Minimizing the Discrepancy between the Clinical Knowledge and Performance of Medical Graduates for Improvement of the Quality of our Health Care System

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Ophthalmic oncology in Nepal – an area requiring special attention

Nepal J Ophthalmol 2013; 5(10): 145-146 DOI: http://dx.doi.org/10.3126/nepjoph.v5i2.8704

Drug-Induced Ocular Hypertension and Angle-Closure Glaucoma

The objective of this study was to review the available literature on the drugs causing ocular hypertension and glaucoma. Electronic literature search was carried out using the Web sites www.pubmed.gov and www.google.com published through the year 2011. The search words were "drug induced ocular hypertension" and "drug induced glaucoma" used in combination. The articles published or translated into English were studied. Quite a significant number of drugs commonly prescribed by various physicians of different specialties can induce ocular hypertension or glaucoma. A brief account of various drugs that can induce ocular hypertension has been given in this article. Those drugs are parasympatholytics; steroids; anticholinergics, adrenergics, and antidepressants; cholinomimetics; antineoplastic agents; antipsychotic and antiparkinsonism agents; H1 and H2 receptor blockers; botulinum toxin, cardiac agents, and anticoagulants; silicone oil; sulfa drugs; and anesthetic agents. Rational use of these drugs and knowledge of their potential adverse effects can help prevent the devastating complications resulting in loss of vision and compromised quality of life.

Manuscript submission: expectations and constraints

Nepal J Ophthalmol 2013; 5(9):1-2 DOI: http://dx.doi.org/10.3126/nepjoph.v5i1.7813

Safety of primary intraocular lens insertion in unilateral childhood traumatic cataract

This study analyzes the results of cataract surgery with primary intraocular lens implantation in unilateral childhood traumatic cataract following penetrating trauma and its long term follow up. It is a hospital based study of 114 children (age 3-10 years) with unilateral traumatic cataract who underwent extracapsular cataract extraction/ lens aspiration with implantation of posterior chamber intraocular lens (IOL). Primary posterior capsulotomy (PPC) was performed in 57 eyes and the rest 57 were without PPC (NPPC). The patients were followed up at regular intervals for a period of 3 years. Postoperative inflammation and pupillary capture were two frequent complications seen during postoperative period. Development of posterior capsular opacification (PCO) was 1/57, 4/57 at 8th week and 7/30 and 14/39 at 6 months, in PPC and NPPC group, respectively. Best corrected visual acuity (BCVA)>or=6/18 was achieved in 50% of eyes at 8th week post operatively and the same at 3 years with/without membranectomy/capsulotomy was evident in 73.3% of eyes. Meticulous case selection with insertion of "in the bag IOL" and subjecting the traumatized cataractous eyes to primary posterior capsulotomy are factors responsible for optimal outcome in unilateral traumatic cataract in children.

Retinopathy of Prematurity in A Tertiary Care Hospital in Eastern Nepal

World Health Organization’s Vision 2020 program has recognized Retinopathy of Prematurity(ROP) as an important cause of childhood blindness in industrialized and developing countries. Inthe last few years, it has been identifi ed in many under developed countries as well, as a result ofimproved neonatal intensive care. In Nepal, ROP screening is carried out in a few tertiary hospitalsbut there is no published data on this disease. The purpose of this study was to fi nd out the incidence,severity and risk factors of ROP among infants screened in a tertiary care hospital in the EasternRegion of Nepal.A prospective cohort study was carried out in neonates with gestational age of 34 weeks or less and,or birth weight of 1700 gm or less born over the period of one year. Dilated fundus examination ofall babies was done by indirect ophthalmoscopy between 2-4 weeks after birth and followed up tillthe retinal vascularization was complete. Classifi cation of ROP was done according to internationalclassifi cation (ICROP). Maternal and neonatal risk factors were also noted.A total of 55 babies fulfi lled the screening criteria. ROP was present in 25.45% (n=14) of the babies.Threshold disease was noted in 5.45% (n=3) of the babies screened. Low birth weight (p<0.01)and low gestational age (p<0.01) was signifi cantly associated with the incidence of ROP. Oxygensupplementation (p=<0.01) was an independent risk factor.ROP screening should be performed in all preterm low birth weight infants where there is availabilityof good neonatal intensive care units. The examination should be intensifi ed in those having riskfactors like oxygen. Further studies in the other tertiary care hospitals in Nepal would help toestablish the screening criteria for Nepalese infants.Key words: Retinopathy of prematurity, Eastern Nepal, screening

Retinopathy of prematurity in a tertiary care hospital in eastern Nepal

World Health Organization's Vision 2020 program has recognized Retinopathy of Prematurity (ROP) as an important cause of childhood blindness in industrialized and developing countries. In the last few years, it has been identified in many under developed countries as well, as a result of improved neonatal intensive care. In Nepal, ROP screening is carried out in a few tertiary hospitals but there is no published data on this disease. The purpose of this study was to find out the incidence, severity and risk factors of ROP among infants screened in a tertiary care hospital in the Eastern Region of Nepal. A prospective cohort study was carried out in neonates with gestational age of 34 weeks or less and, or birth weight of 1700 gm or less born over the period of one year. Dilated fundus examination of all babies was done by indirect ophthalmoscopy between 2-4 weeks after birth and followed up till the retinal vascularization was complete. Classification of ROP was done according to international classification (ICROP). Maternal and neonatal risk factors were also noted. A total of 55 babies fulfilled the screening criteria. ROP was present in 25.45% (n=14) of the babies. Threshold disease was noted in 5.45% (n=3) of the babies screened. Low birth weight (p<0.01) and low gestational age (p<0.01) was significantly associated with the incidence of ROP. Oxygen supplementation (p=<0.01) was an independent risk factor. ROP screening should be performed in all preterm low birth weight infants where there is availability of good neonatal intensive care units. The examination should be intensified in those having risk factors like oxygen. Further studies in the other tertiary care hospitals in Nepal would help to establish the screening criteria for Nepalese infants.

Prevalence of glaucoma in Sunsari district of eastern Nepal

AIMS

To determine prevalence of glaucoma and glaucoma suspect in subjects 40 years and above in Sunsari district of eastern Nepal.

METHODS

A community based cross sectional study examining 1600 selected subjects was carried out. In all subjects best corrected visual acuity was determined. Oblique torch light test was used for anterior chamber depth evaluation. Intraocular pressure (IOP) measurements with Perkins tonometer and fundus examination were carried out in the community. Subjects diagnosed as glaucoma suspect were further evaluated in the hospital using slit lamp examination, gonioscopy and Goldmann perimetry. Glaucoma was defined by characteristic disc and visual field changes irrespective of the level of IOP.

RESULTS

Of 1600 subjects examined, the prevalence of glaucoma was found to be 0.938%. The prevalences of primary open angle glaucoma, primary angle closure glaucoma, secondary glaucoma and ocular hypertension were 0.562%, 0.125%, 0.250% and 0.500% respectively. Lens induced glaucoma accounted for all the cases of secondary glaucoma.

CONCLUSION

The prevalence of glaucoma in the Sunsari District of Nepal is 0.938%, which is lower than that reported in the neighboring regions. Lens induced glaucoma is highly prevalent as a cause of secondary glaucoma.

Striving for the perfect surgery in traumatic cataract following penetrating trauma in a tertiary care hospital at eastern Nepal

This study analyzes the result of traumatic cataract surgery in a tertiary care hospital at eastern Nepal. It is a hospital-based study of 112 patients (age 15-62), who underwent cataract extraction for unilateral traumatic cataracts. The study was carried out to evaluate the surgical outcome of tramatic cataract. Thirty-eight eyes had associated posterior capsular defect. No serious postoperative complications were encountered. Posterior capsular opacification at the end of sixth week was evident only in two eyes. Best corrected visual acuity nof 6/18 or more at the eighth week was achieved in 61 (54%) eyes. Astigmatism of less than 3D was achieved in 82 (73%) eyes. Rational surgical approach in traumatic cataract provides encouraging results. To comment on actual outcome long term follow up is mandatory.

Etiology and clinical profile of pediatric cataract in a tertiary care center of Eastern Nepal

Cataract is one of the leading causes of blindness in children. There are very few studies from Nepal on pediatric cataract. The present study is an attempt to get information on clinical profile and etiology of cataract in pediatric age group with an emphasis on preventable factors. A hospital based cross sectional study was carried out in a tertiary referral hospital in Eastern region of Nepal. After obtaining detail history, all children upto 14 years of age with cataract underwent examination under slit lamp or the operating microscope. Cataract is broadly classified into traumatic and non-traumatic groups. TORCH test for rubella, random blood sugar, urine reducing substance, chromosomal analysis were done in children with non-traumatic cataract Out of 172 children 34 (88%) had non-traumatic and 65 (12%) traumatic cataract. The mean age was 5.63 +/- 3.59 years and 7.39 +/- 3.94 years in non-traumatic group and traumatic group respectively. 8 (9.82%) patients with non-traumatic cataract were below the age of one year. Among non-traumatic cataract, 42 (37.50%) had hereditary, 9 (8.03%) had systemic syndromes, 5 (4.46%) had cataract due to maternal infection, 3 (2.67%) had metabolic disorder. While 11 (9.82%) cataract were associated with other ocular dysmorphology, cause was not ascertained in 31 (idiopathic). 11 (9.82%) had complicated cataract. 24.1% (n=27) of children with bilateral cataract had nystagmus at the time of presentation to hospital. In traumatic group, play related injuries were more common than household injuries. A very few children were below one year of age at the time of presentation to hospital. Establishing pediatric vision screening program in the primary health posts, genetic counseling, maternal immunization, health education to school children and use of safety glasses are some important measures that could prevent cataract blindness in our children.

Topiramate induced bilateral angle-closure glaucoma

Topiramate is a sulfamate-substituted monosaccharide and is used as an antiepileptic medication. It can also be used as a prophylactic agent for headache from migraine. The main purpose of this article is to create awareness among medical colleagues regarding severe ophthalmic side effect of topiramate. This is the first reported case of topiramate induced bilateral angle-closure glaucoma in Nepal. This case was managed successfully by discontinuing topiramate and by starting anti-glaucoma medication along with atropine eye drops which were tapered and eventually discontinued.

Indirect traumatic optic neuropathy--retrospective interventional case series from a tertiary care center in eastern Nepal

To report the demography, nature of insult and ocular characteristics in patients presenting with indirect traumatic optic neuropathy and to evaluate the visual outcome with mega dose methylprednisolone therapy. Retrospective hospital data analysis of all patients admitted with indirect traumatic optic neuropathy and treated with mega dose methylprednisolone therapy in the last three years was conducted. Nine patients (M:F= 8:1) were identified with unilateral optic nerve injury. Road traffic injury was the most common cause of injury. Lid ecchymosis and swelling on the same side was the most frequent ocular abnormality noted, followed by loss of consciousness. Time of presentation varied from 3 hours to 11 days. All patients except two had visual acuity of no light perception at presentation. Following therapy there was improvement in visual acuity in two patients who presented within two days of injury. Patients present late with traumatic optic neuropathy in this hospital. Most of the patients are with no light perception. High dose steroids was found to be beneficial only in patients presenting early (<two days).

Sinonasal inverted papilloma in eastern part of Nepal

OBJECTIVE

To evaluate the clinicopathological profile of sinonasal inverted papilloma in a tertiary referral center in eastern part of Nepal.

METHODS

A prospective study consisting of total 28 histologically proven cases of sinonasal inverted papilloma was conducted in the ENT department of the center. The study period was from April 2002 to November 2005.

RESULT

Out of 28 cases studied, 21 were males and 7 were females with male to female ratio of 3:1. The highest incidence was seen in the 5th and 6th decades of life. The duration of symptoms varied from 5 months to 20 years with mean duration of 3.9 years. The lateral nasal wall and nasal cavity involvement was seen in all 28 cases. Maxillary sinus was involved in 27(96.4%) subjects followed by ethmoid (20), sphenoid (10) and the frontal sinus (7). The principle presenting symptom was nasal obstruction seen in 96.4% of the patients. Twenty two cases were treated by lateral rhinotomy with medial maxillectomy while, orbital exenteration was done in two cases. Associated carcinoma was noticed in 10.15% of all the subjects studied.

CONCLUSION

Sinonasal papilloma mostly presented in fifth to six decades of life mainly affecting the male patients. Majority of the patients were treated by lateral Rhinotomy with medial maxillectomy surgery. Early presentation would have given chances for endoscopic surgery.

Effectiveness of combination of permanent and releasable scleral flap sutures in trabeculectomy: a randomized clinical trial

INTRODUCTION

Trabeculectomy is a commonly used surgical treatment for glaucoma.

PURPOSE

To evaluate the effectiveness of combination of permanent and releasable scleral flap sutures to minimize the immediate postoperative complications of trabeculectomy.

MATERIALS AND METHODS

This study was carried out in Department of Ophthalmology, B P Koirala Institute of Health Sciences, Dharan, Nepal. Forty one eyes of 34 patients undergoing trabeculectomy were randomized to undergo either conventional trabeculectomy (Group A= 20 eyes) or trabeculectomy with combination of permanent and releasable scleral flap sutures (Group B =21 eyes). The parameters studied were intraocular pressure (IOP), anterior chamber depth (ACD) and surgical complications over a period of 6 weeks.

RESULTS

Significantly higher number of eyes belonging to group A (14 eyes) had shallower anterior chamber than group B (7 eyes) on first post operative day (p=0.042). Six eyes (30%) in group A had peripheral or central irido-corneal touch in early postoperative period as compared to only one in Group B. Hypotony was noted in 3 eyes in each group. Two patients in group A required reformation of anterior chamber. Other surgical complications in the two groups were similar. Both the groups had a significant drop in IOP following surgery. However, there was no significant difference in the IOP between the two groups after 6 weeks (Group A: 10.95 +/- 3.03 mmHg vs. Group B: 12.29 +/- 4.67 mmHg; p=0.87). There was a significant drop in IOP following removal of sutures (15.19 +/- 6.15 mmHg to 13.19 +/- 6.13 mmHg; p=006) in group B.

CONCLUSION

Use of combination of permanent and releasable scleral flap sutures is a safe technique that significantly reduces the incidence of immediate postoperative shallow anterior chamber after trabeculectomy.

Effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health

INTRODUCTION

Development of knowledge and attitude takes place during the adolescent period, which can have lifelong effects on the individual, family and society. Proper education in this age group is important for prevention of untoward social and health related problems.

OBJECTIVE

To find out the effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health.

MATERIALS AND METHODS

An experimental study with pretest - posttest control group design was carried out in four selected schools with similar settings in Dharan town of Nepal. All the subjects were divided into two groups: experimental and control, each comprising of two subgroups of 50 boys and 50 girls. Structured teaching program consisting of information on human reproductive system was used as a tool of investigation for the experimental group, whereas conventional teaching method was used for the control group.

RESULTS

A total of 200 Adolescent school students were included in this study. The mean (+/-SD) pretest score of the experimental group on knowledge of reproductive health was 39.83 (+/- 16.89) and of the control group was 39.47(+/- 0.08). The same of experimental group after administration of the structured teaching program (84.60+/-10.60) and of the control group with conventional teaching method (43.93+/-10.08) was statistically significant (p<0.001). Similarly, the post-test scores of knowledge of the groups on responsible sexual behaviour and their attitude towards reproductive health were better in the experimental group than in the control group (p<0.001).

CONCLUSION

The knowledge of adolescent school students on reproductive health is inadequate. The use of structured teaching program is effective in improving knowledge and attitude of the adolescents on reproductive health.

Variation of intraocular pressure in patients with leprosy

INTRODUCTION

There are various controversial reports on intraocular pressure (IOP) in patients with leprosy.

PURPOSE

The current study was undertaken to study the level of intraocular pressure in leprosy patients and its association with the risk factors.

MATERIALS AND METHODS

This was a prospective cross sectional comparative study. An ophthalmologist and a dermatologist evaluated consecutive 93 patients with leprosy. The risk factors studied were age, gender, bacillary index, clinical diagnosis, duration of disease and treatment; and ocular complications. The IOP in these patients was compared with healthy age and sex matched controls.

RESULTS

A total of 186 leprosy patients (93) and healthy controls (93) were studied. The mean applanation IOP for the right and left eyes in leprosy patients was 12.87 1.20 mm of Hg and 13.222.70 mm of Hg respectively. This was found to be significantly lesser (p<0.001) than in the controls (RE=15.142.58 and LE=15.412.36 mmHg). The untreated leprosy patients had significantly lower IOP than those with treatment (p<0.001). None of the risk factors were found to be independently associated with the decrease in IOP. The duration of treatment, however, showed a trend towards having a significant association (p=0.057) with the lower level of IOP.

CONCLUSION

The level of IOP is lower in leprosy patients than in the healthy controls. Age, gender, bacillary index and presence of ocular complications due to leprosy are not independently associated with the decrease in IOP. The untreated leprosy patient tends to have a lower IOP. This finding can be used to monitor effectiveness of treatment of leprosy.

Doctor's Role in Early Detection of Diabetic Retinopathy and Prevention of Blindness from its Complications

Diabetic retinopathy (DR) is a microangiopathy, which is caused by chronic hyperglycemia, affecting theretinal arterioles, capillaries and venules, complications of which lead to incurable blindness.Approximately 10% of the diabetic population has type I diabetes mellitus (DM) which is diagnosed beforethe age of 30 years1 and rest is type II which is diagnosed after the age of 30 years. In UK 2% generalpopulation is affected by DM. In developed countries, diabetic retinopathy is an important and leadingcause of blindness in working age group where as in developing western countries this figure occupy 12% ofthe blindness.In developing countries like Nepal, cataract still remains a main cause of blindness and diabetes is notconsidered as a major problem. However due to a rapid urbanization and modernization of population,diabetes mellitus is becoming an endemic disease and bringing a new challenge in blindness reduction program.Key Words: Early detection of DR, Classification of DR, Complications, Prevention of blindness.

Doctor's role in early detection of diabetic retinopathy and prevention of blindness from its complications

Diabetic retinopathy (DR) is a microangiopathy, which is caused by chronic hyperglycemia, affecting the retinal arterioles, capillaries and venules, complications of which lead to incurable blindness. Approximately 10% of the diabetic population has type I diabetes mellitus (DM) which is diagnosed before the age of 30 years and rest is type II which is diagnosed after the age of 30 years. In UK 2% general population is affected by DM. In developed countries, diabetic retinopathy is an important and leading cause of blindness in working age group where as in developing western countries this figure occupy 12% of the blindness. In developing countries like Nepal, cataract still remains a main cause of blindness and diabetes is not considered as a major problem. However due to a rapid urbanization and modernization of population, diabetes mellitus is becoming an endemic disease and bringing a new challenge in blindness reduction program.

Association between axial length of the eye and primary angle closure glaucoma

Background: Angle closure glaucoma is emerging as a leading cause of blindness in Asia. Objective: To compare the ocular axial length of normal individuals and the subjects with primary angle closure glaucoma. This study has been conducted to determine axial length of eye as a risk factor of primary angle closure glaucoma. Materials and Methods: A cross-sectional comparative study was carried out in Mechi Eye Care Centre, Jhapa, Nepal including forty eyes of 20 diagnosed cases of primary angle closure glaucoma (40 eyes) and 40 eyes of 20 normal subjects selected by simple random sampling. A complete ocular examination of all the subjects was carried out. Axial length measurement was done using ultrasound A scan. Results: Out of 80 eyes, there were 40 eyes of 20 diagnosed primary angle closure subjects and 40 eyes of 20 normal subjects. The mean axial length and standard deviation of primary angle closure glaucoma were 21.93 ± 1.16 mm (95% CI = 21.41 - 22.45) and those of control group were 23.01 ± 0.49 (95% CI = 22.79 - 23.23). The axial length of less than 23 mm was found as a risk factor for angle closure glaucoma (Relative risk =3.40; p = 0.0032). Conclusion: This study showed that patients with the axial length of less than 23 mm are at risk to develop primary angle closure glaucoma. This result can be confirmed by doing population based study in a larger sample size. Keywords: Axial length, Primary angle closure glaucoma, Nepal doi: 10.3126/kumj.v6i3.1712 Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 361-363

The burden of glaucoma in Nepal

DOI: http://dx.doi.org/10.3126/nepjoph.v4i1.5841 NEPJOPH 2012; 4(1): 1-2