The Sight Vol. 8

THE SIGHT Volume 8, Issue 8 November, 2012
Original Article
Onset of Presbyopia: Effect of ambient temperature, socio-economic status, profession and education level
Jit B Ale Magar, BOptom, PhD
Moreton Eye Group, Brisbane, Australia
Abstract
Background: Presbyopia is an age-related impairment in amplitude of accommodation where the near point of the eye recede away ensuing difficulty in near vision. Apart from the age, geographical variation, education, socio-economic status and profession have been occasionally associated with the age of presbyopia onset. Objective: To investigate whether the ambient temperature, socioeconomic status and education influence the age of presbyopia onset. Methods: This is a population based ecological study. The subjects of age range between 30 and 49 years were selected from two sites differing in ambient temperature (Site 1: Syangja, Nepal and Site 2: Andhra Pradesh, India). Subjects were stratified based on age, occupation, socioeconomic status, and education level. Amplitude of accommodation was measured. Statistical analyses include paired t-test, chi-square test, multivariate analysis of variance and perasons correlation where appropriate. Result: Mean age of onset of presbyopia among Site 1 and Site 2 populations were 42.30.46 and 38.70.58 years (p=<0.001) respectively. Mean of the amplitude of accommodation for age matched groups in two sites differed significantly (p<0.001). No association was found between the age of onset of presbyopia and education level, profession, and socioeconomic status in both study populations. Occupation was moderately correlated with onset of functional presbyopia
in both sample groups. Conclusion: Age is the major predictor of the accommodative amplitude. While ambient temperature has a considerable influence in dictating the age of onset, socioeconomic status, occupation, and education level are of little or no importance. Though the nature of near task influences functional presbyopia, this has nothing to do with the amplitude of accommodation and calculated presbyopia. Key words: ambient temperature, functional presbyopia, calculated presbyopia, amplitude of accommodation.
Introduction
Accommodation is a physiological process that facilitates provision of clear vision for a range of viewing distances1. It is accomplished through a complex coordination of the neuromuscular action in the visual system. According to the Helmholtz theory2,3, during accommodation the ciliary muscle contracts releasing tension on zonules. The lens surfaces, mostly the anterior, become more curved thereby increasing the dioptric power of the crystalline lens. While focusing at distance, often called dis-accommodation, the ciliary muscle relaxes leading to increase in the diameter of the ciliary aperture. This imposes tension on the zonules causing the lens surface to become flatter. A young eye is capable of changing focus for a wide range of viewing distances with ease. With age, the crystalline lens becomes more resistant to shape change. As a result the amplitude of accommodation (AA) gradually reduces until it is completely abolished in the
THE SIGHT
1
Vol 8, Issue 8, Nov 2012
mid-sixties.1,4 Presbyopia is an age-related decline in near vision due to insufficient accommodation. Every human being living his or her 4th decade of life encounters this universal problem. The global presbyopic population is estimated to be more than 1.4 billion.5 Clinically, presbyopia may be categorized into two: first, the functional presbyopia, which is subjective and onset is dependent on the customary working distance of an individual. Second, the calculated presbyopia which is the clinician estimated condition. This type solely depends on the AA a person can exert. Variable results have been reported on the age of onset of functional and calculated presbyopia. A study in Hyderabad, India found that the presbyopia starts as early as 30 to 35 years in Indian population.6 Likewise, Dutta et al found that the mean age of onset of presbyopia in Indian population is 35.86 years.7 Rambo and colleagues found the mean age for onset of presbyopia to be 37.5 years in another study done in India.8 Based on the data presented by Duane and Donder, the mean age of onset of presbyopia is 44 years in European population4,9. This variation indicates the geographical and environmental influence for the onset of presbyopia. This characteristic was first noticed by Weale10 who subsequently proposed that ambient temperature is the second major risk factor. Though nutrition, environment, altitude, general health, socioeconomic status, race, income have also been occasionally quoted as contributing factors for the reduced AA and early onset of presbyopia6,7, Hunter and Shipp found no significant association.11 This paper investigates the onset of presbyopia among the population of two different geographical areas. Potential effect of other ambient temperature, education level, socio-economic status and profession is also studied.
formula;
8(1.96 + 0.84)2 x (SD)2
n= 1.96 constant for 95% confidence interval Power of the study of 80% (1- ) SD - the standard deviation found in pilot study d - is the precision (acceptable difference)
(d)
8(1.96 + 0.84)2 x (1.46)2

n=
(1)2
= 133.72 or 134 subjects Considering the age as the strongest confounding factor, subjects were categorized in four age groups in five years interval. Group 1 Age between 30 to 34 years Group 2 Age between 35 to 39 years Group 3 Age between 40 to 44 years and Group 4 Age between 45 to 49 years Furthermore, subjects were categorized according to the socioeconomic status, income, education level and their profession. Likewise, results were matched for nature of the near tasks such as reading and writing, knitting, fine mechanics, scale reading, sewing and non-specific. Subjects having any previous intraocular surgeries (e.g. lens extraction), cataract, Aphakia/pseudophakia, active ocular pathology, known systemic diseases, best corrected distance visual acuity <6/9 (<20/30) and under medication for ocular or systemic diseases were excluded from the analysis.
The Study Sites

Two study sites were selected: one from Nepal (Site 1: Putali Bazar, Pokhara) and another from Andhra Pradesh India (Site 2: Nalgonda, Bibinagar). Brief description of each site is summarized in Table 1. Maximum temperature recorded in individual day for Site 1 was 37.4C in May and in Site 2, it was 47 in June (year 2004). Minimum temperatures were 1C (Dec) and 8C (Dec) in Site 1 and 2, respectively, year (2003). Mean of the monthly maximum temperature was above 30 for 75% of the times in Site 2, whereas it was within 20C to 30C throughout the year in Site 1. Average minimum temperature was below 10C during winter in Site 1 and it was
Methods THE Sample size was calculated using the following SIGHT
2 Sample Size
13.3C in Site 2. Table 1: General geographical features of two study sites Feature Location Nearest City Elevation Latitude Longitude Number of seasons Monsoon Temperature Average Max (SD) Average Min (SD) Site 1: Putali Bazar, Nepal Syangja District, Gandaki Zone Pokhara (30 km) 2000 meters from the sea level 28.1 N 81.4 E Four June to September 25.25C (3.77) 14.08C (4.8) Site 2: Bibinagar, India Nalagunda district, Andhra Pradesh Hyderabad (30 km) 530 meters from the sea level 17.70 N 78.29 E Four June to September 33.25C (4.11) 19.75C (2.18)
Clinical Procedure
Comprehensive ocular examinations were carried out to ensure the normal ocular health by ophthalmologist or qualified optometrist. Slit-lamp biomicroscopy and direct or monocular indirect ophthalmoscopy without mydriasis were performed.
Figure 1: Monthly average minimum and maximum temperature of two sites during the year 2003/2004 based on information published in established daily national newspapers. Temperatures are for nearest cities from the study sites: Pokhara and Hyderabad for Site 1 and Site 2 respectively. Unaided, pinhole and best-corrected distance visual acuities were measured using self illuminated Snellen distance acuity chart placed at six meters in a sufficiently illuminated room. Near vision with and without correction was obtained using N-notation near chart at variable customary distance depending on patients habitual working distance. Dry retinoscopy was performed using a streak retinoscope in minimally illuminated room to determine patients refractive status followed by monocular subjective refraction. Cycloplegic refraction was deferred because of logistic constrains. General health status was determined by thorough past and present medical history. Although, push up method is commonly used to estimate AA (it overestimates the AA significantly
THE SIGHT
3
due to proximal magnification (about 400%) coming into play12-14), in this study, the minus lens method was employed for its reliability and reproducibility.15 The subject was seated comfortably in a well-illuminated room. Fresh distance correction was inserted in a trial frame in front of the eye under test; the fellow eye being occluded. Near target (N8 sized optotype E) was presented. Minus lens was introduced in the trial frame and gradually increased in 0.25D step until the target became just blurred. The absolute value of minus lens required to sustain the first blur was noted and added to 3.33 (dioptric value of 30cm working distance). The resultant value was recorded as monocular AA. Same procedure was repeated in the fellow eye. Binocular AA was determined by introducing minus lenses simultaneously in front of both eyes. For presbyopic subject who could not distinguish N8 target with distance correction on, a plus lense in 0.25D steps increment was added over the distance correction.14 The minimum plus lens required to resolve the N8 target was noted. This was subtracted from 3.33. The resultant power was recorded as AA. Statistical analysis Statistical software SPSS (version 17) was used. Paired students t-test was used to compare the means. Multivariate ANOVA was used to compare the means of three or more groups. Yates corrected Chi-square (2) was calculated to test association of non-parametric variables such as gender, socio-economic status and educational level. Pearson correlation (r2) was calculated to test the strength of relation between two variables wherever applicable. The level of significance was set at 0.05.
Figure 2: Age group distribution of Study Subjects
Figure 3: Socio-Economic Status of Subjects Frequency of illiterates in Site 1 and Site 2 were 11% and 38% respectively. Socioeconomic status of low, lower middle and upper middle classes were 22.2%, 59.7% and 18.1%, respectively in Site 1and 47.3%, 43.2% and 9.5% respectively in Site 2. Occupation, socioeconomic status and level of education are illustrated in Figures 3, 4 and 5. Summary of the distribution of refractive status are given in Table 2.
Results
Demography Total 146 subjects were enrolled in the study: 72 (49.32%) from Site 1 and 74 (50.68%) from Site 2. Overall, 46.58% subjects were male and 53.42% were female. Summary of age group and gender of the subjects are shown in Figure 2.
THE SIGHT
4
Figure 4: Education level of the study subjects
insignificant (p = 1.22). No statistical difference occurred in binocular AA with occupation (p = 0.959 & 0.40 for Site 1 and 2 respectively) and neither did with socioeconomic status (p =0.0955 & 0.303 respectively). A weak positive correlation was observed between AA and occupation and socio-economic status (r2 = 0.021 and 0.161 for Site 1 & 2 respectively). Figure 5: Distribution of Occupation. (O-1: Housemaker, O-2: Student/Trainee, O-3: Retired, O-4: Unskilled worker/small farmer, O-5: Skilled worker/clerk/small business, O-6: Teacher/med. Business/Officer, O-7: Manager/Executive) Amplitude of Accommodation (AA) As expected, monocular and binocular AA decreased with age. Statistically significant negative correlations (r2 = 0.96 and 0.91 for Site 1 and Site 2 respectively) were observed between age and bilateral or unilateral AA (Figure 7). Maximum hypeorpia was +2.0D in site 2 and +1.50D in Site 1. Similarly maximum myopic spherical equivalent was 4.50D, one in each Site. Distribution of the refractive status curve follows the normal distribution curve (Figure 6). Figure 7: Mean of Bilateral Amplitude of Accommodation with Age
There was no significant difference in means of binocular AA with the type of ametropia for any age group (p = > 0.123) except for emmetropic groups for age 45 to 49 years (Table 2). No significant correlation was found between strength of ametropia and AA (r2 = <0.27 for any site and type of ametropia).
Table 2: Means of Binocular Amplitude of accommodation with age Age Group (Year) 30 - 34 35 - 39 40 - 44 Site 1 Mean SD 7.53 1.01 6.03 0.87 4.52 0.89 3.75 0.47 Site 2 Mean SD 5.41 0.94 3.87 0.88 3.06 0.66 2.71 0.46 t-statistics pvalue
6.43 (df = 33) 0.0000 6.34 (df = 29) 0.0000 6.39 (df = 36) 0.0000 6.59 (df = 33) 0.0000
Figure 6: Distribution of Refractive Status Mean AA in the age group 30 to 34 years in Site 1 (7.53 1.01D) was significantly higher (p = 0.000) compared to that for the Site 2 (5.41 0.94D). Similarly, statistically significant differences (p < 0.001 for all groups) occurred between the sites for other age groups (Tables 2 and 3). Male subjects had clinically greater AA in both sites but it was statistically
45 - 49
Presbyopia Calculated presbyopia was determined assuming the mean working distance of 34 cm (Site 1: 34.1 3.31cm; Site 2: 34.0 3.6cm; p = 0.17). Assuming one third AA in reserve is required for a comfortable near work, minimum 4.41D binocular AA is set as the limit of calculated presbyopia. In this study, the calculated presbyopia started as early as 34
THE SIGHT
5
years in 25% of the population and 100% above the age of 41 years in Site 2. In site 1, it started as early as 40 years. Fifty percent of the subjects suffered calculated presbyopia at the age 40 years and 100% above the age of 45 years Site 1. Mean ages of onset of calculated presbyopia were 42.09 + 1.65 years and 37.76 + 2.24 years in Sites 1 and 2 respectively. The difference is statistically significant (p= 0.000). There was no significant correlation between calculated presbyopia and socio-economic status (r2 = 0.161) and the occupation (r2 = 0.124) in both sites. Table 3: Age group, binocular amplitude of accommodation and refractive status. Age Group Emmetropia 30 - 34 years 35 - 39 years 40 - 44 years 45 - 49 years Hyperopia 30 - 34 years 35 - 39 years 40 - 44 years 45 - 49 years Myopia 30 - 34 years 35 - 39 years 40 - 44 years 45 - 49 years Site 1 Mean SD 7.64 1.16 6.32 0.84 4.30 0.84 3.64 0.58 7.16 0.65 5.88 0.78 4.39 0.84 3.58 0.59 7.58 0.12 5.08 0.71 5.33 0.87 3.87 0.30 Site 2 Mean SD 5.83 1.06 4.14 1.00 3.08 0.75 3.08 0.50 4.81 0.67 3.87 0.71 3.08 0.53 2.56 0.41 5.33 0.89 3.39 0.66 3.19 0.32 3.08 0.24 t-statistics 3.11 (df = 14) 4.89 (df = 15) 3.43 (df = 18) 1.53 (df = 7) 5.89 (df = 9) 4.47 (df = 9) 2.84 (df = 11) 3.94 (df = 13) 3.40 (df = 7) 3.25 (df = 5) 5.62 (df = 8) 3.93 (df = 7) p-value 0.008 0.001 0.003 0.169 0.001 0.001 0.016 0.002 0.011 0.023 0.001 0.006
Mean age for the functional presbyopia in Site 1 was 42.311.33 years and in Site 2, it was 38.742.09 years. The difference is statistically significant (p = 0.000). No significant correlation was found between age of onset of functional presbyopia and socio-economic status in Site 1 (p > 0.192) and the result was almost identical for Site 2 (p > 0.936; (Tables 4 and 5). Presbyopia started as early as 40 years in Site 1 and 35 years in Site 2. 100% of the subjects in Site 1 suffered near problem at the age of 44 years and above; this was 41 years and above in Site 2. Table 4: Onset of Functional Presbyopia and Socio-economic Status Socioeconomic Status Site 1 Low Low middle Upper Middle Low Site 2 Low middle Upper Middle MeanSD 43.2 1.33 42.1 1.32 42.4 1.14 38.35 2.29 39.25 1.77 38.75 2.06 t-value 1.335 df 29 p > 0.192 r2 0.241
0.0804
51
> 0.936
0.011
THE SIGHT
6
If the Site 2 is considered as an exposed group (exposed to high ambient temperature) and Site 1 as an unexposed group (low ambient temperature), the risk of developing calculated presbyopia in Site 2 is approximately 4 (RR = 3.78) times greater than among the Site 2 subjects (Yates corrected 2 = 13.39, p < 0.001). The risk of functional presbyopia was 2.6 times higher
among the site 2 subjects (Yates corrected 2 = 7.01, p = 0.008). However, onset of functional presbyopia and nature of a near task had moderate positive correlation and were statistically significant in the both the sites; Site 1: r2 = 0.66, p = 0.001 and Site 2: r2 = 0.51, p = 0.008. Similarly working distance had moderate positive correlation to the age of onset but did not differ significantly in both study sites. Table 5: Age of onset of functional presbyopia with type of near task
Site 1 Mean SD 40.7 0.21 42.5 0.14 43.5 0.19 <0.0014 Site 2 Mean SD 37.1 0.46 39.3 0.34 39.6 0.45 0.0026 p-value <0.0001 <0.0001 <0.0001
(35.8 years).7 In contrast, the age of onset of functional presbyopia among the subjects in Site 1 was 42.31 years, which is in between the age found in European population16 (44 years) and Indian population6-8. Onset of the functional presbyopia was moderately correlated to the nature (r2=0.52 to p=0.66) and distance (r2=0.22 to 0.33, p=0.0617) of near task. The reason is obvious: finer the near work, the more the demand of accommodation; and the closer the working distance, the more the demand of accommodation. At the age of 40 years, only 33.3% subjects from site 1 (lower ambient temperature) had presbyopia; whereas, 92.3% subjects from Site 2 (higher ambient temperature), had near difficulty. Similarly, 17 out of 36 (47%) had borderline or significant calculated presbyopia at the age of 39 years among Site 2 subjects but none of the subjects from Site 1 had symptoms of presbyopia at this age. This study did not find significant association between onset of presbyopia and socioeconomic status (r2 = < 0.24, p = > 0.192), education level (r2 = < 0.154, p = > 0.523), gender (r2 = 0.128, p = > 0.87) and occupation (r2 = < 0.081, p = > 0.400). Similar result was reported by Hunter, and Shipp.8 No associations between refractive status and the onset of calculated (r2 = < 0.132) or functional presbyopia (r2 = 0.33) were established. Conventionally, the onset of functional presbyopia is believed to start in earlier age among a hyperopic person compared to emmetropic and myopic individuals. But, this is theoretically incorrect for calculated presbyopia since there is no evidence suggesting that the hyperopia is a cause for reduced AA. However, for an uncorrected hyperopic eye, certain portion (equal to the hypermetropia) of exerted AA is used in compensating the refractive error. Obviously, a hyperopic eye has to accommodate more than an emmetropic or a myopic eye for the same near working distance. Hence, an uncorrected hyperopic person will become symptomatic to near work where a myopic or an emmetropic person of the same age may perform without
Near Task
n 14 31 22
Knitting/Sewing 15 Reading/Writing 35 Non-specific 16 p value between groups
Discussion
The current study investigated association of factors such as geography and temperature, socioeconomic status and education level to the onset of presbyopia. A high negative correlation between age and AA is confirmed. The AA among the population living in higher annual ambient temperature were significantly lesser compared to those living in lower ambient temperature and so did the age of presbyopia onset. For 30 to 34 years of age, binocular mean amplitude of accommodation was 7.53D among the subjects of lower ambient temperature (Site1), which is similar to the value found by Duane (7.3D).16 Among the subjects of higher ambient temperature, (Site 2) it was 5.41, which concords with the other reports for Indian population.6,8 This study found comparatively earlier onset of functional presbyopia among the Site 2 subjects where mean age of presbyopia onset was 38.7 years, which is close to the result found by Rambo et al8 (37.5 years); however, it is higher than reported by Dutta et al
THE SIGHT
7
difficulty. The biological reason for premature retardation of AA in higher temperature is still ill-understood. A study suggested that heat absorbed by the aqueous and the iris is transferred to the underlying crystalline lens, which causes denaturation of the lens protein.17 For many years, ultraviolet (UV) and infrared (IR) radiation has been suspected as a major factor in the degradation in the functional integrity of the crystalline lens.18 Laboratory studies demonstrated that exposure to UV portion of the spectrum leads to the changes that closely resemble aging process. UV ray is important contributor in the deleterious lenticular changes leading to the premature presbyopia. Stevens and Bergmanson17 reported laboratory scientifically credible evidences supporting this notion. Similarly infra-red portion of the spectrum has thermal effect which denatures cell protein causing a loss of function. Lens proteins, especially the alpha B (B) crystallins, were found to be heat sensitive resulting in its structural deformation. In an experiment, Liang et al found that alpha crystallins of the lens undergo heat-induced aggregation on high temperature by its greater susceptibility of conformational change, becoming more unfolded.19 Magnitude of the UV ray increases as the equator approaches. This explains the earlier retardation in AA among the subjects of Site 2 which is closer to the equator compared to Site 1 (Latitude = 17.1N vs. 28.1N). To conclude, apart from the age, ambient temperature also has considerable influence on amplitude of accommodation hence affects the age of onset and progression of the presbyopia. Exposure to higher ambient temperature causes a reduced AA resulting in the earlier onset of presbyopia. However, age of the onset of presbyopia is not affected by socioeconomic status, occupation, and education level. Nature of near task and the customary working distance almay determine the onset of functional presbyopia but these factors have no effect on amplitude of accommodation and calculated presbyopia.
References
1 Donders FC. On the Anomalies of Accommodation and refraction of the eye. The New Sydenham Society, London, 1864. Helmholtz H. Treatise on Physiological Optics, English Language ed. New York: Dover, 1851. Helmholtz H. Helmholtz's Treatise on Physiological Optics, Electronic Edition, 2001 ed. Menasha, WI: George Benta Publishing Co., 1924. Donders F. Accommodation and refraction of eye. The New Society 1964: 204-215. Holden BA, Fricke TR, Ho SM, Wong R, Schlenther G, Cronje S, Burnett A, Papas E, Naidoo KS, Frick KD. Global vision impairment due to uncorrected presbyopia. Arch Ophthalmol 2008; 126: 1731-1739. Marella M. Amplitude of accommodation in Indian population. In. BSOptometry Project: BITS (Pilani), 2003. Dutta D, Mahapatra R, Rao K. A study on the onset of presbyopia and its relationship with nutrition and socio-economic status. Orissa State Journal 2000: 1921. Rambo V, Sangal S. A study of the accommodation of the people in India. Am J Ophthalmol 1960; 49: 9931004. Duane A. Studies on monocular and binocular accommdaotion with their clinical implication. Am J Ophthalmol 1922; 1922: 865-877.
2 3
4 5
10 Weale R. Human ocular aging and ambient temperature. Br J Ophthalmol 1981; 65: 869-870. 11 Hunter Jr H, Shipp M. A study of racial difference in age at onset and progression of presbyopia. J Am Optom Assoc 1997; 68: 171-177. 12 Chen A, O'Leary J. Validity and repeatibility of the modified push-up method for measuring amplitude of accommodation. Clin Exp optom 1998; 81: 63-71. 13 Lothringer L. Methods for measurement of amplitude of accommodation. In: http://www.emedicine.com/ oph/topic724.htm ed, 2004. 14 Ostrin L, Glasser A. Accommodation measurement in a pre-presbyopic and presbyopic population. J Cataract Refract Surg 2004; 30: 1435-1444.
THE SIGHT
8
15 Rosenfield M, Cohen S. Repetability of clinical measurement of the amplitude of accommodation. Ophthalmic Physiol Optic 1996; 16: 247-249. 16 Duane A. Normal values of the accommodation at all ages. J Am Med Ass 1912; 59: 4. 17 Stevens M, Bergmanson J. Does sunlight cause premature aging of the crystalline lens? J Am Optom
Ass 1989; 60: 660-663. 18 Goldman H. Radiation and eye. Arch Ophthalmol 1930; 125: 648-653. 19 Liang J, Sun T, Akhtar N. Heat-induced conformational changes of human lens recombinant alpha-A amd alpha-B crystallins. Mol Vision 2000; 2: 10-14.
THE SIGHT
9
Original Article
Visual rehabilitation with Combined Contact Lens and Bifocal Spectacle Magnifier in a Case Following Penetrating Keratoplasty
Shrestha, Mr. Gauri Shankar, (M.Optom, FIACLE Lecturer) Chaudhary, Dr. Meenu, (MD Lecturer)
Abstract
B.P. Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Tribhuvan University
A case of bilateral penetrating keratoplasty with left eye pseudophakia post blast injury was studied in 30 year old male. He was prescribed with aspheric rigid gas permeable contact lens which corrected his vision partially. He had optic atrophy in right eye and significant corneal distortion, neovascularization and corneal scar in the left eye. Owing to visual impairment even with the RGP lens and complaint of poor near vision, he was prescribed spectacle microscope in the form of executive bifocal for the near vision task. Key words: penetrating keratoplasty, contact lens, spectacle magnifier
injury in both eyes 8 years back during maoist insurgency. His chief complaint was inadequate near vision with his present contact lens which he had worn only in left eye and had lost. He was a typist by profession. Other ocular and systemic history was within normal limit. Unaided visual acuity was OD 2/60 OS 4/60. On refraction, visual acuity could be improved to 4/60 in right eye with -6.50/-3.00 080 and 6/60 in left eye with -6.00/-4.00 100. Duction as well as version extraocular motility was full in all the gazes. Lid examination revealed mild grade of meibomian gland dysfunction. Mild and diffuse congestion was present in conjunctiva more in left eye than in right eye. An Opacification was present between host and graft in both eyes (figure 1.A&B). In the left eye, neovascularization could be seen extending on to the centre of the donor cornea around 6 to 7 oclock (Figure 1B). There was a central corneal opacity with superficial punctuate keratitis (SPK) around the opacity in the left eye. Bilateral anterior chamber was quite and normal in depth. Peripheral iridectomy was present at around 11 oclock position in right eye. Pupil was inferonasally displaced, oblong and sluggish in reaction due to pupillary capture in left eye. Left eye was pseudophakic. Vitreous was transparent. Retinal examination revealed optic atrophy in right eye and normal in left eye. Right eye topography read Sim K 43.69@162 & 40.90@72 with mean K 40.07@ 67 surface asymmetry index (SAI) 0.42 and surface regularity index (SRI) 0.95. Left eye topography read Sim K 42.97@142 & 39.25@52 with mean K 37.22@ 53 surface asymmetry index
Introduction
Despite good graft clarity in penetrating keratoplasty (PK), patient may require contact lens for visual correction owing to irregular corneal astigmatism not readily correctable with spectacle alone.1,2,3 Rigid gas permeable (RGP) contact lens may be the correction of choice for good visual acuity. It corrects high degree of regular and irregular astigmatism, and has high oxygen permeability, minimal microbial keratitis, and neovascularization.4,5,6 RGP contact lens is a special indication in case of the scar between graft and host cornea.2,7 This case report highlights importance of both contact lens and low vision management in the patient after PK.
A case report
A case of bilateral penetrating keratoplasty with left eye pseudophakia was managed with a contact lens and spectacle magnifier in 30 year old male. He had sustained blast
THE SIGHT
10
(SAI) 3.85 and surface regularity index (SRI) 1.79 (Figure 2). The following parameter of aspheric RGP lens provided acceptable fitting characteristics (Figure 1) that was prescribed to the patient having oxygen permeability of 90Dk two weeks after treatment for meibomitis and SPK (Figure 1C&D). Eye OD OS Base curve 7.60mm 7.40mm Total diameter 9.2mm 9.2mm Optic zone diameter power 7.40mm 7.80mm -6.00DS -3.50DS VA 6/60 6/24
The acceptable fitting characteristics was defined by the best possible alignment fit to minimize bearing which was guided by lens movement, lens centration, fluorescein dye tear pattern, and the maintenance of corneal surface integrity. Bifocal spectacle microscope was prescribed on top of contact lens as his current level of near vision was found inadequate for reading in computer screen and news paper. He didnt have problem in writing, mobility, glare and light adaptation. He was satisfied with current level of distance vision. However he has been advised to use monocular telescope of 3X in left eye for spotting at distance. His near vision was found OD 4M at 12cm over contact lens and OS 2.0M at 30 cm with contact lens and +3.00DS addition. His target acuity for reading was set at 0.8M for equivalent viewing distance of 15cm. His target acuity for viewing a key board was set at 1.6M for equivalent viewing distance of 25cm. Executive bifocal spectacle with segment top at 1mm above lower lid margin was prescribed for near vision having +5.0DS above and +8.0D below segment top for left eye. He was further advised to magnify the font size in the screen during typing the text. He was also advised to keep magnified format of applications in computer screen.
Discussion
Irregular corneal astigmatism and anisometropia remain the optical challenge following PK. 20% to 60% post-PK patients benefit optically from CL wear.2,8 Apart from RGP contact lens, the other contact lens alternatives for the post-keratoplasty patient include soft lenses, piggyback lenses and scleral lenses. Post-PK eyes that exhibit high refractive errors but minimal astigmatism occasionally benefits from hydrogel CLs. However, they can cause hypoxia and secondary cornea neovascularization, which increases the risk of graft rejection.1,9 Piggyback contact lenses can be used where adequate centration cannot be achieved with an RGP contact lens however the reduced oxygen transmissibility of the piggyback lens system
THE SIGHT
11
increases the potential for graft failure. Preformed scleral lenses made in an RGP material are another option for the post-keratoplasty patient. Disadvantage of preformed scleral lens is difficulty in fitting and advantage is good centration on the eye.10 These type of lenses are not available in our clinical set up. Neovascularization in the graft in left cornea suggests a state of compromization with previous contact lens indicating high chance of graft rejection. This finding warrants requirement of both optimal fitting characteristics and high oxygen permeability of the material. The nature of the graft determines type of contact lens management. It may include diameter of the graft, centration of the graft, resultant corneal toricity and topographical relationship between the host cornea and donor cornea. If the graft is too small, the edge of the graft may be within the pupillary zone, leading to glare and other visual symptoms. If the graft is large, the edge of the graft will be close to the limbal vasculature, increasing the chances of blood vessel infiltration into the donor cornea and subsequent graft failure.9 Graft zones of greater than 9mm or more will often allow the practitioner to fit a small diameter RGP lens that position within the region of the graft. However, the graft size in our case was approximately 8.5mm suggesting that the total diameter of the CL usually should be large to improve the stability, centration, and patient tolerance. 1,9 In our case, selected diameter of the lens was 9.2mm which was slightly larger (0.7mm) than the total graft diameter to ascertain adequate edge clearance of lens for tear exchange and to release heavy bearing on the graft. Corneal topography in our case showed normal elevation in spite of significant corneal astigmatism and distortion. Corneal graft was well centered in both eyes. However, optic atrophy in right eye hinders the benefit of contact lens improving the optical clarity. Similarly, eccentric location of pupil in the left eye may cause visual symptoms such as flare and monocular diplopia in spite of having well
centered contact lens. A possible solution was to design lens with either a large or decentered back optic zone diameter of lens or make fitting of lens low riding. However low riding lens decreases the level of comfort associated with the wearing of the lens. In our case, we determined to select a large diameter lens so that pupil coverage can be ascertained. Fortunately corneal astigmatism in our case was within 3 to 4 diopters though corneal distortion was seen remarkably. Corneal astigmatism was found almost similar to the refractive astigmatism indicating possibility of spherical RGP to correct corneal astigmatism as well as distortion.9 Mostly RGP contact lens improves visual acuity up to 6/12 in PK.7 Of interest, he did not achieve normal vision with RGPs suggesting that RGP didnt completely neutralize corneal distortion in left eye and there was optic atrophy in right eye. To meet the patients visual demand for reading and typing, an extra optical consideration had to be considered to achieve this goal. Being that reason, he was prescribed spectacle microscope in the form of executive bifocal. Both the optical portion in bifocal will be used purely for near vision. Non-optical accessory tools also have to be suggested to ease patients near work depending upon the task one has to perform. At last, this study suggests that contact lens alone may not be sufficient in visual rehabilitation after penetrating keratoplasty and optical aids may be necessary for better visual rehabilitation.
References
1. Ho SK, Andaya L, Weissman BA. Complexity of contact lens fitting following penetrating keratoplasty. Int Contact Lens Clin 1999;26:163 7. Smiddy WE, Hamburg TR, Kracher GP, et al. Visual correction following penetrating keratoplasty. Ophthalmic Surg 1992;23:9093. Mannis MJ, Zadnik K. Refracting the corneal graft. Surv Ophthalmol 1990;34:43640. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens associated microbial keratitis and its related morbidity. Lancet 1999;354:1815.
2.
3. 4.
THE SIGHT
12
5.
Dart JK, Stapleton F, Minassian D. Contact lenses and other risk factors in microbial keratitis. Lancet 1991;338:6503. Chan WK, Weissman BA. Corneal pannus associated with contact lens wear. Am J Ophthalmol 1996;121:5406. Wietharn BE, Driebe WT Jr. Fitting contact lenses for visual rehabilitation after penetrating keratoplasty. Eye Contact Lens 2004;30:313. Silbiger JS, Cohen EJ, Laibson PR: The rate of visual recovery after penetrating keratoplasty for keratoconus. CLAO J 1996; 22:266269. Lindsay R. Post keratoplasty contact lens management. Clin Exp Optom 1995; 78:223226.nm
Figure 1. Bilateral penetrating keratoplasty and contact lens fitting. Figure 2. Bilateral corneal topography with placido disc
6.
Corresponding address
Gauri Shankar Shrestha, M.Optom, FIACLE Lecturer B.P. Koirala Lions Centre for Ophthalmic Studies, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu P. O. Box: 8750 Email: gs101lg@hotmail.com
7.
8.
9.
10. Tan DTH, Pullum KW, Buckley RJ. Medical applications of scleral contact lenses: 2. gaspermeable scleral contact lenses. Cornea 1995; 14: 130-137.
THE SIGHT
13
Original Article
Low Vision Devices Prescribed in Low Vision Children of Nepal.

Kishor Sapkota Optometrist, Nepal Eye Hospital Objectives: Low vision devices reduce the
consequences of the visual impairment in life. The aim of this study was to find out the prevalence and the major low vision devices prescribed in pediatric low vision children in low vision clinic of Nepal Eye Hospital (NEH). Methods: It is a retrospective and cross sectional study. All the report files of the children who visited low vision clinic of NEH at the first time from 1st May 2009 to 31st October 2011 (30 months) were reviewed. Their age, sex, best corrected visual acuity, refractive status and the prescribed low vision devices were analyzed. work. WHO defines low vision as the best corrected visual acuity of 6/18 to 3/60 in the better seeing eye. There are 161 million people with low vision in the world [Pascolini 2002]. In Nepal, about 1.85% of the total population is estimated with low vision [Brilliant 1985]. However, no data are available about the prevalence of low vision in Nepalese children. Low vision is responsible for a high proportion of social care service use and results in important reductions in functional status. Low vision devices are the simplest way of reducing the consequences of impaired vision. Low vision devices can improve the quality of life of visually impaired children. The prescribing of LVD depends on the individual: it is not possible to anticipate the optical power of the LVD that a patient will need simply from looking at their diagnosis and measuring their VA because there are so many different requirement depending on their age and visual demand [Gajdosova et al, 2010]. Reading rate increases significantly with improved near visual acuity in school children by low vision devices [Sharma MK et al, 2010]. No studies have been done about need of low vision devices among children in Nepal. This study was designed to investigate the proportion of low vision children needing low vision devices in Nepal. This study also evaluated the major low vision devices prescribed and their magnification. It will help to understand low vision practitioners to use the low vision devices effectively.
Results: In this period, 69 children attended

low vision clinic of NEH. Mean age of the children was 9.87 years. 42% of patients had best corrected visual acuity of 3/60 or worse in the better seeing eye. Nystagmus was found to be the most common cause of visual impairment which was found in 59.42% (41) children. Two thirds of children had multiple causes of low vision. General glasses were prescribed for 77% of children. Low vision devices were prescribed for 28% of children and telescope was prescribed for 68% of them. Hand held magnifier was prescribed for 5 and stand magnifier was prescribed for a single patient.
Conclusion: General glasses improve the visual acuity of many low vision children. Prescription of low vision devices was very low. Telescope was the most common low vision device prescribed. Key words: Children, Low vision devices,
Telescope.
Methods and methodology

It was retrospective study conducted in the low vision department of Nepal Eye Hospital, Kathmandu, Nepal. All the patients who first time visited the clinic with age 15 years or younger and best corrected visual acuity (BCVA) equal or less than 6/18 in the better
Introduction THE SIGHT

14 A person is said to be with low vision if the reduction in visual acuity or visual field hinders the daily living activities and his professional
eye were included. Patients older than 15 years were excluded. All the patients were referred cases from the primary eye care center or other departments of the hospital. Visual acuity was measured with Bailey-Lovie or Snellen chart in each patient. Cycloplegic refraction was performed with instillation of cyclopentolate 1% followed by tropicamide 1% in each eye. Refraction was done by a senior optometrist while other ocular ophthalmic examination was done by consultant ophthalmologist trained in low vision. A cause of low vision was diagnosed after the different investigations. Besides the general refractive error correction, near and/or distance visual acuity of each patients was tested with the low vision devices like high powered glasses, spectacle magnifiers, hand held magnifiers, stand magnifiers and telescopes with different focal strength. Low vision devices were prescribed depending upon the performance of the patients with the device and the need. Data were analyzed by SPSS 13 software and t test, X2 test were used to determine the association between different variables. P value of less than 0.05 was considered as statistically significant.
BCVA 6/24 6/30 6/36 6/60 5/60 4/60 3/60 2/60 1/60 CF PL Total
Frequency 7 5 11 11 3 3 4 9 6 7 3 69
Percentage 10.1 7.3 15.9 15.9 4.4 4.4 5.8 13.0 8.7 10.1 4.4 100
Overall, 52 (75%) patients were improved by general glasses in at least one eye. 6 myopic, 13 hyperopic and remaining 33 had astigmatism in the better seeing eye. The mean refractive error (spherical equivalent) was +1.5D 5.9D with range -18.00D to + 14.00D. 22 had mild refractive error, 13 had moderate refractive error and 17 had high refractive error in the better eye. Table shows the causes of visual impaired in low vision children. Nystagmus was found as the most common etiology of the visual impairment. So, we statistically analyze the association of nystagmus with sexes. Nystagmus was not associated with the sex (Chi-Square test, X2 = 0.82, P = 0.775).
Causes of VI Nystagmus High ref error Amblyopia Cataract Microophthalmus Coloboma Squint RP Albinism Optic attrophy Macular scar/ hole Others Unknown cause Total Frequency 41 17 16 12 9 9 8 6 5 3 3 9 2 140 Percentage 59.42%
Results:
In the period of 30 months, 31,315 children were examined in Nepal Eye Hospital. Out of them 69 (0.2%) children were referred to low vision clinic of NEH. Mean age of the children was 9.873.316 years with range 4 to 15 years. The median age of the children was 10 years. Fifty five percent were male and 45% were female. Boys were younger than girls but there was not significant difference in the age between two genders (Independent Sample T-Test, t = -0.438, df = 67, p = 0.662). Table 1 shows the best corrected visual acuity (BCVA) in the better eye. Visual acuity of 6/36 and 6/60 were found in the highest number of patients in their better eyes. 25 (36%) patients had visual acuity worse than 3/60 in their better eyes.
Majority of the patients had multiple causes of visual impairment. The mean number of
THE SIGHT
15
causes was 20.97. Two had unknown cause, 22 had single cause, 23 had two causes, 18 had three causes and 4 had four causes behind the visual impairment. General glasses were prescribed for 52 (75%) patients. Low vision devices were prescribed for 19 (27.5%) children. Telescope was prescribed for 13 (68%), hand held magnifier for 5 (26%) and stand magnifier for one patient. The magnification of the telescope was 3X in 2 cases while 4X in 11 cases. Similarly, 2X power hand held magnifier was prescribed for 4 and 3X for one patients in hand held magnifier prescribing group. The only stand magnifier prescribed was 3X power. Since the telescope was the most frequently prescribed low vision devices, we investigated any association on the age and gender to prescribing of telescope. There was no association between the age and telescope prescribing (Independent Sample T-Test, t = 0.899, df = 67, p = 0.372). Similarly, there was not significant relationship between the gender and the telescope prescribing (ChiSquare test, X2 = 0.515, P = 0.473).
by general spectacles. This shows that proper refraction is necessary for the low vision patients. Low vision devices were prescribed in 27.5% of low vision children. This is lower in comparison to other study. 65% of the low vision children were prescribed low vision devices in a study done by Gajdosova and co-workers [Gajdosova et al, 2010]. Less than one third low vision children were prescribed low vision device in our study. This may be due to the fact that only few types of low vision devices are available in Nepal. Another factor may be the cost of low vision devices. Majority of the children with low vision are of lower socio-economic status who cannot afford the expensive low vision devices. In our study, telescope was found to be the most frequently prescribed low vision devices. Telescope was prescribed in 68% children, hand held magnifier in 26% and stand magnifier in 6% cases. In contrary to our findings, magnifiers were prescribed in 44% cases, hyperoculars or high aid in 12% and telescope in 38% cases in the study of Gajdosova study [Gajdosova et al, 2010]. This study could not determine the efficacy and the abandonment of the low vision devices. Dougherty and co-workers [Dougherty et al, 2011] did a study on the abandonment of lowvision devices in an outpatient population. They found that, of the 119 prescribed devices, 19% had not been used within the previous 3 months. Patients with visual field loss may be more likely to abandon prescribed devices. Proper training is necessary for the effective uses of low vision devices. However, it was found that additional training is not necessary for the simple low vision devices [Pearce et al, 2011].
Discussion
Only 0.2% of the total patients were referred to the low vision rehabilitation clinic in NEH and more than one third of them had BCVA worse than 3/60 in the better seeing eye. This is lower than the prevalence of low vision in Nepal [Brilliant 1985]. This shows that referral system in NEH has some lacking. One of the possible factors may be the misunderstanding in ophthalmologist in low vision rehabilitation. Another reason may be the fact that many children having low vision do not visit the hospital or the insufficient vision screening programs. This highlights the need of proper referral system of low vision patients and more vision screening programs. Nystagmus was found to be the most common cause of visual impairment. It was not associated with the gender. Majority of the children had multiple causes.
References
Gajdosova E, Kukurova E, Gerinec A. [Improvement in the outcome of visual impairment using low vision aids in children]. Cesk Slov Oftalmol. 2010;66:266-72. Pearce E, Crossland MD, Rubin GS. The efficacy
THE Vision was found improved in 75% of children SIGHT

16
of low vision device training in a hospitalbased low vision clinic. Br J Ophthalmol. 2011;95:105-8. Dougherty BE, Kehler KB, Jamara R, Patterson N, Valenti D, Vera-Diaz FA. Abandonment of low-vision devices in an outpatient population. Optom Vis Sci. 2011;88:1283-7. Pascolini D, Mariotti SP, Pokharel GP, et al. Global update of available data on visual impairment: a compilation of population-based prevalence studies. Ophthalmic Epidemiol 2002;11:67 115.
Brilliant RL, Pokhrel RP, Grasset NC, et al. Bulletin of the World Health Organization 1985;63:375-386. Sharma MK, Thapa H, Paudyal B, Adhikar RK, Dhakwa K. A profile of low vision among the blind school students in Lumbini Zone of Nepal. Nepal J Ophthalmol. 2010;2(4):127-31.
Sudrishti Eye Clinic

Kings way, Kathmandu Tel: 014228531
Available services
General Eye Examination (including evaluation of Glaucoma) Pediatric Eye Examination (Including Squint evaluation and Vision therapy) Contact lens service (Contact lens trial, counseling & dispensing by Qualified Optometrist) Pharmacy (Glaucoma and other medicines) Appointment time: 2PM onwards (Sunday to Friday)
Consultation time: 4PM to 8PM
THE SIGHT
17
Original Article
Pattern of ocular morbidity in a rural community of Nepal

Himal Kandel,1 Safal Khanal,2 Amrit Pokhrel,2 Dr. Subash Bhatta3
1 2
Optometrist, Eye Care Pvt Ltd, Orchid Magu, Male 20262, Republic of Maldives Optometry Student, Institute of Medicine, Trihuvan University, Kathmandu, Nepal 3 Ophthalmologist, Institute of Medicine, Trihuvan University, Kathmandu, Nepal
Abstract Introduction:
By scientific report of free eye screening camp in a rural community, we can understand a particular type of community in a better way and plan for future camps in such communities in a better way. It can also help us to plan for eye care services in such communities.
Conclusion
Free eye screening camps are important for screening and treating ocular morbidity in rural communities. Larger group of passive population, female population and so called lower caste population are extremely benefitted from such camps. Key words: Cataract, Morbidity, Refractive Errors, Rural Population Nepal,
Methods
One day free eye camp was conducted in Tistung VDC; a rural hilly village of central Nepal. Visual acuity was assessed using Snellen chart. Anterior segment evaluation was done with the help of torch light. Posterior segment evaluation was done with ophthalmoscope. Streak-retinoscopy, subjective refraction, Schirmer test I&II, Syringing and Perkins tonometry were performed in required cases. Data on age, gender, ethnicity, religion and major diagnoses were recorded and analysed using SPSS-17 software.
Introduction:
Rural population comprises 85% of the total population of Nepal. Eye screening camps are frequently conducted by different organizations in different rural communities but their reports are rarely presented in a scientific way. If it could be done, a particular type of community would be understood in a better way. It can help to plan for preventive and curative eye care services in such communities1 and eye camps can be conducted in a more systematic way in the future.
Results
68% of the people presenting to the free eye camp had ocular morbidity who were not having any treatment. Mean age of presentation was 48.60 +/- 23.39. 12.92% were pediatric population and 40.62% were elderly. 59.1 % of the total subjects screened were female. Unlike the caste composition of Nepal, a relatively larger percentage of so called lower caste people (20.92%) were screened in the camp. Among 221 cases with ocular morbidity, 40.27% had dry eyes, 30.32% needed refractive correction and 26.24% had visually significant cataract. Among the cataract cases, 62.07% had bilateral visually significant cataract.
Methodology:
One day free eye camp was conducted in Tistung VDC; a rural hilly village of central Nepal. Health post was quite far from the site of the screening camp. Awareness to the local people about the eye screening camp was made through pamphlets and miking. Verbal consent was taken from the subjects for inclusion in the study. Visual acuity was assessed using Snellen chart. Anterior segment evaluation was done with the help of torch light. Posterior segment evaluation was done with ophthalmoscope. Streakretinoscopy, subjective refraction, Schirmer test I&II, Syringing and Perkins tonometry
THE SIGHT
18
were performed in required cases. Data on age, gender, ethnicity, religion and major diagnosis were recorded and analysed using SPSS-17 software. Visually significant cataract was defined by any, best-corrected visual acuity less than 20/40, cataract as the primary cause of vision impairment, and self-reported vision of fair or worse.2
However, no significant difference in the pattern of morbidity was found among them. Unlike the caste composition of Nepal3, a relatively larger percentage of so called lower caste people (20.92%) were screened in the camp. This could imply that so called higher caste people who are comparatively more privileged have better reach to the eye care centres and the former wait for free camps for eye camp for eye care. However, we cant generalize it as we are unaware of the caste composition of the community. Among the dry eye cases, surface disorder dry eye was quite common due to pingueculae and pteregia. Most of the dry eye cases were female. People used firewood as fuel for cooking. Thus female were mainly exposed to the dust and smoke in the kitchen which might have been its reason. Most of the people were unaware of refractive errors. People should be educated about the signs and symptoms of refractive errors.
Results:
A total of 325 subjects were screened for ocular morbidity and treated or referred to higher centres when required. Mean age of presentation was 48.60 +/- 23.39. 12.92% were pediatric population and 40.62% were elderly. 59.1 % of the total subjects screened were female. 20.92% of the cases were so called low caste people. 68% of the people presenting to us had ocular morbidity who were not having any treatment. Among 221 cases with ocular morbidity, 40.27% had dry eyes, 30.32% needed refractive correction and 26.24% had visually significant cataract. (Figure 1) Among the cataract cases, 62.07% had bilateral visually significant cataract.
Conclusion:
Free eye screening camps are important for screening and treating ocular morbidity in rural communities. Larger group of passive population, female population and so called lower caste population are extremely benefitted from such camps.
Discussion:
The present study was carried out to find out the pattern of ocular morbidity in a rural community of hilly part of Nepal. Eye screening camps are important not only for screening the pattern of ocular morbidity but rather more important as eye-health care and people also consider it as a health care service. Larger group of passive population (53.54%) were benefitted from the camp. In the male dominated society, male population has better reach to eye care centers which are located quite far away from their residence areas. So, larger percentage of female are expected to come with ocular problems. In our study, most of the cases (59.1 %) were female. Most of the subjects were Hindus followed by Buddhists and Christians respectively.
References:
1. Gupta M, Gupta BP, Chauhan A, Bhardwaj A. Ocular morbidity prevalence among school children in Shimla, Himachal, North India. Indian J Ophthalmol. 2009;57:1338. 2. Richter GM, Chung J, Azen SP, Varma R; Los Angeles Latino Eye Study Group. Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery: Los Angeles Latino Eye Study. Ophthalmology. 2009;116:2327-35. 3. CBS, 2001 census, Kathmandu Retrieved from http://www. cbs.gov.np/Population/Monograph/Chapter%2003%2 0%20Social%20Composition%20of%20the%20Popula tion.pdf Figure legend: Figure 1 : Pattern of ocular morbidity Correspondence: Himal Kandel, Optometrist, Eye Care Pvt Ltd. Republic of Maldives. himal@eyecare.com.mv, himalkdl@gmail. com
THE SIGHT
19
Original Article
Profile of Binocular Visual status of Pediatric Patients Presenting with complaints of Asthenopia
Arun Prasad Dhungana
Optometrist, RLGEHF
Abstract
AIM: To determine the accommodative amplitude, fusional vergence, vergence status and refractive status of pediatric patients presenting with symptoms of Asthenopia. Method: Total 820 pediatric patients with complaints of asthenopia were enrolled in the study. VA assessment, slit lamp biomicroscopy, retinoscopy and binocular vision assessment were done. Patients who required glasses were prescribed with glasses. Patients who needed exercises on Synoptophore were called for follow up and those requiring pencil-push up exercise, Hart chart rock exercises and other vision therapy were advised to do at home. Results: Total 820 subjects were enrolled in the study. Among them, 51.85% were female and 48.15% were male. Most common age group presenting with symptoms of asthenopia at the OPD was of age group 11-16 yrs. The most common binocular disorder was fusional insufficiency. Conclusion: Asthenopia was found to be related to fusional vergence deficiency, accommodative and convergence insufficiency and refractive error. It can be concluded that factors of asthenopia, whether muscular or refractive seems to give rise to symptoms and cannot be neglected since it can have direct impact on overall physical and academic development of the children. Keywords: Asthenopia, binocular disorders convergence, sense of strain and weakness or ocular fatigue set up by the use of the eyes (a=not, sthenos=strength, ops=vision) (Atencio 1996, palmer 1993). It is a term used to describe different symptoms associated with the use of the eyes such as pain, blurred vision, diplopia, focusing problem, reading problem, eyestrain, tiredness and headaches. It is a common presenting complaint among patients with accommodation and convergence insufficiency, refractive error and intermittent strabismus. It is most often reported in association with near vision. Children with asthenopia complain of such symptoms particularly when reading and writing. It is often divided into two main categories: refractive including refractive errors and anisometropia and muscular comprising strabisimus and convergence insufficiency. Symptoms of asthenopia are becoming more common in modern society where near work at computers required sustained fixation often for hours, at the same visual distance, which puts a strain on the system for near vision. Among school children, recent studies have reported a prevalence of asthenopia in 15.2% in 6 year old children (IP et al 2006) and 34% in school children 6-10 yrs of age (Sterner et al 2006).
Methods and Methodology

This was a hospital based and descriptive study. Children of age group 6-16 yrs presenting with symptoms of asthenopia at the OPD of Ram Lal Golchha eye hospital
Introduction: THE SIGHT Asthenopia is a term used to describe a

20
foundation were included with verbal consent of the guardians .Patients with any ocular or systemic pathologies were excluded from the study General ocular and medical history was taken. Uncorrected visual acuity for distance was measured with Snellen chart at six meters. A complete ophthalmic examination was done including slit lamp examination and ophthalmoloscopy. Cover test, prism cover test were done for near and distance at 40 centimeters and 6mrters respectively. Positive fusional vergence was measured with base out prism at near and distance. Normal range for near was considered as 9/19/10 prism dioptres (blur/break/recovery) and 17/21/11 prism dioptres (blur/break/ recovery) for distance. Prism cover test was used to assess the amount of deviation. Near point of convergence was measured with RAF rule. Normal range of convergence was set at 6-9 cm from the eyes. Near point of 12 cm was denoted mild convergence insufficiency, 13-18 cm as moderate insufficiency and 19 cm and more as marked convergence insufficiency. Near point of accommodation was measured with RAF rule with N6 target. Normal accommodation was set at 6-9 cm, mild accommodative deficit was defined at a near point of 10-15 cm, moderate deficit at 16-20 cm and marked deficit at more than 20 cm. Retinoscopy and subjective refraction was done. Dynamic retinoscopy and cyclo refraction was done whenever required. Exophoria was defined as 4 prism dioptres at distance and 6 prism diopters at near. Esophoria was defined as 2 prism dioptress at distance and 4 prism diopters at near.
Type of Refractive Error Simple Hyperopia Simple Hyperopic Astigmatism Compound Hyperopic Astigmatism Simple Myopic Astigmatism Compound Myopic Astigmatism Myopia Mixed astigmatism Total
Percentage 20% 9% 6% 7% 5% 11% 4% 61%
Fig 1: Distribution of patients with their chief complaints
Table 2: Distribution of Binocular Disorder

Fusional Insufficiency Conv. Insufficiency Conv. + Fusional Insufficiency Accommodative Disorder Accom + Conv + Fusion Total 32% 28% 16% 19% 5% 100%
Table 3: Prevalence of the accommodative dysfunction

Degree of accommodative dysfunction Insufficiency Spasm Infacility Fatigue Total
type
of
Prevalence 80% 4% 9% 7% 100%
Result
Total 820 patients who presented to the OPD with complaints of asthenopia were included in the study. Maximum children were of age group 13-16 years. Male comprised of 48.15% and female comprised of 51.85%. Table 1: Pattern of refractive error on asthenopic children
Table 4: Type of Deviation

Type of deviation Orthophoria Exophoria Esophoria Heterotopia Total Percentage 84.96% 11.04% 2.20% 1.80% 100.00%
THE SIGHT
21
Discussion
We found that the refractive error and binocular disorder was associated with asthenopia in many children. Convergence insufficiency has been reported to be a common binocular disorder in children (Raise et al 1987) but in our study, fusional insufficiency was the commonest binocular disorder. Similar to the study done by Abdis et al (84%) most common accommodate disorder was accommodative insufficiency (80%).
disorder, vergence dysfunction and refractive error. So orthoptic evaluation is very important in case of pediatric patients complaining of asthenopia.
References
1. Atencio R. Eyestrain: the number one complaint of computer user. Computer in libararies 1996; 16:40-44 2. Rouse MW. Management of Binocular anomalies: Efficacy of vision therapy in the treatment of accommodative deficiencies. Am J Optom Physiol opt. 1987; 64:421-429 3. Abdi S, Rydberg A. Asthenopia in school children, orthoptic and ophthalmological finding and treatment. Documenta ophthallmologica, 2005; 111, 65-72
Conclusion
Asthenopia was found to be related to deficiency of fusional vergence system, accommodative
Proprietor: Dr. Sanjeev Mishra Contact: 984122738 Address: Tinkune, Subidhanagar, KTM
THE SIGHT
22
Original Article
Does uncertainty exist among Medical Students Regarding the Definitions of Ophthalmology and Optometry?
Sudan Puri B Optometry final year Background: Optometry program in Nepal was started by Institute of Medicine in 1998 in collaboration with the University of Auckland, New Zealand. It is the only one institution in the country providing Optometry education for the last 14 years. Being a new profession, in many countries it is still in the growing phase and people are still unaware of the services provided by various eye care professionals. Purpose: To determine knowledge and opinions of medical students about the different kinds of eye-care providers and the services they provide Method: A full-page survey was administered to 106 medical students in third phase at Maharajgunj Medical Campus, Institute of Medicine, Kathmandu. Students were asked to respond to questions that tested their knowledge of differences among ophthalmologists, optometrists and opticians in an open phrase and a multiple-choice format. Questions concentrated on the differences in training and qualification in diagnosing and treating various eye conditions. Result: Among the 106 medical students of mean age 23+1.24 years (21 years to 26 years), 79 (74.5%) students had a history of eye checkup , among them 22(27.8%) had been evaluated by ophthalmologists, 26(32.9%) by optometrists and remaining 31(39.2%)by both ophthalmologists and optometrists. For the 28 (26.4%) students using spectacle correction, 15 (53.6%) were prescribed by optometrists, 10 (35.7%) by ophthalmologist and 3(10.7%) by both of them. Most of the medical students when asked in an open response format, recognized that there is a distinction between ophthalmologists and optometrists, but only 85(80.18%) attempted to describe the difference. Of this group, 39 (45.9%) correctly described the difference between the two specialties using the following criteria: 1. Lack of medical school and surgical training 2. Primary focus of education on optics of the eyes, examination of eyes and on recognizing diseases in the eye Furthermore, 55 (51.8%) of those surveyed thought that Ophthalmologists are not trained to prescribe glasses and contact lens and 35 (33%) thought that Optometrists cannot prescribe medications. When asked about surgical training, 17 (16%) said they did not know who was trained to perform Laser Refractive Surgery. 15 (14.1%) thought that both Ophthalmologists and Optometrists can perform Laser Refractive Surgery. Only 52 (49.0%) thought that both Ophthalmologists and Optometrists can perform post-operative care after Laser Refractive Surgery and other 26 (24.5%) were not sure. On question regarding who can treat glaucoma, cataracts and macular degeneration with surgery 12 (11.3%) of the respondents answered that they did not know. Conclusion: There is considerable uncertainty even among medical students, with regard to the differences among eye care professionals and services they provide. Author Correspondence Sudan Puri B Optometry final year Maharajgunj Medical Campus Maharajgunj, Kathmandu E-mail: sudanpuri@hotmail.com
THE SIGHT
23
Review Article
Optometrist- An Independent Eye Care Professional in Nepal

Subodh Gnyawali, OD, MPH President, Nepalese Association of Optometrists Optometrists are primary contact eye care professionals, who can manage majority of eye problems among patients seeking eye care services at any level of health care delivery. In developed countries more than 70% of the eye care is provided by optometrists. World Council of Optometry defines optometry as an independent profession but it is being realized by optometrists in developed countries only. The number of optometrists produced each year being large and their development of professional career which mostly begins as a private practitioner has helped them become an independent professional. Co-management of cases by different health professionals and a clear demarcation of working areas have eased the patients in choosing their clinician as well as the professionals in setting up their own working arena. In Nepal, comparing other parts of the world, optometry is a new profession. We have several eye health professionals with overlapped working areas and lack a clear health policy to delineate job responsibilities. Fewer number of optometrists available in the country, optometrists being deployed as refractionists in most of the settings, potential of optometrists not been optimally utilized by the employers, feeling of insecurity among other eye health professionals adopting optometrists as co eye care providers, feeling of insecurity among optometrists to invest in private practice because of small Nepalese market and more importantly unawareness among the public regarding optometry are some of the factors hindering optometry move towards an independent profession in Nepal. their individual identity. Existing cataract backlog, increasing cases of AMD, diabetic/ hypertensive retinopathy, glaucoma and other non communicable eye diseases in the country with increased life expectancy and changing dietary patterns will engage our ophthalmologists in managing these conditions for another couple of years. On the other hand, refractive error has been alarmingly increasing with changing vision demands and life style of the people. This is high time that we should develop a healthy referral system between ophthalmologists, optometrists and allied eye health professionals for improved eye care in Nepal. Management of refractive error by the provision of glasses, contact lenses or low vision devices is an area where optometrists in the present context can exhibit their independency. Optometrists should enter into private practice in increasing numbers. An opportunity has to be given to the industries producing various ophthalmic products to enter the Nepalese market. Depending on the use and affectivity of these products in eye care they need to be promoted by the practicing optometrists. This will increase competition among the manufacturers, invite them to adopt various marketing strategies to bring awareness among the consumers. If a mechanism is set in coordination with the manufacturers the consumers can be oriented with the profession of optometry and the services they could provide. Independent practice in fact is a more secure form of employment for optometrists in Nepal. If the patient gets access to an optometric service as a primary eye care, this on a long run would help develop optometry as an independent profession as is commonly seen in developed
THE However, there are opportunities for optometrists to come forward and work for SIGHT
24
countries. The present structure for optometry education in Nepal also has to be modified. The university has to have a department of optometry independent to the department of ophthalmology. It should be an optometrist to coordinate the educational activities of optometry rather than an ophthalmologist.
Increasing demand for optometry studies in the country cannot be coped with limited uptake of students at a single institute. More colleges offering optometry degree has to come up so that more optometrists are produced, more are retained in the country, specialty services in optometry can be developed and there are more optometrists as private practitioners.
THE SIGHT
25
Review Article
Pathogenesis of Glaucoma: IOP and beyond

Dr. Madhu Thapa Introduction
Glaucoma is a disease characterized by optic neuropathy secondary to retinal ganglion cell damage and presents with various morphological changes of optic nerve head with specific types of visual field defect. Glaucoma causes irreversible blindness. There were about 60 million cases of glaucoma in 2010 which is expected to rise to 80 million in 2020. One of the reasons for increase in incidence is the greater number of undiagnosed cases until it causes total blindness. In developed world, 40-60% of cases are undiagnosed while those in developing countries it is about 90%. Recent researches and literatures have described that there are multi-factorial risk factors responsible for glaucomatous optic neuropathy apart from elevated IOP, which in past was considered as only the prime factor. As already mentioned there are various factors responsible for pathogenesis of glaucoma. These factors are described here. When the enzyme is activated it initiates the proteolysis of cytosolic, a nuclear component leading to complete destruction of cells. Role of increase IOP in the process of Apoptosis Process of RGC apoptosis is decreased by decreased IOP. IOP increase causes alteration in aqueous humour dynamics which can lead to trabecular changes like cytoskeletal changes, alteration of cellular and extra-cellular matrix. These changes are also co-related with level of IOP increase and duration of elevated IOP. Neuronal loss is seen in two phases in glaucoma. Initial phase when apoptosis is observed and late phase due to toxic effect of primary degeneration of neuron and constant exposure to increased IOP. But about 25-35% of patients with glaucoma are diagnosed in individuals with normal IOP suggesting that elevated IOP is not the only risk factor. Molecular mechanism of RGC apoptosis in glaucomatous eye In glaucomatous eye there is extensive remodeling of extra-cellular matrix (ECM). There is increase in TGF-2, a matrix metalloproteinase (MMP1). Changes in ECM components can interrupt cell-cell and cell-ECM interaction that leads to death by apoptosis. MMP are major matrix degrading enzyme and recent study has shown enhanced MMP1 activity is seen in apoptotic RGC along with destruction of laminin indicating increased degradation of ECM at retinal site in response to increased IOP. Laminin helps in cells adhesion and survival by interaction with cellular integrins. As IOP increases there is retrograde axoplasmic
1. Neuronal loss in glaucoma by apoptosis:

Glaucomatous optic neuropathy is characterized by extensive retinal ganglionic cell (RGC) axon loss leading to cupping of optic nerve head (ONH). RGC damage and destruction in glaucoma occurs by apoptosis. Apoptosis is programmed cell death in the absence of inflammation. It is characterized by DNA fragmentation, chromosomal clumping, cell shrinkage and blebing of cell membrane followed by breakdown of cells into membrane bound vesicals. Caspase family of cysteine aspartyl specific protease has been found to be the central regulator for apoptosis.
THE SIGHT
26
transport block which results in deprivation of supply of brain derived neuro trophin factor (BDNF) to RGC. BDNF is important for cell metabolism and cell survival. When BDNF is deficient, there will be further progression of RGC apoptosis.
2. Vascular insufficiency:
Various reports have already described the strong association between vascular insufficiency and glaucoma. Diseases like migraine, peripheral vascular disease has been associated with glaucoma. This involves dysregulation of cerebral and peripheral vasculature. There is increase in sensitivity to endothelin1 mediated vasoconstriction is observed in these vascular abnormalities. There is increase level of endothelin 1 found in aqueous and plasma of glaucomatous patients. Advanced age is also considered as an important risk factor for glaucoma and a progressive decline in cerebral and ocular perfusion seen on old age. In healthy eye, a constant flow of blood is required to maintain retina and optic nerve head to meet its high metabolic demand. Efficient auto regulatory mechanism is operated to maintain a constant flow in arteries, arterioles and capillaries. This auto regulatory mechanism is not as efficient in old age as seen in young individuals. In POAG and NTG patients have low systemic blood pressure leading to reduced ocular perfusion pressure. Reduced in diastolic pressure is now recognized as an important risk factor for glaucoma. Ocular blood flow = perfusion pressure/ resistant to flow Where, perfusion pressure= mean arterial BPIOP So, decrease in BP or increase in IOP leads to decrease in perfusion pressure to eye.
known to release glutamate which is essential neurotransmitter in central nervous system and retina in normal concentration. But when the concentration increases higher than the physiological state, it becomes toxic to neurons and toxicity depends upon the duration and extent of increase concentration. Glutamate mediated neuro-transmission is via ionotropic glutamate receptor which includes N-methyl D aspartate (NMDA) receptors which after activation by glutamate causes opening of ion channels and leads to entry of extracellular Calcium and Sodium ions into neurons. This increase in concentration of sodium and calcium ions causes apoptosis. Experimental administration of NMDA antagonist have shown to prevent glutamate induced toxicity.
4. Role of nitric oxide (NO)

Though nitric oxide plays an important role in body function where secreted in physiological quantities, its excessive production leads to various non neurological and neurological condition like glaucoma. Nitric oxide synthesis (NOS) produce NO by oxidation of L-arginine and detected in 3 isoforms. Excessive NO produced enters freely into the cells after diffusion through the local micro environment. It is a free radical radical of moderate reactivity but after entry into the cell it leads to production of highly reactive free radicals such as peroxinitrite after combining with super oxide (product of mitochondrial metabolism). It causes massive destruction of cell components. The increase in NO has also been observed in aqueous humour of glaucomatous patients. NOS can produce excessive NO under diverse condition such as exposure to cytokines and increased IOP.
5. Oxidative stress and glaucoma

Ocular tissue is provided with very efficient anti-oxidant defense mechanism which includes glutathione and superoxide dismutase. Ascorbic acid also has an important protective role and high concentration is
3. Role of glutamate in RGC death

Under hypoxic condition the retinal cells are
THE SIGHT
27
detected in vitreous humour, cornea, tear film and aqueous humour. Excessive free radicals and oxidative stress has been seen as an important factor in many ocular diseases such as cataract, age related macular degeneration and recent glaucoma. Glaucoma patient have shown a significant depletion of anti-oxidant potential in aqueous humor, decrease in plasma glutathione and increase in per oxidation in plasma.`
For instance calcium channel blockers are suggested to provide neuro protection by improving ONH blood supply. Likewise, carbonic anhydrase inhibitors are also thought to have similar effect. Various agents with anti-apoptotic activities are also being studied in animal models. Caspases inhibitors are found to protect RGC apoptosis and erythropoietin when given intra-vitreally is found to increase RGC viability in animals. Role of other neuro-protective agents like BDNF N-acetyl L-cystine, Nitrous oxide synthetase inhibitors, NMDA antagonist are also being studied. None of the neuro-protective agents have been tried in human subjects yet. Better understanding of neurological basis of glaucoma can lead us to a new era of neuroprotective anti glaucoma in future.
Conclusion:
Though there are various theories regarding pathogenesis of glaucoma, lowering IOP is the only therapeutic measure achieved till date to control the disease. Reduced IOP can definitely protect the optic nerve damage to remarkable extent. Recent researches have shown that various agent with neuro protective effects may have significant role in glaucoma management.
THE SIGHT
28
Review Article
Craniosynostosis
Mahesh Raj joshi
Craniosynostosis is the premature fusion of one or more of the cranial sutures accompanied by severe orbital abnormalities. This can occur as part of a syndrome or as an isolated defect. Prevalence of craniosynostosis is approximately one in 2100 to 3000 infants (D. Taylor, 2005). Of more than 180 craniosynostosis syndromes; Crouzons and Aperts syndrome account for the majority of cases (Kimonis, Gold, Hoffman, Panchal, & Boyadjiev, 2007). Pathogenesis The growth of skull bones is driven primarily by the expanding growth of brain. There are different sutures present in skull, the major ones being sagital, metopic, coronal and lamboid. These sutures close at different times with completion of closure occurring by 12 years of age (Kabbani & Raghuveer, 2004). Early closure of sutures hinders the growth of brain with brain growing in a direction parallel to the closed suture, instead of normal perpendicular growth. The abnormal development of brain away from the prematurely closed suture results in abnormal structure of skull (D. Taylor, 2005). Abnormal anatomy of skull results in various complications including increased intra cranial pressure, abnormal facial features, hearing and vision abnormalities, and intellectual impairment (Aleck, 2004). Etiology Etiology of non syndromic craniosynostosis is unknown and is sporadic in many cases (Kabbani & Raghuveer, 2004). The syndromic craniosynostosis shows autosomal dominant, recessive or X-linked inheritance. Mutations involving transcription factor (TWIST) and three fibroblast growth factor receptors (FGFR) plays a major role in craniosynostosis (Kabbani & Raghuveer, 2004; D. Taylor, 2005). Craniosystonosis may also occur due to secondary causes like metabolic disorders such as hyperthyroidism, malformations like microcephaly, shunted hydrocephalus, encephalocele and mucopolysaccharidosis. Diagnosis Diagnosis can be made with the help of clinical features but for confirmation and to specify various syndromes radiological investigation are necessary most of the times (Kimonis, et al., 2007). Clinical diagnosis based on the examination can be established soon after delivery and is highly accurate, as high as 98-100%, for the single suture involvement (H. O. Taylor, Ramakrishnan, & Forrest, 2010). Computed tomography (CT) scan are widely used for diagnosis and to aid in surgical planning and rule out other associated intracranial anomalies. Magnetic resonance imaging is reserved for cases with syndromic craniosynostosis and aids in diagnosis of associated anomalies like hydroceplahlus, cerebral vascular anomalies. Prenatal ultrasound is appropriate for diagnosis of various craniosynostosis from second trimester onward (D. Taylor, 2005). Ocular examination: Physical examination comprising close inspection of lid position, size and shape of palpebral fissure is essential. Careful inspection of ocular motility in all gazes, cycloplegic refraction, pupil and fundus evaluation are mandatory (Cohen, 2000). Exophthalmometer readings, intraocular pressure, visual field evaluation, corneal sensitivity and examination under anesthesia should be performed when indicated. Special effort should be directed to measure interpupillary distance, inner and outer canthal distance, palpebral fissure size, shape and symmetry and slant of palpebral fissure (Cohen, 2000). These baseline measurements provide data for future evaluation and to monitor progression. Crouzon Syndrome Crouzon syndrome was first described by Louis Edouard Octave Crouzon in 1912. This is one of the common type of craniosyntnosis; accounting for 5% of craniosynostosis with incidence of 1 in 25,000 live births (Kabbani & Raghuveer, 2004). Half of the cases are familial with complete penetrance but variable
THE SIGHT
29
THE SIGHT
30
expressivity and other half are new mutations (D. Taylor, 2005). Mutations in FGFR 2 gene on chromosome 10 are causative with autosomal dominant inheritance (Kabbani & Raghuveer, 2004; Kimonis, et al., 2007). Characteristics facial features include short anterio-posterior head distance, hypertelorism, beaking of nose, hypoplasitc maxilla and mid face hypoplasia (Kanski, 2007; D. Taylor, 2005). The synostosis of cornonal or multiple suture usually develops during first year of life and completes by 2 or 3 years of age (D. Taylor, 2005). Ocular involvement The structural deformity results in widely separated orbits; hypertelorism and laterally rotated orbital axis known as exorbitism. Proptosis is the characteristic feature (Kreiborg & Cohen, 2010). Shallowing of orbits due to arrested growth of maxilla and zygoma result in proptosis (Kanski, 2007; D. Taylor, 2005). Severe proptosis causes exposure of ocular structures resulting in frequent conjunctivitis, keratitis. In extreme cases luxation of globes anterior to eyelids (Kanski, 2007) and spontaneous proplapse of globe, provoked by coughing may occur (D. Taylor, 2005). Strabismus of V paterrn exotropia and hypertropia is common (Kanski, 2007). Exotropia has been reported in three fourth of patients with Crouzon syndrome (Kreiborg & Cohen, 2010) while others have reported a lower occurrence, 39% (Gray, Casey, Selva, Anderson, & David, 2005). Anomalous extra ocular muscles formation and insertion has also been reported. Refractive error is common with majority having hypermetropia (Hertle, Quinn, Minguini, & Katowitz, 1991). A study reported 77% of patient with ametropia and 57% with hypermetropia of more than 2 dioptres (Gray, et al., 2005). Visual impairment in crouzon syndrome is high, a study reported visual impairment in 35% of patients in one eye and 9% in both eyes (Gray, et al., 2005). Amblyopia due to various etiology is the most common cause of visual impairment (Gray, et al., 2005; Hertle, et al., 1991). Exposure Conjunctivitis and keratopathy is
also common with studies reporting 15% to half of patients reporting the condition (Gray, et al., 2005; Kreiborg & Cohen, 2010). Optic atrophy due to increased Intra cranial pressure is one of the major cause of severe visual impairment (Gray, et al., 2005). In addition, there have been rare reports of aniridia, anisocoria, blue sclera, cataract, corectopia, ectopia lentis, glaucoma, iris coloboma, megalocornea, microcornea, nystagmus, and optic nerve hypoplasia (Cohen, 2000; Fries & Katowitz, 1990). Apert Syndrome Apert Syndrome may involve all the cranial sutures and is most severe form of craniosyntnosis (Kanski, 2007). It constitutes 4% of all craniosynostosis and occurs in one in every 65,000 live births (D. Taylor, 2005). Inheritance is autosomal dominant but majority of cases are sporadic due to FGFR2 mutations with significant association with older parental age (Kanski, 2007; Kimonis, et al., 2007; D. Taylor, 2005). Males and females are equally affected (Cohen, 2000). The features are similar to Crouzon syndrome but is characterised by broad thumbs and great toes, and symmetrical syndactaly involving the second to fourth or fifth fingers and toes (D. Taylor, 2005). Mental retardation is also commonly associated with Apert syndrome (D. Taylor, 2005) with 30% of cases being reported with retardation (Kanski, 2007). Ocular features: Ocular features are similar to the crouzon syndrome but less severe with shallow orbits, proptosis and hypertelorism (D. Taylor, 2005). Most ocular pathology is due to shallow orbits and resulting proptosis. Corneal exposure may lead to traumatic injury and exposure keratitis. Eyebrows may have break in continuity probably due to underlying bony defect (Cohen, 2000). Optic atrophy is very uncommon (Cohen, 2000). V pattern exotropia is a characteristic feature (Kreiborg & Cohen, 2010). Strabisumus is due to various defects in superior rectus and superior oblique muscles ranging from underaction of the muscles to anomalous insertion and complete absence of superior rectus and
superior oblique muscles complex (Greenberg & Pollard, 1998; Jadico et al., 2006). Rare association of keratoconus, ectopia lentis and congenital glaucoma has been reported (Kanski, 2007; D. Taylor, 2005). Manangement of Craniosynostoses Craniosynostoses are best managed by multidisplinary approach consisting of various health care professionals; plastic surgeons, eye care specialist, ENT specialist, neurosurgeons, oral surgeons and others (Panchal & Uttchin, 2003). Various ocular disorders associated with craniosynostosis such as exposure conjunctivitis and keratitis should be treated appropriately with lubricating drops and ointments. Amblyopia due to various causes represents the most common cause of visual impairment and treatment should be directed towards achieving best visual outcome. Surgical procedure is indicated in early infancy preferably during first 6 months of life to prevent further progression (Panchal & Uttchin, 2003). Surgery should be done immediately if vision is threatened by the risk of optic atrophy or corneal exposure (D. Taylor, 2005). The main aim of surgery are to excise the fused suture to allow the normal growth as well as to normalise the clavarial shape (Panchal & Uttchin, 2003). Decompressive osteotomy is the surgery of choice to reduce increased intracranial pressure in early life which can be combined with craniofacial techniques (D. Taylor, 2005). Other surgical methods include removal of prematurely fused suture to complicated procedures such as cranioplasty and orbital remodelling. References Aleck, K. (2004). Craniosynostosis syndromes in the genomic era. Semin Pediatr Neurol, 11(4), 256-261. Bayraktar, S., Bayraktar, S. T., Ataoglu, E., Ayaz, A., & Elevli, M. (2005). Goldenhars syndrome associated with multiple congenital abnormalities. J Trop Pediatr, 51(6), 377-379. Cohen, M. M. (2000). Craniosynostosis : diagnosis, evaluation, and management. New York [u.a.]: Oxford Univ. Press.
Dixon, M. J. (1996). Treacher Collins syndrome. Hum Mol Genet, 5 Spec No, 1391-1396. Esparza, J., Hinojosa, J., Garcia-Recuero, I., Romance, A., Pascual, B., & Martinez de Aragon, A. (2008). Surgical treatment of isolated and syndromic craniosynostosis. Results and complications in 283 consecutive cases. Neurocirugia (Astur), 19(6), 509-529. Fries, P. D., & Katowitz, J. A. (1990). Congenital craniofacial anomalies of ophthalmic importance. Surv Ophthalmol, 35(2), 87-119. Gray, T. L., Casey, T., Selva, D., Anderson, P. J., & David, D. J. (2005). Ophthalmic sequelae of Crouzon syndrome. Ophthalmology, 112(6), 1129-1134. Greenberg, M. F., & Pollard, Z. F. (1998). Absence of multiple extraocular muscles in craniosynostosis. J AAPOS, 2(5), 307-309. Grewal, A., Bhat, D., Sood, D., Garg, S., Singh, A., Bharti, R., et al. ( 2005). Goldenhar Syndrome : Anaesthetic and Airway Management. J Anaesth Clin Pharmacol, 21(3), 313-316. Harb, E., & Kran, B. (2005). Pfeiffer syndrome: systemic and ocular implications. Optometry, 76(7), 352-362. Hertle, R. W., Quinn, G. E., Minguini, N., & Katowitz, J. A. (1991). Visual loss in patients with craniofacial synostosis. J Pediatr Ophthalmol Strabismus, 28(6), 344-349. Hertle, R. W., Ziylan, S., & Katowitz, J. A. (1993). Ophthalmic features and visual prognosis in the Treacher-Collins syndrome. Br J Ophthalmol, 77(10), 642-645. 5 | Jadico, S. K., Young, D. A., Huebner, A., Edmond, J. C., Pollock, A. N., McDonald-McGinn, D. M., et al. (2006). Ocular abnormalities in Apert syndrome: genotype/phenotype correlations with fibroblast growth factor receptor type 2 mutations. J AAPOS, 10(6), 521-527. Kabbani, H., & Raghuveer, T. S. (2004). Craniosynostosis. Am Fam Physician, 69(12), 28632870. Kanski, J. J. (2007). Clinical ophthalmology : a systematic approach. Edinburgh; New York: Butterworth-Heinemann/Elsevier. Kimonis, V., Gold, J. A., Hoffman, T. L., Panchal, J., & Boyadjiev, S. A. (2007). Genetics of craniosynostosis. Semin Pediatr Neurol, 14(3), 150-
THE SIGHT
31
161. Kreiborg, S., & Cohen, M. M., Jr. (2010). Ocular manifestations of Apert and Crouzon syndromes: qualitative and quantitative findings. J Craniofac Surg, 21(5), 1354-1357. Lehman, S. (2006). Strabismus in craniosynostosis. Curr Opin Ophthalmol, 17(5), 432-434. Marszalek, B., Wojcicki, P., Kobus, K., & Trzeciak, W. H. (2002). Clinical features, treatment and genetic background of Treacher Collins syndrome. J Appl Genet, 43(2), 223-233. Mehta, B., Nayak, C., Savant, S., & Amladi, S. (2008). Goldenhar syndrome with unusual features. Indian J Dermatol Venereol Leprol, 74(3), 254-256. Panchal, J., & Uttchin, V. (2003). Management of craniosynostosis. Plast Reconstr Surg, 111(6), 2032-2048; quiz 2049. Tay, T., Martin, F., Rowe, N., Johnson, K., Poole, M., Tan, K., et al. (2006). Prevalence and causes
of visual impairment in craniosynostotic syndromes. Clin Experiment Ophthalmol, 34(5), 434-440. Taylor, D. (2005). Pediatric ophthalmology and strabismus. Edinburgh [u.a.]: Elsevier Saunders. Taylor, H. O., Ramakrishnan, A., & Forrest, C. R. (2010). Advances in the Diagnosis of Craniosynostosis. European Paediatrics, 4, 6671. Touliatou, V., Fryssira, H., Mavrou, A., Kanavakis, E., & Kitsiou-Tzeli, S. (2006). Clinical manifestations in 17 Greek patients with Goldenhar syndrome. Genet Couns, 17(3), 359-370. Trainor, P. A., Dixon, J., & Dixon, M. J. (2009). Treacher Collins syndrome: etiology, pathogenesis and prevention. Eur J Hum Genet, 17(3), 275-283.
THE SIGHT
32
Review Article
Current Diagnosis and Management of Dry Eye

Digen Sujakhu
Optometrist, (B.Sc. Env. Sci, B. Optom.,T.U.) The most recent definition of dry eye published in Dry Eye Workshop (DEWS) report (2007) 1 was asDry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tears film instability, with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. According to the definition, symptoms of discomfort are given priority as compared to signs. A new element is mentioning visual disturbance as a dry eye symptom. This is particularly important for contact lens wearers. Studies consistently show that of all the symptoms experienced by contact lens wearers, that of dryness is most frequent.2, 3 In a survey of 100 contact lens wearers, only 25% of all patients said that they experienced no dryness symptoms.4 Contact lens wear may cause hyperosmotic shift of the tear film.5, 6 The causes for this may be reduced tear stimulation caused by decreased corneal sensitivity, thus reducing blink rate, increased lens induced tear hyperevaporation or accumulation of lens deposits in the tear film. Therefore, if a person has a borderline or moderate dry eye to start with, contact lens wear may comprise tear function to the extent that it begins to cause symptoms. Most researchers agree today that dry eye could be divided into hyposecretive and hyperevaporative dry eye.7 (Hyper) evaporative dry eye is by far the most frequent type of dry eye.6-8 Modern lifestyle, which invariably includes computer work, is perhaps the main culprit for reduced blink rate.9 This is particularly important in contactology, since this cause of hyperevaporative dry eye is frequent among contact lens wearers compounding the problem. Hyposecretive dry eye is mainly found among the elderly and hyperevaporative among younger population from which most contact lens wearers are recruited. Main symptom of hyperevaporative dry eye is tearing, caused by the increased evaporation and condensation of aqueous tears on palpebral margins, particularly in cold weather. Hyposecretive dry eye mainly presents symptoms of burning, grittiness and foreign body sensation.
Diagnostic tests
1) Tear film break up time (TBUT) This test is regarded as pivotal in dry eye diagnostics .As mentioned in DEWS Report dry eye definition, tear film instability is one of the main causes of dry eye, and that is what TBUT test measures. It is easy and quick to perform and moderately invasive though it has dubious repeatability and lack of consensus reading cutoff value between normal and pathologic values: older papers advocate 10 seconds, while several newer ones reduce it to 5 secs. 2) Schirmer test Historically it was the first test used to diagnose dry eye. It still has a place in it, but with strictly defined purpose: only to measure the quantity of aqueous tear production. In hyperevaporative dry eye we often see tears dripping from the test strip-interpreting this result as normal tear function would mean missing the opportunity to properly diagnose and treat patients tear dysfunction. 10 mm of test strip wetted with tears in 5 minutes is
THE SIGHT
33
generally accepted. 3) Lid parallel conjunctival folds (LIPCOF) A group of authors led by Prof. Hoeh in 1995 published the paper Lid-parallel conjunctival folds are sure diagnostic signs of dry eye.10 according to the authors, the height and/or number of bulbar conjunctival folds parallel to the temporal margin of the lower eyelid are observed. Before assessment, lower eyelid is briefly lifted from the eye surface-if folds disappear, they indeed are what is described as LIPCOF. Findings are ranked as follows: Grade 0: no folds normal finding (not dry eye) Grade 1: one fold above the normal tear meniscus height-mild dry eye Grade 2: multiple folds up to the height of normal tear meniscus-moderately dry eye Grade 3: multiple folds above normal tear meniscus height-severe dry eye. It is non-invasive method, takes very short time to perform and has no additional costs as it requires use of no test strips, dyes etc. This may be particularly practical in dry eye screening in contact lens wearers, especially regarding soft contact lens wearers. One recent study reaffirms the potential value of LIPCOF in dry eye screening, placing cutoff value between grades 1 and 2.11 4) Lid Wiper Epitheliopathy (LWE) Korb et al found correlation between dry eye symptoms and the appearance of inner upper eyelid lid wiper portion staining.12in symptomatic patients, 88% had LWE13. Lid wiper can be stained either with fluorescein or with lissamine green. Lid wiper is part of inner margin of upper eyelid that exerts most pressure on the eyeball during blinking. Korb et al explain appearance of staining on lid wiper with decreased lubrication in dry eye and consequently increased friction. LWE has been graded in Prof. Korbs initial paper, and more precisely in
his more recent paper.12, 13 though not widely used it is a promising concept. Its indisputable value is in drawing attention to increased friction as one of the main causes of dry eye symptoms, the fact that was previously overlooked. 5) Meibomian gland expression It is one indirect way of assessing lipid layer function. It was initially as well as most recently described by Prof. Korb in 2008.14 by manually applying pressure on eyelid for 10-15 seconds; we can assess quantity and appearance of meibum. It is non-invasive, requires no additional equipment and at least may give us general idea about lipid layer secretion. 6) Ocular surface staining Ocular surface staining marks a more serious form of dry eye, one in which protective role of tear film has been compromised. Typically, dry eye exhibits staining in the palpebral aperture and at 6 oclock. However, as it is with other signs of dry eye, staining correlates poorly with symptoms: one may have pronounced dry eye symptoms without any surface staining and vice versa. Following diagnostic sequence is recommended, which will not take too much time, and does not require any additional equipment. 1. Case history 2. Slit lamp examination of lid margin for blepharitis 3. TBUT 4. LIPCOF 5. Meibomian gland expression 6. Ocular surface staining
Therapeutic approach
Main goals in dry eye therapy are firstly, to alleviate symptoms and thus enhance patients quality of life, secondly, to prevent development of possible complications of dry eye, such as viral or bacterial infection or scarring. And at last but not least, not to
THE SIGHT
34
minimize the side effects of the therapeutic measures.
Artificial tears
These were and still are the mainstay of any dry eye therapy. Nowadays, their role in lubrication and, most recently, prevention of evaporation, are increasingly gaining importance.
hyperevaporative dry eye by dissolving lipid layer. So monodose preservative-free artificial tears or those with preservatives with less adverse effects, such as higher molecular weight, are compounds of choice here.
Other therapeutic measures

Since air-conditioned environment has low relative humidity, natural ventilation is better option wherever possible. Also placing computer below eye level will narrow the eye aperture and thus reduce ocular area from which tears evaporate. Treat any eyelid disease (blepharitis), eyelid hygiene Reduced blinking in CL wearers may cause Meibomian gland orifices to clog, thus compromising lipid layer function and increasing tear evaporation. To prevent this, eyelid hygiene (cleaning of gland orifices with clean water of commercially available lid scrubs) is recommended on daily basis. Assess contact lens care regimen Improper lens care (lens worn too long, use of improper cleaning solution etc.) may also cause tear film function to be excessively compromised. Change of CL material In case none of the above can help, a change to silicone-hydrogels (SiHs) may help. It has been claimed that ACUVUE OASYS with HYDRACLEAR PLUS (Senofilcon A) lens has improved performance, especially for patients in challenging environments who may have issues with lens comfort and dryness. Change of lens type or wear regimen If gas permeable CLs cause severe discomfort due to ocular dryness, change to soft material may be considered. In case of severe intolerance, consider temporary or permanent reduction of wear time or complete discontinuation of CL wear. In CL practice, diagnosis of dry eye is compulsory and should include number of tests in order to define the type of dry eye,
Rewetting
By volume, all artificial tears are 99% water. However, what makes them different from 100% water are demulcents that keep water on the eye long enough to provide adequate rehydration. A demulcent (derived from the Latin demulcere, caress) is an agent that forms a soothing film over a mucous membrane relieving minor pain and inflammation of the membranes. What is more important, it can swell to many times its dry volume without losing its initial properties. After absorbing water it can slowly release it, providing long lasting rehydration.
Lubrication
Compounds with proven lubricating effects are nowadays available in rewetting eyedrops. By reducing friction, dry eye symptoms such as grittiness and foreign body sensation are reduced.
Evaporation prevention
Though there was not much available to offer diagnosed hyperevaporative dry eye caused by lipid layer dysfunction, recently there are formulations with lipid layer substitutes, presenting perhaps the biggest change in artificial tear therapy since the introduction of hydroxypropyl methylcellulose (HPMC) as an active ingredient of artificial tears in the early fifties.
Preservatives
Benzalkonium chloride (BAK) is still the most frequently used preservative. As a cationic surfactant (detergent), it disrupts lipid layer of the tear film and causes tear breakup. Therefore, BAK-containing eyedrops may actually worsen the symptoms of
THE SIGHT
35
as well as the condition of the ocular surface including potential damage such as staining, lid wiper epitheliopathy, LIPCOF. Special attention should be payed on lens material and its property, lens modality and if applicable CL solutions. Careful CL selection and follow up of each case will improve dry eye related symptoms and ocular surface health.
Osmolarity, basal volumes, and reflex flow rate. Ophthalmology 1981; 88: 852-857. 7. McCauley JP, Shine WE, and Aronowicz J et al. Presumed Hyposecretory/hyperevaporative KCS: Tear Characteristic. Trans Am Ophthalmol Soc 2003; vol 101:141-154. TearLab presentation at TFOS, Florence, 2010. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci 1991; 68:888-892.
8. 9.
References:
1. Definition and Classification of Dry Eye. Report of the Diagnosis and Classification Subcommittee of the Dry Eye Work Shop (DEWS). Ocul Surf 2007; 5:75-92. MacMonnies CW and Ho A. Marginal dry eye diagnosis: History versus biomicroscopy. In: The Preocular tear film in Health, Disease, and Contact Lens Wear 1986; ed. Holly FJ: p. 32-40. Brennan NA and Efron N. Symptomatology of HEMA contact lens wear. Optom Vis Sci 1989; 66: 834-838. Petricek I, Prost M, Popova A. The differential Diagnosis of Red Eye: A survey of Medical Practitioners from Eastern Europe and the Middle East. Ophthalmologica 2006; 220: 229-237. Martin DK. Osmolarity of tear fluid in the contralateral eye during monocular contact lens wear. Acta Ophthalmol (Copenh.) 1987; 65: 551-555. Farris RL, Stuchell RN and Mandel ID. Basal and reflex human tear analysis. I. Physical measurements:
10. Hoeh H, Schirra F, Kienecker C, Ruprecht KW. Lid parallel conjunctival folds are a sure diagnostic sign of dry eye. Ophthalmologe. 1995; 92(6):802-8. 11. W. Sickenberger, H. Pult, B. Sickenberger. LIPCOF and contact lens wearers- anew tool to forecast subjective dryness and degree of comfort of contact lens wearers. Contactologia 2000; 22: 74-79. 12. Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnermore VM, Exford JM, Blackie CA, Douglass T. Lid Wiper Epitheliopathy and dry Eye symptoms. Eye and Contact Lens 2005; 31(1):2-8. 13. Korb DR, OD, Herman JP, Blackie CA, et al. Prevalence of Lid Wiper Epitheliopathy in Subjects With Dry Eye Signs and Symptoms. Cornea 2010; 29:337-383. 14. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea 2008; 27(10):1142-1147.
2.
3. 4.
5.
6.
THE SIGHT
36
Review Article
How not to be bored during undergraduate optometry years and perform better?
Nabin Paudel,
PhD Candidate University of Auckland, Auckland, NZ As an optometry graduate, I think I have a pretty good experience on how it feels to be an optometry undergraduate student in Nepal. We have to bear a huge load of course curriculum which ranges from human anatomy,physiology, pharmacology, community medicine, optics, detailed optometric theory and methods, vision science, practical /clinical postings, presentations, ocular diseaseto a final project work. These are the materials that optometry students usually learn during the whole four years of undergraduate educationwhich might be a bit hectic for some people. This article is my own experience on how I survived my undergraduate years as an optometry student and some tips on how to make your four years interesting without being bored or frustrated at all. Before I was a student of optometry at Institute of Medicine, I had never heard of the word Optometry. But, as soon as I got enrolled in Optometry, and after few months, I think there was no one who would know more about optometry than me. I dug into each and every source ranging from magazines to internet resources. And what I found was optometry as the most fascinating and challenging subjects in life sciences. Though there are very less stuff of surgery and medicine (for those who think surgery and medicine are the only ways to make people feel better), I found optometry as a profession in which a small contribution of yours brings a huge smile on others face. For example, vision therapy for children struggling with learning and providing low vision devices to those people who were told that there is nothing that can be done to their eyes to make them read the newspaper again. This is a real triumph in your life, if you agree with my view. The more interesting part is optometry is interrelated with fields like psychology, neuroscience andvision science. These were some of the motivating factors for me being an enthusiastic learner in optometry. I was always a curious guy and still I am. I want to think out of the box besides the traditional way of learning. I wanted to get updated to current developments and also was curious in learning new ways to explore if there are anyways that I can contribute to the betterment of mankind. That is the reason I chose my career in research. The views and methods I follow might not be generalised to everyone but I think they apply to most of the people if they want to perform better. The most common activities in undergraduate years in optometry education in Nepal are: academic presentations (Ophthalmology/optometry, attending or presenting) clinical posting rotations and attending lectures. This is a bit frustrating that there is nothing you can do in lectures given by your lecturers or instructors to make it more interesting. The only thing you can do is be more interactive (asking questions, contributing newer knowledge, if you are sure) and make the class more active rather than just listening. But, there are a lot of things you can do to make your time exciting in clinical postings, self-learning and attending or giving presentations which I tried during my undergrad years. Here are some of them:
Clinical rotations:
Be a very careful observer Watch carefully how a certain procedure is done by your seniors/instructors
THE SIGHT
37
Note down the procedure or keep in mind ( for searching about that on textbook or internet when you go home) Learn from the basics and dont leap at once Speak softly to patients so that they dont get irritated by the procedure you are doing. Make feel them that you are taking care of them not only learning from them. If you dont know something,(even a very simple thing) ask to your friends/seniors/ instructors(this may help you from doing blunders and potential harm) Discuss the findings of the day with friends, if there are any interesting findings Learn all available procedures within your four years step by step but dont be oversmart A lot of instruments might be kept unused, explore them and know how to use them among yourselves and then on patients. Dont make crowd among each other and behave immaturely (act like a professional). Be tidy and on time.
you are sure about it and have the latest information relevant to the matter. If you are presenting: Start preparing for it very early rather than in the last minute Be on time on the day of your presentation Add humour to your presentation (but must be somehow relevant to your topic) Add graphics, cartoons and animations (not much slide transition and color patterns) so that the audience dont sleep during your session Be confident while presenting and open questions for discussions to the audience Dont read the slide (as the audience will read themselves) rather try to explain in a simple way. Use flow charts, diagrams to demonstrate the results or methods as a picture is worth a thousand words.
Be Polite and ask things you dont know
Be interactive and laborious
Self-Learning/Reading for exams:

Be creative and think out of the box: Besides lecture notes and standard text books scan journal articles on your study topic Be a bit extra than your friends on answering questions (except in MCQs and objective) Internet is a bucket full of fishes in academic resources so explore it. Include figures in your answers if relevant and possible. See lectures from international universities which may have new information and new methods for a certain procedure. Try to solve exam papers and numerical from international university, professional licencing exam papers like OCANZ, University of Melbourne. (for final year students and are available on the internet).
Tidy and professional:
Learn to enjoy some hard days: Though there may be some long days, learn to enjoy by seeing the smile on your patients face as it is the greatest pleasure of the day which will make you day.
Presentations:
Try to attend as many presentations as you can. If you are attending: Takes notes of the presentation materials ( might be useful for you in the future) Contribute your ideas and knowledge if
THE SIGHT
38
Research Project/Project work:

Select a topic which you think will be new in your field and you are interested Know detailed background information about the topic you want to study See core papers (similar papers to your proposed chosen topic) Discuss the feasibility of the paper with your proposed supervisors Try to contact international professors or any academics and ask for suggestions on your topic if they have done similar kind of study previously. ( Most of the academics are good people and are always willing to help if you request them) Take your project as a challenge and be excited that you are going to find something new Never manipulate your data. It is your learning phase, it is an undergraduate project work not a PhD and you are very lucky to have this project in your course which is a significant advantage for further studies.
for optometrists but useful for everyone. http://www.academy.org.uk/ , has very useful resources on procedures, lectures from City University, Aston University etc. More interesting is a virtual patient clinic where you can examine patients online and diagnose them. It is awesome. http://www.odwire.org/a forum of optometrists especially from USA where there are a lot of optometry related discussions (academic and non-academic) http://www.optiboard.com/ a forum of optometrists, opticians and other eye care professionals with a lot of dispensing related information. http://www.ce4optometry.com/web/ clinical articles, some of them are free and for some you may have to pay money. http://www.eyeceonline.com/ hundreds of very interesting articles especially designed for optometrists and opticians. http://www.nova.edu/hpd/otm/index.html Optometric theory and methods, presentation, lectures from NOVA College of Optometry. http://viperlib.york.ac.uk/ if you want to learn a bit more of vision science, explore this. Heaps of vision science stuff from illusions to lectures. There are hundreds of resources in the web, the only thing is you need to explore and get them. I hope your journey for search of new knowledge will start soon. I hope you will find the above resources helpful. If you think I can be of help in any of your activities from academic to research works, feel free to mail me on the following mail address. Thank you so much.
These were some of the things that I tried to follow during my undergraduate years though I might not be able to follow all of them. I am very hopeful that these tips might be helpful for any optometry undergraduate students all around the world. Some of the internet resources those I explored as an undergraduate student and might be of interest to optometry students are: www.optometry.co.uk (Clinical articles)This website has very good clinical articles ranging from ophthalmic optics, ocular disease to contact lens. h t t p : / / w w w. o p t . i n d i a n a . e d u / r i l e y / HomePage/1lecturenotes.html , has lectures notes on various diagnostic procedures like slit lamp, BIO, etc http://www.pacificu.edu/optometry/ce/ online_ce.cfm , has courses especially designed
THE SIGHT
39
Review Article
Consent: A necessary step before medical intervention

Sanjay Marasini
Clinical Optometrist Department of Ophthalmology Dhulikhel Hospital/Kathmandu University Hospital Before planning for any invasive surgical intervention, it is important to give the relevant and comprehensive information of the disease process and alternative treatment methods to the patients. Historically consent was not the important part of medical practice as the involved physician is expected to approach the appropriate intervention which is best for the patients. Those days doctors did not explain what they were doing to the patients and why they were doing it. But, in the 20th century, it has become an important part of medical practice and often a legal necessity for surgical procedures.1,2 The concept of patient consent evolved from a judgement in the US supreme court during 1914 and it became a part of international law following world war two with the basic concept that patient consent is mandatory prior to performing any invasive procedures. 3, 4 The basic concept of the consent revolves around the possible medico-legal defences for the doctors and the right of the patients to make his own decision for the future management of the health conditions.5 once the patient is informed, he is given chance to make decision whether or not to go through with a procedure. Most times it is recorded so that there will be no confusion later. This documentation can become important in the event that there is a dispute about whether or not medical consent was obtained before a procedure. It is the right of the patients to refuse to consent or to consent selectively. When someone lacks the capacity to give consent legally, she or he may still be consulted during the process and may also be informed about the procedure. The ethical form of consent is regarded as the shared process of decision making.6 Shared decision making thus allows both patient autonomy and physician responsibility. In the socioeconomically developing countries like Nepal it is likely that patient would be less determined to decide about the subsequent management plans of their health conditions and they prefer to get decision made by the involved physician. Patients undergoing eye surgeries are concerned of their improvement of vision; questions being when the vision would improve and the overall risks of losing vision from the operation.7 It is a general legal and ethical principle that a valid informed consent must be obtained before starting treatment.9 In the western countries, touching a patient without valid consent may invite a civil or criminal offence.10,11 Many factors, such as access to information, emphasis on patients autonomy and medico-legal considerations have become part of the process of informed consent. A recent study in the Annals of Internal Medicine highlights the importance of informed consent discussions, the role they may play in reducing malpractice risks, and the fact that patients often have unrealistic expectations regarding the potential benefits of procedures. In a study by Pimentel et al carried out in patients with cancer, most of the patients wanted to know as much as possible about their illness and treatment.12 Patients should establish a trustful relationship with the surgeon who operates on them.11 Kiss CG et al.13 report that patients prefer to abstain from taking part in the management decision regarding their care. It is vital that the informed
THE SIGHT
40
consent requires us to do more than tell our patients about the risks of the treatments we offer them and make sure that they fully understand the anticipated benefits. atients want to know about the important complications8 although the preference has been observed to vary with the education level and socioeconomic status of the patients. Kang DK observed that 35.6% of their patients did not want to know about the complications and risk of surgery which is similar to our observations. It is understandable that different patients with different anxiety levels and interest would express different degrees of acceptance or tolerance to how much information they would want to know prior to undergoing surgery.10 It is postulated that providing information about risks and complications causes undue and unnecessary anxiety.14 From the ethical point of view; the consent will be valid only when the patient feels that it would have been possible to refuse and change their mind. It is observed that for many patients consent means the medicolegal document which is generally regarded to be from the doctors perspective. Although, some might be anxious, it should not mean that they do not need information. The information helps patients to cope with the treatment and better surgical outcomes.
3. 4.
Nick WV. Informed consentthe new decisions. Bull Am Coll Surg 1974;59:12-7 Borelli N. The Nuremberg Code, Informed Consent, and Involuntary Treatment. JAMA. 1997;277(9):712712. doi:10.1001/jama.1997.03540330034025 Cheung D, Sandramouli S. The consent and counselling of patients for cataract surgery: a prospective audit. Eye 2005; 19: 9637 Seeking Patients Consent: The Ethical Considerations. General Medical Council publication: London. Elder MJ, Suter A. What patients want to know before they have cataract surgery? Br J Ophthalmol 2004;88:331-2 Marasini S, Kaiti R, Mahato KR, Nepal BP. Informed consent among patients who need to undergo eye surgery: A qualitative study assessing their attitude, knowledge and anxiety level. (Unpublished data) Department of Health. Good practice in consent implementation guide: consent to examination or treatment. 2001
5.
6. 7.
8.
9.
10. Kang KD, Abdul Majid AS, Kwag JH, Kim YD, Yim HB. A prospective audit on the validity of written informed consent prior to glaucoma surgery: an Asian perspective. Graefes Arch Clin Exp Ophthalmol. 2010 May;248(5):687-701. Epub 2009 Oct 15. 11. Ghulam AT, Kessler M, Bachmann LM, Haller U, Kessler Tm. Patients satisfaction with the preoperative informed consent procedure: a multicenter questionnaire survey in Switzerland. Mayo Clin Proc. 2006 Mar;81(3):307-12. 12. Pimentel FL, Ferreira JS, Vila Real M, Mesquita NF, Maia-Goncalves JP. Quantity and quality of information desired by Portuguese cancer patients. Support Care Cancer. 1999 Nov;7(6):407-12. 13. Kiss CG, Richter-Mueksch S, Stifter E, DiendorferRadner G, Velikay-Parel M, Radner W. Informed consent and decision making by cataract patients. Arch Ophthalmol. 2004 Jan;122(1):94-8. 14. Stenchever MA. Too much informed consent?. Obstet Gynecol. 1991 Apr;77(4):631.
References
1. 2. Nisselle P. Informed Consent. N Z Med J 1993;106:331 2. Health and Disability Commissioner (Code of Health and Disability Services Consumers Rights) Regulations (1996). Wellington, New Zealand: Government Printer.
THE SIGHT
41
Review Article
Traditional Beliefs in the Eye Care in Nepal

Adhikary Rabindra
Reiyukai Eiko Masunaga Eye Hospital, Banepa All people, whatever are their statuses, whoever are they; somehow are found to practice traditional treatment approach to diseases, not to mention eye. However the severity of the practice differs in many ways; according to age, educational level, gender, socio-economical background, occupation, ownership of health insurance, rural location of residence etc. The routes of administration of the Traditional Ocular Medications (TOMs) are mainly topical, oral, face-wash, fume-bath, shower and inhalation. When we explore the whys of the traditional ocular medications being still prevalent in the societies, we come across different logical answers. If my friend and one of my cousins got benefitted with the medications, then why cant I try? Someone may reply by asking. If the given area is far more rural then one may find difficulty in accessing the modern eye care facility, so they are bound to have TOMs. By occupation, people who are farmers and unemployed tend to have excessive practices of TOMs. It may be because the famers are almost every time in the farming or jungle area so they can cherry-pick the medicines easily and seek counseling from traditional healers as well. The unemployed people might not be able to afford expensive modern medical therapy, so they refused to go. Very few of the papers has unleashed that there is the phenomenal increase in the use of TOMs over last two decades but however there is no logical and scientific deduction of the fact. If the use of TOMs has not been substantially reasonable, then there must be some unidentified underlying factors those may promote the use of TOMs. Secondarily, with the increasing literacy rate worldwide, one may presume as how come such beliefs and practices prevail. Alternatively, the resort to patronage of TOMs has been variously attributed to ignorance, barriers to access primary eye care services, preference, failure of conventional treatment, desire to take control over medical treatment, communication gap between patients and orthodox eye care providers, and influence of friends and relations. Traditional Ocular Medications (TOMs) are a form of biologically-based therapies or practices that are instilled or applied to the eye or administered orally to achieve a desired ocular therapeutic effect. TOMs are crude or partially processed organic (plant and animal products) or in-organic (chemical substances) agents or remedies that are procured from either a traditional medicine practitioner-TMP (Synonyms: Traditional alternative Medicine Practitioner-TAMP; Traditional Healer-TH, Spiritual Healer) or non-traditional medicine practitioners which could be the patient, relation, or friend. The use of TOMs, either as sole first line treatment, or as adjunct used concurrently with conventional therapy has been associated with poor visual, ocular, and occasionally survival outcome of otherwise treatable eye diseases in clinical ophthalmic practice. TOMs- related poor ophthalmic treatment outcomes have been attributed to delay in uptake of eye care services while on first line TOMs therapy; damage to ocular and or adnexal structures from intrinsic TOMs toxicity or result of interaction with prescribed medications, and microbial contamination of TOMs agent or procedure. The lack of standardization of dosage, low purity level, and non-physiologic physico-chemical properties of TOMs, and its unintended role as culture medium for pathogens account for the observed adverse effects. TOMs use reflects the diverse eye health care needs of the population not met by the existing
THE SIGHT
42
eye care delivery system. Consequently, to effectively rein in the tendency to use TOMs, there is the need to understand the health behavior, health literacy status, socioeconomic variables, and dimensions of barrier to access eye care in the population. The use of TOMs persisted for eons and no one can take a giant step to eradicate it at once. It is something that has become a part of the society for a long time. It helped (presumably) people from long before various orthodox medicines arrived. So, we cant underestimate it when we have got better choices now. The rather progressive approach to eliminate it might be first to upgrade the quality and service delivery system of TOMs providing trainings to the practitioners, educating and counseling them. Gradually, collaborating them to Governmental health posts or subhealth posts to encourage for the practice of modern service would be helpful. When the traditional practitioners start practicing modern and reliable medicines then they themselves counsel the society about its better and quicker advantages. Change is always possible but not abruptly, hence we can wait some more time longer to see the effects. It is reasonable to illustrate some common beliefs of Nepalese people over the eye conditions and its traditional treatment modalities. Most often all the children are applied with the gajal or kajal (combination of soot or oil) soon after they are born. Gajals are supposed to strengthen the eye sight and cure red eyes. Some of them are preserved with the
antibiotic ointments, usually chloramphenical found in the aplicaps. There is no convincing scientific truth as to do any help to eye from its application other than the cosmetic enhancement. Since the ointment also remains outside the closed vial/pack for over months its efficacy for the control of infection is again in question. In some regions Laal Gedi (Ipomoca gnomoclita ) is inserted into the conjunctival cul-de-sac for cleaning or removing foreign bodies. When one cannot take out the Laal gedi from the fornix then there would be formation of foreign body granuloma, disregarding the micro-trauma it may cause. Some use mothers milk in to the babies eye when there is some apparent problems like redness. Although the actual outcome is not completely understood one should be aware of practicing it after adequately cleaning breasts. When people have swollen lids (stye or chalazion), they believe when their lids are touched with the penis of a kid, then they are freed from such problems for ever. This practice may give arise further problem than solving it. Further, the folklore of getting styes in the eyes of liars is groundless to science as well. There are also extant practices of putting various herbal drops and gulaab paani (preparation from the rose petals and water) into the eye, as the composition and purity differ with each preparation and possible contamination render this practice unreliable and insalubrious. (The author declares that he has no competing interests.)
THE SIGHT
43
Review Article
Visual Analysis
Suraj Upadhyaya
Optometrist, B.Optom (IOM) (TU) Optometry profession is primarily interested in preventing the visual problems and enhancing visual skills so that, people can perform their jobs easier, faster and with greater accuracy. Lenses are used primarily as a means to prevent visual distortion and to stabilize adequate visual pattern. Visual analysis is important in each and every cases of optometry practice. Visual analysis is a part of scientific optometry. It is a procedure of summing up optometric analysis for purpose of early decision regarding the proper rehabilitation procedure to follow in any particular case. It helps us to find out the limitation of the prescript able lens for distance and near, whether the case can be solve by lens application alone, by vision training alone or by application of both vision training and lenses. It also helps us to follow the changes in relationship between accommodation and convergence brought about by the new lenses or the vision training. From the point of view of visual analysis refractive error is not the cause of visual difficulties. But a change in the habitual learned pattern of accommodation. Never prescribed a lens greater than the amount of accommodation free of association with convergence. This is the basic foundation of functional optometry. If the lens value we prescribed do not aggravate the existing problems they will be acceptable. This lens value is the subjective at far. For example if a one diopters hyperope without previous correction comes to you without any visual problem then it suggest that he has learned certain freedom between the accommodation and convergence equal to his refractive error. He has created fusional convergence at far equal in amount to the accommodative- convergence stimulated by the accommodation. There is always a habitual pattern between accommodation and convergence, we should keep it in mind that the habitual pattern should not be disturbed by the new lenses. In ancient time of optometry practice, optometrist used to refract for the distance and do subjective for the distance. They prescribe these lenses for constant use. But torch has been focused on the problem caused by the Contact lenses and spectacles we prescribe for distance. If the patient use it for near which is not supposed to be with the distance lenses, the patient will have various problems. Generally these type of problems are occurs in age group btw 10-40yrs of age. The Minimum spherical diopters acceptance at near depend on the positive relative accommodation, negative relative accommodation, positive relative convergence and negative relative convergence. By looking at the Dissociated cross cylinder and Binocular cross cylinder findings of near with a cross grid target, we can say the prescribed lens is correct or not for near also. Never prescribed a lens, which reverse the equilibrium pattern findings (Blur out test at near). The blur findings measure the ability of the organism to inhibit one component. Therefore, the relative relationship between these blur findings indicates the direction in which the greatest degree of flexibility exists. If the lenses change these relationships, visual difficulty would ensue. Every patient should be counseled for the spectacles we give them, what is the purpose of it? Constant use, occasional use, for near only, for distance only or for both distance and near. Visual analysis is very important aspect of optometry practice which can help us to improve our practice as well as in our legal issues. Visual analysis is purely optometry function which is entertained throughout the world.
THE SIGHT
44
Review Article
The 10 Commandments for the Future of Optometry

Roberto Kaplan
O.D., M.Ed., FCOVD.
Abstract
Optometry, as an evolving Profession, has two possible directions it can take. Follow the way of conventional medicine, where the primary care model is to treat the symptom of the problem. This approach considers the absence of symptom being good health. The second possibility, is to recognize the real origin of disease and eye problems. A human being that is out of balance. Not only in their physical life, but their emotional and spiritual one too. This paper draws on 40 years of clinical experience of a vision therapy oriented practitioner, one who has embraced the grandfather principles of functional and behavioral vision concepts. A modern approach that recognizes a new paradigm of vision care that has been born. Can this integrated model be embraced as a second 'upgraded direction for Optometry? Like in biblical times, there are commandments that show the way to enlightenment. These could be the steps to go beyond a symptom based medical model of treatment. An approach that is Holistic in its foundation, and redirects the responsibility for healthy eyes back to the patient.
of Functional and Behavioral Vision Care. In spite of my first practice experience being mostly prescribing glasses, each day, I explored the visual findings and considered home based vision training principles for the patient. This was my way of exploring the relationship between the human being and what their deeper perceptual seeing was communicating to me through my vision analysis findings. At first, I had no real skill in communicating this Holistic way of dealing with eye problems. Over the years I was able to simplify my communication, such that more patients involved themselves in the integrated Vision therapy. In this way, I conducted my own clinical trials. This paper is a result of this process and also includes my 16 year Professorship and clinical research at two Colleges of Optometry in the United States of America. During this time I have observed our profession being politically influenced and pressured to fit into an outdated health care model. One that is driven by the Pharmaceutical and Eye and Contact Lens manufacturers. That is, our vision care delivery is influenced by industry and politics, rather than conscious Holistic health care practice. Even today, there are Optometrists being sucked into being like their medical counterparts, where treating eye disease is the focus. What about good old Functional and Behavioral Approaches. Where the well-being of the patient comes first. An approach that has prevention and regeneration at its heart. The standard Optometric model is for the practitioner to treat disease and eye problems in a standard symptom based approach. It's an easy model to follow, when the patient is unwilling to take self responsibility for their visual well-being.
Introduction
Raised and educated in South Africa, forty years ago I began my career seeing patients as an Optometrist. This was my first and only career choice. To guide people towards healthy seeing. My teachers and colleagues emphasized looking at the whole person when designing a vision care program. There was little interest in being a Junior Ophthalmologist', only treating the eye problem! From the beginning, I thrived on the concepts
THE SIGHT
45
However, the ever growing presence of the Internet in people's lives is accelerating the interest in self-help approaches to health in the U.S. and other countries. Consumer desire for organic and healthy food and complementary healing methods is becoming standard practice. There is easy availability of information via the Internet for the public on alternative and complimentary ways to help their eyes. This opens up the possibility for us as Optometrists to provide a healthy therapeutic form of vision care. Our Optometric Profession must take a stand for the future - Prevention. If we don't, we will always be subservient to Medicine and Ophthalmology. For an effective paradigm shift to occur there needs to be a vision, and a blueprint for steering the direction. The branch of Optometry that evolved on the Functional and Behavioral principles of Skeffington, archived through the Optometric Extension Foundation, can serve as a beginning point. The 10 Commandments is a modern extension of these clinical methods, with an upgrade for the complex virtual world and technological time we live in. Primary Care Optometry, modeled after conventional medicine, is not effectively controlling the ever increasing rise of refractive and eye disease problems. Within these 10 Commandments is the solution. The growing numbers of people interested and committed to a preventive approach to vision care is our opportunity. The clinical know-how is available. It is time for Optometrists to upgrade their model of vision care to bring this possibility into reality. The 10 commandments serve this purpose.
continuum of their life struggles and evolution. My eyes were opened to see the eye problem as an entry point to the human being's way of perceiving themselves more deeply. In this way, they were more able to perceive their life problems from a holistic perspective. This paper is a way to present these discoveries as an introduction to the future. A way for Optometry to steer its direction to a truly preventive profession, much like Dentistry has accomplished. Obviously, to administer this approach in a clinical setting will take additional study and practice.
Here are the 10 Commandments:

Commandment 1 - Treat the human who sees not with the eye, but through the eye There is a scientific myth, that has been heavily conditioned into the thinking of both practitioners and the public alike. We see with the eyes. Light comes into the eye, it is refracted and an upside down image forms on the retina. From a physical point of view this may be stated so. However, from a psychological perceptual and quantum physics point of view, a revised understanding is necessary. Light does enter the eye. This light is transformed by refraction. The upgrade in thinking is that the light carries information. It is not the light per say that we are interested in. It is the invisible information with in the light that provides the impetus for perception. It is perception that ultimately determines how and what we see. When the upside down information is correctly received and processed through the brain, an accurate perception is formed. Note, I stated through, not in the brain. However, there are many variables that can interfere in this processing ability. The main one is the inner state of the person themselves. What exactly is meant by this statement. Recent breakthroughs in understanding the 'Biology of Consciousness' helps point the way. . How receptive the tissue and structures of the eye is to the incoming light is dependent on how
What are the 10 Commandments?

The commandments speak to the wisdom of a functional approach in dealing with patient's vision problems. My patients, by identifying their personal needs taught and directed me to the 'know how'? The commandments speak less to a technique or method of use, but more to the way of how to be with the patient. To see their eye problems as part of a
THE SIGHT
46
present or aware the person is behind the eye. From Brain research one could hypothesize that it is simply a matter of the person's focus and attention that is needed for the retina and macular to receive the light. If this happens, then the assumption is that the light is transmitted. New evidence suggests that it is not so simple. There are actually two primary variables that affect the functionality of the eyes. One certainly is the brain. A very helpful part, since its primary role is to protect and help the human survive. Survival mechanisms can steer the energy to and through the eye, and we can react very quickly. New evidence from 'Monk's Brain' studies reveal another phenomenon. Lamas who are trained in mind\spirit matters, like meditation, are more able, and far quicker, able to activate larger surface areas of brain tissue. The resultant effect is that they can process light through the eye in a much more complex way, such as in hidden computer driven stereoscopic images. This still 'brain state' gives them the ability to see more deeply into themselves and life, with less effort and time. Their visual performance far exceeds that of Western intellectual counterparts. Commandment 2 - How the patient sees, and what we measure in the eye, is a reflection of their perceptions Seeing is promoted as being primarily an eye function is now a belief in normal eye medicine. Few consider that in the total process of vision, the eye probably only contributes about 10 percent. The brain and the human spirit determines how and what is seen. So, when an abnormality is measured in the eye, such as Myopia, Astigmatism, suppressions, Glaucoma etc., the source of the problem is behind the eye. My clinical findings implicate that what we measure at the level of the eye are misperceptions, actually survival perceptions, that get programmed into the eye via the nerves and blood supply. So, this means in vision therapy we are providing experiences to reorganize a very deep inner process. It is not enough to just
treat a measured coded abnormality, like a convergence insufficiency or strabismus, that is even classified as an eye disease. Vision therapy is more than what is accomplished in the training room. The procedures the patient is following must be practiced in their real life, at home. If vision therapy is modifying perception, then the resulting experiences must have a place to land in their personal life. Usually, we think of vision therapy as training certain eye and vision skills that effect reading, working at a computer, learning and in sports. At the very core of not seeing is avoidance. The resistance to see issues or problems in patient's lives can and does show up as measurements of refractive and eye conditions. In the same way, if new healthy perceptions are encoded during the vision therapy process, then the Myopic and Astigmatic perceptions are modified. This can actually be monitored through changes in visual acuity, binocularity, and over time lowered and modified diopter measurements. If these perceptions are more healthy, then this new way of seeing can also benefit how the patient sees their choice of career, relationships, family and lifestyle. To take this one step further, clear perceptions directly impact personal problems in patient's lives. Intimacy, deep connection, and addictions are positively affected by vision therapy. Commandment 3 - Do not treat or try and fix the diopters, suppressions, lack of visual acuity, eye diseases, phorias, and other eye findings. Use them to define what the eye is communicating about deeper perceptions of the person's whole existence It is a very big step for a practitioner schooled in Optometric and Medical Science to modify their own inner perceptions of the reality they have been conditioned to believe. We are trained to diagnose eye problems and provide treatments. This model is predicated upon the belief that if we measure something in the eye, that deviates from a norm, the eye condition is the problem that has to be fixed. The future of Optometry being a truly preventive
THE SIGHT
47
discipline, needs a new perception of the eye measurements and what to do about this so called 'problem'. Consider that our usual eye measurements, and their relationships to the patient's symptoms, are a print-out and communication from the brain. This communication is a call out for help. It is not an eye problem. The brain makes adjustments to its vascular and neural messaging to the eyes when it's in a survival state. This messaging implicates the presence of a survival perceptions, like fear or anger. The most vivid demonstration of this process is the case of retinoscopy. A young patients sees perfect 20/20, and yet the retinoscopy finding already showing a minus projection. The eyeball is fine at this stage, however, the retinoscopy is showing a survival restrictive perception. Our usual treatment strategy is to tell the patient to come in the future. Then when the eye shows the Myopia, we can 'correct' it with minus lenses. Then the question can be asked, "What exactly does our lens and vision therapies provide for the patient?" In conventional primary vision care our "correct the refractive error" model locks the patients perceptions into the survival mode. Compensation is just covering up the symptoms not correcting anything. Except, perhaps preventing the practitioner and patient from dealing with the fear of lowered visual acuity. What this means is that the healthy perceptions of thinking, feeling and emotions are not given the appropriate chance to gain the necessary developmental steps for integration. It could be stated that an eye suppression is a one sided suppression of thinking, feeling or emotional perceptions. Psychiatrist Frederick Schiffer, has identified localized areas of emotional activity related to light coming through one eye. So in vision therapy we are guiding the patient into perceptual experiences of higher and higher levels of fusion or integration of the brain. However, this is still only a stepping stone towards a human experience through the eye that is akin to a visionary meditative state, like the Lama Monks have demonstrated. This still
state of seeing gives the freedom to deal with life problems from a less reactive position. Less terror, wars, anger and a return to honoring the unity of the human family on this Earth. Commandment 4 - Prescribe glasses that are preventive and therapeutic because the correct the refractive error glasses do not correct anything Normal lens prescribing follows the correct the refractive error model of vision care. The measurement in and of the eye is an eye problem, and that is the end of the story. Write the prescription for 20/20 and get the next patient in. We have a new commandment. There are patients who come in to our offices interested in taking more responsibility for their visual well-being. This means that we are needing to upgrade our prescribing approaches to meet this level of consumer interest. The growing interest in corrective surgery, like Lasik, is raising the awareness of the possibility for improving vision. Not just functional vision skills, but also visual acuity. Growing numbers of patients are investigating natural approaches to lowering their dependency upon strong glasses. What is our position in Optometry on this obvious marketing opportunity. One that can serve the profession of Optometry, but more important, help vast number of patients lead a more conscious life through healthier functioning visual systems. At the core of a new form of lens prescribing is the premise that the visual system is a natural biofeedback system. The interaction between the fovea/macula and retinal input sets the stage for clearness and unclearness of sight. A normal correct the error lens neutralizes the unclearness of perception into an over focused fovea focus. This introduces a perceptual experience for the patient to fear unclearness and label it wrong. We, as Optometrists, even reinforce this way of thinking. Everybody has to have a sharp focus and be clear, otherwise it is dangerous for them. On the other hand, an integrated vision therapy model of lens prescribing has been birthed and clinically tested for over 30 years. That is, for the self responsible patient
THE SIGHT
48
(this is emphasized), especially the Myopic patient, provide a reduced lens prescription. In this way, a clear and unclear fovea/retinal relationship is established. What happens next is where the real patient compliance and self motivation comes into play. The patient is coached to become aware of what circumstances in their life produces changes in visual acuity. That is, when does the visual acuity seem less clear and visa versa, when does it increase. Variables like certain foods, fatigue, excessive computer use, and spending time outside produces changes in visual acuity. The main advantage of this lens form of integrated vision therapy is that the patient begins monitoring their own vision. They learn very quickly that their eyesight and perception is under their control. Then the Optometrist becomes the teacher, the guide to true prevention. There is no need to fear that glasses will become obsolete in this model. The opposite is true. Patients will be prescribed more lenses for use in the different parts of their lives. Commandment 5 - Prescribe minus lenses in the direction of a parasympathetic stimulant (less minus and more plus), since minus lenses that compensate for 20/20, or 100% eyesight, are a sympathetic stimulant, a drug. It is not very often that we are given a chance to reflect that a lens acts like its prescription drug, that is it has a direct pharmacological action on the autonomic nervous system. The fifth commandment is each time a new minus lens prescription is written, REMEMBER, you are ordering the patient to look through glasses that is a stimulant, like speed. Yes, you are sharpening visual acuity and giving them a chance to protect themselves from not seeing unclear on a physical level. At the same time you are locking them into survival perceptions of their inner unclearness. This is like supporting an addictive process of not becoming aware. The emerging integrated model of vision care supports the patient in looking at their drugged way of perceiving. To help them look through lenses that wake up
their perceptual consciousness. All inhabitants of our planet Earth need to see themselves and outside in order to restore the survival way we are living. It begins with our perceptions. As Optometrists, we have a big role to play in the future scenario of people seeing correctly through their eyes. For the Myopic population, lowered minus lens prescriptions introduces a relaxed parasympathetic way of looking. Through the retinal stimulation, having more feeling for what we are looking at is awakened. This feeling over time is called compassion. The logical clear view is softened. Slowly, as the patient lives this way of looking and seeing, so the brain and eye adjust. We measure this more balanced state in the refractive and binocular findings. Prevention is started for the patient and their off spring. Commandment 6 - Prescribe glasses, with an integrated vision therapy approach, thus giving the patient the self responsibility for their vision future While considering this therapeutic way of prescribing, it will be necessary for most patients to be educated about returning for regular visits. In actual fact, the patient can be guided to realize that in office supervision, say once per month, will be supportive for their new commitment to prevention and regeneration. This approach serves to maintain a high level of self responsibility. Once the patient makes the decision for regular monthly visits, their integrated vision therapy involvement in their life is more likely to happen. In office visits, can include introduction to conventional vision therapy techniques, however, these visits serve another very important process. It is a chance for the patient to experience the deeper connection between their life processes and change in perceptions. The functional Optometric findings of refractive status, like astigmatism, suppressions, and fusion will reflect what is happening to the patients inner world of perception. In my office sessions, I show the patient these connections and how by using their new perceptions in their life, the measurements in the eyes change. The main variable to monitor is visual acuity in the
THE SIGHT
49
distance. The second is the level of binocular vision. These findings vary according to the perceptual level of presence and awareness of the patient. If they need to block a certain life experience, there will be lower visual acuity, or they will suppress the view through one eye. Commandment 7 - Observe and learn how every eye condition of refraction or disease is a view into how the patient is deviating from their fundamental perceptual EyeCode. (That is their God given way of perceiving) Every condition or variation that we measure at the level of the eye is a reflection of an avoidance of perception in the inside world of the patient. The patient is genetically coded with information, like phorias, structures on the iris, and fusion abilities. Each person has unique astigmatic axes. One can consider that these findings serve as blueprint for an individual EyeCode. Over the years, I have categorized these codes into what has become known as the Kaplan EyeCode. The Iris EyeCode shows the fundamental core perceptual style of the patient, either a logical, feeler or emotional processor. In addition, there is precise information, called perceptual influences, that are passed down from the parents. This forms the basis for the patient to deviate from their core code. The Diopter and Disease EyeCode reveal the deviations from the core perceptions that are related to life conditioning. These are the environmental conditions that begin after birth. For example, a child may have genetic influences to show Myopic measurements at the level of the eye, and the interaction with the Myopic parents and fitting into a Myopic conditioned society then exaggerates their moving into Myopia at a faster rate. On the other hand, a patient with no genetic Myopic influences, has less impetus for Myopic perceptions and development for a Myopic eye. They may however, trigger a Myopic visual style by environmental abuse of their visual system, such as in excessive computer use. In the same way, certain perceptual states, like self imposed pressure, either inherited or learned, can be connected to elevated levels of intra ocular pressure. My
findings suggest that when the patient finds out about this inner and outer connection, they are more motivated to take self responsibility for their eye problems. This is a big relief for us, the practitioner, to have a patient take charge. Our true role in vision care becomes evident. We are then the coach, mentor or guide to the patient opening up to their vision. Commandment 8 - Consider all treatments for eyes to be connected to where the patient is in their life cycle, that is, the variables before their current chronological age, and the future. Is it possible, that the within the Biological workings of the eyes are changes that show up during different periods of our cycle of life? Clinically, I have observed that as we go through life in 20 year cycles, there is a repeating of certain perceptual experiences. It seems that our perceptions of thinking, feeling and emotions are given repetitive chances to evolve themselves. At the same time, the code of the eye, reveals changes, for example Presbyopia. Normally, we say the change of lens and ciliary muscle flexibility is just due to the aging process. Consider that Presbyopia is part of a Biological imperative that is designed to modify thinking perceptions into more feeling and emotional forms. This would make total sense when ones considers the life cycle of when Presbyopia begins. The patients foundation of their life has been concretely built. Usually the career, home and family is established. Now it is time to feel and enjoy life more. Less need to focus and gain knowledge and more time to feel and be touched by life itself. The implication of this is huge. Preventive and life cycle lens prescribing will then take on a very different form than treating the patient as having something wrong with their eyes. The eye condition and the patients age guide us to prescribe lenses that will support the patients life process rather than just giving them false sense of sharpness of eyesight such they can continue being unconscious of their fears or need to evolve. Commandment 9 - Examine the eye and
THE SIGHT
50
visual findings to reveal how well the patient is integrating their perceptions of thinking, feeling and emotion. The visual findings follow a coded perceptual developmental path in addition to the environmental conditioning. Evolvement of inner vision is a life process of integrating perceptions of thinking, feeling and emotion. The anatomy of the eye is the first place to observe this fact. The macula is designed to gather focused light in the fastest way possible. The precise information within this focused light is used to build an understanding known as the content of life. The retinal unfocused light, is slower in being processed by the brain. This information forms the context of what is looked at. This feeling state supports our perceptual processes of being touched, the beginning basis for healthy emotional states. During the life cycle these perceptual states integrated to deeper and deeper levels. Of course, the success of this integration is what we measure as the state of fusion between the two eyed inputs. Clinically, I have observed that many patients under life and visual stress lose the ability to keep this integrated Binocular status of multidimensional vision. If the perceptual state gets stuck in either thinking, feeling or even emotion, a survival state of vision is cemented. This limits the capacity for the eye to receive light and sets up the patient for a lack of fulfillment in their life. Modification of the perceptual state through integrative vision therapy encoding, frees up the natural progression once more. The patient can be guided how to integrate these three levels of perception, preparing them for a future preventing further destruction of eye tissue. Commandment 10 - The vision care program must address the reality that at the very core of measured vision problems is an inability for the patient to handle emotional incongruity. One of the most difficult future steps for the profession of Optometry to take is to recognize and acknowledge that at the very core of measured vision problems is an inability for
the patient to handle emotional incongruity. The implication of this statement is vast. The alterations of the eyeball length, power, and the tissue changes we see extend beyond just the physical. Biological changes at the level of the eye are printouts of survival nature of the human beings brain state. The good news is that through re-traveling the journey of thinking, feeling and emotional perceptions, the survival perceptions can be encoded into a healthy pure view. This higher frequency state can be considered to be a kind of essential seeing, like a spiritual view. Certainly, the brain and mind state investigations of the Monks brain testify to this possibility. Is it possible that in primary care Optometry we are missing out on this vast potential we have in our profession? Is our physically oriented vision therapy only just scratching the surface of the potential we can offer patients? My experience of the higher levels of integrated vision therapy has provided me with a deeply fulfilling career as an Optometrist. I offer these commandments to our profession. Upgrade now, it is time and there is a brilliant possibility. Roberto Kaplan is a Doctor of Optometry with an interdisciplinary Masters Degree in Visual Science, Special Education, Speech Pathology and Psychology. He has been Board Certified in Vision Therapy for 36 years. Retired from normal Optometric Practise, Dr. Kaplan collaborates with Medical Doctors, Optometrists and other Professionals in varying approaches to Psychosomatic and natural Holistic steps to Health and Vision Care. www.robertokaplan. com
THE SIGHT
51
Review Article
Eliminating World Blindness

Bob Kinnear The World Health Organisation (WHO) has a programme to find ways to prevent and eliminate blindness around the world by the year 2020 Vision 2020. Visual impairment causes not only suffering for an individual person but the economic impact on society as a whole is enormous. Eyes are the major sense organs for human beings and any defect in them can contribute to other health and mobility problems. Not only is the world population expanding quite rapidly but the average life expectancy is also moving up causing many challenges. Cataract, glaucoma, diabetic retinopathy, corneal injuries and uncorrected refractive errors are the most common conditions. If sight is causing one or more of these conditions, what needs to be done? What can be done? Its a huge problem now; it will be bigger in the future. Suffering aside, the partially-sighted person is dependent on family or friends for daily help. That may mean the helper must forgo their own education or paid occupation. The economic cost to them and the family is great. Often the visually-impaired person cannot prepare meals, help in the garden, wash clothes, or even identify friends and family. Studies have shown that there is a strong association between depression and the quality of life, and an increase in mortality in these people. Glaucoma sufferers have, for example, a great risk factor for falls because they may have suffered a loss in their lower visual field and a decrease in their contrast sensitivity. It is imperative that governments are aware of the costs that blindness is causing and that they make an effort to fund a blindness prevention programme. Uncorrected refractive errors are the leading cause of visual impairment all over the world and could be costing billions of dollars a year. The majority of these problems are in developing countries where there is a significant lack of trained personnel, and a financial problem. However these issues are not only in less economically developed countries but are common throughout the world. An example is myopia. There has been a marked increase in this refractive condition of late. The cause is thought to be not only genetic but associated with the amount of close work undertaken in childhood and youth. There is a good deal of research work being undertaken to find the reason for this and to eventually prevent this nuisance condition. On the positive side, the treatment of some eye conditions has improved dramatically over the last fifty years, and they have become relatively less expensive. Even though the cost of the procedures may seem large it is small when we take into consideration the terrible problems we would have to endure without them. New and inexpensive instruments are becoming available which will help in the detection and diagnosis of glaucoma and maculopathy. They are really clever and small and can be attached to iPhones where the information can be saved, printed and emailed. Make no mistake - we are all greatly needed, and appreciated.
THE SIGHT
52
Review Article
The Use of Visual Evoked Potentials (VEP) In the Optometric Practice

Charles Shidlofsky, O.D., FCOVD Plano, Texas USA There is a growing numberof NeuroDevelopmental Optometrists in the United States that are using Visual Evoked Potential (VEP) as a tool to diagnose and choose proper treatment protocols. When I was a student in the mid-1980s, VEP was an instrument mostly relegated to the Optometry schools. Advances in computer technology and the testing methodology over the last ten years have made this a very viable tool. Visual Evoked Potentials are electrical signals that are measured from the electophysiological activity at the visual cortex. VEPs occur when a patient observes a visual stimulus such as a flashing checkerboard, a sinusoidal grating or even a flash of light. The results are a representation of the functional integrity of all levels of the visual pathway including the retina, optic nerve, optic radiations and visual cortex. VEP testing is purely objective and does not require the patient to do anything beside look at the pattern on the screen. Patterns can be both high contrast (testing primarily the parvocellular pathway) or low contrast (testing the magnocellular pathway). Because of the nature of the testing, one can easily test patients that are preverbal or non-verbal and even infants. In addition, we can objectively measure the patients responses to our treatment protocols (lenses, prisms, patching, bi-nasal occlusion and vision therapy). Furthermore, testing is repeatable and can measure clinical success over a time period. Other applications of VEP just being released are in the diagnosis and treatment of Glaucoma. Testing is also beneficial in patients with systemic neurological disorders such as Multiple Sclerosis. Many of us are working together to develop new testing protocols. A user group met at the Neuro-Optometric Rehabilitation Association (NORA) meeting this past spring in Memphis, Tennessee, USA. The goal of this users group is to share and standardize protocols over the next few years so that comparative data can be shared and new uses of the instrumentation may evolve. As new protocols develop and testing is further refined, I expect the use of Visual Evoked Potential to increase significantly not only here in the USA but all over the world.
THE SIGHT
53
Review Article
Changing Lives with Vision Therapy

Ruth Villeneuve
Vision Therapist)
The four oclock hour arrives at the office of Vision Therapy Group in Flint, Michigan (USA). Three vision therapists emerge from their offices and head into the therapy room to meet their patients. The patients, many of them children, generally attend vision therapy sessions during the hours immediately after school. They have come for a variety of reasons, but mostly they are searching for explanation as to why they struggle in school and are failing to live up to their full potential. The clinic is administered by Doctor Bradley Habermehl, immediate past president for the College of Optometrists in Vision Development. Dr. Habermehl has been an optometrist for over 23 years offering optical and contact lens services as well as specialized treatments for those struggling with learning and behavioral issues on the autism spectrum. He and his staff of trained therapists have been helping students who struggle in school with reading and comprehension, and those who struggle with a lazy or wondering eye for nearly 18 years. In the United States, vision therapy sessions generally run for 45 minutes to 1 hour, depending on the practice. Patients work one on one with a therapist to correct a variety of functional visual issues. Treatment can involve a variety of activities and exercises that encompass everything from balance boards and tracking sheets, to prisms and metronomes. The most common diagnosis is convergence insufficiency. This condition often leads to difficulties with reading comprehension, visual memory, and depth perception. Patients with convergence insufficiency often report that they see double or ghost images or that the words appear to jump around on the page. As a result, these patients tend to struggle in their studies and can turn to negative classroom
behavior in order to avoid reading, writing, or doing math. Other patients seek out vision therapy for help with strabismus and amblyopia. Often, these patients have sought help from numerous doctors and specialists. It is not uncommon for patients with strabismus to turn to vision therapy after several failed surgeries to correct an eye turn. Vision therapy teaches the brain to use and interpret information from both eyes, negating the need for a compensatory eye turn. Many patients, who suffer from visual motor difficulties, also suffer from poor body awareness and a compromised vestibular system. Therefore, it is frequently necessary for patients to receive treatment for these areas before beginning ocular motor work. Vision therapy treats the whole person and since the visual system does not function independently of other systems, all related motor deficiencies must be addressed as well. Very often, patients who have been previously misdiagnosed with ADD, ADHD, dyslexia, and even autism spectrum disorders, can find help in the optometrists office with vision therapy. Doctors who specialize in vision therapy, developmental optometrists, receive their board certification from the College of Optometrists in Vision Development (COVD). The international office of COVD is also responsible for ongoing training and certification of certified vision therapists (COVTs). Those interested in learning more about vision therapy should contact the College of Optometrists in Vision Development (COVD) at www.covd.org or the Optometric Extension Program at www.oepf.org .
THE SIGHT
54
Review Article
HYPHEMA
Richard Hom OD MPA Hyphema is not a common occurrence and it phema or even a rebleed. Because a rebleed is is even more uncommon to see hyphema in likely to produce a more serious outcome from the presence of past radial keratotomy (RK). the hyphema and is to be avoided, the patient With the onset of laser refractive surgery, the should discontinue the use of anti-platelet, popularity of RK has plummeted significantly. anit-coagulant and NSAIDs or until the paAlthough less common today, a form of form tients personal physician can be contacted.In of radial keratotomy called relaxing incision summary hyphema in the presence of past RK is used during cataract extraction to alter re- is likely to have no difference in outcome than fractive error to stabilize vision.To see hyphe- an eye who has never had hyphema. In most ma (bleeding into the anterior chamber of cases,hyphema is self-limiting and requires the eye) is a serious clinical entity and may re- monitoring IOP, uveitis and rebleeds. quire urgent evaluation. Presenting hyphema Radial Keratotomy Hyphema can alarm the examiner and in the presence Bloom HR, Sands J, Schneider D. Corneal rupof RK scars, even create consternation about ture from blunt trauma 22 months after radial compromise of the globe, anterior uveitis and keratotomy. Refract Corneal Surg. 1990 Mayglaucoma. John and Schmitt (1983) reports Jun;6(3):197-9. seven cases of coincidental hyphema and RK Elgin U, Sen E, Teke MY, Tirhis H, Ozturk F., Miwithout any perforation.The management of a crotrauma-induced recurrent hyphema and patient with hyphema can be found in Shep- secondary glaucoma associated with chronic pards (2011) post at Medscape. As Sheppard acetylsalicylic acid use. Int Ophthalmol. 2012 states the most commonly seen traumatic hy- Feb;32(1):89-92. Epub 2012 Feb 2. phema is one that only fills about one-third Jean D, Detry-Morel M. Stellar corneal rupture (1/3) of the anterior chamber as in the photo and secondary glaucoma after squash trauma below. In fact studies show that nearly 60% of in a keratotomized eye. Bull Soc Belge Ophtalhyphemas involve less than a one-third of the mol. 1992;245:109-13. anterior chamber.Here are some key clinical John ME Jr, Schmitt TE. Traumatic hyphema afimplications. The first is increased intraocular ter radial keratotomy. Ann Ophthalmol. 1983 pressure (IOP). Up to 32% (Sheppard, 2011) will Oct;15(10):930-2. have some elevation in IOP. A consistent el- McKnight SJ, Fitz J, Giangiacomo J. Corneal evation of IOP can be found in hyphemas that rupture following radial keratotomy in cats are almost 75-90% of the anterior chamber. subjected to BB gun injury. Ophthalmic Surg. Monitoring the IOP on a daily basis is prudent. 1988 Mar;19(3):165-7. The second most common entity is to watch Sheppard, J.D. Hyphema Medscape referfor rebleeds (secondary hemorrhages). Re- ence web site. March 9, 2011. Available onbleeds may occur more often in African Ameri- line at http://emedicine.medscape.com/ cans than in white patients (Sheppard, 2011). article/1190165-overview. Retrieved on 19 There is speculation that sickle cell trait can be July 2012. uncovered by a hyphema. Monitoring these Trivedi D, Newton JD, Mitra A, Puri P. A seripatients on a daily basis may not improve the ous drug interaction leading to spontaneous outcome because most rebleeds do not occur total hyphema. J Postgrad Med. 2010 Januntil the third or fourth day of the trauma. Re- Mar;56(1):46-7 bleeds, if they do occur, do worsen the prog- Disclaimer: These are the personal opinions of nosis for a normal eye.Lastly, hyphema can be Dr. Hom. There are no disclosures for this post. stimulated by the use of certain non-steroidal Copyright 2012 Richard Hom OD MPA aka anti-inflammatory medications (NSAIDs). Their Tips4EyeDocs use can actually stimulate a spontaneous hy-
THE SIGHT
55
Review Article
Spectral Domain Optical Coherence Tomography in Glaucoma A review of its interpretation

Mr. Safal Khanal
Final year, B. Optometry High resolution optical imaging of objects hidden in scattering media such as the human eye is a challenging and important problem with many industrial and medical applications. Optical Coherence Tomography(OCT) first described in 1991 (Huang 1991), used this type of system and was rapidly adopted for medical applications, especially for ophthalmic imaging. OCT allows for noninvasive in vivo cross-sectional imaging of ocular structures such as the retina, retinal nerve fiber layer (RNFL), and the optic nerve head. It measures the intensity and echo time delay of backscattered and back-reflected light from the scanned tissues. Spectral domain OCT (SD-OCT) is a newer technology based on Fourier transformation theorem which affords unprecedented ultrahigh resolution ultrahigh speed RNFL imaging. This technology is possible, because it uses a spectrometer that is a fundamentally a more efficient way to process information coming back from the stationary reference mirror and the eye. The advantages of SD-OCT over Time Domain OCT include faster image acquisition, higher resolution, automated real time(ART) image averaging, TruTrack eye traking technology and much better Signal to Noise Ratio (SNR). temporal quadrant and continues clockwise in the right eye and counterclockwise in the left eye. The RNFL thickness values are provided for the four quadrants (temporal, superior, nasal, and inferior) and for 12 clock hours. For OCT circle scans, the retinal nerve fiber layer is automatically segmented and the RNFL thickness is measuresd along the scan. The thickness measurements are compared to a normative database. TruTrack active eye tracking and Automated Real Time (ART) imaging are now significantly improved for the acquisition of circle scans. This results in faster image acquisition and considerably higher image quality of these scans. For the RNFL preset, the default for the number of images averaged with Art is now increased from 16 to 100 images, leading to improved image quality. Thickness profile graph The normal retinal nerve fibre layer thickness
Spectralis OCT in Glaucoma Image acquisitions and interpretations

RNFL circle scans This consists of a 3.4 mm circular scan that is used to measure the thickness of the RNFL. A RNFL curve is obtained by opening up the circular scan. The RNFL curve starts with the
THE SIGHT
56
graph shows a double hump pattern with thicker superior and inferior sectors and thinner nasal and temporal sectors. The graph in the lower right of the window shows the RNFL thickness profile measured along the circular scan, and its comparision to the normal range. The black curve indicates the measired RNFL thickness. The green band represents the normal range of RNFL thickness(within normal limits), defined as the range between 5th and the 95th percentile of the normal distribution. The green within this normal band represents the mean RNFL thickness of the normal eyes. The red area denotes the range below the 1st
Case reports Case- report 1 Interpretation
percentile of the RNFL thickness distribution in the normal eyes. A measurement value falling into this range is considered as outside normal limits. The yellow band represents the values below the 5th percentile but above 1st percentile of the distribution of the normal values. A measurement value falling into this range is highlighted in a yellow color and is labeled as borderline to indicate that it falls between these two percentiles of the normal database sample. Classification The pie chart displays classification results for the 6 sectors of the optical disc (T, TS, TI, N, NS, NI), together with a global classification. The black value gives the average RNFL thickness measurement value for each sector and the
This is an OCT imaging report of RNFL of both eyes of a 52 year old Female diagnosed as Glaucoma suspect. The retinal thickness map in the Right eye looks normal since the black line lies in the green shaded area indicating it is within 95% Confidence Interval(CI) of the normal population. Similarly, the sectorial RNFL thickness is all shaded in green. In contrast, the RNFL thickness graph in the left eye lies in the yellow zone in the nasal region and also the sectorial RNFL thickness is shaded in yellow in the nasal sector indicating the thickness is within 99% CI of normal population. Therefore, the OCT report of RE can be termed as within normal limits whereas that of left eye as outside normal limits as one or more sectors in yellow signifies borderline classification.
THE SIGHT
57
Case- report 2 Interpretation
outside normal limits. An outside normal limits classification means that less than 1% (1 out of 100) of all normals from the database have thickness values this low, indicating a high probability of abnormality. The colored bar below the pie chart indicates the overall classification. The bar is red ("outside normal limits") if one or more sectors or global is outside normal limits, and yellow ("borderline") if one or more sectors or global is classified as borderline but none as outside normal limits. If all sectors and global are classified as within normal limits, the bar will appear green ("within normal limits). RNFL progression report This printout is dedicated to record the progression of RNFL thickness measurements for an individual patient. The examinations are listed chronologically decipting following elements. The OCT circle scan for each examination, shown with RNFL segmented. The comparision of each scan with the normative database including quantitative sector analysis. The RNFL thickness profile on the right side indicating the changes in RNFL thickness with respect to the reference exam. Loss of RNFL is shown in red. RNFL trend report with FoDi This shows a trend diagram displaying the ratio of mean measured thickness and mean normal thickness of the normative data for each sector. The scale of horizontal axis can be set to time or ecamination number. A number of 1.00 indicates the average value of the normative database. Any sector values below 1.00 indicate that the sector is thinner than the average of the normative database while sector values greater than 1.00 indicate that the sector is thicker than the average of the normative database. The Difference to Selected Reference Charts give the difference of every sector compared to the selected reference image that is outlined
This is an OCT imaging report of RNFL of both eyes of a 72 year old male diagnosed as Primary Open Angle Glaucoma. The retinal thickness graphs in both eyes appears to lie in the red shaded area in most regions. Similarly most of the sectorial RNFL thickness in both eyes are shaded in red signifying a greater amount of RNFL loss compared to normal population (less than 99% CI). Since the report is classified abnormal if one or more sectors are shaded in red, the OCT imaging report of this patient in termed as outside normal limits in both eyes. global average (G). The green value below in brackets indicates the average value from the normative database adjusted to the age of the examined patient. If the measured average thickness in a sector is within the 95% confidence interval of the normal distribution (p>.05), the sector is colored green to indicate it is within the normal range. If the average thickness is outside the 95% confidence interval but within the 99% confidence interval of the normal distribution (.01<p<.05), the sector is colored yellow to indicate borderline. If the average thickness is outside the 99% confidence interval of the normal distribution (p<0.01), the sector is colored red, indicating
THE SIGHT
58
by a Red Box in the RNFL thickness area.
Retin Eye Res. 2007;26(1):57-77. 12. Hee MR, Izatt JA, Swanson EA, Huang D, Schuman JS, Lin CP, et al. Optical coherence tomography of the human retina. Archives of ophthalmology. 1995;113(3):32532. 13. Schuman JS, Hee MR, Arya AV, Pedut-Kloizman T, Puliafito CA, Fujimoto JG, et al. Optical coherence tomography: a new tool for glaucoma diagnosis. Current opinion in ophthalmology. 1995;6(2):89-95.
References:
1. Budenz DL, Anderson DR, Varma R, Schuman J, Cantor L, Savell J, et al. Determinants of normal retinal nerve fiber layer thickness measured by Stratus OCT. Ophthalmology. 2007;114(6):1046-52. 2. Vizzeri G, Balasubramanian M, Bowd C, Weinreb RN, Medeiros FA, Zangwill LM. Spectral domain-optical coherence tomography to detect localized retinal nerve fiber layer defects in glaucomatous eyes. Optics express. 2009;17(5):4004-18. 3. Moreno-Montanes J, Anton A, Olmo N, Bonet E, Alvarez A, Barrio-Barrio J, et al. Misalignments in the retinal nerve fiber layer evaluation using cirrus highdefinition optical coherence tomography. Journal of glaucoma. 2011;20(9):559-65. 4. Toteberg-Harms M, Sturm V, Knecht PB, Funk J, Menke MN. Repeatability of nerve fiber layer thickness measurements in patients with glaucoma and without glaucoma using spectral-domain and time-domain OCT. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2012;250(2):279-87. 5. Wu H, de Boer JF, Chen TC. Diagnostic capability of spectral-domain optical coherence tomography for glaucoma. American journal of ophthalmology. 2012;153(5):815-26 e2. 6. Ye C, Lam DS, Leung CK. Retinal nerve imaging with spectral-domain optical tomography: effect of multiple B-scan on RNFL measurement. Journal of 2012;21(3):164-8. fiber layer coherence averaging glaucoma.
7. Coscas G. Optical coherence tomography in agerelated macular degeneration 2ed. New York: SpringerVerlag Heidelberg; 2010. 8. Fercher AF. Optical coherence tomography development, principles, applications. Zeitschrift fur medizinische Physik. 2010;20(4):251-76. 9. Huang D, Swanson EA, Lin CP, Schuman JS, Stinson WG, Chang W, et al. Optical coherence tomography. Science. 1991;254(5035):1178-81. 10. Leitgeb RA. Optical coherence tomography--high resolution imaging of structure and function. Conference proceedings : Annual International Conference of the IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine and Biology Society Conference. 2007;2007:530-2. 11. van Velthoven ME, Faber DJ, Verbraak FD, van Leeuwen TG, de Smet MD. Recent developments in optical coherence tomography for imaging the retina. Prog
THE SIGHT
59
Review Article
Radiographic features of retinoblastoma

Shulav Paudel, Radiography Technologist Retinoblastoma (RB) is the most common intraocular neoplasm found in childhood, and with modern treatment modalities in most cases is curable. Retinoblastoma is a malignant tumor of the developing retina that occurs in children, usually before age 5 years, and may be unilateral or bilateral. About 60% of patients have unilateral RB, with a mean age at diagnosis of 24 months, and about 40% have bilateral RB, with a mean age at diagnosis of 15 months. Mutations in the RB gene (chromosomal location 13q14) predispose individuals to the disease, as well as to an increased risk of developing pineal tumors, extracranial sarcomas, and melanoma. When a patient with RB develops a pineal tumor, the term trilateral RB (TRB) is used.[1, 2, 3] RB may occur sporadically (60%), or it may be inherited (40%). Historically, the RB trait seemed to be transmitted in an autosomal dominant pattern. Occasionally, however, the trait skips a generation in families, indicating genetic carriers. can be used to follow up tumors to determine the effect of treatment and to establish a timely diagnosis of malignant tumor relapses.
Fig. Patient with retinoblastoma, glaucomatous stage. Intracranial extension on CT scan Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is not as specific for diagnosing RB as CT scanning because of MRIs insensitivity for detecting calcium. When calcium is detected, it may be seen as an area of low signal intensity on all pulse sequences.[4] RB is usually visualized as a mass that is slightly hyperintense relative to the vitreous on T1-weighted images and that is hypointense on T2-weighted images. T1 hyperintensity may be due to the presence of melanin. Mild to marked enhancement is seen on gadoliniumenhanced T1-weighted images. Like CT scanning, MRI has a role in the detection of extraocular tumor spread, especially extension into the optic canal. It can also depict intracranial tumors associated with TRB. Ultrasonography Three-dimensional (3D) ultrasonography can be used to perform retinal and tumor mapping, which is useful in planning localized or plaque radiation. Subsequently, 3D ultrasonography can also help confirm the proper positioning of such plaques. In addition, calcification and retinal detachment can be diagnosed with this modality; however, 3D ultrasonography is not useful for depicting the extraocular spread of tumors. General anesthesia must be a part of this examination, because the eye should be still during the scan.[5, 6] Color Doppler imag-
THE SIGHT
60
Fig. Retinoblastoma, glaucomatous stage Radiographic features Computed Tomography On CT scans, RB is seen as a mass that is predominantly located in the posterior ocular pole. The mass may have distinct contours and an inhomogeneous structure, and it may contain calcifications in about 70% of case. CT scanning has high sensitivity in the detection of intraocular tumors, and it has a specificity of 91% for RB. This modality has allowed the staging of intraocular tumors, the detection of extrabulbar growth, and the determination of further treatment approaches. CT scanning
ing reveals slightly vascularized tumor areas and can depict blood flow inside the tumor. Bone scan A bone scan can help show if the retinoblastoma has spread to the skull and other bones. Most children with retinoblastoma do not need to have a bone scan. It is normally used only when there is a strong reason to think retinoblastoma may have spread beyond the eye. For this test, a small amount of low-level radioactive material is injected into a vein intravenously. The material settles in areas of damaged bone throughout the entire skeleton over the course of a couple of hours. Then child lies on a table for about 30 minutes while a Gamma camera detects the radioactivity and creates a picture of the skeleton. This may require sedation. This test shows the entire skeleton at once. Areas of active bone changes appear as hot spots on the skeleton that is, they attract the radioactivity. These areas may suggest the presence of cancer, but other bone diseases can also cause the same pattern. To help tell these conditions apart, other imaging tests such as plain x-rays or MRI scans, or even a bone biopsy might be needed. Angiography Retinal fluorescein angiography helps to confirm the diagnosis of RB. However, it is not usually performed for this disease because of the availability of noninvasive, cross-sectional imaging methods. References 1. Shields CL. Forget-me-nots in the care of children with retinoblastoma. Semin Ophthalmol. Sep-Oct 2008;23(5):324-34. [View Abstract] 2. Mastrangelo D, De Francesco S, Di Leonardo A, Lentini L, Hadjistilianou T. The retinoblastoma paradigm revisited. Med Sci Monit. Dec 2008;14(12):RA231-40. [View Abstract] 3. Schefler AC, Abramson DH. Retinoblastoma: what is new in 2007-2008. Curr Opin Ophthalmol. Nov 2008;19(6):526-34. [View Abstract]
4. McCaffery S, Simon EM, Fischbein NJ, et al. Three-dimensional high-resolution magnetic resonance imaging of ocular and orbital malignancies. Arch Ophthalmol. Jun 2002;120(6):747-54. 5. Finger PT, Romero JM, Rosen RB, et al. Three-dimensional ultrasonography of choroidal melanoma: localization of radioactive eye plaques. Arch Ophthalmol. Mar 1998;116(3):305-12. [View Abstract] 6. Romero JM, Finger PT, Iezzi R, et al. Three-dimensional ultrasonography of choroidal melanoma: extrascleral extension. Am J Ophthalmol. Dec 1998;126(6):842-4.
THE SIGHT
61

The Sight Vol. 8

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Sight Vol. 8

Uploaded by

Copyright:

Available Formats

THE SIGHT Volume 8, Issue 8 November, 2012

Vol 8, Issue 8, Nov 2012

8(1.96 + 0.84)2 x (1.46)2

The Study Sites

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Figure 2: Age group distribution of Study Subjects

Figure 4: Education level of the study subjects

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Knitting/Sewing 15 Reading/Writing 35 Non-specific 16 p value between groups

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Low Vision Devices Prescribed in Low Vision Children of Nepal.

Results: In this period, 69 children attended

Methods and methodology

Introduction THE SIGHT

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE Vision was found improved in 75% of children SIGHT

Vol 8, Issue 8, Nov 2012

Sudrishti Eye Clinic

Consultation time: 4PM to 8PM

THE SIGHT Volume 8, Issue 8 November, 2012

Pattern of ocular morbidity in a rural community of Nepal

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Methods and Methodology

Introduction: THE SIGHT Asthenopia is a term used to describe a

Vol 8, Issue 8, Nov 2012

Percentage 20% 9% 6% 7% 5% 11% 4% 61%

Fig 1: Distribution of patients with their chief complaints

Table 2: Distribution of Binocular Disorder

Table 3: Prevalence of the accommodative dysfunction

Prevalence 80% 4% 9% 7% 100%

Table 4: Type of Deviation

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Optometrist- An Independent Eye Care Professional in Nepal

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Pathogenesis of Glaucoma: IOP and beyond

1. Neuronal loss in glaucoma by apoptosis:

Vol 8, Issue 8, Nov 2012

4. Role of nitric oxide (NO)

5. Oxidative stress and glaucoma

3. Role of glutamate in RGC death

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

Vol 8, Issue 8, Nov 2012

THE SIGHT Volume 8, Issue 8 November, 2012