community/ social ophthalology free papers - aios edu · dr. anamika dwivedi, dr. sujata lakhtakia,...

Community/Social OphthalologyFree Papers

Contents

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Contents

COMMUNITY / SOCIAL OPHTHALMOLOGY - IDemographic and Clinical Predictors of Poor Compliance for Part Time Occlusion in Patients with Amblyopia ...........................................................623Dr. Anamika Dwivedi, Dr. Sujata Lakhtakia, Dr. Dwivedi P.C., Dr. Syed Imran

Knowledge, Attitude, Practice Pattern of Retinopathy of Prematurity Among Ophthalmologist and Pediatrician .................................................................626Dr. Khushbu Bhattad, Dr. Anand Partani

A Survey to Assess the Compliance of Low Vision Aids in Visually Challenged Patients .........................................................................................630 Dr. Sara Jacob, Dr. Giridhar A, Dr. Mahesh G., Dr. Ms. Sreeshma T.S.

Childhood Visual Impairment in Northern India: Causes and Its Co-Relation .............................................................................................................................634Dr. Sunita Mohan

Cataract Care Services for Children: Barriers Encountered in Rural and Backward Regions ............................................................................................639Dr. Jayashree Baruah, Dr. Deva Prasad Kar, Dr. Sanjib Buragohain, Dr. Mrinal Modhur Borgohain

Visual Impact of Community Cataract Services by a Tertiary Eye Care Centre in Rural Central India .......................................................................................642Dr. Ritesh Patidar, Dr. Rahul Shah, Mr. Subramaniam Swami, Dr. Elesh Jain

Paediatric Low Vision: Magnitude, Interventions, Determinants and Compliance ........................................................................................................646Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir Taras

Retinopathy of Prematurity is A Major Cause of Childhood Blindness in Pune Region ................................................................................................................648Dr. Kuldeep Dole, Dr. Madan Deshpande, Dr. Sucheta Kshirsagar, Dr. Tanmayi Dhamankar

Assessment of Compliance in Children (0-16 Yrs) using Low Vision Aids....652Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir Taras

Importance of Medical and Patient Care Audit in Community Ophthalmic Outreach Programme .......................................................................................654Dr. Zawar Swati Vijay, Dr. Mamta Singh

70th AIOC Proceedings, Cochin 2012

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School Eye Health Screening Programme in Ahmedabad District – ‘Making The Invisible Visible’ ........................................................................................658Dr. Priyanka Gupta, Dr. Pina Rasiklal Soni, Dr. Minal Patel

COMMUNITY / SOCIAL OPHTHALMOLOGY – IITele-Ophthalmology and Community Eye Care: Early Experiences, Successes and Pitfalls .....................................................................................660 Dr. Jnanankar Medhi, Dr. Kalyan Das, Dr. Harsha Bhattacharji

Blindness and Visual Impairment in Konkan, Maharashtra ........................662Dr. Anil Kulkarni, Dr. Shailbala Patil, Dr. Siddharth Vora, Dr. Parikshit Gogate

Knowledge, Attitude, Practice Pattern of Ophthalmic Drugs in Pharmacist and Its ‘Over The Counter’ Misuse ................................................................665 Dr. Anand Partani, Dr. Khushbu Bhattad, Dr. Madan Ashok Hukumchand

Comparing 3 models of Community Based Diabetic Retinopathy (DR) Screening, Treatment and Awareness Creation Services ..........................670Dr. Unnikrishnan Nair R., Dr. Manoj S., Dr. Ramachandran Nair K.G.

Sunday Diabetic Retinopathy Camp in a Rural Eye Hospital in Jharkhand..677 Dr. Subhrangshu Sengupta, Dr. Partha Biswas, Dr. Monica Horo, Dr. Sushrut N Pandit Anand

Epidemiological Evaluation of Risk Factors and Outcome in Corneal Ulcer.. 679Dr. Bhavana Sharma, Dr. Vivek Som, Dr. Kavita Kumar, Dr. (Mrs.) Reena Anand

Impact Assessment of Quality Assurance Interventions on Efficiency of Ophthalmic Operation Theatre ........................................................................682Dr. Suneeta Dubey, Dr. Sandeep Buttan, Dr. Shafali, A. K . Arora

Partnership Between Eye Care Provider and Community Development Initiative .............................................................................................................686Dr. Amarendra Deka, Dr. Saikia S.P., Dr. Kumar S.

Prevalence of Vision Threatening Retinal Conditions in Patients Referred for Cataract Surgery ...............................................................................................688Dr. Varada Gokhale, Dr. Khyati Shah, Dr. Ronnie George, Dr. Sripriya A.V.

A Study on Etiology and Antibiotic Resistance Pattern of Organisms Causing Acute Eye Infections.........................................................................................692Dr. Ruchi Shah, Dr. Tejas Desai, Dr. Bharat Ghodadra, Devarshi Mistry

ASHA (Accredited Social Health Activist) Worker – A Novel Approach in Community Ophthalmology ............................................................................695Dr. Pina Rasiklal Soni, Dr. Minal Patel, Dr. Mariam Nisar Mansuri

Community/Social Ophthalmology Free Papers

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COMMUNITY / SOCIAL OPHTHALMOLOGY - IChairman: Dr. Velayutham Veerabahu; Co-Chairman: Dr. Gupta B.N.

Convenor: Dr. Gursatinder Singh; Moderator: Dr. Subudhi B.N.R.

Demographic and Clinical Predictors of Poor Compliance for Part Time Occlusion in Patients with AmblyopiaDr. Anamika Dwivedi, Dr. Sujata Lakhtakia, Dr. Dwivedi P.C., Dr. Syed Imran

Amblyopia is one of the most common causes of visual impairment in children with varying prevalence depending on the type of population

studied. Occlusion of the sound eye has been the mainstay of amblyopia management but treatment success is largely dependent on compliance. Poor compliance not only limits the effectiveness of treatment but also increases costs to the patient’s family and health care system.

We conducted a non-randomized intervention study to assess the role of various demographic and clinical factors influencing compliance in patients undergoing occlusion therapy for amblyopia.

MATERIALS AND METHODS Patients with unilateral amblyopia attending the Squint and Amblyopia Clinic of Ophthalmology department, S.S. Medical College, Rewa between October ’09 and April’11 were enrolled for the study. After excluding patients with any organic cause of decreased visual acuity, history of previous treatment for amblyopia and neurological disease, a total of 125 patients with either strabismic and/or anisometropic amblyopia between 2 to 17 years were selected.

After a comprehensive ophthalmic and orthopedic examination patients were provided with optimal optical correction and advised 6 hrs /day of occlusion. Depending on the VA at presentation, amblyopia was classified as mild to moderate (VA >20/100) and severe (VA < 20/100) based on the amblyopic eye visual acuity. The socioeconomic status of the patient’s family was assessed using the Kuppuswamy’s Socioeconomic Status Scale (2007 modification). The parents were explained in detail about occlusion therapy and its significance in the management of amblyopia. They were then asked to keep an accurate record of number of hours of patching done per day in a diary.

All patients were followed up monthly for 6 months and at each visit ocular alignment and BCVA were evaluated and glasses changed if needed. Early


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response to treatment was defined as >2 log MAR line improvement in <2 months. Compliance was also assessed at each follow-up visit on the basis of diary entries by parents and those with an average duration of occlusion less than 3 hours/day were considered poorly compliant.

RESULTSAlthough 125 patients were enrolled for the study, only 110 patients were finally evaluated since 15 were lost to follow up. Table-1 provides the baseline characteristics of these 110 patients of which 61 were males and 49 females. The patients were divided into 4 groups on the basis of their ages with most patients (30%) belonging to the age group of 2-5 years. The commonest cause of amblyopia in our study was anisometropia seen in 40% and in terms of severity, most patients (57.27 %) had mild to moderate amblyopia.

Compliance as assessed by parental diary showed 45% patients to be poorly compliant. Poor compliance was found to be significantly related with increasing age (p = 0.01), severe amblyopia (p = 0.01), early response to treatment (0.008), low educational (p=0.003) and socioeconomic status of parents (p = 0.001). There was no association of gender (p = 0.27) or cause of amblyopia (p = 0.15) with compliance.

DISCUSSIONIn our study, 55% patients were well compliant with occlusion as assessed by parental diary. Studies by Searle A et al and Al-Zuhaibi S et al show compliance levels of 54% and 45% respectively. Stewart CE et al and Awan M et al used Occlusion Dose Monitors (ODM) for electronic measurement and reported compliance rates between 48-58%.

Among the other variables assessed, our study documented increasing age, severity of amblyopia and poor socio economic and educational status of parents to be significantly correlated with poor compliance. Similar results have been reported by Loudon SE et al (2006) who found low level of parental education and poor initial acuity as predictors of non compliance. However, Searle A et al in their study concluded that severity of visual impairment did not affect compliance; perceived self-efficacy was positively associated with compliance and perceived prohibition of the child’s activities were negatively associated with compliance. Al-Zuhaibi S et al documented improvement in visual acuity as the only significant predictor of compliance.

In conclusion although occlusion therapy has been the mainstay of amblyopia treatment, its success is limited by non compliance. The results of the present study indicate that increasing age, severity of amblyopia and low socioeconomic and educational status of parents are major predictors of poor


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compliance while early improvement in visual acuity is positively associated with compliance.

Table 1: Clinical and Demographic Data Variable Total (%) Poor Compliance (%)No. of Patients 110 50(45)Sex Male 66(60) 32(48) Female 44(40) 18(41)

Age 2-5 33(30) 4(12) 6-10 26(23) 9(35) 11-13 24(22) 14(58) 14-17 27(25) 23(85)

Cause of Strabismus 25(23) 12(47)Amblyopia Anisometropia 44(40) 22(50) Strabismus + 41(37) 16(39) Anisometropia

Severity of Mild To 41(37) 13(32)Amblyopia Moderate Severe 69(63) 37(54)

Early Response Responders 42(38) 14(33)To Treatment Non Responders 68(62) 36(53)

Socioeconomic Upper 24(22) 9(37)Status Upper Middle 31(28) 62(56) 13(42) 24(39) Lower Middle 31(28) 11(35) Upper Lower 14(13) 24(22) 10(71) 17(71) Lower 10(9) 7(70)

Mothers University 22(20) 6(27)Education Higher Education 27(25) 8(30) Secondary 24(22) 7(32) Education Primary Education 20(18) 16(80) None 17(15) 13(76)

Fathers University 35(32) 12(34)Education Higher Education 28(25) 9(32) Secondary 16(15) 6(37) Education Primary Education 20(18) 5(75) None 11(10) 8(72)


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REFERENCES1. Searle A, Norman P, Harrad R, Vedhara K. Psychosocial and clinical determinants

of compliance with occlusion therapy for amblyopic children. Eye. 2002;16:150–5. 2. Al-Zuhaibi S, Al-Harthi I, Cooymans P, Al-Busaidi A, Al-Farsi Y, Ganesh

A.Compliance of amblyopic patients with occlusion therapy: A pilot study. Oman J Ophthalmol. 2009;2:67-72.

3. Stewart CE, Moseley MJ, Stephens DA, Fielder AR. Treatment dose-response in amblyopia therapy: The Monitored Occlusion Treatment of Amblyopia Study (MOTAS). Invest Ophthalmol Vis Sci. 2004;45:3048–54.

4. Awan M, Proudlock FA, Gottlob I. A randomized controlled trial of unilateral strabismic and mixed amblyopia using occlusion dose monitors to record compliance. Invest Ophthalmol Vis Sci. 2005;46:1435–9.

5. Loudon SE, Fronius M, Looman CW, Awan M, Simonsz B, van der Maas PJ et al. Predictors and a remedy for noncompliance with amblyopia therapy in children measured with the occlusion dose monitor. Invest Ophthalmol Vis Sci. 2006; 47:4393-400.

6. Loudon SE, Simonsz B, Joosse MV, Fronius M, Awan M, Newsham D et al. Electronic recording of patching for Amblyopia Study: Predictors for non compliance. Invest Ophthalmol Vis Sci. 2004;45: E-abstract 4991.

7. Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy’s socioeconomic status scale-updating for 2007. Indian J Pediatr. 2007;74:1131-2.

Knowledge, Attitude, Practice Pattern of Retinopathy of Prematurity Among Ophthalmologist and Pediatrician Dr. Khushbu Bhattad, Dr. Anand Partani

Retinopathy of prematurity is a fibrovascular proliferative disorder affecting peripheral retinal vasculature in premature infants. ROP screening is

recommended in all infants with risk factors, such as low birth weight < 2000 gm, gestational age < 35weeks, multiple births, eventful postnatal period- oxygenation, sepsis, respiratory distress and blood transfusions.1

With improving survival of very low birth weight infants, ROP has emerged as a significant preventable cause of blindness in India. The initial signs of ROP may be detected within few weeks after birth and it progresses rapidly. Though ROP can be cured by timely and proper intervention but still in India nearly 500 children are estimated to become blind due to ROP every year.2 It is estimated that out of 100 preterm infants in India approx 20-40 develop ROP; out of which 3-7 become blind.3 Thus awareness and practice of ROP screening


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guidelines, among pediatricians and ophthalmologist is must to tackle this emerging problem.

Present study is conducted to assess the knowledge, attitude and practice patterns (KAP) of pediatricians and ophthalmologist about ROP.

MATERIALS AND METHODSIn this cross-sectional study, responses of KAP questionnaire about ROP was obtained and analyzed from 156 ophthalmologist and 122 pediatricians in central India from may 09-may 11.

ROP-KAP questionnaire for paediatrician (Knowledge, Attitude and Practice Proforma)

Name, age/sex, email id- type of practice-government/private.

1) Are you aware of disease affecting eye relating to premature birth? If yes then what it is? ROP or others.

2) What are the risk factors for ROP? No idea, Low gestational age, Weight<1800 gms, Sick requiring oxygen therapy, All of above (except no idea).

3) What should be the timing of referral for ROP screening? No idea, 4-6 weeks of age, 6-12 weeks of age, depends on gestational age.

4) Do you think ROP can lead to blindness? Yes / no 5) Is ROP treatable if diagnosed at early stage? Yes / no 6) Do you consider importance of regular ophthalmic follow-up to prevent

blindness? Yes / no 7) Do you give guidance to parents for ophthalmic checkup for ROP

screening? Yes /no 8) What are the Barriers for referring preterm babies for screening are-parents not willing unaware of referral facility, too expensive treatment, not necessary to screen.

ROP-KAP questionnaire for ophthalmologist (Knowledge, Attitude and Practice Proforma)

Name, age/sex, email id-type of practice-government/private.

1) What is method of choice for ROP screening? Direct/indirect ophthalmoloscopy.

2) Do you perform it regularly for ROP screening? Yes / no. 3) Which babies are likely to develop ROP? 4) Do you screen such high risk babies for ROP? 5) When should be the 1st eye examination to be performed for ROP

screening?


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6) What are the different stages of ROP?

7) What are the treatment modalities of ROP?

8) Is there enough awareness of ROP among medical professionals around you? Yes / no.

RESULTS Out of 122 pediatricians-male 86(70%) female 36 (30%). Mean age 43.2yrs.

28(23%) were in government practice and 94(77%) in private practice.

106(87%) Pediatricians were aware of ROP and only 16(13%) were not aware of disease.

Risk Factors for ROP No idea 28(23%)Low gestational age 21(17%)Weight<1800gms 23(19%)Sick requiring oxygen therapy 11(9%)All of above (except no idea) 39(32%)

Timing of Referral for ROP ScreeningNo idea 58(47.5%)4-6 wks of age 36(29.5%)6-12 wks of age 11(9%)Depends on gestational age 17(14%)Total 122(100%)

94 (77%) Pediatricians knew that ROP can lead to blindness, while 28(23%)were not aware of it. 56(45.9%) pediatrician knew that ROP can be treatable at early stage, 66(54%) said it is not treatable. 82(67%) consider importance of regular ophthalmic follow up to prevent blindness. 45(36.9%) pediatrician give guidance to parents for ophthalmic checkup for ROP screening. Barriers of pediatricians for referring preterm babies for screening are-parents not willing 44(36%), unaware of referral facility 18(14.7%), too expensive treatment 21(17.2%), not necessary to screen 39(32%).

Out of 156 ophthalmologist- male 98(63%), female 58(37%). Mean age46.2yr 31(20%) were in government practice and 125(80%) in private practice.146 (94.2%) knew that ROP screening is to be done with indirect ophthalmoscope, 10 (5.8%) said direct ophthalmoscopy to be done. Only 54(34.6%) practice IDO regularly. 22(13.8%) ophthalmologist do not know about risk factors for ROP, 134(86.2%) mentioned risk factors. Only 55(35%)screen such high risk babies for ROP. 134(86.2%) knew that 1steye examination to be done at 4-6 weeks after


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birth, 22(13.8%) don’t have idea about it. 70(45%)ophthalmologist knew about stages of ROP. Only 52(33.4%) knew about treatment modalities of ROP. Only 33(21%) ophthalmologist think that there is enough awareness of ROP among medical professionals.

DISCUSSIONIn our study 87% pediatrician were aware of ROP, 23% has no idea about its risk factor, 47.5% don’t have idea of 1st eye test for ROP screening. 45.9% knew that timely treatment can prevent blindness. 36.9% give guidance to parents for regular ophthalmic check-up in high risk babies. Barriers for referring preterm babies are- parents not willing 36%, unaware of referral facility 14.7%, too expensive treatment 17.2%, not necessary to screen 32%.

In a study done by Sathiamohanraj SR, et al4 on 83 pediatrician in coimbatore-65% were aware of ROP, 42%have no idea of risk factors,45.8% have no idea of 1steye test for ROP screening, 39.8% knew that timely treatment can prevent blindness. In a study done by Rani and Jalani5 on 38pediatrician in Hyderabad -100% pediatrician are aware of risk factors, Barriers for referring preterm babies are-parents not willing 18%, unaware of referral facility 15.8%, too expensive treatment 13%.

In the study done by Kemper et al6, in a questionnaire survey of neonatologists regarding the barriers for ROP screening, the most commonly reported major barrier was the lack of available eye care specialists. This indicates the need for postgraduate, undergraduate and in-service training programs for ROP in developing eye care work force who can effectively screen ROP.

Till date according to our search there is no study on KAP of ROP among ophthalmologist in India.

In our study among ophthalmologist 94.2% knew ideal method of screening is indirect ophthalmoscope and practiced by 34.6%. only 35% screen high risk babies. Only 33.4% have knowledge about recent management.

The first step in reducing blindness due to ROP is recognizing that the problem exists. Our study shows that awareness of ROP is poor among pediatricians. Reports from other developing countries like China7, Thailand8 and Vietnam9 also show a similar trend. Even decades after randomized clinical trials for ROP have been published and discussed in ophthalmic literature; this information has not been incorporated into our regular practice. As time is a crucial parameter in ROP screening, the IAP along with the All India Ophthalmological Society (AIOS) should develop national guidelines for its control.

With joint efforts of neonatologist and ophthalmologist we can handle this problem.


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In conclusion study suggests that there is lack of awareness and close coordination between pediatrician and ophthalmologist for screening and service delivery for ROP. So there is intense need for creating awareness to overcome these barriers to avoid childhood blindness.

REFERENCES 1. Jalali S, Hussain A, Matalia J,. Modification of screening criteria for India and other

middle-income group countries. Am J Ophthalmol. 2006;141:966-68. 2. Gilbert C. Retinopathy of prematurity: A global perspective of the epidemics,

population of babies at risk and implications for control. Early Hum Dev 2008; 84:77-82.

3. M.S. Bajaj AIIMS, National programme of control of blindness,paediatric ophthalmology pg;17.

4). SR Sathiamohanraj et al - Awareness of retinopathy of prematurity among pediatricians in a tier two city of South India. Oman journal of ophthalmology. 2011; Volume 4, Issue 2.

5. Padmaja Rani, Subhadra Jalali-Knowledge Attitude Practice of Retinopathy of Prematurity amongst Pediatricians attending a Neonatal Ventilation Workshop in South India 10.5005/jp-journals-10020-1003.

6. Kemper AR, Wallace DK. Neonatologists’ practices and experiences in arranging retinopathy of prematurity screening services. Pediatrics 2007;120:527-31.

7. Chen Y, Li X. Characteristics of severe retinopathy of prematurity patients in China: A repeat of the first epidemic? Br J Ophthalmol. 2006;90:268-71.

8. Trinavarat A, Atchaneeyasakul L,. Applicability of American and British criteria for screening of the retinopathy of prematurity in Thailand. Jpn J Ophthalmol 2004;48:50-3.

9. Phan MH, Nguyen PN, Incidence and severity of retinopathy of prematurity in Vietnam, a developing middle-income country. J Pediatr Ophthalmol Strabismus 2003;40:208-12.

10. Gilbert C, Fielder A, International NO-ROP Group. Characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development: Implications for screening programs. Pediatrics 2005;115:518-25.

A Survey to Assess the Compliance of Low Vision Aids in Visually Challenged Patients Dr. Sara Jacob, Dr. Giridhar A, Dr. Mahesh G., Dr. Ms. Sreeshma T.S.

In 1993, the World Health Organisation redefined LOW VISION as: A person with low vision is one who has impairment of visual functioning even after

treatment and or standard refractive correction and has a visual acuity of <6/18 to light perception or a visual field of <10˚ from point of fixation (20˚ across),


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but who uses or is potentially able to use vision for the planning and execution of a task.1 WHO released the new global estimates on visual impairment in 2010. WHO estimates that the number of people with visual impairment is 285 million (65% of whom are aged over 50 years). Of these, 246 million have low vision (63% over 50 years).2

Aim of the Study: We conducted this study to ascertain the proportion of patients who gain benefit from Low Vision Aids (LVAs). To ascertain how frequently they used the prescribed LVAs and for what purpose they used the LVAs. Did they gain any benefit in the jobs they were employed in? To find out the reason why some prescribed LVAs were left unused. To compare the types of optical LVAs preferred in the various categories of retinal disorders. To compare between the group frequently using their LVAs and the group not using their prescribed LVAs.

MATERIALS AND METHODSA questionnaire and telephone survey was carried out on 83 patients who attended our Low Vision Clinic from January 2010 to February 2011 by an Ophthalmologist. Their clinical records were retrieved from our Medical Records Department and analysed. The questionnaire included questions regarding their educational qualification, employment details, usage rate of LVA, activities for which LVAs were used, deterioration of vision after the prescription of LVA and questions regarding general health were asked. If they were not using the prescribed LVA reason for their non-compliance were enquired. Data collected were compiled and analysed. Descriptive statistics of mean and percentage were used. Statistical analysis was done using Pearson Chi-square test.

RESULTS67 patients were contacted. Time since prescribing LVA ranged from 1 month to 15 months. The patients included 42(62.7%) males and 25(37.3%) females. 53(79.1%) patients were in the age group 51-80 years. 44(65.7%) patients were using the LVAs prescribed. 19(43.2%) patients used them 3 or more times/day. Patients used their LVAs for newspaper reading, reading religious books, magazines, checking minute details, work, study purposes etc. 11(25%) patients used them for Work/Study purpose. Majority 33 patients (75%) used them for newspaper reading. Average reading ability with prescribed LVAs improved from N12 to N6. Frequency of LVA usage >10 times/day 7%, 6-10 times/day 16%, 3-5 times/day 21%, twice daily 16%, once daily 28%, 1-2 times/week 12%. Of the 23 patients not using their LVAs, 10 felt that the prescribed LVA was not clear enough for them to see clearly, 3 felt that it was very strainful to go close, 4 had severe deterioration of vision, 1 was bedridden, 1 had fear of eyestrain for using high powered glass, 2 had difficulty as hands were not free. 14 patients


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experienced some degree of deterioration of vision of which 4 patients stopped using their LVAs due to severe decrease in visual function. In the study 33(49%) patients had Diabetic Retinopathy, 13(19%) patients had Age Related Macular Degeneration, 10 (15%) patients had Optic Atrophy, 3(5%) patients had Retinal Vein Occlusions and 8 (12%) patients had macular degenerations other than ARMD (c/c CSR, PFT, Macular Dystrophy etc). Types of LVAs preferred were Prismatic Spectacles 57%, Hand Magnifiers 13%, Stand Magnifiers 18%, Dome Magnifiers 6% and Aspheric Spectacles 4%. Patients with Diabetic Retinopathy were prescribed prismatic spectacles 19(57.6%), illuminated hand magnifiers 6(18.2%), stand magnifiers 5 (12.1%), dome magnifiers 2 and aspheric spectacles 1. Patients with ARMD were prescribed prismatic spectacles 8 (61.5%), stand magnifiers 4 (30.8%) and dome magnifier 1. Patients with Optic Atrophy and Glaucoma were prescribed prismatic spectacles 5 (50%), illuminated hand magnifiers 2(20%), stand magnifier 1, dome magnifier 1 and aspheric spectacles 1. Chi Square analysis between the groups yielded a value of 4.317 and p value 0.6339 with no statistically significant association. We compared between the group of patients who frequently use the prescribed LVA 3 or more times daily and the group of patients who did not use their prescribed LVAs. The first group had 19 patients and the second group had 23 patients. The educational qualifications appeared to be the same

in two groups. Chi Square value of 0.01375 and p value of 0.7108 was obtained with no statistically significant association. Comparing the group frequently using their LVA with the group not using their prescribed LVA it was noted that patients with moderate degree of visual deterioration (6/36 and worse, N12-N10) used their LVAs frequently compared to those with mild degree of visual deterioration (Chi-Square value of 5.575 and p value of 0.0616 with no statistically significant association). In the

group frequently using LVA 8/19 patients were in 51-60 years category and 4/19 patients were in 61-70 years category. In the group not using LVA 8/23 patients were in 71-80 years category and 6/23 patients were in 51-60 years category. Therefore increasing age may contribute to non-compliance.

Comparing the BCVA for Near Between The Group Frequently Using Their Lvas and The Group Not Using Their LVAS:


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DISCUSSIONIn our study 65.7% of the patients studied were using the prescribed LVA. Mean age of the patients were 60.5 years. 43.2% used them 3 or more times per day. 22.7% used them 6 or more times daily. 25% used them for work/study purpose. 75% used them for newspaper reading. The prompt implementation of low vision aids will help low vision patients to maintain and regain their reading ability, which can lead to an increase in independence, communication, mental agility and quality of life. In our study 14 patients experienced deterioration of vision of which 4 patients stopped using their LVA due to severe decrease in visual function. In a study by Roshrschneider et al. 57% used their optical LVAs more than 5 times daily mostly for reading and writing (74% and 78%, respectively).3

In our study the mean magnification required was 3.3X, the range of magnification 1.25X to 12X. In a study by Nguyen et al, the mean magnification required was 4X.

In a study by Shuttleworth mean magnification required was 3X, range of magnification 1.5X to 20X.4 In our study average reading ability with prescribed LVAs improved from N12 to N6. In a study by H. Court the average reading ability improved from N12 to N5(6). Comparing the group frequently using their LVA with the group not using their prescribed LVA it was noted that patients with moderate severity of visual deterioration(6/60-6/36, N12-N10) used their LVAs frequently compared to those with mild degree of visual deterioration. In our study majority of LVAs supplied were prismatic spectacles (+5DS to +10DS) -56.7%. Spectacles are the best form of aid for prolonged reading. They have the advantage of a larger field and leave both hands free to hold the reading material. They are a cheaper and simpler alternative to the costlier and complex electronic devices. In a study by Shuttleworth where only simple optical aids were used 64% supplied were magnifiers.4

In an AMD study by Nhung Xuan et al. visual rehabilitation was achieved with optical visual aids in 58% of patients, whereas 42% of patients needed electronically closed-circuit TV systems.5 In a study by N.X. Nguyen et al. visual rehabilitation was frequently sufficient with simple optical low-vision aids such as high-plus reading additions and magnifiers in 76%. Closed-circuit television systems were necessary in 26%7 Limitations of the study include small sample size and inability to assess the reading speed as this study was a telephonic survey.

In conclusion results of this survey show that 65.7% of the visually challenged patients are able to improve their quality of life by improving their reading ability with the appropriate LVA. It was noticed that prismatic spectacles were the most preferred LVAs (56.7%) in this particular series. Patients with


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moderate severity of visual loss used their LVAs frequently when compared to those with mild visual loss. Simple Optical Aids are a cheaper and simpler alternative to the costlier and complex electronic devices

REFERENCES1. World Health Organization. International statistical classification of diseases,

injuries and causes of death, tenth revision. Geneva, 1993.2. WHO 2010:[email protected]. Satisfaction with low vision aids, Rohrschneider K, Kiel R, Pavlovska V, Blankenagel

A. Klin Monbl Augenheilkd. 2002;219:507-11.4. How effective is an integrated approach to low vision rehabilitation? 2 year

follow up from South Devon. Shuttleworth et al. British Journal of Ophthalmology 1995;79:719-23.

5. Improvement of reading speed after providing of low vision aids in patients with age-related macular degeneration Nhung Xuan Nguyen, Malte Weismann, Susanne Trauzettel-Klosinski. Acta Ophthalmologica. 2009;87:849-53.

6. How effective is the new community- based Welsh low vision service? H. Court, B. Ryan, C. Brunce. British Journal of Ophthalmology 2011;95:178-84.

7. Spectrum of Ophthalmologic and social rehabilitation at the Tubinger Low Vision Clinic: a retrospective analysis for 1999- 2005 Nguyen N.X; Weisman M, Trauzettel- Klosinske S. Ophthalmologe 2008;105:563-9.

Childhood Visual Impairment in Northern India: Causes and Its Co-RelationDr. Sunita Mohan

Estimated that globally almost one in 1000 children are blind. India shoulders the world’s largest burden of blindness. Of a total population

exceeding one billion, as many as 15 million people are blind, and an additional 52 million are visually impaired. Among these 320,000 children are under the age of 16, constituting one fifth of the world’s blind children. Though no population based nationwide survey has been undertaken on the prevalence of childhood blindness in India, a figure of 0.8/1000 children has been used, using the co-relation between under five mortality rates and prevalence. Visual impairment has significant implications for the affected child and family in terms of education, future employment, personal and social welfare throughout life.

To estimate prevalence of visual impairment in children less than 16 years in rural population of Agra. To evaluate these children for probable causes of visual impairment. To co-relate these causes with their biosocial profile.


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MATERIALS AND METHODSPopulation based cross-sectional survey, conducted in 3 randomly selected villages of Agra district, the population of which is 3.62 million (Census 2001) with a rural population of 2.05 million and urban of 1.57 million. The study was carried out during August 2006 and March 2008. The Study Population comprised of 1096 children less than 16 years of age. Visiting children (resident <6 months), institutionalized children, and those away for 6 months or more were not included in the study population. A household schedule was administered for collecting the Information related to family profile namely: age, sex, educational status of each member, income, immunisation services, school health services. Data on the schooling level of parents from the community were collected. A standard examination procedure was used for each study subject. Detailed history about present and past ocular problems, history of any medical or surgical treatment, and family history were taken. Ocular examination included assessment of visual acuity for distance with Snellen chart at room illumination. Objective refraction was performed with streak retinoscope, followed by subjective refraction, till the best corrected visual acuity was achieved. Cycloplegic refraction was performed in hyperopes aged > 4 years. Detailed ophthalmic workup was offered to those children whose BCVA were not 6/6.

Data Management and Analysis: Enumeration and clinical data were recorded using schedule data forms. Children were divided into three age groups, <5 yrs, 5 - 10 yrs, > 10 yrs for comparison of prevalence. Disease prevalence was compared between these age groups and both sexes.

RESULTSDemographic profile of study populationParameters Interpretation Age wise data of Examined Children Age (in yrs) Boys Girls Number % < 5 25 19 44 4 5 – 10 302 264 566 51.6 > 10 264 222 486 44.4 Total 591 505 1096 100 Literacy Status of Children Status Boys Girls Number % Illiterate 243 248 491 44.8 Literate 348 257 605 55.2 Total 591 505 1096 100

Average literacy rate: 54.9%. The percentage of females having 6 or more yrs of schooling is 7.2% which is almost half of males (13.4%).

Majority of population belonged to age group 5-10 yrs. (51.6%)


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Almost 1/3 male children were involved in education whereas 1/3 of females were engaged in household work. A total of 79.6% females were engaged in some or other kind of occupation besides studying, whereas for males the figure for same is 55.0%. Children not engaged in any kind of work were 11.4% of 1096 children. Average Adult literacy rate was 38.45%. Adult female literacy rate (30.0%) was lower than the adult male literacy rate (47.8%). Most of the children with low vision belonged to age group 5-10 years. Prevalence of blindness noted was 1.46%(16).

Anatomical site of major causative pathology Site Frequency Prevalence/1000Whole Globe 3 2.7 Microphthalmos 2 1.8 Coloboma 1 0.9Cornea 5 4.5 Opacity (VAD) 2 1.8 Opacity(Ophthalmia neonatorum) 1 0.9 Traumatic rupture 2 1.8Optic Nerve 3 2.7 Secondary Optic atrophy 3 2.7Cataract 3 2.7 Congenital 1 0.9 Traumatic 2 1.8Retina 1 0.9 Albinism 1 Others 1 0.9 Glaucoma 1 Total 16 14.6

The relatively high proportion of corneal scarring found in this study is mainly a reflection of poor socioeconomic status, which is associated with inadequate immunisation coverage (23.3% children were unimmunised against measles), poor nutrition and health services for children. 8.3% children showed bitot’s spot, of which 91.2% children were PI/UI. Statistically significant difference in prevalence of Xerophthalmia was observed between male and female children (X2=25.564, P value = 0.0000387). Difference of prevalence of Xerophthalmia in partially immunised and unimmunized categories was statistically significant. (X2=461.854, P value = 1.07x10-94).

Aetiological Categorie Childhood factors along with infectious factors accounted for the majority of cases in this study (62.5%). In a significant proportion of these cases (37.5%),


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the underlying aetiology could not be determined. In most children it was not possible to determine the time of onset owing to lack of reliable history and medical records, or the pathological processes could not be elucidated.

Avoidable Causes Preventable conditions No. of children Percentage VAD 2 4 Ophthalmia neonatorum 1 2 Trauma 4 8 Meningitis 3 6 Refractive Error 34 68 Subtotal 44 88 Treatable conditions cataract 1 2 glaucoma 1 2 Subtotal 2 4 Total avoidable 46 92

In this study, 75% of blind children had avoidable causes of visual loss. Trauma contributed to the majority (25%) of the preventable causes. Almost all the trauma cases were seen in males. Childhood cataract (2 due to tauma, 1 due to congenital causes) was one of the main treatable conditions in our study.

Prevalence of Refractive ErrorOut of total 1096 children examined, 126 (14.5%) were found to have refractive errors. Out of 126 children with refractive error, 54 (4.9%) were boys and 72 (6.6%) were girls. After correction only 34 children (3.1%) had less than 6/18 vision in their better eye. Corrected vision less than 6/60 - 3/60 in the better eye was seen in 8 (0.7%) children. Statistically significant difference in prevalence of refractive error was observed between different age group. (X2 = 26.774, P value = 0.0000221). Although there was difference in prevalence of refractive error between boys and girls, it was not statistically significant. ( X2 = 0.539, P value = 0.764). Majority of children belonged to the middle class, however this difference was statistically not significant. (X2 = 3.087, P value = 0.929). Of 126 (11.5%) children with refractive error 88 (8.0%) children had literate parents, 52 literate mothers and 88 literate fathers, however no significant difference was seen between these groups .(Mother X2 = 0.590, P value = 0.745 Father X2 = 0.865, P value = 0.649).

Profile of visual status in surveyed children: Prevalence of low vision in children was high , 4.6% of which 2.2% contributed to economic blindness which was more prevalent in girls. Social blindness was equal in both girls and boys. Economic blindness and social blindness was more in the younger age group,


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<5yrs contributing to more ocular morbidity and also child mortality. Prevalence of blindness noted was 1.46%(16).Unattended Trauma cases seen in 0.36%(4).Corneal diseases due to Vitamin A deficiency seen 0.27%(3).Infectious optic atrophy seen in 0.36%(4).Cataract seen in 0.27%(3).Neglected Whole globe diseases (glaucoma, coloboma) accounted for 0.36%(4).Uncorrected Refractive errors accounted for visual impairment in 3.10%(34).

In conclusion 75%(12) of blind children suffered from avoidable causes of blindness well attributed to illiteracy of parent, inadequate primary health care services stressing the simple and basic need to educate people about preventable diseases and establish adequate health care centres to improve quality of eye sight in rural area.

DISCUSSIONIn our study the correlation of the visual impairment with factors like: Low socioeconomic

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status, Poor literacy rate, Inadequate Immunisation were reinforced. Following recommendation are proposed based on observations made in our study.

Strategies for Serving the Underserved : Short term year : 1 to 3 years Plan: Includea Campaign approach, Stimulating Political awareness, political will and commitment, including local communities, Harnessing existing knowledge and skills, Mobilizing the necessary human capital, Delivering quality services based on need, Supporting local demonstration projects, Provision of financial and human resources.

Long term interventions: 1 to 5 years plan include Identifying and demarcating areas that are underserved, Revise policies and strategies to strengthen the health delivery system for the underprivileged as a priority Institute or strengthen PHC and infrastructure. Priority areas to control childhood blindness: Development of Pediatric Ophthalmology Units at tertiary level eye care centres , Strengthening of refraction services at Primary and Secondary level of Eye Care Screening and detection of avoidable/preventable causes of blindness (ocular trauma and retinopathy of pre-maturity); Provision of low vision devices at low/no cost. The eyes do not see what the mind does not know. The Heart makes a difference. When the Heart is involved there is concern, compassion and empathy .Then the mind wants to know: Where is the problem? What is the problem? How to overcome the problem? It is only then that we can Reach the Un-reached.

Cataract Care Services for Children: Barriers Encountered in Rural and Backward RegionsDr. Jayashree Baruah, Dr. Deva Prasad Kar, Dr. Sanjib Buragohain, Dr. Mrinal Modhur Borgohain

Globally there are at least 190,000 children blind due to cataract. Childhood cataract is the most common treatable cause of childhood blindness,

being responsible for 10-30% of all childhood blindness. Surgical intervention is the treatment of choice for children who are born with or who develop cataract later. But, such children blinded by cataracts should be operated as soon as possible. Delay in presentation results in less than optimal visual outcome after surgery. Although significant progress has been made in the field of surgical management of congenital cataract, uptake of cataract surgery in children is low in most resource poor countries.

The purpose of this study was to discuss the barriers associated with providing proper cataract care services for children in rural and backward regions.


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MATERIALS AND METHODSThis is a retrospective study conducted at a community eye care centre in Uttarakhand from Jan’09 to Nov’10. The study population comprised of all children under the age of 16, presenting with congenital and/or developmental cataract. Ethical approval for the study was obtained from the ethics committee of the hospital. Informed consent was taken from caregivers before the interview. Parents or guardians of all children presenting to our hospital with congenital or developmental cataract were interviewed with special questioniers, regarding the actions taken and timing of these, before coming to hospital. The questions were designed to enable us to know the barriers to early detection, early referral and uptake of surgical procedures in children. Demographic information was also collected. The predictors of late presentation were assessed.

RESULTSAt our institute, 84 children were operated between Jan’09 to Nov’10, of which 28 were congenital and 56 developmental cataract. 48 were male and 36 female.

Table 1: Table Showing Delay Period Between Recognition of The Condition To Presentation To Hospital Sl. No. Period (in mon) No. of Cases 1 0-3 1

2 3-6 12

3 6-9 31

4 9-12 12

5 12-15 1

6 15-18 2

7 18-21 0

8 21-24 17

9 24-27 1

10 27-30 4

11 30-33 2

12 33-36 1

Among children with congenital cataract, having another sibling increased the likelihood of early presentation, possibly because their expectations of achievable sight at a young age are based on previous experience of their older children. A long delay in presentation was associated with having developmental cataract.


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Table 2: Table Showing The Most Common Barriers Noted in Our StudySl.No. Cause No. of Cases1 Unawareness of parents that the child is suffering 63 from a treatable condition 2 Lack of knowledge amongst primary level health care 36 provider (traditional and modern) to detect childhood cataract.3 No access to eye care services 154 Family decision not to seek advice 255 Lack of referral or inappropriate advice from traditional 29 or modern health practitioners

Thus, overcoming these barriers is important for developing a framework for care.

DISCUSSIONBlindness caused by childhood cataract in developing countries is primarily a result of inadequate or timely use of surgical services. The shorter the duration between onset of visually impairing cataract and surgery, the greater the likelihood that surgical intervention will lead to a good visual outcome. Children with congenital cataract are more likely to have mature cataracts leading to severe visual deprivation compared to children with developmental cataract in whom the cataract may develop more gradually. Regardless of the type of cataract, early presentation is important for visual outcome.

The excessive delay in presentation in our study population suggests that there are barriers to presentation to surgery, including awareness of the problem (and surgical interventions), access to surgical services, or acceptance of surgical services. The major delay occurred between recognition and presentation (the time the caregivers recognised the problem and sought care from a health worker) rather than between the presentation to treatment delay. This suggests that the primary barriers exist at the community level rather than the provider level; however, presentation to treatment delay is still too long.

Parental understanding of the natural growth and development of infants is a function of community norms as well as experience with raising older children. This understanding becomes much more refined after the experience of observing a child progress through stages of infant development. Thus, the finding that children with congenital cataract who had a sibling (an older sibling) were brought to the hospital sooner than congenital cataract cases without a sibling seems logical.

In conclusion this study proposes that the starting point for comprehensive eye care for children should always be an understanding of the barriers


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to providing cataract care services to children especially in rural and backward areas. It also emphasizes the need for establishing community action for children with cataract while at the same time ensuring that the infrastructure is in place to meet the need for services. Delay in presentation remains a significant problem for children needing surgery for congenital or developmental cataract. Educational efforts should aim to reach the most ‘unreachable’.

REFERENCES1. Foster A, Gilbert C, Rahi J. Epidemiology of cataract in childhood: a global

perspective. J Cataract Refract Surg. 1997;23:601–4. 2. Rahi JS, Dezateux C. National cross sectional study of detection of congenital

and infantile cataract in the United Kingdom: role of childhood screening and surveillance. The British Congenital Cataract Interest Group. BMJ 1999;318:362–5.

3. Gilbert C, Rahi JS, Quinn GE. Visual impairment and blindness in children. In: Johnson GJ, Minassian DC, Weale RA, et al, eds. Epidemiology of eye diseases. London: Arnold Publishers, 2003.

4. Kello AB, Gilbert C. Causes of severe visual impairment and blindness in children in schools for the blind in Ethiopia. Br J Ophthalmol 2003;87:526–30.

5. Waddel KM. Childhood blindness and low vision in Uganda. Eye 1998;12:184–92.6. Van Dijk K, Courtright P. Barriers to surgical intervention among blind and low

vision children in Malawi. Visual Impairment Res 2000;2:75–9.7. Yorston D, Wood M, Foster A. Results of cataract surgery in young children in east

Africa. Br J. Ophthalmol 2001;85:267–71. 8. Lewallen S, Roberts H, Hall AB, et al. Increasing cataract surgery to meet Vision

2020 targets: experience from two rural programmes in east Africa. Br J Ophthalmol 2005;89:1237–40.

Visual Impact of Community Cataract Services by a Tertiary Eye Care Centre in Rural Central India Dr. Ritesh Patidar, Dr. Rahul Shah, Mr. Subramaniam Swami, Dr. Elesh Jain

Cataract is the leading cause of blindness worldwide, and is particularly common in poor and developing countries. Of the total estimated 38

million blind people in the world, 9–12 million are in India.1,2 Report estimates that 50%–80% of these people are blind because of cataract.1,2

Uttar Pradesh (U.P.) and Madhya Pradesh(M.P.) are those states of India which are poor, underdeveloped, lacking resources and having large number of rural population.3 Our study based on community based cataract services in rural areas of 4 districts of M.P.- Satna, Panna, Rewa and Chhatarpur and 7 districts


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of U.P.- Allahabad, Banda, Fatehpur, Hamirpur, Kaushambhi, Chitrakoot and Mahoba. These districts cover around 1.86% of total Indian population (census 2011).4

Productivity per individual surgeon/unit should be increased through a high volume, high quality cataract surgery approach to solve the problem of India’s curable blindness.5 This need increase in number of cataract surgeries, while maintaining high quality surgery. Some recent studies of high volume cataract surgery in India and Nepal report good results.6,7,8,9,10,11,12 Cataract Surgery Rate (CSR) is no. of cataract surgeries done per million populations in a year. Target CSR in India is presently 4000/million/year.13

To study Visual Impact of Community Cataract Services conducted by Sadguru Netra Chikitsalaya, Chitrakoot for reducing blindness due to cataract in M.P. and U.P.

MATERIALS AND METHODS Our study design was retrospective Analysis. Total 54,322 Cataract patients through outreach camps, vision centers and teleophthalmology from 4 districts of M.P. and 7 districts of U.P. mentioned earlier in study operated from April 2008 to March 2011 at Sadguru Netra Chikitsalaya, Chitrakoot included in the study. Patients operated for cataract at our hospital which are not under CCS were not included in study. Surgical procedures were Extra Capsular Cataract Extraction (ECCE), Small Incision Cataract Surgery (SICS) and Phacoemulsification with PCIOL implantation. Cataract Surgery Rate (CSR) calculated for yr. 2008-09, 2009-10 and 2010-11. Preoperative and postoperative 1 month follow-up visual acuity noted and categorized.

RESULTSCataract surgeries performed by Community Cataract Services(CCS) of our hospital:

2008-09:- 10,604

2009-10:- 20,837

2010-11:- 22,881

Year wise data of patients through outreach, vision centres and tele-ophthalmology: Year Outreach Vision Tele- Total Growth camps Centres ophthalmology from Yr. 08-092008-09 10604 0 0 10604 2009-10 12840 (61.62%) 7997 (38.38%) 0 20837 196.5%2010-11 12515 (54.70%) 9014 (39.39%) 1352 (5.91%) 22881 215.78%


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Comparison of total cataract surgeries and cataract surgeries under CCS at our hospital:

Year Total cataract surgeries at Cataract surgeries under CCS % our hospital 2008-09 66,730 10,604 15.89%2009-10 77,684 20,837 26.82%2010-11 82,602 22,881 27.70%

Population coverage of Community cataract services of our hospital was 2,15,09,389 in year 2008-09; 2,19,16,287 in year 2009-10 and 2,23,30,882 in year 2010-11.

Cataract Surgery Rate of community cataract services of our hospital:

2008-09: 493/million/yr. (12.32% of target)

2009-10: 950.75/million/yr. (23.77% of target)

2010-11: 1024.63/million/yr. (25.62% of target)

Visual acuity analysis (BCVA) results:

Year Pre-op. BCVA 1 Month Follow-up BCVA 6/6-6/18 6/24-6/60 <6/60 6/6-6/18 6/24-6/60 <6/602008-09 0.78% 6.69% 92.53% 88.15% 6.51% 5.34%2009-10 0.87% 8.40% 90.73% 92.53% 5.44% 2.03%2010-11 0.82% 8.56% 90.62% 93.74% 4.29% 1.97%Total 0.83% 7.94% 91.23% 92.44% 4.92% 2.64%

In 2009-10 and 2010-11, 73.30% and 73.92% of follow-up patients respectively had visual acuity between 6/6-6/12. The follow-up rates for 2009-10 and 2010-11 were 67.14% and 62.15% respectively.

DISCUSSIONOther studies- Post operative BCVA:

Study Site Sample Size Follow – 6/6-6/18 6/24-6/60 <6/60 up Duration LSFEH, Malawi 14 1070 8-25 weeks 86.90% 9.50% 3.60%Madurai , India 15 1469 1 yr. 98.10% 1.30% 0.60%Lahan , Nepal 15 311 1 yr. 93.30% 4.80% 1.90%Satkhira, Bangladesh 16 213 Up to 5 yrs. 67.60% 12.20% 20.20%Our study 54,322 1 month 92.44% 4.92% 2.64%

Strength of our study was huge sample size more than that of other studies.


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The post operative visual outcome was comparable with other studies. High volume cataract surgeries in our study were not compromising quality of surgery (92.44% patients having post operative BCVA between 6/6-6/18).

In conclusion community cataract services of our hospital were effective for reducing burden of blindness due to cataract in the catchment areas. Quantity of surgeries did not compromise quality of visual impact.

REFERENCES1. Jose R . National programme for control of blindness. Indian J Commun Health

1997;3:5–9.2. Dandona L , Dandona R, Naduvilath T, et al. Is the current eye-care policy focus

almost exclusively on cataract adequate to deal with blindness in India? Lancet 1998;351:1312–6.

3. http://www.planningcommission.gov.in/aboutus/speech/spemsa/msa007.pdf4. Census of india 2011- http://www.censusindia.net; http://censusindia.gov.in5. Natchiar G , Robin AL, Ravilla D, et al. Attacking the backlog of India’s curable

blind. Arch Ophthalmol 1994;112:987–93.6. Natchiar G , DabralKar T. Manual small incision suture less cataract surgery—an

alternative technique to instrumental phacoemulsification. Operative Techniques Cataract Refract Surg. 2000;3:161–70.

7. Balent LC, Narendran K, Patel S, et al. High volume sutureless intraocular lens surgery in a rural eye camp in India. Ophthalmic Surg Lasers 2001;32:446–55.

8. Prajna NV, Chandrakanth Ks, Kim R. et al The Madurai intraocular lens study II: Clinical outcomes. Am J Ophthalmol 1998;125:14–25.

9. Civerchia L , Apoorvananda SW, Natchiar G, et al. Intraocular lens implantation in rural India. Ophthalmic Surg Lasers 1993;24:648–53.

10. Civerchia L , Ravindran RD, Apoorvananda SW, et al. High volume intraocular lens surgery in a rural eye camp in India. Ophthalmic Surg Lasers 1996;27:200–8.

11. Ruit S , Tabin GC, Nissman SA, et al. Low cost high volume extracapsular cataract extraction with posterior chamber intraocular lens implantation in Nepal. Ophthalmology 1999;106:1887–92.

12. Hennig A , Kumar J, Yorston D, et al. Sutureless cataract surgery with nucleus extraction: outcome of a prospective study in Nepal. Br J Ophthalmol 2003;87:266–70.

13. Textbook of Preventive and Social Medicine , Park’s ,20th edition14. Moses C. Chirambo et al; Community Eye Health 2002;Vol 15, No. 4415. Lalit Dhandhona et al; Community Eye Health 2000;Vol 13 No. 35.16. Causes of poor outcome after cataract surgery in Satkhira district, Bangladesh; R

Lindfield et al. Eye 2008;22:1054–6; doi:10.1038/sj.eye.6702836; published online 13 April 2007.


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Paediatric Low Vision: Magnitude, Interventions, Determinants and ComplianceDr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir Taras

To assess the low vision problem and its management along with impact assessment in paediatric population

Objectives : A study in paediatric population (children from blind schools and paediatric patients visiting the low vision department of a tertiary eye care centre) between October 1st 2007 and October 1st 2008, so as to -

1. Find out the magnitude of low vision in children aged 0-16 years in two sample populations, viz schools for the blind and a tertiary eye care hospital.

2. Identify the determinants (causes) of low vision in children.

3. Manage / treat the children with low vision by providing low vision devices (optical and non optical) and giving suggestions for environmental modifications.

4. Assess the compliance and impact on the quality of life at the end of 3 months and 9 months.

MATERIALS AND METHODS• cross-sectional study was done ;

• a comprehensive data was collected from children aged 0-16 years, attending schools for blind in and around Pune between November 1st 2007 and September 1st 2008.

• Entire examination done by a team of ophthalmologists, low vision specialist, optometrist and retina specialist.

• Data collected comprises clinical and demographic details and educational status.

• Case record includes a special modified version of WHO/PBL eye examination record for children with blindness; including entire low vision assessment ,prescription of low vision devices.

• The record has a detailed history with age at onset of visual loss, consanguinity and cause of visual impairment .

• Visual functions were assessed using Lea symbols chart for distance and near acuity, Low contrast Flip chart with Lea symbols for contrast sensitivity


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• Complete refraction followed by Evaluation for low vision aids was done.

• Appropriate spectacle and low vision aid (optical and/or non optical) - provided based on the needs with specific training to use them.

• Compliance was checked by observation in the follow up (whether child was wearing/using the aid or not) and by verbal questions regarding the reason for not using the aid.

• Assessment of outdoor and indoor activities was done by means of leading questions related to mobility ,recognition of faces and objects ,own daily routine work, playing , art work (cane work)was also done

RESULTS• In the schools for blind 19.1% children and in the tertiary eye care 1.7%

were found to have low vision

• Majority of children from the schools for blind, i.e. 51.7%, had whole globe anomalies like microphthalmos as the determinant of low vision followed by retinal causes like heredomacular degeneration etc. (28.3%) and others. On the other hand, the majority of children from the tertiary eye care centre had retinal lesions as the determinant of low vision followed by whole globe anomalies

• In the schools for blind, 16.7% children improved to the 6/18-6/9 range of distance vision. All the children with vision (less than) <6/60 showed improvement in vision. Out of 52 children who had vision <6/24, 35 [58.33%] improved to equal to or (more than) >6/24 range. This is statistically significant by t-test, p value <0.01.

• In the tertiary eye care centre, 15.1% children improved to the 6/18 - 6/9 range. 10 of 18 children i.e. 18.86% with vision <6/60 showed improvement in vision. Out of 49 who had vision <6/24, 24 [45.28%] improved to >6/24 range which is statistically significant by t test with p value <0.05.

• After correction, 61.7% in blind schools and 67.9% in the tertiary eye care centre had their near vision improved to the range of 1.6M – 1M [N12-N8]. This is statistically significant with p value <0.05 by t-test.

• All the children from schools for blind were given optical and non optical aids.

• Only 7.5% of children from tertiary eye care centre showed no improvement with aids tried.

• In schools for blind: Out of 60 who were given aids, only 8.3% broke their aids while 2 [3.3%] found it difficult to use the aid, 3 [5%] left the aid somewhere. This suggests that only 5 children were probably not very


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happy with the aid. In tertiary eye care centre: only 1.9% found it difficult to use the aid and another 1.9% broke the aid

• 96.7% children from schools for blind and 92.5% from tertiary eye care centre were dependent in their mobility but with the use of aids provided 61.7% from the schools for blind and 52.8% from the tertiary eye care centre became independent.

• 58.3% children from schools for blind and 35.8% from tertiary eye care centre could comfortably play outdoors with the aids provided.

• 5% children from schools for blind and 7.5 % from the tertiary eye care centre could cross the roads independently with the aids provided

• With regular use of aids: 35% children from schools for blind and 45.3% from the tertiary eye care centre learnt to read. 63.3% children from schools for blind and 50.9% from the tertiary eye care centre started to recognize faces and objects at 3m. 61.7% children from schools for blind and 41.5% from the tertiary eye care centre could wash and maintain their clothes better with the aids

In conclusion Low vision/ “partial sight” can be managed well with low vision services thereby improving the quality of life of children with low vision.

Thus,its important to screen out patients of low vision from blind schools to provide them with appropriate aids.

More so in children as early management and provision of aids will help them cope with their daily needs, social and educational needs as well.

Retinopathy of Prematurity is A Major Cause of Childhood Blindness in Pune RegionDr. Kuldeep Dole, Dr. Madan Deshpande, Dr. Sucheta Kshirsagar, Dr. Tanmayi Dhamankar

Retinopathy of prematurity (ROP) is a vasoproliferative retinopathy which occurs principally, but not exclusively, in premature infants of very low

birth weight who have been exposed to high ambient oxygen concentrations.1 It occurs in 2 overlapping phases:

1) An acute phase in which normal vasculogenesis is interrupted and a response to injury is observable in the retina.

2) A chronic or late proliferative phase in which membranes grow into the vitreous causing tractional retinal detachment,ectopia or macular scarring leading to severe visual loss.


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The proportion of childhood blindness due to retinopathy of prematurity in different parts of the world : Europe- 17%, L.America-38.6%, E.Europe: 25.9%, Asia: 16.9%, Africa: 10.6%.

[SOURCE: Gilbert C.,Retinopathy of Prematurity Epidemiology, Journal of Community Eye Health 10(22):22-4]

In developing countries with a human development index (HDI) of 31-100, ROP is emerging as a major cause of blindness. The reasons were higher premature birth rates and compromised neonatal screening as a result of a lack of resources, lack of awareness, skilled personnel and financial constraints. In poorly developed countries (United Nation Development Program [UNDP] ranking <100) blindness from ROP is virtually unknown,as services for the care of the premature infants are not well developed and the preterm infants do not survive long enough to develop severe ROP.2

The incidence of ROP in neonatal intensive care units (NICUs) or referral to tertiary care hospital in India ranged from approximately 21 to 40%. There is decreasing trend of severe ROP(stage 3)from 46% in 1993-94 to 21% in 1999-2000. In a multivariate analysis,apnea,sepsis and male sex were significant risk factors.3

Available data shows that neonatal intensive care is improving in developing countries like India,as a result of which infant mortality rates have declined (IMR range 9-60/1000 live births).4 As the survival of premature infants is increasing, so is the problem of ROP.

Most of the data of childhood blindness comes from examining children in schools for the blind, as they are readily accessible. In previous studies from blind schools of Maharashtra conducted in 1993 and 2005, ROP blindness does not figure prominently. There is a changing pattern in retinal blindness from 13.8% (in 1993) to 11.2% (in 2005),but no literature is available to comment on blindness due to ROP. Also, these figures reflect blindness statistics of about 10 years back as the children were 10-15 years at the time of examination.

Hence,we collected hospital based data and schools for the blind data in 2010 at Pune to know the recent trends of ROP blindness.

To know the recent trends of ROP blindness among children from schools for the blind and OPD of a tertiary eye care centre in Pune.

Objectives:

1) To examine children(0-16 yrs) with blindness (BCVA< 6/60 in better eye) with respect to anatomical and etiological causes.

2) To identify children with blindness due to ROP and analyse their demographic characteristics.


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MATERIALS AND METHODSA duration based cross sectional study was conducted between 1st October 2010 and 31st March 2011 in children from three schools for the blind in Pune as well as children attending paediatric clinic at H V Desai Eye Hospitl, Pune, after obtaining clearance from institutional ethics committee and written consent from the respective head of institution of the schools for the blind for the examination of inmates.Complete Ophthalmological examination as per the Who/Pbl Eye Examination Record for Children with Blindness and Low Vision6 was done using preverbal visual acuity charts (for children of 0-6 years) and LogMAR visual acuity charts (for children of 7-16 years), slit lamp, direct and indirect ophthalmoscopes and 90D lens wherever possible. Indian definition of blindness was used- best corrected visual acuity <6/60 in better eye.A child was identified as having ROP if: Definite: tractional retinal detachment or retrolental fibroplasia and a history of prematurity or low birth weight, or prolonged intensive neonatal care.

Suspected: tractional retinal detachment without a confirmatory history.6

RESULTSAll 243 children from 3 schools for the blind and 71 children with blindness from OPD were examined.

Table 1: Causes of blindness for schools and OPDAnalysis Anatomical Gender Percentage (%) diagnosis Male Female Total Male FemaleSchool Whole globe 45 82 127 35.43 64.57 Cornea 2 18 20 10.00 90.00 Lens 6 16 22 27.27 72.73 Retina 21 32 53 39.62 60.38 Optic nerve 1 8 9 11.11 88.89 Others 1 1 2 50.00 50.00 Total 76 157 233 OPD Whole globe 7 2 9 77.78 22.22 Cornea 3 1 4 75.00 25.00 Lens 6 5 11 54.55 45.45 Uvea 0 1 1 0.00 100.00 Retina 18 8 26 69.23 30.77 Optic nerve 3 0 3 100.00 0.00 Others 1 4 5 20.00 80.00 Total 38 21 59


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Among those blind due to retinal causes in the schools for the blind,,14 (25%) children had ROP ,while the corresponding figures for OPD children were 13 (44.8%).

Demographic Description of Children with Rop BlindnessSchool Data: (Total 14)

Age and Gender distribution: 0-5 yrs – 1, 6-10 yrs- 8, 11-16 yrs- 5

Males: 5, females: 9

OPD Data: (Total 13)

Age and gender distribution: 0-5 yrs- 12, 6-10 yrs- 1

Males: 9, females: 4

Among the 13 OPD children, 5 underwent vitrectomy with anatomical success; they are being followed up for visual recovery.

DISCUSSIONAs compared to previous blind school studies from Maharashtra, the percentage of retinal blindness in general has increased. In the schools for the blind, 22.7% were blind due to retinal causes and 6% due to ROP alone. The corresponding figures for OPD children were 44% and 22% respectively. The data from schools reflects trends of about 10 years ago. The OPD data reflects current trends as most of the examined children were under 5 years of age.Hence we can say that blindness due to ROP is truly on the rise.

All children with ROP from the schools as well as the OPD were from urban areas. This shows that premature babies are more likely to survive in urban areas as a result of improved neonatal intensive care and hence more likely to develop ROP. Also, families from urban areas are more likely to enroll their children in blind schools and seek consultation at a tertiary eye care centre. None of the affected children had any additional disabilities.

In conslusion ROP is emerging as a major cause of childhood blindness as a result of increased survival of premature and low birth weight babies owing to the improved neonatal care facilities, especially in urban areas. The facilities for screening for ROP are still lacking in these centres.

Hence,there is an urgent need to establish ROP screening programme and train more people in detection and treatment of Retinopathy of prematurity .Also a monitoring mechanism should be established for neonatal intensive care units to prevent occurrence of ROP. This is especially relevant in urban areas where survival of premature babies has increased.


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REFERENCES1. Terry TL,Extreme prematurity and fibrovascular overgrowth of persistent vascular

sheath behind each crystalline lens. Am J Ophthalmol 1942;25:203.2. Nazimul H.,Khanna R.,Anjli H., Expert Rev Ophthalmol. 2008;3:43-50.3. Agarwal R. et al, Changing profile of retinopathy of prematurity, J Trop Paediatr

2002;48:239-42.4. C Gilbert, Retinopaty Of Prematurity: A Global perspective of the epidemics,

population of babies at risk and implications for control. Early Human Development 2008;84:77-82.

5. Gogate et al, Changing pattern of childhood blindness in Maharashtra, India. Br J Ophthalmol 2007;91:8-12.

6. Preventing Blindness in Children, WHO Publication Number WHO/PBL/00.77, 1999.

7. Gogate P, Kishore H, Dole K, Shetty J, Gilbert C, et al. The pattern of childhood blindness in Karnataka, South India. Ophthal Epidemiol. 2009;16:212–7.

8. J S Titiyal, N Pal, G V S Murthy, S K Gupta, R Tandon, R B Vajpayee, C E Gilbert.Causes and temporal trends of blindness and severe visual impairment in children in schools for the blind in North India. Br J Ophthalmol 2003;87:941–5.

Assessment of Compliance in Children (0-16 Yrs) using Low Vision AidsDr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir Taras

To check the compliance in children using low vision aids and thereby its impact on their quality of life.

A study in paediatric population (children from blind schools and paediatric patients visiting the low vision department of a tertiary eye care centre) between October 1st 2007 and October 1st 2008, so as to Assess the compliance and impact on the quality of life at the end of 3 months and 9 months.

MATERIALS AND METHODSAfter a complete low vision evaluation appropriate aids were prescribed to the children. The use of the prescribed device was demonstrated and children were taught to use it before dispensing in order to ensure good compliance. Instructions regarding the do’s and don’ts were explained in the local language when the trial was over. Instructions about the needed environmental modifications were also given, e.g. seating arrangement in the class room.


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Next follow up date was given to the patient: first at 3 months and second at 9 months from the first assessment/visit. Two follow up examinations were done at three months and nine months respectively from the first examination. Children and accompanying guardian were advised to report for the next follow up visit with the aid prescribed. At each follow up visit, the compliance and change in the quality of life of these children were assessed.

Examination at each follow up visit included an ophthalmologic work up including torch light examination, assessment of best corrected visual acuity, and the children were administered a questionnaire to assess the use and satisfaction with the device in the interim period. Direct questions were asked regarding the use of the device provided and the reasons, if any, for not using it as well. The quality of life was assessed on the basis of the changes noticed in mobility, recognition and other outdoor, routine and vocational activities. Additional/ new activities, which the children had started performing after using the devices provided, were also noted as told by the children.

RESULTS• In schools for blind: Out of initial 60 children with low vision, 44 [73.3%]

children were present during the second follow up and 21.7% were using the aid as advised. In tertiary eye care centre: Out of the 53 children with low vision, 36 [67.9%] were present for the second follow up and 66% were using the aid as advised. Thus, at the second follow up more number of children from tertiary eye care centre were found using the aids

• Out of 60 children from schools for blind who were given aids, only 8.33% broke their aids while 2 [3.3%] found it difficult to use the aid, 6 [10%] left the aid somewhere. This suggests that only 8 children probably did not appreciate any significant improvement in their activities over a longer period (9 months from first examination) with the aids.

• With the use of aids provided 29 [48.3%] of the initial 60 children with low vision from the schools for blind and 31 of the 53 [58.5%] from the tertiary eye care centre were independent in their mobility. Out of 60, 30 children from schools for blind and 19 of 53 from tertiary eye care centre could comfortably play outdoors. 5% children from schools for blind and 7.5 % from the tertiary eye care centre could cross the roads independently with their aids.

• At second follow up 23.3% children from the schools for blind could read and write. 48.3% had better recognition of faces and objects at 3m and could wash; maintain their clothes better. In tertiary eye care centre 50.9% children were found to be able to read and write. 62.3% had better recognition of faces and objects at 3m and could wash; maintain their clothes better.


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• 46.7% children from the schools from blind and 60.4% from the tertiary eye care centre improvement in the craft work. This is statistically significant by t-test, p value <0.01.

• With the aids these children could perform routine activities, near and distance activities like opening the cupboard with a key, seeing time on the wrist watch, walking independently etc. One child from the blind school could now see the numbers on the state transport buses. Another child from the tertiary eye care centre noticed improvement in writing on a line.

In conclusion:

• Compliance, as measured in terms of attendance [83.3%, 62.3%] and regular usage of aids provided [66.7%, 58.5%], along with improvement in routine and outdoor activities proves the beneficial change noticed in the quality of life at an individual level by the children with low vision.

• It was very heartening to note that improvement in vocational activities [craft work] was seen in these children, at 3 month follow up [61%, 49.1%] and 9 month follow up [46.7%, 60.4%] in the blind schools and tertiary eye care centre. This assures a very good future for them in getting vocationally settled in life by betterment in these activities.

Importance of Medical and Patient Care Audit in Community Ophthalmic Outreach ProgrammeDr. Zawar Swati Vijay, Dr. Mamta Singh

Initially Quality in health care was an intangible concept. But rapidly changing technology, involvement of medico-legal standards, increased

awareness and demand of the patients has made it necessary to measure quality in delivery of eye care whether free or paying.

Clinical and patient care audit is a tool which we have used to monitor Quality of our community ophthalmic outreach programme to analyze surgical quality, efficacy of follow-up system, behavior of the hospital staff with the patients and to know whether they have comfortable stay in the hospital.

Aims and Objectives

1. To ensure the quality of clinical and surgical services provided to the patients.

2. To analyze patient satisfaction index about hospital services and the entire process of eye care.

3. To study the socio-economic impact of the program.


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4. To review, analyze and study at least 10% operated patients

5. To verify optimal utilization of the resources.

Methodology

Tulsi eye hospital conducts two types of audits to achieve the above aims.

1. Medical field audit

2. Patient care audit

The community ophthalmic outreach programme of Tulsi eye Hospital is spread over in six districts and covers 2.5 million population. For medical field audit a separate auditor who is a senior ophthalmologist in the city is appointed. The list of operated patients is provided to the auditor. The auditor does random selection of area and random sampling of the patients. The list is given to the concerned social worker of that area and the patients are called at the nearby center established by the hospital for routine follow-up and pick up of the patients. In each visit approximately 35 to 40 patients are called and examined. Auditor makes monthly 2 visits to project catchment area. Thus in a year almost 800 -900 patients are examined by the auditor against the target of 8000 free surgeries per year (10%).

The patients who are operated in between 3 mths to 1 year are selected for the audit. Audit team comprises of Auditor, Optometrist or Ophthalmic assistant and social worker. Auditor is provided with hand held slit lamp and hand held autorefractometer. A questionnaire is provided to the auditor.

After the audit report is prepared it is submitted to the hospital authorities. The previous medical record of the patient is checked to find whether it is a surgical complication or pre-existing problem or newly arrived ocular problem. Problematic patients are again called to the base hospital for treatment.

MATERIALS AND METHODSMission for Vision which is the umbrella body under which Tulsi Eye Hospital functions has a dedicated Patient Care Team who is responsible for evaluating the quality of Patient Care that is provided by the hospitals to all the patients. The patient care team ensure the highest level of care to the patient, be it at the camp, during transit or at the hospital. The team conducts an ongoing evaluation with the parameters constantly being modified and improved with an aim to know whether complete ophthalmological care is provided to every patient with dignity.

Team is leaded by General Manager –Patient Care under whom there are four Zonal coordinators and under each zonal coordinator there are 5-6 field social workers.


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Following activities are carried out by patient care department:a. Door to door surveyb. Involving in camp activityc. Monitoring and documenting the results.d. Conducting field level impact studye. Case study selectionf. Referring and follow-up of problematic cases

RESULTS Patient Care Audit (April 2010 March 2011) Patients Surveyed (Nos) 1014 Eyes Surveyed (Nos) 1334 One Eye Operated (Nos) 694 Both Eyes Operated (Nos) 320 Male | Female 412 I 602 Percentage (%) 41% I 59%

Vision Acuity classification Survey vision(best corrected) Eyes (Nos) Percentage (%) Good (6/6-6/18) 763 88% Borderline(6/24-6/60) 96 11% Poor(<6/60) 08 1% Total 867 100%

Ocular Complaints Complaints Patients (Nos) Percentage (%) Watering 36 2.70 Itching 10 0.75 Red eye 12 0.90 Pain 2 0.15

Difference in Life Style Life Style Change Patients (Nos) Percentage (%)Ability to carry out daily activities without help. 1014 100.00Ability to help in household works. 1012 99.80Ability to work and earn. 514 50.69

a) 100% patients were back to work atleast helping in the household work.b) Watering was the commonest complaint but it was not related to surgery.c) 88% of the patients have good visual acuity as per W.H.O. standards.d) 2% of the patients are brought back to the base hospital for further


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management like YAG laser, secondary IOLs, Refractionse) It helped us in improvising the instructions given on the discharge card.f) It helped us to modify the diet given to the patients.g) Females are more compared to males for free surgeries.

DISCUSSIONThere are many charity hospitals in India giving comprehensive eye care to poor and downtrodden people in affordable cost or even free. These hospitals majority of the times run on donations or on some government schemes. Patients are admitted in the hospital for minimum three days. As patients come from long distance it is usually preferred that they will be discharged next day. When patients are admitted in the hospital usually they are under obligation and fear. So to get a proper feedback about the hospital services we have started with this patient care audit and medical field audit.

Patients are selected for medical field audit who are operated in between three months to one year because the hospital team is in contact with the patient for two months in which three consecutive follow-ups of 15 days interval are done and in 4th follow-up they get spectacles. Patient care audit team does door to door survey to know socioeconomic condition and impact and to collect case studies. They attend even the follow-up camps to know about patient comfort in the hospital

The audit is done to measure the quality of care we provide against relevant standards. It is helping us to set priorities and make improvements. It has created a confidence in the management about proper and optimal utilization of its resources

We cannot compare our findings with any other data or literature because to the best of our knowledge this is the first survey or audit done at the field by actual interaction with the patients.

In conclusion:1. Medical field audit is an effective and powerful tool which can be used

to monitor Quality in eye care delivery and to provide evidence for the specific resources to increase quality standards or performance

2. As we remain in contact with the patients for a long period it helped us in building the name of the hospital in the society and mouth to mouth publicity and improves patient confidence about the service delivery.

3. It monitors the performance continuously to ensure results and identifies trends in attendance for eye surgery

4. Third party Audit gives unbiased picture.


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School Eye Health Screening Programme in Ahmedabad District – ‘Making The Invisible Visible’Dr. Priyanka Gupta, Dr. Pina Rasiklal Soni, Dr. Minal Patel

The school going years are the formative years for determining one’s physical, intellectual and behavioural development. Any problem in

vision during the formative years can hamper the intellectual development, maturity and performance of a person in his future life. Children in the school going age represent over 25% of the population in the developing countries. Every five seconds one person in the world goes blind…and a child goes blind every minute. Childhood blindness is one of the most tragic and wasteful global problem. The teachers see their pupils daily so it is possible for them to observe the behaviour of their students to facilitate early detection of eye problems.

MATERIALS AND METHODSThis is a retrospective study conducted in the schools of Ahmedabad district in the year 2009 to evaluate the usefulness of school teachers in detecting ocular morbidity amongst school children. The school eye health screening programme was initiated by District Collector of Ahmedabad in association with district development officer, district education officer, district health officer, civil surgeon and programme officer of District Blindness Control Society. As a part of the programme, the Principal of school selected teachers for vision screening task. The general norm is one teacher per 300 students per school. The teachers were then given one day training and kits by the ophthalmic assistants. The teachers then screened the students according to the set criteria. Students not able to recognize the E chart at 6 metres distance with each eye separately in bright light or having other eye problems were then included in the list. Ophthalmic assistants screened these students as well as the students not covered by the teachers. Children with minor ailments were treated on the spot in the school. Children requiring examination by specialists were sent to the related referral centers. Spectacles were distributed amongst students with refractory errors.

RESULTS AND DISCUSSION Eleven talukas (including Ahmedabad city) of Ahmedabad district have a total of 1800 schools out of which 1245 (69.16%) schools were screened by the trained teachers. 555 (30.83%) schools could not be screened by the teachers due to the lack of manpower. However, the ophthalmic assistants screened 226 schools of the left out ones.


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A total of 3,19,903 students were screened. 28,317 (8.85%) students were detected to have some ocular problem, which corresponds well to the prevalence of ocular problems in Gujarat. This points to a good screening conducted by the teachers and the ophthalmic assistants. Out of these 28,317 students, majority, 12,408 students (43.81%) were found to have refractory error. Hence, even today refractory error constitute the major cause of ocular morbidity amongst school children. 7750 (27.37%) students had minor ailments like conjunctivitis, vitamin A deficiency, colour blindness. 441 students were referred to higher centres for conditions like cataract, squint, congenital anomalies, ptosis etc. Rest 7718 (27.25%) students were false positive detections by the teachers.

All the 12,408 students having refractory errors were given spectacles free of cost. Amongst the 441 students referred to higher centres, 25 (5.66%) had cataract, 288 (65.3%) had squint and 168 (38.1%) had congenital anomalies like ptosis, coloboma.

In conclusion in every community children are the most important assets and future of nation lies in their hands. They must be at the very heart of “development”. Their well being, capabilities, knowledge and energy will determine the future of Nation as a whole.

Globally, about 70 million blind person years are caused by childhood blindness. The major cause of ocular morbidity in school children is refractory error which is very much a preventable cause of blindness. Participation of school teachers and integration of ophthalmic assistants and ophthalmologists in the programme can work significantly to reduce the prevalence of childhood blindness.

REFERENCES1. Vision screening in school children. Training module. Danish Assistance to the

National Programme for Control of Blindness. New Delhi, India: 1.2. Role of optometry in vision 2020. Community eye health; vol 15, No 43; 2002, 35-363. Gupta M, Gupta BP, Chauhan A, Bhardwaj A. Ocular morbidity prevalence among

school children in Shimla, Himachal, North India. Indian J Ophthalmol 2009;57:133-8.

4. Desai S, Desai R, Desai NC, Lohiya S, Bhargava G, Kumar K. School eye health appraisal. Indian J Ophthalmol 1989;37:173-5.


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Tele-Ophthalmology and Community Eye Care: Early Experiences, Successes and Pitfalls Dr. Jnanankar Medhi, Dr. Kalyan Das, Dr. Harsha Bhattacharji

The large majority of Indian populace lives in villages and remote areas where specialist level medical care is not available. The need for the

patients to travel from their villages to the urban areas for treatment is one of the major hurdles in the health care sector. The loss of wages of the patient concerned along with his attendant acts as a major deterrent, not to speak of the hesitation to visit a specialist hospital along with the cost issues. Many a time, geographical hurdles, communication difficulties, other co-existing old age diseases also prevent a person from traveling and seeking medical care. The modern communication technology has come a long way and is being used in health care delivery sector to try to bridge the gap through what is commonly know as Tele-Medicine. Use of tele-medicine principles for facilitating similar services in ophthalmology is known as Tele-Ophthalmology.

Tele-ophthalmology services can be rendered through two major formats viz ‘Store and Forward’ method and ‘Real time’ method. A third format of a hybrid of the above two formats is also practised. In the store and forward format, patient details and clinical pictures can be sent over e-mail or uploaded to a website wherein a specialist, usually in a different location/institution can access the data and give their opinions regarding the management of the case. In “Real time” format, the patient can do a video-consultation with the specialist using VSAT satellite connection or even with a webcam over the internet. Hybrid Format uses the best of both formats.

Sri Sankaradeva Nethralaya utilizes both types of format in rendering patient care through tele-consultation services. The Store and Forward has been in use in Sri Sankaradeva Nethralaya (SSN) for more than 6 years in collaboration with ORBIS. The ‘Real Time’ format was started in SSN from October 2010 and since then has conducted 30 camps and screening more than 6000 patients. SSN has a well established system of conducting community eye check up camps on a weekly basis held on every Sunday. The Tele-ophthalmology Service Van visits these camps with all the necessary diagnostic instruments like photo slit lamp, Fundus camera, Autorefractometer. These camps are managed by optometrists and a well defined work flow chart is adhered to. Any patient requiring a specialist consultation is taken up for tele-ophthalmology services.

COMMUNITY / SOCIAL OPHTHALMOLOGY - IIChairman: Dr. Gangadhara Reddy G.V.B.K. Co-Chairman: Dr. Sriramamurthy C.

Convenor: Dr. Saibaba Goud; Moderator: Dr. Somen Misra


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Visual acuity, refraction values and photographic documentation of the anterior segment and posterior segment are done and sent through e-mail to the Central hub at SSN. A specialist in SSN goes through the case details and at a mutually appointed time during camp hours, a video conferencing is set-up with patient at the camp end with the specialist at SSN. So far the video consultation has been going on using a data card with free-to-use Skype software.

Following is the break-up of the services provided so far. Sl No. 1 Total No of Camps 30 2 Total No Of Patients Screened 6316 3 Average patients per camp 210.53 4 Total Tele-Ophthalmology consultation cases 102 5 Average no of Tele-Oph Consultation cases per camp 4 (average) 6 Patient Epidemiology (M:F) 1.2 :1 7 Districts Covered 7 8 Average camp distance covered ( one way ) 66.38 Km Nearest camp : 10 Km Farthest Camp : 143.5 Km 9 Connectivity success using BSNL Data-card 23.33%

Poor connectivity at 24 % is a key issue. In the instances where we could successfully connect, patients could be provided guidance regarding further management of their disease process. This saves the patient the travel time and expenses to the city hospital. Cases which required further investigation or intervention was called to SSN. VSAT satellite connectivity from ISRO is also being used in Tele-Ophthalmology services. SSN is awaiting a VSAT connection from ISRO and considering the geographical terrain in the North east, we believe VSAT would be the ideal medium to reach and communicate even from the remotest area.

The major issue as noted above is the connectivity issue. Non–accessibility of internet services using the data-card from the remote villages/campsites is the biggest hurdle and has been the most important limiting factor of successful running of camps and delivery of consultation. It is seen that even in areas where the data-card internet was not working, mobile phones were having network connectivity. Development of newer mobile technologies whereby jpeg files or word documents can be sent and received through mobile phones to the central hub would definitely be a great boon. The tele-communication sector has a very significant role to play in this aspect and we are open to collaborations to develop a working technology model in delivery of patient care amongst the masses in the underserved areas.


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Blindness and Visual Impairment in Konkan, MaharashtraDr. Anil Kulkarni, Dr. Shailbala Patil, Dr. Siddharth Vora, Dr. Parikshit Gogate

There have been large surveys looking at the prevalence and causes of blindness across different states in the country, but they had data from a

single district in each state and there are vast differences amongst the populace and services amongst the large states like Maharashtra. Sindhudurg, nestled in the south Konkan region, the western coastal strip, has long been a neglected region. It is geographically secluded even though it is a few kilometer’s drive from Mumbai and across a creek from Goa. Eye care services are negligible in the region and hence it was chosen to map the blindness pattern using the extended RAAB methodology.

The main aim of this study were to estimate the prevalence and causes of avoidable blindness and visual impairment in people aged 50 and above. Stratified cluster random sampling was used for the survey. The sampling universe consisted of all those who were living in the district (staying in the village/town for at least the previous six months). 2500 individuals aged 50+ were needed to be examined in the district. Clusters of 50 people who were 50 years and above were selected with probability proportionate to size using a multistage cluster random sampling method. A total of 55 clusters (49 rural and 6 urban) were covered, 50 individuals aged >50 years were examined in each cluster. Total number of subjects examined was 2747.

Table 1: Age and Sex wise distribution of sample population Age group Male % Female % Total %

50 - 59 643 46.4% 648 47.7% 1291 47.0% 60 - 69 453 32.7% 485 35.7% 938 34.2% 70 - 79 234 16.9% 184 13.5% 418 15.2% 80 - 89 41 3.0% 29 2.1% 70 2.6% 90 + 16 1.2% 14 1.0% 30 1.1% Total 1387 100.0% 1360 100.0% 2747 100.0%

The mean age was 61.8 yrs with 50.6% males and 49.4% females.


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Table 2: Presenting Vision Frequency Percentcan see 6/18 1415 51.69894cannot see 6/18 but can see 6/60 924 33.75959cannot see 6/60 but can see 3/60 266 9.71867Cannot see 3/60 but can perceive Light. 107 3.90939no light perception (PL-) 25 0.913409Total 2737 100

Amongst those examined 1415 (51.7%) had visual acuity (VA) >6/18, 924 (33.8%) had VA 6/60-<6/18(visual impairment), 266 (9.7%) had VA <6/60-3/60 (severe visual impairment) and 132 (4.8%) had VA <3/60 (blindness by WHO standards).

Table 3: Causes of Blindness Causes of Blindness <3/60 <6/60 # % # %Cataract 80 69.0% 309 82.4%Phthisis/globe abnormality 3 2.6% 3 0.8%Corneal pathology 4 3.5% 7 1.97%Glaucoma 2 1.7% 3 0.8%Diabetic retinopathy 0 0.0% 13 3.5%older corneal scar 20 17.2% 29 7.7%other post segment causes 1 0.9% 2 0.5%other 22 31 Total 132 100.0% 398 100.0%

Causes of presenting VA < 6/60 were cataract 82.4%, diabetic retinopathy in 3.5%, corneal scars 9.7%, glaucoma 0.9%.

The most common cause of visual impairment was refractive errors, but when age groups were separated into decades, it was only the commonest cause in age group 50-59 yrs. The most common cause in older age- groups was cataract. Overall, cataract remains the main cause of blindness 82.4%, higher than that reported by the RAAB India study at 77.5%; while refractive errors were the main cause of visual Impairment (44.5%). However, as the age advanced the age groups of 70 - 90+ show a different pattern of visual impairment with posterior segment diseases, age related macular degenerations, corneal opacities, uncorrected aphakia and other cataract surgery related complications being more common. The latter may presumably be because of older cataract surgery techniques and longer follow-up duration. The avoidable causes of blindness like cataract, refractive errors, surgical aphakia, cataract surgery


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complications, trachoma, causes of corneal scarring and diabetic retinopathy constituted 95.3%, compared to 88.2% in the RAAB India study, again stressing the need for provision of eye care services in the region. An alarmingly high prevalence of blindness due to Diabetic Retinopathy i.e. 3.5% was recorded. In previous population based studies from India, Diabetes was the cause for <1% blindness. India is now being recognized as global capital of diabetes and unlike in past, it has now become the disease of masses. The rural population is also showing a high prevalence of diabetes and thus this may be the first study to demonstrate this fact. There is a need for services to diagnose and treat diabetic retinopathy to be integrated into general medical services.In this study the gender disparity in eye care uptake was not evident at all. Both men and women did not show significant difference in prevalence of blindness and visual impairment. The pattern of blindness was also similar in both the genders. In some Indian studies, prevalence of blindness and severe visual impairment (<6/60 in the better eye) was higher among females (9.2%) compared to males (6.5%). The spectacle usage as well as the cataract surgery coverage was similar in both men and women. The wasrai Konkan region of which Sindhudurg is a part of has one of the most positive gender ratios in the country with high female literacy rates in spite of relative economic deprivation.The percentage of population who were having near vision spectacles or any spectacles was high (49%) compared to studies from Andhra Pradesh, (29%). There was no gender disparity evident in buying or using spectacles. With or without glasses, 94% (2582) of subjects did not have N6 vision, only 6% (165) subjects had near vision of N6 with glasses. So while the need for refractive services is there, it has not been matured by service delivery. Only 52% of cataract operated patients had presenting vision 6/18 and better, below the World Health Organization’s norm of 80%. The poor outcome (<6/60) was 14.8% compared to the permissible 5% by WHO norms.Acknowledgement: Mr. Cyril David, Director, Volkart Foundation for funding the study; Dr. Pravin Vashist for sharing the RAAB software; Dr. B.R.Shammanna for helping calculate sample size; Dr. A.H.Mahadik for planning and logistics.

REFERENCES1. Neena J, Rachel J, Praveen V, Murthy GV et al. Rapid assessment of avoidable

blindness in India. PLoS ONE 2008;3:e2867.2. Al Gamra, Al Mansouri F, Khandekar R, Elshafei M, Al Qahtani O, Singh R,

Hashim SP, Mujahed A, Makled A, Pai A. Ophthalmology Epidemiol. 2010;17:292-300. RAAB in Qatar.


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Knowledge, Attitude, Practice Pattern of Ophthalmic Drugs in Pharmacist and Its ‘Over The Counter’ Misuse Dr. Anand Partani, Dr. Khushbu Bhattad, Dr. Madan Ashok Hukumchand

Over the counter (OTC) drugs are those which are legally permitted to be sold by the pharmacy worker without prescription of a Registered

Medical Practitioner. In Indian context, the phrase ‘Over The Counter’ have no legal recognition and are better referred to as ‘non-prescription drugs’ and/or as ‘household remedies’.1

Almost every prescription drug is available without doctor’s prescription all over the country. Even though there are many laws and regulations prohibiting this practice of dispensing prescription drugs without prescription, the practice still continues. In India, easy availability of a wide range of prescription drugs across the counter without a valid prescription, lack of stringent control over medical advertising, low medical literacy among the population and also the compulsion to reduce health-care costs seem to be the motivating factors for ‘over the counter’ drug misuse.

Though OTC use is a common self care practice of patient but it becomes a matter of great concern when complications occur. Many eye problems have increased due to this pharmacy related drug misuse .Blindness from the misuse of the OTC eye-drops has also been reported.2

Thus AIM of our study is to asses KNOWLEDGE, ATTITUDE, PRACTICE PATTERN of ophthalmic drugs in pharmacy worker and it’s ‘Over the counter’ misuse. The term OTC has been used in this article for both prescription and non prescription drugs which are dispensed by the pharmacy workers without prescription.

MATERIALS AND METHODSResponses of structured questionnaire on various aspects of OTC ophthalmic drug use was obtained from 157 pharmacy worker in central India from May10-May11. All the pharmacy workers were assured about confidentiality of data and verbal informed consent along with baseline data like name, age, sex, education was obtained from all the participants. The questionnaire was as under:a. Average number of patients with eye complaints coming to them per day.b. Common eye complaints of the patients (pharmacy workers were asked

to tick from following) Redness, Itching, Pain, Watering, Foreign body sensation, Trauma, Diminution of vision.


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c. Do you have practice of dispensing over the counter ophthalmic drugs ? yes/no.

d. Have you advised the patients coming to you with eye complaints to consult an ophthalmologist? yes/no.

e. Common ophthalmic preparations dispensed. (pharmacy workers were asked to tick from following). Antibiotics, Steroids, Antibiotic and steroid combination, Decongestants, Lubricants.

f. Are you aware of various ocular complications due to misuse of eye drops. ( pharmacy workers were asked to tick from following) Exacerbation of symptom, Corneal toxicity, Cataract/glaucoma by steroid, Resistance following antibiotic use.

g. Any complication seen by the pharmacy workers following OTC dispensing.

h. An opinion regarding banning of OTC dispensing? yes/no Responses were evaluated statistically.

RESULTSThis cross-sectional study was done on 157 pharmacy workers in central India. Mean age of the pharmacy workers was 37.4 years (+/-9.6). 103(65.6%) were males, 54(34.4%) were female. Only 96(61.1%) were graduates.Average number of patients with eye problems seen by the pharmacy workers per day was 5 (+/-1.4). Only 15(11%) pharmacy workers properly guided patients to ophthalmologist without giving any drug. Over the counter dispensing of ophthalmic drug is practised by 140(89%) of the pharmacy workers, out of which 101(72%) pharmacy workers also advise patients taking over the counter drugs to consult an ophthalmologist.


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Redness and itching were the most common complaints encountered by 125 (79.5%) pharmacy workers.Most Common drops dispensed over counter are Antibiotic (89.4%) followed by Antibiotic and steroid combination (69.2%). Awareness regarding antibiotic resistance is in 50(31.2%) Pharmacy workers and steroid complication in 45(28.8%) pharmacy workers. None of pharmacy workers were aware of various other ocular complications due to misuse of eye drops like exacerbation of symptom and Corneal toxicity. Only 14(9%) pharmacy workers had seen patients with complications following the use of drugs over the counter but they refused to reveal the complications. 88(56%) pharmacy workers agreed that there should be strict laws regarding banning of OTC dispensing of ocular medications.

Ocular complaints of the patients to pharmacy workers Ophthalmic preparations prescribed by pharmacy workers.

Eye drops Frequency PercentAntibiotics 140 89.4%Antibiotic and steroid combination 108 69.2%Steroids 89 56.8%Decongestant 57 36%Lubricants 36 23%

Complaints Frequeny Percentage Redness 125 79.5%.Itching 125 79.5%.Foreign body sensation 109 67.5%Watering 103 65.6%Pain 97 61.7%Trauma 24 15.2%Diminution of vision 16 10.1%

DISCUSSIONWe are not able to gather detailed information on what drugs were prescribed for a particular condition, but the available data reveals flagrant misuse of ophthalmic preparations over the counter by pharmacy workers. Decongestants, antihistamines and lubricants are the eye drops which have been approved for OTC use. Recently Chloramphenicol eye drops too have been approved for over the counter use.3 Other available ocular medications are “Prescription drugs”.4

In ocular emergencies, visual prognosis is highly dependent on first-aid measures. The use of OTC drugs can delay a patient’s search for specialized


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care, aggravate his or her condition and ultimately jeopardize the patient’s visual prognosis. Our study reveals that pharmacy workers keep in mind the drugs that had been recommended by doctors for earlier conditions; and, on demand of medicine by patient experiencing the same or similar ophthalmic symptoms, they tend to dispense the same product. Matos (2005)5 states that, “when therapies prove successful, a cause and effect relationship is established (“this treats that”) and people believe that they have learned “how to treat diseases”.

This OTC DRUG MISUSE can have a number of dangerous effects. All ophthalmic preparations showed both corneal and conjunctival cell toxicity. Even Normal saline showed the lowest amount of toxicity. These medications can have a cumulative effect that leads to side effect and adverse reactions after a person uses them for a long period of time. Low doses may lead to the development of bacterial resistance and loss of the drug’s efficacy.6,7 Delay in the actual ophthalmic expert treatment obtained by the red eye patients when treated by the pharmacy workers with antibiotic eye drops can give rise to severe ocular complications. These patients are found to be suffering from uveitis, keratitis or acute angle closure glaucoma, which should get immediate treatment. Antihistamines and decongestants are commonly used to relieve the redness, but when steroids are used it can lead to problems.

Since these patients are relieved of their itching symptoms by the steroids obtained from the pharmacy workers, they fail to consult an ophthalmologist. These patients may end up with steroid induced glaucoma.8 OTC sale of topical steroids has been documented to lead to loss of vision, secondary to glaucoma.9 Administration of corticosteroid eye drops in inflamed eye can result in severe exacerbation of the underlying disease and an increase in the incidence of subsequent complications e.g. Herpetic keratitis, fungal keratitis.10 In our study, steroids were dispensed by 56.8% of the pharmacy workers, a worryingly high figure.

According to Soparkar and co-workers11, Decongestants can result in acute and chronic forms of conjunctivitis by pharmacological, toxic, and allergic mechanisms. The active ingredient in most of the ophthalmic decongestants is an alpha adrenergic receptor stimulator. Rumelt MB12 reported blinding of four eyes in three patients who used OTC preparations like decongestant eye drop when they suffered angle-closure glaucoma. In our study, decongestants were dispensed by 36% of the pharmacy workers. OTC lubricants when used over the long term can produce corneal epithelial toxicity due to the preservatives.13

Our study have some weaknesses like false reporting , loss of past memory or laziness by pharmacy workers, difference in reporting due to the random selection of pharmacies.


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According to The Pharmacy act13 of 1948, Pharmacy workers are expected to be careful and cautious while dispensing medicines to consumers. They are expected to educate the customers about intake and effects of drugs. But our study shows that Pharmacy workers are themselves not knowledgeable enough to educate consumers about OTC drugs. Although some OTC eye preparations are safe and can be used when required, extended use of any such medication needs to be approved by the ophthalmologist.

In conclusion although pharmacy workers don’t have enough knowledge about ophthalmic drugs, it’s ‘Over the counter’ MISUSE is common problem in Central India. ‘Over the counter’ DRUG MISUSE especially in urgent cases, can be either directly harmful or can cause harm by delaying appropriate care. Misuse of prescription eye drops over the counter is an immense public threat.

Educating the pharmacist and the population about the dangers effect of OTC DRUG MISUSE is essential to handle this problem and government needs to take a STRONG initiative to curb this menace.

REFERENCES1. Srinivasan S. OTC Drugs: Some Legal aspects. Bulletin of the Society for Rational

Therapy. July 1991. 2. Rumelt MB. Blindness from misuse of over – the counter eye medications. Ann

Opthalmol. 1988;20:26-7,30.3. Blenkinsopp A, Bradley C. Patients, Society and the increase in self medication.

BMJ 1996;312:629-32.4. OTC. Chloramphenicol eye drops, guidance-www.rpsgb.org.uk/pdfs/

otcchlorampheneyed ropsguid.pdf5. Matos MCA. Auto-Medicação. Psicologia.com [online] . [cited 2007-01-28]. 6. Kim MS, Choi CY, Kim JM, Chang HR, Woo HY. Microbial contamination of

multiply used preservative-free artificial tears packed in reclosable containers. Br J Ophthalmol. 2008;92:1518-21.

7. HammerJS. To prescribe or not to prescribe; on the regulation of pharmaceuticals in less developed countries. Soc Sci Med. 1992;34:959.

8. Munjal VP, Dhir SP, Jain IS. Steroid induced glaucoma. Indian J Ophthalmol 1982;30:379-82.

9. Tabbara KF. Blindness in the eastern Mediterranean countries. Br J Ophthalmol 2001;85:771–5.

10. Thygeson P, Hogan MJ, Kimura SJ. The unfavourable effect of topical steroid therapy on herpetic keratitis. Trans Am Ophthalmol Soc. 1960;58:245-57.

11. Soparkar CN, Wilhelmus KR, Koch DD, Wallace GW, Jones DB. Acute and Chronic conjunctivitis due to over the counter ophthalmic decongestants. Arch Ophthalmol 1997;115:34–8.


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Comparing 3 models of Community Based Diabetic Retinopathy (DR) Screening, Treatment and Awareness Creation Services Dr. Unnikrishnan Nair R., Dr. Manoj S., Dr. Ramachandran Nair K.G.

The problem that Diabetes Mellitus will pose in our country will lead onto a public health concern of gigantic proportions. A rapidly burgeoning

population coupled with a rapid urbanization of rural areas will lead on to a population on the brink of a glycemic disaster. It is estimated that 57 million people in India may be diabetic by 2025.1 When compared to the west diabetes appears at a younger age2 is less associated with obesity,3 and genetic factors appear to be stronger in our population.4 These clinical differences and rising prevalence of diabetes in India5 warrant well-conducted epidemiologic studies on diabetes-related complications including eye problems to assess the health services burden due to diabetes. Though there are a few related studies in our country, a true picture of prevalence of this disease is not evident because of various anomalies- some studies are clinic based6, some amongst self reported diabetics7 rural-urban differences and differences in examination techniques- direct ophthalmoscopy8, indirect opthalmoscopy8,9 photography6, tele-ophthalmology screening etc. Thus the reported prevalence of diabetic retinopathy among diabetics range from 20.8% to 34.1%6,7,8,9

The state of Kerala, though boasts of a high life expectancy and literacy rate, has a high prevalence (16.3%) of diabetes10,11 and therefore possibly diabetic retinopathy. One study on self-reported diabetic subjects revealed retinopathy prevalence of 26.8%.7

In a country like India where resources are limited and the magnitude of the problem seems limitless, a judicious and practical approach to how to distribute services and resources is of utmost importance. In this study we seek to compare to evaluate the effectiveness of 3 models of DR screening from an economic perspective and their effectiveness in awareness creation, screening and ability to deliver treatment.

MATERIALS AND METHODSThe study area included 5 districts in South Kerala-Trivandrum, Kollam, Allepey, Ernakulam and Kottayam. Chaithanya Eye Hospital and Research Institute along with World Diabetic Foundation, a Denmark based foundation, initiated this project called project TRINETRA. The name was decided as to highlight the three aspects of diabetes and diabetic retinopathy services in the community namely:


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• Creating awareness about diabetes and diabetic retinopathy among general public, diabetic patients, medical practioners and other allied medical personnel

• Community based screening through diabetes and Diabetic Retinopathy screening camps in association with diabetologists, diabetic associations and voluntary organizations.

• Service delivery in the form of follow-up, laser treatment, surgery and counseling for diabetic retinopathy screened

A three year prospective study was done with a target of screening 90,000 people for diabetes and diabetic retinopathy and also create awareness about the disease. Subsequent services were rendered for treatment of diabetic retinopathy.

Three models were created in the study.

Model 1: Blood Screening camp

In this model pre camp publicity was done mainly by radio announcement on the local radio channels. Places selected for this type of screening were places with a large movement of population like railway stations, bus terminal, maidan and beach fronts. Large Banners were placed at strategic locations to attract attention to the camp activities. A quick history would be taken and a spot Glucometer check was used to evaluate glycemic levels. Often awareness creation would be by an Information kiosk set up in a Van. Newly detected patient were advised to consult a physician and an ophthalmologist. Pamphlets would be distributed at the camp site. A written note containing the sugar value would be given to the patient, a record would be made of this value in a master record and the hospital route map would be given to all newly detected diabetics and known diabetics. The staff requirement for such a model was 4 : 1, Driver, 1 Nurse, 1 Lab Technician and 1 counselor.

Model 2: Comprehensive eye camp

This included pre-camp publicity for 2-4 weeks. This would include PA system announcement mounted on a autorickshaw, announcement of camp location and purpose at public functions and places like schools , churches and temples. The involvement of local NGOs would also assist in passing on information about the camp and the target population for it. Pamphlet distribution would be done a week before the camp and would include public distribution and also displaying pamphlets at key places like schools , shops etc. The conduction of the camp would be with the assistance of the local partner which would be an NGO, arts club, religious organization or local business. The services in the camp would include glucometer screening of all the attendees and ophthalmological evaluation of anyone with high glucose


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value and any known diabetic. The staff requirement for this model would include 8-10: 1 Driver , 2 Nurses , and 2 counselors, 2 optometrists and 1-2 Ophthalmologists.

Model 3: Institution based screening camp

This included selection of a public or private service provider with an employee strength of more than 500. Awareness creation about DR would be followed by screening activities. The institution’s human resources wing or administrative department would inform their employees via internal notification about the presence of a camp. This would be supplemented by awareness posters placed in the institution prior to the camp. Ophthalmological evaluation including data collection of Demographic details, diabetic history and treatment details were recorded. Ophthalmic examination included vision testing, IOP measurement and dilated fundus examination. A trained ophthalmologist performed retinal examination with direct and indirect ophthalmoscopy. Diabetic retinopathy was categorized using the modified ETDRS classification. Retinopathy was classified as Mild, Moderate and Severe nonproliferative diabetic retinopathy (NPDR), early proliferative diabetic retinopathy (PDR), high risk PDR, advanced PDR. The presence of clinically significant macular edema (CSME) was assessed using indirect and direct ophthalmoscopy. Eyes where posterior segment examination was not possible was defined as ungradable eyes. All the above information was recorded into a proforma at the camp site which was later entered into a computerized data base created at the project office at the base hospital. Subjects who had any form of PDR or CSME were considered to have sight-threatening retinopathy. Subjects with severe NPDR, CSME and PDR were referred for further investigation and management to the base hospital. Subjects with no or minimal retinopathy were advised scheduled follow-up with their regular ophthalmologists at yearly intervals. An expert counselor focused on awareness creation giving patients information about the disease, treatment facilities, dietary advice etc. An on site exhibition displaying diabetic retinopathy related posters was part of all these camps. Pamphlets and booklets on the disease were given to all the camp participants.

RESULTS

Table 1 : Camp attendance and detection Camp Model Number of Camps Total Screened DM detected DR detected Model 1 47 24848 3488 40 Model 2 438 66472 12364 1972 Model 3 18 3673 805 180


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Table 2 : Percentages of detection of DM and DR Camp Model Number of Camps Total Screened DM detected DR in diabetics Model 1 47 24848 14.04 1.14 Model 2 438 66472 18.64 15.94 Model 3 18 3673 21.91 22.4

Camp Expenses would include publicity, Transportation, Hall arrangement, Food for staff and volunteers, Blood sugar testing and staff salary expenses.

Table 3 : Average Cost Calculation per Model (in Rupees) Model 1 Model 2 Model 3 TotalCost per OP 41.6 67.2 75.5 65.0Cost per DM 360.6 440.0 660.5 441.9Cost per DR 14938.5 3716.0 3532.1 4428.4

Statistical Analysis

The normality test failed based on the Kolomogorov Smirvov analysis. But as the sample size was large it was felt that the sample would follow normal distribution with the support of the central limit theorem, it was decided that parametric testing i.e., One-way ANOVA testing would be applied for the subgroup analysis. One-way ANOVA statistical analysis of the mean differences in cost involved to screen one patient, to detect one diabetic and to diagnose one case of diabetic retinopathy was statistically significantly different. However Non-parametric tests like Kruskal Wallis test was also applied and this rejected the null hypothesis that all camp models incurred similar cost to detect diabetes mellitus and retinopathy.

DISCUSSIONAlthough the need for a national diabetic retinopathy screening program in India is recognized, national or regional screening initiatives are yet to be launched. Though recent studies indicate that there has been an increase in the prevalence of diabetes only a few studies have attempted to assess the prevalence of diabetic eye complications in India.7,8 In this study, we report the prevalence of diabetes and diabetic retinopathy in a mixed urban-rural population in south India based on an epidemiologic survey. The prevalence of diabetes in this study was 17.4% which is much higher than other population based reports8 in the country. Considering the fact that this estimation was based on a single random blood sample value of >180 mg% the significance of this high prevalence cannot be underestimated. Many borderline diabetics who may have abnormal GTT were not assessed in this study and this would have increased the prevalence further. The general incidence of diabetic


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retinopathy on the study was 2.2% The prevalence of DR among the diabetics is 16.34% in our study. This confirms the findings of earlier studies from India. A recent study where subjects were examined by ophthalmoscopy reported a 22.4% prevalence8, whereas a similar study on self-reported diabetics revealed a prevalence of 26.8%7 and another clinic-based photographic evaluation study revealed a prevalence of 34.1%.12

This highlights the need of the hour that is to plan and implement screening models for diabetes and diabetic related end organ damage. These plans must go hand in hand with awareness creation activities. Handling of the increasing problem of diabetes and its danger to sight includes effective education and communication with the patients on the one hand, and with physicians and allied health professionals on the other hand. As part of this initiative all the participants in our study received health education including materials related to diabetic retinopathy.

The various models essentially addresses the various questions

• Is a rapid blood screening the most effective way of mass screening

• Would such a strategy be counterproductive to diagnose diabetic retinopathy.

• What is the impact of awareness creation and publicity.

• Is a comprehensive eye camp the most effective way of achieving the target of identifying new diabetics, new DR patients and awareness creation.

• Does work place screening produce more effective screening.

Discussion of resultsThe three models of camps were conceptually different and hence had different attributes. These attributes lead to different nature of usefulness, economic implications and detection rates.

Model 1 camps (Mass blood screening cams) were based on the principles of mass screening with minimal pre camp publicity. Pamphlet distribution occurred at the time of blood screening. Brief counseling was done at the time of detection of diabetes. However due to the large number of participants and nature of location chosen (public places like railways stations, bus terminals beaches and parks), detailed counseling could not be given.

This lead to a very few percentage of either old or new diabetics attending the hospital OPD for DR screening. Only 244 people of the 3488 came to the base hospital and only 40 were detected to have diabetic retinopathy. This has led to conclude that this method is economically viable for detection of diabetes, but was very ineffective from an economic and screening perspective for diabetic retinopathy. The advantage is easy organization of the camp and capability


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to screen large numbers. However an attempt to increase the number of counselors was not fruitful because of the floating nature of the population involved.

Model 2 camps (Comprehensive eye camps) The concept behind this camp was one of pre camp publicity for 2 to 4 weeks followed by a comprehensive eye examination camp and blood screening. The advantage was a reasonably high pick up rate of diabetes and diabetic retinopathy. Adequate counseling and dietary advice could be given to the patients attending the camp. The disadvantage was being labour intensive and also costly. The cost to pick up new diabetic patients and DR patients was Rs. 440 and 3716 respectively. The camp had a greater impact of awareness creation and had a very high rate of patients attending the base hospital for continuing medical care. The camp also probably reflected the incidence rates of DM and DR in the community more accurately than other methods.

Model 3 camps were organized in Institutions. Pre camp awareness activities were done by the institution in the form of internal memos and distribution of pamphlets made by the project. The attendance of these camps was generally better than the community camps and the diabetes detection rates were high (21.91%). There was a high percentage of diabetic retinopathy detection. This was probably because the population screened had more of a sedentary lifestyle with high rates of obesity compared to the general population. There was also a bias to an aging population. The advantage of this method is that it is very economically viable provided large institution with at least 500 employees are involved, such that the camp attendance is at least 200. The disadvantage of this model is the limited reach of these camps and the concentration of these in urban and semi urban areas.

Statistical analysis showed that per capita costs involved to pick up DM and DR were significantly different. This meant that it was unviable to use Model 1 camp to screen diabetics for retinopathy but it was by far the most economical for diabetes screening. It was also the least efficient to give advice for the participants. In Model 3 the cost to detect DM was significantly higher than in Model 2 camps but the per capita cost to detect diabetic retinopathy was lower. Thus the comprehensive eye is the best overall method for both DM and DR screening.

Table 4 : Correlation Analysis of Model 2 Camps: Effect of Publicity TOTAL OP DM DRPublicity Pearson Correlation .212 .119 .145 Sig. (2-tailed) .000 .019 .004 N 438 438 438


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Publicity has a positive correlation with statistically significant to the number of total OP attending the camp, DM and DR detected.

Simple Regression analysisThere was a statistically significant R square value of 0.48 with an unstandardised coefficient of regression of + 0.025. This meant that an increase in expenditure outlay of 1% would be associated with a 2.5% increase in total attendance, DM and DR detection rates.

The inferences drawn may include that Mass blood screening camps are effective in picking up new diabetics while may be counter productive to screening for DR. Community based camps have the best overall pick up rate of DM and good rates of DR detection and are most suited for a rural scenario. Ensuring camp attendances in excess of 300 will increase the camp efficiency. In Urban areas, institution based DR screening is an extremely cost efficient and successful model and when done with the management’s assistance has very high pick up rates.

Awareness creation and adequate pre camp publicity is essential for the successful conduction of camps. Increase in attendance increases the pick up rates of DM and DR.

REFERENCES1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes,

estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047–53.2. Mohan V, Ramachandran A, Snehalatha C, Mohan R, Bharani G, Viswanathan M.

High prevalence of maturity onset diabetes of the young (MODY) among Indians. Diabetes Care. 1985;8:371–4.

3. Joshi SR. Metabolic syndrome: emerging clusters of the Indian phenotype. J Assoc Physicians India. 2003;51:445–56.

4. Viswanathan M, Mohan V, Snehalatha C, Ramachandran A. High prevalence of type 2 diabetes among the offspring of conjugal type 2 diabetic parents in India. Diabetologia. 1985;28:907–10.

5. Mohan V, Shanthirani CS, Deepa R. Glucose intolerance in a selected South Indian population with special reference to family history, obesity and life style factors: The Chennai Urban Population Study (CUPS 14). J Assoc Physicians India. 2003;51:771–7.

6. Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in Southern India. Diabetes Res Clin Pract. 1996;34:29–36.

7. Narendran V, John RK, Raghuram A, Ravindran RD, Nirmalan PK, Thulasiraj RD. Diabetic retinopathy among self reported diabetics in southern India: a population based assessment. Br J Ophthalmol. 2002;86:1014–8.

8. Dandona L, Dandona R, Naduvilath TJ, et al. Population based assessment of


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diabetic retinopathy in an urban population in southern India. Br J Ophthalmol. 1999;83:937–40.

9. Namperumalsamy P, Nirmalan PK, Ramasamy K, Developing a Screening Program to Detect Sight-Threatening DR in South India. Diabetes Care 2003;26:1831-5.

10. Kutty VR, Joseph A,Soman CR. High prevalence of type 2 diabetes in an urban settlement in Kerala, India. Ethn Health Med 1999;4;231-9.

11. Kutty VR, Soman CR, Joseph A et al. Type 2 diabetes in south Kerala: Variation in prevalence among geographic divisions within a region. National Med J India 2000: 13;287-92.

12. Kumar A. Diabetic blindness in India: The emerging scenario. Indian J Ophthalmol 1998;46:65-6.

Sunday Diabetic Retinopathy Camp in a Rural Eye Hospital in Jharkhand Dr. Subhrangshu Sengupta, Dr. Partha Biswas, Dr. Monica Horo, Dr. Sushrut N Pandit Anand

Diabetes mellitus (DM) is a major cause of avoidable blindness in both the developing and the developed countries. Patients with diabetic

retinopathy (DR) are 25 times more likely to become blind than non-diabetics.1 Majority of the patients have non-insulin-dependent diabetes mellitus (NIDDM) or type 2 diabetes. The prevalence of insulin-dependent diabetes mellitus (IDDM) or type 1 diabetes is 10-15% of the diabetic population. Prevalence of DR in Wisconsin Epidemiological Study of Diabetic Retinopathy (WESDR) was 50.1%2 and 54.2% in the diabetes control and complications trial (DCCT) in IDDM3 and 35-39% in United Kingdom Prospective Diabetes Study (UKPDS)4 in NIDDM. In two studies from South India, the prevalence rates of DR in NIDDM patients were 34.1% and 37%.5,6 India has 31.7 million diabetic subjects at present as per the World Health Organization (WHO) estimates.7 In the Andhra Pradesh Eye Disease Study (APEDS) of self-reported diabetics, the prevalence of DR was 22.4%.8 In the Chennai Urban Rural Epidemiology Study (CURES), evaluated urban sample of diabetic patients and estimated the overall prevalence of DR as 17.6%.9

The socioeconomic impact resulting from visual impairment due to diabetic retinopathy particularly in working age group is a serious concern. So, the establishment of an independent retina unit in a peripheral eye hospital has become indispensable. As a first step to this, the Sunday Diabetic Retinopathy Eye Camp concept was started in a rural hospital in Saraikella Kharsawan District of Jharkhand.


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Our work is a cross sectional study of diagnosis and treatment of diabetic retinopathy (DR) in the rural eye hospital in Jharkhand.

MATERIALS AND METHODSDiabetics from nearby villages and towns were invited for a free DR check up using hand bills, newspaper advertisements, announcements using auto rickshaws and word of mouth publicity through local counselors. The camps were organized on alternate Sundays, from October 2010 to March 2011. Approval from the institutional ethical committee was obtained for performing this cross sectional study. The patients underwent complete ophthalmological examination. They were subjected to visual acuity testing, intraocular pressure measurement by applanation tonometry, gonioscopy, slit-lamp examination and biomicroscopy after pupillary dilatation using +90 diopter (D) lens and direct and indirect ophthalmoscopy. Digital Fundus Fluorescein Angiography was performed at the discretion of the examining ophthalmologist after obtaining adequate medical clearance.

RESULTS642 patients were screened over twelve Sunday DR camps. 79% had evidence of DR clinically, with 11% having proliferative DR (PDR), confirmed with DFA. 28% had Clinically Significant Macular Edema (CSME). Patients with PDR were treated in the rural hospital itself using argon laser photocoagulation. Seventeen eyes had vitreous hemorrhage, which was subsequently referred to a tertiary eye care facility in Kolkata. Patients with CSME were asked to follow up with Optical Coherence Tomography (OCT) of macula. Those with Central Macular Thickness (CMT) >350 microns were administered intravitreal injection of Bevacizumab (Avastin) after proper consent from the patient and his party. The Avastin was procured in aliquots from a Tertiary Hospital in Kolkata about 250km away and administered at the rural eye hospital. 78% patients receiving intravitreal bevacizumab had increase in visual acuity by >=5 ETDRS letters equivalent after a single injection itself with no cases of endophthalmitis or retinal detachment. The injections were repeated after 6–8 weeks in required patients. Focal and/or macular grid laser photocoagulation was also performed in some of the patients. In conclusion bimonthly Sunday DR camp in a rural hospital provides excellent resource utilization. The publicity for the camps is organized by the local hospital staff and the basic work up and follow up of the patients is done by the hospital optometrists, technicians and ophthalmologists. The retina evaluation, DFA interpretation, laser photocoagulation and intravitreal injections is performed by trained medical retina specialists from a tertiary eye care facility in Kolkata. This allows us to provide adequate ophthalmic care to the patients and also serves to train up the local ophthalmologists. This


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is the foundation stone for a fully independent retina unit of the rural hospital. And above all this endeavor helps us to extend the latest eye care facilities to all sections of the society and achieve maximum cost effective visual recovery in diabetics of the region.

REFERENCES1. National society to prevent blindness. In: Visual problems in the US data analysis

definition, data sources, detailed data tables, analysis, interpretation. New York: National society to prevent blindness; 1980;1-46.

2. Williams R, Airey M, Baxter H. Epidemiology of diabetic retinopathy and macular edema: A systematic review. Eye 2004;18:963-83.

3. Malone JI, Morrison AD, Pavan PR, Cuthbertson DD. Diabetic Control and Complications Trial: Prevalence and significance of retinopathy in subjects with type 1 diabetes of less than 5 years duration screened for the diabetes control and complications trial. Diabetes Care 200;124:522-6.

4. Kohner EM, Aldington SJ, Stratton IM. United Kingdom Prospective Diabetes Study, 30: Diabetic retinopathy at diagnosis of non-insulin-dependent diabetes mellitus and associated risk factors. Arch Ophthalmol. 1998;116:297-303.

5. Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in Southern India. Diabetes Res Clin Pract 1996;34:29-36.

6. Sharma RA. Diabetic eye disease in southern India. Community Eye Health 1996;9:56-8.7. Wild S, Roglic G, Green A. Global prevalence of diabetes, estimates for the year

2000 and projections for 2030. Diabetes Care 2004;27:1047-53.8. Dandona L, Dandona R, Naduvilath TJ. Population based assessment of diabetic

retinopathy in an urban population in southern India. Br J Ophthalmol 1999;83:937-40.9. Rema M, Premkumar S, Anitha B. Prevalence of diabetic retinopathy in urban

India: The Chennai Urban Rural Epidemiology Study (CURES) eye study. Invest Ophthalmol Vis Sci 2005;46:2328-33.

Epidemiological Evaluation of Risk Factors and Outcome in Corneal UlcerDr. Bhavana Sharma, Dr. Vivek Som, Dr. Kavita Kumar, Dr. (Mrs.) Reena Anand

Microbial keratitis is a serious ophthalmic illness which results in severe functional and structural impairment. In corneal ulcers tissue resistance

is as important as systemic immunity,. Hence there are several factors which can work as predisposing factors and can also affect the treatment outcome in corneal ulcers.


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This study was done to identify predisposing factors in microbial keratitis; to ascertain various clinical characteristics of microbial keratitis with reference to response to treatment. To study the epidemiological profiles in M. Keratitis.

It was a prospective nonrandomized analytical clinical study in which 274 patients presenting with microbial keratitis in RIO Bhopal were evaluated using a dedicated corneal ulcer protocol. The present study evaluates the risk factors assessed at diagnosis as prognostic indicators of treatment outcome. Risk factors were evaluated by comparison among those who had slow indolent healing and progression with or without complication.

Slow indolent healing was defined as failure of epithelialisation of the ulcer after 2 weeks of treatment. Progression with or without complication were associated with an increase in ulcer size or infiltrate, Descematocoele or perforation, sloughing, endophthalmitis, panpohthalmitis.

Detailed medical and ophthalmological histories were taken. Slit lamp examination was done to record clinical features of ulcer. Smear examination for Grams and KOH stain was done. Sample for culture and sensitivity was taken in all patients apart from routine investigations and medical evaluation. Medical therapy was initiated in all patients which consisted of Broad spectrum and fortified antibiotics, supported by cycloplegics, tear substitutes and antiglaucoma medication in selective cases. Patients were followed up for 3 months. Treatment success was taken as healing of ulcer and epithelial defect within 2 weeks of starting of treatment. Ulcers which took longer time were classified as slow/non healing ulcers. Few cases also showed progression with complications.

Commonest age group to be affected was 51-60 (20%); however a substantial 51% cases were more then 40 yrs (Odds ratio –1.09). Outdoor workers, mostly farmers were more commonly involved (36%). Potential risk factors were seen in 78%. Most common predisposing factor to be seen was trauma (29%) RR 5.67. Other concurrent factors were Meibomiantis; Topical steroid use; Lid abnormalities; Dry eye; Chronic dacryocystitis; Trachoma; Systemic illness commonly DM. Mean time of presention was 4 days which was a risk factor for complicating keratitis. 40% patients had presenting vision <2/60. There were 43% culture positive patients out of which most common isolate was, staphylococcus epidermidis. Morphology of ulcer was, evaluated with reference to treatment outcome. Factors which were evaluated were --

1. Size --- <2mm; 2-6mm; >6mm.

2. Location --- central; paracentral; peripheral

3. Depth ----- superficial; midstromal; deep stromal; full

thickness/perforated


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Large central ulcers involving midstroma and deeper were classified as “bad morphological types”. Ulcer characterstics like central seen in 76%, large size seen in 36%, full thickness/perforated seen in 29%, presence of hypopyon seen in 26%, were associated with poor outcome. Thus bad morphological type ulcers had RR->4, and significant P<.001, for progressing to complicating type.

Clinical outcome was evaluated with appropriate statistical indices, Odd’s ratio and relative risk using univariate analysis of the patients enrolled in the

Table 1: Treatment Outcome in Various SubgroupsCharacteristic Number % healed % slow/ indolent % progressed / (n-134) (n-58) complication (n-82)

AGE >50yrs 93 61 17 22 <50yrs 181 71 10 19MORPHOLOGYCentral 208 63 10 27Peripheral 66 88 3 9<2mm 66 98 2 --2-6mm 110 88 4 8>6mm 98 59 14 27Superficial 71 98 2 --Stromal 124 89 3 8Fullthickness/perforated 79 10 28 62hypopyon 71 48 29 23Symptom to treatment interval <5days 116 78 7 15 >5days 158 63 13 24PVA <2/60 109 57 21 22 >2/60 165 77 10 13Concurrent factors Chr.DC 11 2 98 -- Trauma 61 51 24 25 Topical steroid 70 62 26 12 DM 30 58 22 20 Dry eye 11 10 81 9 Trachoma 12 48 33 19 MGD 36 76 15 9 Lid abnormalities 21 81 9 10 Exp. Keratopathy 22 46 28 26


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study, it was seen that 49% showed healing; 21% were slow healing types and 30% showed progression with complications.

Factors shown in Table 1 were evaluated as to their treatment outrcome.Furthermore factors which had significant risk ratio and P-value for poor treatment outcome are described in Table 2.

We conclude that Older age, any predisposing factor, delay in referral to cornea specialist, topical steroid use, poor presenting VA and bad morphological types ocular surface disorder Diabetes Mellitus are risk factors for poor outcome.

Table 2: Significant Predictors for Poor Treatment OutcomeCharacteristics % Risk ratio P value Age>50yrs 39 2.34 <.05 Bad ocular surface 31 3.1 <.05 Trauma 49 3.38 <.01 Diabetes mellitus 42 3.9 <.01 Size>6mm 41 3.71 <.01 Central 37 4.8 <.01 Full thickness 90 7.8 <.01 Symptom to treatment interval >5 days 37 2.09 <.05 Topical steroid 38

Impact Assessment of Quality Assurance Interventions on Efficiency of Ophthalmic Operation TheatreDr. Suneeta Dubey, Dr. Sandeep Buttan, Dr. Shafali, A. K . Arora

Operating theatres play a central part in the modern healthcare system and require maximum utilization to ensure optimum cost benefit. However;

despite all of the money and effort that have been put many are still less effective than they should be because of lack of planning and monitoring. Also, there are remarkably few national standards in place to guide in what to expect from operating theatres. These problems could be resolved by addressing faults in the arrangements immediately before, during and after operations take place.

Identification of the etiology of OT inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OT efficiency. The time savings realized are probably most cost-effective when combined with improved OR scheduling.


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Very few studies have yielded controlled, prospective data evaluating the impact of a multidisciplinary process improvement strategy on OT efficiency and the duration of this impact. Keeping these factors in mind we conducted a prospective study to evaluate the OT efficiency after Quality interventions.Aim of this study is to assess the impact of a structured quality assurance program in improving operating theatre efficiency for a tertiary eye hospital in North India.

MATERIALS AND METHODSObjectives1. Determining the most frequent and time consuming causes of delays in

OT starting time and Inter – operative time 2. To implement and assess the impact of a structured Quality assurance

program in improving these causes.

MethodologyThe study was performed prospectively in surgical suite of Dr. Shroff’s Charity Eye hospital, Daryaganj, New Delhi between Aug’09 and Feb’11.

Data Collection Operation theater efficiency related data was collected from five Operation theatres involving patients who were either hospitalized or were same day admissions.

In the pre–intervention phase of the study, OT times and delay etiologies were collected by OT nurse on a standardized form (Annexure – 1) which provided the following information about the patient: Time of arrival at Ward, Time of arrival at OT, Finishing Time of the previous surgery, Starting time of the present surgery, Time the present surgery was completed.

Data for the starting time in each OT was captured from pre–defined OT list which was prepared a day before surgery, as per the availability of the surgeon.

Exclusion criteria1. All unplanned/ emergency cases.2. All cases planned under general anesthesia.3. Medically unfit cases.

The target time for inter operative preparation was set at 15 minutes, Target times for subsequent cases were determined by adding the allowed time interval (15 min) for inter operative preparation to the time of completion of the previous case.

A case delay and its cause were recorded when a specific OT time lagged the corresponding target time.


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A root cause assessment was performed by Pareto analysis to identify major factor resulting in delays.

InterventionsThe Quality Team identified the most common and time consuming causes for delay in OT starting time and Inter – operative time through Pareto analysis and developed process improvement initiatives to rectify the same. The initiative consisted of a two way strategy.

The first strategy consisted of training and education during which quality representatives informed the members of various departments (Surgeons, Nurses and Anesthetists) of the most common causes of delay in OT specific to their area, target times, and strategies to attain those target times. Additional information was conveyed in monthly MIS meeting, through memos, and notices in wards and OT.

The second strategy addressed delays attributed to inefficient patient transportation (from ward to OT), lack of preoperative evaluations and unavailability of essential personnel. To overcome the shortage of qualified nursing staff existing ancillary nursing assistants were oriented and assigned to pre and inter operative nursing functions. Additionally, patients were instructed during pre-surgical examination to report on time on the day of surgery.

AnalysisPre and post intervention comparison of adherence (percent) to scheduled OT starting time and compliance (percent) to pre defined inter operative duration was performed using Fisher exact Test.

RESULTSData from 10,800 surgical cases that underwent surgical treatment at the hospital during the study period was analyzed.

Causes of Delay in OT Starting Time (As per Pareto Analysis)Causes (Pre intervention) Relative % Cumulative %Lack of punctuality amongst staff 62% 62%Patient reporting delay 13% 75%Equipment failure 4% 79%

Causes of Delay in Inter Operative Time (As per Pareto Analysis)Causes (Pre intervention) Relative % Cumulative %Surgeon related factors 67% 67%Patient factors 10% 77%Patientmedicallyunfit 6% 83%


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Post Intervention AnalysisA midterm evaluation at 18 months (February 2011) showed that there were significant improvements in both the parameters (38% increase in adherence to starting time, p <0.0001 and 16.8% increase in instances where inter-operative duration goal of 15 minutes was met, p <0.0001). These improvements also led to an overall increase in the productivity of the OT.

Comparison of Pre and Post Intervention Parameters Pre intervention Post Intervention P valueAdherence to OT Starting Time 40% 77% >.0001Adherence to Inter Operative Time 72% 88% >.0001

DISCUSSIONThe operating theatre is often portrayed as being at the leading edge of medical science. The case scheduling process is the key system in the functioning of the Operation theatre.

There are a very few well designed studies which provides successful strategies for improving OT efficiency. Study conducted by Mazzei and Frank J et al provided objective data on the first case start time and surgical service-specific timing that could be used for benchmarking purposes. Our study yields similar results and significant improvement after introduction of a structured quality assurance program, training of personnel and sharing of data.

The most common causes of delay in starting first case in our study as per Pareto analysis were lack of punctuality amongst staff, patient reporting delays and equipment failure. These findings are in concurrence with work done by Avi. A. Weinbroum Et al. Simple Quality intervention measures such as constant monitoring, education and training led to remarkable improvement of these factors.


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Our data suggests that there is significant improvement in procedure start time for first cases (from 40%-77%) and compliance with the inter operative time (from 72%-88%), which led to significant improvement in the overall Operation theatre efficiency and more frequent turnover per day with greater time savings and more cases scheduled with regularity.

We conclude that meaningful improvements in OR efficiency can be made by the multidisciplinary efforts of surgeons, anesthesiologists, and nurses. Although collection of accurate and unbiased efficiency data remains a challenge.

Partnership Between Eye Care Provider and Community Development Initiative Dr. Amarendra Deka, Dr. Saikia S.P., Dr. Kumar S.

Since 2006 the secondary eye care hospital, Bawri Nethralaya, has developed a school eye health and community programme in the Northeast Indian

state of Meghalaya with the objective of improving the quality of life and educational capabilities of school-going children by eliminating blindness and visual impairment due to uncorrected refractive errors and other treatable causes of blindness. Meghalaya covers an area of 22,429 km2 with a population of 2.96 million people, 80.4% of which reside in rural areas. The causes of blindness in the state are mainly because of inadequate and unequal distribution of eye care services, uneven distribution of population due to the hilly terrain, the low overall socioeconomic status of the population and lack of awareness on eye health.

The main purpose of the study were to make vision 2020 ‘the right to sight’ a reality and to assess the effectiveness of trained teachers and community representatives in a vision screening program for school children and population in the community of Meghalaya, a state of north east India.

MATERIALS AND METHODSThe study duration was for 2 yrs from January 2009 to December 2010. Two districts were selected randomly for this study. Ophthalmologists trained school teachers and community representatives to measure visual acuity and identify obvious ocular abnormalities in school and the community. The trainees were provided with vision testing kits at the end of the training session. Back at their schools and community, they conducted vision screenings on a continual basis to detect refractive errors and other ocular abnormalities among their pupils and general population in the community. They also


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followed up for compliance with wearing of glasses and create awareness and acceptance among the students’ parents. Persons with visual acuity worse than 20/30 in any eye and/or any obvious ocular abnormality were selected by them and referred to camp site for re evaluation by Ophthalmologist and/or Optometrist. Optometrist repeated eye examinations on a random sample of children and adults identified as normal (approximately 5%) by the teachers and community representatives. Optometrist prescribed spectacles to those needing refractive correction and referred those needing further examination to an Ophthalmologist at the base hospital. The diagnosis and treatment of amblyopia, VKC, congenital cataract, squint, ocular trauma and other minor eye problems were part of the programme. It covered both rural and urban schools and community, where trained teachers and representatives carried out screening tests with single E optotypes and Snellen charts. Children who were diagnosed with refractive error were further evaluated by the optometrist by cycloplegic refraction and provided with free glasses. Those children who did not improve with refraction were referred to the eye clinic for further management and evaluation.

Outcome of this programme was compared with the same numbers of screening camps conducted both in the schools and community during the same period without trained teachers and representatives.

RESULTSAll total 636 school teachers and community representatives were trained. 58 schools were screened and 40 community camps were organized.

Total 69,658 children and adults were screened by trained representatives. Out of which, 5,928 children and adults i.e. 8.5% of screened population were referred with eye defects for further examination by the Ophthalmologist/ Optometrist. During subsequent check up at camp site, Ophthalmologist/Optometrist confirmed eye defects in 4,235 children i.e. 6.0% of all screened population.

Chart 1: More children were screened by trained teachers then with our teachers

Chart 2: Trained representatives screened more in the community than without representatives.


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Assessment of training quality by cross-checking by skilled staff

The quality of the screenings done by the school teachers and community representatives was systematically monitored. In this study only 4.08 % of false negative cases among the screened population by the teachers and community representatives were detected.

DISCUSSIONInteraction between eye care centre and community based initiation has to be interlinked and it is mutually beneficial and together it can find solutions that is both relevant and appropriate for the community.

Utilizing the services of teachers for screening the eyes of school-going children reduces the workload of eye care service providers.

In most of the developing countries two-third population live in villages, where no organised voluntary groups are available to organise eye camps. As an alternative mode, strategy to train the community representatives for screening the population of their locality for common eye problems is very useful. However, high numbers of false negative cases may be a concern, therefore proper training and monitoring of the trained teachers and community representatives is essential.

To conclude, screening done by teachers reduces the workload of eye care service providers and permits outreach to remote rural areas. The strategy to train teachers and community representatives to screen the population of their locality for common eye problems is very useful and increases the impact of eye health programmes.

Prevalence of Vision Threatening Retinal Conditions in Patients Referred for Cataract SurgeryDr. Varada Gokhale, Dr. Khyati Shah, Dr. Ronnie George, Dr. Sripriya A.V.

Nearly 80% of the considerable burden of blindness in India is attributed to curable causes, such as cataracts and refractive errors.1 A recent study2

found that retinal disorders are an important cause of blindness in India. It is estimated that there will be 244 million people (14.9% of the population) 65 years and older by 2050 compared with 42 million (4.5% of the population) in 1995.3 This shift in demographics is likely to be accompanied by a shift in the prevalence of retinal diseases as major causes of blindness in India. Several studies4-7 report on the prevalence of diabetic retinopathy (DR) in urban


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populations of India. Diabetes mellitus was considered as an urban disease previously, however recent studies have clearly shown increasing prevalence in rural areas as well.7,8 Age-related macular degeneration (AMD) has been reported as a major cause of blindness in European populations.9,10 Recent study by Krishnan et al has also reported the prevalence of ARMD in India.15 Such information is essential to understand the magnitude of the problem and the need for services, including rehabilitation.

We describe the prevalence of vision threatening retinal conditions in patients from rural screening camps referred for cataract surgery.

MATERIALS AND METHODSA retrospective review was conducted of all patients diagnosed with cataract and referred from rural cataract screening camp for cataract surgery to Jaslok community ophthalmic centre, a unit of medical research foundation, Chennai.

The medical records of 624 consecutive patients referred for cataract surgery in the month of August 2010 were reviewed.

Complete eye evaluation was done on each visit and included a complete history, demographics, visual acuity, cycloplegic refraction, slit lamp examination. Intraocular pressure was measured by Goldmann’s applanation tonometer (with tonopen whenever applanation was not possible) and gonioscopy was performed, if required. All participants with open anterior chamber angles determined by gonioscopy using the Schaffer classification had their pupils dilated with either 1% tropicamide or 10% phenylephrine hydrochloride. Participants who had dilation deferred because of occludable or narrow angles underwent dilated examinations after laser iridotomy on the same day or on a subsequent day. Binocular indirect ophthalmoscope with a 20-D lens was used to examine entire retina, including periphery. Fundus examinations were also performed by slit lamp biomicroscopy using a 78-diopter (D) lens. Ultrasound, fundus fluorescein angiography (FFA), optical coherence tomography (OCT) and systemic investigations were ordered, if required

RESULTSOf 624 patients, 35(5.608%) patients were diagnosed to have retinal problems. The mean age was between 50-60 years. The male to female ratio was 21:14.Disease Eyes no Subjects Prevalence Diabetic retinopathy 11 7 1.21% NPDR 8 PDR 1 CSME 2 Vascular occlusions 5 4 0.64%


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CRVO 1 BRVO 4 Retinal detachments 9 8 1.28%Congenital conditions 12 8 1.28% RP 10 CHRPE 1 Coloboma 1 Macular conditions 12 8 1.28% MH 2 CME 1 CNVM 4 ARMD 2 Macular scar 3 Total 49 35 5.608%

DISCUSSIONPopulation-based data on the magnitude of disease is essential to plan for required services. Previous studies2-4 from India have merely mentioned that retinal disorders cause blindness or have focused on diabetic retinopathy. The lack of fundus photographs is a limitation of this study. Few retinal findings could not be picked up because of the dense lens haze due to cataract. Therefore, the total prevalence reported may be an underestimation of the actual prevalence.

Diabetic retinopathy has been one of the foremost causes of blindness in both developed and developing countries.5,9 The number of adults with diabetes in the world is estimated to increase by 122% (135 million in 1995 to 300 in 2025). This increase is expected to be 42% in the developed world and 170% in the developing countries. India stands first with 195% (18 million in 1995 to 54 million in 2025).5 Indian studies show threefold increase in rural prevalence of diabetic in last one and half decade (2.2% in 1989 to 6.3% in 2003).7 In a cross sectional study of self reported population attending diabetic retinopathy screening camps it was found that the rural prevalence of diabetes as 20%8 SN DREAMS report shows the prevalence of diabetic retinopathy to be 18% in both rural and urban population.8

The population older than 65 years is expected to be 137 million by 2021 (compared with 42 million in 1995).11 It is also estimated that there will be a rapid increase in the number of persons with diabetes retinopathy as well as age related macular disorders. The prevalence of macular condition according to Praveen K et al is 10.9% (Macular scar 5.8%, macular dystrophy 0.9%, macular hole 0.8%, other maculopathy 3.4%).12 Praveen Sen et al. reported the prevalence


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of macular hole as 0.17% in rural and urban South Indian population. The prevalence of retinitis pigmentosa in South India was reported as 0.17%.13

Getting these people into the eye care delivery system at an appropriate time to preserve vision is a major challenge. This suggests the need for increased awareness in the community regarding vitreoretinal diseases and their potential for causing blindness and need for improving networking between internist and ophthalmologists to ensure that all those with systemic diseases that have a potential for affecting the eye receive an ophthalmic examination, including dilated fundus examination. Besides focusing on infrastructure development, including trained personnel and low vision and rehabilitative services, strategies to address the issue of vitreoretinal disorders in India, should also look at current ophthalmic practices in India. Opportunistic dilated fundus examinations, at least when the patients come for cataract extraction will greatly increase case detection as well as potentially improve surgical outcomes by pre-treating retinal conditions or accurately assessing visual potential in such eyes.

REFERENCES1. Mohan M. Survey of Blindness—India (1986-1989): Summary Results. New Delhi:

Programme for the Control of Blindness, Ministry of Health and Family Welfare, Government of India; 1992.

2. Dandona L, Dandona R, Srinivas M, et al. Blindness in the Indian state of Andhra Pradesh. Invest Ophthalmol Vis Sci. 2001;42:908-16.

3. Hugo G. Over to the next century: continuities and discontinuities. In: Added Years of Life in Asia: Current Situation and Future Challenges. New York, NY: United Nations Publications; 1996. Asian population studies series 141.

4. Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes center in Southern India. Diabetes Res ClinPract. 1996;34:29-36.

5. King H, Aubert RE, Herman WH: Global burden of diabetes, 1995-2025 prevalence, numerical Estimates and projection. Diabetes Care 1998;21:1414-31.

6. Ramachandran A, Jali MV, Mohan V, Snehalatha C, Viswanathan M: High prevalence of diabetes in an urban population in South India. BMJ 1988;297:587-90.

7. Ramachandran A, Snehalatha C, Dharmaraj D, Viswanathan M: Prevalence of glucose intolerance in Asian Indians: Urban-rural difference and significance of upper body adiposity. Diabetes Care 1992;15:1348-55.

8. Rani PK, Raman R, Sharma V, Mahuli SV, Tarigopala A, Sudhir RR: Analysis of a comprehensive diabetic retinopathy screening model for rural and urban diabetics in developing countries. Br J Ophthalmol 2007;91:1425-9.

9. Rahmani B, Tielsch JM, Katz J, et al. The cause specific prevalence of visual impairment in an urban population: the Baltimore Eye Survey. Ophthalmology. 1996;103:1721-6.


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10. Klein R, Klein BEK, Linton KLP. Prevalence of age related maculopathy: the Beaver Dam Study. Ophthalmology. 1992;99:933-43.

11. Global Initiative for the Elimination of Avoidable Blindness: An Informal Consultation. Geneva, Switzerland: World Health Organization; 1997.WHOpublication 97.61.

12. Praveen K. Nirmalan, Joanne Katz, Alan L. Robin, James M. Tielsch, Perumalsamy Namperumalsamy, Ramasamy Kim, V. Narendran, Rengappa Ramakrishnan, Ramasamy Krishnadas, Ravilla D. Thulasiraj, Eric Suan, Prevalence of Vitreoretinal Disorders in a Rural Population of Southern India. The Aravind Comprehensive Eye Study. Arch Ophthalmol/Vol 122, Apr 2004.

13. Parveen Sen, Arun Bhargava, Ronnie George, Ve Ramesh, Arvind Hemamalini, Raju Prema, Govindasamy Kumaramanickavel and Lingam Vijaya. Prevalence of retinitis pigmentosa in south Indian population aged above 40 years. Ophthalmic epidemiology; 15:279-281.

14. Parveen Sen, Arun Bhargava, Lingam Vijaya, Ronnie George. Prevalence of idiopathic macular hole in adult rural and urban south Indian population. Clinical and Experimental Ophthalmology. 2008;36:257-60.

15. Tiruvengada Krishnan, Ravilla D. Ravindran, Gudlavalleti V. S. Murthy, Praveen Vashist, Kathryn E. Fitzpatrick, R. Duraisami Thulasiraj, Neena John, Giovanni Maraini, Monica Camparini, Usha Chakravarthy and Astrid E. Fletcher. Prevalence of Early and Late Age-Related Macular Degeneration in India: The INDEYE Study. Invest Ophthalmol Vis Sci. 2010;51:701–7.

A Study on Etiology and Antibiotic Resistance Pattern of Organisms Causing Acute Eye InfectionsDr. Ruchi Shah, Dr. Tejas Desai, Dr. Bharat Ghodadra, Devarshi Mistry

The most common eye infections include conjunctivitis, keratitis and stye. Most of these eye infections are in their mild form, self limiting

and adequately treated topically. Treatment is usually empirical and so the etiological agents involved in the process are unknown. The bacterial pathogens encompass a vivid microbiological species range. Bacteria are normally present in the conjunctival flora; however the bacterial pattern is influenced by geographic and climatic factors. Thus, the relative prevalence of bacteria differs from place to place even in the same country. Moreover, we are now faced with the emergence of resistant bacteria. Fungal infections are also now emerging and becoming more rampant with similar problems of resistance.


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Ideally successful management requires appropriate antibiotic and antifungal therapy, based on either microbiological studies such as direct smear examination and culture of the conjunctival swab or on microbial prevalence data in a given area or both.

To the best of our knowledge there are no studies from the western Indian region on the prevalence of organisms associated with the most common eye infections.

So this study was carried out.

Aims of the study is:

• To define the microbiological pattern in cases of eye infections.

• To test the antibiotic sensitivity pattern of these organisms amongst the most commonly used ocular antibiotics.

MATERIALS AND METHODSConsecutive patients appearing with eye infections at the outpatient department of Shri C. H. Nagri Eye Hospital and Iladevi Cataract and IOL Research Centre from the period of July 2009 to Feb 2011 were included in the study. The most common eye infections that were included in the study are conjunctivitis, keratitis, stye and endophthalmitis. Patient profile was recorded. A sterile cotton-wool swab presoaked in sterile tryptone soya broth was used. Inferior fornix was retracted and swab taken by gently rubbing along from lateral to medial canthus. The swabs were immediately streaked on blood agar, nutrient agar and chocolate agar followed by incubation at 37degree C for 48 hrs. Colonies were then counted and identified. Antibiotic sensitivity of each isolate was measured using five antibiotics viz. Moxifloxacin, Ciprofloxacin, Chloramphenicol, Vancomycin and Tobramycin using the E-test. Antifungal susceptibility testing was done using microdilution technique for four antifungal agents viz. Fluconazole, Itraconazole, Natamycin and Amphotericin B. The minimum inhibitory concentration (MIC) was read directly. The antibiotic susceptibility was recorded as susceptible, intermediate or resistant based on the MIC value in cases of bacterial infections.

Culture swabs were taken from 306 patients and distribution of infections was as under:

Total no. of cases 306Keratitis 168Conjunctivitis 111Endophthalmitis 20Stye 2Infected Buckle 5


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RESULTSOut of the total eye infections the prevalence was:

Of the total, 76.8% infections were bacterial and the remaining fungal. Further, bacterial infections were classified into gram positive (63.83%) and gram negative (17.02%) organisms.

Antifungal susceptibility testing was done using microdilution technique for four antifungal agents viz. fluconazole, itraconazole, natamycin and amphotericin B. The MIC values were obtained and plotted as below:

Antibiotic sensitivity of each isolate was measured using five antibiotics viz. Moxifloxacin, Ciprofloxacin, Chloramphenicol, Vancomycin and Tobramycin using the E-test. The MIC was read directly. The antibiotic susceptibility was recorded as susceptible, intermediate or resistant based on the MIC value and the following results were obtained.


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In conclusion this study demonstrates:• Bacteria are responsible for majority of acute eye infections, Gram positive

bacteria being more common than Gram negative. • On testing antibiotic sensitivity, fluoroquinolones were found to be most

effective for gram positive isolates and tobramycin for gram negative isolates, though the resistance is fast increasing.

• Amphotericin B and Natamycin were most effective antifungals.

SignificanceThis study is helpful in routine clinical practice, for streamlining of treatment regimen and to provide local antibiotic resistance surveillance data.

REFERENCES1. Acute bacterial infections of the eye: their aetiology and treatment. V M Mahajan;

Br J Ophthalmol. 1983;67:191–4.2. Ocular infections: Research in India. Sharma S.; Indian J Med Microbiol 2010;28:91-43. Review of epidemiological features, microbiological diagnosis and treatment

outcome of microbial keratitis: Experience of over a decade. Gopinathan U, Sharma S, Garg P, Rao G.; Indian J Ophthalmol 2009;57:273-9.

4. Antibacterial effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis. Am J Ophthalmol 1991;112:29S–33S.

ASHA (Accredited Social Health Activist) Worker – A Novel Approach in Community OphthalmologyDr. Pina Rasiklal Soni, Dr. Minal Patel, Dr. Mariam Nisar Mansuri

The Government of India launched National Rural Health Mission (NRHM) to address the health needs of the rural population. For this, a new band of

community based functionaries, named as Accredited Social Health Activist (ASHA) has been introduced. They are selected from the village itself and are trained to work as an interface between the community and the public health system.

MATERIALS AND METHODSThis Project was conducted from 18th February 2010 to 30th March 2010 to study the efficacy of ASHA worker in screening for low vision. Under the guidance of District development officer (Ahmedabad district, Gujarat, India), a total of 1175 ASHA workers were selected out of the total population of 14,55,220 of Ahmedabad district. 1003 ASHA workers completed the training, of which, 40 were of Ranpur taluka (population of 87,914) a part of Ahmedabad


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district. ASHA workers screened the population and selected patients having vision less then 6/60. They were then referred to the ophthalmic assistants for a diagnosis. When in doubt, the patients were referred to the higher centre.

RESULTS AND DISCUSSIONThe population of 87,914 of Ranpur was screened by 40 ASHA workers. This accounts for a lack of 48 ASHA workers in Ranpur itself, as the required number of ASHA in the area is 88, given the norm of one ASHA per 1000 population. This could be due to lack of initiative by the locals. Of the total population, 80610 (91.69%) people were screened, which indicates a good coverage of the area. The rest 7304 persons were either outstation, sick or dead. The ASHA workers could identify 434 patients with vision less than 6/60 which means prevalence of blindness in the area is 5.38 per thousand population. This included 159(36.63%) males and the rest 275(63.36%) females; this could be due to ignorance on the part of females.The ASHA workers then referred these 434 patients to the ophthalmic assistants where provisional diagnosis was made. Out of these 434 patients, 400 patients were detected to have cataract, 14 had corneal opacity, 5 patients had phthisical eye and 15 had other causes like RD, PBK, squint, glaucoma, amblyopia. The diagnosis was confirmed by higher centre when required.SELECTION OF ASHA – General norm is “One ASHA per 1000 population “ASHA must primarily be a literate women resident of the village in the age group of 25 to 45 years.

Roles and Responsibilties: They identify eye problems (Including Cataract) and refer patients. They also provide primary medical care for minor ailments.

Incentives: ASHA is an honorary volunteer. They receive performance – based non monetary incentives. They are given an incentive of Rs 175 per operated cataract patient.In conclusion ASHA is a fountainhead of community participation in public health programmes in her village. Her active and enthusiastic involvement in the project can ensure better delivery of health services and can also decrease workload on the existing health recourse.The ASHA project could help us in detecting ocular diseases in rural population. The major cause of low vision in developing countries like India is still cataract which, luckily, is a preventable cause of blindness. Hence better penetration of health services armed with ASHA project can go a long way in decreasing the prevalence of blindness in the nation. The major drawbacks that we observed included lack of monetary benefits for ASHA workers, less initiation by the locals to volunteer as ASHA worker.

community/ social ophthalology free papers - aios edu · dr. anamika dwivedi, dr. sujata lakhtakia,...

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