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SYNOPSIS FOR PG DISSERTATION FOR MD/MS, UNDER RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU. NAME OF THE Dr. GAURAV CHOWDHURY CANDIDATE DEPARTMENT OF OPHTHALMOLOGY, AND RAJARAJESWARI MEDICAL COLLEGE, ADDRESS BANGALORE – 560074 (IN BLOCK LETTERS) NAME OF THE RAJARAJESWARI MEDICAL COLLEGE AND INSTITUTION HOSPITAL COURSE OF THE STUDY M.S. (OPHTHALMOLOGY) AND SUBJECT 1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA BANGALORE ANNEXURE -1 SYNOPSIS SUBMISSION MS OPHTHALMOLOGY RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL BANGALORE-560074 SYNOPSIS TOPIC “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL” BY: DR GAURAV CHOWDHURY DEPARTMENT OF OPHTHALMOLOGY RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL BANGALORE-560074 GUIDE NAME: DR M SHIVAKUMAR PROFESSOR AND HOD DEPARTMENT OF OPHTHALMOLOGY RAJARAJESWARI COLLEGE AND HOSPITAL BANGALORE-567004 2 3 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE – II SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1. Name of the candidate and Address (In Block Letters) Dr. GAURAV CHOWDHURY DEPARTMENT OF OPHTHALMOLOGY, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE – 560074 2. Name of the Institute RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL 3. Course of Study and M.S. DEGREE IN OPHTHALMOLOGY Subject 4. Date of Admission to Course 5. Title of Topic 17-05-2012 “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL ” 6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION: The cornea, as the most anterior structure of the eye, is exposed to various hazards ranging from airborne debris to blunt trauma of sufficient force to disrupt the globe itself. As a result, corneal injury may assume multiple forms and clinical presentations. Because the cornea is also the major refracting surface of the eye, even minor changes in its contour result in significant visual problems.(1) 4 6.1 NEED FOR THE STUDY Blindness is a major public health problem in most developing countries. Corneal opacification, as a cause of blindness, is second only to cataract in magnitude (2) . One of the most important preventable and avoidable cause of corneal blindness is corneal injuries. By understanding the different types of injuries to which the cornea is exposed, the practitioner may more capably manage these injuries and minimise the structural and visual sequelae of corneal injury. 6.2 REVIEW OF LITERATURE M.P. UPADHYAY, P.C. KARMACHARYA , S.KOIRALA and et al studied a defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions.(3) R.DANDONA and L.DANDONA studied A total of 11 786 people of all ages from 94 clusters representative of the population of the Indian state of Andhra Pradesh were sampled using a stratified, random, cluster, systematic sampling strategy. These participants underwent a detailed interview and eye examination including measurement of visual acuity with logMAR charts, refraction, slit lamp biomicroscopy, applanation tonometry, gonioscopy, and stereoscopic dilated fundus evaluation. Of those sampled, 10 293 (87.3%) people participated in the study. Corneal blindness in at least one eye was present in 86 participants, an age, sex, and urban-rural distribution adjusted prevalence of 0.66% (95% confidence interval 0.49 to 0.86), which included 0.10% prevalence of corneal blindness in both eyes and 0.56% in one eye. The most frequent causes of corneal blindness in at least one eye included keratitis during childhood (36.7%), trauma (28.6%), and keratitis during adulthood (17.7%). Nearly 95% of all corneal blindness was avoidable. Conclusions: There is a significant burden of corneal blindness in this population, the majority of which is avoidable.(4) S.K.KHATRY, A.E.LEWIS, O.D.SCHEIN and et al studied reports of ocular trauma collected from 1995 through 2000 from patients presenting to the only eye care clinic in Sarlahi district, Nepal. Patients were given a standard free eye examination and interviewed about the context of their injury. Follow up examination was performed 2–4 months after the initial injury. 525 cases of incident ocular injury were reported, with a mean age of 28 years. Using census 5 data, the incidence was 0.65 per 1000 males per year, and 0.38 per 1000 females per year. The most common types of injury were lacerating and blunt, with the majority occurring at home or in the fields. Conclusions: The detrimental effects of delayed care or care outside of the specialty eye clinic may reflect geographic or economic barriers to care. For optimal visual outcomes, patients who are injured in a rural setting should recognise the injury and seek early care at a specialty eye care facility.(5) RAJESH SINHA, NAMRATA SINHA and RASIK B. VAJPAYEE studied that in India, there are approximately 6.8 million people who have corneal blindness with vision less than 6/60 in at least one eye, and of these, about 1 million have bilateral corneal blindness.(6) If the present trend continues, it is expected that the number of corneally blind individuals in India will increase to 8.4 million in 2010 and 10.6 million by 2020.(7) Ocular trauma and corneal ulceration are also significant causes of corneal blindness and may be responsible for 1.5 to 2.0 million new cases of uniocular blindness every year.(8) Ocular trauma has been reported to be the most important cause of the unilateral loss of vision in developing countries, and up to 5% of all bilateral blindness has been attributed to direct ocular trauma.15 Corneal and corneoscleral perforation and subsequent scarring due to ocular trauma may result in a variable amount of blindness.(9) GULLAPALLI N.RAO studied that Ocular trauma is responsible for 1% to 10% of corneal blindness. The geographic location, pattern of injury, causative agent, and age are some of the factors that determine the degree of damage (Table 1). TABLE 1. Pathways to Corneal Blindness from Trauma(10) Corneal foreign body Secondary infection Corneal ulcer and opacity Chemical injuries Keratitis Corneal opacification Blunt injury Laceration Corneal opacification Penetrating injury (including intraocular foreign body) Wound & secondary Corneal infection opacification In urban areas and in the industrialized world, chemical injuries, accidents at the workplace, and automobile injuries are common. In rural areas of developing countries, minor trauma due to hazardous practices in agriculture, cottage industries, and other work places, as well as sports accidents, are responsible for a large proportion of corneal blindness.(11) Corneal abrasions (removal of part of the corneal epithelium) are one of the most common ophthalmic injuries. In one English series, corneal abrasions were the cause of 10% of new patient visits to the ophthalmic emergency room.(12) the common causative agents include fingernails, paper, mascara brushes, and plants. 6 Important non contact sources of epithelial injury include chemicals, radiations and heat. Second to corneal abrasions , corneal foreign bodies are the most common forms of ophthalmic trauma. In a recent study in northern Sweden the incidence of eye injuries was estimated to be 8.1 per 1000 population with corneal and conjunctival foreign bodies comprising 40% of these.(13) Traditionally , acid injuries of the eye are , for the most part, thought to be somewhat less destructive than exposure to alkaline compounds. Depending upon the concentration, strength, and duration of contact acids cause a wide spectrum of injury from mild keratoconjunctivitis to devastating bilateral blindness.(14) The entire anterior segment of the eye is seriously jeopardized by exposure to alkali. Non perforating ocular injuries of this type results in destruction of cellular components, denaturation and degradation of collagenous tissues and release of inflammatory mediators by alkaline hydrolysis of a broad range of intracellular and extracellular proteins as well as invading cells.(15) 6.3 OBJECTIVES OF THE STUDY To study the various patterns of corneal injuries and its outcome among patients of ocular trauma attending our tertiary care hospital. 7. MATERIAL AND METHODS 7.1 SOURCE OF DATA All patients who fulfill the inclusion/exclusion criteria will be selected from both the inpatient and outpatient department of ophthalmology of Rajarajeswari Medical College and Hospital. 7.2 METHODS OF COLLECTION OF DATA – (Including sampling procedure if any) The data for this study will be collected from the subjects fulfilling the inclusion/exclusion criteria admitted in RRMCH. Sample size- all patients with corneal injury attending the ophthalmology OPD of RRMCH from 1.11.2012 to 31.10.2013 will be taken for the study. Study duration-data will be collected for 1 year and their follow up will be done for a minimum period of 4 months. Study design-prospective study. Methodology: 7 All patients of ocular trauma above 14 years of either sex will be subjected to slit lamp examination to ensure corneal involvement. Once the cornea is involved the aetiology of the injury would be noted. Then the pattern of the corneal injury would be studied under the slit lamp examination. Informed consent will be obtained after informing the study subjects the details of the procedure. After initial examination the cornea would be stained with 2% fluoroscein strip paper and examined under the slit lamp with blue light to note the type of corneal injury in the form of abrasions of epithelium, stroma and others. After establishing a diagnosis the patient would be subjected to keratometry, A scan, B scan ultrasound or anterior segment Optical Coherence Tomography if required. After noting all the details the patient would be given treatment as needed for the specific type of corneal injury. The patient will then be followed up on day 1, day 3, after 15 days, after 2 months and after 4 months. They would be examined under the slit lamp and staining would be done if required. The improvement or the opacification if developed will be noted. Inclusion criteria. Patients of ocular trauma aged above 14 years of either sex with corneoscleral involvement. Exclusion criteria Patients aged below 14 years. Ocular trauma where cornea is uninvolved Statistical Analysis: The data collected will be analyzed statistically using descriptive statistics like frequency and percentage. The results will be depicted in the form of percentages and graphs. Test of significance will be done with ‘chi-square’ test. 7.3 Does the study require any investigation or intervention to be conducted 8 on patients or other humans or animals? If so please describe briefly? Yes. Routine eye examination with slit lamp biomicroscopy 2% fluoroscien staining of cornea FBS PPBS HIV HBsAg Urine routine Keratometry A-scan B-scan ultrasound Anterior segment Optical Coherence Tomography 7.4 Has ethical clearances been obtained from your institution in case of 7.3 Yes. Ethical clearance has been obtained from Institutional Ethical Committee of Rajarajeswari Medical College, Bangalore 8. LIST OF REFERENCES 1) KRACHMER, MANNIS AND HOLLAND: BOOK OF CORNEA; SECOND EDITION 2005:VOLUME 1;SECTION 8-CORNEAL TRAUMA; CHAPTER 100: MECHANICAL INJURY: pg 1245. 2) THYLEFORS B, NEGREL AD, PARARAJASEGARAM R, DADZIE KY: GLOBAL DATA ON BLINDNESS 1995 BULL WHO 72:115. 3) M P UPADHYAY, P C KARMACHARYA, S KOIRALA, D N SHAH, S SHAKYA, J K SHRESTHA, H BAJRACHARYA, C K GURUNG, J P WHITCHER: THE BHAKTAPUR EYE STUDY: OCULAR TRAUMA AND ANTIBIOTIC PROPHYLAXIS FOR THE PREVENTION OF CORNEAL ULCERATION IN NEPAL, BRITISH JOURNAL OF OPHTHALMOLOGY 2001; 85:388-392. 4) R DANDONA, L DANDONA: CORNEAL BLINDNESS IN A SOUTHERN INDIAN POPULATION: NEED FOR HEALTH PROMOTION STRATEGIES, BRITISH JOURNAL OF OPHTHALMOLOGY 2003; 87:133-141. 5) S K KHATRY, A E LEWIS, O D SCHEIN, M D THAPA, E K PRADHAN, J KATZ: THE EPIDEMIOLOGY OF OCULAR TRAUMA IN RURAL NEPAL, BRITISH JOURNAL OF OPHTHALMOLOGY 2004; 88: 456-460. 9 RAJESH SINHA, NAMRATA SINHA, RASIK B. VAJPAYEE: CORNEAL BLINDNESS PRESENT STATUS, TACKLING WORLD BLINDNESS OCTOBER 2005: 6) GLOBAL INITIATIVE FOR THE ELIMINATION OF AVOIDABLE BLINDNESS. GENEVA, WORLD HEALTH ORGANIZATION, 1997 (UNPUBLISHED DOCUMENT WHO/PBL/97.61/REV 1). 7) LIM AS. MASS BLINDNESS HAS SHIFTED FROM INFECTION (ONCHOCERCIASIS, TRACHOMA, CORNEAL ULCERS) TO CATARACT. OPHTHALMOLOGICA. 1997; 211 : 270. 8) GUPTA V, DADA T, PANGTEY M, VAJPAYEE RB. INDICATIONS FOR LAMELLAR KERATOPLASTY IN INDIA. CORNEA. 2001;20:4:398-399. 9) RAJESH SINHA, NAMRATA SINHA, RASIK B. VAJPAYEE: CORNEAL BLINDNESS PRESENT STATUS, TACKLING WORLD BLINDNESS OCTOBER 2005 pg 61. 10) ADAPTED FROM WORLD HEALTH ORGANIZATION: REPORT OF THE INTERNATIONAL MEETING ON CONTROL OF CORNEAL BLINDNESS WITHIN PRIMARY HEALTH CARE SYSTEMS. GENEVA, WHO, 1988, pp 1-22. 11) GULLAPALLI N. RAO : CORNEAL OPACIFICATION IN THE DEVELOPING WORLD CHAPTER 61. 12) CHIAPELLA AP, ROSENTHAL AR: ONE YEAR IN EYE CASUALTY, BRITISH JOURNAL OF OPHTHALMOLOGY 1985; 69:865-870. 13) KRACHMER, MANNIS AND HOLLAND: BOOK OF CORNEA; SECOND EDITION 2005:VOLUME 1;SECTION 8-CORNEAL TRAUMA; CHAPTER 100: MECHANICAL INJURY: pg 1256 14) KRACHMER, MANNIS AND HOLLAND: BOOK OF CORNEA; SECOND EDITION 2005: VOLUME 1; SECTION 8-CORNEAL TRAUMA; CHAPTER 102: ACID INJURIES OF THE EYE: pg 1277. 15) KRACHMER, MANNIS AND HOLLAND: BOOK OF CORNEA; SECOND EDITION 2005: VOLUME 1;SECTION 8-CORNEAL TRAUMA; CHAPTER 103 : ALKALI INJURIES OF THE EYE : pg 1285. 10 9. SIGNATURE OF THE CANDIDATE 10. REMARKS OF Corneal injuries are very common in both the adult and THE GUIDE pediatric population and account for a significant proportion of the workload of most emergency departments. The blink reflex normally protects the cornea from most injuries. Eye injuries can range from relatively trivial to extremely serious, resulting in permanent loss of vision. Corneal injuries can cause significant morbidity with respect to vision, but accurate diagnosis appropriate intervention at the right time can improve the prognosis. Proper management are vital to prevent potentially sight-threatening sequelae. 11. NAME & DESIGNATION (IN BLOCK LETTERS) 11.1 GUIDE Dr. M.SHIVAKUMAR M.S, D.O.M.S, PROFESSOR AND HOD, DEPARTMENT OF OPHTHALMOLOGY, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE. 11.2 SIGNATURE 11.3 CO-GUIDE (IF ANY) 11.4 SIGNATURE - 11 11.5 HEAD OF THE Dr. M.SHIVAKUMAR, DEPARTMENT M.S, D.O.M.S, PROFESSOR AND HOD, DEPARTMENT OF OPHTHALMOLOGY, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE. 11.6 SIGNATURE 12. 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL 12.2 SIGNATURE 12 PROFORMA 1. 2. 3. 4. 5. 6. 7. NAME OF THE PATIENT:AGE:SEX:ADDRESS:CONTACT NUMBER:OP NUMBER:IP NUMBER:- Parameters:1. H/O INJURY SUSTAINED 2. TYPE OF INJURY SUSTAINED 3. SLIT LAMP EXAMINATION FINDINGS 4. 2% FLUROSCIN STAINING FINDINGS 5. OTHER INVESTIGATION FINDINGS IF DONE LIKE KERATOMETRY A-SCAN B-SCAN USG ANTERIOR SEGMENT OCT 6. TYPE OF TREATMENT GIVEN IN DETAILS FOLLOW UP OF PATIENTS FOLLOW UP PERIOD FINDINGS IMPROVEMENT FURTHER TREATMENT IF REQUIRED DAY 1 DAY 3 DAY 15 AFTER 2 MONTHS AFTER 4 MONTHS 13 Consent form STUDY: “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL”. I have been explained in a language best known to me about my participation in the following study “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL”. I have also been explained the procedure “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL” and the related risks and possible complications that may be involved. I have read the information above and have understood wholly and give my voluntary consent for the same. Interviewers name and signature signature Date: Patients name and Date: 14 BANGALORE 16-10-2012 FROM THE PROFESSOR, DEPARTMENT OF OPHTHALMOLOGY RAJARAJESWARI MEDICAL COLLEGE, BANGALORE, KARNATAKA TO THE PRINCIPAL, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE, KARNATAKA Through proper channel Sir, As per the regulations of the RGUHS for the Dissertation topic, the following post graduate student in M.S DEGREE IN OPHTHALMOLOGY has been allotted the Dissertation topic as follows by the official registration committee of all qualified and eligible guides of the Department of Ophthalmology. NAME TOPIC GUIDE Dr. GAURAV “ A STUDY OF CORNEAL Dr. M.SHIVAKUMAR, CHOWDHURY, INJURIES IN A TERTIARY M.S, D.O.M.S, P.G. IN DEPARTMENT CARE HOSPITAL ” PROFESSOR AND HOD, OF DEPARTMENT OF OPHTHALMOLOGY, OPHTHALMOLOGY RAJARAJESWARI RAJARAJESWARI MEDICAL MEDICAL COLLEGE, COLLEGE, BANGALORE BANGALORE – 560074 Therefore I request you to kindly communicate the acceptance of the dissertation topic allotted to the P.G student at an early date. Thanking you Yours faithfully (Dr. M.SHIVAKUMAR) 15 BANGALORE 16-10-2012 FROM THE PROFESSOR, DEPARTMENT OF OPHTHALMOLOGY RAJARAJESWARI MEDICAL COLLEGE, BANGALORE TO THE REGISTRAR, RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. Sir, Through proper channel As per the regulations of the RGUHS for the Dissertation topic, the following post graduate student in M.S DEGREE IN OPHTHALMOLOGY has been allotted the Dissertation topic as follows by the official registration committee of all qualified and eligible guides of the Department of Ophthalmology NAME TOPIC GUIDE Dr. GAURAV “ A STUDY OF Dr. M.SHIVAKUMAR, CHOWDHURY, CORNEAL INJURIES M.S, D.O.M.S, P.G. IN DEPARTMENT IN A TERTIARY PROFESSOR AND HOD, OF OPHTHALMOLOGY CARE HOSPITAL” DEPARTMENT OF RAJARAJESWARI OPHTHALMOLOGY MEDICAL COLLEGE, RAJARAJESWARI BANGALORE MEDICAL COLLEGE, BANGALORE Therefore I request you to kindly communicate the acceptance of the dissertation topic allotted to the P.G student at an early date. Thanking you Yours faithfully (Dr. M.SHIVAKUMAR) 16 BANGALORE 16-10-2012 FROM Dr. GAURAV CHOWDHURY, P.G. IN DEPARTMENT OF OPHTHALMOLOGY RAJARAJESWARI MEDICAL COLLEGE, BANGALORE TO THE PRINCIPAL, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE THROUGH PROPER CHANNEL Respected sir, Sub: ACCEPTANCE, REGISTRATION AND FORWARDING OF DISSERTATION TOPIC In accordance with the above cited topic, I the undersigned studying in P.G course in M.S degree in Ophthalmology have been allotted the Dissertation topic “A STUDY OF CORNEAL INJURIES IN A TERTIARY CARE HOSPITAL” under the guidance of Dr. M.SHIVAKUMAR, M.S, D.O.M.S, Professor and HOD, Department Of Ophthalmology, Rajarajeswari Medical College, Bangalore. I request you to kindly forward the dissertation topic in the prescribed form to the University for Approval. Thanking you, Yours faithfully (Dr. GAURAV CHOWDHURY) GUIDE: Dr. M.SHIVAKUMAR, M.S, D.O.M.S, PROFESSOR AND HOD, DEPARTMENT OF OPHTHALMOLOGY, RAJARAJESWARI MEDICAL COLLEGE, BANGALORE. 17