Rationale and protocol paper for the Asia Pacific Network for inherited eye diseases.

PURPOSE: There are major gaps in our knowledge of hereditary ocular conditions in the Asia-Pacific population, which comprises approximately 60% of the world's population. Therefore, a concerted regional effort is urgently needed to close this critical knowledge gap and apply precision medicine technology to improve the quality of lives of these patients in the Asia-Pacific region. DESIGN: Multi-national, multi-center collaborative network. METHODS: The Research Standing Committee of the Asia-Pacific Academy of Ophthalmology and the Asia-Pacific Society of Eye Genetics fostered this research collaboration, which brings together renowned institutions and experts for inherited eye diseases in the Asia-Pacific region. The immediate priority of the network will be inherited retinal diseases (IRDs), where there is a lack of detailed characterization of these conditions and in the number of established registries. RESULTS: The network comprises 55 members from 35 centers, spanning 12 countries and regions, including Australia, China, India, Indonesia, Japan, South Korea, Malaysia, Nepal, Philippines, Singapore, Taiwan, and Thailand. The steering committee comprises ophthalmologists with experience in consortia for eye diseases in the Asia-Pacific region, leading ophthalmologists and vision scientists in the field of IRDs internationally, and ophthalmic geneticists. CONCLUSIONS: The Asia Pacific Inherited Eye Disease (APIED) network aims to (1) improve genotyping capabilities and expertise to increase early and accurate genetic diagnosis of IRDs, (2) harmonise deep phenotyping practices and utilization of ontological terms, and (3) establish high-quality, multi-user, federated disease registries that will facilitate patient care, genetic counseling, and research of IRDs regionally and internationally.

Prevalence and associated factors of diabetic retinopathy among people with diabetes screened using fundus photography at a community diabetic retinopathy screening program in Nepal.

BACKGROUND: This study aimed to assess the prevalence and associated factors of diabetic retinopathy (DR) and vision threatening DR (VTDR) among people with diabetes screened using fundus photography in Nepal. METHODS: This is a retrospective study among people with diabetes presented for DR screening using fundus photography from 2013 to 2019. Detailed demographics, duration of diabetes, medical history, visual acuity, and grading of DR on fundus photography were analyzed. Fundus camera used in the study were;Topcon digital fundus camera 900 CXR and digital portable fundus cameras (Nidek-10 portable non-mydriatric fundus camera; Versacam & Trade & Alpha, France), and a Zeiss portable fundus camera (Zeiss Visucout 100). Macula centred and disc centred 45 degree two images were taken from each eye. Pupil were dilated in cases where there was media haze in un-dilated cases. DR was graded using early treatment diabetic retinopathy study criteria. The images were graded by fellowship trained retina specialist. DR prevalence included any DR changes in one or both eyes. RESULTS: Total of 25,196 patients with diabetes were enrolled. Mean age was 54.2 years with Standard Deviation (S.D):12.9 years, ranging from 6 years to 97 years. Type 1 and type 2 diabetes comprised of 451 people (1.79%) and 24,747 (98.21%) respectively. Overall, 1.8% of the images were un-gradable. DR prevalence was 19.3% (95% Confidence Interval (CI): 18.8 - 19.7%). DR prevalence in type 1 and type 2 diabetes was 15.5% (95% CI: 12.5 - 18.6%) and 19.3% (CI: 18.8 - 19.8%) respectively. Clinically significant macular edema (CSME) was found in 5.9% (95% CI: 5.6-6.2%) and VTDR in 7.9% (95% CI: 7.7-8.3%). In multivariate analysis, our study revealed strong evidence to suggest that there is meaningful association between DR and VTDR with duration of diabetes, diabetic foot, diabetic neuropathy, agriculture occupation, those under oral hypoglycaemic agents or insulin or both as compared to those under diet only, and presenting visual acuity > 0.3LogMAR. CONCLUSION: Prevalence and associated factors for DR and VTDR were similar to other DR screening programs in the region. Emphasis on wider coverage of DR screening could help for timely detection and treatment of STDR to avoid irreversible blindness.

Outcomes Of Microincision Pars Plana Vitrectomy In Rhegmatogenous Retinal Detachment.

BACKGROUND: With the technological advances, microincision pars plana vitrectomy is commonly used method for primary treatment of eyes with rhegmatogenous retinal detachment. Objective of this study is to evaluate anatomical and visual outcomes of microincision pars plana vitrectomy in eyes with rhegmatogenous retinal detachment. METHODS: This was a hospital based prospective observational study done in Tilganga Institute of Ophthalmology, Kathmandu, Nepal. All consecutive cases of rhegmatogenous retinal detachment who underwent primary microincision pars plana vitrectomy from October 2020 to March 2021 were included in the study. Patients were evaluated at baseline, postoperative day 1, 1 week, 6 weeks and 3 months. Outcome measures evaluated were anatomical results, visual outcomes and complications of the surgery. RESULTS: Forty-nine eyes with rhegmatogenous retinal detachment treated with primary microincision pars plana vitrectomy with minimum follow up of at least 3 months were evaluated. Anatomical success was achieved in 91.8% of cases (45/49). Baseline mean best corrected visual acuity was logMAR 1.63±0.88 and median best corrected visual acuity was 2.00 (range 0.00 to 2.70) while at 3 months follow up mean best corrected visual acuity was logMAR 1.22±0.66 and median BCVA was 1.00 ( range 0.00 to 2.70). There was significant improvement in median BCVA ( p= 0.005). There were no cases of postoperative hypotony and endophthalmitis. Other complications were also minimal such as silicon oil in anterior chamber in 1 eye, epiretinal membrane in 3 eyes and macular hole in 2 eyes. CONCLUSIONS: Microincision pars plana vitrectomy is an effective surgical method of primary treatment for rhegmatogenous retinal detachment with good anatomical and visual outcomes with minimal complications.

SAARC Academy of Ophthalmology - Tailoring Clinical Standards for Diabetic Retinopathy Care to Available Resources.

The South Asian Association for Regional Cooperation (SAARC) is a geopolitical union of 8 member states of South Asia, one of the rapidly transforming regions in the world. It houses 25% of the world population, with a similar rise in at-risk population for diabetes and its complications. Diabetic retinopathy (DR), is one of the major causes of blindness and visual impairment. Despite the region's dramatic demographic and economic transformation, its healthcare system is nascent enough to achieve the over-reaching recommendations by developed countries. Our review helps in tailoring the clinical care to the available resources, focusing on an integrated approach for timely detection and management of sight-threatening diabetic retinopathy (STDR). Our study also recommends urgent measures to be taken to implement diabetes registers by all care providers and take the responsibility of ensuring that patients with STDR are referred for treatment. This tailored framework helps in the screening and treatment of those with STDR in resource-constrained settings, thereby decreasing the health and economic burden in all SAARC countries.

Comparison of central macular thickness between diabetic patients without clinical retinopathy and non-diabetic patients.

INTRODUCTION: Diabetic retinopathy (DR) is one of the leading causes of blindness in patients between 20 and 60 years of age which can be prevented by early detection of diabetic retinopathy. The duration of diabetes is probably the strongest predictor for development and progression of retinopathy. Optical Coherence Tomography (OCT) is a recent advance in imaging which is sensitive in early detection of small changes in macular thickness. MATERIALS AND METHODS: This hospital based cross-sectional study was done at a tertiary referral center in Kathmandu, Nepal where 364 eyes of 182 patients (182 eyes in 91 patients in each group diabetes without retinopathy group and nondiabetic group) were evaluated. Thickness of the macula was determined by using Spectral Domain Optical Coherence Tomography (SD- OCT) and compared between diabetic patients without clinical retinopathy and nondiabetic patients. RESULTS: The mean CMT as measured by Spectral Domain Optical Coherence Tomography in diabetic patients was 236.29±40.31 µm whereas it was 244.25±30.51 µm in non-diabetic cases. The mean central macular thickness of diabetic patients with duration of diabetes less than 1 year, 1-5 years, 6-10 years, 11-15 years and more than 15 years were 217.19±42.22, 233.49±45.69, 248.5±31.37, 250.89±21.62 and 240.75±11.26 respectively. CONCLUSIONS: This study concluded that in diabetic patients there was an initial decrease in central macular thickness which gradually increased with increasing duration of diabetes mellitus. Examination of macular thickness could be a useful modality to evaluate progression of disease before appearance of other clinical signs of diabetic retinopathy.

Eye injuries from fireworks used during celebrations and associated vision loss: the international globe and adnexal trauma epidemiology study (IGATES).

PURPOSE: To report on the factors associated with severe vision loss from fireworks-related ocular trauma during celebrations, including festivals. METHODS: Tertiary eye care hospitals in 5 countries and private ophthalmology practices in the Netherlands. Patients included received treatment for fireworks-related ocular trauma during celebrations. Demographic and clinical data for patients affected were analyzed and associations with severe vision loss reported. RESULTS: Of 388 patients, 71 (18.3 %) had severe vision loss (worse than 6/60) at 4-week follow-up due to fireworks-related ocular trauma. Mean age overall was 20.6 years (range 2 to 83 years), and there was a male predominance of 4:1. Clinical factors associated with severe vision loss included penetrating injury (OR 4.874 [95% CI 1.298-18.304; p = 0.02]) and lens injury (OR 7.023 [95% CI 2.378-20.736; p = 0.0004]). More patients with closed-globe injuries (CGIs) had improved vision after 4 weeks (OR 3.667, 1.096-12.27) compared to those with open-globe injuries (OGI) (p = 0.035). Eye protection use was reported by 7 patients, and 39.4% patients < 18 years were unsupervised by an adult at the time of injury. CONCLUSIONS: Severe vision loss from fireworks-related ocular trauma occurred during celebrations in a variety of countries and was associated with penetrating and/or lens injury and poor presenting vision. New initiatives are needed to prevent severe vision loss associated with these injuries.

The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES).

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.

Ophthalmic Trauma Correlation Matrix (OTCM): a potential novel tool for evaluation of concomitant ocular tissue damage in open globe injuries.

PURPOSE: To introduce a novel tool to investigate the correlation between concomitant injuries and primary open globe injury (OGI) in the setting of ophthalmic trauma, the "Ophthalmic Trauma Correlation Matrix" (OTCM). METHODS: Retrospective cohort review, performed at a tertiary referral eye care center in Eastern Nepal, involving all eyes with OGI meeting the inclusion criteria from 2015-2018. Clinical data including details of primary injury, concurrent injuries, and clinical course were noted from hospital medical records. A correlation matrix chart was devised using matrix correlation and Pearson's correlation coefficient. This chart was then used to evaluate the association of the various injuries in the setting of OGI. RESULTS: A total of 109 eyes with OGI were included. Majority of the eyes (78, 71.6%) had zone I injuries, while most of the eyes (66, 60.6%) had penetrating injury. The most frequent concomitant injuries in all zones of OGI were traumatic lens injury (77, 70.64%), followed by hyphema (48, 44.03%), and vitreous hemorrhage (35, 32.11%). The most common concomitant injury associated with zone I was hyphema (0.873), while traumatic subluxation/cataract (0.894) and vitreous hemorrhage (0.972) were commonly associated with zone II and III, respectively. CONCLUSIONS: OTCM could be a useful tool to manage injuries related to the primary ocular injury. This additional information will aid in the prognostication, planning, and management of OGI and potentially prevent repeat surgeries and inadequate treatments.

Redefining response in wet AMD to anti VEGF therapy based on non-OCTA versus OCTA evaluation.

PURPOSE: Anti vascular endothelial growth factor (anti VEGF) has been the mainstay of treatment in wet age-related macular degeneration (AMD). Subsequent decision to continue anti VEGF therapy depends on the treatment response quantified by functional (visual acuity) and morphological (optical coherence tomography) parameters then categorized from good to poor. METHODS: This study evaluates the agreement between OCT angiography (OCTA) and non-OCTA (logMAR VA plus OCT) to decide anti-VEGF treatment's continuity. After an anti VEGF treatment, on a follow up visit, a patient underwent non-OCTA evaluation (decision A) then OCTA evaluation (decision B) to judge the necessity of future anti VEGF application. RESULTS: Out of 129 eyes, on 72 eyes (49%), there were agreements on both decision arms, but on 55 eyes (42%) there was disagreement. Particularly, disagreement on 47/55 eyes was important, where OCTA advised "continue anti VEGF" and non-OCTA advised "Stop anti VEGF" therapy. Cohen's Kappa for probability of agreement to continue anti VEGF was fair (0.33) and to stop anti VEGF therapy was none (0.1). CONCLUSIONS: Based on resulting disagreements between the two modalities on deciding the continuity of anti VEGF, we conclude that OCTA must be considered in the conventional decision making algorithm in patients with wet AMD under anti VEGF therapy.

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.

Deep Learning for the Diagnosis of Stage in Retinopathy of Prematurity: Accuracy and Generalizability across Populations and Cameras.

PURPOSE: Stage is an important feature to identify in retinal images of infants at risk of retinopathy of prematurity (ROP). The purpose of this study was to implement a convolutional neural network (CNN) for binary detection of stages 1, 2, and 3 in ROP and to evaluate its generalizability across different populations and camera systems. DESIGN: Diagnostic validation study of CNN for stage detection. PARTICIPANTS: Retinal fundus images obtained from preterm infants during routine ROP screenings. METHODS: Two datasets were used: 5943 fundus images obtained by RetCam camera (Natus Medical, Pleasanton, CA) from 9 North American institutions and 5049 images obtained by 3nethra camera (Forus Health Incorporated, Bengaluru, India) from 4 hospitals in Nepal. Images were labeled based on the presence of stage by 1 to 3 expert graders. Three CNN models were trained using 5-fold cross-validation on datasets from North America alone, Nepal alone, and a combined dataset and were evaluated on 2 held-out test sets consisting of 708 and 247 images from the Nepali and North American datasets, respectively. MAIN OUTCOME MEASURES: Convolutional neural network performance was evaluated using area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), sensitivity, and specificity. RESULTS: Both the North American- and Nepali-trained models demonstrated high performance on a test set from the same population: AUROC, 0.99; AUPRC, 0.98; sensitivity, 94%; and AUROC, 0.97; AUPRC, 0.91; and sensitivity, 73%; respectively. However, the performance of each model decreased to AUROC of 0.96 and AUPRC of 0.88 (sensitivity, 52%) and AUROC of 0.62 and AUPRC of 0.36 (sensitivity, 44%) when evaluated on a test set from the other population. Compared with the models trained on individual datasets, the model trained on a combined dataset achieved improved performance on each respective test set: sensitivity improved from 94% to 98% on the North American test set and from 73% to 82% on the Nepali test set. CONCLUSIONS: A CNN can identify accurately the presence of ROP stage in retinal images, but performance depends on the similarity between training and testing populations. We demonstrated that internal and external performance can be improved by increasing the heterogeneity of the training dataset features of the training dataset, in this case by combining images from different populations and cameras.

Agreement and Diagnostic Test Accuracy on Grading Diabetic Retinopathy Using Fundus Photographs by Allied Medical Personnel at a Community Diabetic Retinopathy Screening Program in Nepal.

Purpose: Diabetic retinopathy (DR) is a leading cause of blindness in low- and middle-income countries. This study aims to assess the agreement and diagnostic test accuracy of DR grading using fundus photographs by the allied medical personnel (AMP) as compared to ophthalmologist at DR screening program.Methods: Two 45 degree disc-centred and macula centred fundus photographs captured using digital fundus camera from 1344 eyes were graded by six AMP twice at three months and six months of training. DR grading was done using Early Treatment Diabetic Retinopathy Study criteria. Retina specialist grading was taken as the reference standard. Percentage agreement using kappa coefficient (k) and diagnostic test accuracy were assessed.Results: Intra-rater agreement of most AMP was almost perfect for detection of any DR and vision-threatening diabetic retinopathy (VTDR) at three and six months. Inter-rater agreement at 3 months at second grading was substantial for any DR (k = 0.62; 95% confidence interval (CI): 0.67-0.68) and VTDR (k = 0.63; 95% CI: 0.47-0.75). Inter-rater agreement in 6 months at second grading was also substantial for any DR (k = 0.66; 95% CI: 0.61-0.71) and VTDR (k = 0.64; 95% CI: 0.52-0.75). The sensitivity and specificity for any DR at second grading in 3 months was 94.99% and 63.97% and at 6 months was 95.55% and 66.91%, respectively.Conclusion: The inter-rater agreement of AMP as compared to ophthalmologists for any DR or VTDR was substantial at both 3 and 6 months. AMP can support as first-level DR graders for timely referral and treatment of VTDR.

Detection, localization, and characterization of vision-threatening features of microaneurysms using optical coherence tomography angiography in diabetic maculopathy.

INTRODUCTION: Diabetic maculopathy is a leading retinal cause of blindness. This study was conducted using optical coherence tomography angiography and noninvasive imaging modalities. Microaneurysms were evaluated for location, flow, and adjacent retinal tissue changes to establish knowledge of possible vision-threatening features.Methodology: This is a hospital-based, cross-sectional observational study. Eighteen patients with diabetic maculopathy were included in the study. Fundus photo, red-free filter image, infrared images with shadowgrams, optical coherence tomography cross sections, and optical coherence tomography angiography were analyzed. Mean, standard deviation, odds ratio, and 95% confidence interval were used for statistical analysis, and p-value of <0.05 was considered statistically significant where applicable. RESULTS: A total of 64 microaneurysms were evaluated. Forty-six (71.8%) microaneurysms were identifiable in all imaging modalities. In total, 53 (82.8%) were high-flow microaneurysms and 11 (17.2%) were low-flow microaneurysms. Thirty-eight of the high-flow microaneurysms (71.6% of the high-flow microaneurysms) were found in the deep capillary plexus, while only 15 (28.4% of the high-flow microaneurysms) were found in the superficial capillary plexus. Twenty-seven (71%) of the high-flow microaneurysms in deep capillary plexus were present in the areas of retinal thickening (odds ratio: 4.5, 95% confidence interval: 1.26-16.0, p = 0.02). A total of 11 microaneurysms were classified as low-flow microaneurysms and identified using fundus photo, red-free filter image, infrared images with shadowgrams, and optical coherence tomography-cross sections. They had a tendency to be present in the areas of decreased capillary plexus density (odds ratio: 25.6, 95% confidence interval: 5.09-128.7, p = 0.001). CONCLUSION: Noninvasive imaging modalities combined with optical coherence tomography angiography can provide valuable information regarding microaneurysms. Certain features such as location and flow may help in predicting impending macular edema or ischemia.

Agreement on Grading Retinal Findings of Patients with Diabetes Using Fundus Photographs by Allied Medical Personnel when Compared to an Ophthalmologist at a Diabetic Retinopathy Screening Program in Nepal.

INTRODUCTION: Diabetic retinopathy (DR) is the emerging cause of blindness in developing countries. This study aimed to assess the accuracy of grading retinal findings of patients with diabetes using fundus photographs by allied medical personnel (AMP) when compared to an ophthalmologist. MATERIALS AND METHODS: Six AMPs were enrolled for grading fundus photographs of patients with diabetes after three and six months of training twice at two weeks interval. The total number of fundus photographs graded were 1,344. Grading by a retina specialist was used as the gold standard. Intra-rater and inter-rater agreement was assessed using the kappa coefficient (k). RESULTS: The intra-rater agreement of half of the AMPs in both three months and six months was almost perfect for grading of any retinal abnormalities, and substantial for retinal hemorrhages. In three months, the overall inter-rater agreement at the second rating was moderate for any retinal abnormalities (k=0.60) and retinal hemorrhage (k=0.48) and was fair for macular exudates (k=0.35). The overall inter-rater agreement of AMPs in six months at the second rating was substantial for any retinal abnormalities (k=0.61), fair for retinal hemorrhage (k=0.30), and moderate for macular exudates (k=0.49). The overall inter-rater agreement at first rating was almost similar to the second rating in both three months and six months. CONCLUSION: Intra-rater agreement of AMPs was almost perfect for any retinal abnormalities and substantial for retinal hemorrhage. The inter-rater agreement of AMP was substantial for any retinal abnormalities and moderate for retinal hemorrhages and macular exudates. The agreement results were almost similar at three months and six months. AMPs could be utilized in screening of DR and other retinal pathologies for timely referral to reduce the blindness in low-resource settings.

Inherited Macular Dystrophies in a Tertiary Care Centre.

BACKGROUND: Inherited macular dystrophies constitute a group of diseases characterized by bilateral central visual loss with symmetrical macular abnormalities usually presenting in the first two decades of life. The aim of this study were to find out the demographic characteristics and disease pattern of inherited retinal dystrophies in subjects attending retina outpatient department in a tertiary care center. METHODS: An observational study among twenty-six participants diagnosed as macular dystrophy visiting a tertiary care centre in Nepal, during January 2018 to June 2018 were included in the study. Detailed history, slit lamp examination, dilated fundus examination, coloured fundus photography, full field electroretinogram, multifocal electroretinogram, automated visual field and colour vision were done. RESULTS: A total of 52 eyes of 26 subjects were diagnosed with macular dystrophy. The male to female ratio was 1:1. The mean age of presentation was 28.38 years. Most common symptom was blurring of vision seen in 96.15%.The mean visual acuity was 0.67 log mar units in right eye and 0.71 log mar units in the left eye. The most common macular dystrophy was cone dystrophy followed by adult vitelliform macular dystrophy and Stargardts dystrophy. CONCLUSIONS: Cone dystrophy is the most common followed by Stargardt's disease and adult vitelliform macular dystrophy. Most presented in the first two decades of life and the most common presenting symptom was blurring of vision.

Lightning Injury to Eye: Brief Review of the Literature and Case Series.

PURPOSE: In ophthalmology, injuries due to lightning strikes have been documented as various entities ranging from keratitis, cataracts, uveitis in the anterior segments to retinal detachments, papillitis, and macular hole formation in the posterior segment. We report the largest case series so far with a total of seven cases of lightning injuries with ocular involvement and its management and a brief review of the literature on this topic. PATIENTS AND METHODS: All of the patients were evaluated for ocular injuries due to a lightning strike and each of the cases has been individually described as case series with their findings and management in this report. RESULTS: Ocular injuries caused by lightning are very rare, but when they occur, they can present with various ocular tissue pathology-ranging from anterior to the posterior segment structures. Most of the cases presented with maculopathy and foveschitic lesions, which resolved over time with the use of steroids. CONCLUSION: Lightning injuries to the eyes, if detected early and managed appropriately, have a very good prognosis. The recovery is usually good with minimal functional loss if there is a quick referral. The macular region seems to be particularly involved in most cases and OCT can be a valuable diagnostic tool to detect and monitor the pathology.

Evaluation of the Effect of Intravitreal Bevacizumab (Avastin) in Patients with Diabetic Macular Edema.

INTRODUCTION: Diabetic macular edema (DME) is the leading cause of visual impairment in patients with diabetes mellitus. The objectives of the study was to figure out the effect of intravitreal injection bevacizumab on visual acuity and retinal thickness in people with DME. MATERIALS AND METHODS: We observed the case records of patients with DME requiring injection Avastin (Genentech Inc., San Francisco, CA, USA) intravitreal from January to July 2016 in Mechi Eye Hospital. The eighty seven eyes of 60 patients with DME were included in the study. Inclusion criteria were determined independently of the age, metabolic control, type of diabetes mellitus, visual acuity, leakage area size,retinal thickness as measured by optical coherence tomography. All the patients were treated with 0.05 ml injection containing 1.25 mg of Avastin (Genentech Inc., San Francisco, CA, USA) after written informed consent. RESULTS: The mean age group was 55.86 ± 9.61 years with 47 males and 13 females. At baseline the median BCVA was 1.00 (0.60-1.30) which improved to 0.78 (0.48- 1.00) at 6 weeks (p=0.001) which further improved to 0.78 (0.48-1.00) Log MAR (p value- 0.005) at 12 weeks and 0.60 (0.43- 1.00) Log MAR at 18 weeks (p value= 0.006). Baseline mean central macular thickness (CMT) on OCT was 436.24 ± 142.2µm which decreased to 387.74±130.98µm at 6 weeks, 346.82 ±116.79 µm at 12 weeks and 307.1 ±105.49µm. Changes in VA and decrease in central subfield macular thickness during follow up visit was statistically significant (p<0.05). CONCLUSION: In this study, intravitreal injection Avastin resulted in improvement in VA and decrease in retinal thickness in patients with DME.