Quantification of Metamorphopsia in Resolved Idiopathic Central Serous Chorioretinopathy: An Analysis Using M-CHARTS, Amsler Grid, and Optical Coherence Tomography.

Purpose: To quantify metamorphopsia in patients with resolved idiopathic Central Serous Chorioretinopathy (CSCR) using M-CHARTS and compare the results with the traditional Amsler grid and optical coherence tomography (OCT). Patients and Methods: For the purpose of this study, all consecutive cases of patients with resolved CSCR were evaluated for metamorphopsia (using the standard Amsler grid and M-CHARTS) and spectral domain OCT. The OCT images were analyzed for the following five parameters: central macular thickness, pigment epithelial detachment, retinal pigment epithelial bumps, discontinuation in the inner segment/outer segment junction or the external limiting membrane, fibrinous exudates in the subretinal space, and hyperreflective dots in the intraretinal and/or subretinal layer. Binary logistic regression was used to find the association between metamorphopsia and foveal morphology. Cohen's Kappa was used to determine the agreement between the M-CHARTS and Amsler grid for diagnosing metamorphopsia. The sensitivity, specificity, and accuracy in the diagnosis of metamorphopsia were calculated against the Amsler grid. Results: Of 41 eyes, Amsler Grid detected metamorphopsia in 39.02%, and M-CHARTS detected metamorphopsia in 53.66%. The agreement rate of detection between the two tests was moderate (Kappa=0.52). M-CHARTS had a sensitivity of 87.50%, a specificity of 68.00%, a positive predictive value of 63.64%; and a negative predictive value of 89.47% for the diagnosis of metamorphopsia compared to the Amsler grid. The presence of PED in OCT was significantly associated with metamorphopsia. Conclusion: M-CHARTS can be a useful ancillary test to detect and quantify metamorphopsia even after fluid resolution in CSCR. Structural changes in macular morphology as observed with OCT can predict the likelihood of metamorphopsia.

Impact of active vision therapy compared to conventional patching therapy on visual acuity and stereoacuity in children with amblyopia.

PURPOSE: To compare improvements in visual acuity (VA) and stereoacuity between active vision therapy (AVT) and conventional patching therapy in children with amblyopia. METHODS: This study included 65 children aged 5 to 16 years (mean age±SD, 11.00±3.29 years) with unilateral amblyopia. Among them, 31 children underwent active vision therapy (AVT group), and 34 children underwent conventional patching therapy (patching group). AVT group underwent three sequential phases of AVT: Monocular phase (pursuit, saccades, fixation, visuomotor, eye-hand coordination, and central peripheral activities), biocular phase (diplopia awareness, antisuppression, monocular fixation in a binocular field, accommodative activities, bilateral integration, and fine motor activities) and binocular phase (fusion and stereopsis). Patching group patched their fellow eyes as per guidelines by Pediatric Eye Disease Investigator Group. Best-corrected monocular VA and stereoacuity were measured at baseline and after three months of therapy in both groups. RESULTS: There were significant improvements in the mean acuities in amblyopic eye (AE) in both AVT (0.32±0.11 logMAR, p <0.001) and patching groups (0.27±0.19 logMAR, p Ë‚ 0.001). However, there was no significant difference in mean acuity gains in AE between AVT and patching groups (p = 0.059). Mean gains in stereoacuities (log seconds of arc) were statistically significant in both AVT (0.81±0.34, p < 0.001) and patching groups (0.32±0.34, p < 0.001). The stereoacuity gain in the AVT group was significantly higher compared to patching group (p < 0.001). CONCLUSION: Active vision therapy had a better impact than conventional patching therapy in terms of improvement of stereoacuity but not in terms of VA when used for treating children with amblyopia.

Kaleidos-based binocular vision analyzer for the estimation of refractive errors and horizontal ocular deviation in children.

CLINICAL RELEVANCE: Knowing the agreement and interobserver variability of the 2WIN-S photorefractometer with cycloplegic retinoscopy and prism cover test is important for judging the clinical usefulness of the device. BACKGROUND: This study aims to determine an agreement and interobserver reliability between 2WIN-S photorefractometer and cycloplegic retinoscopy for estimating refractive errors and between 2WIN-S and prism cover test for measuring horizontal ocular deviation in children. METHODS: Two groups of 129 and 64 participants (range, 5 to 16 years) were recruited for the agreement and interobserver reliability studies, respectively. Non-cycloplegic 2WIN-S refraction was compared with cycloplegic retinoscopy for low and moderate myopia and hyperopia. Similarly, corneal reflex-function (CR-function) of 2WIN-S was compared with prism cover test for horizontal ocular deviation. Bland-Altman plots were used to depict agreement, and the intraclass correlation coefficient (ICC) was used for determining interobserver reliability of repeated measures. RESULTS: The mean differences in spherical equivalent, J0 (Cartesian astigmatism) and J45 (oblique Jackson cross-cylinder) between cycloplegic retinoscopy and 2WIN-S were 1.10 (95% CI = 0.97 to 1.21, p < 0.001), -0.06 (95% CI = -0.09 to -0.03, p < 0.001) and 0.009 (95% CI = -0.01 to 0.03, p = 0.35), respectively. The overall median difference in the horizontal ocular deviation between prism cover test and 2WIN-S was -4.5 (Interquartile range = -12.0 to 4.0). For constant strabismus, this difference was insignificant (median= -2.0, interquartile range = -11.0 to 6.7, p = 0.19) between prism cover test and 2WIN-S. The ICC was high for the spherical equivalent (0.997; p < 0.001), J0 (0.932; p < 0.001) and J45 (0.901; p < 0.001), whereas it was low-to-moderate for horizontal ocular deviation (0.50; p < 0.001). CONCLUSION: 2WIN-S refraction was in agreement with cycloplegic retinoscopy for low and moderate myopia and hyperopia, and requires an adjustment for the consistent differences between cycloplegic retinoscopy and 2WIN-S refraction. The measurement of constant strabismus with 2WIN-S is comparable to that of prism cover test.

Bilateral Iridochorioretinal Coloboma Managed with Low Vision Rehabilitation: A Case Report.

Ocular coloboma is a rare congenital disability. If involving the macula, it affects the patient's vision and subsequently affects childhood development and quality of life in the future. Appropriate low vision aid and timely rehabilitation can provide the best possible quality of life for visually impaired children. We report a 9-year-old boy who presented with a diminution of vision in both eyes, and who was just enrolled in pre-school. He was diagnosed with bilateral iridochorioretinal coloboma associated with nystagmus and unilateral cataract. After all the necessary evaluation, a telescope was prescribed for distance and a dome magnifier for near. Furthermore, a peaked cap and photo grey lens were given for outdoor activities. This case highlights the importance of low vision intervention in a visually impaired child. Appropriate low vision aid and rehabilitation can improve patients' lifestyle and academic performance who are diagnosed with iridochorioretinal coloboma. Keywords: case reports; coloboma; ocular; rehabilitation; training.

Diabetic Retinopathy among Patients with Prediabetes Attending the Outpatient Department of Ophthalmology in a Tertiary Eye Care Centre: A Descriptive Cross-sectional Study.

Introduction: Diabetic retinopathy is a specific microvascular ocular complication associated with diabetes. However, retinopathy has also been reported in people with prediabetes. The study aimed to find out the prevalence of diabetic retinopathy among patients with prediabetes attending the outpatient Department of Ophthalmology in a tertiary eye care centre. Methods: A descriptive cross-sectional study was conducted among patients with prediabetes attending the outpatient Department of Ophthalmology in a tertiary eye care centre from 1 January 2022 and 30 April 2022. Ethical approval was obtained from the Ethical Review Board (Registration number: 594/2021 P). All patients had their eyes dilated and examined under the slit-lamp with a 90 D convex lens or indirect ophthalmoscopes with a 20 D lens to find retinopathy. All patients aged 40 to 79 years with intermediate hyperglycemia were included in the study. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 141 patients with prediabetes, diabetic retinopathy was found in 8 (5.67%) (1.85-9.49, 95% Confidence Interval). Among which all patients 8 (5.67%) had mild non-proliferative diabetic retinopathy. Among patients with retinopathy, all 8 (5.67%) were obese, 3 (37.50%) were hypertensive, 5 (62.50%) patients had intermediate hyperglycemia for more than 6 months, and 2 (25%) had a family history of diabetes mellitus. Conclusions: The prevalence of diabetic retinopathy in prediabetes patient was found to be higher than the other studies conducted in similar settings. Keywords: diabetic retinopathy; prediabetes; prevalence.

Screen time and its correlates among children aged 3-10 years during COVID-19 pandemic in Nepal: a community-based cross-sectional study.

OBJECTIVE: This study aims to determine the prevalence of high screen time among schoolchildren aged 3-10 years in Bhaktapur, its correlates and the parents' strategies to reduce screen time during the COVID-19 pandemic in Nepal. METHODS AND ANALYSIS: This cross-sectional descriptive study was conducted during March 2021. A total of 630 households were selected for the study from 21 randomly selected clusters in Bhaktapur, Nepal. Correlates of high screen time were determined using a logistic model. P<0.002 was taken as significant. RESULTS: Among all the participants, the mean (SD) age was 7.0 (2.2) years, with 50.3% male participation. Few participants had online classes (n=24, 3.8%). The prevalence of high screen time among the participants was very high (55.2%, 95% CI=51.3% to 59.1%), which is even higher in boys (61.8%, 95% CI=58.0% to 65.6%). The median screen time before the COVID-19 pandemic was 1.0 hours (mean rank=275.8) which increased to 2.2 hours (mean rank=116.6) during the pandemic (p<0.001). Participants having smartphones were about seven times (adjusted OR=6.9, 95% CI=1.5 to 31.3, p=0.013) more likely to have high screen time than those who did not have the device. Most parents used to reprimand and urge their children to play outside to limit their screen usage. CONCLUSION: During the COVID-19 pandemic, about one in two schoolchildren of 3-10 years had higher screen time than before the COVID-19 pandemic. Parents' strategies to reduce screen time were not effective. An intervention study is recommended to design and test effective strategies to reduce screen time and its negative effects on children's health.

Burden and Risk Factors of Diabetic Retinopathy Among Diabetic Patients Attending a Multispecialty Tertiary Eye Hospital in Nepal.

INTRODUCTION: As the number of people with diabetes mellitus is increasing because of urbanization and change in dietary habits and sedentary lifestyle, the number of diabetic retinopathy is also expected to increase in future. [1] [sa2] We aimed to find out the prevalence of diabetic retinopathy and associated risk factors among diabetic patients in the tertiary eye hospital. MATERIALS AND METHODS: This is the observational cross-sectional study enrolling 420 diabetic patients visiting the multispecialty tertiary eye hospital between March 2020 and February 2021. Anthropometry measurement, laboratory risk profiles and blood pressure were recorded Results: The prevalence of any diabetic retinopathy, proliferative diabetic retinopathy, and diabetic macular edema were 30.96 %, 6.19 %, and 5.95 % respectively. The duration of DM (p=0.001), hypertension (p=0.04), high SBP (p=0.023), abdominal obesity (p=0.015), high LDL(p=0.011) cholesterol, low HDL cholesterol(p=0.012), and creatinine (p=0.001) were associated with DR in our study. CONCLUSION: A holistic approach should target to control the modifiable risk factors like blood sugar, blood pressure, lipid profile, kidney function, and obesity to prevent DR. Anthropometric assessment of waist to height and waist circumference should be included in the holistic health promotion strategy in Nepal as BMI may not be risk factors for DR in Nepalese people.

Managing a Case of a Congenital Cystic Eyeball: Case Report with Review of Literature.

A congenital cystic eyeball is an extremely rare condition, with only 52 cases reported in the literature to date. An orbital cyst replaces the eyeball which occurs due to the complete or partial failure in invagination of the primary optic vesicle during the fourth week of gestation. We discuss a case of a congenital cystic eyeball in a 14-year-old female who presented to us for a cosmetic blemish due to a large swelling in the right eyelid with the absence of a right eyeball since birth. She underwent removal of the cyst followed by an orbital implant and later prosthesis. Diagnosis of the congenital cystic eyeball was made based on the clinical and ultrasound B-scan features, intraoperative findings, and histopathology report. This article adds one more case to the existing literature on the congenital cystic eyeball. Orbital implant with prosthesis after excision of the cyst provided definitive diagnosis and a good cosmetic outcome in our case.

Clinical variations and therapeutic challenges in the management of symptomatic retinal artery macroaneurysm: a tertiary center experience.

PURPOSE: To find out clinical characteristics, therapeutic options, and visual outcome in symptomatic retinal artery macroaneurysm (RAMA) patients. METHOD: Newly diagnosed cases of symptomatic RAMA from January 2015 to December 2019 were included. Fifteen eyes of 15 patients with mean age 62.46 years ± 14.89 (SD) fulfilled the inclusion criteria. RESULT: Hypertension was present in 66.6% of the patients, and the commonest site was superotemporal (12 eyes, 80%). The most commonly employed treatment was Nd: Yag laser hyaloidotomy in 4 eyes (26.6%). Other treatments were intravitreal bevacizumab in 3 eyes (20%), focal laser with intravitreal bevacizumab in 3 eyes (20%), PPV with focal laser (13.3%) in 2, focal laser only in one (6.6%), PPV with focal and intravitreal bevacizumab in one (6.6%). The mean best-corrected visual acuity (BCVA) at baseline was 1.35 ± 0.84 LogMAR, which improved to 0.39 ± 0.53 LogMAR at the last follow-up. Presenting VA 0.77 (±0.40) improved to 0.20 (±0.17) p value (0.180) in intravitreal bevacizumab only group, 1.29 (±0.35) to 0.75 (±0.15) p value 0.66 in Nd: Yag laser group, 2.67 (±0.58) to 0.46 (±0.28) p value 0.019 in PPV group and did not improve in combined anti-VEGF and focal laser group due to dense hard exudates at the fovea in one and persistent cystoid macular edema in another case. CONCLUSION: With regard to its presentation, which can vary tremendously, there are no approved guidelines for its treatment. The present study reinforces the need for a treatment guideline development. Customization of treatment should be considered depending on the clinical presentation of each case.

Amblyopia among Patients Attending the Outpatient Department of Ophthalmology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Amblyopia is defined as a reduction in visual acuity unilaterally or bilaterally without any detectable cause. It is a major public health issue in developing and underdeveloped countries. Its prevalence is usually underestimated because of proper study and lack of awareness. The aim of the study was to find out the prevalence of amblyopia among patients attending the Outpatient Department of Ophthalmology of a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among outpatients visiting a tertiary care centre in the Outpatient Department of Ophthalmology between 1 January 2017 to 31 December 2019. Ethical approval was obtained from the Institutional Review Board (Registration number: 407/2020 P). All patients had gone through a comprehensive eye examination. Convenience sampling was used. Point estimate and 99% Confidence Interval were calculated. Results: Among 82972 patients, prevalence of amblyopia was 344 (0.41%) (0.37-0.46, 99% Confidence Interval). Amblyopia was more common in anisometropia 263 (63.50%). A total of 117 (34%) patients had no history of eye examination and were newly diagnosed with amblyopia. Astigmatism was the most common type of refractive error among 224 (56.70%) amblyopic patients. Conclusions: The prevalence of amblyopia was found to be lower than in previous studies conducted in similar settings. Early detection and diagnosis of amblyopia can help to design more effective plans and treatments to reduce amblyopia through optical correction and amblyopia therapy. Keywords: amblyopia; anisometropia; astigmatism; refractive errors.

Vitreous Hemorrhage following High-Altitude Retinopathy.

PURPOSE: To report a case of high-altitude retinopathy with vitreous hemorrhage. METHODS: An apparently healthy 29-year-old boy presented with a history of floater and slight diminution of vision in the left eye after climbing the mountain 4760 meters high. RESULTS: The visual acuity at presentation was 20/20 in the right eye and 20/30 in the left eye. Anterior segment findings of both eyes were unremarkable. Fundus evaluation revealed bilaterally dilated major retinal veins. The right eye revealed clear, quiet vitreous, healthy macula, and pink and smooth optic disc. There was fresh vitreous hemorrhage confined just one disc diameter away at the superior and inferior part of the optic nerve in the left eye. The macula and optic nerve head of this eye grossly looked normal. Complete blood count, haemoglobin, ESR, CRP, sugar, renal function test, lipid panel, and serology for HIV, HCV, VDRL, and HBsAg were normal. The Mantoux test and chest X-ray also revealed normal findings. Physician consultation did not reveal other abnormalities. On the 3rd week of follow-up, his vision was 20/20 in both eyes. Fundus examination revealed clear vitreous in both eyes though some venous dilation and tortuosities were still evident in the left eye. A macular OCT scan showed almost normal-appearing fundus. CONCLUSIONS: Vitreous hemorrhage following climbing high altitude can be one of the manifestations of high-altitude retinopathy.

Evolution of Lightning Maculopathy: Presentation of Two Clinical Cases and Brief Review of the Literature.

Lightning is a naturally occurring atmospheric phenomenon. Though uncommon, it is a potentially devastating and underreported natural calamity. Lightning accounts for the second leading cause of weather-related death in most parts of the world. Among the survivors of lightning injury, more than half of the victims may suffer from some form of ophthalmic injury. The lightning-associated ocular injury varies from a range of anterior segment to posterior segment pathologies. We report on two clinical cases of ocular injuries among the survivors of lightning injury. Anatomical involvement is seen at different levels with presentation as uveitis, pupillary abnormality, maculopathy, and later development of lenticular opacification. Optical coherence tomography (OCT), a noninvasive diagnostic tool, is particularly useful in the evaluation of lighting maculopathy as well as to monitor its progression through the course of time. Visual prognosis depends upon the structures of the eyes affected in the injury. The presence of irreversible retinal damage as well as optic nerve damage often result in poor visual outcome in the absence of significant anterior segment pathology. This report highlights the evolution of maculopathy through the course of time and signifies the importance of long-term follow-up postlightning injury.

Use of Intravitreal Bevacizumab Injection among Patients Undergoing Surgical Retinal Interventions at Tertiary Eye Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Intravitreal Bevacizumab injection has now become a routine procedure for retina specialists throughout the world. Easy availability of this monoclonal antibody molecule even in Nepal has brought a revolution in the management of various retinal diseases. This study aims to find out the prevalence of the use of intravitreal Bevacizumab for retinal diseases at the tertiary eye hospital. METHODS: This descriptive cross-sectional study was carried out in the retina department at a tertiary care hospital from January 2017 to December 2019 after obtaining ethical clearance from Nepal Health Research Council (Ref: 125/2020P). The sample size was calculated and the study enrolled all patients who received intravitreal Bevacizumab for retinal diseases using convenience sampling technique. Data were analyzed using Statistical Package for Social Science Version 21. Point estimate at 95% Confidence Interval was calculated, along with frequency and percentage for binary data. RESULTS: Out of 959 total surgical retinal interventions done 296 (30.86%) at 95% Confidence Interval (27.93-33.78) patients received intravitreal Bevacizumab. Out of total intravitreal Bevacizumab injections, 143 (36.7%) injections were given to retinal vein occlusions patients, 127 (32.6%) injections were given to diabetic retinopathy patients and 66 (17%) injections was given to age-related macular degeneration patients. Males 176 (59.5%) outnumbered the females 120 (40.5%) in receiving intravitreal Bevacizumab. Mean baseline Logarithm of the Minimal Angle of Resolution visual acuity, 1.1, improved to, 0.75, after 3 months of intravitreal Bevacizumab. CONCLUSIONS: Intravitreal Bevacizumab was one of the commonest retinal interventions used. Retinal vein occlusion, diabetic retinopathy, and age-related macular degeneration were the commonest retinal diseases needing intravitreal Bevacizumab.

Conventional versus Modified Tarso-frontalis Suspension Surgery using Targeted Lid Crease for Simple Congenital Blepharoptosis with Poor Levator Action.

INTRODUCTION: The routine technique of tarso-frontalis suspension surgery for simple congenital blepharoptosis with poor levator action is cosmetically less rewarding due to either an absence or asymmetry of the postoperative eyelid crease. The objective of this study was to assess the eyelid crease quality after a modified open method of tarso-frontalis suspension surgery compared to the closed method. MATERIALS AND METHODS: This was a retrospective comparative study reviewing the case sheets of all the patients undergoing unilateral tarso-frontalis suspension surgery with silicon rod employing Fox pentagon design from September 2017 to February 2019 at Mechi Eye Hospital, Jhapa, Nepal. A review of 40 case sheets of congenital lid ptosis with poor levator function(<4mm) aged 9 years or more was done. Tarso-frontalis suspension surgery, modified with a mini blepharoplasty incision, direct attachment of silicon rod to tarsus, completion of pentagon design with supra-brow incisions, and skin-orbicularis-tarsus-orbicularis-skin suture (open method) was done in 20 cases whereas other 20 cases underwent surgery with supraciliary stab incisions (closed method). RESULTS: The mean age of the patients was 21.1+5.9 years (range 9-30 years). The ptosis amount ranged from 3-10mm. At the 6th postoperative month, most of the cases had good ptosis correction (90% open group, 85% closed group, p=0.74). However, cosmetic outcomes were better in the open group compared to the closed group: 100% symmetrical eyelid crease compared to 40% (p<0.001) and 90% acceptance rate for eyelid contour compared to 70% (p=0.23). CONCLUSION: Predictable, targeted, and symmetrical lid crease can be obtained using the modified open method of tarso-frontalis suspension surgery.

Ocular Manifestations and Biometrics in Marfan's Syndrome from Eastern Nepal.

PURPOSE: To evaluate the ocular characteristics of Marfan's syndrome (MFS) fulfilling the revised Ghent-2 nosology in Eastern Nepal. MATERIALS AND METHODS: A hospital-based observational and cross-sectional study was conducted. Ocular manifestations and biometrics were incorporated. Patients were subdivided into adults (16 years or older) and children (5-15 years). Ocular biometric parameters consisted of values of refractive error, keratometry readings, anterior chamber depth (ACD), central corneal thickness (CCT), lens thickness (LT) and axial length (AL). RESULTS: A total of 34 eyes of 17 patients with MFS were included, where 32 eyes were phakic. Mean age of the study participants was 14.5 ± 9.1 years. The mean best corrected visual acuity (BCVA) of phakic eyes was 0.99 ± 0.82 LogMAR. Myopia greater than -3 diopters (D) was present in 28/34 (82.35%) eyes. The average spherical equivalent was -12.34 ± 8.85 D. Ectopia lentis (EL) was present in 24/32 (75%) eyes where superonasal was the most common subluxation in 10/24 (41.7%) eyes. AL was longer in adults 26.54 ± 4.42 mm compared to 25.21 ± 1.93 mm in children. Likewise, LT in adults was 4.9 ± 0.70 mm and 4.40 ± 0.59 mm in pediatric participants. Flat corneas were noted in both the groups with an average of 41.53 ± 2.21 D. The mean CCT and ACD were 524.62 ± 21.74 µm and 3.64 ± 0.80 mm, respectively. There was a negative association between the AL and the average corneal curvature (Kmed, correlation coefficient -0.11, p=0.54). CONCLUSION: Myopia is the foremost ocular involvement with significant visual disability in MFS. Though, AL and corneal curvature are not included in the revised Ghent-2 nosology, we strongly recommend these parameters to be considered during ophthalmic evaluation in suspected and diagnosed cases of MFS in the absence of genetic testing.

Ocular manifestation in progeria: A case report.

INTRODUCTION: Progeria also known as Hutchinson Gilford Progeria Syndrome (HGPS) (MIM176670) is a very uncommon fatal genetic untimely aging syndrome. It is characterized by retarded physical development, accelerated degeneration of the skin, cardiovascular and musculoskeletal abnormalities. Other features include prominent eyes, thin nose, small chin and thin lips. Eyebrow hair loss, madarosis and lagopththalmos are the common ocular manifestations. CASE: We report a case of five year old boy with complaints of discomfort in bright light and a whitish appearance in his right eye for two months. He was accompanied by the parents. They complained of loss of eyelashes and eyebrows. In the developmental history he was normal at birth till the age of one year then they noticed gradual hair fall, delayed growth, wrinkling of skin, increase in size of head and thinning of limbs. CONCLUSION: This is the first case report from Nepal with the ocular presentation of progeria indicating the role of ocular senescence in patients with Hutchinson Progeria Gilford Syndrome.