community / social ophthalmology - All India Ophthalmological Society

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION143applicable to our scenario. The behavioralpattern of DR, compliance and treatment ofdiabetes mellitus, lack of awareness about DRand lack of infrastructure makes the scenariodifferent. 1 So we thought a population basedscreening for DR will be helpful not only to findthe magnitude but also to plan treatmentstrategies in this blinding disease. One of theprimary aims of the study was to obtain theaccurate prevalence rate of DR among knowndiabetic patients. Age and gender, specificprevalence and association with type, durationand treatment of diabetes are addressed in thisstudy.Materials and MethodsThis was a population-based study designed toestimate the prevalence of DR in self identifieddiabetes mellitus patients. It was done in theChengamanad panchayat of Ernakulam district.A team was selected from the Kudumbasreeworkers, who belong to a non-governmentalorganization, from all the 12 wards of thepanchayat. They were given training regardingthe DR by doctors MG and team using visualaids. They did a survey of the whole panchayatbetween May 2005 and July 2005. Door to doorvisit was done in 5752 houses to cover apopulation of 25400. 1096 self identified diabetesmellitus patients were identified. Definition ofdiabetes mellitus means taking treatment fordiabetes mellitus in any form, oral hypoglycemicdrugs or injection insulin or a value of bloodsugar level above 140mg/dl. All these patientswere invited to participate in the screeningcamps for detection of DR. They were givenpamphlets regarding the disease. Institutionalethics committee approval was obtained for thewhole project. One screening camp was done foreach ward. The camp was done on Fridaysbetween July 2005 and October 2005. The doorto-doorvisits were done at the end of 12 camps.323 patients attended the screening camp makingthe participation rate 29.47%.A participant was considered diabetic if any ofthe following criteria was met. (1) Any history oftreatment with oral hypoglycemic agent orinsulin. (2) Any value of glycosylatedhaemoglobin above the normal 7.0%. (3) Fastingblood sugar above 120mg/dl and post prandialblood sugar of 140mg/dl. Diabetes wasconsidered type 1 if the age of the patient was lessthan 30 years at the time of diagnosis and patientwas on insulin injection. Otherwise diabetes wasconsidered to be type 2.All the 323 patients attending the screening camphad detailed examination including detailedhistory, treatment details, refraction, tonometry,and dilated fundus examination. Best CorrectedVisual Acuity was found by using Snellen chartat 6 meters. Suspected patients with shallowanterior chamber on torch light examinationwere not dilated and excluded from analysis. Weobtained verbal informed consent from thepatient.Grading of diabetic retinopathy: 4,5,6,7,8Diabetic retinopathy was classified using amodified method used by Klein et al. 4 DR wasclassified as non proliferative retinopathy, severenon proliferative retinopathy, and proliferativeretinopathy using indirect ophthalmoscopicevaluation using 20D lens. NPDR levelsincluded level 1-3, severe NPDR levels includedlevel 4-5, and PDR levels included level 6-7 asdescribed by Klein et al. 4 Maculopathy wasgraded into no maculopathy or diabetic macularoedema. We did not perform fundusphotography due to the high cost involved,which precludes its use in developing countries.In the absence of retinal photography weconsidered indirect ophthalmoscope as the goldstandard at the screening camp. 4-8ResultsDescription of the cohort: 1096 self identifieddiabetes mellitus patients were detected in thepopulation of 25400 making the prevalence ofdiabetes mellitus 4.31%. They were educatedabout the DR and given the pamphlets regardingthe disease. 323 patients (29.47%) came for thedetailed evaluation. They included 149 malesand 174 females. Age of the patients ranged from32 years to 85 years with a mean age of 56.05years and a median age of 55 years. 35 patientshad severe NPDR that required furtherevaluation (10.84%). 29 patients had bilateralmaculopathy (8.97%). 65 patients had DR in atleast one eye, which was evident on clinicalexamination. This gives a prevalence of 20.12%.Diabetic maculopathy was present in 46 patientsin at least one of the eyes. Of this, 29 had bilateralmacular oedema. Regarding the duration of

144 AIOC 2009 PROCEEDINGSdiabetes and the prevalence of retinopathy: thedetails are given in Table-3. 34 out of 149 maleshad some retinopathy (Prevalence 22.81%) whileit was 31 out of 174 females (Prevalence 17.81%).Agewise prevalence is mentioned in Table-1. Agewise prevalence of DR; this was not statisticallysignificant by chi square test.Statistical analysis: Prevalence of DR wascalculated as the ratio of the number ofparticipants with DR in one or both eyes to thetotal number of diabetic patients evaluated.Duration of diabetes was calculated as thedifference between the time of diagnosis of DRas reported by the patient and the time of clinicalexamination. SPSS statistical package version 9was used for statistical analysis. All confidenceintervals are presented at 95% and all analysiswere conducted at a

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION145in a cross section of population by sampleselection. (2) A single trained Vitreoretinalsurgeon screened all the patients. This avoidsinter observer bias.The disadvantages of the study were (1) theparticipation rate was only 29.47% from thetarget group of self identified diabetic patients.(2) Lack of mydriatic fundus photography (3)When invited to participate in the screeningcamp only patients with some eye problem mayturn up thus creating a selection bias, (4)Advanced DR cases with multiple systemicproblems may not have participated in the study(5) The target population misses a whole group1. Narendran V, John R.K, Raghuram A, RaveendranRD, Nirmalan P.K, Thulasiraj RD, Diabeticretinopathy among self reported diabetics insouthern India, a population based assessment.Br.J.Ophthalmol 2002;86:1014-8.2. Kumar A, Diabetic blindness in India; THEEMERGING SCENARIO. Indian J. Ophthalmol1998;46:65-6.3. World Health Organizaiton; Global Initiative for theElimination of Avoidable blindness; As informalconsultation; Geneva, World Health Org., 1997(PBLNo.97.61) Natchiar G, Thulasiraj RD, Robin AL:Attacking the backlog of India’s curable blind ; theAravind Hospital model. Arch Ophthalmol1994;112:987-93.4. Klein R, Klein BEK, Magli YL, Brothers RJ, MeuerSM, Moss SE, Davis MD: An alternative methodgrading diabetic retinopathy. Ophthalmology1986;93:1183-7.5. Buxton MJ Sculpher MJ, Ferguson BA, HumphreysJE, Altman JF, Spiegethalter DJ, Kirby AJ, Jacob JS,Bacon H, Dudbridge SB, et al: Screening fortreatable diabetic retinopathy a comparison ofdifferent methods. Diabet Med 1991;8:371-7.6. Harding SP, Broadbent DM, Neoh C, White MC,Vora J: Sensitivity and specificity of photographyand direct ophthalmoscopy in screening for sightthreatening eye disease ; the Liverpool diabetic eyestudy. BMJ 1995;311;1131-5.7. Kinyoun JLMD, Fujimoto WY: Ophthalmoscopyversus fundus photographs for detecting andgrading diabetic retinopathy. Invest Ophthalmol VisSci 1988;33:1888-93.8. Schatat AP, Hyman L, Leske MC, Connell AM,Hiner C, Javornik N, Alexander J: Comparison ofdiabetic retinopathy detection by clinicalexaminations and photograph gradings: Barbados(West Indies) Eye Study Group, Arch Ophthalmol1993;111:1064-70.Referencesof undetected diabetic patients. So we might bescreening only the tip of the iceberg.In conclusion our data establishes an overallprevalence of DR at 20.47% among self identifieddiabetic patients in rural population of Kerala.This is the first study where the wholepopulation was screened. There is no otheravailable data on the prevalence of DR in thispart of the country. The lack of awareness evenin the so called literate population of Kerala. 17and a prevalence rate of 20.47 means the load ofDR for ophthalmologist will be difficult to tacklein the coming years.9. Zimmet P, Alberti KG, Shaw J, Global and societalimplications of the diabetes epidemic. Nature2001;414:782-7.10. Klein R, Klein BEK, Moss SE, et al. The WisconsinEpidemiologic study of Diabetic retinopathy, III.Prevalence and risk of diabetic retinopathy whenage of diagnosis is 30 or more years. ArchOphthalmol 1984;102:527-32.11. Klein R. Klein BE, Moss SF, et al. Visual impairmentin diabetes. Ophthalmology 1984:91:628-38.12. Klein R. Klein BE, Moss SE, et al. The WisconsinEpidemiologic Study of Diabetic Retinopathy X.Four-year incidence and progression of diabeticretinopathy when age at diagnosis is 30 years ormore. Artch Ophthalmol 1989;107:244-9.13. Varma R, Klein BE, Moss SE, Linton KL. The BeaverDam Eye study. Retinopathy in adults with newlydiscovered and previously diagnosed diabetesmellitus. Ophthalmology 1992:9958-62.14. Klein R, Klein BE, Moss SE, Cruickshanks KJ: TheWisconsin Epidemiologic Study of DiabeticRetinopathy. XIV. Ten year incidence andprogression of diabetic retinopathy. ArchOphthalmol 1994;112:1217-28.15. Vitcheli P. Smith W, Wang JJ, Atteho K, Prevalenceof diabetic retinopathy in an older community. TheBlue Mountains Eye Study. Ophthalmology1998;105:406-11.16. Leske MC: WuS. Hyman L. et al. Diabeticretinopathy in a black population. The BarbadosEye Study. Ophthalmology 1999:106:1893-9.17. Chengamanad diabetic retinopathy awarenessstudy. Presented in Kerala society of ophthalmicsurgeons annual meeting held atThiruvananthapuram Dec.2005.18. R. Varma et al. Los Angeles Latino eye study.Ophthalmol 2006;7:1298-1306.

146 AIOC 2009 PROCEEDINGSA Study and Correlation of Risk Factors for Diabetic Retinopathyin North IndiaDr. R. K. Agrawal, Mr. Sumeet Agrawal, Dr. Dadeye Subhas, Dr. S.V. Singh,Dr. N.P. Singh(Presenting Author: Dr. R. K. Agrawal)Diabetes mellitus (DM) is a major cause ofavoidable blindness and patients withdiabetic retinopathy (DR) are 25 times morelikely to become blind than non diabetics. Earlydiagnosis and management may reduce theincident of blindness. It is important to identifythe prevalence of the various risk factors for DRfor prevention and intervention.The aim of study is to analyze and thetherapeutic implication of the risk factors of DRin type 2 diabetes.Materials and MethodsDuring the period from July 2006 to July 2008,2000 patients of type II DM were selected fromdiabetic clinic, Department of Medicine andGurunanak Eye Center Maulana Azad MedicalCollege (M.A.M.C.) Delhi and R.K. EYE andRetina Center Indore (M.P.) 1000 cases of diabeticcase taken as control (not having DR) and 1000cases having DR taken as case. History was takenwith reference to associated risk factor like ageduration of diabetes, history of taking alcoholand smoking, socio economic condition, anemia,lipid profile, hypertension, insulin intake,glycemic control, type of anti diabetic treatment,symptom of peripheral neuropathy,nephropathy. All patients underwent cardiac,renal, neurological and ophthalmic check up.DR was diagnosed by Ophthalmoscope and FFAResultIncidence of diabetes was equal upto age of 60year. But DR was more after 60 year of age. 17%were of control while 37% were having DR.Table-1: Age of patientsAge (in year) Controls Cases30-40 110 2041-50 350 28051-60 370 33061-70 130 28071-80 40 90Incidence of hypertension in control and DR wasto be equal. DR does not have relationship withsmoking and alcohol.There is indirect relationship between glycemiccontrol and DR Decrease in glycosylatedhaemoglobin level associated with decrease inDR.Table-2 : Relationship between DR andglycemic controlControl CaseControlled diabetic 680 240Un-controlled diabetic 320 760Table-3: Duration of Diabetes in relation with DRDuration Control Case>5 240 1905-10 460 31011-15 170 26016-20 80 180>20 50 60There is direct correlation between the frequencyseverity of DR and declaration of DMTable 4: Nature of Life StyleControl CaseSedentary 690 280Mild to moderate exercise 310 320Incidence of DR is less in person who dophysical exercise.Table-5: Association of DR peripheral neuropathyControl CasePresent 300 700Absent 70 300An interesting association of DR withneuropathy which was more in DR.Table-6: Relationship with anemiaControl CasePresent 630 770Absent 370 230Anemia is an independent risk factor fordevelopment and presence of DR.

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION147DiscussionThere is a direct correlation between thefrequency of DR and duration of DM. It is a mostimportant risk factor. We found that 76% hasdiabetes upto 15 year of duration while 87% ofcontrol case work not having DR.An important risk factor is hypertension whichincrease the risk and progression of DR. This isthe first time a significant correlation was foundbetween peripheral neuropathy and DR. In ourstudy 70% DR case have neuropathy in comparisonwith control of which only 30% case have this.There is increase risk of DR in patients havinghemoglobin level of less than 10 gm. Anemiainduced retinal hypoxia is a speculated cause fordevelopment of micro aneurysm and other DRfeatures Lipid profile was abnormal in 35% of DRin contrast with 21% in control case. There iscorrelation between serum lipid and risk ofretinal hard exudate.Use of lipid lowering drug Atrovastin reduce themacular edema, hard exudates and sub foveallipid migration.We found very significant relation betweenexercise and DR. 68% of DR had sedentary lifewhile 32% who do physical exercise develop DR.In last two decades beside treatment of DR manyrisk factor for DR were identified. Knowing andpresentation of these risk factors reduced theincidence and severity of DR.AUTHORS’S PROFILE:NILUTPAL SARMA: M.B.B.S. (’96); M.S. (2005), Gauhati Medical College, Gauhati University,Gauhati; Fellowship (2006), Sri Sankar Deva Nethralaya, Gauhati. Presently, Asst. Prof. KIMS,Hyderabad, AP.Contact: 9989307536; E-mail: nilutpal.dr@gmail.comRole of Efficient Field Workers in Prevention of BlindnessThrough Community Outreach Programme in A BackwardDistrict of Andhra PradeshDr. Nilutpal Sarma, Dr. Amarendra Deka, Dr. Kavita Patil, Dr. Nilanjan KaushikThakur, Dr. Dipak Bhuyan, Dr. Sudhir Babu Padgul(Presenting Author: Dr. Naresh Babu)Cataract accounts for 41.8% of globalblindness and 81% of blindness in India.By 2020, the elderly population is expected todouble, further increasing the number of blindpeople .The number of blind people in theworld and the proportion due to cataract isincreasing due to :— Population growth : 6,000 million peoplenow in the world , will increase to around8,000 million in 2020 .— Increasing longevity : true of lesseconomically developed countries as wellas the industrialized world .The result of these two factors means thatthe population aged over 60 years willdouble during the next 20 years fromapproximately 400 million now , to around 800million in 2020 . This increase in elderlypopulation will result in a greater number ofpeople with visual loss and blindness fromcataract who will need eye services .With 80% of all blind people in India , sufferingfrom cataract blindness, the most importantfactor in achieving the overall objectives ofreducing the prevalence of blindness is toexpand the reach of cataract treatment to thelargest possible number of people. Thisincludes ensuring availability of equipment,properly trained personnel, and adequatefunds at lowest possible levels.India has a long tradition of performingcataract surgery in eye camps. Camps are

148 AIOC 2009 PROCEEDINGSarranged by village panchayat, privateorganization or by local societies such asLions or Rotary . Camps are held in eithercamp settings such as schools, other largebuildings or in tents or they are held in fixedfacilities, such as primary health centres orCommunity health centres.The main aim of this study is to providequality eye care at the outreach services , withactive participation of very efficient fieldworkers, thus ensuring restoration of highlevel of quality vision .Materials and MethodsA retrospective study was done at our tertiaryeye care center ( Kamineni Institute of MedicalSciences), Narketpally in Nalgonda districtfrom the year 2000-2006, with respect tocataract yield through an outreachprogramme and efficient field workers .Before the year 2000, KIMS, Narketpally didn’thave any efficient outreach program toincrease the number of cataract surgeryperformed .To increase the number of cataractsurgeries , a very well organized outreachprogramme was instituted with involvementof personal relation officer, paramedical staffand adequate financial support, from theInstitution itself .Local support from villagepanchayat and local MP were also taken.Camps were organized by identification ofvenue for camps , sponsors and the bettercommunication in the community about thecamp .Awareness about the camps was createdby organizing meetings with village leadersusing pamphlets, banners, posters, mikeannouncements and through print and massmedia .The study compares the productivity from theeye camps of the years (2000 to 2006) whenmore efficient eye camp was started. Thepresent study makes use of the Community,and the facilities of the Medical College(Tertiary eye care center), for conducting theeye camps, so that best from both is utilizedfor the patients.A total of 25 to 40 eye camps are performedeach year in and around Narketpallyvillage in the Nalgonda district . All thecamps were conducted with the help ofvoluntary organizations, local leaders, NGOsin cooperation with our core team memberscomprising of one Ophthalmologist, 2-3Optometrist and few well trainedparamedical staff, trained specially indiagnosing cataract cases and visionchecking.The screening had the following sequence:(1) Registration of outpatient, (2) VisionChecking, (3) Checking IOP, Blood Pressure,Urine sugar testing by Urostick, (4) Finalexamination by doctor, (5) Selection forSurgery.As soon as the patient is selected for surgerythey will be taken to our Medical College onthe appropriate date for surgery. Once theyreach the hospital, a thorough check up is doneincluding the IOP, syringing, blood sugar,Blood pressure, keratometry and A-scan isdone to calculate the IOL power . The nextmorning the patients, after light breakfast, aredilated with tropicamide (1%) and patientundergoes cataract surgery, either ECCE withPCIOL or SICS with PCIOL, according to thestage of the cataract.The ophthalmologist examines all the patientson the next morning, topical antibiotic andsteroid drops are instilled. All the patients aredischarged 48 hrs after the surgery with aneye patch and steroid antibiotic combinationeye drop.They are also given a small instruction card ,with do’s and dont’s and the time and placefor follow up at about 6 weeks time .At sixweeks follow up, patient undergoes carefulrefraction , fundus examination and best visionnoted with further instruction if indicated .Results1. Our Institute conducts camps , in theNalgonda district where it is placed andits surrounding villages.2. Nalgonda district has a total population of32,47982 , out of which 28,08991 comprisesof rural population and 4,29458 comprises

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION149of urban population . Our Instituteconducts camps in 150 villages comprisingapproximately 1.5 – 2.0 lakhs of populationin the Nalgonda district .3. Introducing a better organized outreachprogramme , with involvement of efficientfield workers the cataract surgery rate hasbeen increased from a mere 600 in theyear 2000 to 2100 in the year 2006.4. The analysis revealed that there has beenan exponential growth ( 350% ) of cataractsurgery rate from the year 2000 – 2006 .5. Case load of mature cataract in year 2000was 50% , which reduced to 25% in 2006.6. Average BCVA, is between 6/12 - 6/18, inall the cases .7. Table below shows the year wise, numberof camps conducted , cases screened andnumber of surgeries performed .Year No of camps No of cases Total no ofconducted screened cat surg perfm2000 25 10,000 6002001 30 15,000 9002002 20 10,000 8002003 35 20,000 10002004 35 22,000 14002005 40 30,000 18002006 40 37,200 2100Discussion(1) The term ‘outreach’ as it is used todaycovers a fairly wide range of strategies andapproaches, some quite different from eachother, but all aimed at providing services tothose who otherwise would not come to theclinic. The community intervention bringsabout a change in behaviour of the patientsgenerating the demand. Outreach programbenefits the unreachable poor who havelimited access to eye care services andprevent high proportion of people fromnon-usage of eye care services.2. Following are the essential elements forany outreach programme - Planning activitiesmust be as thorough as possible, covering atthe very least the following areas:(a) The proposed intervention zone: itsgeographic and administrative boundaries, itstarget population, the other service providerswithin the catchment area and the specific orcomplementary roles they’re likely to play(b) The nature and scope of the outreachprogramme. Is it i) a mere extension ofbase unit clinical and /or surgical activities;ii) a programme to screen and bring in morecataract patients for surgery; iii) the firststep towards the establishment of apermanent eye care structure and servicedelivery in the area? In the latter case, whatelse should be considered at this earlystage? (c) The capacity of the base eye unitto initiate and sustain the outreachprogramme and absorb the expectedincreased workload. (d) The capacity ofthe base unit, or its sponsoring institution,to secure or guarantee financial supportbeyond the traditional three-year life spanof most projects. Carrying out outreachactivities while generous financial supportis available is always the easy part. The realchallenge is to sustain them beyond theinitial project life span, (e) The capacity ofthe team to relate to, partner and workwith the community. Skills needed toadequately engage and work with thecommunity are quite different from thoseneeded to be a good eye care professional ina clinic setting. All members of the outreachteam should therefore be assessed andoffered additional training where needed.1. Beyond the clinic: approaches to outreach , DanielEtya’ale - Co-ordinator of VISION 2020 in Africa,Programme for the Prevention of Blindness, WorldHealth Organization, 20 Avenue Appia 1211,Geneva 27 Switzerland.2. Central Ophthalmic cell, Ministry of Healthand Family Welfare, Government of India:ReferencesAnnual Results.3. Martin.H.Spencer, Cataract surgery in Developingcountries: Bridging the technology Techniques incataract and Refractive Surgery, 3:156-160.4. National Informatics Centre, Collectorate,Nalgonda .

150 AIOC 2009 PROCEEDINGSDiabetes and Diabetic Retinopathy: Knowledge, Attitude, Practice(KAP) Among Paramedical Personnel (PMPS) and CommunityMembers (CMS) In Southern IndiaDr. Naresh Babu, Dr. Kim, Dr. Bharat Ramchandani, Dr. Sachin Tiwari(Presenting Author: Dr. Naresh Babu)K.A.P tells us what people know about certainthings, how they feel and also how theybehave. Knowledge–about various aspects ofhealth and disease. Attitude–is a tendency tobehave in a certain way and Practice–what theyfollow or adopt .Diabetic retinopathy is becoming an increasinglyimportant cause of visual impairment in Indiadue to increase in the Diabetic population as alldiabetics will develop some degree ofretinopathy within twenty years of the onset ofdiabetes. Fortunately, vision loss and blindnessdue to diabetic retinopathy are almost entirelypreventable with early detection and timelytreatment. However, many people with diabeticretinopathy remain completely asymptomaticand unaware that their vision is under threat. Alack of knowledge concerning the need forscreening, especially in the absence of symptoms,is a major barrier to regular screening for manypeople with diabetes. Awareness that diabetescan cause diabetic retinopathy is present in only28.8% of the urban population in southern India.Furthermore, awareness concerning the differenttreatment modalities for diabetic retinopathy isalso expected to be low among paramedicalpersonnel and community. Knowledge, Attitudeand Practice (KAP) study was conducted amongthe community and paramedical personnel ondiabetes and diabetic retinopathy as a part of theawareness creation project.This study was designed to find out the Level ofKnowledge, Attitude and Practices ofParamedical Personnel (PMPs) and CommunityMembers (CM) in diabetes and diabeticretinopathy and compared subsequently to thesame after awareness programs.Materials and MethodsThe paramedical personnel are the front linehealth workers at the grass-root level in the ruraland urban areas, have many opportunities tointeract with community members for healtheducation and to provide health services. If theparamedical personnel have scientificknowledge, favourable attitude and know aboutcommon practices prevailing in the community,they can effectively create awareness and provideservices to the people. So paramedical personnelsuch as village health nurses, health inspectors,block extension educators, block healthsupervisors, pharmacists, ophthalmic assistants,multi purpose health workers, staff nurses etc.were included in the KAP study.One of the objectives of the project was to createawareness in the community about diabetes anddiabetic retinopathy. Various awareness creationactivities were conducted in pursuit of this goal.These activities included press meetings, articlesin the local newspaper, exhibitions, TV and Radiobroadcasts, and the displaying of poster andstickers.A questionnaire, designed with the aid of variousexperts in related fields, was used to gatherinformation from a sample of 204 PMPs and 201community members. The detailed questionnairehad questions as contribution of hereditaryfactors to diabetes, role of lifestyle, effect on eyeslike diabetic retinopathy,cataract,glaucoma,importance of additional risk factors in diabeticretinopathy as high blood pressure, role of dietcontrol, available treatment options for diabetesand diabetic retinopathy. The data was collectedat the beginning and at the end of the project.All of the paramedical personnel in thecommunity were oriented about magnitude ofdiabetes, types and symptoms, the parts of thebody affected, management options, diabeticretinopathy, risk factors for diabetic retinopathy,the role of laser photocoagulation as an option forthe treatment of diabetic retinopathy and itsavailability at surrounding locations.Paramedical personnel’s were involved indiabetic retinopathy awareness program andscreening camp in the project areas.

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION151Relevant I.E.C.Material like leaflets and handbillswere supplied to all the participants whoattended the various educational sessions.During counselling, leaflets on diabetes anddiabetic retinopathy were given to diabetespatients.ResultsTotally 204 Paramedical personnel and 201Community members participated in this study.The first survey was taken in 2002 and the finalsurvey in 2007. All the community personnelwere questioned regarding the knowledgeaspect. Initially 59% of PMP and only 28% ofcommunity were aware of diabetes whichincreased to 62% in PMP and 77% of communityat the end.70% of PMP and 28% of communitywere aware of heredity as a factor for Diabeteswhich increased to 91% in PMP and 81% ofcommunity. Finally with respect to the majorparts of the body affected due to diabetes, 89% ofPMP and 53% of community were aware of eyeproblem which increased to 91% in PMP and 86%in community. Only 55% of PMP and 7% ofcommunity were aware of diabetic retinopathyin the beginning which increased to 79% in PMPand 68% in community finally. Regarding theawareness of treatment option for diabeticretinopathy 24% PMP were aware of laser andonly 3% of community was aware whichincreased to 84% in PMP and 65% in communityfinally. As far as the attitude is concerned, therewas a major difference in attitude regardingdiabetic retinopathy among community andPMP. At the beginning, 88% of PMP had positiveattitude whereas only 52% of community hadpositive attitude which was increased to 94% ofPMP and 83% in community. Regarding thepractice, 80% of people who were advocatingallopathy in PMP group initially, increased to96% whereas among the community it was 83%in the beginning which increased to 96%. Finallyawareness of exercise in diabetes control wasonly 48% among the PMP and 10% of communityinitially which increased to 60% in both thegroup. There was a dramatic increase in theknowledge regarding the diet among communitywhich increased to 100% from 46% and amongthe PMP from 70% to 76%.There was no markedimprovement regarding the medicalmanagement.DiscussionMost of the PMPs and community members areaware of the nature of diabetes. A large numberof respondents were able to identify frequenturination, weakness and non-healing of woundsas symptoms of diabetes, but fewer identifiedexcessive hunger is one of the most importantsymptoms of diabetes.More community members know the importanceof hereditary and lifestyle factors as a cause ofdiabetes. An increase in knowledge occurredregarding the parts of body affected by diabetes,the risk factors for diabetic retinopathy, likeduration, poor glycemic control, blood pressure.The duration of diabetes mellitus seems to havea more direct association with the progression ofdiabetic retinopathy than the severity of thedisease. In insulin dependent diabetes mellitusthe prevalence of diabetic retinopathy is 97.5% ifthe duration is 15 years or more and in noninsulindependent diabetes mellitus it is almost80%. It is the persistently increased blood sugarwhich is a high risk factor in developing DR.Other factors are high blood pressure, smoking,alcohol consumption and increased serum lipids.It is very clear that less than 10% of paramedicalpersonnel and the community know the greatestrisk factor of diabetes for diabetic retinopathy,which increased to considerable levels finally.There are no drugs available at the present timeto treat diabetic retinopathy. Only 3% of thecommunity members and 24% of paramedicalpersonnel know about laser treatment fordiabetic retinopathy. Regarding the knowledgeof Laser as the mode of treatment for DR ,therewas a dramatic increase among both the groups,which is due to the intensive awarenessprogrammes conducted. Both groups are awarethat optimal blood pressure will reduce thechances of developing diabetic retinopathy.88% of paramedical personnel have favourableattitude. 37% of the community have negativeattitude. This negative attitude in the communitydecreased to 16%.The health educationprogramme has successfully converted thosewith negative attitude into more positive attitudeby providing scientific knowledge throughvarious awareness activities in the community.The practice of the diabetes in the community aswell as among the PMPs has improved as a result

152 AIOC 2009 PROCEEDINGSof the project activities. Previously peoplebelieved that diet control and drugs alone caneffectively control diabetes. Exercise is lessemphasised in the community; however therewas an increase in the practice regarding exerciseto manage the disease. This is re-enforced by theincrease in the numbers of respondents whomentioned regular treatment and exercise asmodes of control of DM. This is a good sign ofsuccess of health education programme. There isa slight increase in the allopathy treatmentmethod followed.Substantial improvement in the knowledge ofparamedical personnel and community hasresulted from the efforts of the diabeticretinopathy programme in many areas,compared to the beginning. This is because of theintensive IEC programme initiated during theproject. However a continued IEC activity isimportant to sustain the benefit.Chronic Irritation of Eyes - Where and Why?Dr. Bal Ram Verma, Dr. Poonam Jain, Dr. Ankur Midha, Prof. Indu Arora(Presenting Author: Dr. Poonam Jain)Chronic irritation of eyes are among the mostcommon reasons patient seek help from eyedoctors and are extremely distressing situationboth for the patient as well as for the clinician. Itcan be caused by a group of conditions anddiseases, but most often it is non specific innature. Often a dry eye disorder is the culprit, butfrequently there are other causes.Precorneal tear film forms a remarkably stablecontinuous covering over exposed portion of theglobe. A stable tear film with normal flow isessential for preserving a clear cornea.Wettabilityof the corneal epithelial surface and properties oftear fluids have been regarded as principalfactors in the determination of precorneal tearfilm stability. Ocular surface inflammation andaltered tear composition together contribute totear film instability which in turn leads to ocularsurface diseases and ocular discomfort.People in hot and windy environment areparticularly predisposed to having ocularirritation for the very obvious reasons andtherefore contributing to a sizeable portion ofOPD patients in dry and arid regions.Materials and MethodsWe conducted a study to determine variousaetiological factors underlying chronic irritationof eyes in North Western India and theircorrelation.The hospital based study wasconducted amongst patients with chronicirritation in eyes presenting to eye OPD of SMSHospital, Jaipur over a period of one year fromJan 06 to Jan 07. First 1000 patients were selectedon the basis of laid criteria. Patients with dry eye,blepharitis, meibomitis, chalazion, pterygium,allergic conjunctivitis, vernal conjunctivitis,patients on prolonged topical drugs as well asprolonged computer work with symptoms ofocular irritation were included. Whereas thosewith infected eyes, foriegn body, injury, recentsurgery, entropion, trichiasis, distichiasis,primary corneal pathology, glaucoma, uveitis,sac pathology (acute or chronic) were excluded.Uncooperative patients and those in extremes ofage were also not included. Comprehensivepatient history and symptoms were recordedusing a written questionnaire. They werequestioned for onset, duration, character,location, diurnal variation, aggravating andrelieving factors. The selected patientsunderwent proper slit lamp examination of lids,conjunctiva and cornea to determine theaetiology of disorder. Tear flow and tear filmstability were assessed in every patient bySchirmer Test and Tear film break up time(TBUT) respectively.A Fluorescein strip moistened with distilledwater was applied to the inferior bulbarconjuctiva. The patient was asked to blink severaltimes to distribute the fluorescein evenly andthen to stare directly ahead without blinking; theeye lids were not held. The eye was thenexamined on a slitlamp with a cobalt blue filter.The time taken for the first dry spot to appear onthe cornea was measured using a stop watch.This test was repeated 3 times in each eye, andthe average was taken as BUT.Schirmer's tear test filter paper strips wereinserted in the lateral part of the lower fornix

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION153without using any surface anasthesia. The patientwas instructed to keep his eyes open and look up.At the end of 5 minutes the strips were removedand the dampness measured on a millimetre scale.ResultsOut of 1000 patients included in the study, 452(45.2%) were male whereas 548 (54.8%) werefemale and the male: female ratio was app 0.8.Highest incidence was seen in 4th to 7th decadeof life with maximum number of patients in the5th decade. Incidence was least in patients lessthan 20 years and more than 70 years of age.Children less than 5 yrs and elderly more than 80years of age were not included.The leading causes of chronic ocular discomfortwere Allergic conjunctivitis (276), Meibomitis(238), Dry eyes (212), Blepharitis (88), Computervision syndrome (59), Pterygium (52) and VKC(44). Furthermore, the diagnoses of Dry eye,VKC, Computer vision syndrome werecommoner in urban population whereas those ofblepharitis, meibomitis, allergic conjunctivitisand prolonged use of topical medication weremore in rural population. Overall, the symptomsof chronic ocular irritation were slightly more inrural population 52.1% than in urban 47.9%patients.A correlation was seen among some of theaetiologies and dry eye. Dry eye was seen morecommonly with 29 out of 52 cases of pterygium(55.76%), 38 out of 88 cases of blepharitis (43.18%),76 out of 238 cases of meibomitis (31.93%).DiscussionChronic irritation of eyes is one of the mostcommon ophthalmic medical problem. Irritationis a sandy gritty feeling, burning, foreign bodysensation or increased awareness of eye. In ourstudy we have tried to emphasize on where andwhy of chronic ocular discomfort and our resultshave been comparable to the studies of Khuranaet al (1991) and Malhotra et al (1975). AlsoGilbard J P in his study described dry eye andposterior blepharitis are the two most commoncauses for chronic eye irritation.Dry eye is caused by loss of water from the tearfilm resulting from either decreased tearproduction or increased tear film evaporation.The resultant increase in tear film osmolaritycauses the changes on the eye surface responsiblefor the symptoms of dry eye. Posterior blepharitiscauses eye irritation from inflammation, andleads to the development of meibomian glanddysfunction. The patient history is a powerfultool in narrowing the differential diagnosis ofchronic eye irritation or even establishing thediagnosis. The exam adds power to the history,and sorts out the mechanisms causing dry eyesymptoms. By determining the cause or causes ofchronic eye irritation, effective treatments can beemployed.Chronic ocular discomfort increases with age andis commoner in females. Environmental factorshave an important role to play accounting fordifferences for urban and rural population.Chronic irritation of eyes is a very commonsymptom and misdiagnosis of the correct etiology iscommoner. Accurate diagnosis is essential foralleviation of symptoms and its awareness at primaryhealth care level cannot be overemphasized.Referrences1. Gilbard JP.,Dry eye, blepharitis and chronic eyeirritation: divide and conquer.4. Holly FJ, Lemp MA. Wettability and wetting ofcorneal epithelium. Exp Eye Res 1971;11:239-50.2. J Ophthalmic Nurs Technol. 1999;18:109-15.3. Schepens Eye Research Institute, Boston, 5. Tiffany JM, Winter N, Bliss G. Tear film stability andMassachusetts, USAtear surface tension. Curr. Eye Res. 1989;8:507-15.

154 AIOC 2009 PROCEEDINGSAUTHORS’S PROFILE:DR. PARTHA BISWAS: MBBS, MS, Patna University, Fellow, Vitreoretina, ShankaraNetralaya, Chennai. Hanumantha Reddy Award. Ex-consultant, Netrojyoti Seva Mandiram,Rajgir, Bihar. Currently consultant, B.B. Eye Foundation, KolkataE-mail: parthabiswas@vsnl.netARMD and Diabetic Retinopathy are twoimportant reasons of ocular morbidityworldwide.One major angiogenic stimulus for thedevelopment and progression of the two diseasesis the Vascular Endothelial Growth Factor(VEGF).Various Anti- VEGFs have been discovered in thepast few years to try to arrest the progression ofand possibly try to improve the disease conditionin these diseases, Ranibizumab and Bevacizumabbeing two such drugs.Ranibizumab, has been shown by the Marina andAnchor Trials to have significant effects inARMD(wet type) like:• Stabilization of Visual Acuity• Gain in Visual AcuityHowever, it is extremely expensive, costingnearly Rs.1.2 lakhs for 3 single dose vials.On the other hand, case series have shown thatBevacizumab(Avastin), is effective inNeovascular AMD, Diabetic Retinopathy, CRVOand Neo-vascular Glaucoma and has a cost ofabout Rs. 25,500/- for 4ml. vial, multi dose.Studies, earlier performed with different drugs,have shown them to be effective and safe onadministration on more than one patient on thesame day from a single vial by different doctors.Such a way of administration, besides retainingthe safety and efficacy that would have had beenwith a single recipient, also grossly reduces thecost of a single dose of the medicine to aparticular patient. Unfortunately such studieshave not been performed with these anti-VEGFsearlier.Eye Camp AvastinDr. Partha Biswas, Dr. Ajoy Paul, Dr. Chandrima Paul, Dr. Saurav Sinha,Dr. Kajol Prosad Ghosh, Dr. Arnab Biswas, Dr. Mohd. Parvej Alam(Presenting Author: Dr. Partha Biswas)In our study, we have tried to evaluate how safeand cost-effective Bevacizumab administrationcan be, on multiple patients by multiple surgeonson the same day.Materials and MethodsAims and Objective: To evaluate the safety andcost effectivity of Bevacizumab administration onasingle day on multiple patients bymultiple surgeons.Study design: Retrospective longitudinal.Study period: 21–04-07 to 11–10-07A total of 12 AVASTIN CAMPS wereconducted(twice per month).Study place:• B.B.Eye Foundation, Kolkata.• Purnima Netralaya, Tamolia, Jharkhand (25km. From Jamshedpur)Methodology1. Team and counsellor chosen,2. “Avastin Days” identified,3. “Avastin Surgeon” slots determined,4. Patients –• Registration done for patients withNeovascular ARMD, PDR ,CSME - Diabetic,Macular Oedema (CRVO/ BRVO), RefractoryPseudophakic Macular Oedema, IrisNeovasculari-zation.• OCT and USG done complimentary as andwhen required.• Off-label Consent form executed.• Patients asked to report on predetermined“Avastin days”.

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION1555. Doctors• Surgeons – intimated 1month, 7 days and 2days in advance by Message on the Mobileand phone calls.Operating Surgeons – 11 retinal surgeonsParticipating Surgeons – 25 surgeons (18 fromWest Bengal, 4 from Bihar and 3 fromJharkhand)• Physicians – 26. OT and WARD – Organised.• O.T. i) 1 O.T. with 2 Operating Tablesii) 1 Microscopeiii) 2 Assisting Nursing Staffiv) 3 Running Staffv) 1 Sterilization Operator7. Operative procedure –• Pre-operative :- Medical Check-up (including CVS) done- Topical Antibiotics started 3 days prior to“Avastin Day”.• Operative Procedure :- Eye cleaned and draped- 1.25 mg in 0.05 ml Bevacizumab taken- Intravitreal injection given with 27G needle3.5 - 4 mm posterior to limbus- Injection site compressedO.T. Time - Max. Session 8 hrs, Min. Session45 minutes• Post-operative :- Topical Antibiotics continued for 5 days- Referred back to respective Surgeons- The Vial sent for c/s to Pathological Lab8. Utilising the vial at the Rural Arm (PurnimaNetralaya, Tamolia, Jharkhand) of theAvastin Eye Camp :-• Remaining vial hand carried in sterilechamber to the rural hospital• Avastin - injected within 7 hrs. at PurnimaNetralaya O.T.Results• Avastin vial Bevacizumab - 100 mg/4 ml- 20 - 22 injections 1.25 mg (0.05 ml)• 21.04.07 - 11.10.07 - 12 Avastin Camps- B. B. Eye Foundation• 3 Rural Avastin Camps - Purnima Netralaya,TamoliaComplications• Systemic complications - NIL• Subconj. Haemorrhage - 8 eyes• Endophthalmitis - 1 eye(Diabetic, 6thpost-op day,• Resolved with intravitreal medications)Discussion• Financial Work up :- Avastin 1 vial - Rs. 25,500/-- Consumables per patients approx. Rs.50/-- Avastin Package to the patient Rs. 5000/-per injection.BREAK EVEN AT 6 EYES- SUBSIDY- Urban patients - 12.2%- amount (90% - 20%)- Rural arm patients - 100%• Advantages gained :- Multiple patients benefited on single day- Multiple doses prepared from a singlevial- Multiple surgeons involved- The procedure made safe and effective- Remote rural areas with a large volumeof patient load could be covered.- Cost-effectivity for rural and urbanpatients achieved.- Subsidisation of rates made possible.Though Anti-VEGF, Ranibuzumab, Pegaptanib,have proven efficacy in wet AMD, they are notpractically cost-effective for all sections of theIndian population. Bevacizumab has beenproved efficacious in Neovascular AMD, and itcan be cost- effectively administered to the largerpopulation with financial restraints in the Indianscenario.Our “AVASTIN EYE CAMP” Model is aninnovation, not reported in the literature. It is ahighly cost effective and safe model, based oncoordination and cooperation of Eye Surgeonsand their teams and can be replicated in anyurban or rural eye care set-up.

156 AIOC 2009 PROCEEDINGSAUTHORS’S PROFILE:DR. PARIKSHIT GOGATE: PBMA’s H.V. Desai Eye Hospital, 93, Tarwade Vasti,Mohammadwadi, Hadapsar, Pune-411 028.Contact: (020) 26970043; E-mail: desaieyehospital@vsnl.netVisual Handicap and Ocular Problems in Mentally HandicappedChildrenDr. Parikshit Gogate, Dr. Freya Rao Soneji, Dr. Hemant Dulera, Dr. Arundhati Bhonde,Dr. Sudhir Taras, Prof. Col. Madan Deshpande.(Presenting Author: Dr. Parikshit Gogate)There have been studies carried out in the areaof ocular and visual problems in mentallychallenged adults, notably in the Netherlandsand the United Kingdom. 1 There are alsonumerous studies carried out in India and inother countries pertaining to ocular and visualproblems in school-going, intellectually normalchildren. 2 But a child with mental handicap isgenerally considered to be a ‘difficult’ case andperhaps that is the reason why there are fewreports about ocular and visual problems in thementally challenged children. The presence ofmore than one disability in an individual mayhave a multiplicative rather than additive effecton the life experience of that person. Theamelioration of one disability may have animpact on all spheres of such an individual’s life.The present study aims to study ocular andvisual problems in mentally challenged childrenin special education schools for the mentallyhandicapped in a large urban conglomerate inMaharashtra, India. The co-relation betweenocular and visual problems and perinatal andfamily history was also investigated. All treatableproblems were to be ameliorated whereverpossible.Materials and MethodsSpecial education schools for the mentallychallenged in Pune city were contacted with aletter proposing the examination of all itsstudents with a view to diagnose and treat anyeye problems. The permission to examine thestudents sought from the principal of theconcerned school and the consent of schoolauthorities was taken. All students in theconcerned school for the intellectually disabledchildren were examined by the team ofophthalmologists and optometrists of theHVDEH. The study received approval of theethical committee of the H. V. Desai EyeHospital.The Class teacher and social worker of the schoolwere present during examination of each child.The schools’ record of each child including theirperinatal history, Intellectual Quotient (IQ),psychological assessment and social worker’sassessment was examined. Team members wereencouraged to spend time to establish a rapportwith the child before commencing the formalexamination.External ocular examination was carried out indiffuse illumination with torchlight. Headposture, facial anomalies and extra ocular musclemovement was noted.In examining the Visual Acuity, the Kay Picturetest was the most useful tool as the childrenresponded to the pictures that they saw daily intheir surroundings. Snellen’s chart inEnglish/Marathi/Numbers was useful forchildren who had borderline mental retardation.Glasses were prescribed for all children whorequired correction which included myopia morethan or equal to -1.0DS, hypermetropia morethan or equal to +3.0DS, astigmatism more thanor equal to 0.5DC. Cycloplegic refraction wasdone in all suspected hypermetropes and allchildren with esotropia or esophoria.Cover/uncover and alternate cover tests were

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION157done for children who had abnormalHirschberg’s reflex. Children having Visualacuity

158 AIOC 2009 PROCEEDINGSTable-2Perinatal insult No. Refractiv Strabismus Low Optic Nystagmus OthersError Vision AtrophyPoor ANC 73 13(17.8% 15(20.5%) 14(19.2%) 5(6.8%) 10(13.7%) 6(8.2%)Pre/ Post term 68 20(29.4%) 11(16.2%) 14(17.6%) 9(13.2%) 6(8.8%) 8(11.8%)Delayed cry at birth 157 49(31.2%) 31(19.7%) 27(17.2%) 19(12.1%) 16(10.2%) 10(6.4%)Assisted/ Caesarian 84 24(28.6%) 14(16.7%) 14(16.7%) 8(9.5%) 7(8.3%) 6(7.1%)Low birth wt. 105 37(35.2%) 15(14.3%) 19(18.1%) 8(7.6%) 10(9.5%) 7(6.7%)fever/meningitis/head injury 59 16(27.1%) 11(18.6%) 2(3.4%) 5(8.5%) 1(1.7%) 3(5.1%)h/o incubator required 42 10(23.8%) 8(19.0%) 9(21.4%) 5(11.9%0 7(16.7%) 4(9.5%)h/o convulsions 32 15(46.9%) 10(31.3%) 7(21.9%) 5(15.6%) 4 (12.5%) 2(0.6%)Jaundice 35 10(28.6% 4(11.4%) 4(22.9%) 3(8.6%) 3(8.6%) 0ocular problem. 74 children were knownepileptics. 58 (78.3%) of these children had ocularproblem, refractive error accounted for28(49.3%), Strabismus 19 (32.8%) and opticatrophy 5(8.6%). Out of 56 children with Down’ssyndrome, 35 (62.5%) had ocular problems.54 referrals were made for specialist evaluationand treatment. 30 were for strabismus, of which6 children were operated and the remaining wererefracted. 16 children were offered low visionaids. 8 children were referred for other problemsincluding ptosis, pseudophakic posteriorcapsular opacification, retinal dystrophy andcornea referral.DiscussionMentally challenged children emerge as a groupwith a profound need for ophthalmologicassessment. Only 2 out of the 11 schoolsexamined by us had ever received a visit fromeye health care providers, the most recent being4 years earlier. Out of 144 children found to haverefractive error, only 25 (17%) had ever beenrefracted before and even of these children, only12 were actually using their spectacles. Due to avariety of behavioral problems seen in mentallychallenged children, parents are reluctant to taketheir child for an eye examination. Many parentsand care providers also stated the mistaken beliefthat someone needs to be verbal in order toundergo an eye examination.It was found that preparing the teachers, socialworker and also the care-givers was of immensevalue. The establishment of a rapport betweenthe child and the examiner was the keystone ofthe assessment. It would be ideal if a mentallychallenged child would automatically need tohave ophthalmic examination prior to receivingcertification for mental handicap.Awareness about the need for regular spectacleuse in children needing them was low evenamongst the special educators. The greatestprevalence of refractive error was found inchildren with Down’s syndrome with 26 out ofthe 56 children with Down’s syndrome havingthe need for spectacle correction. 28 out of 74children with history of epilepsy in this subset(48.3%) had refractive error.The prevalence of refractive errors was high in allchildren with known history of perinatal insult.Only 39.7% of children with Strabismus werefound to have an associated refractive error,suggesting that the remainder 60.3% of thestrabismus was due to other causes.Amongst the children with systemic problems,those with epilepsy had the highest prevalenceof strabismus. The next highest prevalence wasamongst children with cerebral palsy.The prevalence of UCVA

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION159References1. Van Splunder J, Stilma J.S., Bernsen R.M.D.; ArentzT.G.M.H.J.; Evenhuis H.M.: Refractive errors andvisual impairment in 900 adults with intellectualdisabilities in the Netherlands. Acta OphthalmologicaScandinavica 2003;81:123-30.2. Nirmalan PK, Vijayalakshmi P, Sheeladevi S,Kothari MB, Kannan Sundaresan and LakshmiRahmathullah: The Kariapatti Pediatric EyeEvaluation Project: baseline ophthalmic data ofchildren aged 15 years or younger in SouthernIndia. American Journal of Ophthalmology 2003;136:703-9.3. Katoch S, Devi A, Kulkarni P. Ocular defects incerebral palsy. Indian J Ophthalmol 2007; 55:154-6.An Epidemiological Study of Ocular Rhinosporidiosis in andaround Raipur, ChhattisgarhDr. Santosh Singh Patel, Dr. A. K. Chandrakar, Dr. M.L. Garg, Dr. Nidhi Pandey,Dr. Vijaya Sahu, Dr. Sonal Vyas(Presenting Author: Dr. Santosh Singh Patel)The etiological agent of rhinosporidiosis, This study describes the clinical features,Rhinosporidium seeberi described as a diagnosis and treatment of rhinosporidiosis ofdisease. 6 water.phycomycete by Ashworth in 1923, has for longbeen a subject of taxonomic uncertainty, becausethe organism can neither be isolated nor cultured.Some authors postulated that the agent is not afungus but a prokaryotic cyanobacterium calledthe eye and its adnexea.Materials and MethodsA total of 82 cases of ocular rhinosporidiosistreated at Dr. B R A M Medical College Hospital,Microcystis aeruginosa. 1 However, through Raipur during a period of 2 years were includedmolecular biological analysis of the organism’sribosomal DNA, the responsible agent is nowin the study. 60 cases, included in this series,were confirmed by histological examination ofconsidered by most as an aquatic protistan hematoxylin and eosin–stained sections of biopsyparasite belonging to a novel group of fish samples. Histopathological analysis was notparasites that infect fish and amphibians, locatedperformed in 22 cases. These cases werephylogenetically between the fungal animaldiagnosed only by clinical features. The clinicaldivergence. 2features, diagnosis, epidemiology (geographicalRhinosporidium seeberi can cause infections of distribution, age, sex, prevalence), and treatmentthe nose, throat, ear, and even the genitalia in of those cases were studied and analyzed. All theboth sexes. 3 However, ocular rhinosporidiosis,conjunctival mass was excised under topicalthat is the infection affecting the eye and itsanesthesia and properly cauterized withadnexea, is the most common manifestation. 4povidone iodine 5% solution. Sac mass wasOcular rhinosporidiosis is worldwide inexcised with dacryocystectomy under G.A./ L.A.distribution but relatively more common inand again cauterization done with povidoneIndia. 5 This paper reviews the clinical manifestations,diagnosis, epidemiology, and treatment ofiodine 5% solutions. At the time of sac surgerynasal endoscopy has been performed by anrhinosporidiosis of eye and its adnexea in a seriesof 82 cases in Chhattisgarh State.E.N.T. surgeon for diagnostic as well astherapeutic purpose.Background: Chhattisgarh is amongst such areaswhere the disease is endemic, probably because Resultsof the hot and humid climate. Here, it is mostlyseen in agricultural labourers belonging to lowsocioeconomic status. Most of the affectedpersons give a history of taking bath in stagnantponds which is shared by cattle who harbor thisRhinosporidiosis of eye and its adnexea wereuniocular in all 82 patients. Of the 82 cases, 28(34%) had R. seeberi infection of the conjunctivaand 54 (66 %) had infection of the lacrimal sac.All patients had a history of taking bath in pond

160 AIOC 2009 PROCEEDINGSPatients came for treatment when theythemselves or their relatives noticed a fleshygrowth protruding through the palpebralaperture. The conjunctival lesions werecharacterized by either polypoidal or flattenedgrowth. The polyps were soft and pink andshowed numerous gray –white spots on theirsurfaces. These were pathognomic of thecondition. All were very vascular and they bledreadily even on touch.Of the 28 conjunctival polyps, 22(27 %) wereattached to the palpebral conjunctiva (14 to theupper lid and 8 to the lower lid), 5 (6%) to thefornices (1 to the upper fornix and 4 to the lowerfornix), 1(1 %) to the bulbar conjunctiva to thesuperior conjunctiva. These were attached to theconjunctiva with a thin stalk. The size of polypivaried in length. All were painless. In all cases,the rest of the conjunctiva was normal.1 patient having infection on superior bulbarconjunctiva presented as asymptomatic scleralstaphyloma with white spots present on itssurface.54 patients had an infection of the lacrimal sac.These cases presented with complaints ofpurulent discharge and occasional bleeding fromthe nose and eye. None of them complained ofpain or gave a history of any other ocularproblems such as conjunctival infections. Thepatients also gave a history of taking bath inpond water. Out of these 54 cases, 48 cases (59%)presented as sac swelling and rest 6 (7%) asperforated Rhino mass in the sac area.Recurrence was noticed in 5 % cases.Epidemiology: Geographic distribution: 17patients from Durg. 17 from Raipur, 12 fromBilaspur etc., it shows that this disease is endemicin almost all parts of Chhattisgarh.Age and sex distribution: The condition wasmore common in males than in the females Theratio of males to females was 3:1. In females, thecondition occurred most commonly in the 8-10yrs of age. In males, the condition occurred in allthe age groups but mostly in 10-12 years of age.DiscussionWe found recurrence in both conjunctival andlacrimal sac rhinosporidiosis. Conjunctivalgrowths recurred less often than growths in thesac. Whether it was a true recurrence or reinfectionis difficult to prove, especially in casesof conjunctival growth, because they arerelatively easily removed in toto unlike thoseinvolving the sac. Cauterizing the base of thelesion after surgery may further help in reducingrecurrences.We routinely use povidone iodine 5% in all ourcases after excision of the growth. Arseculeratneet al. has reported a metabolic inactivation ofendospores on exposure to certain biocidesincluding povidone iodine. This might preventrecurrence of the disease due to autoinoculationof the endospores contaminating the adjacentmucosal surfaces during surgery. 7One part of this study is also to aware the peoplefor rhinosporidiosis prevention, with the use ofseparate ponds for humans and animals. For thiswe organized awareness camps and posterdistribution was done in rural areas of Distt.-Raipur CG.1. Ahluwalia KB. Culture of the organism that causesrhinosporidiosis. J Laryngol Otol 1999;113:523-8.2. Herr RA, Ajello L, Taylor JW, Arseculeratne SN,Mendoza L. Phylogenetic analysis ofRhinosporidium seeberi's 18S Small-subunitRibosomal DNA groups this pathogen amongmembers of the Protoctistan Mesomycetozoa clade.J Clin Microbiol 1999;37:2750-4.3. Cherian PV, Satyanarayana C, 1949.Rhinosporidiosis. Indian J Otolaryngol 1949;1:15–9.4. Kuriakose ET, 1963. Oculosporidiosis.ReferencesRhinosporidiosis of the eye. Br J Ophthalmol 1963;47:346–9.5. Satyanarayana C, 1960. Rhinosporidiosis with arecord of 255 cases. Acta Otolaryngol 1960;51:348–66.6. Mukherjee PK. Rhinosporidiosis. In: FraunfelderFT. Roy FH, editors. Current ocular therapy, 5th ed.WB Saunder Company: Philadelphia; 2000:p. 66-7.7. Arseculeratne SN, Atapattu DN, Balasooriya P,Fernando R. The effects of biocides (antiseptics anddisinfectants) on the endospores of Rhinosporidiumseeberi. Indian J Med Microbiol 2006;24:85-91.