Surgical Outcomes of Ahmed Glaucoma Valve and Aurolab Aqueous Drainage Implant in Nepalese Eyes: Comparison in the First Year.

INTRODUCTION: Glaucoma is the leading cause of irreversible blindness worldwide. Though trabeculectomy still remains the surgical modality of choice for the management of glaucoma, the outcome of glaucoma drainage devices (GDDs) too has been encouraging in recent years. OBJECTIVES: To compare the surgical outcomes of Ahmed glaucoma valve (AGV) and Aurolab aqueous drainage implant (AADI) in cases of refractory glaucoma in Nepalese eyes. MATERIALS AND METHODS: We retrospectively studied the charts of the patients with refractory glaucoma who had undergone GDD implantation at Tilganga Institute of Ophthalmology (TIO), Kathmandu, Nepal. Depending on which GDD was implanted, the eyes of the patients were divided into: AGV group and AADI group. The outcome measures of the study were intraocular pressure (IOP), requirement of antiglaucoma medications (AGMs), surgical success and complications. RESULTS: There were 24 eyes of 23 patients in AGV group and 31 eyes of 30 patients in AADI group with a median (quartiles) follow-up of 12 (12,12) months. In the final visit, IOP and AGMs were both significantly lower than the baseline in both the groups (P <0.001). The median IOP in mmHg and AGMs were both significantly lower in the AADI group compared to AGV group in the final visit, p <0.001 and p=0.002, respectively. The overall success was similar in both the groups: AGV (n=22, 91.67%) and AADI (n=29, 93.55%), p=1.0. However, complete success was significantly more in AADI group (n=16, 51.61%) compared to AGV group (n=6, 25%), p=0.046. Complications and their rates were comparable between the two groups (p=0.4). CONCLUSION: Both AGV and AADI safely and effectively reduced the IOP and the number of AGMs in cases of refractory glaucoma in Nepalese eyes.

Screening of Accompanying First Degree Relatives of Patients with Primary Open Angle Glaucoma.

INTRODUCTION: Glaucoma is one of the common causes of blindness worldwide, and the leading cause of irreversible blindness .The overall prevalence of glaucoma in Nepal is 1.9%. Though poorly understood, primary open angle glaucoma (POAG) is believed to have a genetic or familial component that may occur through polygenic or multifactorial transmission. First-degree relatives of POAG patients have 4-16% risk of developing POAG. Given the circumstances and the prevalence of POAG in first degree relatives of POAG patients, screening the first degree relative/s accompanying the patient to the hospital can be a cost effective and viable tool for glaucoma screening that will not add any extra cost of travel and accommodation. MATERIALS AND METHODS: The authors performed a hospital-based cross-sectional study at a tertiary eye hospital in Nepal. All first-degree family members of POAG patients who accompanied them to the glaucoma clinic underwent a full ophthalmic examination.The optic disc was evaluated and intraocular pressure (IOP) was measured. POAG and glaucoma suspect were defined as per ISGEO classification. RESULTS: Sixty one first degree relatives of 54 glaucoma patients were examined. The mean age was 30.67 years (±12.71). Fifty five(90.2%) of 61 of accompanying first degree relatives were off springs, 6 (9.8%) were siblings. Five out of 61 (8.2%) were diagnosed as glaucoma and started on anti-glaucoma medication. Fourteen participants (23%) were glaucoma suspects. Forty two (68.9%) of the participants had no sign of glaucoma. CONCLUSION: Ocular examination of the first-degree relatives accompanying POAG patients helped to identify a remarkable number of individuals with glaucoma and thus might be used as an effective and viable tool for screening glaucoma in a hospital setting. Awareness regarding glaucoma is very low even among the first degree relatives of glaucoma patients.

Glaucoma in Developing Countries.

Glaucoma is a leading cause of blindness worldwide. The diagnosis and management of glaucoma is especially difficult in the developing countries. Lack of cost effective screening strategies, low income, low rates of literacy and inadequate infrastructures and human resources for eye care services are the obstacles for delivering glaucoma service. Majority of people with glaucoma in developing countries usually present at an advanced stage at the time of diagnosis; which negatively affects their quality of life. Further research, proper allocation of resources and collaborative effort by blindness prevention programs will hopefully provide new evidences on cost effective ways to screen and manage glaucoma in the future. This article aims to highlight the burden of glaucoma and ways to address the challenges in developing countries.

Factors influencing the episode duration and the anatomical and functional outcome in cases of acute central serous chorioretinopathy.

OBJECTIVE: To investigate the factors affecting the duration of subretinal fluid (SRF) resolution and their correlation with the final anatomical and functional outcome in cases of treatment naïve acute central serous chorioretinopathy (CSCR). METHODS AND ANALYSIS: We retrospectively studied 93 eyes of 93 patients diagnosed with treatment naïve acute CSCR presenting within 30 days of onset of symptoms. The eyes were divided into two groups (1 and 2) based on the duration of SRF resolution; which was ≤3 months in group 1 and >3 months in group 2. Demographic and medical history, and spectral domain optical coherence tomography features were noted and their association with duration for SRF resolution, final central macular thickness (CMT) and final best-corrected visual acuity (BCVA) were studied. All the patients were prescribed topical non-steroidal anti-inflammatory drug for 1 month at the diagnosis of CSCR. RESULTS: Longer duration of symptoms, female gender and baseline OCT factors like hyper-reflective dots and retinal pigment epithelial bumps were associated with longer duration for SRF resolution (p<0.001, p=0.04, p=0.001 and p=0.01, respectively). The SRF resolution time had strong correlations with the final CMT (r=-0.589, p<0.001) and final BCVA in logarithm of minimum angle of resolution (LogMAR) (r=+0.599, p<0.001). Group 2 eyes had worse final BCVA and thinner final CMT than Group 1 (both p<0.001). The final CMT of the patients of Group 1 was statistically thinner than the normal population (p<0.001). CONCLUSION: Patient's baseline clinicodemographic and OCT features can be used to predict the course and visual outcome in cases of treatment naïve acute idiopathic CSCR.

Intravitreal Bevacizumab for Macular Edema Secondary to Retinal Vein Occlusion.

INTRODUCTION: The most common cause of vision loss in cases of Retinal vein occlusion (RVO) is due to macular edema. This study was conducted to examine the effect of intravitreal bevacizumab (IVB) in the treatment of macular edema secondary to RVO. MATERIALS AND METHODS: The authors conducted a retrospective study of 94 eyes (N) of 92 patients with macular edema associated with decreased visual acuity secondary to RVO who were treated with IVB. Patients received IVB at baseline, 1 month and 2 months. At each follow up patients were evaluated and re-injected if necessary. RESULTS: The mean age of the patients was 56.6 ±11.51 years. The average number of injections per eye was 2.1 ± 0.87. The baseline median central macular thickness (CMT) and best-corrected visual acuity (BCVA) in LogMAR was 465.00µm (Min 254µm, Max 1218µm) and 1.00 (Min 0.30, Max 2.28), respectively. The median CMT at one month following first, second and third dose of IVB was 258µm (N=94, Z= -7.64, p <0.001), 261µm (N=63, Z= -0.17, p=0.86), and 292µm (N=41, Z= -0.21, p= 0.83), respectively. The median LogMAR BCVA at one month following first, second and third dose of IVB was 0.60 (N=94, Z= -5.70, p < 0.001), 0.60 (N=63, Z= -1.69, p=0.09), and 0.60 (N=41, Z= -0.03, p=0.97), respectively. Pre-operative BCVA was the best predictor of the final visual outcome after IVB in cases of RVO. None of the patients developed any serious ocular or systemic complications due to IVB. CONCLUSION: IVB is an effective and safe treatment for macular edema associated with decreased visual acuity secondary to RVO. The most beneficial effect of IVB is seen at one month after the first dose. The efficacy of subsequent doses could not be established in this study.

A Clinical Study of Optic Disc Edema in a Tertiary Eye Center of Nepal.

PURPOSE: To evaluate the etiology and clinical presentation of cases with optic disc edema presenting to a tertiary eye center of Nepal. BACKGROUND: The etiology of optic disc edema ranges from relatively benign to potentially sight and life threatening conditions. Till date very few studies have been done on disc edema in Nepal. METHOD: The authors conducted a prospective, descriptive study at B.P. Koirala Lions Center for Ophthalmic Studies (BPKLCOS), Nepal. All cases with disc edema presenting to the out patient department (OPD) from January 1, 2014 to June 30, 2015 were included in the study. RESULTS: Total 112 patients were included in the study, out of which diagnosis could be established in 99. The mean age of the patients was 32.54 ± 13.97 years with the majority being female. The most common cause of disc edema was idiopathic intracranial hypertension (IIH) (37.5%,). Majority of the patients complained of isolated diminution of vision (38.4%). Among the eyes affected, 78.3% had best corrected visual acuity (BCVA) 6/6-6/18, 36.6% had color vision defect and 31.4% had reduced contrast sensitivity. The most common visual field defect was isolated enlarged blind spot (39.7 %). CONCLUSION: IIH followed by optic neuritis (ON) are the most common causes of disc edema. Conditions with disc edema mainly affect the age group 21-40 years with females affected 2.5 times more than males. Visual acuity, color vision and contrast sensitivity are deranged in majority of cases of ON and normal in majority of cases of IIH.

Effect of Nd:YAG laser posterior capsulotomy on intraocular pressure, refraction, anterior chamber depth, and macular thickness.

Purpose: To see the effect of Nd:YAG laser capsulotomy on intraocular pressure (IOP), refraction, best-corrected visual acuity (BCVA), anterior chamber depth (ACD), and macular thickness. Methodology: The authors conducted a prospective, descriptive study on pseudophakic eyes with posterior capsule opacification who underwent Nd:YAG laser capsulotomy. BCVA, IOP, spherical equivalent (SE), macular thickness, and ACD were noted preoperatively, at 1 hr postoperatively and at 1-month follow-up. Patients were divided into two groups based on energy used (Group I ≤50 mJ, Group II >50 mJ). None of the patients received prophylactic antiglaucoma medications either before or after the procedure. Results: There were 96 eyes of 83 patients. Mean total energy levels were 26.64±12.92 mJ in Group I and 81.96±32.10 mJ in Group II. BCVA at 1 hr and 1 month postoperatively improved significantly in both the groups compared to preoperative BCVA (P<0.001). There was no significant change in SE compared to preoperative values in both the groups. The ACD continued to increase significantly in both the groups at both 1 hr and 1-month follow-up. In Group I, IOP increased at 1 hr postoperatively (P=0.023) and declined to preoperative levels at 1 month. In Group II, IOP increased at 1 hr postoperatively (P<0.001) and did not return to preoperative levels at 1-month follow-up (P=0.003). Likewise, macular thickness increased at 1 hr in both groups (P<0.001). In Group I, macular thickness decreased significantly to preoperative level at 1 month whereas in Group II, it remained significantly high at 1-month follow-up (P=0.006). There was no case with serious rise in IOP or cystoid macular edema. Conclusion: Statistically significant increment in IOP and macular thickness occurs after Nd:YAG laser capsulotomy which however may not necessitate the use of any medications.

A case of transorbital intracranial injury presenting with subtle neurological deficit.

BACKGROUND: Ocular trauma is a major cause of visual morbidity. OBJECTIVE: To present a rare case of transorbital intracranial injury extending up to the left internal carotid artery (ICA) with no other systemic neural deficit except for the ocular manifestations. CASE: A 14-year-old female presented to our out-patient department (OPD) with the history of trauma to her left eye with stumps of bamboo shoots secondary to a fall injury. Examination and investigations revealed a foreign body extending from left inferior conjunctival fornix into the intracranial cavity, occluding the various segments of left ICA. The patient subsquently underwent craniotomy and foreign body removal by a combined team of neurosurgeons and ophthalmologists. On discharge, the patient had slight improvement in extraocular motility of her left eye. However the trauma rendered the affected eye, non-seeing. CONCLUSION: The intracranial extent of a foreign body entering the cranium via the transorbital route cannot be judged merely by the clinical findings of the nervous system and ocular examination. These patients need timely management by the combined effort of ophthalmologists, neurosurgeons and radiologists.