcoiduveitis (18.7%), Herpetic uveitis (15.6%), Tubercular uveitis (6.2%), VKH (4.6%), HLAB 27(4.6%), Behcet's, endogenous endophthalmitis, Wegener's granulomatosis and lepromatous uveitis (1.5% each). Anterior chamber cell count was grade 1+ in 33 eyes (51.56%) on 1st post-operative day and in 29 eyes (45.31%) on second follow up. Out of total 11 eyes (17.18%) that developed fibrin, 7 eyes were treated with subconjunctival injection of dexamethasone with half hourly topical steroid drops. Other 4 eyes that developed fibrin responded to half hourly topical steroid. Dose of oralprednisolone increased in 6 patients in early post operative duration. At the final follow up, 50 eyes (92.58% ) had improvement in best corrected visual acuity and cystoidmacular edema (CME) in 5% (n=3) eyes. CONCLUSION: Even without the use of preoperative high dose of oral steroid, inflammation was under control with significant improvement in visual acuity 3 months postoperatively.

New Clinical and Laboratory Findings of SHAPU.

INTRODUCTION: The cause of Seasonal hyperacute panuveitis (SHAPU) also known as seasonal endophthalmitis is not yet confirmed. So far, bacteria have been isolated from the vitreous of three cases, VZV from the aqueous of one case and anellovirus from the vitreous of 30 cases of SHAPU. Its connection with moth is still assumed but not proven yet. OBJECTIVE: To study the clinical and microbiological features of SHAPU. To find out indirect evidence of it connection with moths. METHOD: Prospective longitudinal study of all the cases of SHAPU observed at Tilganga Institute of Ophthalmology in 2009 and 2010. A detailed ocular examination was performed on each case and vitreous fluid was removed from almost all cases for microbiological study. RESULT: 66 cases of SHAPU were identified. Most were children. Twenty-three percent reported a recent history of white moth contact. Fine brown hairs, were present in 5 eyes. Bacteria were isolated from the vitreous of 9 eyes, PCR testing of the vitreous of all 48 cases showed no evidence of HSV, VZV or CMV DNA. Twenty of 34 cases (58.8%) who presented within 7 days of onset of symptoms had a final visual acuity ≥ 6/60 whereas 4/25 cases (16.0%) who presented after 7 days had final visual acuity ≥ 6/60 (p=0.001). CONCLUSION: Herpes group of virus is the less likely cause of SHAPU. Bacteria are found in more cases. Early presentation is associated with a better visual outcome. Role of moth in its pathogenesis is still suspected.

Acute Endophthalmitis after Intravitreal Bevacizumab Injections at The Tertiary Centre in Nepal.

INTRODUCTION: There are many reports of endophthalmitis following Anti- VEG F use in developed countries and from India, but there are none from Nepal yet. Therefore, the aim of this study was to report the prevalence and management of acute endophthalmitis after intravitreal injection of bevacizumab. METHODS: This is a clinical, retrospective, non-comparative study, performed in Tilganga Institute of Ophthalmology, Kathmandu, Nepal from Jan 2015 till Dec 2016. All consecutive cases of intravitreal 1.25 mg of bevacizumab injections during the study period were collected from Bevacizumab registry of the operation theatre. A total number of endophthalmitis, following intravitreal bevacizumab injections were collected from Endophthalmitis registry. The statistical analysis was carried out by SPSS for percentage calculation and its 95% Confidence Interval (CI) calculation. RESULTS: There were 4182 injections performed during the study period for various retinal conditions. Two eyes of two patients with acute postoperative endophthalmitis were identified in the first week following intravitreal injections of 1.25 mg bevacizumab among a total of 4128 injections with a prevalence of 0.048% (95% CI: 0.00 to 0.12.). CONCLUSIONS: The prevalence of acute endophthalmitis following intravitreal Bevacizumab in our retrospective series was 0.048% and was comparable with the other studies conducted elsewhere. Acute post-injection endophthalmitis following intravitreal bevacizumab can result in severe loss of vision. Therefore prompt recognition and treatment are important part of its management in such patients.

Patterns of Uveitis and Scleritis in Nepal: A Tertiary Referral Center Study.

PURPOSE: To analyze the patterns of uveitis and scleritis at the tertiary referral center in Nepal. METHODS: A retrospective review of uveitis and scleritis cases at Tilganga Institute of Ophthalmology in 2014. RESULTS: A total of 1113 uveitis, 73 scleritis, 35 sclerouveitis cases were reviewed. Anterior uveitis (590, 53%) was most common, followed by panuveitis (20%), intermediate uveitis (14%), then posterior uvietis (12.9%). The most common causes of anterior, pan, and posterior uveitis were herpetic disease (15.1%), SHAPU (15.2%) and toxoplamosis (27.1%) respectively. The most common cause of scleritis & sclerouveitis was Tuberculosis (15.1%, 31.4% respectively). CONCLUSION: Herpetic disease, toxoplasmosis, tuberculosis and SHAPU were common infections.