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1.  Models for Primary Eye Care Services in India 
Blindness and visual impairment continues to be a major public health problem in India. Availability and easy access to primary eye care services is essential for elimination of avoidable blindness. ‘Vision 2020: The Right to Sight - India’ envisaged the need for establishing primary eye care units named vision centers for every 50,000 population in the country by the year 2020. The government of India has given priority to develop vision centers at the level of community health centers and primary health centers under the ‘National Program for Control of Blindness’. NGOs and the private sector have also initiated some models for primary eye care services.
In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
PMCID: PMC4389507  PMID: 25861167
Primary eye care; tele-ophthalmology; vision center
2.  Toll-like receptor 4 polymorphisms and their haplotypes modulate the risk of developing diabetic retinopathy in type 2 diabetes patients 
Molecular Vision  2014;20:704-713.
Persistent inflammation and impaired neovascularization in type 2 diabetes mellitus (T2DM) patients may lead to development of macro- and microvascular complications. Diabetic retinopathy (DR) is one of the secondary microvascular complications of T2DM. Improper activation of the innate immune system may be an important contributor in the pathophysiology of DR. Toll-like receptor 4 (TLR4) is an important mediator of innate immunity, and genetic alterations in TLR4 support inflammation in the hyperglycemic condition. The present work was designed to investigate whether the TLR4 single nucleotide polymorphisms (SNPs) rs4986790, rs4986791, rs10759931, rs1927911, and rs1927914 are associated with DR in a north Indian population.
The study group of 698 individuals (128 DR, 250 T2DM, 320 controls) was genotyped by PCR-RFLP. Haplotype and linkage disequilibrium between SNPs were determined using Haploview software.
Combined risk genotypes of TLR4 SNPs rs10759931 (odds ratio [OR] 1.50, p = 0.05) and rs1927914 (OR 1.48, p = 0.05) were found to be significantly associated with pathogenesis of DR. A total of 14 haplotypes with frequency >1% were obtained using Haploview software. Haplotypes ACATC (37.5%) and ACATT (14.8%) were the two most common haplotypes obtained.
Results of the present case-control study that included 698 north Indian subjects suggested that TLR4 SNPs rs10759931 and rs1927914 modulate the risk of DR in T2DM cases. Association analysis using haplotypes showed none of the haplotypes were associated with either susceptibility or resistance to DR in a north Indian population.
PMCID: PMC4037533  PMID: 24883015
4.  Association of Toll-Like Receptor 4 Polymorphisms with Diabetic Foot Ulcers and Application of Artificial Neural Network in DFU Risk Assessment in Type 2 Diabetes Patients 
BioMed Research International  2013;2013:318686.
The Toll-Like receptor 4 (TLR4) plays an important role in immunity, tissue repair, and regeneration. The objective of the present work was to evaluate the association of TLR4 single nucleotide polymorphisms (SNPs) rs4986790, rs4986791, rs11536858 (merged into rs10759931), rs1927911, and rs1927914 with increased diabetic foot ulcer (DFU) risk in patients with type 2 diabetes mellitus (T2DM). PCR-RFLP was used for genotyping TLR4 SNPs in 125 T2DM patients with DFU and 130 controls. The haplotypes and linkage disequilibrium between the SNPs were determined using Haploview software. Multivariate linear regression (MLR) and artificial neural network (ANN) modeling was done to observe their predictability for the risk of DFU in T2DM patients. Risk genotypes of all SNPs except rs1927914 were significantly associated with DFU. Haplotype ACATC (P value = 9.3E − 5) showed strong association with DFU risk. Two haplotypes ATATC (P value = 0.0119) and ATGTT (P value = 0.0087) were found to be protective against DFU. In conclusion TLR4 SNPs and their haplotypes may increase the risk of impairment of wound healing in T2DM patients. ANN model (83%) is found to be better than the MLR model (76%) and can be used as a tool for the DFU risk assessment in T2DM patients.
PMCID: PMC3725976  PMID: 23936790
5.  Impact of Janani Suraksha Yojana on Institutional Delivery Rate and Maternal Morbidity and Mortality: An Observational Study in India 
The Government of India initiated a cash incentive scheme—Janani Suraksha Yojana (JSY)—to promote institutional deliveries with an aim to reduce maternal mortality ratio (MMR). An observational study was conducted in a tertiary-care hospital of Madhya Pradesh, India, before and after implementation of JSY, with a sample of women presenting for institutional delivery. The objectives of this study were to: (i) determine the total number of institutional deliveries before and after implementation of JSY, (ii) determine the MMR, and (iii) compare factors associated with maternal mortality and morbidity. The data were analyzed for two years before implementation of JSY (2003-2005) and compared with two years following implementation of JSY (2005-2007). Overall, institutional deliveries increased by 42.6% after implementation, including those among rural, illiterate and primary-literate persons of lower socioeconomic strata. The main causes of maternal mortality were eclampsia, pre-eclampsia and severe anaemia both before and after implementation of JSY. Anaemia was the most common morbidity factor observed in this study. Among those who had institutional deliveries, there were significant increases in cases of eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria after implementation of JSY. The scheme appeared to increase institutional delivery by at-risk mothers, which has the potential to reduce maternal morbidity and mortality, improve child survival, and ensure equity in maternal healthcare in India. The lessons from this study and other available sources should be utilized to improve the performance and implementation of JSY scheme in India.
PMCID: PMC3763618  PMID: 23304913
Conditional cash transfer; Institutional deliveries; Maternal mortality; Maternal survival; India
6.  Inverse Association of Vitamin C with Cataract in Older People in India 
Ophthalmology  2011;118(10):1958-1965.e2.
To examine the association between vitamin C and cataract in the Indian setting.
Population-based cross-sectional analytic study.
A total of 5638 people aged ≥60 years.
Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography.
Main Outcome Measures
Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract.
Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51–0.74; P=1.1×10−6). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, β-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57–0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54–0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54–0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45–0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract.
We found a strong association with vitamin C and cataract in a vitamin C–depleted population.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
PMCID: PMC3185206  PMID: 21705085
7.  Association of Blindness and Hearing Impairment with Mortality in a Cohort of Elderly Persons in a Rural Area 
Studies in developed nations have reported an association of blindness and hearing impairment with mortality in elderly persons.
To study the association of blindness and hearing impairment with mortality in a cohort of elderly persons in rural north India.
Materials and Methods:
This community-based prospective study was conducted in eleven randomly selected villages, in Ballabgarh block, Haryana. A cohort of 1422 participants, of age 60 years and above, was examined at baseline, for their visual and hearing status. Data on the sociodemographic factors, various comorbidities, activities of daily living, and self-rated health were recorded. Baseline data was collected for the period May 2008 to August 2008. Follow-up data collection for mortality was completed in December 2009. The median follow-up period was 518 days.
One hundred out of 1422 elderly (7.0%) participants died during the follow-up period. Significant hazard ratios were found after adjustment for various comorbid conditions. On adjustment for sociodemographic factors (age, sex, and literacy), neither blindness nor hearing impairment was found to be significantly associated with mortality. After adjustment for all covariates in the study, hearing impairment (Hazard Ratio = 2.13; 95% CI, 1.29 – 3.54) was found to be significantly associated with mortality in the age group ≥70 years.
This study demonstrated that hearing impairment was an independent risk factor for mortality in people aged ≥70 years. Similar studies with a longer period of follow-up are required in India, to guide public health interventions.
PMCID: PMC3214446  PMID: 22090675
Blindness; cohort; elderly; hearing impairment; mortality
8.  Wide resection and stabilization of ulnar stump by extensor carpi ulnaris for giant cell tumor of distal ulna: two case reports 
Cases Journal  2009;2:8617.
The distal end of ulna is an extremely uncommon site for primary bone tumors in general and giant cell tumor in particular. Wide resection is usually indicated in such cases and at times it may be necessary to remove of a long segment of the distal ulna. Any ulnar resection proximal to the insertion of pronator quadratus can lead to instability in the form of radio-ulnar convergence and dorsal displacement (winging) of the ulnar stump. This can result in diminution of forearm rotation and weakness with grasp. Stabilization of the ulnar stump after resection for a giant cell tumor was described by Kayias & Drosos. We are adding two more cases to the literature. Both patients had excellent functional outcome and there were no instances of recurrence at three years of follow-up.
PMCID: PMC2740324  PMID: 19830093
9.  Current status of cataract blindness and Vision 2020: The right to sight initiative in India 
Indian Journal of Ophthalmology  2008;56(6):489-494.
India is a signatory to the World Health Organization resolution on Vision 2020: The right to sight. Efforts of all stakeholders have resulted in increased number of cataract surgeries performed in India, but the impact of these efforts on the elimination of avoidable blindness is unknown.
Projection of performance of cataract surgery over the next 15 years to determine whether India is likely to eliminate cataract blindness by 2020.
Materials and Methods:
Data from three national level blindness surveys in India over three decades, and projected age-specific population till 2020 from US Census Bureau were used to develop a model to predict the magnitude of cataract blindness and impact of Vision 2020: the right to sight initiatives.
Using age-specific data for those aged 50+ years it was observed that prevalence of blindness at different age cohorts (above 50 years) reduced over three decades with a peak in 1989. Projections show that among those aged 50+ years, the quantum of cataract surgery would double (3.38 million in 2001 to 7.63 million in 2020) and cataract surgical rate would increase from 24025/million 50+ in 2001 to 27817/million 50+ in 2020. Though the prevalence of cataract blindness would decrease, the absolute number of cataract blind would increase from 7.75 million in 2001 to 8.25 million in 2020 due to a substantial increase in the population above 50 years in India over this period.
Considering existing prevalence and projected incidence of cataract blindness over the period 2001-2020, visual outcomes after cataract surgery and sight restoration rate, elimination of cataract blindness may not be achieved by 2020 in India.
PMCID: PMC2612994  PMID: 18974520
Blindness; cataract; the right to sight; vision 2020
10.  Longitudinal study on visual outcome and spectacle use after intracapsular cataract extraction in Northern India 
BMC Ophthalmology  2003;3:9.
More than 3 million cataract extractions are undertaken in India annually. Almost 60% of these operations are intracapsular Cataract Extractions. The subsequent optical correction is provided by aphakic spectacles. The aim of this study is to assess visual outcome and perceived benefits of post-operative use of aphakic spectacles.
One hundred and sixty-seven persons who had undergone intracapsular cataract extraction and had been given best corrected aphakic spectacles were evaluated one year following prescription of the best corrected aphakic spectacles. Out of these, 82.6% were re-examined in this interview-based longitudinal study.
The mean age of the male participants was 65.95 years and that of females was 71.26 years. 81.2% of the participants were using the provided spectacles. There was no significant association between the spectacle use and gender of the participant. The commonest reason stated by the respondents, for the non-use of the spectacles was 'poor vision'. 61.7% of the current users of provided spectacles had a visual acuity of 6/18 or better. 91.1% of the current users were very satisfied with the spectacles. All the current users could now manage personal activities and the spectacles had facilitated independent mobility. There was no difference in the level of satisfaction between mono-aphakics and bi-aphakics. Among the satisfied users, the modal spherical power was +10 D followed by + 11 D. About one-third of these required a cylindrical correction.
Following intracapsular cataract extraction, provision of the best correction after cataract surgery is desirable to obtain an optimal visual outcome.
PMCID: PMC183851  PMID: 12885300
Cataract; Cataract surgery; spectacles; aphakia; India

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