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.

Short term results of intra-vitreal bevacizumab for the treatment of macular edema secondary to retinal vein occlusion.

INTRODUCTION: Macular edema (ME) is the leading cause of visual impairment in retinal vein occlusion (RVO). OBJECTIVE: To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin; Genentech) on ME secondary to RVO. MATERIALS AND METHODS: A prospective, interventional study was conducted among patients with ME due to RVO from June 2008 to February 2010. Intravitreal bevacizumab (1.25 mg/0.05 ml) was given at 4 to 6 weekly intervals until the ME subsided. Complete ophthalmic evaluation and measurement of central retinal thickness (CRT) by optical coherence tomography (OCT) were performed at baseline and follow up visits. RESULTS: Thirty four eyes (18 CRVO and 16 BRVO) were included in the study. The mean duration of visual symptoms and follow up period were 5.1 months (range 0.3 - 24 months) and 7.5 ± 4.8 months respectively. In CRVO, the CRT improved from 652 ± 206 ?m at the baseline to 257 ± 132 ?m (p less than 0.0001) at the final follow up, and in BRVO, the CRT improved from 540 ±197 ?m to 219 ± 135 ?m (p 0.0001). The improvement in BCVA was significant at each follow up interval for BRVO; in CRVO, there was only a significant improvement between the baseline and the 6 weeks' follow up. BCVA was improved in 75 % cases of BRVO and in 61.6 % in CRVO at the final follow up. There were no ocular or systemic adverse effects. CONCLUSION: Intravitreal bevacizumab is an effective and safe drug for reducing ME and improving visual acuity secondary to RVO in the short term follow up.

Vitreo-retinal disorders at high altitude in Nepal.

INTRODUCTION: Nepal has many mountains including the highest one in the world. People living in high altitude are often involved in climbing mountains. OBJECTIVE: To explore the pattern of vitreo-retinal disorders at high altitude in Nepal. MATERIALS AND METHODS: Consecutive patients aged 40 years and older who presented at the micro-surgical eye camp at Lukla of Solukhumbu district (2,860 metres) were included. Detailed ocular and systemic histories and ocular examination including dilated fundus evaluation were done. RESULTS: There were a total 81 patients with the mean age of 56.7 years (S.D 11.15). Females (51.9 %) outnumbered males. Sherpa comprised of 76.5 % followed by Rai (9.8 %). The main occupation was agriculture (51.9 %) followed by mountain trekking (28.4 %). Smokers comprised of 13.5 %. Hypertension was the predominant systemic problem (28 %). The best corrected visual acuity of 6/18 and better was found in 86.4 % of cases and less than 3/ 60 in 3.6 % of cases. Age-related macular degeneration (AMD) was found in 19.6 % of cases with a predominant mild AMD (16 %), hypertensive retinopathy in 12.2 %, with grade I hypertensive change in 8.6 %, retinal vein occlusion (RVO) in 7.1 % of cases and with a branch RVO in 4.9 %. Dilated and tortuous retinal vessels were present in 25.9 % of cases; out of this, 9.8 % of the cases had concurrent AMD and/or hypertensive retinopathy. Other retinal problems were macular hole (2.46 %), solar retinopathy (2.46 %) and choroidal tear (1.2 %). CONCLUSION: AMD, hypertensive retinopathy, and RVO are the main vitreo-retinal disorders besides the dilated and tortuous retinal vessels in people living at high altitude in Nepal.

Demographics and awareness of diabetic retinopathy among diabetic patients attending the vitreo-retinal service at a tertiary eye care center in Nepal.

INTRODUCTION: Diabetic retinopathy (DR) is one of the leading causes of blindness in Nepal. OBJECTIVE: To investigate the demographic characteristics and awareness of diabetic retinopathy among new cases of diabetes mellitus (DM) attending the vitreo-retinal service of a tertiary eye care centre in Nepal. MATERIALS AND METHODS: A hospital-based, cross-sectional study including all consecutive new cases of DM was carried out. Detailed demographics of the subjects and their awareness of potential ocular problems from diabetes mellitus were noted. RESULTS: A total of 210 patients with a mean age of 57 +/- 10.4 years were included. Brahmins (34.8 %) and Newars (34.3 %) were the predominant ethnic groups. Housewives (38.6 %) and office workers (18.6 %) were the major groups affected. Two-fifths (37 %) of the cases were unaware of DR and its potential for blindness. Awareness was significantly higher among literate patients (P = 0.006). Fundus evaluation was done for the first time in 48.6 %, although almost four-fifths had a duration of diabetes of five years or more. DR was found in 78 % of the cases, with 16.7 % already at the proliferative stage and about 40 % exhibiting clinically significant diabetic macular edema. CONCLUSION: A lack of awareness of DR coupled with a high proportion of cases already at a sight-threatening stage of retinopathy at their first presentation reflects the need for improved awareness programs to reduce the burden of blindness from DR in Nepal.

Optical coherence tomographic assessment of macular thickness and morphological patterns in diabetic macular edema: prognosis after modified grid photocoagulation.

INTRODUCTION: The topographic mapping is useful for monitoring patients for the development of macular edema and following the resolution of edema after laser treatment. OBJECTIVES: To evaluate the usefulness of optical coherence tomography (OCT) for mapping of macula after laser therapy in clinically significant macular edema (CSME). MATERIALS AND METHODS: A prospective study was carried out enrolling 60 eyes of 35 patients with the diagnosis of CSME. OCT was performed at first visit and every successive follow up visit. The retinal thickness was measured automatically using OCT retinal mapping software. STATISTICS: Correlation between vision status and central macular thickness (CMT) was done using the Spearman's correlation test. The analysis of variance (ANOVA) and independent t-test were used for comparison of groups. RESULTS: The OCT revealed sponge like thickening pattern (ST) in 67.4 % followed by cystoid macular edema (CME) in 19.6 %. Best corrected visual acuity (BCVA) improved in 89.1 % after 6 months of treatment. There was high correlation between vision status and CMT (P =less than 0.001). The mean values of baseline CMT were 301.68 (+/-134.738), 434.83 (+/-180.758), 518.67 (+/- 275.184), 327 (+/-108.393) and 334.85 (+/- 158.91) microns for the OCT patterns of ST, CME, sub-foveal detachment (SFD), vitreo-macular interface abnormality (VMIA) and average CMT respectively (p=0.042). CONCLUSION: OCT is a useful tool for evaluating CSME. It can show the various morphological variants of CSME while the BCVA and CMT are fairly different.

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.