Background: Knowing the pattern and presentation of the diseases is critical for management strategies. To inform eye-care policy we quantified the pattern of vitreo-retinal (VR) diseases presenting at the national referral hospital in Bhutan. Methods: We reviewed all new patients over three years from the retinal clinic of the Jigme Dorji Wangchuck National Referral Hospital. Demographic data, presenting complaints and duration, treatment history, associated systemic diseases, diagnostic procedures performed, and final diagnoses were quantified. Comparisons of the expected and observed frequency of gender used Chi-squared tests. We applied a sampling with replacement based bootstrap analysis (10,000 cycles) to estimate the population means and the standard errors of the means and standard error of the 10th, 25th, 50th, 75th and 90th percentiles of the ages of the males and females within 20-year cohorts. We then applied t-tests employing the estimated means and standard errors. The 2913 subjects insured that the bootstrap estimates were statistically conservative. Results: The 2913 new cases were aged 47.2 ± 21.8 years. 1544 (53.0%) were males. Housewives (953, 32.7%) and farmers (648, 22.2%) were the commonest occupations. Poor vision (41.9%), screening for diabetic and hypertensive retinopathy (13.1%), referral (9.7%), sudden vision loss (9.3%), and trauma (8.0%) were the commonest presenting symptoms. Coexistent diabetes and hypertension were the most common associated systemic diseases. Haematological tests (blood sugar, HbA1c and lipid profile, 31.8%), OCT (27.4%), refraction (9.9%), B-scan (8.7%), fundus photography (8.0%) were the most commonly performed diagnostic tests. Hypertensive retinopathy (18.9%) was the commonest VR disease, followed by refractive errors referred for retinal evaluation (16.7%), diabetic retinopathy with macular oedema (15.8%), and AMD (11.0%). Retinal detachment was more prevalent in females (83 vs. 41, p = 0.007). Rare vision-threatening diseases like seasonal hyper-acute pan-uveitis also presented. Conclusions: The developing VR service in Bhutan is challenged by the spectrum of diseases, limited human resources (e.g. one retinal surgeon during the study), and accessibility to tertiary eye-care services, all amidst difficult terrain. Sustained effort and robust coordination among the eye-care professionals, government and non-governmental organisations are critical for optimising VR services, especially as rates of diseases such as diabetes and hypertension grow.

To determine whether visual fields measured by standard automated perimetry (SAP) can be distorted by higher-spatial-frequency image components and, in particular, whether test-retest variability of SAP fields can be explained by the combination of small scale fixational drift, small stimulus size, and coarse spatial sampling of the visual fields. Standard SAP test patterns have points 6° apart. The amplitude spectra of the perimeter's 10-2 fields (model 511 Humphrey Field Analyser [HFA]; Carl Zeiss Meditec, Inc., North Ryde, NSW, Australia) were assessed to see whether their finer grained sampling revealed spatial frequencies that could cause distortions of standard fields because of undersampling. Model visual fields were then constructed whose spectra were similar to the 10-2 fields, and test-retest variability was examined for Goldmann sizes III to VI stimuli and Gaussian fixational drift with standard deviations of 0.075° to 0.3°. The 10-2 fields showed significant spatial frequency content up to 0.25 cyc/deg, three times the highest frequency that a 30-2 or 24-2 sample grid can resolve. As reported for SAP, test-retest variability increased with scotoma depth, and increasing the stimulus size from III to VI caused a reduction in test-retest variability, as did reduced fixation jitter. With fixation drift half the size of that exhibited by good fixators, many of the features of SAP test-retest variability were reproduced. Reducing test-retest variability may therefore involve using large test stimuli that are blurry in appearance and that overlap somewhat when placed on the perimetric test grid. Overlap across the meridians should perhaps be avoided.