Ananda Kumar Sharma

Methanol Poisoning: Ocular and Neurological Manifestations

Purpose. The purpose of this study was to examine the effectiveness of ethanol and high-dose intravenous steroid for preserving vision in acute methanol poisoning. Methods. Eight cases of acute methanol poisoning presented to the emergency department. Detailed physical examination including neurological assessment was performed. Detailed ocular examinations were performed including visually evoked potential and electroretinography in indicated cases. All patients had visual symptoms. Pupillary abnormality was observed in all. Edema of the optic disc and nerve fiber layer were common fundus findings. The majority of cases were treated with methylprednisolone intravenously. Ethanol was given intravenously in four cases who presented within 48 h. Hemodialysis was performed in two cases having neurological manifestations and metabolic acidosis. Sodium bicarbonate was given to four patients. Folinic acid and multivitamins were also given to all the patients based on neurological advice. Results. Most of the patients showed a good response to the treatment. In 87.5% of the cases, improvements in visual acuity of at least two lines were noted in follow-up visits. Conclusions. Early presentation with prompt treatment has a significant role in preserving and improving visual acuity. Ethanol and high-dose intravenous methylprednisolone can be an alternative treatment with better visual outcome where fomepizole is unavailable.

Ptosis: a rare presentation of ocular cysticercosis.

BACKGROUND Cysticercosis is a common parasitic infection involving multiple systems and caused by Cysticercus cellulosae, the larval form of the cestode, Taenia solium. The humans become infected by ingesting its eggs from contaminated food. Here, we present a case of ocular cysticercosis which presented with mild pain, ptosis, inflammation of upper eyelid and slightly restricted ocular motility. CASE A twelve-year-old girl presented with mild pain, unilateral ptosis and inflammation of the right upper eyelid for seven months. There was no history of diurnal variation and trauma. There was neither protrusion of the eyeball nor any mass was palpable in periorbital area. Visual acuity in both the eyes was normal. Periocular and ocular examination revealed a slightly restricted ocular motility in the right upward gaze and a reduced vertical fissure height a with good levator palpebrae function. The Bells phenomenon was good. The magnetic resonance imaging of the orbit showed an intra-conal retro-orbital mass involving the superior rectus muscle of the right eye suggestive of ocular cysticercosis. The orbital sonogram revealed a cystic lesion in the superior rectus muscle with an echogenic intramural nodule. The enzyme-linked immunosorbent assay for serum antibodies against the cysticercus was positive. The ptosis improved with a therapeutic trial of albendazole and oral steroids for 6 weeks. CONCLUSION Extra-ocular cysticercosis can be treated with oral steroid and albendazole.

Nd: Yag laser treatment for sub-hyaloid hemorrhage in childhood acute leukemia

INTRODUCTION Sub-hyaloid haemorrhage is common in acute leukemia. OBJECTIVE To investigate the effects of Nd: YAG Laser hyaloidotomy in 11 eyes of 8 patients with pre-macular haemorrhage in acute childhood leukemia. MATERIALS AND METHODS Premacular sub-hyaloid haemorrhage is one of the leading causes of visual disability in children with acute leukemia. Eleven eyes of 8 patients attending Kanti Children Hospital and BP Koirala Lions Centre for Ophthalmic Studies from January 2006 to July 2007 with premacular subhyaloid haemorrhage were included in the study and treated with Nd: YAG Laser. The haemorrhage originated from acute myeloid leukemia (AML) in 4 cases (6 eyes) and acute lymphoblastic leukemia (ALL) in 4 cases (5 eyes). RESULTS Drainage of premacular sub-hyaloid haemorrhage into the vitreous cavity within 3 months succeeded in 9 eyes out of 11 eyes treated. One eye had a dense clotted haemorrhage and the other had a re-bleed. Overall visual improvement was equal in both AML and ALL cases. No obvious epiretinal membrane, retinal breaks and tractional retinal detachment occurred in any eye. CONCLUSION Nd: Yag laser hyaloidotomy is a relatively safe, simple and alternative treatment for eyes with a dense premacular sub-hyaloid haemorrhage in acute childhood leukemia. The risks and benefits have to be weighed in randomized clinical trials to establish Nd: YAG hyaloidotomy treatment as a routine procedure in leukemic children.

Retinal nerve fibre layer thickness in a healthy Nepalese population by spectral domain optical coherence tomography

OBJECTIVE To determine the normal values for peripapillary retinal nerve fibre layer thickness (RNFL) measured by spectral domain optical coherence tomography (SD- OCT) in a healthy Nepalese population and to compare the RNFL thicknesses between the genders and among the various age groups. MATERIAL AND METHODS One hundred and fifty six eyes of 156 healthy Nepalese subjects (66 males and 88 females) of various age groups were enrolled in this observational, cross-sectional, hospital-based study. The peripapillary RNFL of the randomly chosen eye of each subject was imaged with a high resolution SD-OCT (Spectralis HRA+OCT, Heidelberg Engineering). The RNFL thickness was measured around the optic nerve head using 16 automatically averaged, consecutive, circular B scans with a 3.4 mm diameter and compared between the genders and among the various age groups. RESULTS The mean age of the subjects was 38.94±17.00 years (range-14 to 76 years). The average peripapillary RNFL was found to be 102.64±9.56 μm (95% CI 97.01-101.93). The mean±SD peripapillary RNFL measurements at the superior, nasal, inferior and temporal sectors in the study population were 129.51±15.09 μm, 76.55±12.02 μm, 134.53±17.19 μm and 70.74±15.53 μm respectively. The average RNFL thickness was 99.47±10.18 μm in the male whereas it was 105.09±8.31 μm in the female participants. The RNFL decreased by 2.26 μm per age per decade. CONCLUSION The Average RNFL thickness is 102.64±9.56 μm in the Nepalese population. Gender and age related variation in the RNFL could serve as a useful guideline in the diagnosis of glaucoma in our population.

Ocular injuries in the people’s uprising of April 2006 in Kathmandu, Nepal

INTRODUCTION In April 2006, the people of Nepal organised mass demonstrations demanding the restoration of democracy in the country. The ocular injuries that resulted during the riots that ensued, their pattern and the visual outcome of the injured have not yet been reported. OBJECTIVE To study the demographic profile, type, severity and the visual outcome of ocular injuries that occurred during the 2006 peoples uprising in Nepal. SUBJECTS AND METHODS This was a retrospective interventional series of cases involving 29 subjects. The main outcome measures were demography, laterality of injury, type of injury and the visual status before and after the trauma. RESULTS The age of the victims ranged from 14 to 32 years. Among the victims with eye injuries, 27 (93.1 %) were males, who were unemployed youth, students and construction workers. The left eye was injured more frequently than the right. Non-lethal bullets and explosive tear gas were the commonest agents of the major ocular injuries. The main types of injuries requiring hospitalization were closed globe injuries in eight victims and open globe in six. Surgical intervention was required in 57.2 % (n = 29) of the cases. The visual outcome was poor in cases of open globe injury with posterior segment involvement. CONCLUSION Non-lethal bullets and explosive tear gases can cause significant visual impairment. Severe open globe injury with a retained intra-ocular foreign body is associated with significant visual loss.

Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal

Background: This study was conducted to determine clinical profile and etiological factors for phlyctenular keratoconjunctivitis (PKC) in our patients. Materials and Methods: In the descriptive study, 50 pediatric cases of PKC were enrolled into the study from outpatient department of BP Koirala Lions Center for Ophthalmic Studies between August 2011 and August 2012. The age, sex, exposure to tuberculosis, ocular symptoms, and systemic complaints were recorded. Morphological description of PKC such as number, type, location and scars HISTORY and number of recurrence was also noted. The conjunctival swab was taken from all patients and sent for microbiological examination. Report of systemic involvement, worm infestation was also noted. Mantoux testing for possibility of tuberculosis was also performed. Results: PKC was detected in 59 eyes of 50 children having mean age of 8.0 ± 6.2 years including 54% males, unilateral involvement in 82%, the limbal involvement in 52% and multiple PKC in 34% children. Associated ocular disorder was blepharitis in 12 (24%) children. Conjunctival swab and culture revealed Staphylococcus infection in 10 (20%) children. Of eight recurrent cases, two had urinary tract infection managed with systemic antibiotics, three had parasitic infestation treated with antihelmentics, one had mantoux positive without having evidence of tuberculosis and two cases had blepharitis as a local factor. Conclusions: PKC is mostly presented as unilateral disorder of conjunctiva. PKC is associated with blepharitis, Staphylococcus infection, worm infestation and systemic infection.

Demographic pattern and clinical characteristics of optic neuritis in a tertiary eye care centre

PURPOSE To study the demographic pattern and clinical characteristics of optic neuritis cases in a tertiary eye care centre in Nepal. DESIGN Descriptive, cross-sectional study. METHODOLOGY Complete ocular examination was done in all the newly diagnosed cases of optic neuritis presenting from January 1st 2012 to June 30th 2013. Demographic pattern, clinical features, visual acuity, colour vision, contrast sensitivity and visual field defects were studied. RESULTS Sixty seven eyes of 50 patients (28 females and 22 males) with optic neuritis were included in the study. The mean age was 34.32 years ± 13.72 years. The male: female ratio was 1:1.27. All the cases presented with complaint of blurring of vision. Painful ocular movement was noted in 58%. On ophthalmoscopic examination around 2/3rd of eyes suffered from papillitis (72%) and 1/3rd from retrobulbar optic neuritis (27%). Only one case of neuroretinitis (1%) was seen in the study. The colour vision pattern was variable. Contrast sensitivity was reduced in 94%. Centrocaecal scotoma was seen in 10.5%. CONCLUSION Females were predominantly affected. Unilateral involvement was the most common presenting as papillitis.

Direct microscopy in suppurative keratitis: a report from tertiary level hospital in Nepal

INTRODUCTION Infective keratitis is an ocular emergency that requires prompt diagnosis for appropriate management. This study was done todetermine the sensitivity, specificity and predictive values of Gram stain and potassium hydroxide (KOH) wet mount in the diagnosis of suppurative keratitis. MATERIALS AND METHODS A prospective hospital based study of all patients with clinically diagnosed suppurative keratitis presenting between January 2011 and June 2012 was carried out. Corneal scrapes were taken and subjected to direct microscopy and culture. RESULTS Corneal scrapings were obtained from 108 eyes with suppurative keratitis. Direct microscopy was positive in 39.2% of cases and organisms were grown in 50.9 % of the cases. Bacteria were responsible in 76.4% and fungi in 23.6%. Of the bacterial isolates, 66.7% was Staphylococcus aureus and of the fungal isolates, 30.7% was Aspergillus species. Sensitivity in vitro showed that Cefazolin, Chloramphenicol and Ofloxacin were most effective against bacteria. Sensitivity of Gram stain in detecting bacteria was 50% (95% CI, 34.43 to 65.56) and specificity was 77.3% (95% CI, 65.0 to86.3) and sensitivity of KOH wet mount in detecting fungi was 53.8% (95% CI, 26.12 to79.6) and specificity was 98.9% (95% CI, 93.44 to 99.9). Positivity of direct smear (65.1%) was found to be higher among eyes with larger ulcers (>2mm) than eyes with smaller ulcers ( less than 2mm). CONCLUSION Direct microscopy is of great diagnostic value in the management of suppurative keratitis and it is recommended in all ophthalmic clinics without exception for establishing timely, appropriate and effective treatment.

Diabetic retinopathy with or without clinically significant macular edema: The influencing factors

INTRODUCTION Diabetic retinopathy is the commonest micro vascular complication in patients with diabetes and remains a leading cause of blindness in people of working age group. OBJECTIVE to determine the prevalence of clinically significant macular edema (CSME) and the influence of systemic risk factors Materials and methods: It is a hospital based comparative study conducted in 220 eyes of 110 diabetic patients. DR was graded according to International Clinical Diabetic Retinopathy Severity Scale and CSME was defined according to Early Treatment Diabetic Retinopathy Study (ETDRS) system. The patients were grouped as 1) CSME group (DR and CSME in one or both eyes) and 2) Non- CSME group(CSME in none of the eyes but with any grade of DR).Level of glycosylated hemoglobin (HbA1C), serum total cholesterol, triglyceride (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) and urine for albumin were studied in both groups. RESULTS CSME was present in 36% of 110 patients. Poor glycemic control and high total cholesterol level showed positive association with CSME (p LESS THAN 0.05). LDL and TG levels were higher and HDL lower in CSME group. However, no statistical significance was found. CONCLUSION The CSME is significantly associated with poorer glycemic control and elevated total cholesterol level.

Outcome of the patients with post-operative cluster endophthalmitis referred to a tertiary level eye care center in Nepal

INTRODUCTION The causative organism and treatment outcomes of post operative endophthalmitis may vary depending on several factors. OBJECTIVE To find out the causative organisms and visual outcome after an outbreak of post-operative endophthalmitis. MATERIALS AND METHODS An interventional prospective series of cases of clinically suspected endophthalmitis was studied. Eleven patients who presented within 48 hours after manual cataract surgery on the same day, by a one surgeon in a single center were enrolled in the study. They underwent both anterior chamber and vitreous aspiration and all of them received intravitreal Vancomycin, Amikacin and Dexamethasone. Samples were subjected to microbiological evaluation. All patients were followed up till 8 weeks for clinical and visual outcome. RESULTS Of the 11 eyes of suspected endopthalmitis, only one vitreous aspiration showed Gram negative bacilli on Gram stain and 3 vitreous aspirates showed Gram positive cocci. Of the 11 eyes, 3(42.85%) had culture positive on vitreous aspirate. In 2 cases E Coli was isolated and in 1 Staphylococcus aureus was isolated. After 48 hours of intravitreal injection, 10 out of 11 eyes improved and in one, intravitreal injection of vancomycin, amikacin and dexamethasone was repeated. The best corrected visual acuity of 6/9 was achieved in 2 patients, 5 had 6/18, 2 had 6/60 and 2 had 5/60 at the end of eight weeks. CONCLUSION Staphylococcus aureus and E coli can cause endophthalmitis immediately on the first day post-operatively. Clinically suspected endophthalmitis treated with antibiotics and steroid intravitreal injection can result in better visual outcome.