A New Ray of Hope in the Treatment of Seasonal Hyperacute Panuveitis: Could Intravitreal Triple Combination Therapy of an Antibiotic with Dual Steroids Play a Pivotal Role?

INTRODUCTION: Seasonal Hyperacute Panuveitis (SHAPU) is a blinding disease in Nepal with unknown aetiology. Henceforth, we proposed to study the treatment outcome of a triple intravitreal combination therapy of dual steroids triamcinolone (long-acting steroid) and dexamethasone (short-acting steroid) along with antibiotic moxifloxacin for patients with severe stage of SHAPU. METHODS: A prospective study was conducted among the SHAPU patients presenting in severe stages during the September to December 2023 outbreak. Intravitreal injection of 4-mg preservative-free triamcinolone acetonide (4 mg/0.1 ml) with intravitreal dexamethasone injection (0.4 mg/0.1 ml) and 0.5 mg/0.1 ml of moxifloxacin was given in the operating theatre. Best corrected visual acuity, intraocular pressure measurements, vitreous haze and fundus evaluation, were assessed to determine the treatment outcome on examination on day 7 and day 30 following intravitreal combination therapy. RESULT: A total of 6 patients (2 female and 4 male) were enrolled. At presentation, the mean BCVA was 2.40 ± 0.30 logMAR, mean intraocular pressure was 12.8 mmHg and vitreous haze was 4+ haze in all cases. The evaluation on the 7th day and 30th after injection showed significant improvement in BCVA (p value = 0.039; p value = 0.040, respectively). The change in the IOP at day 7 (p value = 0.85) was insignificant. However, the IOP change was significant at day 30 (p value = 0.5). Similarly, there was a marked reduction in the vitreous haze with better fundus visibility after treatment. CONCLUSION: This study depicted that steroids prevent the dreaded complication of hypotony due to ciliary shutdown by combating severe inflammation, thus adding new hope to the armamentarium of SHAPU management.

Seasonal Hyperacute Panuveitis (SHAPU) Outbreak Amidst COVID-19 Pandemic.

PURPOSE: To document the demographic profile of the SHAPU outbreak amidst the COVID-19 pandemic. METHODS: A multicentric cross-sectional study of the 2021 SHAPU outbreak during the second phase of the COVID-19 outbreak. RESULTS: A total of 135 patients were diagnosed with SHAPU from August to December 2021, 77 (57%) were children <16 years, males 54.8% and 34.8% had direct physical contact with white moths and 41.5% had severe type of SHAPU. Dramatic increment in the moth abundance was noted in these outbreak sites. Few cases presented with atypical ocular findings, unlike past outbreaks. Due to the ongoing COVID-19 pandemic with restrictions on travel and transportation, timely management was difficult and good visual outcome was achieved only in mild-moderate cases with an early presentation. CONCLUSION: The surge in the number of SHAPU patients, its occurrence in areas previously unreported, and some atypical presentation added raised suspicion of a possible link between COVID-19 and SHAPU.

Increase in SHAPU patients, incidence in unreported areas of Nepal, atypical ocular presentations and shift in disease affection from children towards adults population have raised doubt between connections between SHAPU, white moths and COVID pandemic.

Pattern visual evoked potential and foveal sensitivity in amblyopia.

PURPOSE: Amblyopic eyes show impaired visual functions such as poor visual acuity and reduced foveal sensitivity. The purpose of this study was to determine the association between foveal threshold and visual evoked potentials (VEP) in strabismic and anisometropic amblyopia. METHODS: Forty-five subjects (age range: 7-28 years, 43.3% female) including 15 strabismic and 15 anisometropic amblyopes, and 15 age-similar control subjects participated in this study. Each subject had pattern visual evoked potentials and foveal threshold recorded in each eye using RetiScan (Roland Consult, Germany) and Humphrey Visual Field Analyzer II (HFA II; Carl Zeiss Meditec Inc., Dublin, CA), respectively. These outcomes were compared among the amblyopic eyes, their fellow eyes, and the control eyes. RESULTS: Compared to the amblyopic eyes (Mean ± SD: 33.4 ± 3.48 dB), the foveal threshold was higher in fellow eyes (37.0 ± 2.04 dB, p = 0.0002) and in control eyes (38.7 ± 0.96 dB, p < 0.0001). Strabismic amblyopes had a lower foveal threshold than anisometropic amblyopes (31.8 ± 3.86 vs. 35.0 ± 2.17 dB, p = 0.005). Relative to the P100 peak time in fellow eyes (1° checks:116.1 ± 9.00 ms; 0.25° checks:118.8 ± 5.67 ms), amblyopic eyes had delayed P100 peak times for both 1° (122.7 ± 11.4 ms, p < 0.0001) and 0.25° (130.4 ± 11.2 ms, p < 0.0001) check sizes. There were also significant differences in P100 peak time between amblyopic and control eyes (1°:122.7 ± 11.4 vs.112.4 ± 5.01 ms, p = 0.15; 0.25°:130.4 ± 11.2 vs.113.9 ± 5.71 ms, p < 0.0001) and between fellow and control eyes (0.25°:118.8 ± 5.67 vs.113.9 ± 5.71 ms, p = 0.009). Amblyopic eyes exhibited lower N75-P100 amplitudes than fellow eyes (1°:12.6 ± 7.96 vs.15.9 ± 8.82 µV, p = 0.01; 0.25°:10.6 ± 6.11 vs. 15.8 ± 10.6 µV, p = 0.001) and control eyes (0.25°: p = 0.0008). Foveal threshold correlated negatively with P100 peak time (1°: r = -0.45, p = 0.002 and 0.25°: r = -0.58, p < 0.0001) and positively with N75-P100 amplitude responses (1°: r = 0.42, p = 0.004 and 0.25°: r = 0.52, p = 0.002). CONCLUSIONS: Amblyopic eyes showed reduced pattern VEP amplitudes and delayed peak times with significant associations with the foveal sensitivity. However, the VEP measures overlapped extensively between amblyopic and control eyes with no apparent criterion value for optimal discrimination, suggesting that foveal sensitivity might be a better discriminator of amblyopia than pattern VEP.

Visual Impact of Digital Classroom among Students Attending Online Education.

BACKGROUND: COVID-19 outbreak has changed the traditional teaching method of using blackboards to digital devices assisted online classes. Spending long hours in front of digital devices might lead to different ocular problems in children. METHODS: A cross-sectional study was conducted among school-going children attending digital online classes during the COVID-19 pandemic. A web-based online form was used to evaluate the impact of digital classrooms on the visual status of school-going children. Children were selected from 5 randomly selected schools from different parts of Kathmandu Valley who had online classes for at least 2 hours during the COVID-19 pandemic era. RESULTS: A total of 303 usable responses were obtained from a response rate of 41% with an average age of 10 years. Sixty-four percent of children had online classes up to 6 hours a day and 44% used laptops for online classes followed by smartphones (38%). The most common symptom was headache affecting 39.3% of the children, followed by difficulty seeing bright light (35%) and itching of the eyes (35%). Forty percent of the children felt that their eyes were affected after online class. Multivariate analysis showed that the total duration spent on digital devices was the greatest risk factor associated with the ocular symptoms. CONCLUSIONS: Ocular symptoms and digital eye strain related to the excessive use of digital devices have increased due to the increased duration of online classes. Awareness about the prevention and measures to reduce the adverse effects should be stressed.

Ocular toxicity among patients taking anti-tubercular treatment.

INTRODUCTION: Tuberculosis remains a major public health problem in Nepal and anti-tubercular drugs used for the treatment of pulmonary and extrapulmonary tuberculosis can be associated with ocular toxicity. This prospective study aimed to evaluate the incidence of ocular toxicity among patients receiving anti-tubercular therapy and to assess the change in visual functions and ocular imaging before and after use of anti-tubercular therapy. MATERIALS AND METHODS: A total of 89 eyes of 45 TB patients taking anti-tubercular therapy were enrolled. Detailed history and examination including best-corrected visual acuity (BCVA), colour vision (Farnsworth D-15t), contrast sensitivity (Pelli-Robson chart), Goldman visual field analysis and spectral domain optical coherence tomography for retinal nerve fibre layer (RNFL) analysis were assessed at baseline and at 6 months after starting anti-tubercular therapy. Visual evoked potential (VEP) was performed in suspected cases. RESULTS: The mean age of the patients was 29.13±14.00 years and 62.2% were males. The mean weight of the subjects was 54.37±10.36 kg, mean daily dosage of ethambutol was 17.91±1.74 mg/day/kg and mean administration duration was 2.71±1.54 months. The incidence of ocular toxicity was 2.24%. Bilateral retrobulbar optic neuropathy occurred in a 27-year female of 55 kg receiving ethambutol (20 mg/kg/day) for 6 months for Pott's spine. Her best-corrected visual acuity in both eyes was reduced to 6/36 from 6/6 and developed non-specific color vision defect, decreased contrast sensitivity, bilateral cecocentral visual field defect and mean decrease in retinal nerve fibre layer thickness compared to the baseline data. In rest cases, a statistically significant decrease in mean retinal nerve fibre layer thickness in both eyes suggested the evidence of subclinical toxicity. CONCLUSION: Though less common, ethambutol toxicity can occur in patients under anti-tubercular therapy in the form of retrobulbar optic neuritis. Decreased contrast sensitivity and thinning in the mean retinal nerve fibre layer thickness can be the indicator of subclinical toxicity.

Does outer retinal layer thickness correlate with the central visual field indices in early dry age-related macular degeneration?

PURPOSE: Age-related macular degeneration (ARMD) is the leading cause of irreversible blindness worldwide and Nepal is one among them. We aimed to determine the relationship between outer retinal layer thickness parameters with central visual field indices in early dry ARMD cases among Nepalese population. MATERIALS AND METHODS: The subjects for this descriptive, cross-sectional study comprised 40 patients with early dry ARMD from the ophthalmology department of a tertiary level hospital of Nepal. The retinal layer thickness was measured with spectral-domain optical coherence tomography (SD-OCT), and the visual field indices were assessed using the 10-2 protocol of Humphrey visual field analyzer (HFA). Thus, the retinal layer structures correlated with visual field indices among our population. RESULTS: Among our early dry ARMD population, the foveal threshold (FT) was found to be significantly correlated with retinal pigment epithelium (RPE) elevation (P < 0.01, r = -0.541), outer segment (OS) length (P = 0.02, r = 0.465), and inner segment ellipsoid (ISe) band disruption (P = 0.01, r = -0.499), but not with presence of hyperreflective foci (P = 0.464), RPE thickness (P = 0.612), and central macular thickness (P = 0.214). However, no significant correlation between mean deviation and pattern standard deviation of visual field with retinal layer thickness parameters was identified. CONCLUSION: In early dry ARMD, a reduced FT is significantly correlated with the integrity of the ISe band, thinning of OS length, and drusen-associated RPE elevation. The results highlight the utility of both SD-OCT retinal layer measurement and central visual field testing by HFA in ARMD to monitor the progression of the disease.

Clinical Evaluation and Treatment Outcome of Traumatic Optic Neuropathy in Nepal: A Retrospective Case Series.

This study aims to report the clinical features and role of different treatment modalities in final visual outcome in traumatic optic neuropathy (TON). The authors retrospectively reviewed the records of patients with TON over 4 years. There were 37 patients of unilateral TON. Mean age was 28.70 ± 15.20 years (range: 8-90) and 89% (n = 33) were males. Road traffic accident was the common cause (43.2%), followed by fall injury (35.1%). There was improvement of visual acuity in 51.4% (n = 19) cases. Out of different treatment modalities, high-dose intravenous methylprednisolone (1 g/day) led to significant improvement in final visual acuity (p = 0.013). There was no significant improvement in final visual outcome in patients with poor initial visual acuity and those with intracranial injuries.