Background : Many patients with diabetes do not present for eye examinations, foregoing the recommended management for diabetic eye care. Proactive steps are being taken in Oman to retrieve defaulters (patients who do not present or "no-show") with Sight Threatening Diabetic Retinopathy (STDR). We present the outcomes of the defaulter retrieval system in five regions of Oman in 2009. Materials and Methods : Ophthalmologists examine eyes periodically, family physicians focus on primary prevention of Diabetic Retinopathy (DR) and medical retina specialists manage DR in Oman. A person with proliferative stage of DR (PDR) and/or Diabetic Macular Edema (DME) in either eye is considered as STDR and is registered at regional hospitals. The eye care staff identify the defaulters and the hospital staff help them retrieve the defaulters. The reminder of reappointment is sent using the text messages on telephone. The glycemic control of STDR cases was also noted in Nizwa Hospital. Results : We registered 654 STDR cases, of which 494 (75%) were defaulters. Lack of awareness, transport, absence of a decision maker, and fear of laser treatment were the main causes for defaulting. We successfully retrieved 328 (66.4%) defaulters. The retrieval rates among male and female patients were 51.2% and 82%, respectively. The retrieval varied by region. In Nizwa hospital, 114 of 131 STDR cases (85%) had poor glycemic control. Conclusion : Defaulter retrieval system could help healthcare providers to identify and motivate patients with STDR towards better compliance. Primary prevention measures among STDR cases were poor and need further focus.

Background : Globally, and in Africa, after adjusting for age, women are about 1.4 times more likely to be blind than men. While women generally live longer than men, the lack of accessibility to and use of services is likely the most important reason for excess blindness in women in Africa. Aim : We sought to review the literature on vision loss in Africa and summarize the findings related to gender equity. Materials and Methods : Information from across sub-Saharan Africa was collected on the evidence of gender inequity and reasons for this inequity. Finally, the results were used to generate suggestions on how gender equity could be improved. Results : In all published surveys (except one), cataract surgical coverage among women was lower than cataract surgical coverage among men. Although data available are limited, similar findings appeared in the use of services for other disease conditions, notably, childhood cataract and glaucoma. Evidence suggests that a variety of approaches are needed to improve the use of eye care services. Three main strategies are needed to address gender inequity in vision loss in Africa. First, it is important to address transport needs. Second, counseling of patients and family members is required. Finally, programs need to put in place pricing systems that make the services affordable the population. Conclusions : VISION 2020 can be achieved in Africa, but investment is needed in a variety of strategies that will ensure that eye care services are affordable, accessible, and acceptable to women and girls.

The global initiative, "VISION 2020 - The Right to Sight" aims to eliminate avoidable blindness by year 2020. Avoidable blindness by definition are those conditions for which we already have a treatment or a surgical procedure and often a proven strategy to either prevent or cure the condition. Thus, the challenge to realize this goal would be designing the right service delivery systems specific to the local context, organizing the required resources, coordination, and implementing and monitoring these. The key "discipline" that is required to ensure successful implementation is "Management." To be holistic, such management inputs are required both in a program as well as the hospital setting. From a program perspective, the focus will need to be on reaching the unreached, ensuring equity, creating an enabling environment, putting in place the required infrastructure, including that for developing all cadres of the eye care team, and functionally integrating eye care into the general health system and other developmental activities. From a hospital perspective, the management process should manage the internal and external ecosystems as well as all the interfaces to the hospital. It should also put in place systems for ensuring an adequate patient flow, high productivity, quality, sustainability, and accountability. Since in many countries the notion of management in health care or more specifically in eye care is at an early stage or nonexistent, a proactive effort is required to build the management capacity quickly through a structured process.

Childhood blindness has an adverse effect on growth, development, social, and economic opportunities. Severe visual impairment (SVI) and blindness in infants must be detected as early as possible to initiate immediate treatment to prevent deep amblyopia. Although difficult, measurement of visual acuity of an infant is possible. The causes of SVI and blindness may be prenatal, perinatal, and postnatal. Congenital anomalies such as anophthalmos, microphthalmos, coloboma, congenital cataract, infantile glaucoma, and neuro-ophthalmic lesions are causes of impairment present at birth. Ophthalmia neonatorum, retinopathy of prematurity, and cortical visual impairment are acquired during the perinatal period. Leukocoria or white pupillary reflex can be cause by congenital cataract, persistent hyperplastic primary vitreous, or retinoblastoma. While few medical or surgical options are available for congenital anomalies or neuro-ophthalmic disorders, many affected infants can still benefit from low vision aids and rehabilitation. Ideally, surgery for congenital cataracts should occur within the first 4 months of life. Anterior vitrectomy and primary posterior capsulotomy are required, followed by aphakic glasses with secondary intraocular lens implantation at a later date. The treatment of infantile glaucoma is surgery followed by anti-glaucoma medication. Retinopathy of prematurity is a proliferation of the retinal vasculature in response to relative hypoxia in a premature infant. Screening in the first few weeks of life can prevent blindness. Retinoblastoma can be debulked with chemotherapy; however, enucleation may still be required. Neonatologists, pediatricians, traditional birth attendants, nurses, and ophthalmologists should be sensitive to a parent's complaints of poor vision in an infant and ensure adequate follow-up to determine the cause. If required, evaluation under anesthesia should be performed, which includes funduscopy, refraction, corneal diameter measurement, and measurement of intraocular pressure.

Over the last three decades, a lot has been achieved in the control of trachoma worldwide. New assessment techniques, effective evidence-based control strategy with new methods and drugs, and an aggressive global partnership for the control of the disease have evolved. As such the number of people with the disease and blindness due to the disease had drastically reduced. Trachoma is now only responsible for about 4% of blindness worldwide down from 12% some few decades ago. Some countries are on the verge of eliminating the disease as a public health problem. Despite these achievements numerous challenges remain for achieving trachoma control in endemic communities. This article highlights the challenges faced in one of the known trachoma endemic areas - northern Nigeria. Aspects on the dearth of complete situational data on trachoma, fragmented implementation of the SAFE strategy, community apathy, difficulties faced in ensuring safe, and quality lid surgery in the most difficult terrain where the disease thrives are discussed here. Other unique challenges like managing children with severe trichiasis, curbing the high rate of early-onset recurrence of trichiasis after lid rotation surgery and challenges to maintain supply of antibiotics and implementation of facial cleanliness and environmental improvement components of the control strategy are presented along with the learnt experiences and recommendations. These challenges and their remedies are likely to be shared by other trachoma endemic areas in Africa.

Purpose : To estimate the prevalence of low vision and blindness, identify the causes, and suggest policies for an effective eye care program based on 2005 data from Sokoto State, Nigeria. Materials and Methods : A stratified two-stage cluster sampling method was used to quantify the prevalence of blindness and the causes from 4 health zones in Sokoto State. Subjects were evaluated using a magnifying loupe, direct ophthalmoscope and torchlight. Data were collected based on the World Health Organization prevention of blindness coding for an eye examination. Prevalences with 95% confidence intervals (CI) were calculated and surgical coverage for causes of blindness was also analyzed. Results : The response rate was 91%. The prevalence of bilateral blindness was 1.9% (95% CI: 1.5-2.3%) ranging from 1.6% to 2.0% across the four health zones. The prevalence was 2.1% (95% CI: 1.6-2.6%) in males and 1.6% (95% CI: 1.1-2.1%) in females. The leading cause of bilateral blindness was cataract (51.6%), followed by uncorrected aphakia (20.9%) and glaucoma (11%). The prevalence of bilateral operable cataract was 1.9% (95% CI: 1.5-2.3%). The cataract surgical coverage (individuals with visual acuity <6/60) for the study was lower than the couching coverage (4.4% vs. 14.9%, respectively). Surgical coverage for trichiasis was 4.4%. The major barrier to cataract and glaucoma management was cost. Conclusions : The prevalence of blindness in Sokoto State is high yet the main causes are largely avoidable. Barriers can be reduced by appropriate health education regarding the eye care program and the provision of integrated, sustainable, affordable and equitable services.

Purpose : To evaluate the outcomes of 16 years of eye campaigns in 38 countries in Africa, Asia and the Middle East Materials and Methods : A descriptive, retrospective study using the Al-Basar International Foundation (BIF) records. BIF is a non-governmental, non-religious philanthropic organization working in the field of the prevention of blindness since 1989. Having its base in Saudi Arabia and working mainly in Asia and Africa. Study variables included the causes of diminished vision, outcomes of eye surgeries, number of camps, patients assessed, surgeries performed, intraocular lenses (IOLs) implanted, spectacles distributed, general outcomes of campaigns, and other variables. Results : Between the periods of November 1989 and June 2006, BIF conducted 620 eye camps. These camps were conducted by ophthalmologists with expertise of working in eye camps with limited resources and harsh environmental conditions. Over two million people were examined and/or treated, and 186, 765 surgeries were performed. Nearly 100,000 IOLs were implanted and more than 140,000 spectacles were prescribed and distributed. The majority of these activities (74%) took place in Asia and the Middle East. The best corrected visual acuity achieved (BCVA) was ranked good (6/6 -6/18) in 59% of patients and borderline (BCVA 6/18 - 6/60) in 35% and poor (BCVA <6/60) in less than 6% of patients based on World Health Organization (WHO) criteria. Conclusion : Quality assured eye campaigns held by BIF helped the most needy countries and people. Intensive volunteer cataract programs and surgeries such as those provided by the BIF add significant support to the efforts of the WHO and International Agency for the Prevention of Blindness in fighting blindness.

Purpose : To evaluate the clinical and epidemiological characteristics of children with ocular trauma. Materials and Methods : We retrospectively reviewed the medical records of 278 children (aged 15 years or less) hospitalized with ocular injuries and treated as inpatients at a tertiary referral center in Shiraz, Iran, from 2005 to 2008. Nominal variables were evaluated with a Chi-square test. A P-value less than 0.05 indicated statistical significance. Results : The cohort was comprised of 205 (74%) males, outnumbering females by a ratio of 2.81/1. The mean age was 7.6 ΁ 3.96 years. Rural residents comprised 125 (45%) of the cohort. Sharp objects caused ocular injury in 211 (76%) cases, and 207 (74%) cases had open-globe injuries. The lens was injured in 62 (30%) cases at initial examination and 89 (43%) patients according to ultrasound examination (P = 0.006). Twenty-eight cases (10%) developed post-traumatic endophthalmitis. Endophthalmitis was associated with needle injury [odd ratio (OR) = 19.25] and presence of intraocular foreign body (OR = 3.48). Visual acuity of patients with closed-globe injuries was 20/200 or better on both initial and final examinations. Visual acuity of patients with open-globe injuries were in the range of light perception to 20/200. Conclusions : Trauma is an important cause of childhood ocular morbidity in southern Iran. Playing with sharp objects is an important cause of ocular trauma in children, and most injuries can be prevented by careful supervision.

Background : We present the prevalence and determinants of glaucoma among subjects 40 years of age and older in Qatar. Materials and Methods : This community-based survey was held in 2009 at 49 randomly selected clusters. Demographic details and history of glaucoma was collected by the nurses. Ophthalmologists evaluated the optic disc and retina using a digital camera housed in a mobile van. Visual field was tested with an automated perimeter, the intraocular pressure with an applanation tonometer and the angle of the anterior chamber by gonioscopy. A panel of glaucoma experts diagnosed subjects with glaucoma. Results : This survey enrolled 3,149 (97.3%) participants. The age- and sex-adjusted prevalence of glaucoma in the population aged 40 years and older was 1.73% (95% confidence intervals [CI] 1.69-1.77). Accordingly, 5,641 individuals in this age group in Qatar would have glaucoma. Chronological age of 60 years and older (Odds ratio [OR] 11.1) and the presence of myopia (OR 1.78) were predictors of glaucoma. Open-angle glaucoma was diagnosed in 44 (65.7%) individuals with glaucoma. In nine (13.4%) and 15 (20.9%) subjects, angle closure glaucoma and other (post-traumatic, pseudoexfoliation) glaucoma were present. Bilateral blindness (vision <3/60) and severe visual impairment (<6/60) were found in four (6%) and three (4.5%) subjects with glaucoma, respectively. Glaucoma was treated in 36 (54%) subjects. Conclusions : The prevalence of glaucoma among citizens of Qatar aged 40 years and older was 1.71%. Glaucoma was associated with the age of 60 years and older and the presence of myopia.

Purpose : To determine the cataract surgery techniques performed in Iran from 2000 to 2005. Materials and Methods : This study was part of the Iranian Cataract Surgery Survey (ICSS) which was a retrospective cross-sectional study. All major ocular surgery units and 10% of randomly selected minor units throughout Iran were included. Excluding the 2 week Iranian New Year holiday, 1 week per season between 2000 and 2005 (a total of 24 weeks) was selected for each center, and data on all cataract surgeries performed during these weeks were collected by reviewing patient records. The ANOVA repeated measure test was performed to determine longitudinal changes with a P<0.05 denoting statistical significance. Results : Phacoemulsification with intraocular lens (IOL) implantation has become the surgical method of choice in Iran, increasing from less than 7% in 2000 to 57% in 2005 (P<0.0001). Extracapsular cataract extraction showed a reverse trend compared to phacoemulsification, decreasing from greater than 91% in 2000 to 41% in 2005 (P<0.0001). Intracapsular cataract extraction and lensectomy were rarely performed without significant changes over time (P>0.05). Conclusion : Phacoemulsification with IOL implantation has become the preferred cataract surgery method in Iran during recent years.

Purpose : To determine the association between refractive errors and different types of cataract in Tehran, Iran. Materials and Methods : In a cross-sectional survey with a stratified cluster sampling approach, refractive errors were tested under cycloplegia. Myopia and hyperopia were defined as a spherical equivalent refractive error <-0.5 diopters (D) and more than +0.5 D, respectively. Cataract was graded according to the Lens Opacities Classification System III classification and the association between refractive errors and cataract was assessed. Of 1434 participants over the age of 40 years who participated in the study, data from 1313 right eyes were analyzed. Results : The mean age of the participants was 52.7 ± 10.0 years, and 58.3% (n = 767) were female. Overall, myopia was more prevalent among those with cataract (odds ratio [OR]: 2.00, 95% confidence interval [CI]: 1.38-2.89). Based on the type of cataract and refractive errors, the odds of myopia was significantly higher with nuclear cataracts (OR: 1.81, 95% CI: 1.14-2.87). The odds of myopia was higher for cases of nuclear cataract with some degrees of posterior subcapsular cataract (PSC) (OR: 3.33, 95% CI: 1.42-7.80). Of nine participants with cortical cataract, seven participants had hyperopia (OR: 3.77, 95% CI: 0.78-18.31). Conclusion : Individuals with nuclear and PSC showed a significantly higher prevalence of myopia while the prevalence of hyperopia was lower in those with cataract. High myopia was seen in higher grades of nuclear cataract. The high percentage of hyperopia was also significant in patients with cortical cataract. More studies are necessary to clarify the correlation between cortical cataract and hyperopia.

Purpose : To assess risk factors associated with the occurrence of penetrating ocular injuries among patients presenting to an eye hospital at Ibadan, Nigeria. Materials and Methods : All cases of penetrating ocular injury presenting over a 10 - year period, were identified by retrospective chart review. All current cases of penetrating ocular injury identified were included. All information was obtained retrospectively from the medical records. Results : The cohort consisted of 135 cases. The follow-up was for an average period of 24.6 weeks (range, 12-312 weeks). Injuries were most likely to occur at home, in a domestic setting (58%). The most common mechanism of injury was projectile missiles hitting the eye. The age range for injuries was 9 months to 70 years. Penetrating ocular injury was most frequent in the 20-29 years group (31.9%) followed by the 0-9 years age group (31.1%). Males were more frequently involved than females (ratio 4:1). The final acuity was better than 6/18 in 14.8% and less than 3/60 in 59.3% of cases. Conclusions : Penetrating ocular injury occurs, most frequently, in a domestic setting and mostly as a result of working with sharp objects. Preventive measures are recommended to reduce visual disabilities due to ocular injuries.

Purpose : To study the views of ophthalmologists on research priorities and outcomes in Nigeria. Materials and Methods : A structured questionnaire was distributed to 120 ophthalmologists and ophthalmic residents who were attending an annual congress in Nigeria. The participants' background information, relative research priorities, frequency of publications, research types, publication media, challenges faced in publishing and impact on health practice or policy were collected. Results : Eighty-nine (74.2%) of the 120 questionnaires were returned. Childhood blindness was given the highest priority for ophthalmic research by 42.9% of the respondents, and genetic studies had the least priority (19.8%). About two-thirds of the respondents had either never been involved or only involved occasionally in any type of ophthalmic research. Clinical trials (13.1%) and basic science studies (12%) were the least-performed types of research. About 51% of the respondents indicated that they had never published in journals nor did so "occasionally"; only 9% quarterly and 43% published less than once a year. They also indicated that their research very rarely resulted in change of clinical practice or health policy (20%). Conclusions : Research works conducted by respondents were largely simple low-budget ones that rarely had significant impacts and outcomes, including publication. There is a need to retrain and emphasize the importance of research during undergraduate and postgraduate medical education. Adequate resources and research infrastructure should be provided for ophthalmic research in Nigeria.

Purpose : To examine the demographics and indications in patients undergoing eye removal at St. John Eye Hospital (SJEH) in Jerusalem, the largest single provider of ophthalmic care in the Palestinian Territories. Materials and Methods : In this retrospective study, medical records were reviewed for patients undergoing enucleation or evisceration at SJEH from November 2004 to March 2007. Calculation of percentage, mean and median was performed for the demographics, and indications for enucleation and evisceration. Results : Thirty-three eyes of 32 patients were removed during the period under study. Twelve enucleations and 21 eviscerations were performed. Mean age was 39 years, and 19 patients were male. Indications included severe trauma (8 eyes), painful blind eye with (5 eyes) or without (9 eyes) infection, and ophthalmic neoplasm (3 eyes). Conclusion : The incidence of surgical eye removal at SJEH from 2004 to 2007 was around one patient per month for a population over three million. This rate appears far lower than those reported in previous studies of similar Palestinian populations. Prompt access to medical care for Palestinians is required to mitigate ophthalmic morbidity. Approximately half of the cases were caused by severe trauma or infection, with rubber bullet injuries responsible for 20% of the traumatic cases.

Purpose : To provide objective evidence on the transition of cataract surgical care at Farabi Eye Hospital, Iran. Materials and Methods : Two separate years, 2003 and 2006, were selected for evaluation. One thousand nine hundred fifty-seven surgical records of age-related cataract cases were randomly selected and reviewed. Three hundred fifty-three patients (405 eyes) in 2006 and 125 patients (153 eyes) in 2003 were selected randomly for a follow-up examination. The two phases were compared in terms of surgical routines, patient characteristics and outcomes for statistical differences. P <0.05 was considered statistically significant. Results : The phacoemulsification rate increased from 25% to greater than 90% between 2003 and 2006, rates of corneal incisions and use of foldable intraocular lenses tripled, administration of general anesthesia dropped from 80% to 12%, the outpatient admission rate rose from 5.2% to 71%, 4% vs. 66% of the operations were performed by a senior phacoemulsification surgeon and the number of advanced surgeons changed from 6% to 38% (all P-values < 0.001). In 2006, more patients at the two extremes of age, more patients with poor systemic conditions and myopes underwent surgery (all P-values < 0.05); the cataract surgery volume increased by 49% and post-operative visual acuity improved (P = 0.03) while patient satisfaction was unchanged. Conclusion : We objectively documented the transition in cataract surgery technique to phacoemulsification at the Farabi Eye Hospital in the mid-2000s. This was accompanied by significant expansion of the spectrum of cataract surgery candidates and remarkable attainment of surgical skill.

Purpose : To establish the clinical profile of herpes zoster ophthalmicus (HZO) in adults younger than 40 years and correlate the clinical manifestation with their immune status. Materials and Methods : A retrospective chart review was performed of patients younger than 40 years who presented with HZO. Data were collected on demographics, medical history, clinical presentation, results of serological investigations, and visual outcome. Results : The study cohort comprised 18 subjects with a mean age of 29.7 ΁ 6.2 years. Ophthalmic features included lid edema, ptosis, cicatricial lid deformities, sclerokeratitis, peripheral ulcerative keratitis, neuroparalytic keratitis, keratouveitis with concomitant glaucoma, secondary bacterial keratitis and superficial punctate keratitis with dry eye, optic neuritis, and trochlear nerve palsy. Eight of 18 (44.4%) subjects were found to be positive for Human Immunodeficiency Virus (HIV). Disseminated herpetic lesions were seen present in 5 (63%) of these 8 subjects. Postherpetic neuralgia was noted in 6 (75%) of 8 HIV-positive subjects and in 1 HIV-negative patient. Final visual acuity was 20/40 or better in 90% of the immunocompetent subjects and 20/200 or worse in 100% of the HIV-positive subjects. Conclusions : Immunocompetent young adults do present with features of HZO. However, the disease spectrum in HIV-negative patients is localized, less severe, and more amenable to therapy as compared with young adults with HIV.

Purpose : To evaluate the role of primary transpupillary thermotherapy (TTT) in the treatment of choroidal melanocytic lesions. Materials and Methods : Retrospective chart review of 24 patients (24 eyes) with choroidal melanocytic lesions, including 20 choroidal melanoma and four choroidal nevus treated with primary TTT. Choroidal nevus cases treated with primary TTT either demonstrated risk factors for growth into an early melanoma or had overlying choroidal neovascularization. Results : The mean initial tumor basal diameter was 6.6 (3.0-10.0) mm and the mean initial tumor thickness was 3.0 (1.0-5.0) mm. The mean number of TTT sessions was 2.5 (1-6). The mean decrease in tumor thickness was 1.2 mm (from 3.0 to 1.8 mm) at a mean follow-up of 22.7 (range 3-90) months. On the LogMar scale, visual acuity was stable at 1.0. Complications occurred in 50% of eyes. The most frequent complications were vitreous hemorrhage [5 patients (20.8%)], focal cataract [5 patients (20.8%)], iris atrophy [4 patients (16.6%)] and posterior synechia [4 patients (16.6%)]. There was no significant difference in the complication rate with respect to tumor thickness >3 mm versus tumor thickness ≤3 mm and juxtapapillary versus nonjuxtapapillary location (Fisher's exact test, P>0.05). Kaplan-Meier curves showed that 9% of eyes develop recurrence by 1 year and 27% develop recurrence by 5 years after primary TTT. Two eyes (8.3%) were enucleated because of neovascular glaucoma and one eye (4.1%) was exenterated because of extraocular tumor recurrence. Globe salvage was achieved in 21 patients (87.5%). One patient (4.1%) with extraocular tumor recurrence developed liver metastasis and expired. Conclusions : Although TTT may be useful in the treatment of small choroidal melanocytic lesions, the high complication and recurrence rates warrant close monitoring of patients after primary TTT even when a flat chorioretinal scar has been achieved.

In this report, we present an alternative technique to manage Descemet's membrane detachment (DMD). We call the technique supra-Descemet's fluid drainage with intracameral air injection. Under topical anesthesia, we injected air through the stab incision to fill 2/3 of the anterior chamber. Then we inserted the tip of a curved 10/0 needle through the corneal surface (entry angle at 45 degrees) into the supra-Descemet's area 3 times to drain this fluid. In our method, we neither injected expanding gas or viscoelastic nor used a suture. Consequently, there was little chance for suture-induced astigmatism or increased intraocular pressure. This technique may be considered a relatively safe and simple surgical method for the management of postoperative DMD.

Amniotic band syndrome manifests at birth with a variety of malformations ranging from constriction ring to defects incompatible to life, in various parts of the body. Although some theories have been proposed for the development of this syndrome, the exact cause remains unknown. The median facial cleft is an extremely rare manifestation of amniotic band syndrome with a relative paucity of reports available in the literature. Here, we report one such case.