Nepalese Journal of Ophthalmology

Acknowledgement

Eli Pradhan — Sun, 31 Dec 2023 00:00:00 +0000

Not available.

A Case of Full Thickness Parafoveal Hole Associated with Chorio-Retinal Atrophy

Punita Kumari Sodhi, Siddharth Kishore Baindur, Anu Sharma, Nasiq Hasan — Sun, 31 Dec 2023 00:00:00 +0000

Background: An idiopathic full-thickness parafoveal hole (PFH) in the absence of trauma or intraocular surgery is a rare finding.

Case: A 60-year-female who did not gain good vision following an uneventful phacoemulsification with intraocular lens (IOL) implantation in the right eye (RE) consulted a retina specialist, one year after her cataract surgery. There was no history of trauma, radiation exposure, reduced scotopic vision, or any other intraocular surgery. Her personal and family history were unremarkable for any systemic or ocular diseases. Routine blood investigations, an electrocardiogram, and a detailed ocular examination were done.

Observation: She had the best corrected visual acuity (BCVA) of LogMAR 1.0 (20/200; 6/60) in the right eye. The right eye had an axial length (AL) of 23.50 mm and an intraocular lens power of 21.0 dioptres. The ultrawide field fundus examination saw parafoveal chorio-retinal atrophy without significant peripheral myopic degeneration. On optical coherence tomography (OCT), a central foveal thickness of 138 microns with foveal scarring was noticed. There was a full-thickness parafoveal hole between the fovea and optic disc having a height of 198 microns; base diameter of 240 microns; arm lengths of 203 microns and 206 microns; and a minimum linear dimension of 42 microns. The optical coherence tomography angiography scan showed a reduced vessel density in the superficial and deep retina; and increased visibility of choroidal vessels in outer retina chorio-capillaries, chorio-capillaries, and choroid slab at the parafoveal hole The ultrasound B scan was anechoic and there was no posterior vitreous detachment (PVD).

Conclusion: The axial length, intraocular lens power and fundus examination did not indicate pathological myopia. As there was no preceding posterior vitreous detachment or retinal surgery, the underlying retinochoroidal atrophy most probably caused the full-thickness parafoveal hole.

Clinical Characteristics of Patients with Glaucoma Presenting to Bharatpur Eye Hospital: An observational study - Are we doing enough?

Binita KC — Sun, 31 Dec 2023 00:00:00 +0000

Not available.

Developing Artificial Intelligence Model for Prediction of Diabetic Retinopathy and Delivering in a real-world Local Context: BP Eye Foundation’s Perspective

Arjun Shrestha, Pranita Upadhyaya, Madan P Upadhyay — Sun, 31 Dec 2023 00:00:00 +0000

Not available.

Radius-Maumenee Syndrome, A Rare Entity: A Case Report

Rakshya Basnet, Sanjay Kumar Singh — Sun, 31 Dec 2023 00:00:00 +0000

Background: Radius–Maumenee syndrome (RMS) is a rare idiopathic condition characterized by the enlargement of episcleral vessels and an elevation in intraocular pressure (IOP) leading to secondary glaucoma.

Case: In this report, we present a case of RMS in 23-year-old male who experienced redness in Right Eye (RE) and intermittent headaches for a duration of 10 years. The patient exhibited a best corrected visual acuity of 6/6 in both eyes.

Observations: During slit lamp biomicroscopy, episcleral venous engorgement was observed in both eyes. Tonometry measured 28 mmHg in the RE and 14 mmHg in Left Eye (LE). In fundus photographs of RE and LE, there was evident cup asymmetry, along with retinal nerve fiber layer defects in superotemporal and inferotemporal regions of the right eye. Optical coherence tomography (OCT) Optic Nerve Head with hood report of RE showed loss of double hump pattern with asymmetric and severe retinal nerve fiber layer thinning in superior and inferior quadrant. Visual field testing of RE showed superior and inferior arcuate scotoma. Brain and orbit magnetic resonance angiography (MRI Angiogram) revealed no abnormal voids indicating cavernous fistula or other orbital lesions. The presence of secondary open angle glaucoma with episcleral venous engorgement and negative test results for other potential conditions led to the diagnosis of RMS in the patient. The patient is now under combination therapy with aqueous suppressants and uveoscleral outflow increasing drugs.

Conclusion: This case serves as a reminder to ophthalmologists about potential association of glaucoma if there’s enlargement of episcleral vessels in eyes without inflammation.

Hyperostotic Sphenoid Wing Meningioma with Proptosis: A Rare Case Report with Literature Review

Sun, 31 Dec 2023 00:00:00 +0000

Background: We present a case of proptosis with headache, decrease in vision and orbital pain where patient underwent sphenoid-orbital decompression, and excision of mass, resulting in significant improvement in her vision with complete resolution of proptosis, headache and orbital pain. This study was done to diagnose and evaluate clinical outcome of hyperostotic sphenoid wing meningioma with orbital involvement after surgery.

Case: A 40 year-female presented with severe headache, right eye swelling, periorbital pain and decreasing in vision for two years, and right eye proptosis more severe for three months.

Observations: She underwent right frontotemporal craniotomy with removal of hyperostotic sphenoid wing and excision of meningioma after magnetic resonance imaging demonstrated a right sphenoid wing meningioma extending orbital and middle cranial fossa. She had improvement of her symptoms post-operatively.

Conclusion: Surgical decompression of orbit with total resection of meningioma and sphenoid wing hyperostosis can result in significant improvement in the vision and proptosis.

Use of Bedside Ultrasound for Ophthalmic Evaluation in a Case of Traumatic Brain Injury: A Case Report

Sun, 31 Dec 2023 00:00:00 +0000

Background: Ophthalmological examination is an important aspect of the neurological assessment in a patient with traumatic brain injury. However, significant periorbital swelling can make direct visualization of the pupils difficult. Ultrasonic examination can be a valuable bedside tool when direct visualization fails.

Case: A case of a seven-year female child who had presented with a history traumatic brain injury is reported here.

Observations: The periorbital swelling prevented the direct visualization of the eyes. Bedside evaluation with a multipurpose ultrasound (USG) was used to monitor the pupillary diameter (PD) and the consensual pupillary light reflex (PLR) at regular intervals. The PD was measured in the B-mode while the PLR was monitored in M-mode of the USG. The optic nerve sheath diameter (ONSD) was also monitored as a correlate of intracranial pressure (ICP).

Conclusion: Ophthalmic evaluation of PD and PLR can be easily and objectively done on the bedside using USG especially in cases where the direct visualization of the pupils is difficult due to injuries and swelling of the periorbital tissues. Furthermore, ONSD measurements can also be done to monitor the changes in the ICP.

Ocular Findings among the Patients of Renal Transplantation

Madhu Thapa, Gulshan Bahadur Shrestha, Pragati Gautam, Mahesh Raj Sigdel — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Renal diseases are on rise globally due to increased incidence of non-communicable diseases as well as primary-kidney diseases and frequent use of nephrotoxic drugs. Only definite treatment of End-Stage-RenalDisease (ESRD) is renal transplantation. Immuno-suppressive-drugs are prescribed lifelong after renal transplantation especially steroids which can lead to various sight-threatening complications.

Methods: This cross sectional, observational study included 62 eyes of 31 patients who had undergone renal transplantation, at least 3 months prior were referred from Nephrology Department. Comprehensive eye evaluation was done at B. P. Koirala Lions Centre for Ophthalmic Studies (BPKLCOS), Department of Ophthalmology, Institute of Medicine.

Results: The average age of participants was 37 ±10.57 years with 77.4 % (n=24) male. Mean duration of renal transplant was 5.10 ± 3.61 years. Fifty-eight percent (n=18) had hypertensive kidney disease. Diabetes Kidney disease, recurrent UTI, CKD of unknown causes and combined case of diabetes plus hypertension were seen in 6.4% (n=2) each. Sixty percent of the patients had some kind of ocular involvement. Twenty-nine percent (n=18) had subnormal visual acuity of ≤ 6/9. Cataract was seen in 29% (n=18) of eyes followed by pinguecula (17.7%, n=11) and hypertensive-retinopathy (17.7%, n=11). Glaucoma and Diabetic-retinopathy were seen only in 6.4% (n= 4) of each eyes. There was no association seen between ocular findings with cause of renal transplant, duration of transplant and renal function status in bivariate analysis.

Conclusions: Some form of ocular abnormality is commonly seen in patients of renal transplantation who are on immunosuppressive drugs. However, incidence of sight threatening complications are rare.

The Retinal Nerve Fiber Layer and Macular Thickness in Patients with Type 2 Diabetes Mellitus without Retinopathy Using Optical Coherence Tomography: A Comparative Study

Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Diabetes leads to an alteration in retinal nerve fiber layer (RNFL) thickness and macular thickness which can easily be detected with optical coherence tomography (OCT).

Objectives: This study was done to compare the RNFL and macular thickness between diabetic patients without retinopathy and non-diabetic patients so that it would be useful in the early detection of retinal changes if present. The correlation between the RNFL and macular thickness with metabolic blood parameters of diabetic subjects was also studied.

Materials and methods: This is an observational, cross-sectional, hospital-based study including 120 subjects who were further divided into two groups. Group A consisted of 60 diabetic patients without retinopathy and group B consisted of 60 non-diabetic patients. The blood parameters were recorded and the RNFL thickness and macular thickness were compared between the two groups after evaluation by OCT.

Results: The average central macular thickness was found to be more in group A but was statistically insignificant (p=0.29). Macular thickness in the superior quadrant was significantly higher among group A when compared with group B (p=0.01). Whereas RNFL thickness difference between the two groups was statistically insignificant (p=0.53). Blood urea showed significant positive correlation (r=0.269) with central macular thickness (p=0.03).

Conclusion: Our study showed that diabetic patients without retinopathy could have increased macular thickness in the superior quadrant when compared with normal people whereas RNFL thickness may not alter. The blood urea levels of the diabetic patients can provide us clues regarding possible retinal changes.

Safety and Efficacy of Low Dose Atropine in Nepalese Children with Progressive Myopia

Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Myopia is emerging as a public health emergency worldwide. Low dose atropine has been proven to be safe and efficacious in halting the progression of myopia.

Objectives: Aim of this study was to evaluate safety and efficacy of low dose atropine in Nepalese children with progressive myopia.

Materials and methods: It is a prospective non randomized interventional study. Children with myopia progression of >0.5D in the last six months with baseline myopia of -1.5 to -8 Diopter and astigmatism of 3 D or less were prescribed 0.01% atropine daily at bedtime for two years. Demography including age, gender, race, and examinations including anterior and posterior segment, axial length, near point of accommodation and near vision were recorded in all the children. Ocular and systemic side effects were documented.

Results: A total of 200 children were enrolled in the study. Mean age was 11.9±2.97 years with 41% female. Baseline mean axial length was 24.47±1 and mean spherical equivalent was 3.69±1.33. Average increase in axial length was 0.18(±0.02), 0.17(±0.02), and 0.19(±0.04) mm in six months, one year, and two years respectively. The increase in spherical equivalence was 0.2 (±0.01), 0.3(±0.02), and 0.3(±0.02)) diopter in six months, one year, and two years respectively. The myopia progression was found more in the Mongolian race compared to the Aryan race. No ocular or systemic side effects were documented.

Conclusion: Topical low dose atropine appears to be safe and efficacious in halting the progression of myopia in a cohort of Nepalese children. Further randomized control trial on various doses of atropine are recommended.

Association of Meibomian Gland Dysfunction with Serum Lipid Profile: A Hospital-based Cross-sectional study

Prasansa Shakya, Sanket Parajuli, Sadhana Sharma — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Meibomian gland dysfunction (MGD) frequently leads to ocular surface disease, yet its impact on patients’ overall health is often overlooked. With increase in sedentary lifestyle, decreased physical activities and exposure to the digital world people have been facing increasing incidence of dyslipidemia.

Objectives: To investigate the association between serum lipid profile with severity of meibomian gland dysfunction.

Materials and methods: This was an observational, analytical, cross-sectional study carried out in the department of Ophthalmology of Shree Birendra hospital from January 2019 to January 2020. Oxford grading scale was used to grade the severity of MGD as none (grade 0), mild (grade I and II), moderate (grade III), and severe (grade IV and V). Serum lipid profile was obtained from all patients with MGD and analysis was carried out.

Results: Among 100 patients in this study majority of the participants were from the age group 61-70 (n, 40%) among whom 54 (54%) were females and 46 (46%) were males. Statistically significant association was noted between increase in total cholesterol, LDL, and TG levels with severity of MGD. However no significant association was found between HDL and the stage of MGD.

Conclusion: This study demonstrated that patients with increasing severity of meibomian gland dysfunction had greater abnormalities in their serum lipid profiles with respect to total cholesterol, LDL and triglycerides

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

Anil Parajuli, Indira Paudyal, Pratibha Lama Joshi, Suman Shamsher Thapa — Sun, 31 Dec 2023 00:00:00 +0000

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.

Changes in Central Corneal Thickness, Corrected Intraocular Pressure, and Iridocorneal Angle in Unilateral Acute Anterior Uveitis

Sumit Pandey, Ranju Kharel Sitaula, Sagun Narayan Joshi — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: The release of inflammatory mediators in the anterior chamber can lead to the structural alteration of the corneal and uveal tissue.

Objectives: To compare the changes in Central Corneal Thickness (CCT), corrected Intraocular Pressure (cIOP) and Iridocorneal Angle (ICA) in unilateral acute anterior uveitis (AAU) before and after treatment.

Materials and methods: The study was a hospital based comparative study conducted between July 2018 to June 2019. Newly diagnosed, untreated unilateral Acute Anterior Uveitis (AAU) adult cases above 16 years were included in the study. Ethical clearance was obtained from the Institutional Review Committee of Institute of Medicine. Eighty-two unilateral AAU cases (Total 164 eyes including 82 unaffected were analyzed) underwent Goldmann applanation tonometry (GAT) and corneal topography at presentation and three weeks after treatment. The cIOP was calculated by the Ehlers formula.

Results: The mean CCT of affected eyes was greater (563.84±51.49μm) compared to unaffected eyes (535.99±31.48μm) before treatment (p=0.001) and was reduced (533.2±25.71μm) after treatment (p=0.01). There was no significant difference in IOP, cIOP, and ICA between the affected eyes (14.45±6.89mmHg, 13.14±7.14mmHg and 48.78±7.94°) and the unaffected eyes (14.02±2.36mmHg, 14.4±3.09mmHg, and 49.80°±8.21°) before treatment. There was no difference in IOP (14.04±2.76mmHg) and ICA (49.21°±6.72°) after treatment, however, there was a significant increase (p=0.01) in the cIOP (14.95±2.93mmHg).

Conclusion: In the study, CCT of affected eyes was greater compared to unaffected eyes and reduced after treatment. There was no difference in cIOP and ICA in case eyes compared to control before treatment. However, cIOP increased after treatment.

Outcome of Optical Keratoplasty for Corneal Scar due to Infective Keratitis

Leena Bajracharya — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Corneal opacity is an important cause of blindness in developing countries.

Objectives: This study analyzes optical keratoplasty performed for corneal opacity due to infective keratitis.

Materials and methods: This is a retrospective study of all consecutive cases of optical keratoplasty performed between 2011 and 2014 (four-year period) for healed infective keratitis. Cases with less than two months’ followup were excluded during outcome evaluation. Comparison was made between keratoplasty for Microbial and Viral (herpetic) Scar.

Results: Ninety-three eyes of 93 patients were enrolled. Fifty-nine (63.4%) were male. Average age of patients was 38.9±19.5 years. Average donor endothelial cell count was 2713±434.5 cells/mm2. Fifty-four (58%) corneal scars were due to microbial keratitis and others were herpetic. Eighty-five (91.4%) had undergone penetrating keratoplasty. Eighty-eight (94.6%) cases were included for outcome analysis. Average follow-up duration was 37±27.5 months. Fifty-two (59%) had clear graft at their last visit. Twenty-three (26.1%) grafts had endothelial failure and 13 (14.7%) grafts failed due to late onset keratitis. Twenty-five (28.4%) had vision of ≥6/18. Rejection occurred in 24(27.2%) and glaucoma in 11(12.5%). Post-operatively viral keratitis in the graft occurred significantly more inViral Scar Group (38.6%, n=15) than in Microbial Scar Group (5.5%, n=3). But there was no significant difference in graft clarity, rejection, vision and secondary glaucoma between the two Groups.

Conclusion: Outcome of keratoplasty for post-infectious scars was found fairly satisfactory. Although occurrence of viral keratitis was higher in case of keratoplasty done for Viral Scars, the final result was similar to that of microbial scar.

Indication and Outcome of Paediatric Keratoplasty at a Tertiary Referral Eye Hospital in Nepal

Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Paediatric keratoplasty is rarely performed surgery with high risk of graft failure. Developing countries have not benefited due to lack of sufficient facilities and trained surgeons.

Objectives: The objectives of the study were to analyze the indications and its outcome in terms of vision and graft survival.

Materials and methods: This retrospective chart review used electronic medical records from January 2017 to December 2019 of all consecutive patients aged upto18 years or below that underwent paediatric keratoplasty after ethical approval at Tilganga Institute of Ophthalmology. Outcome was defined as anatomical or visual success and graft clarity. Different demographic and surgical parameters were studied among 59 eyes of 48 patients.

Results: Mean age of recipient was 12.23± 3.81 years. Majority 37 (52.5%) had unilateral grafts with keratoconus being the most common 24 (40.6%) acquired non-traumatic indication. Mean post-operative best corrected visual acuity 0.6 Logmar was significantly (p <0.001) low as compared to preoperative 1.3 Logmar. Overall graft survival rate was 47 (78%) at one-year follow-up; keratoconus accounting for 24 (100%). Major factors in contributing for graft failure were rejection, infection, and glaucoma.

Conclusion: A good outcome in terms of anatomical and visual success was achieved in our study. Keratoconus has an excellent graft survival. Visual rehabilitation by cycloplegic refraction should be done to prevent amblyopia. Enhancing the training of surgeons and addressing challenges faced in a paediatric population will help decrease corneal blindness among paediatric patients in the future.

Changes in Central Corneal Thickness and Central Macular Thickness following Uncomplicated Small-incision Cataract Surgery

Sanket Parajuli, Sadhana Sharma, Ruchi Shrestha, Senny Chapagain — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Cataract surgery is an invasive procedure that causes mechanical and inflammatory insult to the eye.

Objectives: The objective was to study the changes in central corneal thickness (CCT) which is an indirect indicator of corneal endothelial dysfunction and the changes in macular thickness following uncomplicated small incision cataract surgery (SICS)

Materials and methods: This was a prospective observational study with a before-and-after design conducted in Reiyukai Eiko Masunaga eye hospital, Banepa, Kavrepalanchok, Nepal. SICS was performed on 68 eyes of 62 patients. Change in CCT and central macular thickness (CMT) from baseline was observed post-surgery on the first day, one week, and six weeks.

Results: There were 27 (43.5%) females and 35 males (56.5%) in the study. Mean age was 58.26 ±10 years. This difference of visual acuity between pre and post-operative state was statistically significant. The first post-operative day (POD) and first week post-operative CCT values when compared with preoperative CCT values were statistically significant. However, post-operative CCT values at six weeks were similar to preoperative values. Also, the differences at day one, first week and six weeks post-operative CMT values when compared with preoperative CMT values were statistically significant.

Conclusion: This study revealed that there is a significant rise in CCT after SICS which gradually tends to normalize at six weeks. Similarly there is a gradual rise in CMT after SICS persisting even at six weeks. These changes were subtle and there was a marked improvement of visual acuity at six weeks after SICS.

Indications and Outcomes of Repeat Keratoplasty for Graft Failure at a Tertiary Eye Care Center in Nepal

Jyoti Sapkota, Leena Bajracharya, Reeta Gurung, Rachana Singh Rana — Sun, 31 Dec 2023 00:00:00 +0000

Introduction: Graft failure is a common complication following keratoplasty requiring repeat keratoplasty (re-KP).

Objectives: To determine the indications and outcome of repeat keratoplasty at a tertiary eye care centre in Nepal.

Materials and methods: This was a retrospective study of 78 patients who underwent re-KP for graft failure in Tilganga Institute of Ophthalmology from Jan 2015 to Dec 2020. Indications for the primary keratoplasty, causes of graft failure and outcomes of re-KP in terms of vision acuity, graft clarity and secondary glaucoma were evaluated. Cases of regraft with less than one-year follow-up period were excluded.

Results: A total of 78 re-KPs had been performed in 78 patients during the study period. Seventy eyes had undergone single corneal regraft and 8 eyes had undergone multiple (second or third) regraft surgery. Most common indication of primary keratoplasty was infectious keratitis (n=36; 46.2%). On follow up, 36 eyes (46.2%) were clear at the last visit, of which 31 eyes were single regraft cases and 5 were of multiple regraft cases. Most common cause of graft failure was graft infection (n=34; 43.6%) followed by corneal scarring (n=12; 15.4%). Of 42 eyes with failed regrafts, recurrence of the preoperative infection was commonest cause (n=15, 35.7%) followed by secondary glaucoma (n=11; 26.2%). Of 36 eyes with clear regraft, only 4 eyes (11.11%) achieved best corrected vision of ≥6/18 and remaining 32 eyes had BCVA <6/18 due to associated cataract, secondary glaucoma and high astigmatism.

Conclusion: The most common cause for re-KP includes graft infection followed by secondary glaucoma. Outcomes of corneal regrafts in the form of graft clarity and visual acuity are suboptimal.