Spectrum of Ocular Diseases at a Military Hospital in Ladakh, North India
Correspondence Address :
Kirti Nath Jha Professor, Department of Ophthalmology Manipal Teaching Hospital/ Manipal College of Medical Sciences Pokhara, Nepal
The objective of this study was to study the spectrum of patients with ocular diseases, attending a referral military hospital in a remote hilly region of north India. 793 consecutive patients were treated in the Ophthalmology Department over a four year period (Jan 2001 to Dec 2003) at a referral military hospital in Laddakh, Jammu and Kashmir. Males outnumbered females (M: F ratio 3:1), with 56.7 % patients being below 40 years age The spectrum of diseases in the descending order was: refractive errors 33.8%, cataract 21.4%, inflammatory conjunctival diseases 16.8%, pterygium 8.4 %, corneal diseases 5.5%, injuries 3.9 %, diseases of ocular adnexa 3.4%, glaucoma 2.4%, uveitis 2.1%, and miscellaneous 2.3%. Among the cases of blindness, cataract accounted for 85% of cases, refractive errors for 5.5 %, injuries for 5.5 %, corneal opacity for 1.9% , glaucoma for 0.5%, and others for 1.6 %.
conjunctival diseases, Ladakh, cataract, refractory errors
Due to its extreme cold climate and its remoteness, Laddakh remains one of the east known parts of the country. Therefore, this geographically large region with a small population (1, 63,000; Census 1991) has remained outside the realm of epidemiological research and statistics, because of which health problems of this region are practically non-existent in literature. This hospital-based study of ocular morbidity was carried out at a referral military hospital that delivers medicare to the locals under the armyâ€™s goodwill programme, â€˜Operation Sadbhavanaâ€™. This hospital attracts patients from all the regions-central Laddakh, Nubra valley, Suru valley, Zanskar and Changthang of Laddakh, where the whole of the population is permanently located at high altitudes (i.e. above 9000 feet above mean sea level). In Laddakh, human habitations exist at altitudes of up to 14,500 feet under temperature conditions that dip down in some areas to as low as - 60Âº C in winters. The relative humidity in this region varies between a low of 31-64 %.
To assess the prevalence of eye diseases in the Laddakhi population, a descriptive study was carried out on the patients attending the Eye Department of our hospital for OPD / indoor treatment over a three year period (January 2001 to Jan 2004). The patients included soldiers of Laddakhi origin, their dependents, and the civilians of Laddakhi origin only.
A total of 793 patients were treated during this period. Any individual who reported for the second time for the same illness was eliminated for the purpose of assessing the disease prevalence.
Amongst 793 patients, 595 were males and 198 were females. The M: F ratio was 3: 1. The age distribution of the patients is given in (Table/Fig 1)450 (56.7 %) individuals were below 40 years of age, and 343 (43.3%) were aged 40 years and above. As regards ethnicity, 94.7 % were Laddakhi natives, and 5.3 % were Tibetan refugees settled in Laddakh . The prevalence of eye diseases is given in (Table/Fig 2). Among the cases of blindness, cataract accounted for 85%, refractive errors for 5.5 %, corneal opacity for 1.9%, glaucoma for 0.5%, injuries for 5.5 %, and others for 1.6 %.
High altitude areas are natural stress areas due to low barometric pressure, and consequently, low oxygen concentration (1). In addition, lowered temperature and low humidity causing dryness of skin, nose and mouth, increased intensity of sunshine causing injury to eyes and skin, and cosmic electric conditions, pose additional problems to health. Although ground reflection of UVB from grass is negligible, it is markedly increased from snow, sand, and concrete (2). Therefore, UV light exposure in high altitude areas like Laddakh, where vegetations are scarce, terrain is rocky, and large areas remain snow bound for large parts of the year, increases markedly. Since surface reflectivity is an important factor in determining UVB ocular dose (3), exposure to deleterious UVB in Laddakh is high. This increases the risk of cataract formation due to chronic exposure of eyes to UVB that damages the lens protein and DNA (2), and snow blindness in unprotected eyes.
In the studied population, 56.7% patients were below 40 years of age, and 43.3 % were above 40 years of age. The M: F ratio was 3:1, because a majority of our patients constituted serving and ex- soldiers.
Refractive errors accounted for a majority of OPD attendance (33.8 %). Amongst the cases of refractive errors, 64.5 % were myopic with or without astigmatism, if aphakia was excluded.
Cataract constituted for 21.4 %. This is in spite of the fact that 56.7 % of the patients were below 40 years of age. This high prevalence of cataract is supported by another study involving a Tibetan population that reported an overall 60% higher incidence of cataract in Tibet (altitude 4000m) than in Beijing (altitude 50 m) (4). Amongst the cases of cataract, about 60 % were mature and hyper mature types. Such high cumulative levels of UVB exposure, significantly increases the risk of cortical cataract (5). Age-wise, 75% of the cases of cataract were above 40 years of age.
Traumatic cataract accounted for 14.4% of total cataracts. This high prevalence of traumatic cataract is an interesting fact in Laddakh. Among the cases of traumatic cataracts, a majority of patients were below 20 years of age, and belonged to the regions where a thorny shrub seabuckthorn (Leh-berry), grows in abundance in the wild. In the below 20 years age group, 10(71.42 %) out 14 cataracts were traumatic in nature.
Inflammatory conjunctival diseases accounted for 16.8 % of cases, of which about half (8.2 %) were the cases of allergic conjunctivitis only. This problem is seen more commonly and in florid forms in higher altitudes like Changthang (northern plains) region and in Zanskar regions. Pterygium accounted for 8.4% of cases. This figure is lower than the prevalence rate in some of the south Asian countries like Indonesia, where age adjusted prevalence rate of any pterygium was 10.0% (6). Among the cases of pterygium, 63% cases were bilateral, which is much higher than the 4.1 % rate reported in the above quoted study (6).
About 5% of total cases reported with non-specific complaints like irritation, redness and sensation of a foreign body in their eyes in the absence of any other identifiable eye disease. These cases could be due to high UV exposure and aridity of the region, and therefore needs to be studied separately for correlation with relative humidity; altitude and possible tear film abnormalities.
The prevalence of glaucoma was seen in 2.4 % of cases. A majority of the cases of glaucoma reported in the advanced / absolute stage because of lack of awareness and access to eye care facilities in far-flung areas. Therefore, there is a need for screening of the susceptible population for early detection of glaucoma. However, none of the cases of glaucoma from our study population had
In conclusion, refractive errors (33.8%) and cataract (21.4%) account for more than half of the OPD attendance. Among the various forms of cataract, prevalence of traumatic cataract is high (14.4%), with a majority (71.4 %) of them belonging to the below 20 years age-group. In addition, a good proportion, about 16.8% of cases suffer from conjunctival inflammatory diseases. About half of them (8.2 %) suffer due to various forms of allergic conjunctivitis. Allergic conjunctivitis is particularly common in the higher altitude regions of Changthang and Zanskar. Prevalence of pterygium is high (8.4 %) in Laddakh where almost two third of cases (63%) suffer from bilateral affliction.
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