Teaming-up nurses with ophthalmologists to expand the reach of eye care in a middle-income country: Validation of health data acquisition by nursing staff in a telemedicine strategy

Telemedicine can be used to conduct ophthalmological assessment of patients, facilitating patient access to specialist care. Since the teleophthalmology models require data collection support from other health professionals, the purpose of our study was to assess agreement between the nursing technician and the ophthalmologist in acquisition of health parameters that can be used for remote analysis as part of a telemedicine strategy. A cross-sectional study was conducted with 140 patients referred to an ophthalmological telediagnosis center by primary healthcare doctors. The health parameters evaluated were visual acuity (VA), objective ophthalmic measures acquired by autorefraction, keratometry, and intraocular pressure (IOP). Bland-Altman plots were used to analyze agreement between the nursing technician and the ophthalmologist. The Bland-Altman analysis showed a mean bias equal to zero for the VA measurements [95%-LoA: -0.25–0.25], 0.01 [95%-LoA: -0.86–0.88] for spherical equivalent (M), -0.08 [95%-LoA: -1.1–0.95] for keratometry (K) and -0.23 [95%-LoA: -4.4–4.00] for IOP. The measures had a high linear correlation (R [95%CI]: 0.87 [0.82–0.91]; 0.97 [0.96–0.98]; 0.96 [0.95–0.97] and 0.88 [0.84–0.91] respectively). The results observed demonstrate that remote ophthalmological data collection by adequately trained health professionals is viable. This confirms the utility and safety of these solutions for scenarios in which access to ophthalmologists is limited.

Prevalence of Ophthalmological and Dermatological Problems Related to Pesticide Exposure among Sugarcane Farm Workers in Western Maharashtra

BACKGROUND Insecticides, herbicides, etc. are frequently used to improve yields and its overuse and improper use affects the respiratory, cardiovascular systems as well as the eyes and skin of farmers (that is ophthalmological and dermatological systems). Thus, there is need to analyse the prevalence of ophthalmological and dermatological problems related to pesticide exposure among sugarcane farmers in western Maharashtra, which will help to provide advices for education and prevention. The purpose of this study was to analyze and find out the prevalence of ophthalmological and dermatological problems related to pesticide exposure among sugarcane farm workers in western Maharashtra. METHODS This study was an observational studywhich was carried out in southern zone of western Maharashtra. Depending on the basis of inclusion, (males 35 – 45 years old, Exposure more than 5 years.) and exclusion criteria (females, farmers with hypertension and any other metabolic diseases.) 79 farmers (sample size) were selected. Study duration was six months and it was conducted from July 2020 to December 2020. Written consent was taken from them. Participants were selected by random sampling method from 19 villages of western Maharashtra and their detailed outcome assessment was done by using dermatological assessment (assessment of skin) and ophthalmological assessment (assessment of eyes) protocol. RESULTS The obtained results had shown significant problems in both ophthalmological and dermatological systems. Ophthalmological problems are irritation in eyes [51 (64.55 %)] in subjects of the sample size [79 (100 %)], burning sensation [48 (60.7 %)], itching [43 (54.4 %)], blurring of vision [17 (21.5 %)], watering of eyes [35 (44.3 %)], cataract [2 (2.53 %)] and conjunctivitis [10 (12.65 %)]. Out of above problems, irritation in eyes, burning sensation and itching were the most common problems. Dermatological problems are contact dermatitis [(29 (36.70 %)], urticaria [13 (16.4 %)], ashy dermatosis [5 (6.32 %)], itching [46 (58.22 %)], hypopigmentation [1 (1.26 %)], nail dystrophy [0 (0 %)], skin cancer [0 (0 %)] erythema multiforme [9 (11.39 %)] and people are found to be dehydrated [51 (64.55 %)]. Out of above problems, itching (46 subjects) and dehydrated skin (51 subjects) were the most common problems. CONCLUSIONS It was concluded that a large number of pesticide exposed sugarcane farmers were exposed to various impairments with different levels of vulnerability. Both, ophthalmological and dermatological systems are vulnerable. Prevalence of ophthalmological and dermatological problems were 37.2 % and 21.6 % respectively. KEY WORDS Pesticides, Insecticides, Contact Dermatitis, Porphyria Cutanea Tarda, Urticaria, Cataract, Conjunctivitis, Blurring of Vision

Frequency and risk factors for hydroxychloroquine retinopathy among patients with systemic lupus erythematosus

Background Hydroxychloroquine (HCQ) is an antimalarial drug, recently used in COVID-19 treatment. Also it is considered over many years the cornerstone in treating systemic lupus erythematosus (SLE) in adults and children. The incidence of retinal affection and retinal toxicity from hydroxychloroquine is rare, but even after the HCQ is stopped, loss of vision may not be reversible and may continue to progress. Fundus autofluorescence (FAF) is one of the screening methods recommended by AAO used for the diagnosis of hydroxychloroquine retinopathy. Our aim is to detect early HCQ-induced retinopathy among SLE patients and the risk factors for its development by using fundus autofluorescence. Results In the present study, 11.3% of the studied patients had significant visual field changes upon testing. Of those, 6.3% had abnormal fundus autofluorescence. We found a significant statistical relation between hydroxychloroquine retinopathy and the duration and cumulative dose of hydroxychloroquine therapy (p value = 0.003) and decreased best-corrected visual acuity of both eyes (p value = 0.000). There was no relationship between HCQ retinopathy detected by fundus autofluorescence and daily dose of HCQ/kg, age, sex, and SLEDAI score. Conclusion Frequency of SLE patients who had confirmed HCQ-induced retinopathy was 6.3%. Hydroxychloroquine could be safely used in all SLE patients regardless of age, sex, and SLE activity. Routine ophthalmological assessment is recommended for SLE patients who received HCQ especially for those who received HCQ longer than 7 years. Fundus autofluorescence is a modern objective tool which is specific for the early detection of HCQ retinopathy.

Apoplexy of microprolactinomas during pregnancy

Context: Prolactinomas frequently cause amenorrhoea, galactorrhoea and infertility and require dopamine agonist (DA) treatment to normalize prolactin levels and hence restore ovulation. The vast majority of female patients harbour microprolactinomas in whom DA treatment is usually discontinued at the time of pregnancy diagnosis, and surveillance is generally limited as symptomatic growth is considered very rare. Case Descriptions: We report five cases of women harbouring a microprolactinoma in whom symptomatic pituitary apoplexy occurred during pregnancy. Only one necessitated surgery during pregnancy, while the others were treated conservatively by reintroducing DAs in three. A systematic literature review found reports of four additional cases among 20 cases of prolactinomas (both macro- and microprolactinomas) complicated by apoplexy during pregnancy. Conclusion: During pregnancy, pituitary apoplexy may occur in pre-existing microprolactinomas, causing tumour enlargement and headache, which may be self-limiting but may require intervention by re-initation of dopamine agonists or surgery. Our literature review confirms that this clinical event is rare; nevertheless, physicians managing pregnant patients with microprolactinomas must be aware that symptomatic pituitary apoplexy may incidentally occur in all trimesters of pregnancy and require prompt radiological, endocrine and ophthalmological assessment and treatment.

Persistent Retinal Detachment in Retinoblastoma: The Challenges

Introduction. Retinoblastoma (RB) is the most common eye tumor in children. There have been significant improvements in treatment options targeting killing the tumor while also conserving the eye and attempting to conserve functional vision. Retinal detachment (RD) is not an uncommon event and compromises the vision and sometimes RB treatment. Materials and Methods. Retrospective review of 62 patients over a period of 8 years between 2012 and 2019 with eyes treated for RB and having persistent RD that did not resolve after complete tumor regression. Results. Forty-two patients of these 62 cases developed RD (67%). The RD resolved in 35 patients (83% of RD), and 7 patients (16% of RD) developed a persistent RD. In all the persistent RD groups (7 patients/11 eyes), RB and RD were present simultaneously in the first ophthalmological assessment. Sex ratio was 2 females/5 males. The mean age of diagnosis was 11 months. All eyes had advanced RB stages. Eight eyes had local treatment with transpupillary laser, 6 eyes received IAC, and 3 patients received systemic chemotherapy. In 9 eyes, the RD had both exudative and tractional components. Only one eye had a pure tractional RD due to persistent fetal vasculature, and one eye had rhegmatogenous RD component with presence of a tear in addition to exudation. None of the eyes received RD surgical repair. Conclusion. Persistent RD occurs in eyes with advanced RB stages with complex RD with more than one component. The dilemma is performing a vitrectomy in eyes with cancer and poor visual outcome.

Ultrasound Examination of the Pupil – A New Tool for the Neuro-Ophthalmological Assessment

Background Pupil examination represents a diagnostic and prognostic test in the management of several neurological diseases. Infrared video pupillometry (IVP) is the gold standard, since it is not routinely available, a noninvasive bedside ultrasound assessment has been proposed as an alternative. The aim of this study was to assess the feasibility and reproducibility of ultrasound pupillometry (UP) in comparison with IVP. Materials and Methods 81 subjects (43 men and 38 women, mean age: 52 ± 20 years and 49 ± 19 years, respectively) with no history of neurophthalmologic disease were enrolled. UP was performed with a 12-MHz linear probe according to current guidelines for orbital insonation. Light and painful stimuli were applied to test pupillary light reflex (PLR) and ciliospinal reflex (CR). In 30 of these subjects IVP examination was performed additionally to obtain intra-observer and inter-observer agreement. Results Increasing age was associated with a decreased pupillary diameter (PD) at rest, after PLR and CR (R –0.728, p < 0.01, R –0.643, p < 0.01, R 0.674, p < 0.001 respectively), while no association was noticed with time to constriction/dilation. UP measurements were reproducible (rate of inter- and intra-observer agreement: R 0.979, p < 0.01, R 0.946, p < 0.01 respectively) and concordant with IVP (PLR R 0.831, p < 0.01; CR R 0.879, p < 0.01). Conclusion According to our study, ultrasound pupillometry is a feasible and reliable technique for bedside pupillary function assessment, and is a good alternative to infrared video pupillometry. Moreover, it represents the only way for functional pupillary assessment in patients with periorbital hematoma.

The Effect of Amino Acid, Carbohydrate, and Lipid Metabolism Disorders on Eyes

Inherited metabolic disorders (IMDs) are a class of genetic disorders. Each metabolic disorder may have different forms with different age of onset, clinical manifestations, severity, and even type of inheritance. Ideally, a group of different specialists, including ophthalmologists, pediatricians, biochemists, and medical geneticists are needed for the final diagnosis and management of IMDs. Because of the importance of the aforementioned issue, we investigated the effect of IMDs on the eye in this review. Metabolic disorders can induce abnormalities in conjunctiva, cornea, lens, retina, optic nerve, and eye motility. In this study, the authors aimed to address the effect of metabolic diseases of amino acids, carbohydrates, and lipids on eye metabolism. Because of the direct toxic mechanisms of abnormal metabolites on the eyes and regarding the effect of eye monitoring on follow-up, management, and treatment of IMDs, a detailed ophthalmological assessment is essential.

Notable Near Miss

In this case, a 70-year-old female presents to the emergency department (ED) of a community hospital with facial swelling and rash. She was seen at her family doctor’s office 4 days earlier, when she was diagnosed with herpes zoster and started on medication. She complains of headache, blurred vision, severe pain in her scalp, and swelling around her eye. Attention is initially focused on her skin infection and the appropriate antibiotic treatment. She has two further visits to the same ED before a complication of her infection is noted, requiring referral for ophthalmological assessment.