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Natalia Christina Angsana,1 Firman Setya Wardhana,1 Supanji,1 Mohammad Eko Prayogo,2 Muhammad Bayu Sasongko1 1Department of Ophthalmology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia; 2Department of Ophthalmology, Universitas Gadjah Mada Academic Hospital, Yogyakarta, IndonesiaCorrespondence: Muhammad Bayu Sasongko, Department of Ophthalmology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Yogyakarta, Indonesia, Tel/Fax +62 274 552850, Email mb.sasongko@ugm.ac.idPurpose: To present a modified technique of 4-point scleral fixation using polymethyl methacrylate (PMMA) 2 eyelets intraocular lens (IOL) with 8-0 polypropylene sutures.Methods: A 270-degree conjunctival peritomy is done, and 4 sclerotomies (2 nasal and 2 temporal) are created. Lamellar scleral or clear corneal incision is made at superior site (6 mm wide for sclera or 5.5– 6 mm for corneal). A short segment of 8-0 polypropylene is inserted into each eyelet, each thread of the suture is externalized through the sclerotomy site, and the lens is inserted. The suture is tightened evenly, and the knot is rotated and internalized. Scleral incision and conjunctival peritomy are sutured with 8-0 vicryl.Results: We have performed this technique in 6 patients with excellent visual outcomes and no reported complications over 1 year of follow-up. This technique has practical advantages including rigid and stable PMMA IOL, high tensile, and slim 8-0 polypropylene suture which is easily internalized and less irritated, and affordable and widely available overall consumables.Conclusion: We present a modified 4-point scleral fixation technique for posterior chamber IOL placement using PMMA IOL with 2 eyelets and 8-0 polypropylene as compared to previous studies that used foldable IOL with 4 eyelets and 10-0 polypropylene or Gore-Tex sutures. This procedure has moderate technical complexity, comparable to previously reported techniques with good overall clinical outcomes and several practical advantages, particularly related to the affordability and availability of the consumables.Plain Language Summary: This paper presents a modification of currently existing 4-point sutured scleral fixation technique for posterior chamber intraocular lens implantation using PMMA IOL with 2 eyelets using 8-0 polypropylene. This technique has some practical advantages compared to previously reported techniques with potential applicability in low-resource setting.Keywords: sutured scleral fixation, four-point, polymethyl methacrylate, 2-eyelets, secondary intraocular lens implantation

Dhimas Hari Sakti,1,2 Aufar Tirta Firdaus,1 Tiara Putri Utami,1 Krisna Dwi Purnomo Jati,1,2 Indra Tri Mahayana,1,2 Firman Setya Wardhana,1,2 Novika Handayani3 1Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; 2Department of Ophthalmology, Dr. Sardjito General Hospital, Yogyakarta, Indonesia; 3Center for Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, IndonesiaCorrespondence: Dhimas Hari Sakti, Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, 55281, Indonesia, Tel +62 274 560300, Email Dhimas.hari.s@ugm.ac.idPurpose: To evaluate patients’ satisfaction with ophthalmology health services in a teaching clinic of a tertiary public hospital.Patients and Methods: This was a cross-sectional study in ophthalmology clinic of Dr. Sardjito teaching hospital, Yogyakarta, Indonesia conducted in 2019. Patients were surveyed using the Patient Satisfaction Questionnaire-18 (PSQ-18). PSQ-18 subscale score was analyzed based on patients’ characteristics. The main outcome was the odds of reaching top satisfaction score (TSS) of 4– 5 from a Likert scale 1 to 5.Results: Our study recorded 269 participants who consisted of 138 males (51.3%) and 131 females (48.7%) with median age of 52 (18– 87) years old. Variables with higher odds of reaching TSS on “patient overall satisfaction” was public health insurance (OR: 7.959 [95% CI: 1.989– 31.852], p=0.003) while examination time (OR: 0.955 [95% CI: 0.923– 0.988], p=0.008) had lower odds. Examination waiting time (OR: 0.992 [95% CI: 0.985– 0.999], p=0.027) and examination time (OR: 0.941 [95% CI: 0.908– 0.976], p=0.001) had lower odds of reaching TSS in “general satisfaction”. Family monthly income (OR: 1.829 [95% CI: 1.038– 3.223], p=0.037) had higher odds of reaching TSS in “technical quality” while examination time (OR: 0.961 [95% CI: 0.931– 0.993], p=0.017) and education (OR: 0.549 [95% CI: 0.322– 0.934], p=0.027) had lower odds. Comorbidities (OR: 0.533 [95% CI: 0.301– 0.944], p=0.031) had lower odds of reaching TSS in “financial aspects”. Retina subspecialty clinic (OR: 3.436 [95% CI: 1.154– 10.232], p=0.027) had higher odds of reaching TSS in “time spent with doctor”. Registrar as attending physician (OR: 0.427 [95% CI: 0.205– 0.89], p=0.0230) and examination time (OR: 0.957 [95% CI: 0.924– 0.991], p=0.013) had lower odds of reaching TSS in “accessibility-convenience”.Conclusion: Examination time and examination waiting time should be shortened, specialist doctors should always see the patients whenever possible, and registrars’ technical and communication skill should be improved. Alternative funding for patients without health insurance also should be provided to increase satisfaction.Keywords: Patient Satisfaction Questionnaire-18, PSQ-18, health service quality, examination time, health survey

Supanji Supanji,1– 4 Dewi Fathin Romdhoniyyah,1,2 Muhammad Bayu Sasongko,1,2,4 Angela Nurini Agni,1,2,4 Firman Setya Wardhana,1,2,4 Tri Wahyu Widayanti,1,2,4 Muhammad Eko Prayogo,1,2,4 Ayudha Bahana Ilham Perdamaian,1,2 Aninditta Dianratri,1,2 Masashi Kawaichi,5 Chio Oka5 1Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; 2Department of Ophthalmology, Dr. Sardjito General Hospital, Yogyakarta, Indonesia; 3Ophthalmology Clinic, Military Air Force Central Hospital Dr. Suhardi Hardjolukito, Yogyakarta, Indonesia; 4Ophthalmology Clinic, Dr YAP Eye Hospital, Yogyakarta, Indonesia; 5Laboratory of Gene Function in Animals, Nara Institute of Science and Technology, Ikoma, Nara, JapanCorrespondence: Supanji SupanjiDepartment of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Farmako Sekip Utara, Yogyakarta, 55281, IndonesiaTel +62 274 560300Fax +62 274 581 876Email supanji@ugm.ac.idPurpose: This study aimed to determine the association of ARMS2 A69S, ARMS2 del443ins54, and CFH Y402H polymorphisms with neovascular age-related macular degeneration (nAMD) for the first time in an Indonesian population.Patients and Methods: Our case–control study involved 104 nAMD and 100 control subjects. AMD diagnosis was evaluated by retinal specialists based on color fundus photography and optical coherence tomography. The polymorphisms on CFH Y402H and ARMS2 A69S were analyzed by PCR-restriction fragment length polymorphism (PCR-RFLP), whereas ARMS2 del443ins54 was evaluated by PCR-based assay.Results: Significant allelic associations with nAMD were detected on all polymorphisms (P< 0.05), with stronger association with the ARMS2 A69S (OR 3.13; 95% CI 2.08– 4.71; P< 0.001) and ARMS2 del443ins54 (OR 3.28; 95% CI 2.17– 4.95; P< 0.001) polymorphisms than with CFH Y402H (OR 2.08; 95% CI 1.08– 3.99; P=0.028). Genotype analysis showed a statistical difference between nAMD and the control group for all polymorphisms (P< 0.05). However, the association with nAMD was weaker for CFH Y402H (P=0.043) than for ARMS2 A69S and ARMS2 del443ins54 (P< 0.001). A significant interaction between ARMS2 A69S and hypertension was documented (OR 9.53; 95% CI 3.61– 25.1; P< 0.001).Conclusion: Our findings indicate that ARMS2 A69S and ARMS2 del443ins54 polymorphisms are strongly associated with the risk of nAMD for the first time in an Indonesian population. The risk of nAMD increased when the presence of risk alleles from ARMS2 A69S was combined with the presence of hypertension.Keywords: age-related macular degeneration, ARMS2, CFH, polymorphism

Background: Neovascular age-related macular degeneration (nAMD) is one of the main causes of blindness in developed countries. Complement factor H (CFH) is one of the genes involved in the pathogenesis of nAMD. This study investigated the rs10737680 polymorphism in CFH and its conferred susceptibility to nAMD in Yogyakarta, Indonesia., Methods: This case-control hospital-based study recruited participants consisting of 96 patients with nAMD and 101 controls without nAMD from the Eye Polyclinic of Sardjito Hospital, YAP Eye Hospital, and Hardjolukito Hospital Yogyakarta. nAMD was diagnosed when fundus examination, fundus photographs, and optical coherence tomography revealed hard or soft drusen in the macular area measuring > 63 µm that appeared below the retinal pigment epithelium, with or without macular hypo- or hyperpigmentation, and was accompanied by choroidal neovascularization. Genomic DNA was extracted using a commercial DNA isolation kit. The restriction fragment length polymorphism technique was used to identify the rs10737680 polymorphism in CFH ., Results: The mean (standard deviation [SD]) age of the nAMD group was not homogeneous with that of the control group ( P < 0.05); 65.41 (9.74) years versus 68.24 (7.82) years. The number of patients with hypertension in the nAMD group was significantly higher than in the control group ( P < 0.05). In the nAMD group, the genotype distribution indicated homozygous risk allele in 34.38%, heterozygous risk allele in 57.29%, and homozygous non-risk allele in 8.33%. In the control group, the genotype distribution indicated homozygous risk allele in 21.78%, heterozygous risk allele in 36.63%, and homozygous non-risk allele in 41.58%. Statistical analysis between the two study groups according to homozygous risk allele genotype (odds ratio [OR], 7.87; 95% confidence interval [CI], 2.88-22.79) and heterozygous genotype (OR, 7.80; 95% CI, 3.11-21.19) showed a significant difference (both P < 0.01)., Conclusions: Homozygous risk allele was less frequent than heterogeneous risk allele in patients with nAMD; however, both increased the risk for nAMD. Although the homozygous or heterozygous risk-alleles were detected in most patients, yet other important genetic or environmental factors could be involved in the pathogenesis of nAMD. Overall, we found a significant association between rs10737680 polymorphism in CFH and the susceptibility to nAMD in Yogyakarta, Indonesia; however, future studies are needed to fully delineate the mechanism., Competing Interests: None, (© Author(s).)

Introduction: Neovascular age-related macular degeneration (nAMD) is a major factor contributing to blindness and impaired visual acuity in elderly people. The pathophysiology of nAMD involves excessive inflammation events in the macula. Thus, it is crucial to study the dynamics of an important pro-inflammatory cytokine, interferon-gamma (IFN-γ)., Materials and Methods: This research is aimed to investigate plasma IFN-γ profiles of patients with nAMD. In this crosssectional study, blood plasma samples of 16 patients with AMD and 23 age-matched controls were collected. Samples were examined for two inflammatory cytokines (IFN-γ) using a commercially available enzyme-linked immunosorbent assay.Acquired data were log transformed to normalize any outliers before conducting student'st-test using the SPSS software., Results: IFN-γ levels were higher in the control group, without statistically significant difference between the two groups., Conclusion: IFN-γ levels were not significantly different between patients with AMD and controls.

Objectives: To report the prevalence of total diabetes in pregnancy (TDP) and diabetes-related microvascular complications among Indonesian pregnant women., Methods: We conducted a community-based cross-sectional study with multi-stage, cluster random sampling to select the participating community health centers (CHC) in Jogjakarta, Indonesia between July 2018-November 2019. All pregnant women in any trimester of pregnancy within the designated CHC catchment area were recruited. Capillary fasting blood glucose (FBG) and blood glucose (BG) at 1-hour (1-h), and 2-hour (2-h) post oral glucose tolerance test (OGTT) were measured. TDP was defined as the presence of pre-existing diabetes or diabetes in pregnancy (FBG ≥7.0 mmol/L, or 2-h OGTT ≥11.1 mmol/L, or random BG ≥11.1 mmol/L with diabetes symptoms). Disc and macula-centered retinal photographs were captured to assess diabetic retinopathy (DR). Blood pressure, HbA1c and serum creatinine levels were also measured., Results: A total of 631/664 (95%) eligible pregnant women were included. The median age was 29 (IQR 26-34) years. The prevalence of TDP was 1.1% (95%CI 0.5, 2.3). It was more common in women with chronic hypertension (p = 0.028) and a family history of diabetes (p = 0.015). Among the TDP group, 71% had a high HbA1c, but no DR nor nephropathy were observed., Conclusions: Although a very low prevalence of TDP and no diabetes-related microvascular complications were documented in this population, there is still a need for a screening program for diabetes in pregnancy. Once diabetes has been identified, appropriate management can then be provided to prevent adverse outcomes., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The aim of this study was to investigate the association of the HtrA1 rs11200638 polymorphism with neovascular age-related macular degeneration (nAMD) in Indonesia., Methods: This case-control study included 80 patients with nAMD and 85 controls. Demographic parameters and whole blood were collected from each participant. Genomic DNA was extracted and used to assess the rs11200638 genotype by PCR and restriction enzyme digestion. Associations between the HtrA1 rs11200638 polymorphism and other risk factors for susceptibility to nAMD were assessed using the logistic regression model., Results: Significant allelic associations between the HtrA1 polymorphism and nAMD were detected (odds ratio [OR] 8.67; 95% confidence interval [CI] 4.88-15.41; P < 0.001). Genotype analysis showed a statistical difference between the nAMD group and the control group (P < 0.001). In the multiple adjusted logistic regression model, people with the AA genotype were more likely to have nAMD although there was a wide confidence interval (OR 19.65; 95% CI 4.52-85.38; P < 0.001)., Conclusion: Our findings show that the risk of nAMD increased in the presence of risk alleles of HtrA1 rs11200638., (© 2021. The Author(s).)

Among 100 Indonesian adults with type 2 diabetes having vision-threatening diabetic retinopathy, less than 25% of individuals had appropriate treatment within 12 months from their initial screening due to lack of information about the treatment cost (88%), no permission from family member (77.3%) and having no eye complaint (77%)., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: To estimate the total healthcare cost associated with diabetic retinopathy (DR) in type 2 diabetes in Indonesia and its projection for 2025., Methods: A prevalence-based cost-of-illness model was constructed from previous population-based DR study. Projection for 2025 was derived from estimated diabetes population in 2025. Direct treatment costs of DR were estimated from the perspective of healthcare. Patient perspective costs were obtained from thorough interview including only transportation cost and lost of working days related to treatment. We developed four cost-of-illness models according to DR severity level, DR without necessary treatment, needing laser treatment, laser +intravitreal (IVT) injection and laser + IVT +vitrectomy. All costs were estimated in 2017 US$., Results: The healthcare costs of DR in Indonesia were estimated to be $2.4 billion in 2017 and $8.9 billion in 2025. The total cost in 2017 consisted of the cost for no DR and mild-moderate non-proliferative DR (NPDR) requiring eye screening ($25.9 million), severe NPDR or proliferative DR (PDR) requiring laser treatment ($0.25 billion), severe NPDR or PDR requiring both laser and IVT injection ($1.75 billion) and advance level of PDR requiring vitrectomy ($0.44 billion)., Conclusions: The estimated healthcare cost of DR in Indonesia in 2017 was considerably high, nearly 2% of the 2017 national state budget, and projected to increase significantly to more than threefold in 2025. The highest cost may incur for DR requiring both laser and IVT injection. Therefore, public health intervention to delay or prevent severe DR may substantially reduce the healthcare cost of DR in Indonesia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate the associations of estimated resting metabolic rate (RMR), body fat (BF), subcutaneous fat (SCF), visceral fat (VF), fat-free mass (FFM) percentage, BMI, and waist circumference (WC) with diabetic retinopathy (DR) in Indonesian adults with type 2 diabetes., Research Design and Methods: This was a community-based cross-sectional study of 1,184 subjects with type 2 diabetes. DR was assessed from fundus photography and categorized as mild, moderate nonproliferative DR (NPDR), and vision-threatening DR (VTDR). RMR and body composition parameters were measured using automated body composition scan. Logistic regression with semipartial correlation analysis was used., Results: DR and VTDR were present in 43.1 and 26.3% of participants, respectively. After adjustment for age, sex, diabetes duration, fasting glucose, systolic blood pressure, smoking, diabetic ulcer, and use of combined diabetes treatment, per SD increase in RMR (odds ratio [OR] 2.60 [95% CI 2.19-3.07]; P < 0.001) was associated with DR, while per SD increases in BF (0.66 [95% CI 0.56-0.78]; P < 0.001), FFM (0.69 [0.57-0.84]; P < 0.001), VF (0.77 [0.67-0.88]; P < 0.001), BMI (0.83 [0.73-0.94]; P = 0.004), and WC (0.81 [0.73-0.91]; P < 0.001) were inversely associated with presence of DR. Similar associations were found for VTDR. Among all variables, RMR had the largest contribution to the variance in the DR model (39%)., Conclusions: In this study, RMR and body composition measures were strongly associated with and contributed considerably to the presence and severity of DR. These findings, if confirmed, suggest that RMR and body composition may be strong markers that represent actual metabolic state in the pathophysiology of DR., (© 2018 by the American Diabetes Association.)

Purpose: To investigate the association of physical activity (PA) and sedentary behaviour with diabetic retinopathy (DR) in type 2 diabetes adults., Methods: A community-based cross-sectional study of adults with type 2 diabetes. DR was assessed from disc- and macula-centred fundus photograph, and categorised into mild, moderate non-proliferative DR (NPDR), and Vision-Threatening DR (VTDR). Worse eye was used to determine the person's DR severity. PA was assessed using WHO Global Physical Activity Questionnaire (GPAQ). All of the PA components, including daily sitting time, walking distance, sleeping duration, and exercise were converted based on the physical activity ratio and then calculated to obtain the mean physical activity level (PAL). The mean PAL was then classified into sedentary, moderate, and vigorous lifestyle., Results: There were 1116 participants, 43.1% with any DR and 26.3% VTDR. The prevalence of DR/VTDR in sedentary, moderate, and vigorous physical activity group was 41.9%/22.7%, 39.2%/23.9%, and 32.7%/20.4% respectively. A longer duration of daily sedentary lifestyle (>3 hours) was significantly associated with presence of DR (OR 1.66; 95% CI 1.17-2.35; p < 0.01) and VTDR (OR 1.74; 1.16-2.62; p < 0.01). These associations remained significant after adjusting for age, gender, duration of diabetes, systolic blood pressure and physical activity. There was no significant association between sleeping duration, walking distance, and vigorous activity and DR., Conclusions: In this study, prolonged daily sedentary activity was strongly associated with VTDR. This finding suggests that public health campaign for reducing daily sedentary activities in individuals with type 2 diabetes may offer benefit to reduce the burden of DR and VTDR.

Purpose: To report the prevalence of diabetic retinopathy (DR) and DR-related blindness in an Indonesian population with type 2 diabetes., Methods: Design: Population-based cross-sectional study., Setting: Community health centers., Study Population: We recruited 1184 people aged older than 30 years with type 2 diabetes residing in Jogjakarta, Indonesia. Multistage, clustered random sampling based on regencies and districts in Jogjakarta was used., Observation Procedure: Detailed interviews, general and eye examinations, and anthropometric measurement were performed. Disc- and macula-centered retinal photographs were taken to assess DR. The definition of DR followed a modified Airlie House classification system and was categorized into mild, moderate, and vision-threatening DR (VTDR)., Main Outcome Measure(s): Prevalence and severity of DR., Results: The median (range) age and diabetes duration of participants was 59 (52-65) and 4 (2-9) years. The prevalence of DR was 43.1% (95% confidence interval 39.6%-46.6%), with mild, moderate, and severe NPDR and PDR to be 9.41%, 7.46%, 11.1%, and 12.1%, respectively. The prevalence of VTDR was 26.3% (23.1%-29.5%). Longer diabetes duration, higher fasting glucose, presence of hypertension, and foot ulcers were associated with DR and VTDR. The prevalence of bilateral blindness was 4% and 7.7% in persons with DR and VTDR., Conclusions: This study reports a high prevalence of any DR and VTDR among Indonesian adults with type 2 diabetes in urban and rural areas: approximately 1 in 4 adults with diabetes had VTDR and 1 in 12 of those with VTDR was bilaterally blind, suggesting the need for appropriate screening and management of DR among the Indonesian population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: There are no available data about diabetic retinopathy (DR) in the Indonesian population. This report summarizes the rationale and study design of the Jogjakarta Eye Diabetic Study in the Community (JOGED.COM), a community-based study to estimate the prevalence and risk factors of DR in persons with type 2 diabetes in Jogjakarta, Indonesia., Methods: The JOGED.COM aimed to examine a cross-sectional sample of 1200 persons with type 2 diabetes aged 30 years and older residing in the study area. We identified 121 community health centers (CHCs) in Jogjakarta and listed 35 CHCs with non-communicable diseases facilities. Multi-stage, clustered random sampling was used to select 22 CHCs randomly. We included CHCs with coverage population >30,000, and excluded those classified as 100% rural. Lists of persons with diabetes confirmed by their family physician were provided from each CHC. Examinations procedures included detailed interviews, general and eye examinations, anthropometry and body composition scan, and dilated fundus photography., Results: We collaborated with local health authorities, family physicians, and local health practitioners in the recruitment phase. A total of 1435 invitations were distributed, and 1184 people (82.5%) with type 2 diabetes participated in this study, of whom 1138 (79.3%) had completed data with gradable retinal images., Conclusions: JOGED.COM is the first epidemiologic study of DR in an Indonesian population. This study will provide key information about the prevalence and risk factors of DR in the community. These data are very important for future health promotion programs to reduce the burden of DR in the population.