Nepalese Journal of Ophthalmology

Pain in and Around the Eye: How Big is the Problem?

Balkrishna Bhattarai — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23011

Not available.

Keywords: Pain in eye

Qualitative Research: A way of Listening to Patients

Sailaj Ranjitkar — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23010

Not available

Keywords: Qualitative Research

Outcomes of Silicone Oil Removal in Complex Retinal Detachment

Ritesh Shah — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23012

Introduction: Pars plana vitrectomy in combination with intraocular tamponade with silicone oil is a standard technique in the treatment of complex retinal detachment. Although the use of silicone oil has improved the results of retinal detachment surgery, its removal is recommended due to the ocular complications related to its long term use. However, retinal redetachment can occur after silicone oil removal.

Objective: To evaluate the anatomical and visual outcome after silicone oil removal (SOR) in eyes with complicated retinal detachment.

Material and Methods: We retrospectively analyzed 64 eyes of 64 consecutive patients of silicone oil removal over a period of 12 months. All eyes had undergone standard 3 ports pars plana vitrectomy with silicone oil placement for complicated retinal detachment. Cases that completed at least 1 month follow up duration after SOR were included in the study. Anatomical success after SOR was achieved in 56 of 64 eyes (87.5%). Seven of 8 redetachments (87.5%) were seen in eyes with silicone oil tamponade duration of less than 6 months. Visual acuity improved or was stabilized in 49 of 64 eyes (76.6%). Using paired T-test, it was found that there was no significant difference in pre and post SOR visual acuity. Postoperative ocular hypertension, corneal decompensation, band shaped keratopathy and hypotony was observed in 9.4%, 4.7%, 6.4% and 21.9% respectively.

Conclusion: Although there was no significant improvement in visual acuity, redetachment and complication rates were comparable to other studies. The duration of endotamponade was not significantly associated with the redetachment rate. Key words: Silicone oil removal, Redetachment, Visual outcome, Keratopathy, ocular hypertension.

Keywords: Silicone oil removal, Redetachment, Visual outcome, Keratopathy, ocular hypertension

Assessment of Antimicrobial Prescribing Pattern in the Outpatient Department of Ophthalmology in a Tertiary Care Hospital of Western Uttar Pradesh, India

Amit Kumar Jain — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23014

Introduction: Assessment of prescribing pattern at regular interval is essential to avoid inappropriate use of drugs, especially of antimicrobial drugs.

Objectives: The present study was performed to evaluate the prescribing pattern of antimicrobial drugs in the Ophthalmology Out-Patient Department (OPD) of Santosh Medical College and Hospital, Ghaziabad, India.

Material and method: The present study included a total 600 prescriptions of patients attending OPD. A structured proforma was used to record all necessary information of each patient including demographic profi le of patient, diagnosis, total number of drugs and antimicrobials prescribed, group of antimicrobial prescribed, the percentage of antimicrobials prescribed by generic name etc.

Results: Total 600 prescriptions were evaluated. Mean age of the study subjects was 28.4 ± 15.05 years. Total 720 antimicrobials were prescribed and the average number of antimicrobial drugs per prescription was 1.2. Fluoroquinolones were most commonly prescribed antimicrobial drugs followed by aminoglycosides and macrolides. 85% of drugs were prescribed in the form of eye drops while 15% were in the form of an ointment. 1.2% of antimicrobial drugs were prescribed by generic names. Out of total antimicrobials drugs, 420 drugs were in the form of fi xed dose combination. Only 1.6% of drugs were prescribed from National Essential Medicines List (NEML) 2015, India.

Conclusion: Most of the antimicrobials were prescribed by brand names which require important consideration to promote rational use of antimicrobial drugs. In addition, the number of drugs prescribed from NEML was very less, indicating the need of sensitization among prescribers for the promotion of rational use of drugs

Keywords: Prescribing pattern, Ophthalmology, Antimicrobials, Generic name, Rational

Etiologies of Optic Disc Edema in Tertiary Eye Care Centre in Nepal

Keepa Vaidya — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.19472

Introduction: Optic disc edema is a common clinical finding that can be caused by benign to vision and or life-threatening conditions.

Objective: To investigate the etiologies of optic disc edema among patients presenting to Tilganga Institute of Ophthalmology, Kathmandu, Nepal.

Materials and Methods: A retrospective chart review of patients with optic disc edema presenting to Neuro-ophthalmology department of Tilganga Institute of Ophthalmology from May 2012 to May 2014, was made.

Results: 98 patients were diagnosed with disc edema. Females (64%) were frequently affected. It was noted more in the 21 – 50 age groups. Papilledema was the most frequent cause (35.7%) of disc edema followed by papillitis (28.6%), pseudopapilledma (18.4%) and ischemia (17.3%), respectively. Brain tumors (13%) were the most common etiology for papilledema.

Conclusion: Papilledema along with other causes, are common etiologies for disc edema. A detailed history and careful evaluation are necessary as the treatment strategy highly depends on it’s underlying etiologies.

Keywords: Optic disc edema, Papilledema, Pseudo papilledema, Ischemic optic neuropathy

Management of Ocular Surface Squamous Neoplasia with Topical and Intralesional Interferon Alpha 2B in Mexicans

Ángel Nava-Castañeda — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.18574

Introduction: Ocular surface squamous neoplasia (OSSN) is the most common nonpigmented ocular surface neoplasm and it can originate from the conjunctiva and/ or corneal epithelium. Since the rate of recurrence after surgical excision is high, chemotherapeutic and immunotherapeutic agents such as interferon alpha-2b (IFN α-2b) have been used for its treatment.

Objective: Our objective is to describe the demographic variables of patients with OSSN treated with IFN α-2b and to describe the outcomes of its use in Mexican patients, treated between 2011 and 2017 at Instituto de Oftalmología Fundación Conde de Valenciana.

Materials and Methods: This is a non-randomized retrospective interventional case series. We reviewed the files of patients older than 18 years, with clinical and/or histopathological diagnosis of OSSN, treated with IFN α-2b alone or in combination with surgery, with a minimum of 6 months follow-up. We studied demographic variables, such as gender, age, eye affected and associated risks factors; we also studied the type of therapy with interferon (topical, intralesional and/or associated with surgery), time of treatment, time of follow up, recurrences and complications.

Results: A total of 39 patients were included. The mean age of diagnosis was 61 ± 16 years and OSSN was more frequent in males (64.1% of cases). Most of the cases (43.6%) had no identifiable risk factors. The mean time of IFN α-2b treatment was 5 ± 2 months, being higher in the intralesional group (6.5 months) than in the topical group (4.2 months). The clinical resolution with the use of IFN α-2b was evidenced between 0.5 and 10 months, being achieved in 87.1% of the patients.

Conclusions: The use of IFN α-2b is effective for the treatment of OSSN with a high success rate (87.1%) and a low incidence of relapse (5 cases), with no reported complications during follow up.

Keywords: Ocular surface squamous neoplasia, Interferon alpha 2b, chemotherapeutic agents, immunotheraeutic agents

Anatomical and Visual Outcome of Rhegmatogenous Retinal Detachment Managed with Scleral Buckling at a Tertiary Eye Centre in Nepal

Roshija Khanal Rijal — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.18832

Objective: To study the anatomical status and visual outcome of scleral buckling surgery in rhegmatogenous retinal detachment (RRD) at tertiary eye care center in Nepal.

Method: This is a prospective, noncomparative, consecutive, interventional study of rhegmatogenous retinal detachment managed with scleral buckling surgery performed in Lumbini Eye Institute, Nepal. All the patients underwent surgery by a single experienced surgeon and had at least 3 months follow up.

Result: A total of 50 patients (50 eyes) were operated, 38 males and 12 females, with a mean age of 39.46. Retinal reattachment was achieved in 46 (92%). Improved best corrected visual acuity (BCVA) was seen in 84%, whereas in 8% BCVA was same and deteriorated in another 8%.

Conclusion: Rhegmatogenous retinal detachment is one of the common causes of visual impairment and blindness. Timely surgical management with scleral buckling surgery can give good anatomical and visual outcome.

Keywords: retinal detachment, scleral buckling, vitrectomy, pneumatic retinopexy

Correlation of Peripapillary Retinal Nerve Fibre Layer Thickness and Visual Evoked Potential in Optic Neuritis in a Tertiary Eye Care Centre

Manita Sunam Godar — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23025

Introduction: Optic neuritis (ON) is the involvement of the optic nerve as a result of inflammation, demyelination or infection.

Objective: To study the correlation between peripapillary retinal nerve fibre layer thickness (pRNFL) and visual evoked potential (VEP) in ON cases.

Materials and Method: A non-interventional, descriptive, cross sectional study enrolling 66 eyes of 49 patients with ON was done. pRNFL thickness was measured by Optical Coherence Tomography (OCT) and VEP was also done. OCT and VEP findings were compared with the control group. In addition correlation between pRNFL thickness and VEP was done.

Results: The mean pRNFL in affected eyes were significantly higher than the control superiorly (p-value<0.001), inferiorly (p-value <0.001), temporally (p-value 0.005) and nasally (p-value <0.001). The mean P100 latency in the affected eyes were significantly prolonged than the control eyes both at 1º (p-value<0.001) and at 15’ (p-value=0.05). The mean N75-P100 amplitude in the affected eyes were significantly reduced than the control eyes both at 1º (p-value<0.001) and at 15’ (p-value<0.001). The mean pRNFL thickness in all four quadrants and VEP findings of the affected eyes showed no significant correlation.

Conclusion: The increased thickness in non-myelinated pRNFL has no correlation with the increased latency or decreased amplitude in cases of ON. However, OCT is seen as a useful tool in detecting and quantifying even subtle pRNFL changes in cases of optic neuritis.

Keywords: optic neuritis, optical coherence tomography, peripapillary retinal nerve fi bre layer, visua evoked potential

Comparative Study of Extra Capsular Cataract Extraction (ECCE) and Small Incision Cataract Surgery (SICS): Experience on Cataract Surgery in a Tertiary Center of Army Hospital, Kathmandu

Sagar Rajkarnikar — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.19185

Introduction: Cataract is a common ailment of the old age hindering daily activities leading to poor quality of life due to poor vision. It is the commonest cause of treatable blindness. In practice, extracapsular cataract excision and small incision cataract surgery are the two-common surgery for cataract these days in developing part like in Nepal. Between these two cataract surgeries, ECCE and SICS; SICS gives the better visual outcome.

Methods: This retrospective cohort study was carried out including 286 eyes which were operated either by conventional extracapsular cataract extraction or small-incision cataract surgery. The patient’s demographics, preoperative vision, postoperative parameters/variables were studied from the patient’s record keeping. The postoperative visual outcome and complications were compared in both groups at the immediate post-operative period and at 8 weeks follow up period.

Result: Among the total 286 cases, 138 underwent ECCE and 148 underwent SICS. 145 (50.6%) were right eye, 141 (49.3%) were left eye. Among total operated cases, 123 (43%) were mature cataract, 97 (33.9%) immature cataract, 66 (23.1%) hyper-mature cataract. In 172 cases (60.1%) there was a good vision, in 104 cases (36.4%) it was borderline while in rest 10 (3.5%) cases it was poor on the 60th postoperative day. There was the better visual outcome (≥6/18) with SICS (78.3%) than ECCE (40.5%) (p<0.001) on the 60th post-operative day. Among cases undergoing SICS the complications were less than ECCE. (p<0.001, OR=5.72 (2.10-15.51)).

Conclusion: This study supports that SICS is safer than ECCE with less complication rate and better visual outcome in short term observation.

Keywords: Cataract extraction, intraocular lenses, visual acuity, Nepal

Endocannabinoid System and Ocular Vascularization

Raluca Iancu — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.20464

The focus of this review is the role of endocannabinoid system in ocular and systemic circulation. By critically examining preclinical and clinical research, we explore the cannabinoid receptors localization and vascular implications as well as their interaction with other anti-inflammatory drugs. The objective is to transfer knowledge on the use of cannabinoids, specifically their effect on ocular circulation and intraocular pressure, and provide a better understanding of the endocannabinoid system complexity in modulating local and systemic circulations in order to identify potential uses and limitations of cannabinoid-based therapeutics.

Keywords: Cannabinoids, endocannabinoid system, ocular vascularisation, vasorelaxation, glaucoma

Chronic Discharging Sinus of Upper Lid Due to the Missed Wooden Foreign Body

Anupam Singh — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23028

Background: Foreign bodies of the orbit can have a diverse range of clinical presentations, which may be perplexing to the most Ophthalmologists. Wooden foreign bodies can remain quiescent for a long time, before presenting with various complications. We report a case of Post-traumatic chronic non-healing discharging sinus in the left upper lid, which on exploration revealed the presence of the missed wooden foreign body.

Case: A 48-year-old male, presented to Ophthalmic OPD with a complaint of discharge from the left upper eyelid for 18 months. The patient had a history of minor trauma to the left upper eyelid while collecting wood in the forest, 18 months back. The patient was misdiagnosed on previous examinations elsewhere. The diagnosis of retained wooden foreign body was made at our center and surgical exploration was done to remove the same.

Observation: On clinical examination, there was a 2-3mm long sinus in the left upper eyelid with purulent discharge and granulation tissue. Surrounding skin showed hyperpigmentation and excoriation. CT scan orbit was inconclusive. MRI orbit revealed a peripherally enhancing extraconal/conal collection in the left orbit with a central hypo intense structure suggestive of a foreign body. Surgical exploration of the wound was done and a small wooden foreign body measuring 9mm was removed with excision of the sinus tract.

Conclusion: A history of trauma followed by chronic discharging sinus should evoke suspicion of a retained foreign body. Prompt imaging, followed by surgical exploration should be done to prevent misdiagnosis and inappropriate management.

Keywords: Chronic discharging sinus, Post traumatic retained foreign body, retained wooden foreign body

‘Double Bubble’ Technique for Successful Reattachment of Total Descemet Membrane Detachment after Deep Anterior Lamellar Keratoplasty

Jeewan S. Titiyal — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23029

Background: A double anterior chamber may be observed after deep anterior lamellar keratoplasty (DALK) and the management may be difficult especially in cases with a total descemet membrane detachment (DMD).

Case Observations: We describe a novel “reverse double bubble” surgical technique for safe and effective reattachment of total DMD following DALK. Total DMD with air bubble in the interface was noted on the first postoperative day following DALK for healed keratitis. Intracameral air was injected via a 30-gauge needle inserted through a partial thickness MVR entry made at the posterior limbus, without disturbing the interface air-bubble. During this maneuver, the interface bubble did not change in size and moved towards the centre. The two distinct air bubbles, one in interface and other in anterior chamber indicated that air injection was in the anterior chamber, as per the reverse double bubble technique. The interface air bubble was removed by gently milking with an iris repositor towards the end of surgery. Thus, successful reattachment of DM was achieved despite difficult assessment of the plane of injection with the DM lying fl at on the surface of the iris.

Conclusion: The reverse double bubble technique aids in the safe and successful reattachment of total DMD following intraocular surgeries.

Keywords: Descemet membrane detachment, deep anterior lamellar keratoplasty, double anterior chamber

Anterior Segment Optical Coherence Tomography Signs of Local Dilatation Effect of a Micro-Stent on Schlemm’s Canal

Kevin Gillmann — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23030

Introduction: The iStent inject® (Glaukos Corporation, CA, USA) is a relatively new device designed to be implanted ab-interno through the trabecular meshwork. This is, to the best of our knowledge, the first in-vivo description of a trabecular bypass device visualised with anterior segment optical coherence tomography (AS-OCT), and report of its structural effect on Schlemm’s canal.

Case Report: A 74 year-old female patient suffering from long-standing primary open-angle glaucoma and nuclear sclerosis underwent cataract surgery combined with the implantation of two iStent injects®. Surgery was uncomplicated and achieved intraocular pressure (-1 mmHg) and medication (-2 molecules) reduction at 6 months. Under AS-OCT (Spectralis OCT, Heidelberg Engineering AG, Germany) the stent appears as a 300 μm long hyper reflective hollow device within the trabecular meshwork. Approximately a third of it protruded into the anterior chamber. Profound OCT signal loss was notable within the shadow of the device. A second AS-OCT section 500 μm beside the microstent shows a markedly dilated Schlemm’s canal, with a major diameter of 390 μm.

Discussions: This report confirms that AS-OCT is a suitable technique to assess microstent positioning, and provides a first report on the in-vivo appearance of a functioning stent. It also indicates that iStent injects® could have a tangible effect on adjacent portions of Schlemm’s canal with, in this case, a 220% increase in canal diameter compared to the observed average (122 μm). This suggests the IOP-lowering effect of trabecular bypass devices could rely on a dual mechanism involving Schlemm’s canal dilatation.

Keywords: Schlemm’s Canal, Micro-Stent

A Case of Descemet’s Membrane Endothelial Keratoplasty in a failed Penetrating Keratoplasty

Sanjay Kumar Singh — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23031

Background: Descemet’s membrane endothelial keratoplasty (DMEK) is an evolving option for failed penetrating keratoplasty (PK) as it has shown promising results compared to repeat PK.

Case description: A 22 years young gentleman presented with gradual diminution of vision in the left eye (LE) for six months following therapeutic PK for a perforated fungal corneal ulcer. His best spectacle corrected visual acuity (BSCVA) was 6/60 in LE. Slit-lamp examination of LE revealed circumcorneal congestion with full thickness corneal graft with micro and macrobullae, diffuse stromal edema, DM folds and seven well-buried sutures. Intraocular pressure was 20 mmHg in the right eye whereas it could not be assessed in the left eye. The diagnosis of LE failed PK was made and the patient underwent DMEK. At four months postoperative follow up visit, BSCVA improved to 6/9. This is the first reported case of DMEK after a failed PK in a young patient from Nepal which was successfully treated without any complications.

Conclusion: DMEK has a higher potential for better visual rehabilitation compared to DSEK and PK. It has also proved its efficacy in the treatment of endothelial graft failure following PK as it is a less invasive procedure.

Keywords: Descemet membrane endothelial keratoplasty, Penetrating keratoplasty

Cerebral Artery Aneurysm Masquerading as Ptosis in a Child

Sanket Parajuli — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.19951

An 8-year-old female presented to Eye OPD of Dhulikhel Hospital, Kathmandu University Hospital, with drooping of the right upper lid and inability to move right eye ball since 3 days. She had no history of trauma or fall injury. On ocular examination, visual acuity was 6/6 on both eyes and there was severe ptosis on the right eye in which eyeball remained abducted with restriction of ocular motility on all gazes. The pupil was dilated and 6mm on the right eye in room light. Posterior segment examination was normal. MRI angiography was done which revealed a right Posterior cerebral artery aneurysm.

Keywords: Ptosis, PCA aneurysm

Traumatic Luxation of the Eye Ball with Optic Nerve Transection Following Road Traffic Accident: Report of Two Cases and Brief Review of Literature

Narayani Roka — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.20031

Background: Traumatic luxation of the eye ball is rare with only 106 cases reported in PubMed till date. The anatomic location of the eyeball within the socket and the resilience of the globe to pressure force, attachment to extraocular muscles and optic nerve prevents luxation during trauma.

Case: Road traffic accidents (RTA) is the most common cause for these injuries and the outcome can vary from complete recovery on repositioning to visual loss due to globe perforation or optic nerve injury. We report two unique cases of traumatic right globe luxation and complete optic nerve transection due to RTA and give a brief review of literature.

Conclusion: RTA leading to eye ball luxation though rare can be a challenging situation when encountered. Given the limited time for the salvage of the eye early intervention is not always possible especially in developing countries where there is delay in reaching the hospital. Despite all these confounding factors attempt must be made to salvage the eye either for functional, cosmetic or psychological reasons.

Keywords: globe luxation, optic nerve avulsion, road traffic accidents, trauma

Surgical Management of Live Intraocular Parasite in the Anterior Chamber

Anadi Khatri — 2019-05-27

DOI: https://doi.org/10.3126/nepjoph.v10i2.23036

Not available.

Keywords: Surgical Management, Intraocular Parasite