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OPHTHALMICHORIZON

Volume : 14, September, 2019

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RIZONISSN 2075 - 8138

OPHTHALMICHORIZON

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Institute of Community OphthalmologyChittagong Eye Infirmary and Training Complex

CONTENTSVolume: 14, September, 2019

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Editorial

Original Articles

A Newer Technique of Ocular Surface Reconstruction in Unilateral Lime BurnDr. Sujit Kumar Biswas, Dr. A.S.M. Mahbubul Alam, Dr. Soma Rani Roy,Dr. Tanjila Ahmed Ria, Dr. Abdul Matin Bhuyn

Pattern of presentation, management outcome of lens induced glaucomaat a tertiary eye care centreDr. Umme Salma Akbar, Dr. Shams Mohammed Noman, Dr. Rajib Husain,Dr. Mohammed Quamrul Islam

Ocular Health Status of Severely Visual Impaired Students of DifferentEducational Institution (College, University) and Assessment oftheir Socio-educational PotentialityUrmi Atika Islam, Prof. Dr. Munirujzaman Osmani, Rahnoma Tarannom

Management of Centurian Syndrome: an unexplained cause of epiphoriaDr. Murtuza Nuruddin, Dr. Soma Rani Roy, Dr. Fahmida Hoque

Clinico-epidemiological evaluation of diabetic retinopathy patientsattending a tertiary eye care centreDr. Shaila Sharmin, Dr. Jasmin Ahmad

Etiology and Ocular manifestations in children associated with Cerebral PalsyJannatun Noor, Urmi Atika Islam, Dr.Farzana Akter Chowdhury, Dr. Nasimul Goni Chowdhury

Case ReportsHurler syndrome ---- a case reportDr. Umme Salma Akbar, Dr. Shams Mohammed Noman

Millard- Gubler Syndrome: A Case ReportDr. Tanima Roy, Dr. Mumu Das

Foster Kennedy syndrome: A case reportDr. Tanima Roy, Dr. Fatema Begum

CONTENTS

OPHTHALMIC HORIZON

Journal of Institute of Community Ophthalmology and Chittagong Eye Infirmary & Training Complex

Journal of Institute of Community Ophthalmologyand

Chittagong Eye Infirmary and Training Complex

OPHTHALMIC HORIZON

Volume : 14 ISSN 2075 - 8138 September 2019

Printed bySuchitra Computer & Printers38/3, N. A. Chy. Road, AnderkillaChittagong, Bangladesh.E-mail: [email protected] : 01712-900576, 01875-477467

Compiled Under the Supervision ofDr. Ahmadur Rahman Research Center

CEITC CampusPahartali, Chittagong, Bangladesh

Editors in ChiefProf. Dr. Rabiul HusainProf. Dr. Munirujzaman Osmani

Executive EditorsDr. Murtuza NuruddinDr. Shams Mohammad NomanDr. Rajib Husain

Editorial Advisers Prof. Dr. Khurshid AlamDr. Mohd. Quamrul IslamDr. Jasmin Ahmad

EditorsDr. Nasimul Gani ChowdhuryDr. Sujit Kumar BiswasDr. Soma Rani RoyDr. Tanima RoyDr. Shaila SharminDr. Shaila Begum

Advisory BoardProf. Dr. Sharfuddin AhmedProf. A. H. G. QuddusDr. Para RajasegaramDr. Rogers Pearson

Published ByDr. Ahmadur Rahman Research Centre

Editorial OfficeInstitute of Community Ophthalmology &Chittagong Eye Infirmary and Training ComplexPahartali, P.O. Box : 729Chittagong - 4000, BangladeshPhone : 880-31- 659325, 659017-19Fax : 880-31- 659020E-mail : [email protected] [email protected] [email protected] site : www.ctgeyeinfirmary.info www.icoedu.org

ReviewersProf. Dr. Clare Gilbert (UK)Prof. A. H. G. Quddus (USA)Dr. Mahi Muqit (UK)Prof. Dr. Eli Pradhan Ranjitkar (Nepal)Prof. Dr. Zafar KhalidProf. Dr. Nazrul IslamProf. Dr. Anisur Rahman AnjumProf. Dr. Khurshid AlamDr. Nuzhat ChoudhuryDr. Syeed Mehbub Ul KadirDr. Jasmin AhmadDr. Rajib HusainDr. Murtuza NuruddinDr. Shams Mohammad NomanDr. Nasimul Gani ChowdhuryDr. Sujit Kumar BiswasDr. Soma Rani RoyDr. Tanima Roy

EditorialEditorialEditorialEditorialEditorialVisual impairment (VI) is defined as a functional limitation of the eye or visual system and can manifest as reduced visual acuity or contrast sensitivity, visual field loss, photophobia, diplopia, visual distortion, visual perceptual difficulties, or any combination of the above.1 A visual impairment can cause disabilities by significantly interfering with one's ability to function independently, to perform activities of daily living, and/or to travel safely through the environment. When these disabilities limit personal or socioeconomic independence, a visual handicap exists.2

The International Classification of Diseases (ICD 11, 2018) classifies vision impairment into two groups, distance and near presenting vision impairment. Distance vision impairment is classified as Mild (presenting visual acuity worse than 6/12), Moderate (presenting visual acuity worse than 6/18), Severe (presenting visual acuity worse than 6/60) and Blindness (presenting visual acuity worse than 3/60).5 Near vision impairment is addressed if any person has presenting NVA worse than N6 or M.08 with existing correction.3,5

Vision plays an important role in every stage of life. Vision impairment can be pervasive, affecting every aspect of a person’s life. Among global population of 7.7 billion; approximately 1.3 billion people live with some form of vision impairment.7 With regards to distance vision, 188.5 million people have mild vision impairment, 217 million have moderate to severe vision impairment, and 36 million people are blind.4 With regards to near vision, 826 million people live with a near vision impairment.6 Without vision rehabilitation and other supports and services, these people with vision impairment are often poorer and more disadvantaged than their peers. Later in life, vision is used to ensure the completion of everyday activities, maintenance of independence and is a factor in better overall health.8

Fight for Visual Impairment : An In Time and Useful Thinking

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Globally, the leading causes of vision impairment are uncorrected refractive errors and cataracts. Approximately 80% of all vision impairment globally is considered avoidable.8 Among of all VI people, 55% are women.9 Eighty nine percent of VI people live in low and middle income countries. The aged populations from underdeveloped countries are suffering from various social adverse effects especially in terms of quality of life which can be addressed by several psychosocial factors.8 So it is imperative that action should be taken now to mitigate future risks, as well as to better meet current needs.

Provision of effective and accessible eye care services is a key for effectively controlling visual impairment including blindness. The preference should be given to strengthening eye care services through their integration into the health system. According to universal eye health global action plan (2015-2019; WHO),6 dedicated eye care team are working on reducing the VI prevalence by 25% by 2019, so that people who are blind or who have low vision can participate fully in the social, economic, political and cultural aspects of life.6,9

Presently there are several technologies and treatment options for patient’s adjustment to vision loss like magnification devices for near and distances, telemicroscopes, electronic devices, devices for visual field awareness, non-optical devices, training for orientation & mobility with white cane etc. by which people with visual impairment get visual, auditory, and haptic cues from the environment. Portable assistive devices that enhance residual vision also represent important gains. Some progress has also been made in the development of assistive intraocular aids such as the implantable monocular telescope and bionic eye.10,11

There has been progress in raising awareness of visual impairment and rehabilitation. Education and outreach programs in schools, community centers, and elsewhere are teaching ways to prevent vision loss and manage visual impairment. Mass media can contribute enormously in raising awareness on this issue.11 Well-written and targeted educational materials, many on the Web, are helping convey the message that progress is being made to understand and overcome vision loss and develop technologies for managing visual impairment.

Prof. Dr. Munirujzaman OsmaniEditor - in- ChiefOphthalmic Horizon

Care of the Patient with Visual Impairment (Low Vision Rehabilitation); American Optometric Association .Approved by the AOA Board of Trustees June 11, 1997 and October 18, 2007.Making Eye Health a Population Health Imperative: Vision for Tomorrow. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health; Welp A, Woodbury RB, McCoy MA, et al., National Academies Press (US); 2016 Sep 15.“Blindness and vision impairment”- WHO; https://www.who.int/news-room/fact sheets/ detail/ blindness-and-visual-impairmentBourne RRA, Flaxman SR, Braithwaite T, Cicinelli MV, Das A, Jonas JB, et al.; Vision Loss Expert Group. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta- analysis. Lancet Glob Health. 2017 Sep;5(9):e888–97.Fricke, TR, Tahhan N, Resnikoff S, Papas E, Burnett A, Suit MH, Naduvilath T, Naidoo K, Global Prevalence of Presbyopia and Vision Impairment from Uncorrected

Presbyopia: Systematic Review, Meta-analysis, and Modelling, Ophthalmology. 2018 May 9.World Health Organization; Universal eye health: a global action plan 2014-2019. ISBN; 978 9241506564.WHO- world report for vision; https://www.who.int/ blindness/vision-report/Consultation-draft-World-report-on-vision.docx?ua=1Swenor KS LM, Varadaraj V, Ramulu PY. Ageing with visual impairment: The value of vision function and the impact on quality of life of older people. 2017.Global causes of vision loss in 2015: are we on track to achieve the vision 2020 target? The lancet global health; Volume 5, Issue 12, PE1164-E1165, December 01,2017.Bryan Gerritsen, M.A., CLVT, Maureen A. Duffy, M.S., CVRT, Overview of Low Vision Devices; https://www.visionaware.org/info/everyday-living/helpful-products/overview-of-low-vision-devices/124.Trysight low vision devices, https://trysight.com/? gclid=Cj0KCQjw2efrBRD3ARIsAEnt0ejqHMEq9pP3oidYZhaJfr51WpUUz6iifL55XSJOirIcXqqgxhPz-5waAqrREALw_wcB.

References

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ARTICLES

Dr. Sujit Kumar Biswas, Dr. A.S.M. Mahbubul Alam, Dr. Soma Rani Roy,Dr. Tanjila Ahmed Ria, Dr. Abdul Matin Bhuiyan

A Newer Technique of Ocular Surface Reconstructionin Unilateral Lime Burn

IntroductionLime or chuna, Calcium hydroxide Ca(OH)2, is a very common house hold chemical mainly used as edible lime and whitewash of wall in India and Bangladesh. Accidental injury occurs in children at home and adult at workplace. Even with the prompt treatment, possible result is an eye with a scarred vascularized cornea due to limbal stem cell destruction and it is not always possible to restore full visual recovery by conjunctival or corneal surgery. The limbal stem cells probably reside in the basal layer of the palisades of Vogt which are a series of fibrovascular palisade like structures found predominantly along the superior and inferior limbus.1

Insult to this microenvironment leads to limbal stem cell deficiency (LSCD). Chemical injury is one of the cause of LSCD. The current treatment strategies include conjunctivallimbal auto graft (CLAU), culitvated limbal epithelial transplantation (CLET) and simple limbal epithelial transplantation (SLET) for unilateral cases.2 Here we tried to restore some vision and cosmetic appearance by annular conjunctival autograph harvesting from healthy normal fellow eye and transplanted to affected eye with fibrin glue.

Materials and Methods This was a prospective observational case series study. The study was done in a tertiary eye care center; Chittagong Eye Infirmary and Training Complex (CEITC), Bangladesh. Total 15 patients were included over a period of one year (January 2015 to December 2015). Inclusion criteria were unilateral lime burn with total limbal stem cell deficiency (TLSCD), normal tear film, normal B-scan and normal intraocular pressure.

Correspondence to:Dr. Sujit Kumar Biswas, MBBS, DCO, FCPSConsultantChittagong Eye Infirmary and Training ComplexChittagong, BangladeshE-mail: [email protected]

ABSTRACTPurpose: To observe the effects of annular conjunctiva auto graft from fellow eye in unilateral lime burn [Ca (OH)2] with limbal stem cell deficiency and symblepharon. Materials and Methods: This was a prospective observational case series study of 15 patients. Patients with secondary glaucoma, posterior segment pathology and dry eye were excluded from this study. Conjunctival peritomy was done and all scar tissues were removed from cornea and adjacent sclera. Annular conjunctival auto graft were taken from healthy fellow eye including part of palisades of Vogt. The graft was then repositioned to affected eye with fibrin glue and bandage contact lens was applied. Patients were treated with topical steroid, antibiotics and artificial tear and later tapering according to response. Patients were reviewed one week, 1 month, 3 months, 6 months and 12 monthly. Result: All patients showed no recurrence of symblepharon and conjunctivalization of cornea in 12 months follow up period. Fellow eyes showed no vision deterioration, no sign of limbal stem cell deficiency. Ninety three percent patients were highly satisfied.Conclusion: Annular conjunctival auto graft could be a good option for reconstruction of ocular surface in unilateral chemical burn [Ca (OH)2] with limbal stem cell deficiency and symblepharon. Long term follow up is necessary to detect any limbal stem cell deficiency in fellow eyes. Keywords: Annular conjunctival auto graft, limbal stem cell deficiency, symblepharon, simple limbal epithelial transplant, fibrin glue.

7September, 2019Volume : 14

Original Article

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Manuscript Received : 30.04.2019Revision Accepted : 04.08.2019

All the patient included in this study had unilateral lime burn [Ca (OH)2] with total limbal stem cell deficiency (TLSCD) with symblepharon. Patients with bilateral involvement, posterior segment pathology (retinal detachment, large cupping of disc etc), secondary glaucoma and dry eye were excluded from this study. All patients were examined preoperatively. The tests included were visual acuity, digital tonometry, B-scan ultrasonography, Schirmer test, fundus evaluation of fellow eye and status of symblepharon. The status of symblepharon were graded as mild (mild fornicial shortening with no associated ptosis), moderate (visible fornicial shortening with associated ptosis) and severe (globe fixed with eye lid). All patients were explained about risks and benefits of the procedure. Patient’s satisfaction was recorded by a semi structured questionnaire. The grading was done by 3 scales: Not Satisfied, Satisfied & highly Satisfied.

Surgical Technique: General anesthesia was used in pediatric patient and all other patients underwent surgery under peribulbar anesthesia with 2% lignocaine and 0.5% bupivacaine. Three sixty degree conjunctivalperitomy was done and all scar tissue was removed from cornea and adjacent sclera. A ring shaped area of sclera around the cornea was exposed. After giving sub-conjunctival 2% lignocaine, annular conjunctival autograft was taken from healthy fellow eye in such a manner that minimal disturbance of underlying tennon’s and part of palisades of Vogt included in superior and inferior part of the graft. The graft was the 1 mm larger than the exposed sclera area of the affected eye. The graft was then repositioned to affected eye with same orientation with fibrin glue. Topical moxifloxacin 0.5% and topical atropine 1% eye drop were instilled and bandage contact lens was applied in affected eye. Only topical moxifloxacin 0.5% eye drop was instilled in donor eye. Pad and bandage were applied in both eyes at the end of surgery. Post operatively all patients were treated with topical dexamethason 0.1% eye drop in both eye 8 times daily for 7 days then tapered according to response for the next 3 months, atropine 1% eye drop 3 times daily only in the grafted eye for one week and artificial tear in both eye for 3 months. Bandage contact lenses were removed after 3 weeks and showed complete epithelialization of cornea in all cases.

After that all patients were reviewed at 1, 3, 6 and 12 monthly. In each visit visual acuity, graft status, donor site of fellow eye and intraocular pressure of both eyes were measured.

Figure-01: Affected eye (A) before conjunctivalperitomy, (B) after conjunctivalperitomy and removal of all scar tissue over sclera and cornea, (C) after annular conjunctival auto graft with fibrin glue and bandage contact lens application

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Figure-02: Fellow eye (D) annular conjunctival auto graft is taken, (E) after removal of graft tissue, (F) free annular graft

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September, 2019Volume : 148


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Patients Data:

Table-02: Operative and post operative data

Note: Symblepharon: + mild (mild fornicial shortening with no associated ptosis); ++ moderate (visible fornicial shortening with associated ptosis); +++ severe (globe fixed with eye lid). LSCD: Limbal Stem Cell Deficiency.

Note: Corneal clarity: +iris detail clear; ++ iris detail hazy; +++ no iris details; Satisfaction: +not satisfied, ++ satisfied, +++ highly satisfied.

1. 15 M OD 3/60 6/6 66 + 30 (30) No 3600

2. 10 M OD PL 6/6 17 ++ 15 (20) Upper Lid Entropion correction 36003. 05 M OS HM 6/6 07 +++ 24(30) No 36004. 13 M OD HM 6/6 98 ++ 15(27) No 36005. 37 M OS PL 6/6 60 ++ 11(18) No 36006. 05 F OD CF 1m 6/6 14 ++ 14(20) No 36007. 18 F OS CF 1m 6/6 84 ++ 20(20) No 36008. 45 F OS CF 1m 6/9 36 +++ 17(24) No 36009. 23 M OS HM 6/6 144 +++ 13(19) No 36001o. 05 F OD HM 6/9 06 ++ 21(30) No 360011. 12 F OS CF 1m 6/6 108 ++ 22(23) No 360012. 10 M OS CF 1m 6/6 96 ++ 26(26) No 360013. 16 F OD 1/60 6/6 144 ++ 21(20) No 360014. 15 F OS 6/60 6/6 72 ++ 30(30) No 360015. 35 M OS HM 6/6 12 ++ 12(30) No 3600

No. Ageyear

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surgerydone

before

LSCD

No.VA of

operatedeye

VA offellow

eye

RecurrentSymblepharon

Cornealclarity(scar/

vasculari-zation)

Followup

period(months)

Patientsatisfaction

Any other surgeryafter

ConjunctivalAutograft

1. 6/60 6/6 No + No 20 ++2. CF 6/6 No ++ No 12 +3. 3/60 6/6 No ++ No 18 +++4. 1/60 6/6 No ++ No 14 ++5. 2/60 6/6 No ++ No 15 +++6. 6/60 6/6 No ++ No 18 +++7. 6/24 6/6 No + Yes- ptosis correction done 17 +++8. 6/18 6/9 No + No 15 +++9. CF 6/6 No ++ No 14 ++1o. 3/60 6/6 No ++ No 16 ++11. 6/60 6/6 No + No 13 +++12. 1/60 6/6 No + No 13 +++13. 2/60 6/6 No + Ptosis correction advised 12 +++14. 6/24 6/6 No + No 12 +++15. 3/60 6/6 No ++ No 12 +++



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Table-01: Preoperative data

ResultsOut of 15 patients 8 (53.3%) patients were male and 7 (46.7%) were female [Fig.-03]. The mean age was 17.6 ± 1.23 years range was 5 - 45 years. Ten (66.7%) patients were below 16 years and 5 (33.3%) patients were above [Fig.-04]. Right eyes were affected more (60%) than left eyes [Fig.-05]. Time gap between occurrence of burn and annular conjunctival auto graft (ACAU) was minimum 6 months and maximum 144 months (mean 64.27 ± 4.8 months).

Eleven (73.3%) patients had fornicial shortening associated with ptosis (moderate symblepharon) [Fig.-09-13], where as 3 patients (20%) had globe fixed with eye lids (severe symblepharon) [Fig.-13,14] and only one patient (6.7%) had mild fornicial shortening with no ptosis (mild symblepharon) [Fig.-06,15]. One patient (6.7%) had been corrected his entropion 3 months before annular conjunctival auto graft, one patient (6.7%) underwent ptosis correction 12 months after annular conjunctival auto graft [Fig.-10] and one patient (6.7%) was advised for ptosis correction 12 months post operatively [Fig.-12].

Male Female

53%

47%

Figure-03: Gender distribution

Figure-04: Age distribution

Child Age Adult Age

67%

33%

Figure-05: Affected eyes

Right Eye Left Eye

40% 60%

7%

73%

20%

Figure-06: Status of symblepharon

Table-03: Pre-and post-operative Visual acuity of affected eyes

Table-04: Pre-and post-operative Visual acuity of fellow eyes

Note: VA: Visual acuity; PL: Perception of light; HM: Hand Motion; CF: Counting finger.

Note: VA: Visual acuity; PL: Perception of light; HM: Hand Motion; CF: Counting finger.

All patients were followed up at least for 12 months (12 to 18 months). Within this follow up period vision in affected eyes were not improve much [Table-03] but cosmetically improved [Fig.-09-16]. Fellow eyes showed no vision deterioration [Table-04], no sign of limbal stem cell deficiency, no corneal vascularization and no symblepharon formation [Fig.-09-16].



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Mild

Moderate

Severe

VA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Pre-op 6/6 6/6 6/6 6/6 6/6 6/6 6/6 6/9 6/6 6/9 6/6 6/6 6/6 6/6 6/6

Post-op 6/6 6/6 6/6 6/6 6/6 6/6 6/6 6/9 6/6 6/9 6/6 6/6 6/6 6/6 6/6

VA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Pre-op 3/60 PL HM HM PL CF CF CF HM HM CF CF 1/60 6/60 HM

Post-op 6/60 CF 3/60 1/60 2/60 6/60 6/24 6/18 CF 3/60 6/60 1/60 2/60 6/24 3/60

In term of corneal clarity of affected eye, seven (47%) patients had relatively clear cornea with iris details clear [Fig.-10-13,15,16] and 8 (53%) patients had scarred cornea with iris details haze [Fig.-07, 09,14].

Ten (66%) patients were highly satisfied [Fig.- 09-15], four (27%) were satisfied [Fig.-16] with their surgery as they achieved cosmetic improvement compared with past. One (7%) patient did not satisfy with this surgery [Fig.-08].

Figure-07: Corneal clarity of affected eye

Iris Detail Clear

Iris Detail Hazy

47%

53%



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Figure-08: Patient satisfaction

7%

27%

66%

Not Satisfied Satisfied Highly

Figure-09: Preoperative (A,B); postoperative (C,D); fellow eye (E)

A

C

E

B

D

Figure-10: Preoperative (A,B); postoperative (C,D); after correction of ptosis (C); fellow eye (E)

A

C

E

B

D



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Figure-11: Preoperative (A,B); Postoperative (C,D); ptosis automatically corrected (C);fellow eye (E)

A

C

E

B

D

Figure-13: Preoperative (A,B); postoperative (C,D); ptosis automatically corrected (C); fellow eye (E)

A

C

E

B

D

Figure-14: Preoperative (A,B); postoperative (C,D); ptosis automatically corrected (C); fellow eye (E)

A

C

E

B

D

Figure-12: Preoperative (A,B); postoperative (C,D); postoperative persistent ptosis advised for correction (C); fellow eye (E)

A

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E

B

D



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D


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DiscussionLimbal stem cells (LSCs) deficiency either due to inherited (aniridia, congenital erythrokeratodermia) or acquired (thermal/chemical injury or chronic inflammatory) diseases leading to conjunctivalization, neovascularization of cornea and eventually to blindness.3,7 Calcium hydroxide [Ca(OH)2], a common house hold chemical used as edible lime and whitewash of wall in Indian subcontinent. The devastating nature of Ca(OH)2 injury causes severe LSCD resulting into conjunctivalization, symblepharon and blindness as well as personal, social and economic loss. Children are more prone to accidental injury at home. Sixty six percent of affected patients of our study were pediatric age group (below 16 years) [Fig.- 11,14,16]. The current treatment strategies include conjunctivallimbal autograft (CLAUG), cultivated limbal epithelial transplantation (CLET) and simple limbal epithelial transplantation (SLET) for unilateral cases. Keratolimbal allograft, allogenic CLET, keratoprosthesis and cultivated oral mucosal transplantation are meant for bilateral cases. The emerging treatment modalities include tissue- engineering approaches, stem cell-based regenerative therapies and ocular surface regeneration using embryonic stem cells, induced pluripotent and mesenchymal stem cells.2

In recent years, the risk of secondary LSCD due to removal of large limbal grafts has been significantly reduced by the optimization of cultivated limbal epithelial transplantation (CLET). Despite the great successes of CLET, there still is room for improvement as overall success rate is 70% and visual acuity often remains suboptimal after successful transplantation. Simple limbal epithelial transplantation reports higher success rates but has not been performed in as many patients yet.8 Nidhi et al. showed autologous SLET is an effective limbal cell transplantation technique for the treatment of unilateral LSCD. It is especially beneficial for centers where cell cultivation laboratory is unavailable. Presence of severe symblepharon, which requires PK per-operatively, has poor outcome.9 Basu et al.also reported a case of unilateral, total limbal stem cell deficiency (LSCD) who underwent SLET and after 6 weeks postoperatively, a focal recurrence of LSCD with symblepharon and fornicial shortening was noted superiorly.



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This was successfully managed by performing conjunctival autografting along with supplemental SLET.10

In our study we used annular conjunctiva harvested from healthy fellow eye with minimal disturbance of underlying Tennon’s and part of palisades of Vogt included in superior and inferior part of the graft [Fig.-02 E, F]. We prepared the graft with the aim that part of palisade of Vogt remaining in the limbus of fellow eye will prevent LSCD and also act as a barrier of vessels from conjunctiva to grow over the cornea and part of Vogt’s palisade in the graft act as a source of stem cells for grafted eye. Intact underlying Tenon’s capsule subsequently healed without any symblepharon and granuloma formation in our all cases, although healed conjunctiva showed less mobility in grafted eyes as well as fellow eyes [Fig.-09-16]. This less mobility of conjunctiva may cause subsequent difficult to do trabeculectomy in either eye if glaucoma develop in future.

It is our hypothesis that in annular conjunctival auto graft (ACAU) there is no focal area of limbal stem cell deficiency as in SLET. In SLET there is a chance of corneal vascularization at the site of limbal tissue harvesting area [Fig.-17], but in ACAU there is no such focal defect of stem because part of palisade of Vogt was remaining in the limbus [Fig.-02E, 13E].

All our patients came to us with the aim of cosmetic improvement and secondarily vision improvement. We observed that 14 (93.4%) patients were satisfied, out of them 10 (66.7%) were highly satisfied [Fig.-08-15]. Vision was not improved satisfactorily [Table 03]. For further vision improvement patient had to undergo penetrating keratoplasty (PKP) or anterior lamellar keratoplasty (ALK). Pre- and post operative visual status of fellow eyes had not showed any change [Table-04]. It was observed that out of 14 (93.4%) patient associated with ptosis and globe fixed lid [Fig.-09-15], only 2 (13.33%) patients needed postoperative ptosis correction, one already done [Fig.-10] and one was advised for ptosis correction [Fig.-12]. After release of symblepharon and removal of scar tissue, most of the ptosis corrected automatically [Fig.-09,11,13-15]. Limitations of this study are small sample size, lack of long term follow up, lack of comparison with other treatment modalities and difficult situation in future for trabeculectomy if subsequent glaucoma develop. Although in 12 months follow up our patients were satisfied with their cosmetic outcome, we need a longer follow up and larger sample size to draw a conclusion.

ConclusionAnnular conjunctival auto graft (ACAU) could be a good option for reconstruction of ocular surface in unilateral chemical burn [Ca(OH)2] with limbal stem cell deficiency and symblepharon. Long term follow up is necessary to detect any LSCD in fellow eye. We have to compare with other modalities to prove its efficacy.

Figure-17: Focal area of limbal stem cell deficiency indicated by arrow

Davanger M, Evensen A. Role of the pericorneal papillary structure in renewal of corneal epithelium, Nature 1971; 229:560-61.A. Sati, S Shukla, I. Lal, VS Sangwan. Review article- Treating limbal stem cell deficiency: current and emerging therapies. 16 Apr 2015:619-631S. Mathews, Jd Chdambaram, S Lanjewar, J mascarenhas, NV Prajna, V Muthukkaruppan, and GP Chidambaranathan. In vivo confocal microscopic analysis of normal human anterior limbalstroma. Cornea. 2015; 34(4): 464-470.

References

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Financial Support & Sponsorship : NilConflicts of interest : There are no conflicts of interest.



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Kobayashi A, Sugiyama K. In vivo corneal confocal microscopic findings of palisades of Vogt and its underlying limbalstroma. Cornea. 2005;24:435-7. [PubMed]Patel DV, Sherwin t, MeGhee CN. Laser scanning in vivo confocal microscopy of the normal human corneosclerallimbus. Invest Ophthalmol Vis Sci. 2006;47:2823-7. [PubMed]Miri A, Al-Aqaba M, Otri AM, et al. In vivo confocal microsopic features of normal limbus. Br J ophthalmol. 2012;96:530-6. [PubMed]Zarei-Ghanavati S, Ramirez-Miranda A, Deng SX. Limbal lacuna: a novel limbal structure detected by in vivo laser scanning confocal microscopy. Ophthalmic Surg Lasers Imaging. 2011;42:e129-31. Online. [PubMed]

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Haagdorens M1, Van Acker S12, Van Gerwen V2, NiDhubhghaill S3, Koppen C3, Tassignon MJ3, Zakaria N4. Limbal Stem Cell Deficiency: Current Treatment Options and Emerging Therapies. Stem Cells Int. 2016;Nidhi Gupta, Jagdish Joshi, JavedHussainFarooqui, UmangMathur. Results of simple limbal epithelial transplantation in unilateral ocular surface burn. Department of Cornea, External Diseases and Refractive Surgery, Dr. Shrof’s Charity Eye Hospital, New Delhi, India 2018;66(1):45-52.JayeshVazirani, SayanBasu, and VirenderSangwan. Successful simple limbal epithelial transplantation (SLET) in lime injury-induced limbal stem cell deficiency with ocular surface granuloma. BMJ Case Rep. 2013 Jun 19:bcr2013009405.

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Dr. Umme Salma Akbar, Dr. Shams Mohammed Noman, Dr. Rajib Husain,Dr. Mohammed Quamrul Islam

Pattern of presentation, management outcome of lensinduced glaucoma at a tertiary eye care centre

IntroductionLens induced glaucoma; one of the commonest causes of 2º glaucoma due to senile cataract mandates an early recognition and management to prevent blindness.1

Although lens induced glaucoma is prevalent in developing countries it also occurs in developed countries.2

Lens-related elevation in IOP results from a variety of mechanisms such as lens dislocation, lens swelling (intumescent cataract), inflammation due to phcacoanaphylaxis and lens particle blocking the trabecular meshwork. Untreated rise in IOP damages the optic nerve mechanically which inevitably leads to blindness.

Cataract occurs when crystalline lens loses its transparency normally as part of ageing process.

Neglected cataractous lens may swell because of osmotic effect of degenerated lens proteins.

In phacomorphic glaucoma, the swollen lens may block the anterior flow of the aqueous humour from the posterior chamber pushing the iris forward. Eventually, the trabecular meshwork gets blocked by the iris and leads to a sudden and extreme rise in IOP.3

Phacolytic glaucoma is a principle complication of hyper mature cataract. Hyper mature cataract may cause leakage of lens protein from an intact capsule. The lens protein causes intense inflammation and blockage of trabecular meshwork, subsequently responsible for elevation of IOP.4

The purpose of this review was to study and determine the clinical presentations, management and outcome of lens induced glaucoma at Chittagong Eye Infirmary and Training Complex.

Correspondence to:Dr. Umme Salma Akbar, DCOSenior Assistant SurgeonChittagong Eye Infirmary and Training ComplexChittagong, BangladeshE-mail: [email protected]

ABSTRACTObjective: To outline the clinical presentation, management and outcome of lens induced glaucoma in Chittagong Eye Infirmary and Training Complex.Methods: A case series review was done among the patients who visited Chittagong Eye Infirmary and Training Complex from January 2015 to December 2018. Demographic data, clinical presentations, management and outcome were recorded and analyzed.Results: Thirty phacomorphic cases and twenty phacolytic glaucoma patients were included in our study. The mean age at presentation was 60 years. Female to male ratio was 2:1. The reason for late presentation was distance between their home and the hospital which was 60% in phacomorphic glaucoma and 50% in phacolytic glaucoma. The main symptoms were reduced vision followed by ocular pain and redness of eye. Visual acuity was either HM or PL in all eyes before surgery. All patients underwent SICS with posterior chamber lens implantation. IOP was reduced tremendously at the time of discharge and vision kept improving up to a month after surgery.Conclusion: Reduced vision, ocular pain and redness were the main clinical presentations of lens induced glaucoma. Cataract surgery was proved to be effective in lowering IOP and visual recovery in patients with lens induced glaucoma.Keywords: Lens induced glaucoma, phacomorphic glaucoma, phacolytic glaucoma.



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Original Article

MethodsA case series review was conducted on records of patients who were diagnosed with lens induced glaucoma in Chittagong Eye Infirmary and Training Complex between January 2013 and December 2018.

Lens induced glaucoma was diagnosed on the presence of increased IOP and lens related problem.5 The diagnosis of phacomorphic glaucoma was based on the presence of pain and redness, shallow anterior chamber, corneal edema and increased IOP with intumescent lens.

Phacolytic glaucoma was diagnosed clinically based on the presence of hyper mature cataract, presence of lens protein and flare in anterior chamber. Goldmann applanation tonometry was used to measure IOP. All patients underwent small incision cataract surgery with posterior chamber lens implantation. Exclusion criteria included those patients who had primary glaucoma or other underlying causes of secondary glaucoma and inadequate data.

Demographic data, clinical presentations, management and outcome were documented and statistical analysis was conducted using SPSS 16.

ResultsA total of 50 cases were included in our study. Phacomorphic glaucoma was found to be more 30 (60%) than phacolytic 20 (40%). There was a female preponderance compared to male with female to male ratio of 2:1. At presentation, all patients in the effected eye had VA either of HM or PL (Table-01). In phacomorphic glaucoma vision is usually better than HM.

Examination of fellow eye revealed 53.33% had immature cataract, 43.33% were pseudophakic and 3.33% had no ocular morbidity in phacomorphic glaucoma group and in case of phacolytic glaucoma group, 35 % had immature cataract, 55% were pseudophakic and 10% had normal ocular status (Table-02). The reason for delay in presentation was distance between their home and the hospital which was 60% in phacomorphic glaucoma and 50% in phacolytic glaucoma. All patients underwent SICS +PCIOL implantation. IOP at presentation ranged from 21 to 60mm Hg. 33.33% had IOP more than 40mm Hg

at presentation in case of phacomorphic glaucoma and 50% in case of phacolytic glaucoma. Following surgery, 90% had an IOP of 21mm Hg at the time of discharge.

After 1 month follow-up, 19 (63.33%) had VA 6/60 or better, 5 (16.67%) had less than 6/60 and 6 (20%) had less than 3/60 in case of phacomorphic glaucoma. In case of phacolytic glaucoma, 11(55%) had VA 6/60 or better, 6 (30%) had less than 6/60 and 3 (1%) had less than 3/60 (Table-03).

6/6 - 6/18 0 0 0 0

6/18 - 6/60 0 0 0 0

6/60 - PL 20 40 30 60

Percentage %

Phacolytic GlaucomaPresentingVisual Acuity

Phacomorphic Glaucoma

N Percentage %N

Table-03: 1 Month follow up visual acuity of the patients

6/6 - 6/18 11 22 19 38

6/18 - 6/60 6 12 5 10

6/60 - PL 3 6 6 12

Percentage %

Phacolytic Glaucoma1 Month VA Phacomorphic Glaucoma

N Percentage %N

Table-02: Condition of Other Eye

Normal 2 4 1 2

Cataract 7 14 16 32

Pseudophakia 11 22 9 18

Glaucoma 0 0 4 8

Percentage %

Phacolytic GlaucomaCondition ofOther Eye

Phacomorphic Glaucoma

N Percentage %N

Table-01: Presenting Visual Acuity of total 100 eyes of 50 patients



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DiscussionIn our study, phacomorphic glaucoma was more common than phacolytic glaucoma which is similar to a study by Prajina et al. Nirmalan et al reported a prevalence of phacomorphic glaucoma of 3.9% of all cataract surgeries.6 In our study, females seemed to have a significant increased risk of having lens induced glaucoma. In our study, VA at discharge was better which is similar to a study by Jain IS, et al.5 IOP after cataract surgery was below 21 mm of Hg in 90% in our study. In our setup, the patients presented late, probably because of distance from hospital, poverty, ignorance, lack of awareness and facilities for treatment.

These results highlight the importance of early diagnosis and treatment of mature cataract.7 There is a need to educate both the patient and the cataract surgeon of the dangers of lens induced glaucoma and of the poor outcome if treatment is delayed. All the factors could not be demonstrated in our study due to the smaller sample size. The pre-operative mean and post operative mean of IOP in lens induced glaucoma who underwent SICS was statistically significant (P< 0.001) without long term medication.8 In our study, pre-operative and post-operative IOP mean was not calculated.

ConclusionLens induced glaucoma is an important vision-threatening disease. Phacomorphic lens disease secondary to a neglected senile cataract is

the major cause of lens induced glaucoma. Removal of the cataractous lens results in prompt reduction in IOP and a favorable visual outcome.

Pant Sitoula et al. Lens induced glaucoma in eastern Nepal. Nepal J Ophthalmol 2016;8(16):161-166.Sowka J. Phacomorphic glaucoma: Case and review. Optometry. 2006; 77:586–9.Jonathan PE, Ellant, Stephen A. et al. Lens induced glaucoma. Documenta Ophthalmia. 1992;(81):317–38.Johns KJ, Feder RS, Hamill MB. et al. Lens and cataract. American Academy of Ophthalmology. 2002-2003.Jain IS, Gupta A, Dogra MR. et al. Phacomorphic glaucoma Management and visual prognosis. Ind J Ophthalmol. 1983;31:648–53.Paradhan D, Hennig A, Kumar J, Foster A. A prospective study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol 2001; 49:103-107.Yaakub A, Abdullah N, Siti Raihan I, Ahmad Tajudin LS. Lens-induced glaucoma in a tertiary centre in northeast of Malaysia. Malays Fam Physician 2014; 9(2):48-52.R Ramakishanan et al. Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthal; 2010 Jul-Aug; 58(4): 303–306.

References

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Urmi Atika Islam, Prof. Dr. Munirujzaman Osmani, Rahnoma Tarannom

Ocular Health Status of Severely Visual Impaired Students ofDifferent Educational Institution (College, University)and Assessment of their Socio-educational Potentiality

IntroductionVisual impairment and blindness is a curse to a person who ultimately remains as a burden to family, society and to the country. A large number of people are visually impaired world widely. In a study of WHO (World Health Organization) which was held in 2012,1 around 285 million people are visually impaired; among of them 39 million are blind. About 90 percent of the visually impaired persons are in developing countries.1 According to recent statistics, there are

8,00,000 visually impaired people in Bangladesh whom are within 20 to 25 years of old.1

Blind and visually impaired students face many challenges and barriers when it comes to higher education. The national federation for the blind estimates that in 2015, 7.29 million adults reported to have a visual disability.2 In 2015, 42% of blind or visually impaired individuals were in the work force, but less than 15% had to earn a bachelor’s degree at an accredited higher learning institution. In contrast, more than a quarter do not finish high school.2,3,4

At the educational levels, vision loss is classified into three major categories which are based on an individual functional limitation and how those limitations impact his or her ability to perform daily activities. For this reason, it is important for

Correspondence to:Urmi Atika IslamOptometristInstitute of Community OphthalmologyChittagong, BangladeshE-mail: [email protected]

ABSTRACTPurpose: The purpose of this study was to explore the ocular health condition of different higher educational institute like College and University students to provide necessary support for a stable ocular health condition and to establish a proper management policy according to their stage of visual impairment. Emphasis was given to provide potential visual aids for further improvement of visual function in every case.Methods: It was a community based prospective study. A total of 50 students of different higher educational institutions with visual impairment were included in this study. The questionnaire was coded according to the “National Eye Institute Visual Functioning questionnaire – 25 (VFQ – 25) version 2000”. A comprehensive ocular examination was done which included visual acuity test, refraction, color vision test, and trial of Optical and Non-optical low vision devices. Proper management protocol was maintained according to the ocular status of every case.Results: Mean age of the student was 21.86 ± 2.28. There were 82% male & 18% female. The most common causes of visual impairment were Refractive error (21.6%) and Nystagmus (20.5%). Other common causes were Macular dystrophy (6.7%), Retinitis Pigmentosa (5.7%), Aphakia (4.5%), Strabismus (5.2%), Amblyopia (10.2%), Optic Atrophy (3.4%), Uveal coloboma(2.3%). Some other causes of low vision were Micro-cornea, Corneal dystrophy, Aniridia, Glaucoma, Rubeosis Iridis, Subluxation of lens, Developmental cataract, Vitreous haemorrhage, Macular scar, Heridoretinal degeneration, Chorioretinal dystrophy, Phthisis bulbi. Percentage of improvement of visual acuity with the low vision devices was 62%.Conclusion: Student with low vision usually need special care specific to their residual vision. Inadequate rehabilitation of low vision conditions can restrict the student’s education as well as their social and emotional status. Appropriate low vision management could open new and easier way for their development in every aspect of life.


Original Article

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students who are blind or have visual impairments to organize and care for the special tools and materials. Adapting and accommodation needed by blind people which can be applied to all students with vision impairments. Most visually impaired students use a combination of accommodation for class participation and learning needs, including books on tape, e-text or voice synthesizing computers, optical scanners, readers and Braille.

This study helped us to determine the condition of ocular health of the severe visual impaired students of different institute and evaluate the effectiveness of the use of various visual aid. We also looked at the factors that act as the barriers of using device.

ObjectivesTo identify the proper ocular health status, risk factors, risk groups of higher educational institutional students with visual impairment and to provide a need based medical and social support. It also helped to identify about their daily living activities and their extracurricular activities with their existing vision and also draw a line of management for visually impaired and blind students.

Literature review1. Archanaet al, 20112 carried out a study on profile of low vision in children less than 16 years of old where 65 children were included. In that study, mean age was 11.58 ± 3.83 years. Among them 55.45% were male. More than one third (34%) of the total children were in the category of blindness, two thirds (72.30%) patients had refractive error. Majority (66.15%) had multiple causes of visual impairment.Major causes of visual impairment were Nystagmus (58.46%), high refractive error (26.15%) and amblyopia (24.61%).

2. Fichtenet al 20163, carried out a study on an exploratory study of college & University students who indicated only that they were blind and those who indicated having only low vision on variables showed only that students who are blind experienced less campus climate social alienation than those who have low vision. Among them 53% of students who were blind and the 41% with low vision who worked did so for

an average of 19 hours per week (range = 2 – 40 hours). Chi-square tests showed no significant differences.

3. A study was conducted by Mohammad et al4, 2009 to find out the causes of vision loss, levels of distance, near vision and the use of low vision devices in children studying at special schools in Malaysia. Out of 139 children, near visual acuity of 71 children ranged from N4 to N64. Sixty eight (68) children were totally blind. Only 8 students were using low vision devices before intervention. Seventy one (71) children were referred for low vision assessment and 48 were found to benefit from the LVDs prescribed. The major cause of visual impairment was cataract (17%). Hand held magnifier was the most preferred LVDs.

4. Gilbert et al5, 2008 to determine the prevalence and causes of FLV among children recruited in eight population-based prevalence surveys of visual impairment and refractive error from six countries. The prevalence of FLV ranged from 0.65 to 2.75 in 1000 children, with wide confidence intervals. Retinal lesions and amblyopia were the commonest causes.

5. Another study in Bangladesh done by Hossain et al6, 2005 under a programme of vision 2020 where presented the information’s as the childhood prevalence of 0.75/1000 children, about 40,000 blind, 12,000 children were suffering from unnecessary blindness due to un-operated cataract. Another 10,000 children were blind due to corneal scaring which was ignorable with awareness of ocular injury and proper primary eye care treatment. For every million population here would be 3000 blind children. In Bangladesh assuming a prevalence of 4% of children aged 5 to 15 years to have visual acuity less than 6/18.

6. Gothwalet al7,2002, stated in his study about the characteristics of pediatric low vision population in India which was a cross sectional survey. On presentation, 49% of the children were classified as moderately visually impaired. 31% were severely visually impaired and 20% were blind.

7. Harper et al8, 2007, presenting a survey of the demographical, educational and visual functional characteristics of children attending a specialist pediatric low vision assessment clinic. The most common cause of visual impairment was albinism (20%) followed by rod cone dystrophy (10%).



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MethodologoyThe study was prospective in design; both qualitative and quantitative data were collected. Quantitative data was collected by ocular examination and Qualitative data was collected by a semi-structured questionnaire from the students. All the students included in the study were selected according to previous categorization in their respective educational institution (college, university). They were scheduled for meticulous examination in a tertiary eye care center; Chittagong Eye Infirmary and Training Complex (CEITC) where a team comprising Low vision specialist, Optometrist and Counselor have done comprehensive eye examination.The study period was 1 year. Sample size was 50. All data were collected individually from the patient and informed consent was taken from them before eye examination and interview. All relevant particulars of the students were noted in standard formats and were reviewed by experts before the finalization of the format.

Interview Schedule:Qualitative data were collected with an interview schedule, which included demographic, socio economic background and educational status and their daily living activities. The questionnaire was coded according to the “National Eye Institute Visual Functioning questionnaire – 25 (VFQ – 25) version 2000”. Each interview was first written separately and then findings were organized thematically for analysis.

Clinical Examination:Ophthalmologist and Optometrist were attended in ocular examination. Presenting visual acuity and pinhole visual acuity was taken with the help of Snellen VA chart. Dry refraction was done in all cases with the help of Streak Retinoscope; Subjective refraction was done with the help of trial set, for near visual acuity N notation near vision chart test was used. The Anterior segment was assessed with the help of a slit lamp biomicroscopy and posterior segment examination was carried out using a direct and indirect ophthalmoscope by dilating the pupil when indicated. Proper refractive correction was prescribed in spectacle form. Intra ocular pressure, Ocular motility, pupillary reaction, color vision were measured.

Management and prescribing low vision deviceA trial of telescopes was carried out for suitable patients and the visual acuity with telescopes was noted. Similarly, the near magnifiers of appropriate magnification were tried and the near visual acuity with magnifiers was noted. A management of each patient was given on the basis of patient’s need, ability and acceptability.

Statistical analysis All quantitative and qualitative data were processed using SPSS (version 16). Both univariate and bivariate analysis was done to describe and show relationships. Graphs, Charts and tables were used for easy understanding and presentation of the findings.

ResultsDemographic and Socioeconomic Information: A total number of 50 students were examined during the period of this study. The study subjects were classified into two groups. About 46% of the respondents were between 18-21 years old and 54% of the respondents were between 22-25 years old shown in the figure 01. The mean age of the respondents was 21.86 ± 2.28 years.

In this study, about 82% of the respondents were male and 18% of the respondents were female. Male students were attending in higher education far more than females in spite of having visual impairment.

Among the visually impaired students of university and colleges, the system and way of education of all students were not same. The educational system was different for different stage of visually impairments. Among them, 24% were gaining education by Braille and Audio recording system, 42% of students in Braille only and 34% students were coping with normal educational system by optical correction and low vision aids.

Causes of Visual Impairment of the Respondents

In our study prevalence of refractive error was 1.6%, where 11.4% was due to pathological myopia. Other mentionable ocular morbidities were strabismus (5.2%), amblyopia (10.2%), macular dystrophy (5.7%), Retinitis Pigmentosa (5.7%), lenticular causes (7.8%) etc. It was observed that, most of the respondents had multiple structural abnormalities. Percentage of the other associated abnormalities were mentioned in the Table-01 below.



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Table-01: Causes of visual impairment of the respondents

Table-02: Unaided visual acuity of right & left eye at distance

Table-03: Percentage distributions of difficulty level for distance work of the respondents

Unaided Visual Acuity at Distance of Respondents

We have categorized unaided visual acuity of the respondents according to right and left eye. Around 62% of right eye had VA in the range of >3/60 to PL. But around 40% of the left eye had VA in the range of >6/18 to 6/60.

In cases of reading street signs or the names of stores, 36% students were facing extreme difficulties and most of them stopped trying to do so afterwards (Table–03). Going up stairs or down stairs in dim light or at night were faced with extreme difficulties by 30% students. Percentage of difficulty level during reading and climbing ups and down in the stairs mentioned in the Table-03.

Improvement of Visual Acuity after Optical Correction

The Table–04 is showing the improvement of vision after giving refractive correction. Around in 20% students distance visual acuity improved in Right eye and 50% student’s visual acuity improved in left eye after giving optical correction.

Corneal Dystrophy

Keratoconus

Microcornea

Aniridia

Uvealcoloboma

Glaucoma

Rubeosis Iridis

Subluxation of lens

Ectopic lens

Developmental Cataract

Aphakia

Vitreous Hemorrhage

Optic atrophy

Macular dystrophy

Retinitis Pigmentosa

Macular hole

Heridoretinal degeneration

Macular scar

Chorioretinal dystrophy

Phthisisbulbi

Ptosis

Nystagmus

Uncorrected Refractive Error

Strabismus

Amblyopia

1.1%

1.1%

3.4%

1.1%

2.3%

1.1%

1.1%

1.1%

1.1%

1.1%

4.5%

1.1%

3.4%

6.7%

5.7%

1.1%

1.1%

1.1%

1.1%

1.1%

1.1%

20.5%

21.6%

5.2%

10.2%

Total

>6/18 – 6/60

>6/60 -3/60

>3/60-PL

Total

(N=50)

16%

22%

62%

100%

(N=50)

40%

26%

34%

100%

5.6%

5.6%

7.8%

1%

20.2%

2.2%

57.5%

MorbidityAnatomic site

Corneal cause

Uveal cause

Lenticular cause

Vitreous

Retina

Orbital cause

Others

Total 100%

PercentageN=50 UVA- right eye

Reading street signsor

name of the stores(percentage)

N=50

Grade

Stopped doing this for otherreasons or not interested

in doing this

Total

Going up stairs ordown stairs or

curbs in dim light(percentage)

N=50

UVA-left eyeVA

No difficulty at all 4.0

14.0

10.0

36.0

26.0

10.0

100

2.0

14.0

24.0

30.0

20.0

10.0

100

A little difficulty

Moderate difficulty

Extreme difficulty

Stopped doing becauseof eyesight



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Table-04: Improvement of Visual acuity with optical correction

Table-05: Difficulty level of the respondents in their daily life activities (near)

Table-06: Distribution of refractive error among the respondents

Figure-01: Unaided near visual acuity

Summary of Presenting Unaided near Visual Acuity

Unaided visual acuity at near was measured in all subjects. The majority of the students showed no response (54%) without any low vision aids shown in figure 01. Twenty four (24%) students were responded with N24 letter size.

Maximum of the respondents (30%) stopped reading ordinary printed newspapers. Most of them (40%) had extreme difficulty and stopped reading text book at their Arm length. By using eyesight, 32% students were facing extreme difficulty rather than moderate difficulty and 22% stopped doing things like signing checkbook, writing documents in a straight line or notes. Without touching or feeling, 40% students were having extreme difficulty in distinguishing various amounts of TK or coins and rest of them (20%) were stopped to do this because of their poor eyesight (Table–05).

Pattern of Refractive Error

In this study, total refractive error was 21.6%. In Table–6, distribution of refractive error was highest at the group of Compound Myopic Astigmatism (37.65%) and least group of refractive error was simple hyperopic astigmatism (3.53%).

Summary of aided near visual acuity

Although 46% students were able to read N8-N18 letter size comfortably from 25cm but around 26% students could not improve even with visual aid.

Improved

Not improved

Total

20%

80%

100

50%

50%

100

Grade

Stopped doing thisfor other reasons or

not interestedin doing this

Total

Improvement ofvisual acuity in left eye

N=50

Improvement ofvisual acuity in Right eye

N=50Improvement

No difficulty at all 2.0 12.0 2.0 9.0

14.0 14.0 18.0 15.0

24.0 8.0 12.0 6.0

20.0 24.0 32.0 40.0

30.0 40.0 22.0 20.0

10.0 2.0 14.0 10.0

100 100 100 100

Simple Myopia 23.53

Simple Hyperopia 10.59

Simple myopic astigmatism 11.77

Simple hyperopic astigmatism 3.53

Compound myopic astigmatism 37.65

Compound Hyperopic astigmatism 5.88

Mixed astigmatism 7.05

Total 100

A little difficulty

Moderate difficulty

Extreme difficulty

Stopped doingbecause of eyesight

Not response

N40

N36

N24

N18

N14

N12

N8

4%

6%

4%

24%

54%

4%

2%

2%Percentage (%)

(n=50)Types of refractive error



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Difficulties inreading

Newspapers(percentage)

N=50

Difficulties inreading text

book-Arm Length(percentage)

N=5

Difficultiesin signing

checkbook,writing

documents(percentage)

N=50

Difficulties indisstinguishing

variousamounts ofTK or coins

(percentage)N=50

Table-08: Visual acuity of the respondents before & after giving optical & low vision devices

Table-09: Visual acuity improvement with telescopes

Figure-02: Aided near visual acuity

Table-07: Types of low vision devices prescribed for near visual acuity

Type of Low Vision Device Prescribed for Near Visual Acuity

The most commonly prescribed low vision device for near was stand magnifier (58%). Some of the student were not prescribed any device for near due to presence of their adequate near vision and some student were prescribed hand held magnifier (10%), dome magnifier (6%), bar magnifier (2%) and prism (6%).

Visual acuity of the Students before & after giving Optical Correction & Low Vision Devices

The presenting visual acuity of the respondents was higher (52%) in the range of visual acuity

same syllabus & questions pattern as the mass student does which creates a barrier for them to face the competition and challenges. They want special syllabus with special pattern of examination which will remove the barrier to reach at higher education level.

DiscussionPresent study comprised of a large number of male students (82%). The age range of students in this study varied from 18 to 25 years. The higher enrollment of male students over female students in this study is not unexpected. A study showed that the male percentage was higher than the female students.8 These findings are particularly disturbing in view of the fact that women represent two thirds of the blindness visual impairment in Nepal, yet there are fewer girls studying in schools for the blind. One of the reasons may be lack of social security. Most probably it is the most important factor for girls’ lagging behind here. If girls are given opportunity by creating social security, they will go a long way in studies.

In this study we have found different causes of visual impairment. The major causes of visual impairment were Nystagmus (20.5%) and refractive error (21.6%). Pathological myopia was another cause that we found (11.4%). Other common causes were Macular dystrophy (6.7%), Retinitis pigmentosa (5.7%), Aphakia (4.5%), squint (5.2%), Amblyopia (10.2%), Optic Atrophy (3.4%),Uveal coloboma (2.3%). In a cross sectional study about profile of low vision children in special education schools in Malaysia shows that major causes of visual impairment were congenital cataract (17%) followed by childhood Nystagmus (15%), Amblyopia (14%), Retinal dystrophy (12%), Glaucoma (7%) and Corneal opacity.4

In this study, management of the students with low vision was given in a various range on the basis of their educational status, diseases, symptoms and preference. Low vision devices were distributed as optical devices & Non-optical devices. Among the Low vision devices for near stand magnifier (58%) was most preferred by the students than spectacle magnifier (16%). There was 4% student who had adequate near visual acuity without any LVD. Only one distance low vision device was Telescope which was trialed and preferred

by the students. Percentage of improvement of visual acuity with the device was 62% and 38% of them had no improvement of visual acuity. It is seen that 18% students can see the writings in N14 notation after being provided with near aids. Their study will be easier if institutional authorities print books especially for them in N14 size. Malaysian study showed in his study about profile of low vision children in Malaysia that Hand-held magnifier was the most preferred low vision device.4 Spectacle magnifier and Stand magnifier, prism was also preferred but in a little amount. Telescope for distance visual acuity was only preferable LVD for distance.

Another study of about pediatric low vision assessment in a specialist clinic in the UK7 shows that mean improvement of visual acuity with LVD was 0.67 ± 0.27 where as in my study mean improvement of VA was 0.48 ± 0.33. The commonly prescribed near aids were stand magnifiers 61%. Relatively few hand held devices were issued due to increased difficulty in maintaining focus with hand held devices for prolonged periods of time.

Alternative exam procedure such as braille exam paper, a reader, an oral exam, Exam paper in large print, a personal computer with software including voice synthesizer, screen reading and large text are more important for the visually impaired students. According to present study alternative exam arrangements was not applicable in the University of our Country.

An interesting finding of this study was that a significant number of student achieved useful vision with refraction and prescription of spectacles and low vision devices. This study also brought out the limitations of providing and using low vision device. This study have provided much needed data on eye health needs of students admitted to different Colleges and Universities with low vision. It will enable the concerned authority to develop strategies for continuing education of visually impaired student.

ConclusionStudents who have visual impairment attending in higher education level need special method for completing their education. We had found several cause of low vision where refractive error and nystagmus were more common around 21.6% and 20.5 % respectively.



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According to the present study 62 % of the participant got improvement with low vision aid. Along with visual aid, sophisticated modification including modern technologies can be implied to them to make their life easier. Proper guidance, adequate help from the institute, government support and social concern can play a big role in the education of the visually impaired students. Periodic eye examination with appropriate treatment and relevant support will ensure a safe socio-educational life.

World Health Organization (WHO), Visual impairment and blindness, 2012.Pokharel, Archana et al. 2011. “Profile of visual impairment in children attending low vision clinic of Nepal Eye Hospital” Medical Journal of Shree Birendra Hospital. Vol. 10.Fichten, Al et al 2016 “An exploratory study of college and University students with visual impairment in Canada”. British Journal of visual impairment. Vol. 34(1)91-100Mohammed, Z et al. 2009. “Profile of Low Vision Children in the special education schools in Malaysia” Med J Malaysia. Vol.64(4):289-93.Gilbert, Clare E. 2008. “Prevalence and Causes of Functional Low Vision in School-Age Childre: Results from Standardized Population Surveys in Asia, Africa, and Latin America”. Invest. Ophthalmol. Vis. Sci. Vol.49 no. 3877-881.Gothwal, VK et al. 2002. “Characteristics of a paediatric low vision population in a private eye hospital in India. ” Ophthalmic Physiol. Opt. Vol. 20 (3):212-9.

Harper, Robert et al. 2007. “Pediatric Low vision assessment & management in a specialist clinic in the UK”. the british journal of ovisual impairment. Vol. 25(2) 103-119.

Margrain, Tom H.200 “Helping blind and partially sighted people to read: the effectiveness of low vision aids.” Br j Ophthalmol. Vol.84:919-921”.

Thakur, Ajit Kumar et al. 2011. “Profile of low vision clinics in eastern region of Nepal: A retrospective study. British Journal of Visual Impairment”. (Vol.29:215-2268)

Subodh Gnyali Jyoti Baba Shrresthaet al 2012. Optical Needs of student with low vision in Integrated schools of Nepal. Optometry & vision Science. Vol. 89, NO.12,PP.1752-1756.

Mousa, Ahmed et al. 2010. “Visual Funtion of Egyptian Children with low Vision and the Demographic Determinants.” Middle East Afr J Ophthalmol. Vol. 17(1).

Mosuro,AL et al. 2008. “Survey of low vision among students attending schools for the blind in Nigeria” A descriptive & International study.Vol.19(4):382-91

Samaddar, Manjuet al. 2003. “Strengthening Integrated Education Programs for Blind & Visually Impairred Children in Bangladesh”. WA 092

Moore, J. Elton et al.2009. “Low vision. International encyclopedia of Rehabilitation.”

Subramanian A et al.2011. ”The effect of visual impairment on quality of life of children aged 3-16 midleyears”; Br J Ophthalmology. Vol.26:170-189.

Md Shahwnawaj Khan, Chandan the Visionary [Newspaper online].2014, January 03/last modified March 08, 215 (Available from www.thedailystar.net)

Saidat Abaila Fakoya-Michael and Michael Bamidele Fakoya “visually impaired university students Quest for information and the challenges faced in a Rural university context” 11th October 2017:Journal of social science: Vol. 42, No. 3.

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Dr. Murtuza Nuruddin, Dr. Soma Rani Roy, Dr. Fahmida Hoque

Management of Centurion Syndrome:A Cause of Unexplained Epiphora

Epiphora is one of the common complaints in routine ophthalmic practice. Though nasolacrimal duct obstruction is the most common cause of epiphora, there are various other causes. Centurian syndrome, caused by abnormal anterior insersion of medial canthal tendon, is one of the rare causes of epiphora. This medial canthal anomaly causes punctal ectropion and pulls the lower punctum out of lacrimal lake, resulting into epiphora. The patients with centurion syndrome typically have prominent nasal bridge similar to the anatomy of Roman Centurion. Hence the term “Centurion Syndrome” has derived.1,2

Though this condition is not so common, diagnosis of such case is important to relief patients from agonising epiphora as surgical outcome of this anomaly is excellent.2,3 In this study, we are addressing clinical features, surgical treatment and outcome of 12 patients who presented with epiphora and subsequently diagnosed as Centurion Syndrome.

MethodRetrospective review of medical records of twelve patients who presented with unexplained epiphora and subsequently diagnosed as Centurion syndrome at Orbit and Oculoplasty clinic of Chittagong Eye Infirmary and training complex between January 2016 to September 2018 was done. All these patients were referred due to persistent epiphora inspite of patent syringing test and hence termed ‘unexplained’. Detailed ocular examination including assessment of lacrimal passage was carried out. Any cause of lacrimation like corneal or eyelash pathology was ruled out.

Correspondence to:Dr. Murtuza Nuruddin, DCO, FCPS, FRCSConsultant (Orbit & Oculoplastic Clinic)Chittagong Eye Infirmary and Training ComplexChittagong, BangladeshE-mail: [email protected]

Purpose: To describe the unexplained cause of epiphora in relation to Centurion syndrome along with its clinical features and outcome of surgical management. Methods: A retrospective review of medical records of patients with Centurion syndrome who presented with unexplained epiphora (patent syringing test) between January 2016 to September, 2018 was done.The position of the punctum, prominent nasal bridge, Hertel exophthalmometry and the inferior angulation of the medial canthus were noted. The patients were managed surgically by anterior canthal tendon release along with medial conjunctivoplasty with or without punctoplasty.Results: Among 12 patients, 10 were male (83.3%) and 2 (12.7%) were female. The mean age of onset was 18.4 years. Epiphora commenced during the second decade of life in the majority of our patients (75%). A prominent nasal bridge along with sharp inferior angulation of the medial canthus, the ‘beak’ sign was present in 10 (83.3%) cases. Probing of the canaliculi and irrigation of the lacrimal drainage system confirmed anatomic patency in all patients. All patients underwent Anterior Canthal Tendon Release (ACTR) and Medial Spindle (MS) procedure (also termed as medial conjunctivoplasty) to correct punctal ectropion. Occluded or slit-like punctum was managed by an additional 3 snip procedure in 6 patients. Postoperatively, epiphora was relieved in all patients except two.Conclusion: Centurion syndrome is characterized by the abnormal anterior insertion of the medial canthal tendon with a displacement of the punctum out of the lacrimal lake. Most cases present with unexplained watering. Surgical management is easy and yields good result. Keywords: Centurion, epiphora, anterior canthal tendon.


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ABSTRACT

Introduction

Diagnosis of Centurion syndrome was based on clinical features including prominent nasal bridge, downward angulation of medial canthus (beak sign) and punctual position out of lacrimal lake (Fig.-01). Hertel’s exophthalmometry was done to rule out enophthalmos. Exophthalmo- metry reading less than 16 mm was considered as enophthalmos (Fig.-02). All patients underwent Anterior Canthal Tendon Release (ACTR) and Medial Spindle (MS) procedure (also termed as medial conjunctivoplasty) to correct punctal ectropion. Occluded or slit like punctum was managed by additional 3 snip procedure. The surgical procedure was performed under local anaesthesia in all cases. Release of anterior canthal tendon was performed through a curvilinear incision 3-4 mm medial to the medial canthus (Fig.-03). The anterior limb of the medial canthal tendon was exposed after blunt dissection and was traced along its attachment. Then the tendon was cut near its insertion by sharp scissor. Medial spindle or medial conjunctivoplasty was performed by giving a diamond shaped incision in conjunctiva 4-6 mm below the punctum so that central part of diamond lies at lower border of inferior tarsus (Fig.-04). A double armed 6/0 vicril was then passed through the upper part of diamond and then through the retractor of lower lid was brought anteriorly to the skin. The suture was then tied and thus the punctum was retracted towards the globe. 3 snip punctoplasty was performed in both upper and lower puncti after dilating them properly with nittleship punctal dilator. A vertical incision along the lateral portion of the punctum followed by a horizontal incision along the lid margin was made. Finally a diagonal incision from the inferior aspect of the vertical incision to the medial edge of the horizontal incision was made to complete the procedure.

ResultTwelve patients underwent surgical intervention after being diagnosed as centurion syndrome (Table-01). All patients had patent syringing test and treated with topical antibiotic before referral. The mean age of patients at onset of epiphora was 18.4 years (range 15 to 23 years).

The majority of patients (75%) had onset of symptoms in second decade of life and the rest (25%) complained of epiphora in early third decade of life. Prominent nasal bridge and downward angulation of medial canthus (beak sign) were present in 10 out of 12 patients (83.3%). Neither of these features was present in two patients. Lower punctum on both sides was out of lacrimal lake in all patients. All patients underwent combined anterior canthal tendon release and medial spindle procedure to bring back the punctum into lacrimal lake. Antero-inferior displacement of anterior canthal tendon was noted per-operatively. Six patients had either occluded or slit like punctum. They underwent additional 3 snip procedure. Epiphora was resolved in all patients except two, though anatomical success was achieved in all patients.

M: Male; F: Female; ACTL: Anterior canthal tendon release; MS: Medial Spindle

Table-01: Clinical features and surgical management of patients with centurion syndrome

1. 15 M Yes Yes Yes No ACTR + MS Yes

2. 18 M Yes Yes Yes No ACTR + MS+3 snip Yes

3. 17 M Yes Yes Yes Yes ACTR + MS+ 3 snip Yes

4. 22 M Yes Yes Yes No ACTR + MS No

5. 23 F Yes Yes Yes No ACTR + MS+ 3 snip Yes

6. 17 M No No Yes No ACTR +MS Yes

7. 21 M Yes Yes Yes No ACTR + MS+ 3 snip Yes

8. 19 M Yes Yes Yes Yes ACTR + MS+ 3 snip No

9. 16 M No No Yes No ACTR+MS Yes

10. 19 F Yes Yes Yes No ACTR + MS+ 3 snip Yes



SLNo.

Ageof

Onset

SexBeaksign

ProminentNasalBridge

Punctumout of

lacrimallake

Enophth-almos

Surgicalprocedure

Epiphorare-

solved



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Figure-02 : Patient with centurion syndrome associated with enophthlmos

Figure-03: Incision for anterior canthal tendon release

Figure-04: Medial conjunctivoplasty along with anterior canthal tendon release

Figure-05: Before and after surgical correction of Centurion syndrome by anterior canthal tendon release and medial conjunctivoplasty. Beak sign has been resolved postoperatively

DiscussionThe “Centurion syndrome” was first described by Sullivan et al in 1993.1 Epiphora in this condition is caused by idiopathic medial canthal anomaly, resulting in loss of apposition between the medial part of eyelid and globe. As a result, lacrimal puncta comes out of the lacrimal lake. Patients typically have prominent nasal bridge and inferiorly directed sharp medial canthus, also termed as ‘beak sign’2 (Fig.-04).

Various studies have reported that epiphora in patients with centurion syndrome begins in second or third decade of life.2,3,4 The commencement of symptoms during this period attributed to the growth of bones of the mid face which shifts the medial canthal tendon anteriorly and thus retracting the punctum out of the tear lake.

However, Sullivan reported symptoms in children below 10 years of age.1 Centurion syndrome typically occurs in male. Murthy et al2 reported 10 out of 13 and Sujatha et al3 reported 38 out of 40 were male. All patients except two in our case series were also male.

Centurion syndrome can be treated only surgically.2-6 The aim of surgery is to bring the medial part of the lid in apposition with the globe. As a result the lacrimal puctum is retracted back into the tear lake. The procedure of choice is to release the anterior canthal tendon. Additional procedures like medial conjunctivoplasty, punctoplasty or lower eyelid retractor plication are also performed based on the severity of punctual displacement.2-4 We have managed all our cases by anterior canthal tendon release along with



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Figure-01: Patient with inferiorly directed medial canthal angulation (beak sign)

Figure : 5 (a) Figure : 5 (b)

medial conjunctivoplasty. Murthy et al2 managed four cases and Sujatha et al3 managed all their cases by anterior canthal tendon release only. Peroperatively, after releasing anterior canthal tendon, we were not satisfied with the position of the puntum. Therefore we performed additional medial conjunctivoplasty in all our cases. Six cases underwent additional 3 snip procedure due to occluded or slit punctum.

Surgical success was assessed by relief of symptoms at 3 months follow up. Epiphora was resolved in all our patients except two in spite of correction of punctal ectropion. Lacrimal pump failure might be attributed to the cause of surgical failure in these two patients. Anatomical success was achieved in all patients as beak sign was resolved (Fig.-05) and punctal ectropion was corrected.

Two of our patients had enophthalmos with Hertel’s exophthalmometry reading 14 mm on both sides. There is a disagreement whether enophthalmos play any role in the pathogenesis of this condition.1,2 Sullivan et al1 showed normal Hertel’s exophthalmometry reading in all their cases, while Murthy et al2 reported 4 out of 13 cases were associated with enophthalmos.

Centurion syndrome is a unique clinical entity that manifests as epiphora mostly during second decade of life. Any unexplained epiphora in young patients should be carefully examined for centurion syndrome. Surgery for this condition is simple and yields satisfactory outcome.

Sullivan TJ, Welham RA, Collin JR, Centurian syndrome. Idiopathic anterior displacement of medial canthus. Ophthalmology 1993;100:328-33Murthy R, Honavar SG, Naik M, Menon V, Bhaduri A, Das S. Centurion Syndrome: Clinical Presentation and Surgical Outcome. Orbit 2009; 28:269–274.Sujatha Y, Sathish S, Stewart WB. Centurian syndrome and its surgical management. Ophthal Plast Reconstr Surg 1999; 15:243-244.Chang JH, O’Donnell BA. Medial canthal tendon release and lower eyelid retractor plication for Centurian syndrome. Clin Experimental Ophthal 2006; 34:284-287.Mal’uf RN,Bashshur ZF, Noureddin BN. Anterior canthal tendon release for correction of Centurian syndrome. Ophthl Plast Reconstr Surg 2003;19:446-8Huerva V, Sanchez MC, Canto LM. Surgical management of Centurion syndrome. Can J Ophthalmol 2007;42(6):879–880.

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Dr. Shaila Sharmin, Dr. Jasmin Ahmad

Clinico-epidemiological evaluation of diabetic retinopathypatients attending a tertiary eye care centre

Diabetic Retinopathy (DR) is a chronic disease of the retina caused by microangiopathy due to long-term effects of Diabetes Mellitus (DM), leads to progressive damage of retina causing blindness.

Diabetic Retinopathy (DR) is the leading cause of vision loss in adults aged 20-74 years.1 From 1990-2010, DR ranked as the fifth most common cause of preventable blindness and fifth most common cause of moderate to severe visual impairment.2 With diabetes now recognized as a global epidemic, the incidence of retinopathy, a common microvascular complication of diabetes, is expected to rise to alarming levels. The major causes of severe visual impairment are Proliferative

Diabetic Retinopathy (PDR) and Diabetic Macular Edema (DME). Nearly all patients with Type 1 diabetes and>60% of patients with Type 2 diabetes are expected to have some form of retinopathy by the first decade of incidence of diabetes.3, 4

In 2010, of an estimated 285 million people worldwide with diabetes, over one-third have signs of DR, and a third of these are afflicted with vision-threatening diabetic retinopathy (VTDR), defined as severe non-proliferative DR or proliferative DR (PDR) or the presence of diabetic macular edema (DME).5 These estimates are expected to rise further due to the increasing prevalence of diabetes, ageing of the population and increasing of life expectancy of those with diabetes.

It is estimated that more than 11 million people of Bangladesh will have diabetes by the year 2030 with an expected increase of population with diabetes complications.6 Diabetic retinopathy is the most common complication of diabetes and a leading cause of blindness in working age group.

Correspondence to:Dr. Shaila Sharmin, FCPSSr. Assistant SurgeonChittagong Eye Infirmary and Training ComplexChittagong, BangladeshE-mail: [email protected]

Purpose: To study the epidemiological and clinical factors influencing the presence of diabetic retinopathy.Methods: This observational cross-sectional study was done over 300 diabetic populations who attended Diabetic Retinopathy Education Training and Treatment (DRETT), a digital screening program at Chittagong Eye Infirmary and Training Complex. Patients fulfilling inclusion criteria were enrolled and epidemiological data such as age, sex, occupation, habits etc. and other information had been recorded in the predesigned case record form. Blood pressure was recorded for all. All patients underwent detailed eye examination and fundus photography to diagnose the presence and severity of diabetic retinopathy. All patients were advised lab investigations for HbA1c, Fasting Cholesterol and serum LDL. All data were documented in the case record form and analyzed using SPSS 16.Results: Among the 300 diabetic patients enrolled in the study majority were male (54%), middle aged (53.41 ± 8.86), sedentary workers (90%) with a positive family history of DM (61.3%). Retinopathy was present in 57.3% patients and more common in smoker (66.67%). While duration of diabetes were among major risk factors for the development of retinopathy (P < 0.001) as well as high serum cholesterol and LDL level, HbA1c was found to be the most important factor for the presence (P < 0.001) of retinopathy.Conclusion: High Prevalence of retinopathy was found which was directly linked to duration of diabetes, poor glycemic control, dyslipidemia, and hyperglycemia.Keywords: Diabetes, diabetic retinopathy.


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