Alarm Fatigue among Nurses Working in Critical Care Setting in a Tertiary Hospital, Nepal.

Background Alarm fatigue is a well-recognized patient safety concern in critical care settings. It occurs when nurses become overwhelmed by the total number of alarm signals which can result in alarm desensitization and eventually contributes to missing of serious and important changes in a patient's condition, thus failing to respond properly. Objective To find out alarm fatigue and its associated factors among nurses working in critical care setting. Method A cross-sectional study design with convenient sampling technique was used to select 56 nurses working at different critical care settings in Dhulikhel Hospital. A selfconstructed semi structured questionnaire and nurses alarm fatigue questionnaire was used for the survey. Frequency, percentage, mean and standard deviation were used for descriptive statistics whereas Independent t-test and One-way ANOVA were used for inferential statistics. Result The result shows that more than half of the nurses were less than 25 years, single and more than two-third of the participants worked in Adult Intensive Care Unit. Out of total obtainable score 44, the overall mean score of the Alarm Fatigue was 28.03±12.813. The result showed that there was no significant difference between alarm fatigue and selected socio-demographic and work related characteristics. Conclusion The alarm fatigue among nurses working in critical care settings was found to be higher in this study. Since alarm fatigue is directly related to patients' safety, the effective management of medical device alarms can reduce alarm fatigue and prevent potentially dangerous outcomes.

Behcet's Disease with Absent HLA Serotyping and Pathergy Test.

Behcet's disease is a multisystemic vasculitis of unknown etiopathogenesis characterized by recurrent acute inflammation. A 30-year male presented with progressive blurred vision in both eye for one month associated with photophobia, redness and ocular pain. On presentation best corrected visual acuity was 6/9 both eyes. Bilateral ocular examination of anterior segment demonstrated occasional cells. Treatment history of multiple joint pain along with oral aphthous ulcers. Erythematous papulopustular lesion over face, neck, trunk and genital ulcers were being treated. Irrespective of negative human leucocyte antigen B51 and pathergy, patient was diagnosed as Behcet's disease on the basis of clinical criteria and started with topical steroid and cycloplegic. At one-month, ocular symptoms were relieved. Behcet's disease is a rare, autoimmune disease, which lacks universal pathognomonic test and investigations, therefore diagnosis is primarily done with international criteria for Behcet's disease. Multidisciplinary approach certainly helps in early diagnosis and eliminating morbidity.

A Case of Rare Choroidal Tumor, Choroidal Osteoma.

Choroidal osteoma is a rare benign tumor of unknown etiology, commonly found in young asymptomatic females in their second or third decade of life. It typically appears as an orange-yellow to yellow-white lesion in juxtapapillary region which can extend over to involve macula. Lesion solely located in macular region is less common. Diagnosis is based on fundoscopic appearance and findings of ancillary tests like B scan ultrasonography, optical coherence tomography (OCT), fundus fluorescein angiography (FFA) and computerized tomography (CT) scan. We report a case of unilateral macular choroidal osteoma in a fifteen-year-old girl with normal vision.

Outcome of cluster endophthalmitis in western plain region of Nepal.

BACKGROUND: Post-operative endophthalmitis remains one of the most visually devastating complications of cataract surgery. Cluster endophthalmitis is defined as five or more cases of endophthalmitis occurring on a particular day in a single operating room in one centre. Excessive inflammation, particularly in the early post-operative phase, should be regarded as infective endophthalmitis. Early diagnosis and immediate intervention in such case, lead to salvage of eye as well as better visual outcome. OBJECTIVE: To find out the causative organisms and visual outcome after an outbreak of post-operative endophthalmitis in high volume cataract surgical centre. MATERIALS AND METHODS: Retrospective, interventional case series of 19 patients with acute post-operative endophthalmitis after manual small incision cataract surgery in a single day, underwent vitreous tap and received intravitreal Vancomycin, amikacin and Dexamethasone. Subconjunctival vancomycin was given at the end of the procedure. Vitreous samples were stained using Grams stain, Giemsa stain and KOH mount. Samples were sent to the hospital's microbiology laboratory for culture and sensitivity testing. All patients received intravenous ciprofloxacin for 3 days and oral ciprofloxacin for 7 days. Topical Prednisolone acetate, Ofloxacin, Gentamycin and atropine were given to all patients. Patients were followed up till 6 weeks. RESULTS: 10 eyes had vitreous tap culture negative (52.6%) where as 9 eyes (47.4%) had bacterial culture growth. The culture reports showed 4 cases (21%) of Staphylococcus epidermidis, 3 cases (15.8%) of Staphylococcus aureus and 2 cases (10.5%) of mixed growth. 48 hours after the intervention, 15 patients improved clinically. On sixth week follow up, 7 eyes (37%) had visual acuity better than 6/18, 7 eyes had 6/18 to 6/60 and 5 eyes had visual acuity between 1/60 to 5/60. CONCLUSION: Intravitreal antibiotics and steroid, along with systemic ciprofloxacin and subconjunctival vancomycin has good visual outcome for post operative cluster endophthalmitis.

Childhood blindness and visual impairment in the Narayani Zone of Nepal: a population-based survey.

Purpose: To estimate the prevalence and causes of blindness (BL), severe visual impairment (SVI), moderate visual impairment (ModVI) and mild visual impairment (MildVI) in children in Narayani Zone, Nepal. Methods: In 2017, 100 population clusters within the Narayani Zone of Nepal were selected using RAAB software. Children (aged 0-15 years) suspected of having visual problems were identified using Key Informants (KIs) and school teachers and were referred for ophthalmologic examination. Eye care staff actively sought children who failed to present for examination. Causes of BL/SVI/ModVI/MildVI were categorized using standard World Health Organization definitions. Results: Of 76,588 children selected, 72,900 (95%) were screened. Of 2,158 children referred for examination, 1,322 were referred by teachers and 836 by KIs. A total of 1,617 (75%) children received a detailed examination, of whom 128 children [65 girls (51%)] mean age of 9.4 (± 4.1 years) were confirmed to have BL 7 (5.5%), SVI 16 (12.5%), ModVI 19 (15%) or MildVI 86 (67%). The combined prevalence of BL/SVI/ModVI/MildVI was 175/100,000 (95% CI 172-178/100,000); BL/SVI/ModVI was 55/100,000 (95% CI 53-57/100,000) and the combined BL/SVI estimate was 30/100,000 (95% CI 29-31/100,000). The leading causes of BL/SVI/MVI were refractive error 23 (55%) and whole globe disorders 5 (12%). Total avoidable causes were 31 (74%). Conclusion: The prevalence of BL/SVI/ModVI among children in Narayani Zone was moderate and included a high proportion of avoidable and treatable cases. Pediatric ophthalmic services need improvement, mainly refractive error correction in rural areas of Nepal.

Retinopathy in a diabetic population.

AIMS AND OBJECTIVES: The study was conducted with the aim to find out the prevalence of diabetic retinopathy among diabetics on treatment, to find out the presence of associated risk factors and to determine the knowledge of diabetic retinopathy among patients with diabetic mellitus. METHODOLOGY: Cross sectional screening of 316 diabetic patients on treatment presenting to Kalimati Diabetic Clinic and Kathmandu Medical College was done over a period of 8 months for the presence of diabetic retinopathy, associated risk factors and the knowledge of diabetic retinopathy. RESULTS: 21% of the known diabetics had evidence of various grades of diabetic retinopathy although 75.3% of the enrolled patients had history of diabetes mellitus of less than 10 years. Associated risk factors were present in 66.46%. However, only 50% diabetics had the knowledge of diabetic retinopathy. CONCLUSION: As 21% of the diabetic patients on treatment had various grades of diabetic retinopathy and 50% of the diabetic patients were not aware of diabetic retinopathy, emphasis has to be given for the awareness of ocular involvement in diabetes mellitus such that blindness from retinopathy can be prevented. The responsibility lies on treating physicians or Diabetic Centres for referral of diabetic patients for ophthalmic evaluation. Similarly, control of associated risk factors like hypertension, hyperlipidemia is equally important.

Visual outcome of laser treatment in diabetic retinopathy.

OBJECTIVE: To determine the visual outcome of laser treatment in diabetic retinopathy. DESIGN: Prospective, non-comparative case series. MATERIALS AND METHODS: A total of 80 eyes of 50 patients with diabetic retinopathy in different stages were photocoagulated using diode green laser. Focal laser only was given in 46 eyes and pan retinal photocoagulation only was given in 29 eyes while 3 eyes received focal laser and pan retinal photocoagulation. One eye was given grid laser only and one eye received both grid and focal laser. The best corrected visual acuity was noted and fundus examination was carried out prior to laser therapy and at the last follow-up and results were compared. RESULTS: Non- proliferative diabetic retinopathy was present in 76%. Following laser treatment, best corrected visual acuity improved in 52.50%, remained static in 35% and deteriorated in 12.5%. Maculopathy improved in 52%, remained static in 6% and deteriorated in 2% in right eyes while there was no maculopathy in 40% in right eyes. Similarly, maculopathy improved in 38% and remained same in 10% while 52% had no maculopathy in left eyes. After laser treatment, NVD (OD) regressed in 6% and remained unchanged in 4%. Similarly, NVE (OD) regressed in 18% and remained unchanged in 4% and NVE (OS) regressed in 18% and remained unchanged in 2% following laser therapy. CONCLUSION: Timely and adequate laser treatment helps in saving the vision in patients with diabetic retinopathy.

Retrospective study on outcome of macular hole surgery.

INTRODUCTION: Macular hole is a common and treatable cause of central visual loss. Classic macular hole surgery consists of vitrectomy, posterior vitreous cortex removal and intraocular gas tamponade, but during the past decade focus has especially been on internal limiting membrane (ILM) peeling as adjuvant therapy for increasing closure rates. OBJECTIVE: To determine and evaluate anatomical and visual outcome of macular hole surgery. MATERIALS AND METHODS: Retrospective analysis of all cases of macular hole surgery done by single surgeon between 2014 -2015. RESULTS: 16 eyes were analysed with follow up of 3 months. Macular hole closure after vitrectomy was 75% with visual improvement of two or more line in 62.5%.Post surgical complication included cataract 18.8%, Increased IOP 12.5% and retinal detachment 6.2%. CONCLUSION: Vitrectomy along with ILM peeling and Gas Tamponade with effective positioning improves in visual acuity and achieve hole closure in people with macular hole.

Clinico-epidemiological characteristics of central retinal vein occlusion in a tertiary level eye care center of Nepal.

BACKGROUND: Central retinal vein occlusion (CRVO) is one of the common retinal disorders causing severe visual impairment. OBJECTIVE: To study the clinical profile, risk factors and visual outcome in central retinal vein occlusion. MATERIALS AND METHODS: Seventy-four eyes of 74 patients with central retinal vein occlusion were retrospectively enrolled during the period of one year. All the patients in the study were classified with regard to their ischemic status into two groups, ischemic CRVO and non-ischemic CRVO. The demographic pattern of the patients was recorded. The other parameters studied were visual acuity, history of glaucoma, hypertension, diabetes mellitus and hyperlipidemia. The patients were followed up at 1 month, 3 months and 6 months after treatment. RESULTS: The majority of the patients (n = 49, 66.2 %) had the ischemic type of CRVO, whereas, 25 (33.8 %) of them had the non-ischemic type. The CRVO was more commonly observed in males in both the groups. Hypertension was the most common risk factor associated with CRVO. The visual improvement was significantly better in non-ischemic CRVO (RR = 0.04, 95% CI = 0.01 - 0.31, p = 0.000). CONCLUSION: The CRVO was more common in males than in females. It was associated with systemic hypertension. The ischemic type of the CRVO was more prevalent than the non-ischemic one in this study. Visual outcome was better in the non-ischemic CRVO.

Scleral buckle surgery for pseudophakic and aphakic retinal detachment in western Nepal.

INTRODUCTION: Retinal detachment remains one of the most serious complications of cataract surgery. Treatment of this condition has represented a challenge for vitreoretinal surgeons.Scleral buckle (SB) surgery is one of the treatment options in pseudophakic and aphakic retinal detachment (RD). AIMS: To find out the anatomical and visual outcome of SB in pseudophakic and aphakic RD. SUBJECTS AND METHODS: Retrospective case series of 46 consecutive eyes of 46 patients with RD (38 pseudophakic and 8 aphakic eyes) that had undergone conventional SB surgery were reviewed from patient files. Postoperative retinal status at 3 weeks, 6 weeks and 3 months were recorded to see the anatomical success rate after retinal reattachment surgery. Best corrected visual acuity (BCVA) at 3 months follow-up was noted. RESULTS: The mean age of the patients was 54.28 ± 13.49 years. Forty eyes (86.9 %) had primary attachment by 6 weeks duration. Five eyes had undergone repeat surgery within a six-week duration (pars plana vitrectomy). Forty patients had follow-up visit to 12 weeks, achieving retinal attachment in 37 eyes (80.5 %). Best corrected visual acuity (BCVA) at 3 months was better than 6/60 in 18 eyes (39.1%), BCVA better or equal to 1/60 but less than 6/60 in 18 eyes (39.1%) and BCVA less than 1/60 in 4 eyes (8.7 %). CONCLUSION: Conventional scleral buckling has good outcome for pseudophakic and aphakic RD and can be useful for patients in peripheral eye hospitals where patients cannot afford high cost surgeries.

Retinal detachment surgery at Nepal Eye Hospital.

INTRODUCTION: Retinal diseases are one of the important causes of blindness in Nepal. This study is done with objectives of finding the outcome of retinal detachment surgery. METHODS: A retrospective analysis of 110 patients who underwent retinal detachment surgery over five year period was conducted in Nepal. RESULTS: Retinal re-attachment was achieved in 94.4% and postoperative visual acuity of 6/36 to 6/6 was achieved in 52.7% (As possible risk factors, myopia was present in 34.5% ophkia in 29%, trauma in 9%, and lattice) degeneration was 5.4%. CONCLUSIONS: The study has shown a promising result for the retinal detachment surgery.

Barriers to up take cataract surgery in Gandaki Zone, Nepal.

OBJECTIVE: Cataract though avoidable remains as leading cause of blindness in Nepal. Though, Himalaya Eye Hospital rendering high quality surgical service through its base hospital and out reach service in Gandaki Zone having cataract surgical rate is below 1500 per million. Therefore, it is mater of interest to investigate the reason and the finding would be helpful to plan the future cataract programme to CSR to desirable level, if we know the reason(s) that forced them living as blind in community and not seeking available surgical services. METHOD: All person with cataract affecting their visual acuity to <6/60 (corrected) in either eye found in stratified cluster design sampling were enrolled in the study. They were interviewed with structured questionnaire investigating their knowledge and attitude of their visual impairment and barriers for not seeking cataract surgical service to date. RESULTS: A total of 303 eligible subjects were enrolled in the study. Out of them 57.8% of people knew about the cataract and they also think their vision impairment is due to cataract. But 56.11% of people were not aware their vision will improve. Surgical camp attendant or operated patients were found to be effective media to spread the message that the cataract is curable. Among the barriers: fear for surgery 31.1%, lack of attendant and geographical distance 32.8%, financial 24.1% and other clinical reason were found to be 12% as a reason for not seeking available surgical service. CONCLUSION: The cataract service marketing, eye health education disseminating the information on cataract and its curability is not found to be adequate. Therefore, the future cataract programme should give more concentration on creating awareness on cataract and subsidizing the available surgical service and service need to be brought to more proximity for the needy poor people.

Intermediate uveitis: a hospital based study.

UNLABELLED: Intermediate uveitis affecting pars plana, peripheral retina and underlying choroid affects primarily healthy children and young adults. OBJECTIVE: To study the components of intermediate uveitis at Nepal Eye Hospital in the year 2003 August to 2004 March. MATERIALS AND METHODS: A prospective study was done in patients with intermediate uveitis visiting Nepal Eye Hospital. Sample size was 50. Specially designed proforma of intermediate uveitis was used to collect particulars of the patients, history, clinical examination findings, investigation reports, management protocols used and the final visual outcome. RESULTS: Intermediate uveitis was seen more in 20 to 29 years age group (38%) and more prevalent in males (52%). Among the study population farmers constituted maximum proportion (36%) and Mongoloid origin was mostly affected (30%). High number of patients were from the central development region with highest proportion from Dhading district (34%). Anterior segment affection with keratic precipitates and anterior chamber cells were noted in 72% of involved eyes. Vitreous cells were noted in all affected eyes while 4% had vitreous snow banking and 3% had vitreous snow balls. Most of the patients (52%) received between topical steroid and posterior subtenon injection of Triamcinolone. Visual Acuity was improved in 52% of cases and remained static in 46%.while deteriorated in 2%. CONCLUSION: Significantly high number of patients with intermediate uveitis has been reported from the central development region mainly from Dhading Kathmandu and Nuwakot districts People in their third decade were found to be commonly involved and Mongloid origin were more commonly affected Anterior chamber spill over was seen in higher percentage of patients than described in literature As the patients presented in milder forms visual acuity improved is of cases with the treatment protocol followed.

Visual outcome of vitrectomy in seasonal hyperacute pan uveitis.

INTRODUCTION: Seasonal Hyper Acute Panuveitis (SHAPU) is a sight threatening condition often affecting children. Its management as yet is a challenge in ophthalmic practice. Most of the eyes even after treatment end up in pthisis bulbi. MATERIALS AND METHODS: A retrospective hospital based analysis of 18 patients with SHAPU managed with vitrectomy at Himalaya Eye Hospital (HEH) Pokhara over a period of two years was carried out. RESULTS: Out of 18 patients 10 were males. Majority of them were below the age of 15 years. Best corrected visual acuity (BCVA) at presentation was less then 3/60 in 72% of them. BCVA was better then 6/60 in 7 (50%) out of 14 patients, who underwent vitrectomy. CONCLUSION: Vitrectomy is a useful procedure in management of SHAPU.

Analysis of 400 cases of posterior segment diseases visiting retina clinic of Nepal Eye hospital.

OBJECTIVE: To determine the disease pattern of 400 patients attending Nepal Eye Hospital for strategic planning. MATERIALS AND METHODS: A retrospective hospital based analysis of 400 cases visiting Retina Clinic of Nepal Eye Hospital (NEH) over a period of one year was carried out in order to know the disease pattern for planning purpose. RESULTS: Males slightly outnumbered females (58% versus 42%). The diseases were more common in age group 50 to 59 years. Diabetes mellitus with or without retinopathy was the commonest cause (20.25 %) for attendance in retina clinic followed by hypertensive retinopathy and venous occlusive disorders.