Assessment of needs and gaps in public health cadre in India - a situational analysis.

BACKGROUND: A structured and organized public health set up with systematically trained personnel to manage and deliver public health services from grassroot levels to higher administrative levels with separate public health directorate is the need of the hour. The objective of this study was to conduct a situational analysis of public health cadre in select states in India to gain an in-depth understanding of the progress and explore the gaps and challenges in its implementation. METHODS: Four states from the country were selected based on stages of implementation of the cadre. The WHO health systems framework was the basis of assessment. In-depth interviews of 78 stakeholders from public health system across various categories and levels were conducted. RESULTS: Every state has a dedicated cadre for public health in the form of a separate hierarchical structure and Directorate. There are deficits in human resources skilled enough to manage and implement public health across all levels. Its penetration below districts level is limited. There are limited opportunities available for contractual staffs in terms of remuneration and job progression. The respondents strongly emphasized on having personnel with training in public health, especially at leadership positions. Funding was not reported to be a problem although some challenges in the timeliness of release of funds were reported. Under the existing Health Management Information System, duplication of data exists and there is underutilization of data for policy making. CONCLUSION: A dedicated public health cadre is under evolution in India. The main challenge is inadequate workforce skilled in public health management. States are committed to finding solutions to overcome these barriers.

Carotid cavernous fistula masquerading as orbital cellulitis.

We report a case of direct carotid cavernous fistula (CCF) in a patient of head injury due to road traffic accident who presented several weeks after the injury with sudden onset of pain, redness, and proptosis of right eye. A 56 years old male patient with no known comorbidities presented to ophthalmology OPD with acute onset of pain, redness, swelling, and proptosis of right eye of one week duration and visual acuity of 1/60. Initially he was misdiagnosed and treated as orbital cellulitis. However, digital subtraction angiography confirmed the diagnosis of right direct CCF. Patient underwent endovascular treatment with a good visual recovery post operatively. Ophthalmologists should keep CCF higher up in their differential diagnosis of patients with red edematous eyes, especially with a history of trauma and get thorough investigations in order to provide timely aggressive management to such patients.

Pattern and distribution of neovascularization in proliferative diabetic retinopathy on fundus fluorescein angiography: A growing paradigm.

Background: The objective of this study was to evaluate pattern and distribution of neovascularization of optic disc (NVD) and elsewhere (NVE) in proliferative diabetic retinopathy (PDR). Methods: A cross-sectional study was conducted among freshly detected cases of PDR. Fundus fluorescein angiographic images of 61 eyes were assessed. Parameters studied for NVD were their number and location and for NVE were their number, location, type of leak, and distance from center of optic disc. Results: Of 61 eyes, 29 eyes (47.5%) had NVD with a total of 49 leaks. Of these 49 NVD leaks, the maximum was concentrated in the superotemporal quadrant with 21 leaks (42.9%; 95%CI 28.8-57.8%). Of 61 eyes, 50 eyes (82%) had NVE with 97 leaks. Of 97 NVE leaks, 41 were found in the superotemporal quadrant (42.3%; 95%CI 32.3-52.7%). Maximum NVE was found within the circle of radius 3-6 mm centered on optic disc (p value = 0.001) with no leaks in central macula. Of 29 eyes with NVD, only 7 eyes had >1/3 area of disc involvement. Also, of 18 eyes with concurrent NVD and NVE, only 2 eyes had >1/3 area of disc involvement which is a high-risk characteristic of PDR. Conclusion: Neovascular lesions have a predilection for superotemporal part for both NVD and NVE. NVE leaks were almost double the number of NVD leaks. Maximum NVE leaks were found at posterior pole with no central macular involvement. This study provides comprehensive data and further adds to knowledge of neovascularization for early diagnosis and management of PDR.

Evaluation of primary Ahmed Glaucoma valve implantation in post-traumatic angle recession glaucoma in Indian eyes.

PURPOSE: To highlight the efficacy of primary Ahmed glaucoma valve implantation in angle recession glaucoma following blunt ocular trauma in Indian eyes. DESIGN: A retrospective analytical study. MATERIALS AND METHODS: This study included 52 patients of angle recession glaucoma, who presented between Mar 2006 to Feb 2016, out of which 38 patients had undergone primary AGV implantation, while the rest were managed with topical anti-glaucoma medications. Preoperative data included age, sex, type and mode of injury, duration of injury, assessment of best-corrected visual acuity (BCVA) and intraocular pressure (IOP). The extent of angle recession was observed by gonioscopy. The intraocular pressure, visual acuity, and the number of anti-glaucoma medications were measured postoperatively. The success of this technique was analyzed by using a Kaplan-Meier cumulative survival curve. RESULTS: Following AGV implantation, the mean IOP was significantly reduced to 8.7 ± 2.2 at 1st day, 10.1 ± 2.2 at 7th day, 14.2 ± 3.4 at 3rd month, 15.6 ± 3.7 at 1 year, and 15.6 ± 3.6 at 3rd-year follow-up showing statistically significant values (p < 0.001) at each visit. The IOP was successfully controlled at the last follow-up without topical treatment. Mean BCVA at 3 years -post-AGV was 0.144 (0.151) (LogMAR) which was statistically significant (p < 0.001) as compared to the mean BCVA of 0.898 (± 0.205) LogMAR units at presentation. The success rate by Kaplan-Meier survival curve analysis was 90% at the mean follow-up duration of 29.47 ± 3.39 months. Overall surgical complications were noted in the form of prolonged hypotony, hyphema in 7 patients (13.5%). CONCLUSIONS: In medically uncontrolled post-traumatic angle recession glaucoma, primary AGV Implantation is a safe and effective surgical procedure with lesser complication rates providing long-term IOP control in a younger population.

Descemet Stripping Endothelial Keratoplasty in Microcornea for Pseudophakic Bullous Keratopathy With Anterior Chamber Intraocular Lens.

To report a case of bilateral pseudophakic bullous keratopathy (PBK) in a patient having bilateral microcornea with pre-existing anterior chamber intraocular lens (ACIOL) who underwent Descemet stripping endothelial keratoplasty (DSEK) with a successful postoperative visual outcome. A 36-year-old female, diagnosed with microcornea and congenital cataract in both eyes underwent lens aspiration sequentially followed by ACIOL implantation in both eyes. The patient reported to our centre and was diagnosed with bilateral PBK with ACIOL with microcornea. She also had associated secondary glaucoma, postoperative chronic uveitis, and hyphaema, which were controlled with medical management first and taken into consideration while planning DSEK. The patient underwent manual DSEK without intraocular lens exchange under local anaesthesia in both eyes sequentially with a good visual recovery postoperatively in both eyes. Descemet stripping automated endothelial keratoplasty (DSAEK)/DSEK seems a viable option in patients with microcornea who develop PBK following cataract surgery with retained ACIOL where there is absence of capsular support as well as deficiency of iris tissue.

Severe Atypical Optic Neuritis in a Patient With Pemphigus Foliaceus on Immunosuppressive Therapy.

Bilateral simultaneous acute optic neuritis is a rare occurrence in adults, which has been reported mostly in the setting of untreated systemic autoimmune disorders. Such clinical presentations are encompassed in the spectrum of 'atypical' optic neuritis with resultant poor visual outcome and mainly associated with neuromyelitis optica spectrum disorders. We report an unusual presentation, that is, severe atypical optic neuritis in a patient of pemphigus foliaceous on immunosuppressive therapy with significant visual recovery after treatment.

Prevalence and effectiveness of innovative techniques in ophthalmic surgical training during COVID-19 pandemic in India.

PURPOSE: This study aimed to determine the various innovative surgical training techniques prevalent among ophthalmology residents in India during the COVID-19 pandemic. METHODS: This was a prospective cross-sectional study. An online survey questionnaire was completed by ophthalmology residents from different parts of the country. The survey consisted of questions related to the impact of the pandemic on training, innovative training techniques adapted during the pandemic and their effectiveness, and COVID-19 duty-related information. RESULTS: A total of 147 responses were obtained. The mean age was 29.3 years (range: 24-40 years, SD: ±3.82). Of which, 87 (59.2%) respondents were females. A total of 61 (41.5%) respondents reported practicing steps of ocular surgeries on goat eye, 69 (46.9%) on model eye/vegetables/fruits, 30 (20.4%) on surgical simulators, and 26 (17.7%) utilized 3-D virtual images and videos. In addition, 22 (15%) respondents reported never using any such techniques. Furthermore, 130 (88.4%) respondents reported practicing steps of cataract surgery, 52 (35.4%) practiced steps of open globe repair, and steps of trabeculectomy were reported by 24 (16.3%). The steps that were reported to be practiced most are incision or tunnel construction by 108 (73.5%), suturing by 92 (62.6%), capsulorrhexis by 91 (61.9%), primary wound repair by 82 (55.8%), and conjunctival peritomy by 75 (51%). CONCLUSION: The present study demonstrates that residents across the country are adapting to the present scenario by utilizing several innovative methods to sharpen their surgical acumen. The current pandemic situation can serve as an impetus to emphasize upon the institutes and medical regulatory bodies to appropriately remodel the residency curriculum.