Challenges of Pediatric Cataract Surgery in a Case of Seasonal Hyperacute Panuveitis (SHAPU).

A four-year-old female child diagnosed as a case of severe Seasonal Hyperacute Panuveitis (SHAPU) underwent lens-sparing core vitrectomy in her left eye with intravitreal antibiotic and steroid. Patient responded well to treatment and intraocular inflammation subsided. However, three months later, she developed vision impairing dense cataract which also made posterior segment assessment difficult. Lens aspiration with primary posterior capsulotomy and anterior vitrectomy with intraocular lens (IOL) implantation was performed. However, four weeks later, the patient developed occlusio pupillae with iris bombe. She did not respond to medical management so synechiolysis with surgical iridectomy was performed after which a normal depth anterior chamber was attained. Synechia and iris bombe were also relieved, and vision was regained.

Clinical Assessment and Etiological Evaluation of Optic Nerve Atrophy.

INTRODUCTION: Optic atrophy results from the disease process that cause irreversible damage to the ganglion cells and the anterior visual pathway, but may also result from posterior visual pathway involvement. The etiology causing this condition is vast and regardless of underlying cause it carries bad visual prognosis and at times may be life threatening. The study aims to assess patients with optic nerve atrophy presenting to B.P. Koirala lions centre for ophthalmic studies and identify the underlying etiology. MATERIALS AND METHODS: This is a descriptive study conducted at B.P. Koirala Lions Centre for Ophthalmic studies. All cases of optic atrophy who presented to our outpatient department from March 2016 to March 2017 were included in the study. In addition to detailed evaluation, assessment of visual acuity, color vision, contrast sensitivity and visual field were done if feasible. Other relevant investigations were conducted to establish the underlying etiological cause. RESULTS: A total of 62 patients were included in the study, with 35 patients having bilateral disease and 27 having unilateral disease accounting for 97 eyes with optic atrophy. The mean age of the affected was 40.63±17.36 years with male to female ratio of 1.2:1. The most common etiology for optic atrophy was traumatic neuropathy (n=16, 25.8%). Majority of eyes had pale disc (n=70, 72.2%) and the rest had temporal pallor (n=27, 27.8%). CONCLUSION: Traumatic optic neuropathy was the most common etiological cause of optic nerve atrophy.

A Clinical Study of Optic Disc Edema in a Tertiary Eye Center of Nepal.

PURPOSE: To evaluate the etiology and clinical presentation of cases with optic disc edema presenting to a tertiary eye center of Nepal. BACKGROUND: The etiology of optic disc edema ranges from relatively benign to potentially sight and life threatening conditions. Till date very few studies have been done on disc edema in Nepal. METHOD: The authors conducted a prospective, descriptive study at B.P. Koirala Lions Center for Ophthalmic Studies (BPKLCOS), Nepal. All cases with disc edema presenting to the out patient department (OPD) from January 1, 2014 to June 30, 2015 were included in the study. RESULTS: Total 112 patients were included in the study, out of which diagnosis could be established in 99. The mean age of the patients was 32.54 ± 13.97 years with the majority being female. The most common cause of disc edema was idiopathic intracranial hypertension (IIH) (37.5%,). Majority of the patients complained of isolated diminution of vision (38.4%). Among the eyes affected, 78.3% had best corrected visual acuity (BCVA) 6/6-6/18, 36.6% had color vision defect and 31.4% had reduced contrast sensitivity. The most common visual field defect was isolated enlarged blind spot (39.7 %). CONCLUSION: IIH followed by optic neuritis (ON) are the most common causes of disc edema. Conditions with disc edema mainly affect the age group 21-40 years with females affected 2.5 times more than males. Visual acuity, color vision and contrast sensitivity are deranged in majority of cases of ON and normal in majority of cases of IIH.

Awareness of Eye Health and Diseases among the Population of the Hilly Region of Nepal.

PURPOSE: To collect information regarding awareness and knowledge of eye health and diseases among the population of the hilly region of Nepal. METHODS: In a population-based survey, 1834 participants were enrolled in to the study. Field procedures included the development of a survey questionnaire, field orientation, pretesting, and household data collection. Association between knowledge of eye diseases was derived using the Chi-square test and odds ratios with a 95% confidence interval. A P value of ≤0.05 was considered significant. RESULTS: Most participants were 31-40 years old (33.4%), female (51.1%), of upper caste (43.4%), Hindus (83.3%), received secondary level of education (34.4%), and involved in agriculture (48.6%). Awareness of cataract, night blindness, glaucoma, strabismus, and systemic diseases was 74.6%, 53.4%, 17.4%, 70.8%, and 46.5%, respectively. Knowledge regarding these diseases among those aware was 39.1%, 72.2%, 50.9%, and 92.3%, respectively. Awareness of cataract was significantly higher (88.4%) among higher caste groups (P < 0.001; OR, 4.29; 95% CI, 3.34-5.54), followed by business as an occupation (88.2%; P = 0.001; OR, 2.65; 95% CI, 1.44-4.9). Awareness of night blindness was significantly higher among students (72.6%; P < 0.001; OR, 2.46; 95% CI, 1.65-3.67). CONCLUSION: There was a general lack of awareness and knowledge of common eye diseases. Improved awareness and knowledge are required for the prevention, early treatment, and access to eye care.

Clinical Evaluation and Treatment Outcome of Traumatic Optic Neuropathy in Nepal: A Retrospective Case Series.

This study aims to report the clinical features and role of different treatment modalities in final visual outcome in traumatic optic neuropathy (TON). The authors retrospectively reviewed the records of patients with TON over 4 years. There were 37 patients of unilateral TON. Mean age was 28.70 ± 15.20 years (range: 8-90) and 89% (n = 33) were males. Road traffic accident was the common cause (43.2%), followed by fall injury (35.1%). There was improvement of visual acuity in 51.4% (n = 19) cases. Out of different treatment modalities, high-dose intravenous methylprednisolone (1 g/day) led to significant improvement in final visual acuity (p = 0.013). There was no significant improvement in final visual outcome in patients with poor initial visual acuity and those with intracranial injuries.

Correlation of Peripapillary Retinal Nerve Fibre Layer Thickness and Visual Evoked Potential in Optic Neuritis in a Tertiary Eye Care Centre.

INTRODUCTION: Optic neuritis (ON) is the involvement of the optic nerve as a result of inflammation, demyelination or infection. OBJECTIVE: To study the correlation between peripapillary retinal nerve fibre layer thickness (pRNFL) and visual evoked potential (VEP) in ON cases. MATERIALS AND METHOD: A non-interventional, descriptive, cross sectional study enrolling 66 eyes of 49 patients with ON was done. pRNFL thickness was measured by Optical Coherence Tomography (OCT) and VEP was also done. OCT and VEP findings were compared with the control group. In addition correlation between pRNFL thickness and VEP was done. RESULTS: The mean pRNFL in affected eyes were significantly higher than the control superiorly (p-value<0.001), inferiorly (p-value <0.001), temporally (p-value 0.005) and nasally (p-value <0.001). The mean P100 latency in the affected eyes were significantly prolonged than the control eyes both at 1º (p-value<0.001) and at 15' (p-value=0.05). The mean N75-P100 amplitude in the affected eyes were significantly reduced than the control eyes both at 1º (p-value<0.001) and at 15' (p-value<0.001). The mean pRNFL thickness in all four quadrants and VEP findings of the affected eyes showed no significant correlation. CONCLUSION: The increased thickness in non-myelinated pRNFL has no correlation with the increased latency or decreased amplitude in cases of ON. However, OCT is seen as a useful tool in detecting and quantifying even subtle pRNFL changes in cases of optic neuritis.

Demographic pattern and clinical characteristics of optic neuritis in a tertiary eye care centre.

PURPOSE: To study the demographic pattern and clinical characteristics of optic neuritis cases in a tertiary eye care centre in Nepal. DESIGN: Descriptive, cross-sectional study. METHODOLOGY: Complete ocular examination was done in all the newly diagnosed cases of optic neuritis presenting from January 1st 2012 to June 30th 2013. Demographic pattern, clinical features, visual acuity, colour vision, contrast sensitivity and visual field defects were studied. RESULTS: Sixty seven eyes of 50 patients (28 females and 22 males) with optic neuritis were included in the study. The mean age was 34.32 years ± 13.72 years. The male: female ratio was 1:1.27. All the cases presented with complaint of blurring of vision. Painful ocular movement was noted in 58%. On ophthalmoscopic examination around 2/3rd of eyes suffered from papillitis (72%) and 1/3rd from retrobulbar optic neuritis (27%). Only one case of neuroretinitis (1%) was seen in the study. The colour vision pattern was variable. Contrast sensitivity was reduced in 94%. Centrocaecal scotoma was seen in 10.5%. CONCLUSION: Females were predominantly affected. Unilateral involvement was the most common presenting as papillitis.

Direct microscopy in suppurative keratitis: a report from tertiary level hospital in Nepal.

INTRODUCTION: Infective keratitis is an ocular emergency that requires prompt diagnosis for appropriate management. This study was done todetermine the sensitivity, specificity and predictive values of Gram stain and potassium hydroxide (KOH) wet mount in the diagnosis of suppurative keratitis. MATERIALS AND METHODS: A prospective hospital based study of all patients with clinically diagnosed suppurative keratitis presenting between January 2011 and June 2012 was carried out. Corneal scrapes were taken and subjected to direct microscopy and culture. RESULTS: Corneal scrapings were obtained from 108 eyes with suppurative keratitis. Direct microscopy was positive in 39.2% of cases and organisms were grown in 50.9 % of the cases. Bacteria were responsible in 76.4% and fungi in 23.6%. Of the bacterial isolates, 66.7% was Staphylococcus aureus and of the fungal isolates, 30.7% was Aspergillus species. Sensitivity in vitro showed that Cefazolin, Chloramphenicol and Ofloxacin were most effective against bacteria. Sensitivity of Gram stain in detecting bacteria was 50% (95% CI, 34.43 to 65.56) and specificity was 77.3% (95% CI, 65.0 to86.3) and sensitivity of KOH wet mount in detecting fungi was 53.8% (95% CI, 26.12 to79.6) and specificity was 98.9% (95% CI, 93.44 to 99.9). Positivity of direct smear (65.1%) was found to be higher among eyes with larger ulcers (>2mm) than eyes with smaller ulcers ( less than 2mm). CONCLUSION: Direct microscopy is of great diagnostic value in the management of suppurative keratitis and it is recommended in all ophthalmic clinics without exception for establishing timely, appropriate and effective treatment.

Topographic corneal changes in children with vernal keratoconjunctivitis: A report from Kathmandu, Nepal.

PURPOSE: The present study was conducted to determine corneal topographic characteristics of children with vernal keratoconjunctivitis (VKC) and compare the corneal topographic indices in VKC subjects with normal subjects MATERIAL AND METHOD: In the hospital based comparative study, 115 consecutive subjects with VKC and 102 age and sex matched normal subjects were selected for the videokeratography with NIDEK ophthalmic operating system. Keratoconus-like topography was determined based on the expert classifier system. Other assessments included visual acuity testing with LogMAR chart, slit lamp biomicroscopy, dilated fundus examination, measurement of central corneal thickness and intraocular pressure. Topographic indices were analyzed and compared using unpaired t-test among different groups. Sensitivity and specificity was estimated by the ROC curve. RESULT: Among 115 subjects with VKC, males comprised of 86 subjects (66.1%) and mean age of presentation was 10.9 (SD 4.9) years with mixed VKC in 56.5%. Keratoconus-like topography was present in 13 subjects (11.3%). The keratoconus predictiv index (sensitivity 92.3%, specificity 98.5%), the opposite sectoral index (sensitivity 84.6%; specificity 93.2%), the differential sectoral index (sensitivity 92.3%; specificity 90.8%) were found to be signficantly associated with VKC subjects having keratoconus-like topography. CONCLUSION: A high prevalence of keratoconus-like topography was observed in patients with VKC.

Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal.

BACKGROUND: This study was conducted to determine clinical profile and etiological factors for phlyctenular keratoconjunctivitis (PKC) in our patients. MATERIALS AND METHODS: In the descriptive study, 50 pediatric cases of PKC were enrolled into the study from outpatient department of BP Koirala Lions Center for Ophthalmic Studies between August 2011 and August 2012. The age, sex, exposure to tuberculosis, ocular symptoms, and systemic complaints were recorded. Morphological description of PKC such as number, type, location and scars HISTORY and number of recurrence was also noted. The conjunctival swab was taken from all patients and sent for microbiological examination. Report of systemic involvement, worm infestation was also noted. Mantoux testing for possibility of tuberculosis was also performed. RESULTS: PKC was detected in 59 eyes of 50 children having mean age of 8.0 ± 6.2 years including 54% males, unilateral involvement in 82%, the limbal involvement in 52% and multiple PKC in 34% children. Associated ocular disorder was blepharitis in 12 (24%) children. Conjunctival swab and culture revealed Staphylococcus infection in 10 (20%) children. Of eight recurrent cases, two had urinary tract infection managed with systemic antibiotics, three had parasitic infestation treated with antihelmentics, one had mantoux positive without having evidence of tuberculosis and two cases had blepharitis as a local factor. CONCLUSIONS: PKC is mostly presented as unilateral disorder of conjunctiva. PKC is associated with blepharitis, Staphylococcus infection, worm infestation and systemic infection.

Diabetic retinopathy with or without clinically significant macular edema: The influencing factors.

INTRODUCTION: Diabetic retinopathy is the commonest micro vascular complication in patients with diabetes and remains a leading cause of blindness in people of working age group. OBJECTIVE: to determine the prevalence of clinically significant macular edema (CSME) and the influence of systemic risk factors Materials and methods: It is a hospital based comparative study conducted in 220 eyes of 110 diabetic patients. DR was graded according to International Clinical Diabetic Retinopathy Severity Scale and CSME was defined according to Early Treatment Diabetic Retinopathy Study (ETDRS) system. The patients were grouped as 1) CSME group (DR and CSME in one or both eyes) and 2) Non- CSME group(CSME in none of the eyes but with any grade of DR).Level of glycosylated hemoglobin (HbA1C), serum total cholesterol, triglyceride (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) and urine for albumin were studied in both groups. RESULTS: CSME was present in 36% of 110 patients. Poor glycemic control and high total cholesterol level showed positive association with CSME (p LESS THAN 0.05). LDL and TG levels were higher and HDL lower in CSME group. However, no statistical significance was found. CONCLUSION: The CSME is significantly associated with poorer glycemic control and elevated total cholesterol level.

Unusual case of bilateral angle closure glaucoma.

Bilateral angle closure glaucoma is a rare ocular emergency which can be a potentially blinding condition. A case of 72 years male, who developed headache and vomiting after five days of demise of his mother followed by blurring of vision. He was taken to the general hospital where all the routine tests and CT Scan head failed to reveal the cause. After two days of admission, patient was referred for ophthalmic consultation. On ocular examination he was diagnosed as a case of bilateral angle closure glaucoma. After two hours of treatment patient was comfortable with normal intraocular pressure and reasonably good vision.

Methanol poisoning: ocular and neurological manifestations.

PURPOSE: The purpose of this study was to examine the effectiveness of ethanol and high-dose intravenous steroid for preserving vision in acute methanol poisoning. METHODS: Eight cases of acute methanol poisoning presented to the emergency department. Detailed physical examination including neurological assessment was performed. Detailed ocular examinations were performed including visually evoked potential and electroretinography in indicated cases. All patients had visual symptoms. Pupillary abnormality was observed in all. Edema of the optic disc and nerve fiber layer were common fundus findings. The majority of cases were treated with methylprednisolone intravenously. Ethanol was given intravenously in four cases who presented within 48 h. Hemodialysis was performed in two cases having neurological manifestations and metabolic acidosis. Sodium bicarbonate was given to four patients. Folinic acid and multivitamins were also given to all the patients based on neurological advice. RESULTS: Most of the patients showed a good response to the treatment. In 87.5% of the cases, improvements in visual acuity of at least two lines were noted in follow-up visits. CONCLUSIONS: Early presentation with prompt treatment has a significant role in preserving and improving visual acuity. Ethanol and high-dose intravenous methylprednisolone can be an alternative treatment with better visual outcome where fomepizole is unavailable.

Duane's retraction syndrome: a retrospective review from Kathmandu, Nepal.

PURPOSE: The aim was to study the clinical characteristics of Duane's retraction syndrome (DRS) in Nepalese patients. METHOD: Medical records from 52 cases of DRS from May 2003 to April 2010 were retrospectively reviewed for age, gender, laterality and clinical characteristics. Forty-one case records (78.8 per cent) that had complete clinical findings were considered for further evaluation. Examination included visual acuity by Snellen chart, refraction, associated horizontal and vertical strabismus in primary gaze, upshoot and downshoot on attempted adduction, binocular vision assessed with the Worth four-dot test on adopted gaze and stereopsis examined with the Titmus stereo test. RESULTS: DRS type I was the most common type observed in 73.2 per cent of cases, followed by DRS type II (14.6 per cent) and DRS type III (12.2 per cent). It was more common in female patients (58.5 per cent) than male patients (χ(2) = 4.6, df = 1, p = 0.03). DRS was more common in the left eye (68.3 per cent) than the right eye and unilaterally present in 95.1 per cent of subjects. In primary gaze, orthotropia (41.5 per cent) was more common than exotropia (34.1 per cent) and esotropia (24.4 per cent) and vertical strabismus was present in 24.4 per cent of subjects. Upshoot and downshoot on attempted adduction was seen in 14.6 and 9.8 per cent, respectively. Binocular single vision was present in 68.3 per cent of subjects by Worth four-dot test at near. Stereopsis of 3,000 seconds of arc was present in 9.8 per cent, 100 to 200 seconds of arc in 14.6 per cent and 40 to 60 seconds of arc in 43.9 per cent with the Titmus stereo test. CONCLUSION: DRS is more common in female patients and the left eye. DRS type I is the most common type.