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.

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.

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.

A Study on Pattern of Retinal Detachment in Patients with Choroidal Coloboma and Its Outcome after Surgery at a Tertiary Eye Hospital in Nepal.

BACKGROUND: To review the pattern of retinal detachment (RD) in patients with choroidal coloboma and type of reattachment surgery performed and to study its outcome in terms of retinal reattachment, visual acuity, and postsurgical complications. METHODS: Observational case series of a single tertiary eye institution of 13 eyes having choroidal coloboma with RD done from January 2015 to June 2017. RESULTS: Mean age of presentation was 29.3 years (Range 14-60 years). Males were two times more affected than females (2.25 : 1). The overall rate of anatomic success achieved after RD repair and silicon oil removal at 6 months was 92.3% (12/13 eyes). Following surgery, visual acuity improved in 6 out of 11 eyes (54.54%), remained unchanged in 4 eyes (36.36%), and worsened in 1 eye (9.1%). The most common complication following surgery was secondary glaucoma in 30.7% (4/11 eyes). CONCLUSION: The overall anatomic success rate of retina reattachment surgery in colobomatous eye is good, and the visual outcome following surgery can improve in majority of the cases or may remain same in few cases. Hence, timely surgery is advocated. But careful follow-up is required as the risk of postoperative complications is also high.

Clinical characteristics and visual outcome, prognostic factor, visual acuity and globe survival in posterior segment intraocular foreign body at Tilganga Institute of Ophthalmology.

PURPOSE: To evaluate clinical characteristics, visual outcomes and globe survival after intraocular foreign body removal from posterior segment via pars plana approach. METHODS: A hospital based retrospective study. All the patients of penetrating eye injury with intraocular foreign body in posterior segment as detected by computed tomography were enrolled from 2012 to 2014. RESULTS: Thirty patients of 30 eyes were included. The mean age was 27.7 years. (2-52). Twenty-four (80%) were male. Out of 30 eyes 19 (63.3%) eyes had injury at Zone 1 and 11 (36.7%) eyes had injury at Zone 2. The mean time spent between primary repair following surgery and intra ocular foreign body removal, was 15.47 days. Retinal detachment and endophthalmitis prior to intraocular foreign body removal was present in 9/30 of eyes. We looked for correlation between post operative Phthisis bulbi with zone of injury and pre operative endophthalmitis and preoperative retinal detachment. However, p value for the above correlation was more than 0.552 and 0.815 respectively, which was statistically not significant. CONCLUSIONS: The eyes with posterior segment intraocular foreign bodies showing clinical features of preoperative endophthalmitis, retinal detachment and the zone of injury also did not have any direct significance with globe survival.

Acute Endophthalmitis after Intravitreal Bevacizumab Injections at The Tertiary Centre in Nepal.

INTRODUCTION: There are many reports of endophthalmitis following Anti- VEG F use in developed countries and from India, but there are none from Nepal yet. Therefore, the aim of this study was to report the prevalence and management of acute endophthalmitis after intravitreal injection of bevacizumab. METHODS: This is a clinical, retrospective, non-comparative study, performed in Tilganga Institute of Ophthalmology, Kathmandu, Nepal from Jan 2015 till Dec 2016. All consecutive cases of intravitreal 1.25 mg of bevacizumab injections during the study period were collected from Bevacizumab registry of the operation theatre. A total number of endophthalmitis, following intravitreal bevacizumab injections were collected from Endophthalmitis registry. The statistical analysis was carried out by SPSS for percentage calculation and its 95% Confidence Interval (CI) calculation. RESULTS: There were 4182 injections performed during the study period for various retinal conditions. Two eyes of two patients with acute postoperative endophthalmitis were identified in the first week following intravitreal injections of 1.25 mg bevacizumab among a total of 4128 injections with a prevalence of 0.048% (95% CI: 0.00 to 0.12.). CONCLUSIONS: The prevalence of acute endophthalmitis following intravitreal Bevacizumab in our retrospective series was 0.048% and was comparable with the other studies conducted elsewhere. Acute post-injection endophthalmitis following intravitreal bevacizumab can result in severe loss of vision. Therefore prompt recognition and treatment are important part of its management in such patients.

Coagulase gene polymorphism, enterotoxigenecity, biofilm production, and antibiotic resistance in Staphylococcus aureus isolated from bovine raw milk in North West India.

BACKGROUND: Staphylococcus aureus is the predominant bacterium responsible for various diseases in animals and humans. Preventive strategies could be better implemented by understanding the prevalence, genetic patterns, and the presence of enterotoxin and biofilm-producing genes along with the antibiotic susceptibility of this organism. This study was conducted in Rajasthan, the northwestern state of India, holding the largest population of cattle that makes it the second largest milk producer in India and no such prior information is available on these aspects. METHODS: A total of 368 individual quarter bovine raw milk samples were collected from 13 districts of Rajasthan, and screened for the presence of S. aureus. Microbiological and molecular approaches were followed for bacterial identification. Genetic diversity was determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) of coagulase gene (coa), whereas enterotoxin and biofilm-producing genes were studied by PCR analysis. Antibiotic strips were employed to study the antibiotic resistance among strains. RESULTS: In all, 73 S. aureus strains were obtained from 368 bovine raw milk samples out of that only 30 showed the presence of coa. Nine types of coa patterns ranging from 730 to 1130 bp were observed among these isolates. PCR-RFLP of coa distinguished the isolates into 15 genotypic patterns, of which patterns I, IV, V, and VI were predominant. Of the isolates, 30% were positive for sec, 10% for sea, and 3.3% for seb; these genes are responsible for enterotoxin production, whereas all isolates were found positive for icaAD and eno. The prevalence rates of other biofilm-producing genes fnbA, clfB, ebpS, sasG, fnbB, sasC, cna, bap, fib and, bbp were 97, 93, 90, 80, 80, 77, 53, 27, 10, and 6.6%, respectively. Twenty-seven (90%) strains were multidrug resistant, of which 15 were methicillin resistant. Maximum sensitivity was reported for kanamycin and it could be considered as a drug of choice for controlling S. aureus mediated cattle infections in the studied regions. CONCLUSIONS: Overall, these strains could cause several diseases to humans, insisting the need for developing a stricter hygiene program for improving milking practices and animal health.

Prevalence, Virulence Potential, and Antibiotic Susceptibility Profile of Listeria monocytogenes Isolated From Bovine Raw Milk Samples Obtained From Rajasthan, India.

Listeriosis is a serious foodborne disease of a global concern, and can effectively be controlled by a continuous surveillance of the virulent and multidrug-resistant strains of Listeria monocytogenes. This study was planned to investigate prevalence of L. monocytogenes in bovine raw milk samples. A total of 457 raw milk samples collected from 15 major cities in Rajasthan, India, were analyzed for the presence of L. monocytogenes by using standard microbiological and molecular methods. Five of the 457 samples screen tested positive for L. monocytogenes. Multiplex serotyping showed that 3/5 strains belonged to serotype 4b followed by one strain each to 1/2a and to 1/2c. Further virulence potential assessment indicated that all strains possessed inlA and inlC internalins, and, in addition, two strains also possessed the gene for inlB. All strains were positive for Listeriolysin O (LLO) and showed phosphatidylinositol-specific phospholipase C (PI-PLC) activity on an in vitro agar medium with variations in production levels among the strains. A good correlation between the in vitro pathogenicity test and the chick embryo test was observed, as the strains showing higher LLO and PI-PLC activity were found to be lethal to fertilized chick embryos. All strains were resistant to the majority of antibiotics and were designated as multidrug-resistant strains. However, these strains were susceptible to 9 of the 22 tested antibiotics. The maximum zone of inhibition (mm) and acceptable minimum inhibitory concentration were observed with azithromycin, and thus it could be the first choice of a treatment. Overall, the presence of multidrug-resistant L. monocytogenes strains in the raw milk of Rajasthan region is an indicator of public health hazard and highlighting the need of consumer awareness in place and implementation of stricter food safety regulations at all levels of milk production.

Impact of udder and teat morphometry on udder health in Tharparkar cows under climatic condition of hot arid region of Thar Desert.

Prevention of subclinical mastitis (SCM) is an important tool for sustainable dairying and implementing higher production level in animals. The present investigation involved a total of 397 quarters of milk examination of 105 indigenous Tharparkar cows at Livestock Research Centre, Chandan located in the Jaisalmer district of Rajasthan in Thar Desert to study the impact of udder and teat morphometry on udder health. Udder health was examined by somatic cell count to check the status of subclinical mastitis while udder and teat morphometry of 90 udder and 386 quarters, i.e., udder shape and depth, teat end shape, teat length, and teat diameter were examined at individual animal level and quarter level. Data were collected from the record register maintained at the farm and data evaluated by parity (no. of lactation) and stage of lactation. On analysis of variance, result revealed the significantly (P < 0.05) higher incidence of SCM was for pendulous shape udder in respect of regular udder, as well as for inverted and flat teat end shape in respect of pointed teat end shape. Large teat length and upper depth animals had significantly (P < 0.05) more incidence of SCM as compared to small and medium teat length and udder depth group, respectively. Thick teat diameter group animals were significantly (P < 0.01) more prone to infection as compared to medium and thin teat diameter group animals. So, it can be concluded that selection for optimum udder and teat morphometry in breeding program may help to reduce susceptibility for intramammary infections in Tharparkar cows. Microbiological study of milk samples could be helpful in the nearby future for identification of subclinical mastitis.