Inclusive Eye Health - A Milestone Towards Achieving Universal Health Coverage in Pakistan.

Null.

A Prospective Study on Diabetic Retinopathy Detection Based on Modify Convolutional Neural Network Using Fundus Images at Sindh Institute of Ophthalmology & Visual Sciences.

Diabetic Retinopathy (DR) is the most common complication that arises due to diabetes, and it affects the retina. It is the leading cause of blindness globally, and early detection can protect patients from losing sight. However, the early detection of Diabetic Retinopathy is an difficult task that needs clinical experts' interpretation of fundus images. In this study, a deep learning model was trained and validated on a private dataset and tested in real time at the Sindh Institute of Ophthalmology & Visual Sciences (SIOVS). The intelligent model evaluated the quality of the test images. The implemented model classified the test images into DR-Positive and DR-Negative ones. Furthermore, the results were reviewed by clinical experts to assess the model's performance. A total number of 398 patients, including 232 male and 166 female patients, were screened for five weeks. The model achieves 93.72% accuracy, 97.30% sensitivity, and 92.90% specificity on the test data as labelled by clinical experts on Diabetic Retinopathy.

Prevalence of diabetic retinopathy in rural Pakistan: A population based cross-sectional study.

Purpose: To estimate the prevalence of diabetic retinopathy (DR), an emerging cause of sight threat and blindness from a large rural population in Pakistan. Methods: This was a population-based cross-sectional study. We selected a rural district of Matiari Sindh Province in Pakistan, where we selected all the health facilities and their attached Lady Health Workers (LHWs)/Lady Health Supervisors (LHSs). These female health workers were trained to identify high-risk diabetic individuals in their catchment areas using pre-defined criteria and to refer them to the nearest health facilities for screening and testing random blood sugar (BSR). Adults of 18 years or above, male or female, were included in the study for DM and DR screening. Ophthalmic examination was conducted by the optometrists on those who had BSR level >180 mg/dl for the evidence of DR. Identified DR patients were referred to a linked tertiary-level ophthalmology institute for their free DR treatment. Results: Of the identified and referred 24,463 participants, 23,999 were tested for BSR and 2,331 (9.74%) were found to be high-risk patients (BSR >180 mg/dl) and had ophthalmic examination conducted. Of these, 563 had clinically established DR, a prevalence of 24.2% (95% CI, 22-26%). Significantly more DR patients (228, 40.5%) were found in the age group >60 years, with more among female (327, 58.1%) with DR. Conclusion: DR is highly prevalent in the Pakistani rural population. The establishment of an integrated approach within the health care system could decrease the burden of DR in Pakistan.

Improving equity, efficiency and adherence to referral in Pakistan's eye health programmes: Pre- and post-pandemic onset.

Background: Over one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral. Context: Peek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and "Lady Health Workers". Results: From the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42-48%) to 78% (95% CI: 76-80%) in women, and from 48% (95% CI: 45-52%) to 70% (95% CI: 68-73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level. Discussion: Despite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

Determination of Risk Factors and Treatment of Dry Eye Disease in Type 1 Diabetes Before Corneal Complications at Sindh Institute of Ophthalmology And Visual Sciences.

OBJECTIVE: The objective of this study was to assess and determine the risk factors and treatment of dry eye disease in type 1 diabetes before any ocular surface or corneal complication occurs. This study was conducted at Sindh Institute of Ophthalmology And Visual Sciences, Hyderabad, Pakistan. METHODOLOGY: Subjects and methods for observational study were undertaken at the Department of Ophthalmology Sindh Institute Of Ophthalmology And Visual Sciences, Hyderabad, Pakistan. Hundred confirmed cases of type 1 diabetes were included in the study by non probability convenience sampling. Tear film breakup time and schrimer test were carried out to determine dry eye disease. Data was collected by self-prepared questionnaire and entered and analyzed by using Statistical Program for Social Sciences (SPSS, version 20.0). The frequencies and percentage were recorded and any associations with predisposing factors were statistically analyzed by t test. RESULTS: Out of hundred patients, 71 (71%) were found to have dry eyes (P<0.001). The mean age of the subject in this study was 50.97 years (range 30-70 years). Old age was related to high risk of dry eye disease (P<0.001). There was no big difference in the incidence of dry eyes in males and females. Long duration was found to be related with increased occurrence of dry eyes (P<0.001). We found higher values for abnormal tear film break up time than schirmer test values leading to increased occurrence of evaporative dry eyes. CONCLUSION: There is marked increase in frequency/ risk of developing dry eye disease in type 1 diabetes patients. Therefore, it is recommended to have periodic ophthalmic examination for type 1 diabetic patients.

Results of a community-based screening programme for diabetic retinopathy and childhood blindness in district Hyderabad, Pakistan.

PURPOSE: To present the results of a community-based screening programme for diabetes, diabetic retinopathy (DR) and childhood blindness (CB) in District Hyderabad, Pakistan. METHODS: Prospective cross-sectional data collection from January 2014 to December 2015 of screening for diabetes, DR and CB in Hyderabad District. Female health workers were trained to identify high-risk (potential) patients for diabetes and childhood eye disorders to undertake preliminary screening and refer patients to basic health units. The patients were further assessed by medical officers with the support of qualified optometrist, after which they were referred to Sindh Institute of Ophthalmology and Visual Sciences, Hyderabad, Pakistan for management. RESULTS: A total of 995 244 population was covered in this screening programme during which 2622 children (0-≤15 years) were screened for CB while 16 760 adult patients (>15 years) were screened for diabetes. Random blood glucose level of 3075 patients was >140 mg/dL. Out of these patients, 17% were diagnosed with DR. Refractive error (42%) was the most common cause of childhood visual impairment. CONCLUSION: The diabetic screening programme detected a high prevalence (17%) of retinopathy in patients with diabetes living in Hyderabad District. The most common cause of childhood visual impairment was refractive error (42%), which was successfully managed due to timely diagnosis. A large number of patients benefited from this community-based screening programme.

Axial length variability in cataract surgery.

OBJECTIVE: To determine the mean axial length and biometric measures in patients undergoing cataract surgery and further compare the variability of axial length between the gender and with age. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Eye Unit I, Department of Ophthalmology, Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan from January 2010 to December 2012. METHODOLOGY: All patients referred for cataract surgery were assessed. The study included 886 eyes which were straightforward cataract cases with no other ocular problem. The data was collected for axial length, keratometric values and Intra-Ocular Lens (IOL) power prior to cataract surgery. The collected data was then analyzed using SPSS version 19 for windows software. RESULTS: Gender based comparison showed significant difference in age, axial length, keratometric values and IOL power between the two groups (p=0.000). 86% of the eyes had an axial length between 21.00 mm and 23.99 mm. In univariate analysis there was significant (p=0.000) relation between overall age and axial length. The keratometric values ranged between 36.75 D and 52.50 D. Majority of the IOL powers ranged between 20.00 D and 23.00 D. CONCLUSION: The mean axial length of patients undergoing cataract surgery was 22.96 ± 1.04 mm, was comparable to Indian and Chinese population but shorter than the Western population. Females had shorter axial lengths, similar to other studies. Axial length was positively associated with age among the females, the cause of which is yet to be determined.

Cluster of Urrets-Zavalia syndrome: a sequel of toxic anterior segment syndrome.

PURPOSE: To report the largest cluster of Urrets-Zavalia Syndrome (UZS), which occurred as a sequel of toxic anterior segment syndrome (TASS) after uneventful cataract surgery, and to evaluate the possible causes and risk factors to prevent additional cases. SETTING: Department of Ophthalmology, Liaquat University of Medical & Health Sciences, Hyderabad, Pakistan. DESIGN: Prospective Case Series. METHODS: 15 consecutive TASS cases following uneventful cataract surgery were evaluated for potential causes and risk factors. Main outcome measures included visual acuity, anterior segment reaction, corneal oedema, intraocular pressure, pupillary reaction and response to topical and/or systemic steroid therapy at first day, first week and first month postoperatively. RESULTS: The TASS incidence in this study was 0.08%. All cases presented with corneal oedema, anterior chamber reaction and fixed dilated pupils on first postoperative day. One month postoperatively, the anterior segment inflammation improved considerably in all patients. There was a statistically significant difference between the mean Best-corrected visual acuity (BCVA) at first postoperative day (2.32±0.93 LogMAR) and mean BCVA at 1 month (0.49±0.12 LogMAR) (p=0.0001). The rate of UZS in this study was 93%. Ringer lactate solution was found to be the offending agent of TASS, and replacing it brought a halt to this cluster. CONCLUSIONS: Timely diagnosis, steroid therapy and close monitoring are the main keys for properly managing TASS. To our knowledge, we report, for the first time, the largest cluster of UZS occurring as a sequel of TASS.

Congenital myasthenia gravis.

Congenital myasthenia gravis is caused by genetic mutations affecting neuromuscular transmission, characterized by muscle weakness usually starting in childhood. A two and a half years old male child presented with bilateral ptosis and hoarseness of voice. The symptoms progressed giving the clinical impression of congenital myasthenia gravis. A series of tests were done including Ice Pack Test, acetylcholine receptor antibody test, trial of steroids and finally neostigmine test which confirmed the diagnosis. This case illustrates the challenges in diagnosing congenital myasthenia gravis and highlights the potential benefits of neostigmine test in its diagnosis.