Govinda Paudyal

Low-cost high-volume Extracapsular cataract extraction with posterior chamber intraocular lens implantation in Nepal

OBJECTIVEnTo improve current clinical practices and ways of thinking about the problem of curable Third-World blindness resulting from cataract.nnnDESIGNnA two-site prospective, nonrandomized, comparative clinical trial.nnnPARTICIPANTSnPatients from 2 distinct surgical venues underwent cataract surgery following the same carefully outlined protocol: 62 consecutive cases from the Tilganga Eye Centre in Katmandu, Nepal, and 207 cases from a remote eye camp in rural Chaughada, Nepal.nnnINTERVENTIONnExtracapsular cataract extraction with posterior chamber intraocular lens (IOL) implantation surgery using a technique developed by Dr. Sanduk Ruit of the Tilganga Eye Centre in conjunction with the Medical Directorate of the Fred Hollows Foundation of Australia. Also presented is the teaching method used to help make local doctors proficient in this technique.nnnMAIN OUTCOME MEASURESnVisual acuity recorded at 2 months after surgery as well as surgical complications.nnnRESULTSnPreoperative visual acuities for the 62 patients from the Tilganga Eye Centre ranged from 20/60 to light perception only (4 patients were untested). At 2 months after surgery, 87.1% had a best-corrected visual acuity of 20/60 or better. There were zero major surgical complications reported from the Tilganga group. Of the 207 patients at the Chaughada eye camp, preoperative visual acuities (recorded for 177 [85.5%]) ranged from 20/200 or greater to light perception only. One hundred eighty-nine (91.3%) of the patients returned for an examination at 2 months after surgery, at which time 54.5% had an uncorrected visual acuity of 20/60 or greater, improving to 74.1% with correction. There were six (2.9%) surgical complications documented at Chaughada.nnnCONCLUSIONSnBecause the average operative time using the technique presented here is less than 10 minutes per case and the cost per surgery is less than

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

20, the surgical results are significant in addressing the massive problem of cataract blindness in the Third World. With some changes in preoperative care, a simplified surgical technique, the development of local lens factories, and the implementation of teaching programs, effective lens implantation cataract surgery can be done in high volume at affordable costs in remote areas of underserved nations.

Penetrating keratoplasty in Nepal

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.

Intravitreal bevacizumab in macular edema secondary to branch retinal vein occlusion: 12-month results

Purpose: To identify indications and outcomes in a large series of penetrating keratoplasty surgeries performed in Nepal. Methods: A retrospective case series of 472 consecutive penetrating keratoplasty surgeries (408 patients) performed at Tilganga Eye Center, Kathmandu, Nepal from June 1994 to September 1999. Results: Mean recipient age was 39.2 years (± 19.7 years). Main indications for PKP were corneal scar (37%), adherent leukoma (35%), perforation or impending perforation (9%), pseudophakic bullous keratopathy (6%), keratoconus (4%), and aphakic bullous keratopathy (3%). Mean duration of follow-up was 27.6 ± 25.1 months. Sixty-five percent of available grafts were clear at 6 months, and 70% of available grafts were clear at 3 years. Six months postoperatively, 15% of patients had acuity better than 6/18, 37% had acuity between 6/18 and 6/60, and 17.7% had acuity between 6/60 and 3/60. Common causes of graft failure were endothelial failure (43%), increased intraocular pressure (15%), ulcer (14%), and trauma (7%). Conclusions: The corneal diseases and indications for transplant surgery in Nepal are different from those in the Western world. Despite these differences, penetrating keratoplasty is a successful and reasonable way to reduce corneal blindness in developing nations.

Prevalence of and risk factors for age-related macular degeneration in Nepal: the Bhaktapur Retina Study

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Prevalence and risk factors of diabetic retinopathy among an elderly population with diabetes in Nepal: the Bhaktapur Retina Study

Aim This study aimed to explore the prevalence of and risk factors for age-related macular degeneration (AMD) in an elderly population in Nepal. Subjects and methods This is a population-based, cross-sectional study. A sample size of 2,100 was calculated. A total of 1,860 (88.6%) subjects aged >60 years were enrolled for the study from 30 clusters in the district. Detailed history, visual acuity, and anterior segment and posterior segment examinations were performed. AMD was graded according to the International ARM Epidemiological Study Group. Results Among the total study population, 659 subjects had any AMD (35.43%; 95% confidence interval [CI]: 33.25–37.65), 484 had mild dry AMD (26.02%; 95% CI: 24.04–28.08), 143 had intermediate dry AMD (7.69%; 95% CI: 6.52–8.99), 19 had geographic atrophy (1.02%; 95% CI: 0.61–1.59), and 13 had wet AMD (0.70%; 95% CI: 0.37–1.19). The overall prevalence of early and late AMD was 33.71% and 1.72%, respectively. Among subjects with dry and wet AMD, 36.53% and 46.1% had visual impairment, while 2.78% and 23.08% were blind, respectively. In multivariate analysis, AMD was significantly higher in subjects with an increased number of cigarettes smoked per day (odds ratio [OR] 1.02, 95% CI: 1.01–1.04; P=0.007) and in subjects with pseudophakia (OR 1.45, 95% CI: 1.12–1.87; P=0.005). Conclusion One-third of the population aged ≥60 years have some form of AMD. There was a significant association with the number of cigarettes consumed and with previous cataract surgery.

Anatomical and visual outcome of intravitreal bevacizumab (Avastin) in patients with diabetic macular edema

Aim Diabetic retinopathy (DR) is an emerging cause of blindness in developing countries. This study aimed to explore the prevalence and risk factors of DR in an elderly population in Nepal. Subjects and methods This is a population-based, cross-sectional study. A total of 1860 subjects at the age 60 years and above participated (response rate 88.6%). A detailed history was obtained, presenting and best-corrected visual acuity were measured, and anterior segment and posterior segment examinations were carried out. Blood pressure and random blood sugar were recorded; body mass index was calculated, and abdominal girth was measured. DR was graded by clinical examination using Early Treatment Diabetic Retinopathy Study criteria. Results Diabetes was found in 168 (9%) subjects (mean age 69.6 years), 31 (18.5%) of whom were newly diagnosed. The prevalence of DR was 23.8% (95% confidence interval [CI]: 17.7%–31%) among the persons with diabetes. The prevalence of DR among newly diagnosed subjects with diabetes was 6.5% (95% CI: 0.8%–21.4%). The prevalence of vision-threatening DR was 9.5% (95% CI: 5.5%–15%) and was higher in males. The prevalence of DR was 83.3% (95% CI: 35.9%–99.6%) among those with diabetes for over 20 years. In multivariable logistic regression analysis, duration of diabetes, hypertension, and alcohol consumption were significantly associated with DR. Conclusion DR is a common problem among the elderly population with diabetes in Nepal. The duration of diabetes, hypertension, and alcohol consumption are the risk factors for the development of DR. Strategies have to be developed for timely diagnosis of diabetes and screening for DR.

A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal.

BACKGROUNDnIntravitreal bevacizumab has been shown to be an effective treatment of diabetic macular edema.nnnOBJECTIVEnTo assess the anatomical and visual outcome of intravitrealbevacizumab (Avastin) in patients of diabetic macular edema.nnnMATERIALS AND METHODSn52 eyes of 33 patients with diabetic retinopathy with CSME were included in this study. Detailed ophthalmic examination, including best-corrected visual acuity(BCVA), stereoscopic biomicroscopy, and retinal thickness measurement by Optical coherence tomography (OCT), was done at baseline and at each follow- up visit. All patients were treated with 0.05 mL intravitreal injection containing 1.25 mg of bevacizumab and repeat injection was given in cases of recurrent/persistent subretinal or intraretinal fluid shown by OCT and deterioration of BCVA.nnnRESULTSnAll patients completed 6 months of follow-up with mean number of 2.78 intravitreal injections per eye.The mean BCVA at baseline was 0.80 log MAR, with significant changes 0.68 (p=0.012), 0.63 (p=less than0.001) and 0.60 log MAR (p=less than0.001) at 6 weeks, 3 months, and 6 months respectively. Final BCVA analysis demonstrated that 25 eyes (48.07%) remained stable and 22 (42.30%) improved ≥2 lines on BCVA. The mean central retinal thickness was 449.03 μm at baseline and it decreased significantly to 410.09 (pless than0.001),345.76(p less than 0.001), 344.55(p less than 0.001) and 326.51(p less than 0.001) at 1st day, 6 weeks, 3 months and 6 months post injection, respectively. Mean macular volume changed significantly from baseline of 10.77 μm to 10.33μm (p less than 0.001) 8.97 (p less than 0.001), 8.82 (p less than 0.001), 8.95 (p less than 0.001) at 1st day, 6 weeks, 3 months and 6 months post injection respectively.nnnCONCLUSIONnIntravitreal bevacizumab injection resulted in significant improvement in BCVA, central retinal thickness and total macular volume in patients with diabetic retinopathy with CSME, and this beneficial effect is maximum at 6 weeks. Also, slight reduction in these parameters at 3 month follow up suggests that visual improvement and stable macular thickness can be maintained longer with injection frequency of probably 6-12 weeks.