Padmaja Kumari Rani

Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience

Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.

Population Based Outcomes of Cataract Surgery in Three Tribal Areas of Andhra Pradesh, India: Risk Factors for Poor Outcomes

Purpose To report visual outcomes and risk factors for poor outcomes of cataract surgery in three Integrated Tribal Development Agency (ITDA) areas of Andhra Pradesh, India. Methods and Results Using validated Rapid Assessment of Avoidable Blindness (RAAB) methodology, a population based cross-sectional study, was conducted in three ITDA areas. A two-stage sampling procedure was used to select 7281 participants aged 50 years and above. Vision assessment using a tumbling E chart and standard ocular examinations were completed. Visual outcomes and risk factors for poor outcomes were assessed among subjects undergoing cataract surgery (1548 eyes of 1124 subjects). Mean age at surgery was 67±8 years; Among the operated eyes, presenting visual acuity (PVA) and best corrected visual acuity (BCVA) worse than 6/18 was seen in 492 (31.8%; 95% CI, 29.5–34.2%) and 298 eyes (19.3%; 95% CI, 17.3–21.3%), respectively. Similarly, PVA and BCVA worse than 6/60 was seen in 219 (14.1%; 95% CI, 12.4–16%) and 147 eyes (9.5%; 95% CI, 8.1–11.1%), respectively. When either eye was taken into consideration, the PVA and BCVA worse than 6/18 was seen in 323 (20.1%; 95% CI, 18.9–23%) and 144 subjects (9.3%; 95% CI, 7.9–10.9%), respectively. PVA and BCVA worse than 6/60 was seen in 74 (4.8%; 95% CI, 3.8–6%) and 49 subjects (3.2%; 95% CI, 2.4–4.2%), respectively. Posterior capsular opacification was seen in 51 of 1316 pseudophakic eyes (3.9%; 95% CI, 2.9–5.1%). In multivariable analysis among pseudophakic subjects with PVA worse than 6/18, increasing age (p = 0.002) and undergoing free surgery (p = 0.05) were independent risk factors. Undergoing surgery before 2005 (p = 0.05) and being illiterate (p = 0.05) were independent risk factors for BCVA worse than 6/18. Conclusions There are changing trends with improved outcomes in cataract surgery among these tribal populations of India. However, post-operative refractive error correction remains an issue, especially for those undergoing free surgeries.

Unusual Adverse Choroidal Reaction to Intravitreal Bevacizumab in Aggressive Posterior Retinopathy of Prematurity: The Indian Twin Cities ROP Screening (ITCROPS) Data Base Report Number 7*

Abstract Purpose: To describe a case of choroidal ischemia in a neonate after single, bilateral, intravitreal bevacizumab (IVB) injection for severe zone 1 aggressive posterior retinopathy of prematurity (AP-ROP). Methods: A six-week-old baby, born at a gestation age of 28 weeks and birth weight of 1.08 kg, presented at a postconceptional age of 34 weeks for ROP screening. On examination, both eyes revealed engorged iris new vessels with poorly dilating pupils. Retinal examination showed media haze, severe zone 1 APROP with confluent new vessels, severe plus disease, and early vitreous condensation at the edge of new vessels for 12 clock hours. The child was treated bilaterally, with single IVB injection before laser. After 16 hours, hypotony and exudative retinal detachment with patches of choroidal whitening suggestive of choroidal ischemia were seen. Results: The child was treated with topical steroids and cycloplegic drops and exudative retinal detachment resolved on the tenth day. Initial resolution of new vessels showed recurrence after two weeks and was treated with laser photocoagulation. Stable retinopathy status was noted up to six months follow-up. Conclusion: Choroidal ischemia secondary to a single IVB injection for the treatment of AP-ROP could be an unusual complication which raises the concern of its use as a monotherapy in neonates.

Telemedicine in diabetic retinopathy: Current status and future directions

Telemedicine is exchange of medical data by electronic telecommunications technology that allows a patient′s medical problems evaluated and monitored by a remotely located physician. Over the years, telemedicine and telescreening have become important components in health care, in both disease detection and treatment. Highly visual and image intensive ophthalmology is uniquely suited for telemedicine. Because of rising disease burden coupled with high opportunity cost in detection, diabetic retinopathy is an ideal ophthalmic disease for telescreening and decision-making. It fits to Wilson and Jungner′s all 10 criteria of screening for chronic diseases and the American Telehealth Association′s 4 screening categories.

Bilateral herpes simplex-2 acute retinal necrosis with encephalitis in premature twins

Acute retinal necrosis, caused by the herpes family of viruses, is a rapidly progressing ocular inflammatory disorder commonly reported in adults but rarely in children. The accepted diagnostic criteria include presence of 1 or more foci of retinal necrosis, rapid progression, circumferential spread, occlusive vasculopathy, and inflammation in the vitreous and anterior chamber. We report bilateral acute retinal necrosis with encephalitis due to herpes simplex virus (HSV-2) in newborn twins.

Prevalence and Causes of Blindness and Visual Impairment and Their Associated Risk Factors, in Three Tribal Areas of Andhra Pradesh, India

Objective To assess the prevalence of blindness and visual impairment (VI), their associated causes and underlying risk factors in three tribal areas of Andhra Pradesh, India and compare this data in conjunction with data from other countries with low and middle income settings. Methods Using a validated Rapid Assessment of Avoidable Blindness methodology, a two stage sampling survey was performed in these areas involving probability proportionate to size sampling and compact segment sampling methods. Blindness, VI and severe visual impairment (SVI) were defined as per the WHO guidelines and Indian definitions. Results Based on a prior enumeration, 7281 (97.1%) subjects were enrolled (mean age  = 61.0+/−7.9 years). Based on the presenting visual acuity (PVA), the prevalences of VI, SVI and blindness were 16.9% (95% CI: 15.7–18.1), 2.9% (95% CI: 2.5–3.4), and 2.3% (95% CI: 1.9–2.7), respectively. When based on the Pinhole corrected visual acuity (PCVA), the prevalences were lower in VI (6.2%, 95% CI: 5.4–6.9), SVI (1.5%, 95% CI: 1.2–1.9) and blindness (2.1%, 95% CI: 1.7–2.5). Refractive error was the major cause of VI (71.4%), whereas, cataract was the major cause of SVI and blindness (70.3%). Based on the PVA, the odds ratio (OR) of blindness increased in the age groups of 60–69 years (OR = 3.8, 95% CI: 2.8, 5.1), 70–79 years (OR = 10.6, 95% CI: 7.2, 15.5) and 80 years and above (OR = 30.7, 95% CI: 19.2, 49). The ORs were relatively higher in females (OR = 1.3, 95% CI: 1.0, 1.6) and illiterate subjects (OR = 4.3, 95% CI: 2.2, 8.5), but lower in those wearing glasses (OR = 0.2, 95% CI: 0.1, 0.4). Conclusions This is perhaps the first study to assess the prevalence of blindness and VI in these tribal regions and the majority of the causes of blindness and SVI were avoidable (88.5%). These findings may be useful for planning eye care services in these underserved regions.

Bilateral exudative retinal detachment as a presenting sign of acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) can present with various ocular complications but exudative retinal detachment is a rare complication. A 36-year-old healthy young adult male presented with gradual decrease in the vision in both eyes over nearly 2 weeks. His best-corrected visual acuities were 20/50 and 20/25 at distance and N12 and N10 at near in the right and left eyes, respectively. Fluorescein angiography and optical coherence topography indicated bilateral exudative retinal detachment. Systemic workup revealed a marked increase in the number of white blood cells with 30% blast cells and immunophenotyping revealed common acute lymphoblastic leukemia-associated antigen (CALLA) positive precursor B-cell lymphoblastic leukemia. Cerebrospinal fluid (CSF) tap was negative. The patient started systemic chemotherapy and steroids. Bilateral exudative retinal detachment may be a presenting sign of acute lymphoblastic leukemiaALL in an otherwise healthy young adult. Clinicians should be aware of the possibility of leukemia in such patients. A simple blood investigation such as complete blood profile confirms the diagnosis.

Hypopyon uveitis following panretinal photocoagulation.

We report the case of a 58-year-old man with proliferative diabetic retinopathy in both eyes, and a history of recurrent anterior uveitis in the right eye, who underwent panretinal laser photocoagulation (PRP) for the retinopathy in both eyes, following which he developed hypopyon uveitis in the right eye. The condition was managed with topical steroids and cycloplegics, to which he readily responded. The case highlights that there is a breakdown of the blood aqueous barrier consequent to PRP. Patients with a history of uveitis are predisposed to develop recurrent uveitis after the said procedure and should be closely watched for such complications.

Frosted Branch Angiitis in a Patient Coinfected With Dengue Hemorrhagic Fever and Malaria

Amaninhis30s,whowasknowntobecoinfectedwithdenguehemorrhagic fever andmalaria for a duration of 20 days, presentedwith suddenonsetofdefectivevision inhis lefteyeforadurationof10days. Theresultsofserologictestingwerepositivefor IgMantibodiestodengue virus, andhis peripheral blood smear showedmalarial parasites. His visual acuity was handmotion in the left eye. Discussion Afundusphotographofthelefteyerevealedmultiple intraretinalhemorrhages, vascular sheathing typical of frosted branch angiitis, and macular edema (Figure). The patient received an intravitreal bevacizumab injection in the left eye for the management of macular edema. At the 4-month follow-up, his visual acuity improved to counting fingers (at 1 m) in the left eye, and a fundus examination of the left eye revealed the partial resolution of the hemorrhages, vascular sheathing typical of frosted branch angiitis, and the resolution of macular edema.

Impact of the day-30 screening strategy on the disease presentation and outcome of retinopathy of prematurity. The Indian twin cities retinopathy of prematurity report number 3

Context: Outcomes of various screening strategies in retinopathy of prematurity are not well reported. Aim: To assess the impact of a city-wide, ROP screening strategy, on the disease presentation and treatment outcome. Materials and Methods: A retrospective case-control study from a prospectively collected ROP data-base was analyzed. Cases (group 1a) included ROP babies that were screened directly in neonatal intensive care units, and controls (group 1b) were babies referred directly to the institute from other neonatal centers during the same period. Historical controls (group 2) were ROP cases seen in the years preceding establishment of this ROP program and database. Primary outcome measure was the risk of eyes presenting with stage 4 or worse ROP, and main secondary outcome measure was the final anatomic outcome. Results: Of the 643 cases screened, 322 eyes of 161 babies had ROP. The median age of 7.19 months at presentation for the 46 patients (92 eyes) in group 2 was higher than the median age of 1.29 months for the 115 patients (230 eyes) in group 1. Within the group 1, group 1a had lower median age at presentation than group 1b (0.91 months versus 2.30 months). The relative risk of an eye presenting in the stage 4 and 5 in group 2 was 4.7 times higher (95% confidence interval 3.07 -7.32) than in group 1. Eyes that could be given treatment in group 2 were significantly less (P < 0.0005) than in group 1. The relative risk of poor outcome in group 2 was 3.83 times higher (95% confidence interval 2.75 -5.34) than in group 1. Group 1a eyes had the best outcomes. Conclusion: Early screening before one month of age in neonatal centers detects the disease early where prompt treatment can lead to favorable outcomes. The study provides early results of a model strategy for ROP screening.