Introduction Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease. Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively. Methods and analysis We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2–6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF). Ethics and dissemination The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication. Trial registration number ISRCTN14332621; pre-results.

Clinically diagnosing fungal keratitis (FK) is challenging; diagnosis can be assisted by investigations including in vivo confocal microscopy (IVCM), smear microscopy, and culture. The aim of this study was to estimate the sensitivity in detecting fungal keratitis (FK) using IVCM, smear microscopy, and culture in a setting with a high prevalence of FK. In this cross-sectional study nested within a prospective cohort study, consecutive microbial keratitis (MK) patients attending a tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. IVCM and corneal scrapes for smear microscopy and culture were performed using a standardised protocol. Smear microscopy was performed using potassium hydroxide (KOH), Gram stain, and calcofluor white. The primary outcomes were sensitivities with 95% confidence intervals [95% CI] for IVCM, smear microscopy and culture, and for each different microscopy stain independently, to detect FK compared to a composite referent. We enrolled 642 patients with MK; 468/642 (72.9%) were filamentous FK, 32/642 (5.0%) were bacterial keratitis and 64/642 (10.0%) were mixed bacterial-filamentous FK, with one yeast infection (0.16%). No organism was identified in 77/642 (12.0%). Smear microscopy had the highest sensitivity (90.7% [87.9–93.1%]), followed by IVCM (89.8% [86.9–92.3%]) and culture (75.7% [71.8–79.3%]). Of the three smear microscopy stains, KOH had the highest sensitivity (85.3% [81.9–88.4%]), followed by Gram stain (83.2% [79.7–86.4%]) and calcofluor white (79.1% [75.4–82.5%]). Smear microscopy and IVCM were the most sensitive tools for identifying FK in our cohort. In low-resource settings we recommend clinicians perform corneal scrapes for microscopy using KOH and Gram staining. Culture remains an important tool to diagnose bacterial infection, identify causative fungi and enable antimicrobial susceptibility testing.

Fungal corneal infection (keratitis) is a common clinical problem in South Asia. However, it is often challenging to distinguish this from other aetiologies, such as bacteria or acanthamoeba. In this prospective study, we investigated clinical and epidemiological features that can predict the microbial aetiology of microbial keratitis in Nepal. We recruited patients presenting with keratitis to a tertiary eye hospital in lowland eastern Nepal between June 2019 and November 2020. A structured assessment, including demographics, history, and clinical signs, was carried out. The aetiology was investigated with in vivo confocal microscopy and corneal scrape for microscopy and culture. A predictor score was developed using odds ratios calculated to predict aetiology from features. A fungal cause was identified in 482/642 (75.1%) of cases, which increased to 532/642 (82.9%) when including mixed infections. Unusually, dematiaceous fungi accounted for half of the culture-positive cases (50.6%). Serrated infiltrate margins, patent nasolacrimal duct, raised corneal slough, and organic trauma were independently associated with fungal keratitis (p < 0.01). These four features were combined in a predictor score. The probability of fungal keratitis was 30.1% if one feature was present, increasing to 96.3% if all four were present. Whilst microbiological diagnosis is the “gold standard” to determine the aetiology of an infection, certain clinical signs can help direct the clinician to find a presumptive infectious cause, allowing appropriate treatment to be started without delay. Additionally, this study identified dematiaceous fungi, specifically Curvularia spp., as the main causative agent for fungal keratitis in this region. This novel finding warrants further research to understand potential implications and any trends over time.

Background: Usage of digital devices has become one's basic need. Digital eye strain is repeatedly noticed sequelae in optometry practice. Objectives: This study aims to estimate the different aspects of eye strain. Methodology: Altogether, 55 students with a mean age of 21.25 years, vision (≥6/9) were enrolled. A survey related to common asthenopic (eyestrain) symptoms was carried before and after reading an extract from a novel. Accommodative facility and non-invasive first tear breakup (NTBUT) time were measured before and after the reading. The viewing distance to a smartphone was measured every 20 minute. Results: The total eye strain symptom score was significantly greater post-experiment (score = 7.07±2.84) than pre-experiment (score = 1.54±1.60, p < 0.001). Symptoms of tired eyes, sore eyes, and sleepy eyes increased significantly after 60 min of a smartphone use (p < 0.05). The mean viewing distance while using a smartphone over 60 min was 30.15 ± 3.29 cm. There was a significant correlation between change in total symptom score and change in viewing distance (r = ˗0.301, p = 0.026). The symptom that correlated with a change in viewing distance was ‘sore eyes’ (r = ˗0.382, p = 0.04) and sleepy eyes (r= ˗0.363, p=0.06). There was a significant decrease in monocular and binocular accommodative facilities and NTBUT after 60 min of reading. Conclusion: Closer viewing distance and eyestrain symptoms are obvious after a smartphone reading. Prolonged use of smartphones appears to have important implications for accommodative function, causing ocular symptoms having an impact on quality of life.

Background: Nepal was under a severe lockdown for several months in 2020 due to the COVID-19 pandemic. There were concerns regarding misinformation circulating on social media. This study aimed to analyse the knowledge and awareness of COVID-19 amongst eye care professionals in Nepal during the first wave of the pandemic. Methodology: We invited 600 participants from 12 ophthalmic centres across Nepal to complete a qualitative, anonymous online survey. Altogether, 25 questions (both open and closed-ended) were used. An overall performance score was calculated from the average of the 12 “Knowledge” questions for all the participants. Results: Of the 600 eye care professionals invited, 310 (51%) participated in the survey. The symptoms of COVID-19 were known to 94%, whilst only 49% of the participants were aware how the disease was transmitted, with 54% aware that anyone can be infected with SARS-CoV-2. Almost 98% of participants recognized the World Health Organization’s (WHO) awareness message, but surprisingly, 41% of participants felt that consumption of hot drinks helps to destroy the virus, in contradiction to WHO information. Importantly, 95% of the participants were aware of personal protective equipment (PPE) and what the acronym stands for. Social distancing was felt to be key to limiting the disease spread; whilst 41% disagreed that PPE should be mandatory for eye care practitioners. The mean overall “Knowledge” performance score was 69.65% (SD ± 22.81). Conclusion: There is still considerable scope to improve the knowledge of COVID-19 amongst ophthalmic professionals in Nepal. Opinion is also split on measures to prevent transmission, with misinformation potentially fuelling confusion. It is recommended to follow WHO and national guidelines, whilst seeking published scientific evidence behind any unofficial statements, to accurately inform one’s clinical practice.

Background: A new coronavirus causes COVID-19, a developing respiratory illness. Unfortunately, there is little information assessing healthcare workers' understanding of technology and preventative strategies during the Nepalese epidemic. Researchers from other subspecialties uncovered some mythical thoughts. As a result, we decided to put it to the test with healthcare personnel on the front lines. The research also looked at the problems experienced by frontline health care personnel (HCP) because of the COVID-19 strategic shift in work policy.Methods: Nepalese healthcare workers participated in web-based cross-sectional research. A pre-tested, structured questionnaire utilizing a Google form was used to get self-informed, digitally typed consent, and examine critical perspectives and problems with current technology and COVID-19 prevention efforts.Results: In total, 243 participants with mean age of 29.66 ± 7.61 years agreed to participate and were doctors (n = 27), health assistants (n = 2), medical intern doctors (n = 1), paramedical (n = 139), pharmacy (n = 1), and paramedical interns (n = 73) in this study. The calculated mean percentage score of knowledge on instruments and tools was 73.64 (SD ± 10.43) %, and perception on COVID-19 transmission and control was 70.06 (SD ± 18.30) %. At various levels, frontline health workers faced significant challenges, including the adoption of digital health technology.Conclusion: Frontline HCPs are anticipated to have updated knowledge from what the study has outlined. It is recommended to follow national guidelines. Policies should be put in place so that every frontline worker can demonstrate high standards in prevention, control, and equipment use that do not create misinformation among HCPs. Throughout, support for digital health materials and disease control methods for HCPs is essential.