Indications for keratoplasty in Nepal: 2005 - 2010

Introduction: Corneal disease, especially infective keratitis, is one of the major causes of visual impairment and blindness in developing countries. Objective: To find out the current indications for keratoplasty, how these indications have changed over time as well as how they are different from those in other parts of the world. Materials and methods: A retrospective study of a case series of 645 keratoplasty surgeries (589 patients) was conducted at the Tilganga Institute of Ophthalmology from January 2005 to December 2010. Outcome measures: The cases were evaluated in terms of demographic parameters, preoperative diagnosis and the type of surgery performed. Results: The most common indication for surgery was active infectious keratitis (264 eyes, 40.9 %), followed by corneal opacity (173 eyes, 26.8 %), regraft (73 eyes, 11.2 %), bullous keratopathy (58 eyes, 9.0 %), keratoconus (45 eyes, 7.0 %) and corneal dystrophy (11 eyes, 1.7 %). The mean recipient age was 41.7 ± 19.9 years with over a half of the patients between 15 to 49 years of age. More men (64.1 %) underwent keratoplasty than women (35.8 %). 59.8 % of the eyes with infectious keratitis had a perforated corneal ulcer. 49.7 % of corneal opacities were due to previous infectious keratitis. 72 % of regrafts were for endothelial failure of various causes. In older patients (> 50 years), bullous keratopathy was an important indication, after infectious keratitis. Keratoconus and corneal scar were major causes of keratoplasty in children of 14 years or less. Four percent of the patients had keratoplasty in both the eyes. 17.1 % of the patients who had one eye operated on had a blind fellow eye with a vision of less than 3/60. Conclusion: Currently, keratitis, either active or healed, is the major indication for keratoplasty, suggesting that improved primary eye health care is necessary to decrease the prevalence of corneal blindness. Nepal J Ophthalmol 2013; 5(10): 207-214 DOI: http://dx.doi.org/10.3126/nepjoph.v5i2.8730

Vitreo-retinal disorders at high altitude in Nepal

INTRODUCTION

Nepal has many mountains including the highest one in the world. People living in high altitude are often involved in climbing mountains.

OBJECTIVE

To explore the pattern of vitreo-retinal disorders at high altitude in Nepal.

MATERIALS AND METHODS

Consecutive patients aged 40 years and older who presented at the micro-surgical eye camp at Lukla of Solukhumbu district (2,860 metres) were included. Detailed ocular and systemic histories and ocular examination including dilated fundus evaluation were done.

RESULTS

There were a total 81 patients with the mean age of 56.7 years (S.D 11.15). Females (51.9 %) outnumbered males. Sherpa comprised of 76.5 % followed by Rai (9.8 %). The main occupation was agriculture (51.9 %) followed by mountain trekking (28.4 %). Smokers comprised of 13.5 %. Hypertension was the predominant systemic problem (28 %). The best corrected visual acuity of 6/18 and better was found in 86.4 % of cases and less than 3/ 60 in 3.6 % of cases. Age-related macular degeneration (AMD) was found in 19.6 % of cases with a predominant mild AMD (16 %), hypertensive retinopathy in 12.2 %, with grade I hypertensive change in 8.6 %, retinal vein occlusion (RVO) in 7.1 % of cases and with a branch RVO in 4.9 %. Dilated and tortuous retinal vessels were present in 25.9 % of cases; out of this, 9.8 % of the cases had concurrent AMD and/or hypertensive retinopathy. Other retinal problems were macular hole (2.46 %), solar retinopathy (2.46 %) and choroidal tear (1.2 %).

CONCLUSION

AMD, hypertensive retinopathy, and RVO are the main vitreo-retinal disorders besides the dilated and tortuous retinal vessels in people living at high altitude in Nepal.

Optimal single intraocular lens power for the Nepali population

AIM

To evaluate optimal standard intraocular lens power for Nepalese eye camp cataract patients.

METHOD

A retrospective case series of 5109 preoperative cataract patients.

RESULTS

Average axial length of 23.08 (SD 1.26). Average dioptre intraocular lens power 21.37 (3.04).

CONCLUSION

An increase in the intraocular lens power used at Nepalese eye camps from +21.0 to 22.5 dioptres would improve overall visual outcome.

Ketamine anaesthesia for paediatric ophthalmology surgery

AIMS

Children with treatable, vision impairing conditions may not have access to surgical care when they live in regions where anaesthesia is unavailable. The use of ketamine anaesthesia in a developing region was studied to determine its safety and effectiveness.

METHODS

This is a consecutive series of 679 children who had a variety of paediatric eye disorders necessitating a short general anaesthesia. Ketamine was administered intravenously by a paediatrician with training in paediatric resuscitation procedures. Both intraocular and extraocular procedures were performed. The location of treatment was the Tilganga Eye Hospital in Kathmandu, Nepal, a developing region of the world. The study took place over a 5 year period.

RESULTS

All procedures were performed without any anaesthetic complications. No child required unanticipated resuscitation or laryngeal intubation. Postoperative dysphoria occurred occasionally and was difficult to measure quantitatively. This side effect of ketamine resolved by the first postoperative day.

CONCLUSION

Ketamine is an effective agent for both intraocular and extraocular surgery in the paediatric age group. None of the children in this series needed resuscitation or intubations, and the ophthalmic surgery was carried out safely. Ketamine can be used safely in any ophthalmic procedure of short duration by a person having some training in anaesthetic resuscitation procedures. Because of its simplicity and safety, ketamine may be useful in a simple ophthalmic setup in the developing word.

Atypical presentation of Acanthamoeba keratitis

PURPOSE

To present two cases of minimal pain Acanthamoeba keratitis to alert clinicians to remember Acanthamoeba when evaluating atypical cases of keratitis.

METHODS

The histories of two cases were reviewed with attention to clinical presentation subjective complaints, treatment, and long-term outcome.

RESULTS

In case 1, a 24-year-old man presented with decreased vision and an irritated feeling in his eye. He did not wear contact lenses. His initial diagnosis was adenoviral conjunctivitis. One month later, he was diagnosed with atypical herpes simplex keratitis and started on acyclovir. Two weeks later, he was referred to the Cornea Service. Further history revealed the patient to be a professional triathlete who trained by swimming in a fresh water pond. He was found to have an unusually high pain tolerance. Biopsy revealed Acanthamoeba. He was admitted for intensive therapy with neomycin, propamidine isethionate, and polyhexamethylene biguanide. Two years after diagnosis, he has best-corrected visual acuity of 20/100. In case 2, a 28-year-old man with known herpes simplex keratitis presented with decreased vision. He was started on topical trifluridine. After 6 weeks without improvement, he was referred for corneal evaluation. His eye always remained comfortable. Corneal sensation was markedly decreased. Further history revealed that he swam in fresh water. Biopsy was positive for Acanthamoeba. After 1 year of therapy with polyhexamethylene biguanide and neomycin, visual acuity was 20/200, and the patient underwent a corneal transplant.

CONCLUSION

Acanthamoeba keratitis must be considered in the differential diagnosis of keratitis, even without the classic presentation of severe pain and predisposing corneal trauma, including contact lens wear.

An innovation in developing world cataract surgery: sutureless extracapsular cataract extraction with intraocular lens implantation

PURPOSE

The benefits of sutureless cataract surgery have not been available to the majority of developing world patients. This report describes a surgical technique developed to gain the benefits of self-sealing sutureless techniques, without the need for costly, complex instrumentation, expensive consumables, or difficult nucleus fragmentation manoeuvres in the anterior chamber.

METHOD

A detailed description of a sutureless technique that uses only standard manual extracapsular cataract extraction instrumentation is presented. The clinical records of 362 consecutive completed sutureless surgeries were reviewed, and preliminary indicative data of visual outcome for those having follow up between postoperative weeks 3 and 8 are also presented.

RESULTS

Hospital and eye camp experience confirms this operation offers speed, routinely 5 min or less with mature cataracts, reduced cost because no suture, viscoelastic or anterior chamber maintainer is needed, wound security and stability, and rapid effective visual rehabilitation. Uncorrected distance visual acuity during the third to eighth postoperative week was available for 266 of the 362 patients (73%): 10, 145, 101, and 10 had acuities of better than 6/9, 6/9-6/18, 6/24-6/60, and worse than 6/60, respectively. Ninety-seven, 165, 12, and two of the 276 (76%) patients with recorded corrected distance acuity were in the same groups. Comparing postoperative with preoperative corneal astigmatism for each patient with postoperative information available (208), without regard to axis, the amplitude of astigmatism worsened by a mean of 0.94 dioptres (+/- 0.17, 95% confidence; +/- 1.23 standard deviation; 7.5D maximum worsening; 2.5D maximum improvement). No attempt has been made to analyse complication type or frequency in this preliminary report.

CONCLUSION

The authors believe this sutureless cataract extraction technique to be an innovation with widespread application in the developing world. Further and more exhaustive critical appraisal is warranted.

Late recurrences and the necessity for long-term follow-up in corneal and conjunctival intraepithelial neoplasia

PURPOSE

The purpose of the study was to elucidate the natural history of corneal-conjunctival intraepithelial neoplasia (CIN) and suggest treatment and follow-up guidelines.

METHODS

The records of all histologically proven cases of CIN at the Royal Victorian Eye and Ear Hospital between 1979 and 1994 were reviewed.

RESULTS

Seventy-nine eyes of 76 patients had a pathologic diagnosis of CIN and were observed for up to 15 years. The lesion recurred in 31 eyes (39%) overall. There was no statistical difference shown in the likelihood of recurrence based on histologic classification. Complete excision was attempted in each case. In 18 eyes, dysplastic cells were evident at the excision margin. Ten (56%) of these tumors recurred, compared to a 33% recurrence rate in completely excised lesions. The time to the first recurrence ranged from 33.0 days to 11.5 years between the first and second surgeries, with 11 lesions recurring after more than 4 years. Incompletely excised lesions reappeared more rapidly (average, 2.5 years) than did those with clear surgical margins (average, 3.8 years). Seven cases progressed to invasive squamous cell carcinoma and four cases led to blindness or removal of the eye.

CONCLUSIONS

This study suggests that excision margin at the time of surgery is the most important factor in predicting recurrence. The slow growth of the recurrent lesions combined with the ever-present malignant potential leads the authors to suggest that all patients with a history of CIN warrant annual follow-up for the remainder of their lives.

Keratoprosthesis, Dohlman Type I device for a patient with repeated corneal graft failure

Background: Keratoprosthesis (Kpro) surgery is performed in patients in whom traditional penetrating keratoplasty (PK) surgery has no hope for graft survival. The burden of corneal blindness is high in a developing country like Nepal. Case: A thirty-year-old man, with multiple graft failure in his only eye, underwent Kpro surgery. He had ambulatory vision and a stable Kpro 29 months after the surgery. Conclusion: Kpro surgery has been introduced in the country with this as the first case. Patients with poor prognosis for PK can benefit from this type of surgery. DOI: http://dx.doi.org/10.3126/nepjoph.v4i1.5869 NEPJOPH 2012; 4(1): 165-169