Examining the association between perceived stigma, its correlates, and restrictions in participation among persons with disabilities in Nepal: a cross-sectional study.

BACKGROUND: Disability stigma in low- and middle-income countries is one of the most persistent and complex barriers limiting persons with disabilities (PwDs) from enjoying their rights and opportunities. Perceived stigma among PwDs and its impact on participation restriction is rarely assessed in Nepal. OBJECTIVE: This study aimed to measure the extent of perceived stigma by PwDs, identify its relationships with specific demographic factors, and assess the impact on social participation. METHODS: A cross-sectional survey was conducted between May and July 2022 among PwDs in Nepal, with a sample of 371. The Explanatory Model Interview Catalog (EMIC) stigma scale and P-scale suitable for people affected by stigmatized conditions were used, and the generated scores were analyzed. One-way ANOVA was performed to determine group differences for sociodemographic variables, and linear regression and correlational analysis were used to identify their association and measure the strength and direction of the relationship. RESULTS: The mean stigma score was 16.9 (SD 13.8). 42% of respondents scored higher than the mean. The scores differed significantly by disability type, caste and ethnicity, education, occupation, and household wealth. Over 56% reported participation restriction, and 38% had severe/extreme restriction. Approximately 65% of participants with intellectual disabilities, 53% with multiple disabilities, and 48.5% of persons with severe or profound disabilities experienced severe or extreme restrictions. Perceived stigma had a positive correlation with Disability type (r = 0.17, P < 0.01) and negative correlations with Severity of disability (r= -0.15, P < 0.05), and Household wealth (r= -0.15, P < 0.01). Education was inversely associated with both stigma (r= -0.24, P < 0.01), and participation restriction (ß= -9.34, P < 0.01). However, there was no association between stigma and participation restriction (ß= -0.10, P > 0.05). CONCLUSION: All participants exhibited stigma in general; however, the severity varied based on disability type, level of education, and sociocultural circumstances. A large proportion of participants reported facing a high degree of restrictions in participation; however, no association was detected between perceived stigma and participation restriction. A significant negative linear correlation was observed between education and participation restriction. Stigma reduction programs focusing on education and empowerment would be especially important for overcoming internalized stigma and increasing the participation of PwDs.

Demography, indications and outcome of descemet stripping automated endothelial keratoplasty in Nepal.

BACKGROUND: Descemet stripping automated endothelial keratoplasty (DSAEK) is performed for corneal endothelial pathology. It had gained popularity over penetrating keratoplasty (PK) because of better outcome. METHODS: Retrospective data was collected from records of patients who underwent DSAEK from 2005 to 2019. Demography, indications and post-operative complications of DSAEK were analyzed. Outcome was measured in terms of graft clarity and vision. RESULTS: 93 eyes of 86 patients had undergone DSAEK in the study period of 15 years. Average age of the patients was 61.0 years. 55.9% were female. The common indications for DSAEK were cataract surgery related bullous keratopathy (n=47, 50.5%), Fuchs dystrophy (n=22, 23.6%) and failed graft (n=11, 11.8%). 8.6% of surgeries had graft detachment and 5.3% had pupillary block in the early post-operative period. Outcome analysis was done for cases (n=80) which had follow-up duration of at least 2 months (range: 2 months to 11 years; average: 28.5 months).Endothelial rejection occurred in 8 cases (10.0%), 5 of which regained graft clarity after treatment. At the last follow-up visit, 23.8% (n=19) of grafts had failed, which was mostly due to endothelial failure (n=16); 3 grafts failed due to infective keratitis. 42.5% (n=34) acquired best corrected vision of 6/18 or better. The average astigmatic error was 1.6 Diopter Cylinder by refraction. CONCLUSION: DSAEK showed good outcome with our results comparable to other studies. It had replaced traditional PK in our institute for endothelial dysfunction. Surgeons in the country should be encouraged and trained to do the procedure.

Effect of exposure to biomass smoke from cooking fuel types and eye disorders in women from hilly and plain regions of Nepal.

BACKGROUND/AIM: To study the association between exposure to biomass smoke from cooking fuels andi cataract, visual acuity and ocular symptoms in women. METHODS: We conducted a community-based cross-sectional study among women (≥20 years and without a previous diagnosis of cataract, ocular trauma or diabetes or those taking steroids) from hilly and plain regions of Nepal. Eligible participants received an interview and a comprehensive eye assessment (cataract development, visual acuity test and ocular symptoms). Participants' data on demographics, cooking fuel type and duration of use, and cooking habits were collected. We addressed potential confounders using the propensity score and other risk factors for ocular diseases through regression analysis. RESULTS: Of 784 participants, 30.6% used clean fuel (liquefied petroleum gas, methane, electricity) as their primary current fuel, and the remaining 69.4% used biomass fuels. Thirty-nine per cent of the total participants had cataracts-about twofold higher in those who currently used biomass fuel compared with those who used clean fuel (OR=2.27; 95% CI 1.09 to 4.77) and over threefold higher in those who always used biomass. Similarly, the nuclear cataract was twofold higher in the current biomass user group compared with the clean fuel user group (OR=2.53; 95% CI 1.18-5.42) and over threefold higher among those who always used biomass. A higher proportion of women using biomass had impaired vision, reported more ocular symptoms compared with those using clean fuel. Severe impaired vision and blindness were only present in biomass fuel users. However, the differences were only statistically significant for symptoms such as redness, burning sensation, a complaint of pain in the eye and tear in the eyes. CONCLUSIONS: Cataract was more prevalent in women using biomass for cooking compared with those using clean fuel.

Recurrence of Avellino Corneal Dystrophy Following Penetrating Keratoplasty: A Case Report.

Granular - lattice (Avellino) corneal dystrophy is inherited in an autosomal dominant fashion which affects stroma of the cornea with recurrent erosions and decreased vision due to clouding of cornea in later stage. We reported a case of 53-year old woman presented with pain and blurring of vision of left eye for 10 days with history of right eye deep anterior lamellar dystrophy and Left eye penetrating keratoplasty 5years back for Avellino dystrophy. On examination right eye graft was clear and left eye showed circular edges of irregular epithelium with patchy stains and epithelial defect suggestive of recurrence of dystrophy. A patient with recurrent corneal erosions and opacity in cornea has to be examined carefully so as not to overlook Avellino corneal dystrophy. Being a rare disorder this case has been reported to draw the attention of ophthalmologists about its recurrence following keratoplasty.

Acanthamoeba Keratitis - A Case Report.

INTRODUCTION: Acanthamoeba keratitis is a serious infection of the cornea which causes severe inflammation of the eye and loss of vision. CASE DESCRIPTION: A 45 years female came with a history of trauma of right eye with vegetative matter with severe pain and redness. Patient was treated with antibacterial, antifungal eye drops but the condition deteriorated. Diagnosis was based on presence of motile trophozoites and cyst in the culture of non nutrient agar with a lawn of E coli of the corneal ulcer scraping. Therapeutic penetrating keratoplasty was performed as the patient's condition deteriorated. CONCLUSION: Acanthamoeba keratitis is a rare parasitic vision threatening infection with poor prognosis in comparison to other infectious keratitis. Therefore prevention is very important.

A Case of Acute Gonococcal Conjunctivitis in an Unusual Age Group.

INTRODUCTION: This is a case of case of acute gonococcal conjunctivitis in a 2.5 years old female child. CASE: A 2.5 years old female child presented with redness, purulent and profuse discharge from left eye with associated upper eyelid swelling. The culture of conjunctival swab revealed Neisseria gonorrhoeae. The child was treated with intravenous antibiotics and fortified medications. CONCLUSION: Unlike young adults and newborn gonococcal conjunctivitis (GCC), children can have a nonsexual mode of transmission and could be seen in an unusual age group. For the management of the diseases, proper history including sexual abuse history and thorough physical examination is mandatory, which is sometimes difficult in a developing country. Gonococcal conjunctivitis in the toddler group should be kept in consideration.

Female Clients Satisfaction towards Primary and Secondary Eye Health Facilities and Cost of Eye Care in Nepal.

INTRODUCTION: In Nepal, females suffer from disproportionately higher burden of blindness and vision impairment with low access to eye care. The available knowledge is inadequate to address the issues related to gender and generate information to reduce the gender disparity. The aim of this study was to determine female clients' satisfaction with services at eye facilities in Nepal and to estimate the cost of cataract surgery. MATERIALS AND METHODS: Exit interviews were conducted in 2018 with 308 female clients from eight facilities in five districts. Face to face interviews were conducted using a pretested semi-structured questionnaire adopted from the midterm review of Vision 2020. RESULTS: The mean age of participants was 54±17 years. Ninety seven percent (97%) of the participants reported that they received service as per their expectation and were satisfied with the service of the facilities. Major factors for satisfaction were: thorough eye examination (54%), behavior of health staff (40%), and cleanliness of health facility (39%). Another eighty percent (80%) of the participants mentioned that they would recommend or return to the same facility. Fifteen percent of the participants perceived that they faced problems at the eye facility because of their gender. Around three quarters (73%) paid health expenses from their pocket. Most (83%) of the participants rated user fees as either reasonable or inexpensive. CONCLUSION: The majority of participants reported receiving service as expected and willingness to return to the same eye health facility for future consultation. However, most participants had to pay the health care expenses out-of-pocket.

Demography, Risk Factors, and Clinical and Microbiological Features of Microbial Keratitis at a Tertiary Eye Hospital in Nepal.

BACKGROUND: Infective keratitis is the most common corneal pathology in developing countries. Updated knowledge is needed for its control and proper management. METHODOLOGY: All cases of presumed microbial keratitis that presented in an 18-month period from October 2013 to March 2015 were enrolled. Data collected were demographic profile, risk factors, clinical features, and organisms isolated and their sensitivities. RESULTS: A total of 602 cases of microbial keratitis were enrolled. Mean age of subjects (598 patients) was 47.9 years with 53.8% male. 64.1% worked in agriculture. 38.3% gave history of trauma followed by history of herpetic eye diseases (17.9%) and topical steroid use (14.2%). A total of 473 who were referred came at an average of 21.5 days of symptoms. 14.9% (n=90) of cases were either perforated or impending to perforate at presentation. 69.6% had infiltrate in the visual axis. A total of 516 (85.7%) underwent diagnostic corneal culture. A total of 256 (49.6%) yielded a positive result. Pure bacterial growth was seen in 111 (43.4%), pure fungal growth in 138 (53.9%), and mixed microbial growth was present in 7 (2.7%) cases. Out of 121 bacterial isolates, 95.0% were Gram positive. Streptococcus pneumoniae (45.5%, n=55) was the most common bacterial isolate followed by Staphylococcus aureus (20.6%, n=25). Out of 145 fungal isolates, Aspergillus and Fusarium species were found in equal numbers (n=41, 28.3% each). Over 85% of Gram-positive organisms isolated in the study were sensitive to vancomycin, cefazolin, moxifloxacin, and gatifloxacin. Over 80% of Gram-negative organisms were sensitive to gentamicin, tobramycin, and amikacin. CONCLUSION: Microbial keratitis and associated risk factors occurring in farmers implies a lack of awareness and prevention programs. Delay in reaching tertiary care is resulting in complicated cases. Training of local health workers for prophylaxis, updated guidelines for treating keratitis, and timely referral to higher centers are all important in a chain to decrease the incidence of microbial keratitis.

Tectonic Graft for Persistent Leakage and Visual Outcome After Corneal Perforation Repair: A Case Series.

Keratoplasty is a modality of treatment for large and leaking corneal perforation in a tertiary center. We report cases of 20and 30-years old men presented in an emergency with history of road traffic accident 1 and 3 days back. Best corrected visual acuity was hand movement in both injured eye. Slit lamp examination of both cases revealed full thickness corneal laceration with Siedel test positive. Both cases underwent corneal laceration repair with resuturing and corneal glue on consecutive days but couldn't seal the leaking wound. Then ultimately both were undergone for tectonic keratoplasty. The final best corrected visual activity of involved eye was 6/36 in case 1 and 6/24 in case 2. Most cases of traumatic corneal perforation undergone urgent corneal repair but sometimes very difficult to seal the wound. In such cases donor cornea tissue may have to be used to maintain integrity of globe and better visual potential. Keywords: corneal perforation; laceration; siedel test; tectonic keratoplasty.

Continuous Knowledge Translation in Action: Designing a Programmatic Research Trial for Equitable Eye Health for Rural Nepalese Women.

Reaching vulnerable populations through programmatic eye health interventions requires a focus on not only the intervention strategies, but the adaptability of the program design process itself. Knowing who is left behind and why solutions that will be effective on the ground at the time of implementation are not necessarily generated. There is a need for eye health programmatic design processes that can trial interventions and allow for continuous knowledge translation along the way. In rural Nepal, women are impacted by multiple and interconnected determinants of health, as well as unique barriers to accessing information and services, requiring targeted programming strategies. This article describes a programmatic design and knowledge translation process that aims to increase women's uptake of eye health services in rural Nepal. The article outlines key learnings of this knowledge translation process, and how this may contribute to addressing gender equity in eye health.

Teleophthalmology through handheld mobile devices: a pilot study in rural Nepal.

BACKGROUND: To compare screening referral recommendations made by remotely located ophthalmic technicians with those of an ophthalmologist examining digital photos obtained by a portable ophthalmic camera system powered by an iOS handheld mobile device (iPod Touch). METHODS: Dilated screening eye exams were performed by ophthalmic technicians in four remote districts of Nepal. Anterior and posterior segment photographs captured with a Paxos Scope ophthalmic camera system attached to an iPod Touch 6th generation device were uploaded to a secure cloud database for review by an ophthalmologist in Kathmandu. The ophthalmic technicians' referral decisions based on slit-lamp exam were compared to the ophthalmologist's recommendation based on the transmitted images. RESULTS: Using the transmitted images, the ophthalmologist recommended referral for an additional 20% of the 346 total subjects screened who would not have been referred by the ophthalmic technician. Of those subjects, 34% were referred to the retina clinic. Conversely, among the 101 patients referred by the technician, the ophthalmologist concurred with the appropriateness of referral in more than 97% of cases but thought eight (2.8%) of those patients had variants of normal eye pathology. CONCLUSION: An ophthalmologist who reviewed data and photos gathered with the mobile device teleophthalmology system identified a significant number of patients whose need for referral was not identified by the screening technician. Posterior segment pathology was most frequently found by the remote reader and not by the technician performing dilated slit lamp examinations. These results are promising for further clinical implementation of handheld mobile devices as tools for teleophthalmic screening in resource-limited settings.

Clinical Profile on Keratoconus Presenting at A Tertiary Eye Care Centre- Tilganga Institute of Ophthalmology.

INTRODUCTION: Keratoconus (KC), is a bilateral, noninflammatory degenerative disease of the cornea which is characterized by progressive corneal ectasia and loss of visual function. The onset of KC is commonly seen at puberty and affects approximately 1 in 2000 in the general population. OBJECTIVE: The aim of this study was to assess the clinical profile of keratoconus in the tertiary eye centre in Nepal. MATERIAL AND METHODS: It is a retrospective, hospital based, consecutive study from June 2017 to May 2018. A total of 66 patients (114 eyes) were diagnosed cases of Keratoconus presented in Cornea clinic of Tilganga institute of Ophthalmology. Parameters investigated included patients' demography, keratometric readings, visualacuity and manifest refraction. Classification of keratoconus was based on Amslern-Krumeich grading system (modified). RESULTS: The mean age of subjects was 18.73 (range: 10-65). Male/female distribution was 48 (72.7%) and 18 (27.3%) respectively. 48 (72.7%) had bilateral keratoconus and 18 (27.3%) were unilateral. Mean Uncorrected visual acuity (UCVA) was 0.80 (range: 0.01-1.00), mean visual acuity ( VA) with spectacle correction was 0.47 (range: 0.01-1.00). Mean spherical amount of refractive was -2.17 (range: -0.50 to -17.00D) and mean cylindrical amount of refraction was -2.85 (range: 0.00 to -6.00). Mean spherical equivalent (SE) of refraction was -4.26 (range: -0.50 to -22.50D). Mean flattest keratometric reading (K1) was 49.63 (range: 40.63-76.70D) and mean steepest keratometric reading (K2) was 53.14 (range: 41.63-73.21D). Mean average keratometric reading was 51.43 (range: 41.63-72.10D). Regarding disease severity, 35.68% of subjects were classified as mild keratoconus, 29.73% as moderate keratoconus, 9.73% as advance keratoconus, while 24.86% were found with the severestage of keratoconus. 78.9% of total eyes presented with minimum pachymetry of 401 to 500 mm. CONCLUSION: Clinical profile of Nepalese keratoconus patients looks similar to that reported earlier worldwide. The condition was found to manifest at a younger age and was more common in males.

Role of laser refractive surgery in cross-subsidization of nonprofit humanitarian eyecare and the burden of uncorrected refractive error in Nepal: Pilot project.

PURPOSE: To establish a refractive surgery unit at Tilganga Institute of Ophthalmology through support from international donations and provide knowledge transfer for doctors and management to make the unit self-sustaining, nonprofit laser refractive surgery, and financial support for other eyecare projects at Tilganga. SETTING: Tilganga Institute of Ophthalmology, Kathmandu, Nepal. DESIGN: Retrospective study. METHODS: A foundation was created to establish a refractive surgery unit using a cost-recovery model; that is, patients are charged according to their financial status to cover running costs, patients without funds to pay for surgery, and other eyecare projects for the underprivileged population of Kathmandu, Nepal. Donations were obtained to fund refurbishment within Tilganga Hospital and purchase equipment and technology. A Nepalese surgeon was selected from Tilganga and completed an 8-month fellowship and proctorship of the first series of surgeries. The refractive surgery unit was opened in January 2012, and the cost-recovery model was evaluated up to December 2016. RESULTS: During the period evaluated, 74.8% of patients were treated at full cost, 17.2% at subsidized cost, and 8.6% free of charge. The refractive surgery unit generated a profit representing 28% of the running cost in this period, which was used to reduce the deficit of the main hospital. Surgical outcomes achieved were comparable to those reported by groups in the developed world. CONCLUSION: A self-sustaining nonprofit laser refractive surgery clinic, operating with high quality, was successfully implemented supported by international donations for initial setup costs and a cost-recovery model thereafter.

Etiologies of Optic Disc Edema in Tertiary Eye Care Centre in Nepal.

INTRODUCTION: Optic disc edema is a common clinical finding that can be caused by benign to vision and or life-threatening conditions. OBJECTIVE: To investigate the etiologies of optic disc edema among patients presenting to Tilganga Institute of Ophthalmology, Kathmandu, Nepal. MATERIALS AND METHODS: A retrospective chart review of patients with optic disc edema presenting to Neuro-ophthalmology department of Tilganga Institute of Ophthalmology from May 2012 to May 2014, was made. RESULTS: 98 patients were diagnosed with disc edema. Females (64%) were frequently affected. It was noted more in the 21 - 50 age groups. Papilledema was the most frequent cause (35.7%) of disc edema followed by papillitis (28.6%), pseudopapilledma (18.4%) and ischemia (17.3%), respectively. Brain tumors (13%) were the most common etiology for papilledema. CONCLUSION: Papilledema along with other causes, are common etiologies for disc edema. A detailed history and careful evaluation are necessary as the treatment strategy highly depends on it's underlying etiologies.

The role of small incision suture-less cataract surgery in the developed world.

PURPOSE OF REVIEW: Manual small incision cataract surgery (MSICS) has recently gone through much refinement and fine tuning. It is often taken as an alternate option for phacoemulsification, especially in developing country. This review will present some insight on its applications especially for developed nations. The role of MSCIS in tackling complex cataracts with stony hard nucleus is fairly established. The role of training residents with MSCIS has certain advantages though debatable. RECENT FINDINGS: MSCIS is much faster and cost-effective surgical technique often possible in suboptimal condition and avoids the capital and maintenance cost of phacoemulsification. The visual outcome and postoperative complications in both phacoemulsification and MSCIS are comparable. Slightly greater astigmatism in MSICS can be lessened with a slight modification of surgical technique. The successful application of MSCIS in large public health programmes has successfully helped to increase the cataract surgical rate and quality. It is the technique of choice for blindness control programme in developing country. SUMMARY: MSICS is established as safe and cost-effective procedure in developing country with results as good as phaoemulsification. Although it may not be the best option for developed nations, it is a valuable skill especially for surgical conversion and to deal with complex and advance cataract cases. Hence, it should be a part of resident training programme in developed world and it should be in the armamentarium of every cataract surgeon.