Relationship Between Intraocular Pressure and Age: A Population-Based Study in Nepal.

PRCIS: Intraocular pressure (IOP) decreased with age in a population-based study in Nepal, from a mean of 14.1 mm Hg among those 60-64 years old to 13.0 mm Hg among those 80 years old or older. PURPOSE: Few studies have assessed the distribution of IOP from the Indian subcontinent, despite its large population and high burden of glaucoma. The objective of this study was to assess the distribution of IOP measurements from adults living in a lowland region of Nepal. METHODS: In a population-based cross-sectional study, all individuals aged 60 years and older from an area of lowland Nepal were invited for an IOP assessment with a rebound tonometer. RESULTS: Of 160 communities (28,672 people aged ≥60 y) enrolled, 79 (13,808 people aged ≥60 y) were randomly selected for IOP testing. Of those eligible, 10,017 (72.5%) individuals underwent tonometry. Mean IOP decreased monotonically over 5-year age groups, from 14.1 mm Hg (SD: 3.6) among those aged 60-64 years to 13.0 mm Hg (SD: 4.2) among those 80 years or older. The 97.5th percentile IOP measurement was 21.0 mm Hg for all age groups. In adjusted analyses, younger age, self-reported diabetes, and higher population density were each associated with higher IOP, and self-reported cataract surgery was associated with lower IOP. CONCLUSIONS: Mean IOP was lower among older individuals in Nepal, consistent with many studies from East Asia and in contrast to many studies from western populations. These results suggest that ethnic background might be a consideration when diagnosing ocular hypertension.

Rhegmatogenous retinal detachment in Coats' disease: a case report.

BACKGROUND: Coats' disease was originally defined as a unilateral idiopathic exudative retinopathy in young males, characterized by abnormal retinal vascular telangiectasia with intraretinal and subretinal lipid exudation. The retinal detachment is usually exudative. Herein, we describe a case of rhegmatogenous retinal detachment with detectable retinal break in a patient with Coats' disease. CASE PRESENTATION: A 15-year-old Indo-Aryan male patient presented with sudden painless diminution of vision in his right eye of 4 days duration. Upon examination, the anterior segment in both eyes and left fundus was within normal limits. Dilated fundus evaluation of the right eye revealed telangiectasia of the retinal vessels, with subretinal exudation in superotemporal and superonasal quadrants and presence of subretinal fluid in the superotemporal area extending into fovea. There was also presence of single flap horseshoe tear in the superotemporal quadrant at around the 10 o'clock position in the equatorial region, with no secondary changes. The retina was reattached with encircling band buckle combined with vitrectomy and silicon oil tamponade. Seven months post vitrectomy, lenticular opacification developed, for which he underwent silicon oil removal, along with lens aspiration and implantation of foldable intraocular lens. Over the period of 1 year, his best corrected visual acuity improved from 6/60 to 6/18 in the affected eye at the last follow-up visit. The recovery was uneventful following the subsequent surgery. CONCLUSION: Coats' disease has a remarkable diversity in clinical presentation and morphology. The disease can also present with an underlying break, which may not be attributed to any iatrogenic modality. The treatment modalities in coats' disease should be tailored individually due to the low incidence of the disease and the great variation in severity upon presentation. Prompt management restores the best possible anatomical outcome and maintains good vision.

Central retinal artery occlusion in optic disk melanocytoma.

Optic disk melanocytoma (ODM) is a rare benign tumor of the optic disk. We report a rare occurrence of profound visual loss due to central retinal artery occlusion associated with ODM in a 78-year-old female with no significant medical history. The clinical findings were supplemented by ancillary investigations.

Comparative Study of Dry Eye Indices Following Cataract Surgery.

BACKGROUND: This study aims to assess dry eye indices following cataract surgery. MATERIALS AND METHODS: A single center descriptive and comparative study was performed. A total of 100 eyes of 100 cases fulfilling the inclusion criteria from 1st June 2017 to 30th May 2018 were enrolled. Out of 100 eyes, 50 eyes each went through manual small incision cataract surgery (MSICS) and phacoemulsification respectively. For objective analysis : schirmer 1 test(ST-I), tear breakup Time(TBUT) along with lissamine Green Surface Staining(LGSS) was performed on pre-operative day, 1st, 4th and 12th week respectively. Ocular Surface Disease Index (OSDI) was done for subjective analysis on pre-operative day and at 12th week. RESULTS: The mean age of the patient was 53.66 ± 7.839 years with 34 (68%) being female in a small incision cataract surgery group. In the phacoemulsification group, mean age was 54.72 ± 7.985 years and 32 (64%) were female. On analyzing the objective dry eye indices: ST-I,TBUT and LGSS at 12thweek was 18.80 ± 7.393 mm, 11.30 ± 5.456 seconds and 1.62 ± 1.193 in Small incision cataract surgery group and 27.10 ± 6.326 mm, 16.60 ± 4.699 seconds and 0.38 ± 0.602 in Phacoemulsification group respectively which was statistically significant. (p< 0.001). CONCLUSION: Regardless of the type of cataract surgery, dry eye disease is unavoidable affecting both tear quality and quantity postoperatively. In our study, phacoemulsification had lesser effect in dry eye indices than small incision cataract surgery.

Outcomes of the Perplexed Surgical Management of Retinal Detachment in Eyes with Coloboma.

PURPOSE: To determine the anatomical and visual outcomes of retinal detachment in eyes with chorioretinal coloboma managed by pars plana vitrectomy, endolaser photocoagulation and silicone oil (SO) tamponade. METHODS: Retrospective review of 29 eyes of 29 patients with retinal detachment associated with chorioretinal coloboma. All the cases were managed by vitrectomy procedures concluding with SO tamponade. Encircling band was placed based on pre-operative evaluation and/or surgeon's discretion. Endolaser photocoagulation was applied around the peripheral retina, all around the peripheral breaks and around the colobomatous area. The outcome measures were evaluated with regard to functional and anatomical success. RESULTS: The average age at the time of surgery was 21.76 ± 9.58 years (range, 10-50 years). The mean follow-up duration was 12.28 ± 4.8 months (range, 6-24 months). Primary attached retina was obtained in 21 / 29 (72.4%) eyes after single surgery. Re-detachment in 8 / 29 (27.6%) eyes which required revision surgery was the most frequent postoperative complication followed by raised intraocular pressure in 4 / 29 (13.8%) with SO in situ. Out of 29 eyes, 23 were followed up after the removal of SO. The mean duration of SO removal was 7.91 ± 3.9 months (range, 4-18 months). Implantation of encircling band, lens removal and cryotherapy provided no added advantage. At the final examination, improvement in vision was observed in 21 (72.4%) eyes and the anatomical attachment of the retina was attained in 27 (93.1%) eyes. CONCLUSIONS: Complete pars plana vitrectomy, endolaser photocoagulation along with SO tamponade is effective for retinal detachment associated with chorioretinal coloboma. This technique improves the anatomical outcome and helps in regaining significant visual acuity.

Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts in Primary Pterygium Surgery.

INTRODUCTION: Surgical excision is the definitive treatment for pterygium. Following excision, conjunctival autograft is usually preferred. Various methods for grafting with sutures, glue or autologous serum from the recipient bed are in use. The objective of this study was to compare surgical outcomes of sutureless glue free conjunctival autograft with sutured (vicryl 8-0) conjunctival autograft in primary pterygium excision. MATERIALS AND METHODS: A prospective randomized interventional study was carried out in 100 eyes with primary pterygium. They were divided into two groups for conjunctival graft adhesion; sutureless glue free (group 1; n=50 eyes) and sutured with absorbable (vicryl 8-0) suture (group 2; n=50 eyes). Time taken for surgery, complications, postoperative symptoms and overall satisfaction score were noted. The patients were followed up on day 1, day 14 and 6 weeks after surgery. Recurrence was noted till 1 year after surgery. RESULTS: The mean age was 46.76 ± 11.97 years (group 1) and 47.24±12.76 years (group 2). Group 1 had shorter duration of surgery (p<0.001), less postoperative complaints (p<0.001) and better patient satisfaction (p<0.001) than group 2. Postoperative complications and gain in visual acuity in both the groups were not clinically significant. Recurrence was not significant in both groups until 1 year of follow up. CONCLUSION: Pterygium surgery with sutureless glue free conjunctival autograft had fewer postoperative complaints and better patient satisfaction than pterygium surgery with sutured conjunctival autograft. The postoperative complications, recurrence were comparable to conventional sutured technique.

Posterior Scleritis Simulating Choroidal Melanoma: A Case Report.

Nodular posterior scleritis (NPS) is rare; however, it is critical to differentiate it from similar intraocular pathologies to prevent inappropriate and potentially irreversible treatment. Multimodal imaging is beneficial in the diagnosis of NPS. This report describes the diagnosis and management of a case of NPS with corticosteroid therapy that led to complete resolution.

Cluster-randomised trial of community-based screening for eye disease in adults in Nepal: the Village-Integrated Eye Worker Trial II (VIEW II) trial protocol.

INTRODUCTION: The majority of blindness worldwide could be prevented or reversed with early diagnosis and treatment, yet identifying at-risk and prevalent cases of eye disease and linking them with care remain important obstacles to addressing this burden. Leading causes of blindness like glaucoma, diabetic retinopathy and age-related macular degeneration have detectable early asymptomatic phases and can cause irreversible vision loss. Mass screening for such diseases could reduce visual impairment at the population level. METHODS AND ANALYSIS: This protocol describes a parallel-group cluster-randomised trial designed to determine whether community-based screening for glaucoma, diabetic retinopathy and age-related macular degeneration reduces population-level visual impairment in Nepal. A door-to-door population census is conducted in all study communities. All adults aged ≥60 years have visual acuity tested at the census visit, and those meeting referral criteria are referred to a local eye care facility for further diagnosis and management. Communities are subsequently randomised to a community-based screening programme or to no additional intervention. The intervention consists of a single round of screening including intraocular pressure and optical coherence tomography assessment of all adults ≥60 years old with enhanced linkage to care for participants meeting referral criteria. Four years after implementation of the intervention, masked outcome assessors conduct a repeat census to collect data on the primary outcome, visual acuity. Individuals with incident visual impairment receive a comprehensive ophthalmological examination to determine the cause of visual impairment. Outcomes are compared by treatment arm according to the originally assigned intervention. ETHICS AND DISSEMINATION: The trial has received ethical approval from the University of California San Francisco Institutional Review Board, Nepal Netra Jyoti Sangh and the Nepal Health Research Council. Results of this trial will be disseminated through publication in peer-reviewed journals and presentation at local and international meetings. TRIAL REGISTRATION NUMBER: NCT03752840.

Chemotherapy-Induced Central Retinal Artery Occlusion in Gestational Trophoblastic Neoplasia: Case Report.

The use of anticancer chemotherapy (ACC) has resulted in longer patient survival but has also increased drug-related adverse effects. A 22-year-old female receiving cisplatin-based intravenous chemotherapy for high risk variant of gestational trophoblastic neoplasia (GTN) presented with complaints of sudden painless loss of vision in her right eye for a duration of 4 hours. Ocular findings were suggestive of central retinal artery occlusion (CRAO). After exclusion of other potential aetiological risk factors, the patient was diagnosed with CRAO associated with cisplatin. Cancer patients are prone to thromboembolic events (TEE) not only due to primary disease but also due to underlying comorbidities and treatment modalities. The high incidence of TEE in patients under cisplatin therapy mandates a high degree of suspicion among the treating physicians. This rare possibility of irreversible visual toxicity should also be considered among the patients under cisplatin chemotherapy.

Reviving the lost art of scleral buckling surgery for rhegmatogenous retinal detachment: evaluation of risk factors of detachments, poor physiological outcomes, and perspective from a developing country.

PURPOSE: To evaluate the primary anatomic and physiological success of scleral buckling surgery for rhegmatogenous retinal detachment and factors influencing its outcomes. METHODS: This is a prospective analytical study of 92 eyes that underwent scleral buckling at the Lumbini Eye Institute and Research Center, in Lumbini, Nepal. Parameters evaluated which could influence the outcome of the surgery included the lens status, duration of symptoms, locations of breaks, the extent of retinal detachment, and preoperative proliferative vitreoretinopathy. RESULTS: A total of 92 eyes from 88 patients with rhegmatogenous retinal detachment were evaluated; 68 (74%) eyes were of male and 24 (26%) were of female. The mean time of presentation was 4.71 ± 8.45 months. The overall primary anatomical and physiological success was achieved in 79 (84.9%) and 68 (73.9%) of the cases at 6 months. Sixteen cases developed re-detachment (mean duration of 2.8 ± 1.8 months). Eleven of the cases had a successful anatomical outcome and five of the patients had persistent detachment despite second surgery. In phakic patients, the primary success rate was 92.7% whereas in pseudophakic it was 71.4%. Proliferative vitreoretinopathy 10 (63%) was the most common cause of surgical failure. Bilateral buckling at the same setting was done to two patients-both achieving primary success. CONCLUSION: Scleral buckling is a very good surgical option for rhegmatogenous retinal detachment and represents a surgical technique worth being trained, performed, practiced, and continued despite advancements in modern vitreoretinal surgical devices and preference for vitrectomy and tamponade agents. It may also be successfully tried in cases of bilateral rhegmatogenous retinal detachment if a doubt regarding compliance for follow-up and surgery for the fellow eye exists.

Factors Affecting the Outcome of Scleral Buckling Surgery for Primary Rhegmatogenous Retinal Detachment.

INTRODUCTION: Scleral buckle surgery retains a special place in treatment of retinal detachment despite development of new and advanced vitreoretinal surgical techniques. The outcome of any retinal detachment surgery depends on correct selection of patient, type and nature of detachment, and the expertise. This study aims to evaluate various other parameters that determine the outcome of scleral buckle surgery. METHOD: Records of 55 patients with primary rhegmatogenous retinal detachment treated with scleral buckling over a duration of 18 months that had a minimum of 3-month follow-up were retrospectively reviewed. Preoperative and postoperative characteristics were recorded. Parameters that were evaluated to determine the outcome were best-corrected visual acuity (BCVA), anatomical success, and complications. RESULTS: A total of 51 eyes of 50 patients that met the inclusion criteria were included. Mean age was 41 ± 19.9 years (range: 9 to 83). Primary anatomical success was achieved in 80.4%. Parameters significantly associated with the anatomical outcome of surgery were status of lens, preoperative visual acuity, and extent of retinal detachment. There was a significant improvement of visual acuity postoperatively. CONCLUSION: Scleral buckle surgery is a highly effective surgery in uncomplicated retinal detachment cases, and single surgery success rates are better in cases with good preoperative visual acuity, partial detachment, and clear crystalline lens.

Outcomes of Silicone Oil Removal in Complex Retinal Detachment.

INTRODUCTION: Pars plana vitrectomy in combination with intraocular tamponade with silicone oil is a standard technique in the treatment of complex retinal detachment. Although the use of silicone oil has improved the results of retinal detachment surgery, its removal is recommended due to the ocular complications related to its long term use. However, retinal redetachment can occur after silicone oil removal. OBJECTIVE: To evaluate the anatomical and visual outcome after silicone oil removal (SOR) in eyes with complicated retinal detachment. MATERIAL AND METHODS: We retrospectively analyzed 64 eyes of 64 consecutive patients of silicone oil removal over a period of 12 months. All eyes had undergone standard 3 ports pars plana vitrectomy with silicone oil placement for complicated retinal detachment. Cases that completed at least 1 month follow up duration after SOR were included in the study. Anatomical success after SOR was achieved in 56 of 64 eyes (87.5%). Seven of 8 redetachments (87.5%) were seen in eyes with silicone oil tamponade duration of less than 6 months. Visual acuity improved or was stabilized in 49 of 64 eyes (76.6%). Using paired T-test, it was found that there was no significant difference in pre and post SOR visual acuity. Postoperative ocular hypertension, corneal decompensation, band shaped keratopathy and hypotony was observed in 9.4%, 4.7%, 6.4% and 21.9% respectively. CONCLUSION: Although there was no significant improvement in visual acuity, redetachment and complication rates were comparable to other studies. The duration of endotamponade was not significantly associated with the redetachment rate. Key words: Silicone oil removal, Redetachment, Visual outcome, Keratopathy, ocular hypertension.

Anatomical and Visual Outcome of Rhegmatogenous Retinal Detachment Managed with Scleral Buckling at a Tertiary Eye Centre in Nepal.

OBJECTIVE: To study the anatomical status and visual outcome of scleral buckling surgery in rhegmatogenous retinal detachment (RRD) at tertiary eye care center in Nepal. METHOD: This is a prospective, noncomparative, consecutive, interventional study of rhegmatogenous retinal detachment managed with scleral buckling surgery performed in Lumbini Eye Institute, Nepal. All the patients underwent surgery by a single experienced surgeon and had at least 3 months follow up. RESULT: A total of 50 patients (50 eyes) were operated, 38 males and 12 females, with a mean age of 39.46. Retinal reattachment was achieved in 46 (92%). Improved best corrected visual acuity (BCVA) was seen in 84%, whereas in 8% BCVA was same and deteriorated in another 8%. CONCLUSION: Rhegmatogenous retinal detachment is one of the common causes of visual impairment and blindness. Timely surgical management with scleral buckling surgery can give good anatomical and visual outcome.