Treatment outcomes of retinal vein occlusion in clinical practice in Nepal.

BACKGROUND: This study evaluated the treatment outcomes of retinal vein occlusion (RVO) in a routine clinical practice in Nepal. METHODS: This was a retrospective analysis of observational data of patients with RVO who attended the retina clinic of the Tilganga Institute of Ophthalmology from 1 November 2017 to 31 October 2018. The main outcome was the mean change in visual acuity (VA) at 12 months from the start of treatment. Other outcomes of interest were the mean change in central subfield thickness (CST) and the number of treatments over 12 months. RESULTS: A total of 99 eyes (of 99 patients) with RVO (60 - branch RVO [BRVO] and 39 - central RVO [CRVO] were available for the analysis. Eyes with CRVO had worse VA and CST at baseline. Eyes in both groups were similar for age, associated factors for RVO, duration of vision loss and the presence of ischemia at baseline. The mean (95% Confidence Interval [CI]) VA change at 12 months for BRVO was - 0.35 (- 0.46, - 0.23) logMAR (p < 0.001) from a mean (SD) of 0.75 (0.42) logMAR at baseline with 63% achieving VA < 0.3 logMAR while for CRVO it was - 0.35 (- 0.46, - 0.23) logMAR (p = 0.19) from 1.13 (0.61) logMAR at baseline and VA < 0.3 logMAR in 36%. The mean (95% CI) change in CST over 12 months was - 114 (- 189, - 40) µm (p = 0.003) from a mean (SD) of 423 (151) µm at baseline for BRVO and - 184(- 276, - 91) µm (p < 0.001) from 519 (213) µm for CRVO. Patients in both groups received a median of 2 bevacizumab injections over 12 months. Around 37% eyes were lost before 12 months' observation. The mean VA and CST trajectory in these eyes at their last visit was similar to those that completed 12 months. CONCLUSION: The outcomes of RVO over the 12 months were inferior and the number of treatments fewer than those of the clinical trials and other reports from routine clinical practice. Future studies to identify the treatment barriers are warranted to improve the treatment outcomes in our patients.

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.

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.

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 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.

Comparison of axial lengths in occludable angle and angle-closure glaucoma--the Bhaktapur Glaucoma Study.

PURPOSE: To compare the anterior chamber depth (ACD) and axial length of eyes in a population-based sample among normal, occludable angle, and primary angle-closure glaucoma (PACG) groups. METHODS: Totally, 3979 subjects from a population-based glaucoma prevalence study underwent complete ocular examination including four mirror gonioscopy. An angle in which >270 degrees of the posterior trabecular meshwork could not be seen was considered occludable. PACG was considered when there were features of primary angle closure (eye with an occludable angle, peripheral anterior synechiae, increased intraocular pressure, iris whorling, lens opacities, or excessive pigment deposition on the trabecular surface) and optic disc with glaucomatous damage. A handheld ultrasonic biometer was used to measure the ACD and the axial length of subjects. The ACD and axial length were measured on all subjects with occludable angles (n = 86), PACG (n = 17) and a random subgroup of normal subjects (n = 685). The measurements were compared among the groups and statistically analyzed using independent t-test, one-way analysis of variance, χ2 test, and logistic regression. RESULTS: The mean age among occludable angle and angle-closure glaucoma groups was 59.64 ± 9.70 and 71.23 ± 8.5 years, respectively, which was significantly higher (p < 0.001) than the mean of 54.03 ± 10.90 years among normal subjects. In the occludable angle group, the ACD (2.55 ± 0.69) was significantly different (p < 0.001) than the normal group (2.85 ± 0.39). The axial length (22.08 ± 0.83) in the occludable angle group was also considerably different (p < 0.001) when compared with the normal group (22.62 ± 0.90). In PACG group, the ACD and axial length were 2.48 ± 0.22 and 22.02 ± 0.59, respectively. The risk of having an occludable angle decreased with per unit millimeter increase in ACD (odds ratio, 0.24; 95% confidence intervals, 0.12-0.50) and axial length (odds ratio, 0.49; 95% confidence intervals, 0.36-0.67) after adjusting the effect of age and sex. CONCLUSIONS: The eyes in Nepalese population with occludable angle and angle-closure glaucoma appear to have significantly shallower anterior chambers and shorter axial lengths when compared with the normal group.

Outcomes of cataract surgery: a population-based developing world study in the Bhaktapur district, Nepal.

BACKGROUND: To evaluate the visual outcome after cataract surgery in a population of Nepal. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Forty years and above residing in Bhaktapur district. METHODS: Subjects were selected from 30 clusters using cluster sampling procedure. All underwent a detailed examination at the base hospital, including logarithm of minimal angle of resolution visual acuity, refraction, applanation tonometry, cataract grading, retinal examination and perimetry when indicated. MAIN OUTCOME MEASURES: Visual acuity after cataract surgery. RESULTS: Out of 4003 subjects examined, 151 had undergone cataract surgery. Pseudophakia was present in 142 (94.0%), aphakia in nine (6%). Presenting and best-corrected visual acuity ≥6/18 was achieved in 123 (54.4%) and 164 (72.4%) eyes, respectively. Among the pseudophakic eyes, at presentation 122 (57.5%), 72 (33.9%), 18 (8.5%) and after best correction 162 (76.2%), 33 (15.8%), 17 (8.0%) had visual acuity of ≥6/18, <6/18-≥6/60 and <6/60, respectively. Retinal disease (35.5%), surgical complications (27.4%) and posterior capsular opacification (14.5%) were the principle causes of visual impairment after best correction in all eyes. There was no significant association in visual outcome based on age, sex, literacy and the duration of surgery. CONCLUSION: Correction of refractive errors, preoperative screening of coincidental diseases, reduction in surgical complication rates and monitoring of postoperative follow-up care has to be addressed seriously in order to improve the outcome of cataract surgery to meet standards proposed by the World Health Organization. In the future, longitudinal studies need to be undertaken to provide specific information on the outcomes of cataract surgery in this community.

Glaucoma in Developing Countries.

Glaucoma is a leading cause of blindness worldwide. The diagnosis and management of glaucoma is especially difficult in the developing countries. Lack of cost effective screening strategies, low income, low rates of literacy and inadequate infrastructures and human resources for eye care services are the obstacles for delivering glaucoma service. Majority of people with glaucoma in developing countries usually present at an advanced stage at the time of diagnosis; which negatively affects their quality of life. Further research, proper allocation of resources and collaborative effort by blindness prevention programs will hopefully provide new evidences on cost effective ways to screen and manage glaucoma in the future. This article aims to highlight the burden of glaucoma and ways to address the challenges in developing countries.

Referral parameters for diagnosis of glaucoma in general eye clinic at Tilganga Institute of Ophthalmology.

OBJECTIVE: To find out the most common referral parameter among the glaucoma suspects patients from general eye clinic and to establish glaucoma diagnosis. METHODS: This study is a retrospective cohort hospital based study. Two hundred patients from January to February 2017 sent to glaucoma clinic as glaucoma suspects were re-evaluated meticulously by glaucoma specialist and were diagnosed as glaucoma, non glaucoma, suspects and ocular hypertension. RESULTS: Out of the 200 patients referred to glaucoma clinic as glaucoma suspects only19% were diagnosed to have glaucoma. The mean age at which glaucoma diagnosed was 55.29(14.4) compared to 41.6(15.1) in normal group. One hundred and sixty five patients were referred on the basis of suspicious optic nerve head, among them 14.5% (24/165) had glaucoma. This study showed that, open angle glaucoma (OAG) 28.9% was the most common type of total glaucoma diagnosed. The mean vertical cup discratio in the OAG group was 0.69±0.1 (0.4 -0.9) compared to 0.56 ± 0.11((0.2-0.8)(p=0.00) normal. The mean intra ocular pressure (IOP) in OAG group was 19.73 ±4.95(11-32) mmHg compared to 16.74± 3.36(10-30) mmHg (p=0.00) in normal group. The mean central corneal thickness (CCT) in OAG group was 533.05 ± 31.24µm (467-606) compared to normal was 534.9±33.6 µm (432-696) (p=0.670). CONCLUSIONS: Suspicious optic nerve head is the most common referral parameter between the general ophthalmologist and residents, but this study shows only few of them were diagnosed with glaucoma. This gives us a clue that the ophthalmologists and residents are to be trained better to help them identify the signs of glaucoma on the optic nerve head beside its size, which will reduce unnecessary burden to the resources of patients and hospital.

A novel approach to glaucoma screening and education in Nepal.

BACKGROUND: Glaucoma is a major cause of blindness worldwide and an increasingly significant global health problem. Glaucoma prevention and management efforts have been challenging due to inherent difficulty in developing a simple and cost-effective screening plan, limited access to health care and educational resources, poverty, and inadequate knowledge of the disease, particularly in developing countries. Starting in 2004 the Tilganga Eye Centre in Kathmandu, Nepal has provided targeted glaucoma screening, treatment, and education through a combination of clinical outreach programs and educational activities for patients. METHODS: A simple, age-based glaucoma screening algorithm was incorporated into three one-day cataract screening clinics. Using this algorithm, patients who were newly diagnosed with glaucoma were referred to TEC, where medication and surgery were provided free of charge through private donor funding. In addition, we describe two ongoing educational programs for increasing glaucoma awareness: an annual Glaucoma Awareness Week (which includes free screening, treatment, and counseling), and a repeating lecture series which generates new counselors. RESULTS: From 2004 to 2007 screening at the annual Glaucoma Awareness Week resulted in the diagnosis of 120 individuals with glaucoma, or 7.6% of total registrants. Attendance increased annually with a trend toward an increasing number of returning patients but a decreasing percentage of newly diagnosed patients, though the absolute numbers have remained relatively stable (range 21 to 38). Data from the three one-day screening clinics in 2006 show that approximately 2 to 4% of patients 50 years of age or older per clinic were newly diagnosed with POAG. CONCLUSION: This multi-faceted approach appears to successfully identify individuals with glaucoma and provide treatment to those who would otherwise not be able to afford it. While more data is needed to validate this model, specifically regarding the effectiveness of educational activities, long-term visual outcomes, and medication compliance, it may serve as a useful framework for other developing countries with similarly limited resources.

Glaucoma Screening in Nepal: Cup-to-Disc Estimate With Standard Mydriatic Fundus Camera Compared to Portable Nonmydriatic Camera.

PURPOSE: To compare cup-to-disc ratio (CDR) measurements from images taken with a portable, 45-degree nonmydriatic fundus camera to images from a traditional tabletop mydriatic fundus camera. DESIGN: Prospective, cross-sectional, comparative instrument validation study. METHODS: Setting: Clinic-based. STUDY POPULATION: A total of 422 eyes of 211 subjects were recruited from the Tilganga Institute of Ophthalmology (Kathmandu, Nepal). Two masked readers measured CDR and noted possible evidence of glaucoma (CDR ≥ 0.7 or the presence of a notch or disc hemorrhage) from fundus photographs taken with a nonmydriatic portable camera and a mydriatic standard camera. Each image was graded twice. MAIN OUTCOME MEASURES: Effect of camera modality on CDR measurement; inter- and intraobserver agreement for each camera for the diagnosis of glaucoma. RESULTS: A total of 196 eyes (46.5%) were diagnosed with glaucoma by chart review; 41.2%-59.0% of eyes were remotely diagnosed with glaucoma over grader, repeat measurement, and camera modality. There was no significant difference in CDR measurement between cameras after adjusting for grader and measurement order (estimate = 0.004, 95% confidence interval [CI], 0.003-0.011, P = .24). There was moderate interobserver reliability for the diagnosis of glaucoma (Pictor: κ = 0.54, CI, 0.46-0.61; Topcon: κ = 0.63, CI, 0.55-0.70) and moderate intraobserver agreement upon repeat grading (Pictor: κ = 0.63 and 0.64, for graders 1 and 2, respectively; Topcon: κ = 0.72 and 0.80, for graders 1 and 2, respectively). CONCLUSIONS: A portable, nonmydriatic, fundus camera can facilitate remote evaluation of disc images on par with standard mydriatic fundus photography.

Central corneal thickness and intraocular pressure in a Nepalese population: the Bhaktapur Glaucoma Study.

PURPOSE: The purpose of the study was to evaluate the characteristics of central corneal thickness and its association with age, sex, and intraocular pressure in a Nepalese population. PATIENTS AND METHODS: The study design was a cross-sectional, population-based survey. Two thousand three hundred thirty patients aged 40 years and older were examined at Tilganga Institute of Ophthalmology, a tertiary referral eye centre in Kathmandu, Nepal. All patients underwent a complete ophthalmic examination that included measurements of central corneal thickness with an ultrasonic pachymeter and intraocular pressure with a Goldman type applanation tonometer. RESULTS: The main outcome measures were central corneal thickness and intraocular pressure. Mean age of the 2330 patients examined was 51.3 years (SD±9.56). The mean central corneal thickness and mean intraocular pressure was 539.10 µm (SD±33.73) and 13.33 mm Hg (SD±2.26), respectively. Central corneal thickness showed an average decrease of 2.67 µm (95% confidence interval, 2.21-4.1) per decade increase in age. A 100 µm increase in central corneal thickness was associated with a 1.03 mm Hg (95% confidence interval, 0.79-1.26) increase in intraocular pressure after adjusting for age and sex. CONCLUSIONS: The changes in central corneal thickness values cause a significant variation in intraocular pressure in this population, suggesting that measurement of central corneal thickness will have implications in the diagnosis and management of glaucoma.