Prevalence of Nonalcoholic Fatty Liver Disease in a Tertiary Care Teaching Hospital: A Cross Sectional Study in Province 4 of Nepal.

Background Nonalcoholic fatty liver disease (NAFLD) is collection of lipids in hepatic tissues excluding other hepatic diseases and chronic alcohol intake. It may advance to nonalcoholic steatohepatitis or cirrhosis. Ultrasonography has high sensitivity and specificity for detecting nonalcoholic fatty liver disease. Objective Lack of sufficient information in this region on sonological prevalence of nonalcoholic fatty liver disease, lead us to design the survey and may also serve as reference for further researches. Method This is a cross sectional study with 600 participants, conducted at Gandaki Medical College Teaching Hospital, Province 4 of Nepal, from September to October 2017. Ethical approval is taken from the Institutional review board. The study group includes the participants referred for abdominal sonography from outpatient department. Result In present survey, 367 (61.2%) are female and 233 (38.8%) are male participants. The mean age is 41.6 years and median age is 38 years. The prevalence of nonalcoholic fatty liver in our observation is 229 cases (38.2%) of which, 102 cases (44.5%) are male and 127 cases (55.4%) are female participants. Normal liver was seen in 61.8%, Grade one fatty liver was discovered in 24.8%, Grade one in 12.6% and Grade three in 0.6%. The mean liver size in those with fatty liver was 14.1 cm. Conclusion Province 4 of Nepal is not exempt from the growing epidemic of nonalcoholic fatty liver disease with prevalence of 38.2%. The study shows that with higher grades of fatty liver, the size of liver is also increased and the mean age of the participants involved is also in the higher side of the spectrum.

Bruckner red light reflex test in a hospital setting.

BACKGROUND: Childhood blindness is a major problem in developing world including Nepal that needs to be addressed. OBJECTIVE: The objective of study was to measure the effectiveness of the Bruckner red reflex test for screening of posterior segment opacities in children. METHODS: Patients aged less than five years who came to the Tilganga Institute of Ophthalmology, Kathmandu from March to August, 2009 were recruited in this cross-sectional descriptive study. Children were screened with the Bruckner red light reflex test in a dark room. Patients with abnormal Bruckner tests had their eyes dilated for further investigations. Abnormalities were recorded. The number of patients with an abnormal Bruckner test was recorded and correlated with their potential pathology. RESULTS: A total of 172 patients with 97 boys and 75 girls were included. Twenty-three had abnormal Bruckner test results in either one or both eyes. Four of these twentythree patients had no pathology diagnosed; hence the sensitivity of the Bruckner screen to diagnose significant pathology was calculated at 82.6%. Of the 153 patients with normal results, two patients were found to have pathology detected, which included cataract and strabismus. Hence, the specificity of this test was 98.7%. The screening test had a positive predictive value of 90.5% and a negative predictive value of 97.4%. CONCLUSION: Bruckner test screening is a sensitive and specific marker for detecting the posterior segment opacities in children. We recommend utilizing the test to evaluate these problems where other technologies are rare.

Age-related macular degeneration in Nepal.

BACKGROUND: The Age related Macular Degeneration (AMD) is a common cause of visual impairment and blindness worldwide in elderly. OBJECTIVE: This study aimed to explore the demographic characteristics, pattern and risk factors for AMD at a tertiary referral eye centre in Nepal. METHODS: This is a hospital-based prospective study, conducted at Tilganga Institute of Ophthalmology, Nepal from September 2008 to May 2009. All the consecutive cases of AMD diagnosed at the institute were included. RESULTS: A total of 141 patients (266 eyes) with AMD recruited for the study. The mean age was 69.5 years (9.1SD) with three fifth males (58.9%). Housewives and occupations like agriculture comprised of 38.3% and 42.5% respectively. Three fourth (75.6%) of the patients were illiterate. The proportion of dry and wet AMD were found in 62.4% and 37.6% respectively. Bilateral involvement was seen in 88.7% of the subjects. Three fourth (71.4%) of the AMD eyes had presenting visual acuity less than 6/18. History of smoking was found in 69.9% of patients. Hypertension was the predominant systemic problem (45.4%) followed by diabetes mellitus (12.8%). CONCLUSION: AMD is correlated with ageing in our study as well. Dry AMD is more in age groups 45-64 years and wet AMD at 65 years and older. Bilateral involvement with one eye dry and fellow eye wet AMD is more predominant (44%). Smoking and occupations like agriculture and housewife are significant risk factors for AMD. Likewise male sex, illiteracy and hypertension are other risk factors for AMD in hospital settings.

Outcome of pneumatic retinopexy at a tertiary eye care centre in Nepal.

BACKGROUND: Rhegmatogenous retinal detachment is one of the commonly encountered retinal problems where timely treatment could prevent irreversible vision loss. Pneumatic retinopexy (PR) is a simple and minimally invasive procedure for retinal reattachment. AIM: This study aimed to assess the outcome of pneumatic retinopexy in primary rhegmatogenous retinal detachment at our facility. STUDY DESIGN: This was a retrospective- prospective, interventional case series. MATERIALS AND METHODS: All subjects with rhegmatogenous retinal detachment who underwent pneumatic retinopexy at Tilganga Eye Centre of Nepal from January 2002 to June 2007 were included in this study. RESULTS: A total of 32 cases were included in the study. The mean age of patients was 55.2 year (SD=11.0). The majority of cases (62.5%) presented within two weeks of symptoms with blurring of vision in 90% of cases. Pre-operatively, 56.3% (18) patients had a best corrected distance visual acuity of <6/60. Retinal detachment involving less than two quadrants consisted of 37.5% (12). A single retinal break was present in 78.1% (25) of cases and 87.5% (28) of the retinal breaks were located in the superotemporal quadrant. The macula was attached in 37.5% (12) of the cases. Sulfurhexafluoride and Perfluoropropane were used in 68.8% (22) and 31.3% (10) respectively. The average follow up period was 1.02 years (range one month to four years). The retina was completely attached in 81.3% (26) of cases at the last follow up. The best corrected distance visual acuity of 6/18-6/60 was found in 40.6% (13) of subjects in the last follow up. There was a transient rise in intraocular pressure in 6.3% (2) of subjects after the procedure. CONCLUSION: The anatomical success rate following pneumatic retinopexy is quite high (81.3%) with good visual recovery and less morbidity translating to higher productivity for the patient. This procedure, being quicker than the alternatives, will also save surgeon's time making PR a good choice for managing primary rhegmatogenous retinal detachment in countries like Nepal where resources are scarce.

Willingness to pay for cataract surgery in Kathmandu valley.

AIM: A cross sectional study was carried out on 78 screened cataract patients of two screening camps in Kathmandu valley, Nepal, to assess the willingness to pay for cataract surgery. METHODS: A non-probability sampling technique with open ended and close ended questionnaires was used. RESULTS: The average age of patients was 68.8 years. The ratio of men and women was 0.9:1. 42.3% (33) of patients were willing to pay for cataract surgery. Among them 48.5% (16) of people were willing to pay less than dollars 13 and 51.5% (17) were willing to pay more than dollars 13. The mean was dollars 2.3 (SD dollars 15.5) per case. Patients with bilateral cataract were more willing to pay than unilateral cases. Poverty (44.4%, 20) was the main barrier for unwillingness to pay for cataract surgery. Other reasons were the lack of family support (28.9%, 13), lack of knowledge of surgery and belief that it was an unnecessary procedure (15.6%, seven), and waiting for a free surgical service (11.1%, five). CONCLUSION: This study clearly indicates that although there was awareness of the availability of treatment and services provided within the reach, people are not willing to pay for the surgery and use the facility primarily because of poverty. Hence, to change patients' attitudes, a more holistic approach is needed, keeping in view the cultural, social, and economic background of the society.

Visual Axis Opacification in Children Following Paediatric Cataract Surgery.

Visual axis opacification (VAO) occurs in up to 40% of pediatric patients after cataract surgery withintraocular lens implantation(IOL) even with a primary posterior capsulotomy (PPC). In both children and adult group, opacification does obscure the visual axis. However, in children after PPC, there is no capsule. Hence, the terminology VAO is used in children rather than posterior capsular opacification. This opacification is caused by a proliferation of epithelial cells on the posterior capsule or anterior vitreous face and can hinder the optical image quality needed for normal visual development. The rate of epithelial mitotic activity is higher in children compared to adult. It can be managed by Yag laser or surgical membranectomy, the latter is preferable. International and national published articles were systematically reviewed on aetio-pathogenesis, surgical techniques and equipment, type and material of IOL, and management of VAO in children operated for cataract. Author's experience was also included to write manuscript. VAO is frequent complication following cataract surgery in pediatric patients. Age of cataract patients, surgical technique and type and materials of IOL are most common influencing factor for VAO. Immediate management with advance equipment of VAO reduces the incidence for development of irreversible stimulation deprivation amblyopia.

Computed tomogram guided fine-needle aspiration cytology of lung and mediastinal masses with cytological correlation: a study of 257 cases in Western region of Nepal.

Computed tomogram guided fine needle aspiration cytology (FNAC) is an important and useful investigation to differentiate between benign and malignant lesions of lungs. To evaluate the lung and mediastinal masses and to analyze and compare the results with cytological findings, 257 patients were retrospectively studied who underwent CT guided FNAC over a period of 2007 to 2013. The study was done in patients who presented with respiratory symptoms with a localized lung lesion which was confirmed radiologically. 252 cases of lung masses and 5 cases of mediastinal cases were included. Patients' age ranged from 24 to 84 year and the male to female ration was 1.2:1. Radiologically, out of 257 cases, 225 cases were given as malignant, 8 cases as benign and 24 cases as inflammatory lesions. Cytologically, 212 cases were malignant, 12 cases were benign and 21 cases were inflammatory. Most common lung malignancy was adenocarcinoma (87 cases) followed by squamous cell carcinoma (56 cases). 8 cases of lung metastasis were seen. Compared to biopsy, CT guided FNAC shortens the diagnostic interval and helps in differentiating lung malignancy into different cytopathological types which aids in proper management of the malignant lesion.

Accessory hepatic lobe in right lumbar region - an incidental finding.

An accessory lobe of liver is a rare congenital anomaly which can be detected incidentally or can even present as acute surgical emergency due to torsion. We report a case of accessory hepatic lobe in right lumbar region in a 21years old female who came for a ultrasound abdomen for lower abdominal pain. We report the importance of ultrasonography and Computed Tomogram (CT) scan for the diagnosis of accessory hepatic lobe.

Bilateral Synchronous Testicular Seminoma in a Patient with Bilateral Cryptorchidism.

Cryptorchidism is a known cause of testicular tumor. The incidence of testicular tumor is 11 times more in inguinal testes and 50 times more in intra-abdominal testes. The position of the undescended testis is related to the likelihood of carcinogenesis with the intra-abdominal location having the highest risk for malignancy. Bilateral testicular tumors are rare and 80% of bilateral tumors are metachronous. Synchronous bilateral testicular tumors are rare and bilateral synchronous testicular seminoma in a patient with bilateral cryptorchidism is very rare.

Retinoblastoma: geographic distribution and presentation at a tertiary eye care centre in Kathmandu, Nepal.

INTRODUCTION: Several aspects of retinoblastoma in Nepal remain enigmatic. OBJECTIVE: To assess the demographic and geographic distribution, clinical presentation, and treatment methods of retinoblastoma at a tertiary level ophthalmic institution in Kathmandu, Nepal. MATERIALS AND METHODS: A retrospective analysis of all the patients diagnosed with retinoblastoma at Tilganga Institute of Ophthalmology from July 2004 to June 2008 was performed. The main outcome measures included region of residence, treatment options and histopathological findings. The histopathological analysis was performed on enucleated and exenterated specimens. STATISTICS: The statistical analysis was performed with SPSS Version 11.5. Descriptive statistics are represented as mean ± standard deviation. All tests were two-sided and the P-values of less than 0.05 were considered statistically significant. RESULTS: Thirty patients presented with retinoblastoma during the study period. The mean age at presentation was 2.5 ± 1.6 years (range five months to seven years). Ten of the 12 patients who presented with bilateral retinoblastoma (83 %) were from the Terai region of Nepal. The ratio of unilateral to bilateral cases in the Terai region was 1:2. This differed significantly with the ratio in the hilly region (Fisher's Exact Test, p = 0.0012). The mean duration of symptoms before presentation was 2.5 3.2 months (range three days to 12 months). Twenty-four patients (80 %) presented with leukocoria. Eleven patients (36.6 %) presented with leukocoria as their only symptom. Ninety-seven percent of the patients underwent either enucleation (90 %) or exenteration (6.7 %) of at least one eye. CONCLUSION: Bilateral retinoblastoma is more prevalent in the Terai region of Nepal. The majority of the patients present with leucokoria and are treated with enucleation.

Gender equity in eye health of Nepal: a hospital-based study.

INTRODUCTION: There is a lack of literature examining the impact of gender on access to eye care in developing countries. OBJECTIVE: To assess the differences in access to eye care between females and males, in the urban hospital setting and in rural outreach clinics. MATERIALS AND METHODS: A retrospective study was designed to review the patients who sought eye care at a tertiary level eye care institute and its rural outreach clinics from 2006 to 2009 in Nepal. Data were retrieved from clinical records. RESULTS: In the hospital, females accounted for 50.8% of patients receiving outpatient care and 48.3% of patients receiving surgical care. In rural outreach clinics, females accounted for 56.1% of clinic patients and 51.5% of patients undergoing surgery. Fewer girls than boys aged 0-14 years (44.3%) sought clinical care at the hospital. CONCLUSION: Females account for approximately half of the hospital eye care services in Nepal. More females seek care at rural outreach clinics than at the urban hospital. However, given the female burden of disease in Nepal, there is still much improvement to be made in this area of care.

Evaluation of nurse providers of comprehensive abortion care using MVA in Nepal.

BACKGROUND: Although Nepal's maternal mortality ratio has fallen over the past decade, unsafe abortion remains a leading cause of maternal morbidity and mortality. A key strategy for improving access to safe abortion services is to train mid-level providers such as nurses in comprehensive abortion care (CAC). The Family Health Division of the Nepal Ministry of Health trained an initial cohort of 96 nurses to provide first trimester CAC services using manual vacuum aspiration (MVA) between September 2006 and July 2009. This study evaluates the acceptability and quality of CAC services provided by trained nurses in Nepal. METHODS: Five assessments were used to evaluate post-training service provision on CAC: facility logbooks registry, nurse provider interviews, facility assessments, facility manager interviews and procedure observation checklists. Ninety-two nurses from 50 facilities participated in the evaluation. Descriptive statistics are reported. RESULTS: Overall, 5,600 women received CAC services from 42 facilities where nurses were providing services between June 2009 and April 2010. Complications were experienced by 68 surgical abortion clients (1.6%) and 12 medical abortion clients (1.2%). All nurses reported that clients were happy to receive care from them, and 67% of facility managers reported that clients preferred nurse providers over physicians or had no preference. Facility managers and nurses reported a need for additional support, including further training and improved drug and equipment supply. CONCLUSIONS: Trained nurses provide high quality CAC services in Nepal. Additional support in the form of facilitative supervision and training should be considered to strengthen CAC service provision.

Axial length in eyes with bilateral pediatric cataract at tertiary eye care center in Nepal: a preliminary report.

The aim of the study was to determine the average axial length reading of the bilateral pediatric cataract undergoing cataract surgery. Pre-operative axial length measurement was done in 80 children below 15 years who had bilateral pediatric cataract. Axial length measurement was done in 56 fellow eyes. The axial length was measured under general anesthesia with the Accutome A-scan. The mean age was 69.7 months (SD=52.6), range from one month to 168 months. The mean axial length reading was 21.3 mm in operated eyes and 21.1 mm in fellow eyes. The range of axial length reading was 16.2 -31.5 mm in operated eyes and it was 16.5 -31.5 mm in fellow eyes. This short observation found that in bilateral pediatric cataract, the axial length value is similar in both operated and fellow eyes. Based on the axial length value of the operated eye, the patients with bilateral congenital cataract can undergo surgery in those eye hospitals where facilities of measurement of axial length is not available.

Diagnostic accuracy of computed tomogram in the evaluation of a neck mass.

OBJECTIVE: The concept of dividing extracranial head and neck into different spaces is a notion that dates back to the 1800s. Various studies have led to detailed description of the soft tissue spaces that are contained within the fascial layers. This study was carried out to determine the accuracy of computed tomogram (CT) in differentiating malignant from benign lesions in the neck, to study the spatial distribution of different types of histological groups in the neck and the prevalence of malignant versus benign diseases involving the neck. METHODS: This was a hospital-based, prospective study conducted in the department of Radiodiagnosis, Kasturba Medical college, Mangalore, from 2005-2008. A hundred consecutive patients referred for CT scan examination presenting with complaints related to involvement of neck spaces or presence of palpable neck masses were enrolled in this study. The details of all the cases regarding their radiological findings and histopathology were reviewed. RESULTS: Of the 100 patients studied, 53 % had malignant lesions, out of which 43 % were squamous cell carcinoma and 4 % were metastatic lymph nodal involvement. Twenty percent of the lesions were of an infective origin while 23 % were benign and congenital cystic lesions. CONCLUSION: CT scan as an imaging modality has the ability to evaluate the malignant and benign tumors of the neck. Considering histopathology as the gold standard, the sensitivity of CT in detecting malignant/benign lesions was 96.5 % with a specificity of 100 %. The positive predictive value was 100 % and the negative predictive value 95.2 %.

Adrenal gland teratoma in a 40-year-old woman.

Teratoma is a germ-cell tumor that commonly affects the gonads. Extragondal teratoma is a rare entity. Teratoma in the region of adrenal gland is a rare and uncommon retroperitoneal tumor; only few cases have been reported. This case report describes such a tumor in a 40-year-old-woman who presented with multiple vague complaints. Ultrasonography of the abdomen showed a mixed echogenic mass with areas of calcification in right suprarenal region and a lymph nodal mass in the right renal hilar region. Computed tomography showed a mass containing fat, calcification and soft tissue component in right supra-renal region indenting the superior pole of kidney. Intraoperatively a supra-renal tumor was found within in a pseudocapsule that covered most of the tumor with a part of duodenum fixed to the mass.

Substance use among third year medical students of Nepal.

BACKGROUND: Substance use is very rampant in a developing country like Nepal. Unfortunately, medical field is not exempt from it either. Substance use among medical students and doctors not only reduces their efficiency at present but also increases their DALY on long term. The main objectives of the study were to assess the prevalence of substance use among medical student and to find out whether substance use started before or after joining the medical school. METHODS: The study design employed for the research was descriptive cross sectional. A structured questionnaire about current use of tobacco, alcohol and marijuana was used to collect the data from third year students from eight medical and one dental college from across the country having 2006 batch. RESULTS: The overall response rate was 74.12% (N=510). Among those who responded, prevalence of substance use was 49.6%, of which 38.2% were Nepalese nationals and 11.4% were foreign nationals and 39% were male and 10.6% female. Alcohol based product users were 52.3%, tobacco based product users were 55% and marijuana users were 65.7% and all started using them after joining the medical school. CONCLUSIONS: Almost half of the respondents were involved in some sort of substance use and more than half of those using started after joining medical school. Hence if proper measures are taken to address this then its prevalence can be significantly reduced if not eliminated completely.

Ocular morbidity among orphanages.

INTRODUCTION: The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley. METHODS: A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression. RESULTS: A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbidity was 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall). CONCLUSIONS: Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal.

Keratometry in eyes with bilateral pediatric cataract at tertiary eye care center in Nepal: a preliminary report.

Pre-operative keratometry measurement of the subjects was done in 80 children with bilateral congenital cataract below 15 years who had undergone pediatric cataract surgery. The objective of the study was to evaluate the average keratometry reading in Nepalese children with bilateral cataract. The keratometry reading was taken under general anesthesia with the Nidek Auto Keratometer, model KM-500. The mean age was 69.7 months (SD = 52.6), range from one month to 168 months. The mean keratometry reading was 44.8 (SD = 2.7) in operated eyes and 44.7 (SD = 2.6) in fellow eyes. The minimum and the maximum values of keratometry reading in operated eyes were 39.4 and 51.5 respectively where as it was 40.3 and 51.5 in fellow eyes. We concluded that in bilateral pediatric cataract the keratometry value is similar in both operated and fellow eyes. Based on the keratometry value of the operated eye, the patients with bilateral congenital cataract can undergo surgery in those eye hospitals where facilities of the keratometry is not available under general anesthesia. We also recommended that additional study on axial length will be needed to calculate the Intra Ocular Lens power in fellow eye.

Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation.

BACKGROUND/AIMS: The aim of the study was to compare surgical outcomes of external dacryocystorhinostomy (DCR) with and without silastic intubation for treatment of primary uncomplicated nasolacrimal duct obstruction (NLDO). DESIGN: The study was a prospective randomised trial conducted at the Tilganga Eye Centre (Kathmandu, Nepal). METHODS: One-hundred consecutive patients with uncomplicated primary NLDO were randomly assigned into two groups (44 underwent DCR with silastic intubation and 56 underwent DCR without intubation). Patients were re-assessed at 1 week, 6 weeks and 6 months after surgery. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The success rate at 6 months was 90% for DCR with silastic intubation and 87% for DCR without silastic intubation. There was no statistically significant difference between the two groups (p = 0.77). No complications were encountered in either group. Silicone tubes increased surgical cost by 20% at the Tilganga Eye Centre. CONCLUSION: DCR without silastic intubation is less expensive than DCR with silastic intubation in primary uncomplicated NLDO, and has a similar success rate. DCR with silastic intubation may create increased burden for patients in the form of more post-surgical follow-up visits. In cases of uncomplicated primary NLDO, the use of silastic intubation in DCR may be unnecessary.