Assessment of Skin Carotenoid Measurement as a Means to Detect Vitamin A Deficiency in Children and Pregnant Women of Nepal.

BACKGROUND: Vitamin A deficiency (VAD) is an ongoing public health concern among children and pregnant women in Nepal despite robust national efforts to screen and treat this vision- and life-threatening condition. OBJECTIVES: This study aimed to evaluate skin carotenoid scores measured using the Veggie Meter as a rapid, noninvasive screening tool for VAD in Nepali children and pregnant women. METHODS: This comparative cross-sectional study enrolled 164 pregnant women and 168 children (aged 8 to 12 y) from public hospitals in three distinct outlying ecological regions of Nepal (Terai, Hill, and Mountain). The primary outcome assessed whether skin carotenoid status could be a biomarker for VAD. We determined skin carotenoid scores using the Veggie Meter and compared them with serum retinol and total carotenoid concentrations assessed by HPLC. Correlation analysis was used to determine bivariate associations between serum retinol and total carotenoid concentrations, and the Veggie Meter assessed skin carotenoid status. Receiver operating characteristics curves were determined, and a P value <0.05 was considered statistically significant. RESULTS: We found that 8.5% of pregnant women and 13.0% of children in this study had severe VAD (serum retinol < 200 ng/mL). There were significant correlations between skin carotenoid scores with serum retinol and total carotenoid concentrations among pregnant women and children (r = 0.253-0.530, P ≤ 0.001). The Veggie Meter detected severe VAD with 57.1% sensitivity and 82.7% specificity in pregnant women and 61.9% sensitivity and 75.9% specificity in children. CONCLUSIONS: Although sensitivity and specificity were moderate for detecting VAD with the Veggie Meter, skin carotenoid assessment using this rapid, noninvasive portable device could still be valuable for high-risk VAD screening in Nepal and similar developing countries with limited access to laboratory measurement of serum vitamin A concentrations.

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.

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.

The individual and household impacts of cataract surgery on older blind adults in ethiopia.

PURPOSE: To comprehensively measure the impacts of cataract surgery on patients' activities and mental and physical health, caregivers' well-being, and household incomes in a resource-poor setting Methods: One thousand two hundred thirty-four bilaterally blind older adults in Amhara region, Ethiopia, were interviewed at baseline and 1030 (83%) re-interviewed at follow-up 1 year later. Six hundred ninety three (45%) at baseline were diagnosed with cataracts and offered free surgery, of which 484 (73%) were operated. Difference-in-difference was used to estimate impacts of surgery, using surgery-ineligible, mostly non-cataract blind as controls. RESULTS: For patients, surgery resulted in a 0.31 standard deviation increase in an index of social participation (p < 0.001), a 30% proportional increase in ability to perform activities of daily living (p < 0.001), and a 17% proportional reduction in Center for Epidemiologic Studies Depression Scale (CES-D) depression score (p < 0.001). A small (6%) increase in work participation occurred among men (p = 0.093) in this elderly sample. No change occurred in individual or household food insecurity, household consumption, or assets. Caregivers' mental health improved slightly (7.3% proportional reduction in CES-D; p = 0.024). Estimates show no change in caregiver work participation or social participation; however, subjective responses regarding changes from surgery suggest that reduced caregiving time was an important benefit to households. CONCLUSION: Cataract surgery significantly improved the vision as well as mental health, social engagement, and physical functioning of older adults. However, increases in work participation were very limited, likely reflecting the advanced age of the patients (mean = 76 years); in addition, possibly, to cumulative impacts of blindness on ability to work or on household assets. Earlier surgery may lead to larger economic effects.

Prevalence and Severity of Diabetic Retinopathy among Diabetic Patients Presenting to a Tertiary Eye Hospital in Nepal.

PURPOSE: The purpose of the study is to evaluate the prevalence and severity of diabetic retinopathy (DR) among all diabetic patients presenting to a tertiary eye care center in Nepal over a 3-year period. MATERIALS AND METHODS: This was a retrospective review of all clinical records from the initial presentations of diabetic patients at the Tilganga Institute of Ophthalmology (TIO) from 2012 to 2014. RESULTS: In total, 8855 patients were identified who presented to TIO with a prior diagnosis of diabetic mellitus (DM) during the study period. DR was found in 1714 patients (19.4%) at the time of initial presentation, 1305 (14.7%) of which had nonproliferative DR (PDR), while 617 (6.9%) demonstrated diabetic macular edema (DME) and 409 (4.6%) demonstrated PDR. Of the 1714 patients with DR, 825 (48.1%) required treatment at initial presentation for DME and/or PDR. Male gender, hypertension, age at presentation, and interval from diagnosis of DM to initial eye consultation were significantly associated with the presence of DR (P < 0.05). CONCLUSIONS: The prevalence of DR among patients with DM was 19.4%, which is lower than previously published estimates. However, among patients diagnosed with DR, over half presented with a vision-threatening complication warranting some measure of initial treatment.

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.

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.

Clinical Application of a Smartphone-Based Ophthalmic Camera adapter in Under-Resourced Settings in Nepal.

BACKGROUND: The ability to obtain high quality ocular images utilizing smartphone technology is of special interest in under-resourced parts of the world where traditional ocular imaging devices are cost-prohibitive, difficult to transport, and require a trained technician for operation. PURPOSE: The purpose of this study was to explore potential anterior and posterior segment ocular imaging use cases for a smartphone-based ophthalmic camera adapter (Paxos Scope, Digisight Technologies, San Francisco, CA, USA) in under-resourced settings in Nepal. METHODS: From September to November of 2015 we utilized the Paxos Scope smartphone camera adapter coupled with an iPhone 5 to explore anterior and posterior segment clinical applications for this mobile technology. We used the device at a tertiary eye care facility, a rural eye hospital and a rural cataract outreach camp. We tested the device's capability for high quality photo-documentation in clinic, in the operating room, and in the outreach camp setting. Images were automatically uploaded to a secure, cloud-based electronic medical record system that facilitated sharing of images with other providers for telemedicine purposes. RESULTS: Herein we present 17 ocular images documenting a wide variety of anterior and posterior segment pathology using the Paxos Scope from clinical cases seen in a variety of settings in Nepal. CONCLUSIONS: We found the quality of both the anterior and posterior segment images to be excellent in the clinic, the operating room, and the outreach camp settings. We found the device to be versatile and user-friendly, with a short learning curve. The Paxos Scope smartphone camera adapter may provide an affordable, high-quality, mobile ocular imaging option for under-resourced parts of the world.

Blindness, cataract surgery and mortality in Ethiopia.

PURPOSE: To examine the relationships between blindness, the intervention of cataract surgery and all-cause mortality in a rural Ethiopian population. DESIGN: Population-based, interventional prospective study. METHODS: Community-based detection methods identified blind Ethiopian persons from two selected kebeles in Amhara region, Ethiopia. Data from 1201 blind patients were collected-628 cataract-blind and 573 blind from other conditions. Free cataract surgery was provided for consenting, cataract-blind patients. Follow-up surveys were conducted after 12 months (±1 month)-the main outcome measure for this report is all-cause mortality at 1 year. RESULTS: During the follow-up period, 110 persons died from the selected population (mortality 9.2%), which consisted of those cataract-blind patients who received cataract surgery (N=461), cataract-blind patients who did not receive surgery (N=167) and all non-cataract-blind patients (N=573). Of the 461 patients who received cataract surgery, 44 patients died (9.5%). Of the 740 patients who did not receive surgery, 66 died (8.9%)-28 patients from the cohort of cataract-blind patients who did not receive surgery (16.8%) and 38 patients from the cohort of non-cataract blind (6.6%). Subgroup analysis revealed significantly increased odds of mortality for cataract-blind patients over 75 years of age who did not receive surgery and for unmarried patients of all age groups. CONCLUSIONS: In this population, mortality risk was significantly elevated for older cataract-blind patients when compared with non-cataract-blind patients-an elevation of risk that was not noted in an age-matched cohort of cataract-blind patients who underwent cataract surgery as early as 1-year follow-up.

Health literacy of common ocular diseases in Nepal.

BACKGROUND: Poor health literacy is often a key cause of lack of or delayed uptake of health care services. The aim of this study was to assess the health literacy of common ocular diseases, namely cataract, glaucoma, night blindness, trachoma and diabetic retinopathy in Nepal. METHODS: A cross sectional study of 1741 participants randomly selected from non-triaged attendants in the outpatient queue at Tilganga Institute of Ophthalmology, a semi urban general population of Bhaktapur district of Kathmandu Valley and patients attending rural outreach clinics. Participants responded to trained enumerators using verbally administered, semi structured questionnaires on their awareness and knowledge of cataract, glaucoma, diabetic retinopathy, night blindness, and trachoma. RESULTS: The awareness of cataract across the entire sample was 49.6%, night blindness was 48.3%, diabetic retinopathy was 29%, glaucoma was 21.3% and trachoma was 6.1%. Patients presenting to rural outreach clinics had poorer awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma compared to those from a semi-urban community and an urban eye hospital (p<0.05), Old age was directly associated with poorer awareness of cataract, glaucoma, night blindness, trachoma and diabetic retinopathy (p<0.05). Female gender was associated with lower awareness of cataract, glaucoma, night blindness and trachoma (p<0.05). Literacy was associated with greater awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma (p<0.05). Higher education was significantly associated with greater awareness of cataract, night blindness and trachoma (p<0.05). Multivariate analysis found that the awareness of common ocular diseases was significantly associated with level of education (p<0.05). Similarly, awareness of cataract, glaucoma, trachoma and night blindness was associated with female gender (p<0.05) whereas awareness of cataract, night blindness, trachoma and diabetic retinopathy was associated with age (p<0.05) but the awareness glaucoma and diabetic retinopathy was associated with camps. CONCLUSIONS: Low awareness of common ocular conditions is associated with factors such as female gender, old age, lower levels of education and rural habitation. A would be successful health promotion programs should specifically target health determinants to promote health literacy and to ensure timely utilization of eye care services.

External dacryocystorhinostomy: do we really need to repair the posterior flap?

PURPOSE: This study aims to compare a simplified technique of external dacryocystorhinostomy (DCR), where the posterior flap is excised, with the more traditional approach of double flap repair. METHODS: A prospective, comparative, single surgeon, single centre clinical trial was conducted of eighty-three patients who received external DCR, with either anterior and posterior flap anastomosis (Group A), or anterior flap anastomosis and excision of the posterior flap (Group B), in a tertiary referral hospital in Nepal. Patients with nasolacrimal duct obstruction and epiphora were assigned to one of two groups. Follow up was a minimum of 6 months for inclusion in the study. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The overall success rate of external DCR was 89.2%, after a mean follow up of 13.5 ± 2.2 months. There was no difference in success between the two groups (p-value = 0.73), with 90.7% success in Group A and 87.5% in Group B. The frequency of complications was not statistically different between Groups A and B (p-value = 0.79). CONCLUSIONS: Excision of the posterior flap and anastomosis of only the anterior flap is not disadvantageous to the outcomes of external DCR surgery when compared with the more traditional approach of anastomosis of both flaps. We believe this simplified procedure can be implemented as the standard technique for external DCR, particularly in developing nations such as Nepal.

A population-based survey of the prevalence and types of glaucoma in Nepal: the Bhaktapur Glaucoma Study.

OBJECTIVE: To determine the prevalence and types of glaucoma in a Nepalese population. DESIGN: Cross-sectional, population-based survey. PARTICIPANTS: A total of 4800 subjects aged 40 years or older from the Bhaktapur district of Kathmandu valley. METHODS: Subjects aged 40 years or older were selected using a cluster sampling procedure and door-to-door enumeration for a population-based, cross-sectional study. All subjects underwent a detailed ocular examination at the base hospital, which included logarithm of minimal angle of resolution visual acuity, refraction, applanation tonometry, gonioscopy, Lens Opacities Classification System II cataract grading, retinal examination, and Swedish Interactive Thresholding Algorithm standard perimetry when indicated. MAIN OUTCOME MEASURES: Diagnosis of glaucoma was based on criteria described by the International Society for Geographic and Epidemiological Ophthalmology. RESULTS: A total of 4003 subjects underwent a comprehensive eye examination (response rate 83.4%), and complete data were available in 3991 subjects. The mean intraocular pressure was 13.3 mmHg (97.5th and 99.5th percentiles, 18 and 20 mmHg, respectively), and the mean vertical cup-to-disc ratio was 0.26 (97.5th and 99.5th percentiles, 0.6 and 0.8 mmHg, respectively). There were 75 subjects with glaucoma, an age- and sex-standardized prevalence of 1.80 (95% confidence interval [CI], 1.68-1.92). Age- and sex-standardized prevalence was 1.24% (95% CI, 1.14-1.34) for primary open-angle glaucoma (POAG), 0.39% (95% CI, 0.34-0.45) for primary angle-closure glaucoma (PACG), and 0.15% (95% CI, 0.07-0.36) for secondary glaucoma. The prevalence of glaucoma increased with an increase in age with no significant difference in gender. Primary angle-closure glaucoma was 3 times more common in women. Nine eyes were blind, and 2 subjects were bilaterally blind from glaucoma. CONCLUSIONS: The overall prevalence of glaucoma was 1.9%. Of all glaucoma cases, POAG accounted for 68%, PACG accounted for 22.67%, and secondary glaucoma accounted for 9.33%. Among the subjects with POAG, 96.08% had not been previously diagnosed.

Preoperative visual acuity of people undergoing cataract surgery in rural and urban Nepal.

BACKGROUND: Preoperative presenting visual acuity (PPVA) is not a commonly reported indicator for the delivery of cataract services. This study aimed to evaluate the PPVA of patients undergoing cataract surgery in rural and urban areas of Nepal. DESIGN: A prospective, non-interventional study conducted from October 2007 to March 2008 in a tertiary hospital and outreach clinics of Nepal. PARTICIPANTS: A total of 3023 consecutive subjects from urban and rural settings (1323 from the tertiary hospital and 1700 from outreach clinics) with cataract were included. METHODS: Visual acuity was tested with a Snellen E-chart at 6 m by ophthalmic assistants. All Outreach Microsurgical Eye Clinic patients were examined by either ophthalmologists or senior ophthalmic assistants. Patients at the Tertiary Eye Care Centre were examined only by ophthalmologists. MAIN OUTCOME MEASURES: Preoperative presenting visual acuity of patients undergoing cataract surgery was measured in both the settings. RESULTS: The sex ratio was 0.96 (male/female). Based on PPVA, 11.5% of patients operated were blind (PPVA < 3/60 in the better eye). The proportion of blind people operated was similar in rural (11.4%) to urban (11.6%) areas. The proportion of blind eyes operated was higher in rural (50.7%) compared to urban (38.9%) areas. CONCLUSION: Despite a comparatively high volume of cataract surgery carried out in Nepal every year, only about one in eight patients operated for cataract in the sample population was blind. PPVA is an important indicator for the progress towards eliminating cataract blindness.

Outcomes of cataract surgery: a population-based developing world study in the Bhaktapur district, Nepal.

BACKGROUND: To evaluate the visual outcome after cataract surgery in a population of Nepal. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Forty years and above residing in Bhaktapur district. METHODS: Subjects were selected from 30 clusters using cluster sampling procedure. All underwent a detailed examination at the base hospital, including logarithm of minimal angle of resolution visual acuity, refraction, applanation tonometry, cataract grading, retinal examination and perimetry when indicated. MAIN OUTCOME MEASURES: Visual acuity after cataract surgery. RESULTS: Out of 4003 subjects examined, 151 had undergone cataract surgery. Pseudophakia was present in 142 (94.0%), aphakia in nine (6%). Presenting and best-corrected visual acuity ≥6/18 was achieved in 123 (54.4%) and 164 (72.4%) eyes, respectively. Among the pseudophakic eyes, at presentation 122 (57.5%), 72 (33.9%), 18 (8.5%) and after best correction 162 (76.2%), 33 (15.8%), 17 (8.0%) had visual acuity of ≥6/18, <6/18-≥6/60 and <6/60, respectively. Retinal disease (35.5%), surgical complications (27.4%) and posterior capsular opacification (14.5%) were the principle causes of visual impairment after best correction in all eyes. There was no significant association in visual outcome based on age, sex, literacy and the duration of surgery. CONCLUSION: Correction of refractive errors, preoperative screening of coincidental diseases, reduction in surgical complication rates and monitoring of postoperative follow-up care has to be addressed seriously in order to improve the outcome of cataract surgery to meet standards proposed by the World Health Organization. In the future, longitudinal studies need to be undertaken to provide specific information on the outcomes of cataract surgery in this community.

Prevalence of visual impairment, cataract surgery and awareness of cataract and glaucoma in Bhaktapur district of Nepal: the Bhaktapur Glaucoma Study.

BACKGROUND: Cataract and glaucoma are the major causes of blindness in Nepal. Bhaktapur is one of the three districts of Kathmandu valley which represents a metropolitan city with a predominantly agrarian rural periphery. This study was undertaken to determine the prevalence of visual impairment, cataract surgery and awareness of cataract and glaucoma among subjects residing in this district of Nepal. METHODS: Subjects aged 40 years and above was selected using a cluster sampling methodology and a door to door enumeration was conducted for a population based cross sectional study. During the community field work, 11499 subjects underwent a structured interview regarding awareness (heard of) and knowledge (understanding of the disease) of cataract and glaucoma. At the base hospital 4003 out of 4800 (83.39%) subjects underwent a detailed ocular examination including log MAR visual acuity, refraction, applanation tonometry, cataract grading (LOCSΙΙ), retinal examination and SITA standard perimetry when indicated. RESULTS: The age-sex adjusted prevalence of blindness (best corrected <3/60) and low vision (best corrected <6/18 ≥ 3/60) was 0.43% (95%C.I. 0.25 - 0.68) and 3.97% (95% C.I. 3.40 - 4.60) respectively. Cataract (53.3%) was the principal cause of blindness. The leading causes of low vision were cataract (60.8%) followed by refractive error (12%). The cataract surgical coverage was 90.36% and was higher in the younger age group, females and illiterate subjects. Pseudophakia was seen in 94%. Awareness of cataract (6.7%) and glaucoma (2.4%) was very low. Among subjects who were aware, 70.4% had knowledge of cataract and 45.5% of glaucoma. Cataract was commonly known to be a 'pearl like dot' white opacity in the eye while glaucoma was known to cause blindness. Awareness remained unchanged in different age groups for cataract while for glaucoma there was an increase in awareness with age. Women were significantly less aware (odds ratio (OR): 0.63; 95%, confidence interval (CI): 0.54 - 0.74) for cataract and (OR: 0.64; 95% CI: 0.50 - 0.81) for glaucoma. Literacy was also correlated with awareness. CONCLUSION: The low prevalence of visual impairment and the high cataract surgical coverage suggests that cataract intervention programs have been successful in Bhaktapur. Awareness and knowledge of cataract and glaucoma was very poor among this population. Eye care programs needs to be directed towards preventing visual impairment from refractive errors, screening for incurable chronic eye diseases and promoting health education in order to raise awareness on cataract and glaucoma among this population.

Rationale, methods and baseline demographics of the Bhaktapur Glaucoma Study.

BACKGROUND: To describe the methodology and baseline data of a population-based study designed to determine the prevalence of glaucoma and to study the risk factors for glaucoma development in a Nepali population. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Subjects 40 years and above residing in Bhaktapur District. PATIENTS AND METHODS: Power calculations suggest that a sample size of 4758 is required. Thirty clusters were randomly selected from the 2 municipalities and 16 Village Development Committees of Bhaktapur District in Nepal. A door-to-door census was conducted in the selected clusters to identify citizens 40 years of age and older. Demographic details were collected and a structured interview, regarding awareness for cataract and glaucoma was taken. All individuals fulfilling the eligibility criteria were recruited and referred to the Tilganga Institute of Ophthalmology in Kathmandu for a detailed clinical examination including glaucoma diagnostic procedures. Peripheral blood samples were taken to facilitate future genetic analysis. MAIN OUTCOME MEASURES: Prevalence of glaucoma, risk factors and genetic screening. RESULTS: A total of 4800 people were selected. The mean age of participants was 55.4 ± 12.3 years (range: 40-99) and 51.8% were female. In total, 64.8% of our cohort was aged less than 59 years and 60.5% were illiterate. Among the various ethnic races, 69.7% belonged to the Newar ethnic group. CONCLUSION: This study will determine the prevalence of glaucoma and allow for an increased understanding of the risk factors for glaucoma development in this region.

A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal.

PURPOSE: To compare the efficacy and visual results of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery (SICS) for the treatment of cataracts in Nepal. DESIGN: Prospective, randomized comparison of 108 consecutive patients with visually significant cataracts. METHODS: settings: Outreach microsurgical eye clinic. patients: One hundred eight consecutive patients with cataracts were assigned randomly to receive either phacoemulsification or SICS. intervention Cataract surgery with implantation of intraocular lens. main outcome measures: Operative time, surgical complications, uncorrected and best-corrected visual acuity (BCVA), astigmatism, and central corneal thickness (CCT). RESULTS: Both surgical techniques achieved excellent surgical outcomes with low complication rates. On postoperative day 1, the groups had comparable uncorrected visual acuity (UCVA) (P = 0.185) and the SICS group had less corneal edema (P = 0.0039). At six months, 89% of the SICS patients had UCVA of 20/60 or better and 98% had a best-corrected visual acuity (BCVA) of 20/60 or better vs 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at six months in the phaco group (P = 0.30). Surgical time for SICS was much shorter than that for phacoemulsification (P < .0001). CONCLUSION: Both phacoemulsification and SICS achieved excellent visual outcomes with low complication rates. SICS is significantly faster, less expensive, and less technology dependent than phacoemulsification. SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.

Patient's perception towards the eye health care system in a tertiary eye care centre in Nepal.

This study was performed to determine patient's perceptions towards eye health care systems in a tertiary eye care center in Nepal. Subjects were randomly selected from the outpatient department of Tilganga Eye Centre (TEC), a tertiary eye care center in Kathmandu, Nepal. The study was performed in April 2003 with 54 patients responding to several questions concerning their satisfaction of the eye care process. Over 40 (74.1%) of the respondents expressed overall satisfaction with the service provided by the hospital staff, and 4 (7.4%) were not satisfied. In addition, a total of 40 (74.1%) respondents were dissatisfied with the extended waiting time for eye examinations and other ocular services, while 7 (13.0%) were satisfied. The study shows that the majority of patients who are treated at Tilganga Eye Centre have positive feelings about Tilganga and its service system. Some processes, however, could be altered or improved to augment the overall quality of patient care.

Treatment of vitreoretinal disorders in the developing world: indications and outcomes of vitreoretinal surgery in Nepal.

PURPOSE: To examine the outcomes of vitreoretinal surgery for retinal disorders at Tilganga Eye Centre in Kathmandu, Nepal. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Records of 255 patients undergoing vitreoretinal surgery from December 2000 to January 2003 were reviewed. METHODS: Demographics, diagnoses, duration of symptoms, vision, and examination findings were noted before and after vitreoretinal surgery. MAIN OUTCOME MEASURES: Postoperative data were categorized by surgery type and analyzed by anatomic success, symptoms, and visual acuity (VA). RESULTS: Sixteen percent of patients had >6/60 vision preoperatively, and the mean duration of vision loss before presentation was 4.9 months. Major indications for surgery were retinal detachment (RD) (75%) and vitreous hemorrhage (19%). Anatomic success was achieved in 74.5% of patients. Postoperatively, 39% of patients experienced improved VA, with 33% obtaining >6/60 vision. CONCLUSIONS: Despite prolonged duration of vision loss at presentation, vitreoretinal surgery in the developing world can restore useful vision in many patients with RD and vitreous hemorrhage.