G6PD deficiency in malaria endemic areas of Nepal.

BACKGROUND: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is currently a threat to malaria elimination due to risk of primaquine-induced haemolysis in G6PD deficient individuals. The World Health Organization (WHO) recommends G6PD screening before providing primaquine as a radical treatment against vivax malaria. However, evidence regarding the prevalence and causing mutations of G6PD deficiency in Nepal is scarce. METHODS: A cross-sectional, population-based, prevalence study was carried out from May to October 2016 in 12 malaria-endemic districts of Nepal. The screening survey included 4067 participants whose G6PD status was determined by G6PD Care Start™ rapid diagnostic test and genotyping. RESULTS: The prevalence of G6PD deficiency at the national level was 3.5% (4.1% among males and 2.1% among females). When analysed according to ethnic groups, G6PD deficiency was highest among the Janajati (6.2% overall, 17.6% in Mahatto, 7.7% in Chaudhary and 7.5% in Tharu) and low among Brahman and Chhetri (1.3%). District-wise, prevalence was highest in Banke (7.6%) and Chitwan (6.6%). Coimbra mutation (592 C>T) was found among 75.5% of the G6PD-deficient samples analysed and Mahidol (487 G>A) and Mediterranean (563 C>T) mutations were found in equal proportions in the remaining 24.5%. There was no specific geographic or ethnic distribution for the three mutations. CONCLUSIONS: This study has identified populations with moderate to high prevalence of G6PD deficiency which provides strong evidence supporting the WHO recommendations to screen G6PD deficiency at health facility level before the use of primaquine-based radical curative regimen for Plasmodium vivax.

Prevalence and causes of low vision and blindness in an elderly population in Nepal: the Bhaktapur retina study.

BACKGROUND: This study aims to explore the prevalence and causes of low vision and blindness focused on retinal disease in a population above 60 years in Nepal. METHODS: Two thousand one hundred subjects were enrolled in a population-based cross-sectional study. History, presenting and best corrected visual acuity after subjective refraction, anterior and posterior segment examinations was obtained in detail. RESULTS: Among the total subjects, 1860 (88.57%) had complete information. Age varies from 60 to 95 (mean age: 69.64 ± 7.31) years. Low vision and blindness in both eyes at presentation was found in 984 (52.90%, 95% confidence interval (CI): 50.60-55.19) and 36 (1.94%, 95% CI: 1.35-2.66) subjects respectively. After best correction, bilateral low vision and blindness was found in 426 (22.92%, 95% CI: 21.01-24.88), and 30 (1.61%, 95% CI: 0.10-2.30) subjects respectively. As compared to 60-69 years old, risk of visual impairment was four times higher (95% CI:3.26-5.58) in the 70-79 year olds and 14 times higher (95% CI: 9.72-19.73) in the age group 80 years and above. Major causes of bilateral low vision were cataract (68.07%), followed by retinal disorders (28.64%), and for blindness; retinal disorders (46.66%), followed by cataract (43.33%). Illiteracy was significantly associated with visual impairment. CONCLUSION: Among the elderly population, prevalence of visual impairment was high. Refractive error, cataract and retinal disorders were the major cause of low vision. Screening the population at the age 60 years and above, focused on cataract and posterior segment diseases, providing glasses and timely referral can help reduce visual impairment.

Constructing Item Banks for Measuring Quality of Life in Refractive Error.

SIGNIFICANCE: Existing patient-reported outcome instruments in refractive error are paper-based questionnaires. They are not comprehensive and psychometrically robust. This study has identified the content of the refractive error-specific item banks that aim to provide comprehensive and scientific measurement of refractive error-specific quality of life. PURPOSE: The purpose of this study was to identify minimally representative, optimally informative, and efficient sets of items for measuring quality of life in people with refractive error. METHODS: First, items were identified from existing patient-reported outcome instruments. Second, items were developed from qualitative studies with people with refractive error (48 and 101 in-depth interviews in Australia and Nepal, respectively). Third, classification and selection of items were done based on a set of systematic criteria using an iterative process of binning and winnowing. The resulting items underwent cognitive testing with people with refractive error in Australia and in Nepal. Each step was guided by an expert panel consensus. RESULTS: We retrieved 792 items from the existing patient-reported outcome instruments. From the interviews conducted in Australia, a total of 2367 comments were coded into 807 initial items. Similarly, from the interviews conducted in Nepal, 3477 comments were coded into 914 initial items. After binning and winnowing, followed by cognitive testing, a final set of items comprising 337 items for the Item-pool (Australia) and 308 items for the Item-pool (Nepal), both spanning 12 domains, was obtained. Forty-seven percent of items were common across the two item pools. In the Item-pool (Nepal), 65% items were common for corrected and uncorrected refractive error. CONCLUSIONS: We identified the content of two different sets of item banks to comprehensively measure the impact of refractive error on quality of life for people in Australia and Nepal, which may be applicable to high-income country settings and low- and middle-income country settings, respectively. Future work aims to develop computer-adaptive testing system to administer the item banks, resulting in useful measurement tools for researchers, clinicians, and policy planners.

Prevalence, pattern and risk factors of retinal vein occlusion in an elderly population in Nepal: the Bhaktapur retina study.

BACKGROUND: This study aims to explore the prevalence, pattern and risk factors of retinal vein occlusion (RVO) in an elderly population of Nepal. METHOD: One thousand eight hundred sixty subjects of age 60 years and above were enrolled in a population-based, cross-sectional study. Detailed history, visual acuity, anterior segment and posterior segment examinations were done. Blood pressure, non-fasting blood sugar, body mass index and abdominal girth were measured. Retinal vein occlusions were further divided into branch retinal (BRVO), hemi-retinal and central retinal vein occlusion (CRVO). RESULT: Age ranged from 60 to 95 years with a mean of 69.64 ± 7.31 years. Overall population prevalence for RVO was 2.95% (95% Confidence interval (CI): 2.23-3.83), BRVO 2.74% (95% CI: 2.05-3.58) and CRVO 0.21% (95% CI: 0.06-0.55). BRVO was seen in 51 subjects (92.73%) and CRVO in 4 (7.27%). Among the total RVO, unilateral and bilateral involvement was 85.45% and 14.55%, respectively. Among the subjects with BRVO and CRVO, 37.25% and 50% had low vision, respectively. The risk of RVO increased with ageing and was more among males. There was an increased risk of RVO among those with hypertension, and with diabetes and hypertension. There was also an increased risk of RVO among subjects with hypermetropia, those with pseudophakia and those who were smokers and consumed alcohol. CONCLUSION: Retinal vein occlusion is a common retinal vascular disorder in the elderly population of Nepal. The main risk factors for RVO were increasing age and hypertension.

Intra- and inter-rater agreement between an ophthalmologist and mid-level ophthalmic personnel to diagnose retinal diseases based on fundus photographs at a primary eye center in Nepal: the Bhaktapur Retina Study.

BACKGROUND: Early detection can reduce irreversible blindness from retinal diseases. This study aims to assess the intra- and inter-rater agreement of retinal pathologies observed on fundus photographs between an ophthalmologist and two-mid level ophthalmic personnel (MLOPs). METHOD: A population-based, cross-sectional study was conducted among subjects 60 years and above in the Bhaktapur district of Nepal. Fundus photographs of 500 eyes of 500 subjects were assessed. The macula-centered 45-degree photographs were graded twice by one ophthalmologist and two MLOPs. Intra-rater and inter-rater agreements were assessed for the ophthalmologist and the MLOPs. RESULT: Mean age was 70.22 years ± 6.94 (SD). Retinal pathologies were observed in 55.6 % of photographs (age-related macular degeneration: 34.2 %; diabetic retinopathy: 4.2 %; retinal vein occlusion: 3.8 %). Twelve (2.4 %) fundus pictures were non-gradable. The intra-rater agreement for overall retinal pathologies, retinal hemorrhage, and maculopathy were substantial both for the ophthalmologist as well as for the MLOPs. There was moderate inter-rater agreement between the ophthalmologist and the first MLOP on second rating for overall retinal pathologies, [kappa (k); 95 % CI = 0.59 (0.51-0.66)], retinal hemorrhage [k; 95 % CI = 0.60 (0.41-0.78)], and maculopathy [k; 95 % CI = 0.52 (0.43-0.60)]. Inter-rater agreement between the ophthalmologist and the second MLOP for second rating was moderate for overall retinal pathologies [k; 95 % CI = 0.52 (0.44-0.60)], substantial agreement for retinal hemorrhage [k; 95 % CI = 0. 68 (0.52-0.84)], moderate agreement for maculopathy [k; 95 % CI = 0.59 (0.50-0.67)]. CONCLUSION: There is moderate agreement between the MLOPs and the ophthalmologist in grading fundus photographs for retinal hemorrhages and maculopathy.

Population awareness of diabetic eye disease and age related macular degeneration in Nepal: the Bhaktapur Retina Study.

BACKGROUND: Diabetic retinopathy (DR) and age-related macular degeneration (AMD) are among the leading causes of visual impairment and blindness in developing countries. This study aims to explore the awareness of these retinal diseases in Nepal. METHOD: A population based cross-sectional study conducted among individuals 60 years and older from the Bhaktapur district of Nepal. One thousand consecutive subjects were enrolled and subjected to a structured questionnaire. RESULT: Subject age ranged from 60 to 93 years with a meanof 69.5 years ± 7.1(S.D.). Males and females comprised 45.1 and 55.9 % of the population, respectively. The majority was illiterate (78.2 %), and agriculture was the predominant occupation (79.8 %). 12.1 % were aware of the effect of diabetes on the eye, and among them, 99 % were aware that diabetes was a blinding disease caused by DR.11.5 % of the subjects were aware of DR, and 10.1 % were aware that subjects with diabetes should undergo periodic eye examinations. Only 7.6 % of subjects were aware of AMD.7.5 and 7.4 % were aware about its aggravation with smoking and sunlight exposure, respectively. Younger age group, males, literates, service holders, best corrected visual acuity >0.3 LogMAR, were each significantly associated with an increase in awareness of diabetic retinopathy. Smokers and those with agricultural occupations were less aware regarding AMD. Those with diabetes,with or without DRwere significantly more aware than those not having the disease. CONCLUSION: Among the Bhaktapur population, awareness of DR and AMD was only 11.5 and7.6 % respectively. Older age groups, females, illiterates, farmers, and those with poor visual acuity were less aware of these blinding diseases. We recommend community-based eye health education programs targeted at raising awareness of these diseases and preventive measures.

Postoperative surgical site infection after preoperative use of razor versus clipper for hair removal in inguinal hernia surgery: A quasi-randomized clinical trial.

Trail Design: Quasi-randomized clinical trial. Methods: Participants: This study includes adult patients (≥18 years) who gave written consent for preoperative site preparation using razors or clippers. Exclusions comprised individuals <18 years, bilateral hernias, prior laparoscopic hernia repair, steroid/chemotherapy use, diagnosed chronic obstructive pulmonary disease, and incomplete medical documentation. Intervention: Patients who underwent hernia surgery during the initial week of the study underwent site preparation using a razor, while in subsequent weeks underwent site preparation using a clipper. This randomization was maintained throughout the study. Uniform site preparation was done by consistent staff. Postpreparation interviews, follow-up interviews of the patients, and unbiased evaluation of digital photographs were conducted by nonoperating surgeon panels. Outcome: Preoperative, patient response, degree of skin trauma, quality of hair removal, and association between site preparation-like parameters were compared and analyzed between two groups using Statistical Package for Social Sciences-25. Blinding: In this study, blinding was not done and the primary investigator was aware of the two groups. Results: The total number of participants was 320. The mean age of the Razor group was 45.36 ± 14.68 years and that of Clipper was 44.42 ± 13.77 (p < 0.98). The incidence of surgical site infection (SSI) was 23 (14.4%) in the razor group and 8(5%) in the clipper group, (p = 0.01). Skin trauma was found more in the razor group as compared to the clipper group. Also, the analysis of the provided data revealed that 65% of participants who experienced sustained cuts developed SSI. Conclusion: In summary, the practice of preoperative hair removal on-site preparation using a razor is associated with the incidence of skin trauma but overall shave quality at the operative site was better in the razor group with an apparent increased risk of SSI. Based on these findings, it would be better for surgeons to decide on an operation for either razors or clippers for preoperative preparation.

Prevalence and pattern of vitreo-retinal diseases in Nepal: the Bhaktapur glaucoma study.

BACKGROUND: Vitreo-retinal diseases are among the leading causes of visual impairment and blindness worldwide. This study reports the prevalence and pattern of vitreo-retinal diseases in the Bhaktapur Glaucoma Study (BGS), a population based study conducted in Nepal. METHODS: BGS was a population based cross-sectional study involving 4800 subjects aged 40 years and over from Bhaktapur district. Subjects were selected using a cluster sampling methodology and a door-to-door enumeration. All subjects underwent a detailed ocular examination at the base hospital which included log MAR visual acuity, refraction, applanation tonometry and a dilated fundus examination. Fundus photography, optical coherence tomography and fundus fluorescein angiography were performed where indicated. RESULTS: Complete data was available for 3966 (82.62%) out of the total of 4800 enumerated subjects. The mean age was 55.08 years (SD 11.51). The overall prevalence of vitreo-retinal disorders was 5.35% (95% CI, 4.67 - 6.09). Increasing age was associated with a higher prevalence of vitreo-retinal disorders (P < 0.001). The prevalence of diabetes mellitus was 7.69% (95% CI, 6.88 - 8.56). Age-related macular degeneration (AMD) was the most common vitreo-retinal disorder with a prevalence of 1.50% (95% CI, 1.15 - 1.94), increasing significantly with age. The prevalence of diabetic retinopathy among the study population was 0.78% (95% CI, 0.53 - 1.11) and among the diabetic population 10.16% (95% CI, 7.01 - 14.12). The population prevalence of other retinal disorders were hypertensive retinopathy 0.88%, macular scar 0.37%, retinal vein occlusion 0.50%, macular hole 0.20%, retinitis pigmentosa 0.12%. and retinal detachment 0.10%.The prevalence of low vision and blindness due to vitreo-retinal disorders was 1.53% (95% CI, 1.18 - 1.97) and 0.65% (95% CI, 0.43 - 0.96), respectively. The prevalence of low vision and blindness was 28.77% (95% CI, 22.78-35.37) and 12.26% (95% CI, 8.17-17.45), respectively among cases with vitreo-retinal disorders. Blindness was observed to be unilateral in 19 cases (73%), and bilateral in 7 cases (27%). CONCLUSIONS: The prevalence of vitreo-retinal disorders in this Nepalese population was 5.35%, which increased significantly with age. AMD was the predominant retinal condition followed by diabetic retinopathy. One fourth of the subjects with vitreo-retinal disorder had low vision. Taking into consideration the aging population and emerging systemic diseases such as diabetes mellitus and hypertension, vitreo-retinal disorders could be of future public health importance.

Spontaneous Bacterial Peritonitis among Chronic Liver Disease Patients with Ascites Admitted to the Department of Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Chronic liver disease is a common problem worldwide. Spontaneous bacterial peritonitis is a dreaded complication and has high in-hospital mortality. Few studies have been done about the prevalence of spontaneous bacterial peritonitis and associated clinical and biochemical features in a hospital-based population. The aim of this study was to find out the prevalence of spontaneous bacterial peritonitis in chronic liver disease patients with ascites admitted to Department of Medicine in a tertiary care centre. Methods: A descriptive cross-sectional study was done among patients with chronic liver disease with ascites admitted to the Department of Medicine of a tertiary care centre between 18 March 2021 to 28 February 2022 after receiving ethical approval from the Institutional Review Committee (Reference number: PMM2103161493). Convenience sampling method was used. Diagnostic paracentesis was done in every such patient. Point estimate and 95% Confidence Interval were calculated. Results: Among 157 patients, the prevalence of spontaneous bacterial peritonitis was 46 (29.29%) (22.17-36.41, 95% Confidence Interval). The most common presenting symptom was pain abdomen seen in 29 (63.04%). Conclusions: The prevalence of spontaneous bacterial peritonitis in chronic liver disease patients with ascites was similar to studies done in similar settings. Clinicians should be aware that it can present with or without abdominal pain. Keywords: ascites; liver diseases; peritonitis; prevalence.

Surgical Outcomes of Ahmed Glaucoma Valve and Aurolab Aqueous Drainage Implant in Nepalese Eyes: Comparison in the First Year.

INTRODUCTION: Glaucoma is the leading cause of irreversible blindness worldwide. Though trabeculectomy still remains the surgical modality of choice for the management of glaucoma, the outcome of glaucoma drainage devices (GDDs) too has been encouraging in recent years. OBJECTIVES: To compare the surgical outcomes of Ahmed glaucoma valve (AGV) and Aurolab aqueous drainage implant (AADI) in cases of refractory glaucoma in Nepalese eyes. MATERIALS AND METHODS: We retrospectively studied the charts of the patients with refractory glaucoma who had undergone GDD implantation at Tilganga Institute of Ophthalmology (TIO), Kathmandu, Nepal. Depending on which GDD was implanted, the eyes of the patients were divided into: AGV group and AADI group. The outcome measures of the study were intraocular pressure (IOP), requirement of antiglaucoma medications (AGMs), surgical success and complications. RESULTS: There were 24 eyes of 23 patients in AGV group and 31 eyes of 30 patients in AADI group with a median (quartiles) follow-up of 12 (12,12) months. In the final visit, IOP and AGMs were both significantly lower than the baseline in both the groups (P <0.001). The median IOP in mmHg and AGMs were both significantly lower in the AADI group compared to AGV group in the final visit, p <0.001 and p=0.002, respectively. The overall success was similar in both the groups: AGV (n=22, 91.67%) and AADI (n=29, 93.55%), p=1.0. However, complete success was significantly more in AADI group (n=16, 51.61%) compared to AGV group (n=6, 25%), p=0.046. Complications and their rates were comparable between the two groups (p=0.4). CONCLUSION: Both AGV and AADI safely and effectively reduced the IOP and the number of AGMs in cases of refractory glaucoma in Nepalese eyes.

Gallstone among Patients Presenting to the Department of Surgery in a Tertiary Care Center: A Descriptive Cross-sectional Study.

Introduction: Gallstone is the most common biliary pathology. Once thought of as a disease of the western world, the incidence and burden of cholelithiasis are increasing in Asia. Its literature from Nepal is however still primitive. The study aimed to find out the prevalence of gallstone among patients presenting to the Department of Surgery in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients presenting to the Department of Surgery after receiving ethical approval from the Institutional Review Committee (Registration number: 625). The study was conducted from 1 June 2022 to 1 November 2022. Patients with age more than 18 years were included and patients less than 18 years of age, having common bile duct stones, suffering from biliary malignancy or having an immunocompromised state were excluded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1700 patients, gallstone was seen in 200 (11.76%) (10.23-13.29, 95% Confidence Interval). Among the 200 patients, 133 of them (66.50%) were females. Multiple gallstones were present in 118 (59%) cases whereas 82 (41%) cases had a single stone. Conclusions: The prevalence of gallstone was found to be similar as compared to other reported literature. Keywords: cholelithiasis; gallbladder; prevalence.

Disseminated cysticercosis with tongue involvement: a rare case report from Nepal.

Introduction and importance: Cysticercosis is a condition in which humans are infected by the larval form of the pork tapeworm Tenia solium. Cysticercosis in humans is common in the cerebral tissue but rare in the tongue. Case presentation: Here, the authors report a rare case of a 38-year-old male with neurocysticercosis and cysticercosis of the tongue. The patient presented with a complaint of loss of consciousness for 4-5 min. Local examination of his oral cavity revealed a swelling of ~2×2 cm on the tongue. An MRI of the brain showed various stages of neurocysticercosis involving the neuroparenchyma and tongue. For this, he was started on low-dose prednisolone of 50 mg tapered over 6 weeks and levetiracetam of 500 mg BD continued for his seizure episodes. He is responding well with the medications and is planned to start antiparasitic agent only after the perilesional edema decreases. Clinical discussion: Cysticercosis may involve the central nervous system, muscle, heart, lungs, peritoneum, eye, and subcutaneous tissue. Oral cavity and perioral involvement by cysticercous larva is rare in humans. Radiologic imaging, serology, and tissue biopsy can be used to confirm a diagnosis of cysticercosis. The most common locations for oral cysticercosis are the tongue, buccal mucosa, lower lip, and upper lip.Only 102 cases of oral cysticercosis have been reported based on a PubMed English-language literature search. Conclusion: Oral cysticercosis is a rare event, and it represents a difficulty in clinical diagnosis. But a patient with a mass in the tongue should be considered as a possible case of cysticercosis especially in endemic regions like Nepal.

A cross-ethnicity investigation of genes previously implicated in primary angle closure glaucoma.

PURPOSE: To investigate the underlying genetic variation between candidate genes and primary angle closure glaucoma (PACG) in both Nepalese and Australian populations. METHODS: A total of 213 patients with PACG (106 Nepalese and 107 Australian) and 492 age and sex matched controls (204 Nepalese and 288 Australian) were included in the current study. Three candidate genes were selected; methyl-tetrahydrofolate reductase (MTHFR), calcitonin receptor-like receptor gene (CALCRL), and membrane frizzled-related protein (MFRP). Tag single nucleotide polymorphisms (SNPs) were selected and genotyped to capture the majority of common variation across each locus. Allele and haplotype analyses were conducted using PLINK. RESULTS: SNPs in the nanophthalmos gene MFRP were found to be nominally associated with PACG under the allelic model. Two SNPs were associated in the Australian cohort (rs948414; p=0.02 and rs36015759; p=0.02), and a single SNP in the Nepalese cohort (rs10790289; p=0.03), however these SNPs failed to remain significant after adjustment for sex and age. A haplotype at the CALCRL gene (AATACAGAT) was associated in the Australian cohort (corrected p-value=0.024). No association was observed in either cohort for MTHFR. CONCLUSIONS: This study implicates genetic variation at the CALCRL gene in the pathogenesis of PACG in an Australian Caucasian cohort. Additionally, the MFRP gene shows tendency to be associated with PACG in both the Australian and Nepalese cohorts. Further investigation in a larger cohort is warranted to confirm these findings. No statistically significant associations were identified between MTHFR and PACG in either population.

A population-based survey of the prevalence and types of glaucoma in Nepal: the Bhaktapur Glaucoma Study.

OBJECTIVE: To determine the prevalence and types of glaucoma in a Nepalese population. DESIGN: Cross-sectional, population-based survey. PARTICIPANTS: A total of 4800 subjects aged 40 years or older from the Bhaktapur district of Kathmandu valley. METHODS: Subjects aged 40 years or older were selected using a cluster sampling procedure and door-to-door enumeration for a population-based, cross-sectional study. All subjects underwent a detailed ocular examination at the base hospital, which included logarithm of minimal angle of resolution visual acuity, refraction, applanation tonometry, gonioscopy, Lens Opacities Classification System II cataract grading, retinal examination, and Swedish Interactive Thresholding Algorithm standard perimetry when indicated. MAIN OUTCOME MEASURES: Diagnosis of glaucoma was based on criteria described by the International Society for Geographic and Epidemiological Ophthalmology. RESULTS: A total of 4003 subjects underwent a comprehensive eye examination (response rate 83.4%), and complete data were available in 3991 subjects. The mean intraocular pressure was 13.3 mmHg (97.5th and 99.5th percentiles, 18 and 20 mmHg, respectively), and the mean vertical cup-to-disc ratio was 0.26 (97.5th and 99.5th percentiles, 0.6 and 0.8 mmHg, respectively). There were 75 subjects with glaucoma, an age- and sex-standardized prevalence of 1.80 (95% confidence interval [CI], 1.68-1.92). Age- and sex-standardized prevalence was 1.24% (95% CI, 1.14-1.34) for primary open-angle glaucoma (POAG), 0.39% (95% CI, 0.34-0.45) for primary angle-closure glaucoma (PACG), and 0.15% (95% CI, 0.07-0.36) for secondary glaucoma. The prevalence of glaucoma increased with an increase in age with no significant difference in gender. Primary angle-closure glaucoma was 3 times more common in women. Nine eyes were blind, and 2 subjects were bilaterally blind from glaucoma. CONCLUSIONS: The overall prevalence of glaucoma was 1.9%. Of all glaucoma cases, POAG accounted for 68%, PACG accounted for 22.67%, and secondary glaucoma accounted for 9.33%. Among the subjects with POAG, 96.08% had not been previously diagnosed.

Screening of Accompanying First Degree Relatives of Patients with Primary Open Angle Glaucoma.

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.

Prevalence, Associated Factors and Awareness of Hypertensive Retinopathy among an Elderly Population with Hypertension in Nepal: The Bhaktapur Retina Study.

INTRODUCTION: Hypertensive retinopathy is a common complication in patients with hypertension. This study aims to assess the prevalence, associated factors and awareness of hypertensive retinopathy among an elderly population with hypertension in Bhaktapur, Nepal. MATERIALS AND METHODS: This is a population-based, cross-sectional study conducted from 2013 to 2015 in Bhaktapur district, Nepal. The sample size was 2100 subjects aged 60 years and above. From this sample, all diagnosed patients with hypertension were analyzed. A detailed history was obtained, and an ocular examination was performed. RESULTS: Information was complete for 1860 (88.57%) subjects. The age of the study population ranged from 60 to 95 years with the mean age of 69.64±7.31 years. Hypertension was found in 643 subjects (34.61%), of which 224 (12.04%) were newly diagnosed cases. Among the subjects with hypertension, hypertensive retinopathy was found in 81 cases (12.6%). Hypertensive retinopathy was more frequent in the age group 70-79 years (15.23%), males (13.25%), illiterates (13.56%), diabetics (16.49%), and body mass index (BMI) ≥25 kg/m2 (14%). None of the factors was found to be statistically significant. Among the study participants, awareness regarding the effect of hypertension on eye, retina and vision was found to be 13.84%, 8.4%, and 11.98% respectively. CONCLUSION: Prevalence of hypertension and hypertensive retinopathy among an elderly population of 60 years and above in Bhaktapur district, Nepal were similar to other countries. Hypertensive retinopathy was higher among males, illiterates, diabetes and BMI> 25kg/m2. Awareness of hypertensive retinopathy was 8.4% among hypertensive subjects. Emphasis should be directed toward improving awareness campaigns.

Deep Learning for Glaucoma Detection and Identification of Novel Diagnostic Areas in Diverse Real-World Datasets.

Purpose: To develop a three-dimensional (3D) deep learning algorithm to detect glaucoma using spectral-domain optical coherence tomography (SD-OCT) optic nerve head (ONH) cube scans and validate its performance on ethnically diverse real-world datasets and on cropped ONH scans. Methods: In total, 2461 Cirrus SD-OCT ONH scans of 1012 eyes were obtained from the Glaucoma Clinic Imaging Database at the Byers Eye Institute, Stanford University, from March 2010 to December 2017. A 3D deep neural network was trained and tested on this unique raw OCT cube dataset to identify a multimodal definition of glaucoma excluding other concomitant retinal disease and optic neuropathies. A total of 1022 scans of 363 glaucomatous eyes (207 patients) and 542 scans of 291 normal eyes (167 patients) from Stanford were included in training, and 142 scans of 48 glaucomatous eyes (27 patients) and 61 scans of 39 normal eyes (23 patients) were included in the validation set. A total of 3371 scans (Cirrus SD-OCT) from four different countries were used for evaluation of the model: the non overlapping test dataset from Stanford (USA) consisted of 694 scans: 241 scans from 113 normal eyes of 66 patients and 453 scans of 157 glaucomatous eyes of 89 patients. The datasets from Hong Kong (total of 1625 scans; 666 OCT scans from 196 normal eyes of 99 patients and 959 scans of 277 glaucomatous eyes of 155 patients), India (total of 672 scans; 211 scans from 147 normal eyes of 98 patients and 461 scans from 171 glaucomatous eyes of 101 patients), and Nepal (total of 380 scans; 158 scans from 143 normal eyes of 89 patients and 222 scans from 174 glaucomatous eyes of 109 patients) were used for external evaluation. The performance of the model was then evaluated on manually cropped scans from Stanford using a new algorithm called DiagFind. The ONH region was cropped by identifying the appropriate zone of the image in the expected location relative to Bruch's Membrane Opening (BMO) using a commercially available imaging software. Subgroup analyses were performed in groups stratified by eyes, myopia severity of glaucoma, and on a set of glaucoma cases without field defects. Saliency maps were generated to highlight the areas the model used to make a prediction. The model's performance was compared to that of a glaucoma specialist using all available information on a subset of cases. Results: The 3D deep learning system achieved area under the curve (AUC) values of 0.91 (95% CI, 0.90-0.92), 0.80 (95% CI, 0.78-0.82), 0.94 (95% CI, 0.93-0.96), and 0.87 (95% CI, 0.85-0.90) on Stanford, Hong Kong, India, and Nepal datasets, respectively, to detect perimetric glaucoma and AUC values of 0.99 (95% CI, 0.97-1.00), 0.96 (95% CI, 0.93-1.00), and 0.92 (95% CI, 0.89-0.95) on severe, moderate, and mild myopia cases, respectively, and an AUC of 0.77 on cropped scans. The model achieved an AUC value of 0.92 (95% CI, 0.90-0.93) versus that of the human grader with an AUC value of 0.91 on the same subset of scans (\(P=0.99\)). The performance of the model in terms of recall on glaucoma cases without field defects was found to be 0.76 (0.68-0.85). Saliency maps highlighted the lamina cribrosa in glaucomatous eyes versus superficial retina in normal eyes as the regions associated with classification. Conclusions: A 3D convolutional neural network (CNN) trained on SD-OCT ONH cubes can distinguish glaucoma from normal cases in diverse datasets obtained from four different countries. The model trained on additional random cropping data augmentation performed reasonably on manually cropped scans, indicating the importance of lamina cribrosa in glaucoma detection. Translational Relevance: A 3D CNN trained on SD-OCT ONH cubes was developed to detect glaucoma in diverse datasets obtained from four different countries and on cropped scans. The model identified lamina cribrosa as the region associated with glaucoma detection.

The Prevalence of Glaucoma in the Jirel Ethnic Group of Nepal.

Glaucoma is one of the leading causes of blindness worldwide with individuals in Asia disproportionately affected. Using a cross-sectional study design as part of the Jiri Eye Study, we assessed the prevalence of glaucoma in the Jirel population of Nepal and provide new information on the occurrence of glaucoma in south central Asia. Over a four-year period, 2,042 members of the Jirel population, aged 18 years and older, underwent a detailed ocular examination. Glaucoma was diagnosed using the International Society of Geographical and Epidemiological Ophthalmology criteria. The mean (SD) age at exam was 42.3 (16.7) years and 54.1% of the sample was female. In the total sample, the mean (SD) intraocular pressure (IOP) and vertical cup-to-disc ratio (VCDR) was 14.55 (2.42) mmHg and 0.31 (0.15), respectively. The 97.5th and 99.5th percentile for IOP and VCDR was 20 mmHg and 22 mmHg, and 0.7 and 0.8, respectively. The overall prevalence of glaucoma in the population was 2.30% (n = 47). Of these 47 individuals, 37 (78.7%) had primary open angle glaucoma, 6 (12.8%) had primary angle closure glaucoma, and 4 (8.5%) had secondary glaucoma. There was a significant (p = 5.86×10-6) increase in the prevalence of glaucoma with increasing age overall and across glaucoma subtypes. Six individuals with glaucoma (12.8%) were blind in at least one eye. Of the individuals with glaucoma, 93.6% were previously undiagnosed. In individuals aged 40 years or older (n = 1057, 51.4% female), the mean (SD) IOP and VCDR was 14.39 (2.63) mmHg and 0.34 (0.16), respectively, and glaucoma prevalence was 4.16% (n = 44). The prevalence of glaucoma and undiagnosed disease is high in the Jirel population of Nepal. This study will inform strategies to minimize glaucoma-associated burden in Nepal.

The association of hepatocyte growth factor (HGF) gene with primary angle closure glaucoma in the Nepalese population.

PURPOSE: Genetic variation in the hepatocyte growth factor (HGF) gene has recently been associated with hyperopia, which is a known risk factor for primary angle closure glaucoma (PACG). This study aimed to investigate whether genetic variation in HGF is associated with primary angle closure glaucoma in the Nepalese population. METHODS: One hundred six Nepalese patients with primary angle closure glaucoma and 204 matched controls were recruited. Twelve tag single nucleotide polymorphisms (SNPs) were selected and genotyped to cover the majority of common variation within HGF. Genotype and haplotype analyses were conducted in PLINK. RESULTS: Four HGF SNPs were found to be significantly associated with PACG, rs5745718, rs12536657, rs12540393 and rs17427817 (p=0.002, 0.002, 0.0006, and 0.0006, respectively). In addition, haplotype analysis showed one common haplotype to be significantly associated with PACG (p=0.001) in this population. CONCLUSIONS: Genetic variation in HGF is associated with PACG in the Nepalese population. Additional replication studies in other populations are necessary to confirm this association and to further explore the role of HGF in the pathogenesis of this blinding disease.

Prevalence of visual impairment, cataract surgery and awareness of cataract and glaucoma in Bhaktapur district of Nepal: the Bhaktapur Glaucoma Study.

BACKGROUND: Cataract and glaucoma are the major causes of blindness in Nepal. Bhaktapur is one of the three districts of Kathmandu valley which represents a metropolitan city with a predominantly agrarian rural periphery. This study was undertaken to determine the prevalence of visual impairment, cataract surgery and awareness of cataract and glaucoma among subjects residing in this district of Nepal. METHODS: Subjects aged 40 years and above was selected using a cluster sampling methodology and a door to door enumeration was conducted for a population based cross sectional study. During the community field work, 11499 subjects underwent a structured interview regarding awareness (heard of) and knowledge (understanding of the disease) of cataract and glaucoma. At the base hospital 4003 out of 4800 (83.39%) subjects underwent a detailed ocular examination including log MAR visual acuity, refraction, applanation tonometry, cataract grading (LOCSΙΙ), retinal examination and SITA standard perimetry when indicated. RESULTS: The age-sex adjusted prevalence of blindness (best corrected <3/60) and low vision (best corrected <6/18 ≥ 3/60) was 0.43% (95%C.I. 0.25 - 0.68) and 3.97% (95% C.I. 3.40 - 4.60) respectively. Cataract (53.3%) was the principal cause of blindness. The leading causes of low vision were cataract (60.8%) followed by refractive error (12%). The cataract surgical coverage was 90.36% and was higher in the younger age group, females and illiterate subjects. Pseudophakia was seen in 94%. Awareness of cataract (6.7%) and glaucoma (2.4%) was very low. Among subjects who were aware, 70.4% had knowledge of cataract and 45.5% of glaucoma. Cataract was commonly known to be a 'pearl like dot' white opacity in the eye while glaucoma was known to cause blindness. Awareness remained unchanged in different age groups for cataract while for glaucoma there was an increase in awareness with age. Women were significantly less aware (odds ratio (OR): 0.63; 95%, confidence interval (CI): 0.54 - 0.74) for cataract and (OR: 0.64; 95% CI: 0.50 - 0.81) for glaucoma. Literacy was also correlated with awareness. CONCLUSION: The low prevalence of visual impairment and the high cataract surgical coverage suggests that cataract intervention programs have been successful in Bhaktapur. Awareness and knowledge of cataract and glaucoma was very poor among this population. Eye care programs needs to be directed towards preventing visual impairment from refractive errors, screening for incurable chronic eye diseases and promoting health education in order to raise awareness on cataract and glaucoma among this population.